Influence of pancreas transplantation on cardiorespiratory reflexes, nerve conduction, and mortality in diabetes mellitus.

Cardiorespiratory reflexes (CRR) were studied by measuring heart-rate variation during 6 breaths/min respiration and a Valsalva maneuver in 232 insulin-dependent diabetic subjects. Abnormalities were found in 175 patients. During a 7-yr follow-up, 41 (23.4%) patients with abnormal and 2 (3.5%) with normal CRR tests died. The mortality rates of diabetic patients with abnormal autonomic function tests were 17% at 2.5 yr, 33% at 5 yr, and 40% at 7 yr, significantly higher (P less than 0.002) than in patients with normal tests (rates of 4.6, 4.6, and 13.8% at the respective intervals). Nerve conduction studies (NCS) were indicative of somatic neuropathy in 148 of 205 patients. Mortality rates were higher in patients with abnormal NCS than in those with normal results (P less than 0.025). Among patients with abnormal autonomic function, patients with a functioning pancreas transplantation (PTx) had better survival rates than patients with a failed PTx (P less than 0.005) and, on long-term follow-up, better rates than patients without PTx. Similar results were found comparing the same group of patients who had abnormal NCS.

Medical complications of cardiopulmonary arrest.

The clinical courses of 63 survivors of cardiopulmonary arrest were reviewed to determine the incidence and temporal occurrence of noncardiac complications and their relationships to mortality. Complications were grouped as occurring within 48 hours or less, within 48 to 96 hours, or more than 96 hours after cardiopulmonary arrest. Pneumonia, electrolyte level disturbances, and gastrointestinal tract hemorrhage each occurred in more than 28 (45%) of the 63 patients. Resuscitation-related injuries, seizures, and liver function test abnormalities each occurred in at least 18 (28%) of the 63 patients. Pneumonia and liver function test abnormalities were each significantly correlated with increased mortality. Septicemia, acute renal failure, and adult respiratory distress syndrome each occurred in three (5%) to four (7%) of the 63 patients and were always associated with mortality.

The limited usefulness of nasopharyngeal EEG recording in psychiatric patients.

The authors retrospectively studied 150 psychiatric inpatients, 96 of whom had had nasopharyngeal EEGs and 54 of whom had had regular EEGs. The nasopharyngeal recordings did not reveal significantly more epileptiform abnormalities than did the regular EEG in patients with suspected seizures.

Critical frequency of photic driving in the diagnosis of multiple sclerosis.

Pattern visual evoked response (PVER) and critical frequency of photic driving (CFPD) to repetitive flash stimuli were studied in 68 consecutive patients suspected of multiple sclerosis (MS) and 15 normal controls to assess the diagnostic value of combined PVER-CFPD testing. Clinically, 38 qualified for the diagnosis of MS while 30 did not. The CFPD was found to be unreliable for detecting optic nerve dysfunction (OND) in MS, since well-defined photic driving at all frequencies above 40 flashes per second was not present in 14 patients without MS (47%) and in three normal control subjects (20%). The PVER, on the other hand, was highly sensitive and specific for OND, being abnormal in 12 patients with definite MS (92%) but in none of the normal controls. It is concluded that PVER by itself is a valuable test for the diagnosis of OND in MS and additional CFPD testing is uninformative and may even be misleading.

Seasonal incidence of phenytoin allergy unrelated to plasma levels.

In a three-year prospective study of patients to whom phenytoin was administered, 26 (8.5%) of 306 patients manifested an erythematous morbiliform rash within three weeks of onset of therapy. Occurrence of the rash was not related to the mode of administration of treatment (loading v maintenance) or initial phenytoin levels. A striking seasonal incidence of the rash was noted: None of the 79 persons who received the initial dose during December to February had a reaction, whereas 13 (20.6%) of 63 persons treated during June to August manifested the rash. For March to May, the rate was 10% (8/88), and for September to November, 6.7% (5/76). Monthly rates were significantly different by chi 2 test.

Ictal characteristics of pseudoseizures.

The spontaneous pseudoseizures resembling tonic-clonic seizures in 25 patients were recorded on simultaneous videotape and electroencephalograms and were compared with the seizures recorded from 25 patients with true tonic-clonic epileptic events. The goal of the comparison was to identify bedside clinical criteria to assist in differentiating between the two groups. The variables of age, sex, and selected physical manifestations of the events were compared for the two groups by appropriate statistical methods, including a multivariate step-wise discriminate analysis. Significant differences between the two groups of seizures were identified for several variables, and most strikingly for the character of upper and lower extremity movements, the time of vocalization during the event, the character of pelvic movements, and the nature of body tone during the events. Useful bedside criteria for distinguishing a pseudoseizure from a tonic-clonic seizure were identified.

