Increased physical activity may be more protective for metabolic syndrome than reduced caloric intake. An analysis of estimated energy balance in U.S. adults: 2007-2010 NHANES.

BACKGROUND AND AIM: The purpose of this study was to examine the association between physical activity (PA), caloric intake, and Metabolic Syndrome (MetS) in a representative sample of the United States population. METHODS AND RESULTS: Data for 4327 adults from 2007 to 2010 NHANES were analyzed. MetS was defined using both ATPIII and AHA/NHLBI criteria. Weekly moderate and vigorous physical activity (PA) minutes from work, leisure-time, and transportation PA were used to estimate Total Energy Expenditure (TEE) from Basal Metabolic Rate (BMR) using the Harris-Benedict equation. Average total calories (KCAL) from two 24-h dietary recalls were used to compare energy intake and expenditure between subjects with and without MetS. An alpha of 0.05 was used to determine statistical differences. The age adjusted prevalence of MetS was 21.9% (95% CI 20.1-23.6) and 36.8% (34.7-39.0) using ATPIII and AHA/NHLBI criteria, respectively. The estimated population mean for KCAL/TEE was 0.83 (95% CI 0.82-0.84), and the mean for KCAL/BMR was 1.25 (95% CI 1.23-1.27). Subjects without MetS (MetS-) reported 36 ± 13 (ATPIII) and 45 ± 18 (AHA/NHLBI) more daily moderate PA minutes than subjects with MetS (MetS+). At each level of PA, MetS- consumed more calories relative to BMR and TEE than MetS+. For both normal and overweight adults, KCAL/BMR was higher for MetS- than MetS+. For all BMI groups, there were no differences between MetS- and MetS+ with respect to KCAL/TEE. Though MetS+ adults in either MetS criteria were generally less physically active, MetS- adults maintained a higher caloric intake relative to estimated energy needs. CONCLUSIONS: These results suggest energy needs may be distorted in Metabolic Syndrome and increased physical activity may be more protective than reduced caloric intake.

Multimechanistic (sumatriptan-naproxen) early intervention for the acute treatment of migraine.

BACKGROUND: Research suggests treating a migraine at the first sign of pain increases the likelihood of the best clinical outcome. OBJECTIVE: To investigate the efficacy and tolerability of a fixed-dose, single-tablet formulation of sumatriptan 85 mg, formulated with RT Technology, and naproxen sodium 500 mg (sumatriptan/naproxen) as early intervention acute therapy for migraine. METHODS: Patients (aged 18 to 65 years) with International Headache Society-defined migraine with or without aura were enrolled in one of two identically designed, randomized, double-blind, parallel group, placebo-controlled studies. Patients treated a single migraine within 1 hour of onset of migraine head pain and while the pain was mild with either sumatriptan/naproxen or placebo. The primary efficacy measure was the percentage of patients who became pain-free 2 hours postdose. RESULTS: Intent-to-treat analyses consisted of 576 and 535 migraineurs. At 2 hours, 52% and 51% of sumatriptan/naproxen-treated patients were pain free, as compared to 17% and 15% of placebo-treated patients (p < 0.001). Significant pain-free responses in favor of sumatriptan/naproxen were demonstrated as early as 30 minutes, maintained at 1 hour, and sustained from 2 to 24 hours. At 2 and 4 hours, sumatriptan/naproxen provided significantly lower rates of traditional migraine-associated symptoms (nausea, photophobia, and phonophobia) and nontraditional migraine-associated symptoms (neck pain/discomfort and sinus pain/pressure). The most commonly reported adverse events were nausea (< or =4%) and dizziness (< or =2%). CONCLUSION: The fixed-dose single-tablet formulation of sumatriptan/naproxen was effective and well tolerated in an early intervention paradigm for the acute treatment of migraine, including traditional and nontraditional symptoms.

Baseline differences between vascular cognitive impairment no dementia reverters and non-reverters.

