Association of dementia in patients with benign paroxysmal positional vertigo.

OBJECTIVE: We conducted a cohort study to investigate whether benign paroxysmal positional vertigo (BPPV) is correlated with an increased risk of dementia. METHODS: We established a case cohort comprising 7818 patients aged over 20 years who were diagnosed with BPPV from 2000 to 2010. In addition, we formed a control cohort by randomly selecting 31,272 people without BPPV and matched them with the BPPV patients according to gender, age, and index year. Cox proportional hazard regressions were performed to compute the hazard ratio (HR) of dementia after we adjusted for demographic characteristics and comorbidity. RESULTS: The prevalence of comorbidity was higher among patients with BPPV than among those without BPPV. In addition, patients with BPPV exhibited a 1.24-fold (95% confidence interval, CI 1.09-1.40; P < 0.001) higher risk of dementia than those without BPPV after we adjusted for age, gender, and comorbidity. An analysis stratified according to demographic factors revealed that women with BPPV exhibited a 1.36-fold (95% CI 1.16-1.59; P < 0.001) higher risk of dementia. Patients with BPPV aged over 65 years exhibited a significantly higher risk of dementia (adjusted HR: 1.26; 95% CI 1.10-1.43; P < 0.001) than those without BPPV. CONCLUSIONS: Patients with BPPV exhibited a higher risk of dementia than those without BPPV.

Bacteremia caused by Brevundimonas species at a tertiary care hospital in Taiwan, 2000-2010.

We investigated clinical and microbiological characteristics of 30 patients with Brevundimonas bacteremia treated at a tertiary care hospital in Taiwan during 2000-2010. All the 30 bacteria isolates were confirmed to the species level by 16S rRNA sequencing analysis. Minimum inhibitory concentrations (MICs) of 11 antimicrobial agents against these isolates were determined by the agar dilution method. Seventeen (57%) patients had underlying malignancy, 12 (40%) had undergone central catheter placement, and 13 (43%) had received chemotherapy within the previous three months. Eight (27%) patients had community-acquired bacteremia and the remaining 22 patients (73%) had healthcare-associated bacteremia. The overall 14-day and 30-day mortality rates were 13% and 17%, respectively. Among the 30 isolates, B. vesicularis constituted most commonly (n = 22, 63%), followed by B. nasdae (n = 5) and B. diminuta (n = 3). All isolates were susceptible to piperacillin-tazobactam and amikacin, while all were resistant to ciprofloxacin and colistin. Tigecycline (MICs at which 90% of isolates are inhibited [MIC(90)] was 0.12 mg/L) and doripenem (MIC(90) of 1 mg/L) both possessed good in vitro activities. In conclusions, Brevundimonas should be considered a pathogen that can cause bacteremia in immunocompromised hosts. Piperacillin-tazobactam, amikacin, doripenem, and tigecycline exhibit good in vitro activities against these ciprofloxacin- and colistin-resistant Brevundimonas species.

Positive culture for Klebsiella pneumoniae in relevant sputum samples as a predictor of rapidly fatal outcome in septic patients at medical intensive care units.

Sixty-five patients with main diagnosis of sepsis, who were directly admitted to the emergency department (ED) and had fatal outcomes after transfer to the medical intensive care units (MICU), were included. Patients who died within 48 hours of MICU transfer were defined as having rapidly fatal outcomes (RFO). The following clinical variables, including diagnosis of infection source; results of blood, sputum, and urine cultures; management for sepsis in the ED and MICU and survival time, were analyzed. There were 30 (46%) patients with RFO. The median survival time in the RFO group was 22.6 hours in MICU. Klebsiella pneumoniae was the most common pathogen isolated from blood (7/65, 10.7%) and relevant sputum samples (7/45, 15.5% ). Multivariate analysis revealed that age, gender and positive sputum culture for K. pneumoniae (hazard ratio, 11.898, p < 0.001) were independently associated with RFO in septic patients. The median survival times for patients with positive and negative K. pneumoniae sputum culture were 17 hours and 66.8 hours (p < 0.001, by the log rank test), respectively. This study found that positive sputum culture of K. pneumoniae was an important independent predictive factor of RFO in septic patients admitted to the MICU.

NAT2 and CYP2E1 polymorphisms and susceptibility to first-line anti-tuberculosis drug-induced hepatitis.

BACKGROUND: Most cases with anti-tuberculosis drug-induced hepatotoxicity (ATDH) have been attributed to isoniazid. OBJECTIVE: To evaluate whether the polymorphisms of the cytochrome P450 2EI (CYP2E1) and N-acetyltransferase 2 (NAT2) gene are associated with ATDH. DESIGN: A total of 140 tuberculosis (TB) patients without liver diseases before treatment who received anti-tuberculosis treatment were followed prospectively. Their CYP2E1 and NAT2 genotypes were determined using the TaqMan polymerase chain reaction assay. RESULTS: Forty-five (32.1%) patients were diagnosed with ATDH. No significant differences were reported in age and sex between patients with and without ATDH. Slow acetylators defined by NAT2 genotypes had a higher risk of hepatotoxicity than rapid acetylators (51.2% vs. 25.2%, P = 0.0026). Odds ratio (OR) analysis showed that slow acetylator status (OR 3.15, 95%CI 1.47-6.48) was the only independent risk factor for ATDH. Pyrazinamide co-administration induced hepatitis was also associated with NAT2 acetylator status. CYP2E1 c1/c1 homozygotes are prone to developing more severe hepatotoxicity than other c1/c2 and c2/c2 genotypes. CONCLUSION: The slow acetylator status of NAT2 is a significant susceptibility risk factor for ATDH. CYP2E1 is associated with the severity of ATDH.

