Cognitive Motor Dual Task Costs in Older Adults with Motoric Cognitive Risk Syndrome.

The purpose of this study was to characterize Cognitive Motor Dual Task (CMDT) costs for a community-based sample of older adults with Motoric Cognitive Risk Syndrome (MCR), as well as investigate associations between CMDT costs and cognitive performance. Twenty-five community-dwelling older adults (ages 60-89 years) with MCR performed single and dual task complex walking scenarios, as well as a computerized cognitive testing battery. Participants with lower CMDT costs had higher scores on composite measures of Working Memory, Processing Speed, and Shifting, as well as an overall cognitive composite measure. In addition, participants with faster single task gait velocity had higher scores on composite measures of Working Memory, Processing Speed, and overall cognition. Taken together, these results suggest that CMDT paradigms can help to elucidate the interplay between cognitive and motor abilities for older adults with MCR.

Successful treatment of peripartum massive pulmonary embolism with extracorporeal membrane oxygenation and catheter-directed pulmonary thrombolytic therapy.

Chronic thromboembolic pulmonary hypertension during pregnancy is uncommon but is associated with maternal mortality in excess of 35%. We report a case of decompensated thromboembolic pulmonary hypertension requiring emergency caesarean section and postpartum treatment with extracorporeal membrane oxygenation and thrombolytic therapy with urokinase. The use of extracorporeal membrane oxygenation, catheter-directed pulmonary thrombolytic therapy and other pulmonary vasodilators for management of this life-threatening disease is discussed.

CT and CT angiography in massive haemoptysis with emphasis on pre-embolization assessment.

Massive haemoptysis is a respiratory emergency. Computed tomography angiography (CTA) can play a crucial role in assessing the cause and origin of the haemoptysis and directing the interventional radiologist prior to treatment. The bronchial arterial supply and to a lesser extent the non-bronchial systemic arterial supply are responsible for the majority of cases of massive haemoptysis, but uncommon causes of massive haemoptysis should be considered to avoid misdiagnosis and delayed treatment. Failure to assess the imaging appropriately prior to endovascular treatment may result in early recurrent massive haemoptysis or patient death.

Central pontine myelinolysis, an update.

Central pontine myelinolysis (CPM) can be regarded as one of the demyelinating syndromes. First described by Adams et al. in 1959 in their chronic alcoholic patients, it has now been described in the malnourished, the chronically debilitated, the renal, the hepatic and the transplant patient among others. Pathologically, it is defined as a symmetric area of myelin disruption in the center of the basis pontis, although similar symmetric lesions have also been described occurring with CPM as well as independently in other brain areas (extrapontine myelinolysis or EPM) including the cerebellar and neocortical white/gray junctional areas, thalamus and striatum. Possible mechanisms include a hyperosmotically induced demyelination process resulting from rapid intracellular/ extracellular to intravascular water shifts producing relative glial dehydration and myelin degradation and/or oligodendroglial apoptosis. The process most often occurs during rapid rebalancing of the electrolyte parameters in the hyponatremic patient. Avoidance of CPM/EPM is dependent upon recognizing those patients with conditions pre-disposing them to osmotic myelinolysis and then moderating the rate of normalization of the electrolyte imbalance. The morbidity and mortality of CPM/EPM has been greatly reduced by recognition of pre-disposing conditions, increased understanding of the pathophysiology, intensive treatment, and rapid diagnosis and monitoring with advanced neuroimaging.

An occipital lobe epileptogenic focus in a patient with West Nile encephalitis.

Although most human cases of West Nile (WN) fever are benign, approximately 1% produce severe neurological illness. Meningitis and/or encephalitis comprise 75% of hospitalized cases with seizures in 10-15%. Occipital lobe seizures, often mimicking other primary seizure types due to extra-occipital spread, is uncommon in adults and especially so from an infectious origin. A case of WN encephalitis presenting with a simple partial seizure, focal motor, resulting from an occipital epileptogenic focus is reported. The atypical epileptogenic location of the case and the observed frequency of seizures in WN encephalitis suggest that this virus is particularly irritative to cortical neuronal networks. Thus when seizures especially with atypical EEG patterns present during an acute febrile illness in the warmer months, WN encephalitis should be considered.