BACKGROUND: The underlying factors of reversion from cognitive impairment to normal cognitive functioning in stroke are not well understood. We compare demographic, cognitive and imaging factors in Vascular Cognitive Impairment, No Dementia (Vascular CIND) patients who revert to normal cognitive functioning to Vascular CIND patients who do not revert. METHODS: Thirty-one ischaemic stroke patients, who met classification criteria for Vascular CIND, were >49.5 years old, met NINDS stroke criteria, and were free from additional neurological illness, completed baseline and 1-year examinations. Forty-five per cent of the Vascular CIND participants reverted to no cognitive impairment at 1-year follow-up examination. RESULTS: There was greater cognitive impairment in non-reverters on a summary score spanning several neuropsychological domains and on psychomotor and working memory summary scores. There were no differences on demographic factors or in stroke severity between reverters and non-reverters. Structural MRI analyses revealed no baseline differences in number of strokes, stroke volume or stroke location. However, there was greater frontal white matter hyperintensity load in the non-reverter group. CONCLUSIONS: These results suggest that Vascular CIND reversion may be a function of a combination of baseline neuropsychological function and location of cerebrovascular disease.

Modelling the circle of Willis to assess the effects of anatomical variations and occlusions on cerebral flows.

Blood flow in the circle of Willis (CoW) is modelled using the 1-D equations of pressure and flow wave propagation in compliant vessels. The model starts at the left ventricle and includes the largest arteries that supply the CoW. Based on published physiological data, it is able to capture the main features of pulse wave propagation along the aorta, at the brachiocephalic bifurcation and throughout the cerebral arteries. The collateral ability of the complete CoW and its most frequent anatomical variations is studied in normal conditions and after occlusion of a carotid or vertebral artery (VA). Our results suggest that the system does not require collateral pathways through the communicating arteries to adequately perfuse the brain of normal subjects. The communicating arteries become important in cases of missing or occluded vessels, the anterior communicating artery (ACoA) being a more critical collateral pathway than the posterior communicating arteries (PCoAs) if an internal carotid artery (ICA) is occluded. Occlusions of the VAs proved to be far less critical than occlusions of the ICAs. The worst scenario in terms of reduction in the mean cerebral outflows is a CoW without the first segment of an anterior cerebral artery combined with an occlusion of the contralateral ICA. Furthermore, in patients without any severe occlusion of a carotid or VA, the direction of flow measured at the communicating arteries corresponds to the side of the CoW with an absent or occluded artery. Finally, we study the effect of partial occlusions of the communicating arteries on the cerebral flows, which again confirms that the ACoA is a more important collateral pathway than the PCoAs if an ICA is occluded.

Low volume bowel preparation for colonoscopy: randomized, endoscopist-blinded trial of liquid sodium phosphate versus tablet sodium phosphate.

OBJECTIVE: The aim of this study was to compare the colon-cleansing effectiveness, ease of consumption, and side effect profiles of two commercially available preparations of sodium phosphate: liquid Fleet Phospho-soda and Visicol tablets. METHODS: Outpatients undergoing elective colonoscopy were sequentially randomized to one of two preparation groups: liquid: 45 ml at 7:00 PM, 45 ml 3 h before colonoscopy; or tablet: 20 tablets at 7:00 PM, 20 tablets 3-5 h before colonoscopy. Subjects rated preparation tolerability on a 5-point Likert scale. A Residual Stool Score was calculated for each subject based on the amount of stool, consistency of residual stool, and percent of bowel visualized (range 0-11, 0 = best). The endoscopists were blinded to the preparation used. RESULTS: A total of 101 subjects were enrolled (43 male, 58 female, mean age 58.2 yr). The groups were similar in age and indications for colonoscopy. Overall, bowel cleansing was rated "Excellent" or "Good" in 92% of liquid preparation subjects, compared with 74% of tablet preparation subjects (p = 0.03). Subjects in the liquid group demonstrated significantly less residual stool than did tablet subjects (Residual Stool Scores: liquid 1.3 +/- 1.2 vs tablet 1.9 +/- 1.5, p < 0.05). Subjects rated the liquid preparation easier to swallow (p < 0.005) and more convenient to take (p < 0.005) than tablets. Among liquid subjects, 45 of 50 reported a willingness to take their preparation for future colonoscopies, compared with 36 of 49 who took tablet sodium phosphate (p < 0.04). CONCLUSIONS: Liquid sodium phosphate is better tolerated and more effective at colon cleansing when compared with sodium phosphate in tablet form.

