Minor salivary gland inflammation in Devic's disease and longitudinally extensive myelitis.

Devic's disease is often considered as a variant of multiple sclerosis (MS). However, evidence suggests that Devic's disease may be distinct from MS. Devic's disease can coexist with connective tissue diseases, particularly Sjögren's disease, but this association is rare with MS. Diagnosis of Sjögren's disease in patients with neurological symptoms is often difficult. During early stages of Sjögren's disease, patients may not fulfill all criteria for Sjögren's disease. A high percentage of patients with Sjögren's disease have inflammatory infiltrates in minor salivary glands, and this may be a reliable indicator of early or subclinical disease. We show high prevalence (80%) of salivary gland inflammation in Devic's disease and longitudinally extensive transverse myelitis (LETM). We diagnosed 16 patients with Devic's disease, and 2 of these satisfied criteria for Sjögren's disease as did 2 of 9 patients with LETM. Anti-SSA/B titers were infrequently elevated. Although most did not satisfy criteria for Sjögren's disease. 9 of 12 Devic's disease patients and 7 of 8 LETM patients had severe salivary gland inflammation. Thus: (1) patients with Devic's disease or with LETM who have positive labial biopsies but do not satisfy criteria for Sjögren's disease could have subclinical Sjögren's diseases. Alternatively, (2) as patients with Devic's disease have elevated titers of several autoantibodies, so there may exist a set of antibodies that react with antigens in minor salivary glands and cause inflammation. Minor salivary gland biopsy is more sensitive than anti-SSA/B serology in providing histological evidence for possible Sjögren's disease with CNS lesions.

Prospective longitudinal assessment of hallucinations in Parkinson's disease.

OBJECTIVE: To monitor the evolution of hallucinations over 4 years in a stratified sample of patients with PD. METHODS: Using a modified version of the Unified PD Rating Scale (UPDRS) Thought Disorder question, the authors stratified patients into five baseline behavioral groups. They recruited up to 20 patients for each group to participate in sequential interviews (Rush Hallucination Inventory) at baseline and 6, 18, and 48 months. UPDRS motor examinations and Mini Mental State Examinations (MMSE) were obtained at baseline and 48 months. Data were analyzed with Wilcoxon rank sum tests, Mantel-Haenszel tests, and Spearman correlations. To determine features that influenced the new development of hallucinations, a cumulative logit regression model of hallucination severity over time was fit using generalized estimating equations. RESULTS: Based on the design stratification, 60 patients had no hallucinations at baseline (20 with no behavioral problems, 20 with sleep fragmentation, 20 with altered dream phenomena). Twenty-nine patients had hallucinations (20 with retained insight and 9 with loss of insight). At 48 months, the authors could account for all but two subjects (98% retrieval). In 4 years, the presence of hallucinations increased (33% at baseline, 44% at 18 months, and 63% at 48 months, p < 0.0001). The presence of frequent hallucinations (at least three times weekly) also increased (p = 0.0002). Having hallucinations at baseline or at any given assessment was a strong predictor at all follow-up evaluations of continued hallucinations (p < 0.0001). Hallucinations were not associated with increased mortality (chi(2) = 0.59, df (1), p = 0.47). Among the 60 subjects without hallucinations at baseline, time was the only significant factor influencing the development of hallucination over 48 months. Baseline age, PD duration, sex, medications, and UPDRS or MMSE scores did not influence the incidence of hallucinations. CONCLUSIONS: This prospective, longitudinal study documents the persistent and progressive nature of hallucinations in PD patients on chronic dopaminergic therapy. The consistent association of hallucinations with combined levodopa/agonist therapy suggests that these drugs may play a role in the pathophysiology of hallucinations.

Detection, treatment, and control of adult hypertension in northwest Indiana. Ispat Inland/United Steelworkers of America Health Care Network.

Recent data from the third National Health and Nutrition Examination Survey (NHANES-IIIB) suggest that detection and treatment of hypertension is improving, but only 27.4% of American hypertensives achieved controlled blood pressure ([BP] < 140 and < 90 mm Hg). Our objective was to assess the degree of BP control in a group of steelworkers and their families whose health care is financed by a large corporation. A random sample of 792 adults (age > 18 years, average 55 +/- 1 years, 50.4% male) was selected from a roster of patients who were known (from claims data) to have visited a physician in 1995 to 1996. Office charts were reviewed by trained nurses, who abstracted dates of 4095 visits, 3352 BP readings, and 3331 prescribed medications. Filled prescriptions were identified from 54,689 claims submitted for pharmacy services. Hypertension, defined (per NHANES) as more than one BP reading of 140/90 or higher, or taking antihypertensive medication, was found in 437 (55%). At least one antihypertensive medication was prescribed for 386 (88%) of the hypertensives; only 10 failed to have any prescription for antihypertensive medications filled. Controlled hypertension, as defined by Healthcare Employer Data Information Sheet (HEDIS) 3.0 (average BP < 140 and < 90 mm Hg in the office during a year-long period of observation), was observed in 189 patients (43% of total sample, or 50% of the 382 with at least one recorded BP measurement). These data suggest that in this population, insured by a jointly run employer-union health benefits plan, Healthy People 2000's BP goal-at least 50% of hypertensives having BP under control by the turn of the century-may be achieved ahead of schedule.