B-mode, real-time carotid ultrasonic imaging. Correlation with angiography.

B-mode, real-time ultrasonic imaging was prospectively evaluated as a screening test for atherosclerotic occlusive vascular disease in the carotid bifurcation region, as defined by carotid angiography in 100 carotid systems in 50 patients. Preliminary reliability studies for each technique assessed agreement between examiners. Sensitivities of ultrasonography for stenosis greater than 50% of luminal diameter, complicated plaque ulceration, complete occlusion, and "surgical disease" by any of these parameters were 79%, 26%, 25%, and 73%, respectively. Thirty-seven percent of the 100 carotid systems were found to contain surgically relevant disease by angiography, compared with 19% and 56%, respectively, of the carotid systems with negative and positive ultrasonographic results. Judicious use of ultrasonography as a screen for angiography requires awareness of these limitations.

Essential tremor: treatment with propranolol.

A double-blind trial of propranolol, in a dosage of 120 mg a day, and placebo was conducted in 11 patients with essential tremor. An improvement in tremor was observed in all patients who received propranolol and was most pronounced in the upper extremities. The favorable clinical assessment was further confirmed by improvement in a grooved pegboard test and in the quality of handwriting as evaluated by two "blind" observers. No side effects were encountered. It is concluded that propranolol is at present the best available drug for the treatment of essential tremor.

Eye tracking dysfunction in Alzheimer-type dementia.

Performance on visual tracking tasks was measured in groups of Alzheimer-type dementia, pseudodementia of depression, and elderly normal controls. Smooth pursuit tracking errors were identified by counting the number of catch-up saccades required to compensate for failure of the smooth pursuit system. The group with Alzheimer-type dementia had significantly worse (p less than 0.0001) smooth pursuit tracking than either pseudodementia subjects or elderly normal controls. A strong correlation (r = 0.74, p less than 0.005) was found in Alzheimer patients between severity of visual tracking abnormality and severity of dementia.

Cerebral dysfunction after chronic hypoxia in children.

Although the long-term effects of acute anoxia have been studied, the effects of chronic hypoxia on the developing human brain have received little attention. We studied children with a cyanotic congenital heart defect to assess the impact of chronic hypoxia by eight measures: neurologic examination, visual evoked response, EEG, behavioral adjustment, cognitive, perceptual-motor, and attentional functioning, and school performance. On outcome evaluation, these children evidenced diverse neurophysiologic dysfunction. Chronic hypoxia was associated with impaired motor function, inability to sustain attention, and low academic achievement.

B-mode real-time ultrasonic carotid imaging: impact on decision-making and prediction of surgical findings.

The roles of B-mode real-time ultrasonic imaging (USI) and carotid angiography (CAG) in deciding on endarterectomy were analyzed. When greater than 50% stenosis and/or complicated ulceration were predicted by both techniques, endarterectomy was undertaken in 21/25; by only CAG in 5/8; and by only USI in 10/21. In vessels with adequate surgical data, stenosis was accurately predicted by CAG in 27/32, USI in 20/32, and ulceration by both CAG and USI in 21/29. USI results were sometimes used to justify endarterectomy despite unimpressive CAG. CAG is a better predictor of stenosis, whereas both are limited in predicting ulceration.

Antiepileptics and the development of congenital anomalies.

We are conducting a prospective cohort study of epilepsy and pregnancy to determine the nature and extent of adverse pregnancy outcomes in infants of mothers with epilepsy (IME). Women with epilepsy were enrolled no later than the first trimester and were matched with controls; their infants were examined at 8 weeks by pediatricians blinded to maternal status. A number of variables were compared between case and control infants: birth weight, length, gestational age, head circumference, Apgar scores, feeding difficulties, neonatal irritability, and presence of major malformations and minor anomalies. The number of minor anomalies per infant was greater for IME than for controls (mean, 5.05 and 3.65, p less than 0.0001 per infant, respectively). Prominent occiput was the only anomaly seen significantly more often in IME than in controls (p less than 0.05).

The design of clinical studies to assess therapeutic efficacy in multiple sclerosis.

Poorly designed trials of therapy for multiple sclerosis (MS) can waste time and money, and may lead either to false hopes or to the overlooking of a potentially effective treatment. A well-designed trial may well develop useful scientific information even if the putative therapy fails to show any therapeutic effect. The diagnosis, clinical course, and definitions of the stages of MS are discussed as they relate to trials of therapy. The goals of such trials include favorable modification of an exacerbation, favorable modification or prevention of future exacerbations, effective treatment of the progressive stage, and improvement of function in the stable-deficit stage. There should be an orderly progression from a small preliminary trial to a modest pilot trial and, when indicated, a full trial. All types of trials require careful organization and management, appropriate selection of patients, and properly planned and recorded observations. The treatment contrast--how the new treatment will be evaluated--provides the essential structure of the trial. The hypothesis being examined, the treatment contrast, and the observations being made in the designed clinical trial will govern the form of the analysis and the nature of the interpretations. Each goal requires that specific strategies and design considerations be applied to preliminary, pilot, and full trials.