Diode laser transscleral cyclophotocoagulation as a primary surgical treatment for primary open-angle glaucoma.

OBJECTIVES: To evaluate the feasibility of diode laser transscleral cyclophotocoagulation (TSCPC) as a primary surgical treatment for primary open-angle glaucoma and to compare 2 laser energy settings used for treatment. METHODS: In a prospective clinical trial in Cape Coast and Accra, Ghana, 1 eye of each of 92 patients with primary open-angle glaucoma was treated by diode laser TSCPC as a primary surgical treatment. Eyes were randomly assigned to receive treatment by 20 applications of either 1.5 W applied for 1.5 seconds or 1.25 W applied for 2.5 seconds. RESULTS: Seventy-nine (86%) of 92 patients completed 3 months of follow-up; follow-up was 13.2 +/- 6.0 months (mean +/- SD). Intraocular pressure decreased in 53 (67%) of the 79 eyes. The drop in intraocular pressure was 20% or more in 37 eyes (47%) and final intraocular pressure was 22 mm Hg or less in 38 eyes (48%). An atonic pupil was a previously unreported complication that arose in 27 (28%) of 92 eyes. There were no serious complications of hypotony, phthisis bulbi, or sympathetic ophthalmia. Visual acuity decreased in 18 (23%) of 79 eyes treated by TSCPC and in 10 (23%) of 47 fellow eyes treated only with glaucoma medications. There was no difference in outcomes between the 2 laser energy settings. CONCLUSIONS: Diode laser TSCPC is a practical, rapid, well-tolerated procedure that may provide a modest and variable lowering of intraocular pressure. The treatment, used with conservative energy levels applied to the eye, seems to have few serious complications, although a previously unrecognized complication of atonic pupil needs further evaluation. A moderate variation in laser energy settings does not influence the results of treatment.

Excellence in school nursing workshop: Florida's experience in standardizing school nursing orientation and education.

Specialty preparation is needed for safe, effective school nursing practice. The Excellence in School Nursing workshop was envisioned as a means to provide a statewide orientation and education program for school nurses in Florida. As a result of a needs assessment, the Florida Departments of Health and Education formed a curriculum development committee to address the educational needs of school nurses. A 3.5-day workshop was designed for school health nursing supervisors and school nurses employed by county health departments, school districts, and community agencies. The workshop was piloted and, based on evaluations and feedback, was revised and replicated nine times throughout the state. The workshop has proved to be an effective method of providing statewide orientation and education for school nurses. The purpose of this article is to describe the workshop curriculum, planning, implementation, and evaluation. Recommendations for adaptation and replication in other states are included.

Postmeningitic ossification in pediatric cochlear implantation.

OBJECTIVE: The goals of this study were to retrospectively review high-resolution CTs (HRCTs) of pediatric postmeningitic cochlear implant recipients and to correlate results with surgical findings. METHODS: HRCTs of 20 children (11 months to 12 years old) who underwent implantation with multichannel devices were reviewed. Results were correlated with the degree of ossification observed at surgery. RESULTS: Ninety percent of subjects required drilling of ossified bone within the basal turn at surgery. HRCT of the cochleas suggested ossification within the basal turn in 45% (50% sensitivity). Ossification of the lateral semicircular canal on HRCT was present in 72% (77% sensitivity). Five of 6 cases without radiographic evidence of ossification had positive findings at surgery. CONCLUSION: Ossification is a common occurrence in postmeningitic deaf children. Ossification of the lateral semicircular canal on HRCT is a more sensitive measure for predicting ossification than evidence of cochlear involvement. Absence of ossification on HRCT is no guarantee of cochlear patency at the time of implantation.

Short TE proton MRS and neurofibromatosis type 1 intracranial lesions.