Postoperative nausea and vomiting in women following breast surgery: an audit.

A prospective observational study of 101 women having breast surgery under general anaesthesia was performed to assess the extent of postoperative nausea and vomiting in this group of women. The overall rate of postoperative nausea and vomiting was high, 56% and 41%, respectively, and was significantly associated with length of surgical procedure and morphine use. Techniques to reduce morphine requirement should be evaluated to try and reduce this cause of morbidity.

A controlled study for gender selection using swim-up separation.

OBJECTIVE: To evaluate the success for gender selection using a sample of semen separated by a modified swim-up technique. DESIGN: We retrospectively compared the gender outcome of two treatments (A and B) for either a male or female offspring with those who conceived spontaneously. SETTING: Private practice of one author (M. A.K.). PATIENTS, PARTICIPANTS: The treatment groups consisted of 52 total pregnancies for couples who conceived by the separation technique. Of these 52 participants, 15 desired a female offspring and were placed into treatment A and 37 desired a male offspring and were placed into treatment B. The control groups consisted of 162 women who were presented with initial consultation for gender selection and conceived spontaneously. Control group A consisted of 80 women who initially chose a female offspring, and control group B consisted of 82 participants who initially chose a male. INTERVENTIONS: In treatment group A, one timed intrauterine insemination (IUI) was carried out with the bottom 0.5 ml of the separated semen on cycle days 12-14, when the follicle was 18-22 mm. Patients in this group were also administered clomiphene citrate and human chorionic gonadotropin. In treatment group B, one timed IUI was done with the top 0.5 ml of the separated semen, when the follicle was 18-22 mm. MAIN OUTCOME MEASURE: The gender outcome of the pregnancies of two treatment and control groups was evaluated based on the known desired gender. RESULTS: The success rate for conceiving a female child after intervention (treatment group A) was 86.7% effective (p = 0.002) as compared to the control group A. Couples seeking a male child (treatment group B) were 89.2% effective (p = 0.0002) as compared to the control group B. CONCLUSIONS: This study reveals that the modified swim-up method with additional monitoring results in statistically significant gender preselection.

Nocardia asteroides: an unusual cause of breast abscess.

A case of nocardial breast infection is presented and infection by nocardia organisms must be considered as a rare differential diagnosis of chronic inflammation of the breast.

False aneurysm of the common femoral artery after total hip arthroplasty. A case report.

A 59-year-old healthy man presented with osteoarthritis of his left hip that was recalcitrant to nonoperative treatment. He subsequently elected to have arthroplasty of the hip performed. At 3 months after arthroplasty, he returned reporting progressive groin pain: most remarkable was a palpable mass in the groin region. An arteriogram showed a radiodense mass adjacent to the acetabulum, and a computed tomography scan with contrast confirmed a large false aneurysm originating from the common femoral artery. In this particular case, a pointed Hohmann retractor punctured the common femoral artery, creating the dynamics of the development of a false aneurysm. Primary suture repair of the vascular defect was performed, followed by a complete and uncomplicated recovery of the patient to full activity. Since this case, the authors have discontinued the use of pointed. Hohmann retractors and now use a blunt, rounded Hohmann retractor during total hip arthroplasty without compromising acetabular exposure. However, care must be taken in blunt retractor placement to avoid retractor slippage during the procedure. This case shows the need for awareness of potential mechanisms for vascular injury related to total hip arthroplasty.

Syndromal vertigo identified by magnetic resonance imaging and angiography.

The advent of magnetic resonance imaging and angiography has clarified the location and vascular basis for vertigo of a syndromal type. The composite presentation of a vestibular symptom with evidence of cranial nerve or cerebellar dysfunction suggests a lesion within the pons, medulla, or cerebellum. The location may be exactly defined by noninvasive techniques and appropriate therapy can be initiated. Clinical examples are presented; the syndromes of vertebrobasilar artery perfusion disorder are described, and appropriate images are illustrated for confirmation.

Evaluation of the vestibular system by magnetic resonance angiography.