Insulin sensitivity and resistin expression in nitric oxide-deficient rats.

AIMS/HYPOTHESIS: The aim of this study was to investigate changes in insulin sensitivity and expression of the gene encoding resistin (Retn) in adipocytes from long-term nitric oxide (NO)-deficient rats. METHODS: Male Sprague-Dawley rats received [Formula: see text]-nitro-L: -arginine methyl ester (L-NAME 0.5 mg/ml) in their drinking water for 4 weeks, while control rats received plain drinking water. During the experimental period, changes in plasma glucose, insulin and C-peptide levels were measured. After administration of L-NAME for 4 weeks, insulin sensitivity was evaluated in vivo and in vitro. An insulin binding assay was also performed to determine the number and binding affinity of insulin receptors in adipocytes. Adipocyte Retn mRNA levels were examined using northern blotting. RESULTS: Successful induction of NO deficiency was demonstrated by an increase in systemic blood pressure. No difference in plasma glucose levels was found between the two groups. Compared with the control rats, plasma insulin and C-peptide levels were significantly decreased in the NO-deficient rats, and insulin sensitivity was significantly increased. Insulin-stimulated glucose uptake and insulin binding capacity, but not binding affinity, were significantly increased in adipocytes isolated from NO-deficient rats. In addition, adipocyte Retn mRNA levels, but not plasma resistin levels, were significantly decreased in NO-deficient rats, and the Retn mRNA levels were negatively correlated with insulin sensitivity. CONCLUSIONS/INTERPRETATION: Insulin sensitivity was increased in NO-deficient rats and this was associated with insulin binding capacity and downregulated Retn expression. These findings suggest that NO plays a regulatory role in metabolism. Dysregulation of NO production may result in the development of metabolic disorders.

Functional recovery of chronic complete idiopathic transverse myelitis after administration of neurotrophic factors.

STUDY DESIGN: Case report. OBJECTIVE: To evaluate the functional recovery of chronic complete idiopathic transverse myelitis (ITM) after administration of acidic fibroblast growth factor (aFGF). METHODS: A 28-year-old woman presented with a 4-year history of spastic paralysis, sensory level at T10, urinary retention and constipation due to ITM. In all, 20 microg aFGF bolus injection was applied via intradural lumbar puncture, which was repeated every 5 months for 15 months. RESULTS: At 3 weeks after first injection, the patient experienced vague sensation at approximately T12-L1 dermatomes. At 2 months after the second injection, muscle activities and gait pattern were recorded in bilateral gluteus and hip abductors as she ambulated with long leg brace and axillary crutches. Increased walking speeds, reduced pelvic tilting and reduced compensatory trunk rotation during the swing phase were also demonstrated as compared to the initial gait analysis. At 18 months after injection, motor evoked potentials were obtained in hip abductors of both legs. CONCLUSIONS: aFGF may increase the efficacy of spinal reactivation/regeneration and is a potential remedy for chronic transverse myelitis.

Using the Dermatology Index of Disease Severity (DIDS) to assess the responsiveness of dermatitis.

BACKGROUND: The Dermatology Index of Disease Severity (DIDS) is designed as an instrument for staging severity of inflammatory dermatoses. It measures the therapeutic effectiveness and magnitude of clinical improvement in several types of dermatitis, eczema and psoriasis. When used in the Psoriasis Outcomes Study, it was simpler and easier than the Psoriasis Area and Severity Index. The reliability and validity of DIDS have already been established in our previous study. AIM: To test the responsiveness of the DIDS in patients with various types of dermatitis following treatment. METHODS: The DIDS was used to stage patients with dermatitis over time. In total, 142 patients with dermatitis were enrolled into the study. Only 55 patients completed the follow-ups on days 30 or 60, thus the data from these 55 patients only were analysed. The Wilcoxon signed rank test for paired comparisons was used to test for significance of shift in the individual's DIDS staging over the time period. RESULTS: 35 patients were seen on or close to day 30 after the initial visit, of whom 34 patients (76%) had an improvement of at least one stage on DIDS. There were 51 patients seen at or close to day 60, of whom 40 patients (78%) had an improvement of at least one stage on DIDS. The remaining 22-24% of patients did not improve, but neither did they worsen. The joint shift of each individual's DIDS staging from baseline to follow-up was statistically significant (P < 10(-5), two-sided t-test). CONCLUSION: The results of this study support the responsiveness of the DIDS for tracking severity of disease over time in patients with various types of dermatitis.

Decreased incidence of nonmelanoma skin cancer in patients with type 2 diabetes mellitus using insulin: a pilot study.