Neurologic prognosis after cardiopulmonary arrest: II. Level of consciousness.

Sixty-three patients with isolated global anoxic-ischemic injury were prospectively evaluated after cardiopulmonary arrest (CPA); 25 (40%) survived, 16 to an excellent recovery, 8 to a good recovery, and 1 with severe deficits. Forty-six percent of the patients achieved full alertness, and only patients who did so survived. Seventy-five percent of patients arousable or initially alert (level of consciousness [LOC] greater than or equal to 4) survived, all but two with excellent outcomes. Twenty-eight percent of patients initially in deep coma (LOC less than or equal to 3) survived, all with excellent or good outcomes. Ninety percent of patients who became fully alert did so within 72 hours. The likelihood of alerting is correlated with the LOC at given intervals after CPA. Reliable predictions of survival and outcome can often be based upon LOC alone within 2 days after CPA.

Neurologic prognosis after cardiopulmonary arrest: III. Seizure activity.

Nineteen (30%) of 63 adult survivors of cardiopulmonary arrest had seizures after admission to the hospital. Eleven of 19 had more than one type of seizure. Myoclonic seizures began within 12 hours of the arrest in eight patients, and after 3 or more days in four patients. Only two (17%) patients with myoclonic seizures survived. Partial seizures usually began within 12 hours of the arrest and were controllable with anticonvulsants; 4 of 12 patients survived. Two of four patients with generalized tonic-clonic seizures survived; one of four with "shivering" lived. Overall, patients with seizures had a survival rate of 32% (6 of 19), compared with 43% for patients without seizures. None of the survivors had recurrent seizures within 6 months after hospital admission.

Piped water supply and intestinal parasitism in Zimbabwean schoolchildren.

The prevalence of intestinal parasitism in primary schoolchildren in three areas, communal (peasant farm) lands, commercial farms and urban townships, was assessed by examination of concentrated and stained stool specimens to determine the effect of water supply on intestinal parasitism. Piped water in communal lands was associated with decreased frequency of schistosomiasis and hymenolepiasis, but not with decreased frequency of protozoa. Schistosomiasis was very common in commercial farm labour communities, particularly on farms adjoining the local river, despite the availability of stored borehole water supplied through communal taps. The prevalence of intestinal parasitism in children from urban areas with municipal water supplied to taps in each household was similar to that of children in communal areas who obtained water from surface streams. The frequency of Giardia lamblia infection was higher in urban than in rural schoolchildren, and within communal areas was higher in children with access to protected borehole water. The provision of piped water was, therefore, not found to be associated with reduced prevalence of intestinal parasitism, though additional factors such as frequency of contact with infected water, the provision of ancillary improvements and the actual usage of available water supplies would need to be more closely assessed.

Home-based oral rehydration therapy in rural Zimbabwe.

A study was carried out in four rural areas of Zimbabwe to assess the acceptability, feasibility and accuracy of sugar-salt solutions and to investigate the action taken during a recalled episode of diarrhoea in a child. Only 5% of respondents gave the child a sugar-salt solution at home during the described illness yet a majority (52%) claimed knowledge of oral rehydration techniques. A great variety of recipes were described; 46% of respondents knew a recipe for a solution containing sugar and salt and 12% were able to describe the standard recipe for sugar-salt solutions. Those who knew a recipe for a sugar-salt solution were asked to prepare a sample for chemical analysis; of those who prepared a sample, 26% prepared a solution having both sucrose and sodium concentrations within the safe and effective ranges. Surprisingly therefore, 12% (26% X 46%) of rural adults were able to prepare a safe and effective oral rehydration solution, despite the fact that there is as yet no concerted programme for the promotion of home-based oral rehydration therapy in Zimbabwe. The standard method of preparation was taught to all respondents who had no previous knowledge of sugar-salt solutions. Recall of the standard method was good; after a period of 11 to 26 days 64% of respondents remembered the correct recipe and 84% prepared a solution having both sucrose and sodium concentrations in the safe and effective ranges. 92% of all households had a teaspoon, sugar and salt and 88% had all the required items: a 750 ml bottle, a teaspoon, sugar and salt. It is concluded that home-based oral rehydration therapy using sugar-salt solutions is an acceptable and feasible strategy for the early management of acute diarrhoea in rural Zimbabwe.