This report describes the normal arterial patterns of the vestibulocerebellar regions visualized by magnetic resonance angiography. Variations in the vertebrobasilar arterial system are described, limitations in imaging are discussed, and collateral connections within the cerebellar vessels and the circle of Willis are reviewed. Clinical correlations are defined between the vestibular nuclei, the associated intraaxial tracts, and with specific posterior cerebral and brain stem arteries.

Preventing relapse. Guidelines for the pediatrician.

Preventing relapse into substance use means first helping the teenager to develop a state of recovery. This involves completing a First Step of a 12-Step program, whereby the teenager accepts that drugs and alcohol have been destructive in his or her life and that moderate use is impossible. Thus, abstinence is necessary in a productive life. Parental support is also established. The two more common causes of relapse are being in the presence of alcohol- and drug-using peers and the presence of co-existing psychiatric problems.

Effect of opioid antagonism on beta-endorphin processing and proopiomelanocortin-peptide release in the hypothalamus.

Previous studies have shown that chronic opioid receptor blockade has significant effects on POMC gene expression and peptide levels in the hypothalamus. We have now examined the effects of the opioid antagonist naltrexone on beta-EP processing in the hypothalamus and on the release of 2 POMC-derived peptides, beta-EP and gamma 3-MSH, from the perifused hypothalamus in vitro. The beta-EP immunoactivity in the medial basal hypothalamus (MBH) of 7 rats infused for 1 week with naltrexone by osmotic minipump, was individually analyzed by HPLC and compared to 7 control rats. The mean ratio of beta-EP1-31 compared to beta-EP1-27 plus beta-EP1-26 was 2.34 +/- 0.41 in the naltrexone treated rats, significantly higher than the ratio of 1.26 +/- 0.09 in the control rats (P < 0.02). Thus in the setting of chronic opioid antagonism although beta-EP content decreases, there is relatively more beta-EP1-31, the biologically active opioid form of the peptide, compared to the C-terminally cleaved forms of beta-EP which have reduced biological activity. To study the effects of naltrexone on beta-EP and gamma 3-MSH release, hypothalami were perifused in vitro with 10(-6) M naltrexone. Basal release of gamma 3-MSH was significantly higher from the naltrexone treated brains compared to the controls (221 +/- 20 pg/60 min vs. 161 +/- 6.7 pg/60 min) (P < 0.01); KCl stimulated gamma 3-MSH was also significantly higher in the naltrexone group (951 +/- 94 vs. 543 +/- 85 pg/60 min) (P < 0.005).(ABSTRACT TRUNCATED AT 250 WORDS)

An early caesarean operation (1800) performed by John and Charles Bell.

An articulated skeleton in the Bell Collection in the Museum of the Edinburgh College of Surgeons is of a woman who died shortly after a Caesarean section, believed to be the 18th recorded case of such an operation performed in the UK and Ireland. The fact that John and Charles Bell were the surgeons involved is of particular interest, due to their importance in the practice of surgery and surgical anatomy in Edinburgh during the early part of the 19th century. The woman had a restricted pelvic inlet and outlet resulting from puerperal osteomalacia, the commonest indication for carrying out this operation during the 18th and 19th centuries. Evidence from the examination of contemporary parish baptism and burial records, as well as meteorological records, established that the Caesarean operation was performed on 29 January 1800. The surviving child was subsequently baptized 'Caesar', in accordance with the common practice at that time.

Incidence of severe ovarian hyperstimulation syndrome with extremely elevated serum estrogen levels.

The incidence of ovarian hyperstimulation syndrome (OHSS) is directly correlated with the pre-human chorionic gonadotropin blood estrogen (E) levels. The higher the E content, the greater the chances of OHSS. However, even when the E levels are very high, only 2.96% of the patients developed severe OHSS. Younger women with primary ovarian dysfunction are more at risk than older women. Human chorionic gonadotropin should be withheld when the estradiol levels are over 4,000 pg/ml; however, the patients should be individualized, since some patients--particularly older women--may require higher blood estradiol levels for successful ovulation induction.

Nonclassical 3 beta-hydroxysteroid dehydrogenase deficiency: a review of our experience with 25 female patients.