PURPOSE: The intracranial lesions of neurofibromatosis type 1(NF-1) have variable pathology and growth based on molecular genetics. Because of this variable pathology and growth, the lesions are followed by sequential MRI. Our hypothesis was that MR spectroscopy (MRS) could provide a noninvasive neurochemical biopsy of NF-1 lesions, thereby distinguishing the different lesions, monitoring their variable growth, and having added value when compared with MRI. METHOD: Nineteen patients fulfilling the National Institutes of Health criteria for NF-1 were followed with sequential MRI and short TE proton MRS. MRI monitored the lesions by observing the area of prolonged T2, mass effect, and degree of enhancement. MRS monitored the lesions by following the level of neurons, cellularity, and a by-product of the inositol signaling pathway. A comparison was made between the MRI and MRS findings to determine if MRS provided added value. Sixty-nine spectra were obtained in 24 resions. RESULTS: MRI was able to identify hamartomas, gliomas, and indeterminate lesions. MRS was able to distinguish three distinct spectra when compared with the cellularity of normal deep white matter (DWM): a hamartoma spectrum with a choline/creatine (CHO/CRE) ratio below 1.5, a transitional spectrum with a CHO/CRE ratio above 1.5 and below 2.0, and a glioma spectrum with a CHO/CRE ratio above 2.0. On comparing MRS and MRI, MRS provided added value by identifying changes in cellularity while MR images were stable, identifying spectra that could distinguish hamartomas from gliomas, and identifying a transitional spectrum that could progress or regress into glioma or hamartoma spectrum. CONCLUSION: MRS was able to identify three distinct spectra in NF-1 lesions when compared with the cellularity of normal DWM, thereby providing a neurochemical means to characterize lesions.

Clinical impact of MR spectroscopy when MR imaging is indeterminate for pediatric brain tumors.

OBJECTIVE: We undertook this study to determine if single-voxel proton (hydrogen) MR spectroscopy could have clinical impact on the management of pediatric brain tumors when MR findings were indeterminate. SUBJECTS AND METHODS: Eleven children (mean age, 9 years) being examined for brain tumors underwent MR imaging that revealed indeterminate criteria of enhancement, mass effect, and prolonged T1 and T2 signal. MR spectroscopy was then used to distinguish radiation necrosis from tumor in one patient, differentiate residual tumor from scarring in two patients, document early treatment response in three patients, and discriminate benign from malignant masses in five patients. RESULTS: In 10 of the 11 patients, spectra were successfully acquired. Based on the chemical analysis of the indeterminate area shown on MR imaging, clinical impact was achieved in these 10 patients. Clinical impact included treatment modification in five patients, follow-up studies replacing further treatment in three patients, and tumor characterization in the remaining two patients. Confirmation was by histology in four patients and by follow-up MR imaging and MR spectroscopy for up to 30 months in the remaining six patients. CONCLUSION: When MR imaging is indeterminate in evaluating pediatric brain tumors, MR spectroscopy can provide objective neurochemical information, thereby altering treatment.

Vascular surgical society of great britain and ireland: transcranial doppler ultrasonography as a predictor of haemodynamically significant carotid stenosis

BACKGROUND: Transcranial Doppler (TCD) ultrasonography can detect evidence of collateral flow across the anterior communicating artery and/or the posterior communicating artery, which occurs when there is significant alteration of 'inflow' to the brain. The aim of the study was to determine the blood flow velocity produced by a carotid stenosis which produces this haemodynamic effect on the cerebral circulation and evokes collateral circulation. METHODS: Forty-eight patients with varying degrees of carotid stenosis (10 per cent to occlusion) who underwent both carotid duplex and TCD examination were reviewed. An ATL HDI 3000 ultrasound system was used for the carotid and TCD studies. The carotid examination recorded peak-systolic velocity (PSV) and end-diastolic velocity (EDV) in the carotid systems bilaterally. TCD recorded Doppler spectra from the bilateral middle cerebral, anterior cerebral, posterior cerebral, intracranial vertebral and basilar arteries. Collateral flow was assessed in two ways: 'intracranial crossover' collateral and 'posterior to anterior' collateral. Each internal carotid artery (ICA), together with the ipsilateral hemisphere, was analysed for the presence or absence of collateral flow. Data were expressed as mean(s.e.m.). RESULTS: The PSV of the group with collateral circulation was 472(14) cm s-1 and that of the group without collateral flow was 164(3) cm s-1 (P < 0.0001, Mann-Whitney test). The respective EDVs were 158(13) and 58(7) cm s-1 (P < 0.0001). CONCLUSION: PSVs and EDVs in the ICA, in conjunction with collateral flow measured by TCD, are indicators of a haemodynamically significant carotid lesion, and provide more information than two-dimensional imaging studies. In the future, parameters set by combining carotid duplex and TCD investigations may represent the 'gold standard' for evaluation of cerebral blood flow.