PIP: The acceptability, feasibility, and accuracy of sugar-salt solutions and household practices related to the management of infantile diarrhea were investigated in 4 diverse rural areas of Zimbabwe. 52% of the 402 study respondents claimed knowledge of oral rehydration treatment and 46% were able to provide a recipe for sugar-salt solution. 12% of those who volunteered recipes were correct about the various measurements (6 teaspoons of sugar and 1/2 teaspoon of salt in a 750 ml bottle of water). All respondents who indicated knowledge of an oral rehydration solution were asked to demonstrate its preparation; chemical analysis revealed that 26% prepared a solution having sucrose and sodium concentrations within a safe and effective range. Respondents who had no previous knowledge of oral rehydration therapy were instructed in the preparation of the standard sugar-salt solution. At follow-up 11-26 days after this instruction, 64% remembered the correct recipe and 84% prepared an effective solution. 88% of the households included in the survey had all the items required to prepare sugar-salt rehydration solution. Despite the high level of awareness of oral rehydration among respondents, only 5% gave their child such a solution during the most recent episode of diarrhea; 53% took the child to a health facility and 28% administered traditional remedies. Thus, vigorous educational efforts are needed to build on this knowledge base and promote the actual use of sugar-salt solution. To date, there has been no concerted program in rural Zimbabwe for the promotion of home-based oral rehydration therapy.

Factors influencing serum levels of carbamazepine and carbamazepine-10,11-epoxide in children.

Carbamazepine-10,11-epoxide (CBZ-E), the principal metabolite of carbamazepine (CBZ), is reported to have antiepileptic and toxic effects similar to CBZ. Steady-state CBZ and CBZ-E levels (high performance liquid chromatography, HPLC assay) were reviewed in 225 outpatient children and young adults taking CBZ with or without other antiepileptic drugs (AEDs). In patients on CBZ alone, mean serum concentration of CBZ was 7.9 +/- 1.9 micrograms/ml and of CBZ-E was 1.5 +/- 0.6 micrograms/ml. The CBZ-E/CBZ ratio was 19.6 +/- 2.4%. Serum CBZ increased with increasing age and with CBZ dose. CBZ-E increased with increasing CBZ dose but was unaffected by age. The CBZ-E/CBZ ratio progressively declined with age. Co-medication with barbiturates or valproic acid significantly increased CBZ-E. Phenytoin showed a similar trend while ethosuximide caused the least change. Patients on CBZ and two or more other AEDs had highest CBZ-E levels and CBZ-E/CBZ ratio. CBZ and CBZ-E levels are variably affected by age, CBZ dose, and co-medication with other AEDs. When other AEDs are administered, careful monitoring is especially indicated in order to avoid toxicity.

Adverse behavioral response to clonazepam as a function of Verbal IQ-Performance IQ discrepancy.

Eight of 38 consecutive patients who received clonazepam had significant behavioral side effects. In these 8 patients, the mean absolute IQ discordance between Verbal IQ (VIQ) and Performance IQ (PIQ) was 17.5 points. Thirty of 38 patients had no adverse behavioral side effects while receiving clonazepam. In these 30 patients, the mean absolute VIQ-PIQ discrepancy was 6.5 points. Full neuropsychological testing had been performed on all patients. The only test variable showing a statistically significant difference was the absolute discrepancy between VIQ and PIQ (P less than 0.0001).

The impact of home monitoring and daily diary recording on patient status in cystic fibrosis.

An experimental home monitoring system for assessing the progress and planning changes in the care of patients with cystic fibrosis (CF) has been implemented at the University of Minnesota Cystic Fibrosis Center. One group of patients and families did daily recording of physical measurements and symptoms, and sent the diary to the data coordinating center weekly for analysis. The remaining patients were not part of the home monitoring program. Twenty-five patients were randomly selected from the home monitoring group. They were compared to an age- and sex-matched control group not doing home monitoring to ascertain if home self-measurement and daily diary recording, in the absence of any therapeutic intervention, produced any change in physical or psychological status, pulmonary function, or growth over a 4-year study period. Subjects ranged in age from 6 to 43 years. Clinical status was measured by the National Institutes of Health cystic fibrosis scoring system. Pulmonary function was assessed as percent of predicted forced vital capacity and percent of predicted forced expiratory volume in 1 sec (FEV1). Growth was analyzed as percent of predicted weight based on age-, sex-, and height-dependent equations. Psychological status was determined by self-assessment and referral for conseling. Only percent predicted FEV1 in the control group declined significantly. There were no statistically significant changes in any other measures either within or between diary and nondiary groups over the 4-year period.(ABSTRACT TRUNCATED AT 250 WORDS)