OBJECTIVE: To report 15 new menarcheal women affected with nonclassical 3 beta-hydroxysteroid dehydrogenase deficiency (nonclassical 3 beta-HSD) and evaluation of glucocorticoid therapy in treated patients. DESIGN: Diagnosis of these new patients using a standard adrenocorticotropin test. Effects of glucocorticoid therapy on clinical hormonal and sonographic features of each patient are appreciated for periods varying between 4 months and 7 1/2 years. SETTING: All at The New York Hospital-Cornell Medical Center. The Pediatric Endocrinology Ambulatory Service; the Children's Clinical Research Center Core Laboratories; and the Department of Radiology. PATIENTS, PARTICIPANTS: Fifteen menarcheal women (14 to 30 years of age) newly diagnosed and 10 women previously diagnosed were evaluated for symptoms of hyperandrogenism and/or irregular menses. MAIN OUTCOME MEASURE(S): Positive effect of glucocorticoid therapy on signs and symptoms, hormonal levels, and ovarian imaging. RESULTS: Polycystic ovarian syndrome is noted in approximately half the cases. Glucocorticoid treatment greater than 3 months duration results in a reversal of symptoms in most cases.

Cytogenetics of müllerian agenesis. A case report.

A 38-year-old woman presented with primary infertility and primary amenorrhea. The evaluation revealed müllerian agenesis and mosaicism, 45,X/46,XX/47,XXX.

Effect of opioid receptor antagonism on proopiomelanocortin peptide levels and gene expression in the hypothalamus.

In order to determine how brain beta-endorphin (beta-EP) and its precursor proopiomelanocortin (POMC) adapt to chronic opioid blockade we have examined the effects of treatment with the opioid receptor antagonist naltrexone (NTX) on POMC gene expression and peptide levels in the hypothalamus. Male rats were treated with NTX by daily injection or constant minipump infusion. RNA was isolated from the medial basal hypothalamus (MBH) after an aliquot was removed for peptide RIA and the amount of POMC mRNA was measured by solution hybridization SI nuclease protection assay. beta-EP and several other POMC-derived peptides including alpha-melanocyte-stimulating hormone (alpha-MSH) and corticotropin-like intermediate lobe peptide (CLIP) or gamma(3)-MSH were measured in the MBH and anterior hypothalamus (AH) by RIA. In an initial experiment POMC peptide levels were measured after 7 days of NTX (4.8 mg/day) infusion. There was a marked fall in the concentrations of beta-EP, alpha-MSH, and CLIP; levels in the MBH declined by more than 60% (P < 0.001). In the next experiment NTX (1 mg) was injected daily and POMC peptides and mRNA were measured after 2 and 5 days of treatment. (beta-EP) and alpha-MSH levels fell progressively in the MBH and AH and were significantly less than those of the controls by 5 days of treatment (P < 0.02). POMC mRNA levels, however, did not change after 2 or 5 days. When NTX was infused for 3 weeks there was a decrease in the concentrations of beta-EP, alpha-MSH, and gamma(3)-MSH in the MBH (P < 0.001). The concentration of POMC mRNA in the MBH, however, was significantly higher in the NTX-treated animals, 0.99 +/- 0.06 pg/mug RNA vs 0.81 +/- 0.05 pg/mug RNA (P < 0.05). Since NTX can affect LH and testosterone release, the study was repeated in castrated rats. POMC peptide levels again fell after 3 weeks of NTX. POMC mRNA levels were higher in the castrated rats than in the intact rats, 1.14 +/- 0.06 pg/mug RNA vs 0.85 +/- 0.09 pg/mug RNA (P < 0.05), consistent with our previous findings in longterm castrated rats. However POMC mRNA increased further to 1.40 +/- 0.09 pg/mug RNA in the castrated animals treated with NTX (P < 0.05). We conclude that opioid receptor blockade has significant effects on POMC peptide levels and gene expression in the MBH. The increase in POMC gene expression associated with a fall in peptide levels is consistent with a compensatory increase in brain beta-EP synthesis and release in the setting of chronic opioid receptor blockade.