Transcranial Doppler imaging in pediatric abnormalities in older children.

Transcranial Doppler (TCD) is a noninvasive diagnostic ultrasound study which uses a 2 megahertz pulsed Doppler transducer to measure the velocity and pulsatility of blood flow within the major intracranial arteries. It has proved to be extremely useful as a screening test or to help confirm the diagnosis of several clinical conditions in infants and children. Some of the proved indications for TCD is for evaluating cerebrovascular occlusive disease especially in screening children with sickle cell disease, hydrocephalus, asphyxia and cerebral edema, confirming brain death, arteriovenous malformations, and vasoplasm. TCD technique, indications, and common pathological findings are emphasized.

Medical control of intraocular pressure after cataract surgery.

PURPOSE: To compare the effectiveness of 2 medications commonly used to prevent intraocular pressure (IOP) elevation in the early period after cataract surgery. SETTING: Palo Alto Veterans Affairs Health Care System, Palo Alto, California, USA. METHODS: This prospective study comprised 202 eyes of patients scheduled for cataract extraction who agreed to participate. Patients were randomized to receive oral acetazolamide, 500 mg 1 hour preoperatively; oral acetazolamide, 500 mg immediately postoperatively; apraclonidine hydrochloride 1%, 2 drops 1 hour preoperatively; or artificial tears (control group). Intraocular pressure was measured preoperatively and 4 to 6 and 24 hours postoperatively. RESULTS: Preoperative IOP was not significantly different among the 4 groups. At 4 to 6 hours postoperatively, only preoperative acetazolamide was significantly more effective than the control medication (P = .038); at 24 hours there were no significant differences among the 4 groups. Postoperative IOP elevation in excess of 35 mm Hg at 6 or 24 hours decreased significantly in the preoperative acetazolamide group (3/46 eyes) compared with the control group (14/54 eyes). There was no statistically significant difference in IOP elevation between eyes having extracapsular cataract extraction and those having phacoemulsification, independent of treatment group. CONCLUSION: The results favor preoperative acetazolamide to control postcataract IOP elevation. The method of cataract removal did not affect postoperative IOP elevation.

The prevalence of cerebral infarcts in the Asymptomatic Carotid Surgery Trial (ACST) in relation to prior contralateral symptoms.

BACKGROUND: The ACST has randomised over 1670 patients to determine if carotid endarterectomy (CEA) prolongs stroke free survival versus best medical treatment alone. Some patients have had contralateral symptoms to the side under investigation, for which CEA may have been performed. This study aims to determine the prevalence of hemispheric cerebral infarcts in relation to prior contralateral symptoms. METHODS: Patients with preoperative CT or MR scans were divided into those with prior contralateral stroke, cortical TIA, amaurosis fugax or no symptoms. RESULTS: There were 1144 patients with preoperative CT and 170 patients with MR scans. Incidence of contralateral hemispheric CT and MR infarcts were 19% (222/1144) and 20% (34/170) respectively. Those with prior contralateral stroke (141) had the highest incidence of hemispheric CT infarcts (62%). Those with TIA (129) had a 30% incidence of CT infarct. Incidence of hemispheric CT infarcts were 17% with amaurosis fugax (46) and 10% with no prior symptoms (803). Mantel-Haenszel test for linear association was significant (p < 0.001) for increasing severity of symptoms. Considering MR scans, those with prior contralateral stroke (17) had the highest incidence of hemispheric MR infarcts (53%). Patients with TIA (23) or amaurosis fugax (6) had a 27% incidence of MR infarction. Those with no prior symptoms (121) had a 14% incidence of MR infarcts. Mantel-Haenszel test was significant (p < 0.001). CONCLUSIONS: In the ACST, currently asymptomatic patients have an incidence of contralateral hemispheric CT and MR infarcts proportional to the severity of prior contralateral symptoms.

Prevalence of asymptomatic CT infarcts in the ongoing Asymptomatic Carotid Surgery Trial (ACST).

BACKGROUND: The ACST has randomised over 1670 patients to determine if carotid endarterectomy (CEA) prolongs stroke free survival when compared with best medical treatment alone. This study aims to assess the prevalence of asymptomatic cerebral infarcts in patients grouped by sex, age, mean blood pressure (MBP), total cholesterol, diabetes and coronary artery disease (CAD). METHODS: The type of study was retrospective. Patients with preoperative CT scans were included. In those with previous stroke, only the contralateral cerebral hemisphere was studied for presence of infarcts. One thousand one hundred and forty-two patients were studied. RESULTS: The proportion of patients with CT infarcts was 19% (211/1142). Men (155/777) had a higher incidence of CT infarction (20% vs 15%, p = 0.01). Mean age was 68 years and mean MBP was 107 mmHg. The incidence of CT infarcts was not associated with age or MBP. Diabetics or those with definite CAD had no difference in the incidence of cerebral infarction. Diabetics with definite CAD (51/796) had a greater incidence of CT infarcts (33% vs 21%, p = 0.03) compared with those without evidence of CAD and diabetes together (745/796). CONCLUSIONS: In ACST, CT infarcts are more prevalent in men compared to women, and in diabetics with CAD. There was no difference in the incidence of CT infarction by age, mean BP, or by the presence of diabetes or CAD alone.

Late postirradiation occlusive vasculopathy in childhood medulloblastoma. Report of two cases.

The authors report two cases of ischemic stroke secondary to occlusive vasculopathy two decades after radiation therapy (RT) for medulloblastoma. Both patients underwent posterior fossa medulloblastoma partial resection, followed by craniospinal RT in which a cobalt 60 source was used; 40 Gy were given to the whole brain plus a 15-Gy boost to the posterior fossa. Both patients received multiagent chemotherapy, immediately following radiation therapy in the first case and after repeated craniotomy for recurrence 13 years after radiation in the second case. They experienced multiple sequelae from radiation and chemotherapy, including growth retardation and psychomotor delay. However, 20 years after treatment, they remained tumor free and able to work, until they presented with focal neurological deficits and seizures. Computerized tomography and magnetic resonance imaging of the brain in both cases showed no tumor recurrence, but did demonstrate ischemia in a posterior cerebral artery distribution. Cerebral angiography revealed multiple mid-sized arterial wall irregularities as well as focal stenoses consistent with a postirradiation vasculopathy. The pathophysiological mechanisms, radiological appearance, and incidence of this syndrome are reviewed from the literature.

Risk of hypotony after primary trabeculectomy with antifibrotic agents in a black west African population.

PURPOSE: To evaluate the risk of hypotony and hypotony maculopathy following trabeculectomy with 5-fluorouracil (5-FU) and mitomycin C (MMC) in a black West African population. METHODS: One hundred and one eyes of black Ghanaian patients with advanced primary open-angle glaucoma received intraoperative antifibrotic therapy with trabeculectomy as part of two randomized clinical trials. Overall, 57 patients received 5-FU (50.0 mg/ml for 5 minutes) and 44 received MMC (0.5 mg/ml for 3.5 minutes). All cases were performed by one of five surgeons at a single outpatient surgery center. RESULTS: Two of 101 eyes had a final intraocular pressure (IOP) of less than 5 mm Hg and were thus classified as having hypotony. No patient in either group was noted to develop hypotony-related maculopathy. Overall mean pre- and postoperative IOPs were 30.1 and 15.9 mm Hg, respectively. The patients receiving intraoperative MMC had a lower mean postoperative IOP (14.7 mm Hg) than those receiving 5-FU (first study, 17.1 mm Hg; second study, 16.7 mm Hg; p = 0.05). Mean overall follow-up was 17.7 months and did not differ significantly between the MMC and combined 5-FU groups. CONCLUSION: Hypotony following trabeculectomy supplemented with antifibrotic agents is a rare complication in this population. No eyes in either clinical trial developed hypotony maculopathy, suggesting that the prevalence of this condition is substantially lower in black West Africans than in whites.