BACKGROUND: In order to prevent the propagation of genetic mutations, human keratinocytes irradiated with ultraviolet (UV) B light in vitro undergo premature stress-induced senescence or apoptosis. This response to UVB irradiation is dependent on the functional activation of the insulin-like growth factor-1 receptor (IGF-1R). Based on this in vitro functional data, we hypothesized that the increased serum levels of insulin in patients with type 2 diabetes may activate the IGF-1R in skin and lead to a decreased frequency of skin cancer in these patients. OBJECTIVES: To determine whether the use of insulin by patients with type 2 diabetes correlated with a change in the incidence in nonmelanoma skin cancer (NMSC). METHODS: A historical cohort study identifying the incidence of NMSC following the use of two different pharmacological therapies. The patient population was restricted to caucasians who were at least 50 years old when they began the indicated pharmacological therapy. The first group consisted of 1440 patients who used insulin therapy to treat type 2 diabetes and the second group comprised 4135 patients who used cimetidine to treat their gastrointestinal ailments. An additional group of 6131 patients with diabetes who used noninsulin antidiabetics was added to examine the effect of noninsulin therapies. All patients had regular follow-up visits at the Regenstrief Clinics during the study period between 1980 and 1999. The Regenstrief Clinics is an outpatient facility which serves the general population in Metro-Indianapolis, Indiana, U.S.A. RESULTS: The incidence of NMSC in patients using insulin was significantly lower than in patients using cimetidine (1.25% vs. 2.35%, P < 0.02). The decrease in NMSC in patients with type 2 diabetes correlated specifically with the use of insulin (NMSC incidence insulin-only patients with diabetes: 1.40% vs. those with diabetes using noninsulin therapies: 2.35%, P = 0.11). CONCLUSIONS: Patients using exogenous insulin had a lower risk of developing NMSC and the protective effect of insulin use becomes more distinct with increasing age.

Temporal differences in relative phasing of gait initiation and first step length in patients with cervical and lumbosacral spinal cord injuries.

STUDY DESIGN: Comparison group design. OBJECTIVE: To compare the temporal distance factors during gait initiation between patients with incomplete cervical spinal cord injury, incomplete lumbosacral spinal lesion, and unimpaired control adults. SETTING: Human performance and movement analysis laboratory, Taiwan. PARTICIPANTS: Five patients with an incomplete cervical spinal cord injury (Group 1), five patients with an incomplete lumbosacral spinal lesion (Group 2) and nine unimpaired control adults (Group 3). METHODS: Subjects underwent a three-dimensional gait analysis. The total gait initiation period, reaction time, each relative phasing of gait initiation and the length of the first step were identified by using the kinematic measurement system. MAIN OUTCOME MEASURES: The total gait initiation period (start of the auditory cue for gait initiation to heel-strike of the first swing leg); each relative phasing of gait initiation indicated that the duration of the preparatory phase (start of auditory cue for gait initiation to heel-off of the first swing leg), the duration of the push-up phase (heel-off to toe-off of the first swing leg), and the duration of the single-stance phase (toe-off to heel-strike of the first swing leg) established by the total gait initiation period; and the length of the first step. RESULTS: The gait initiation period was greater in Groups 1 and 2 than that of Group 3 (P<0.05). Each relative phasing including the duration of the preparatory phase, the push-up phase, and the swing phase relative to the total gait initiation period, did not differ among Groups 1-3 (P>0.05). The length of the first step, measured while the nonpreferred leg stepped first in Groups 1 and 2, was shorter than that of Group 3 (P<0.05). CONCLUSIONS: Patients with incomplete cervical spinal cord injuries or lumbosacral spinal lesions took more time in gait initiation than unimpaired control adults. The first step length also reduced in these patients while the nonpreferred leg stepped first, as compared to unimpaired control adults. The data indicated that centrally programmed gait initiation might be preserved in ASIA-D spinal patients who, in this study, executed gait initiation with varying temporal distance strategies to compensate for peripheral impairments, as compared to unimpaired control adults.

Lack of an association between granuloma annulare and type 2 diabetes mellitus.

BACKGROUND: Conflicting reports have been published regarding whether a relationship exists between granuloma annulare (GA) and diabetes mellitus (DM). OBJECTIVES: To evaluate the prevalence of DM in patients with GA using a case-control design. METHODS: The incidence of DM was determined in 126 patients with GA. Fifty of the 126 patients with GA were further compared with an age-, sex- and race-matched population of psoriasis patients seen during a similar time period in the same clinical setting. RESULTS: Eleven (9%) of 126 GA patients suffered from type 2 DM. In the matched comparison of 50 patients, 11 (22%) GA patients and 10 (20%) psoriasis patients suffered from type 2 DM. CONCLUSIONS: This case-control study failed to reveal any statistically significant correlation between GA and type 2 DM.

Use of the Dermatology Life Quality Index (DLQI) in a midwestern US urban clinic.

BACKGROUND: The Dermatology Life Quality Index (DLQI), a self-administered general dermatology quality of life instrument, was originally developed and published in a dermatology clinic at University Hospital of Wales. OBJECTIVE: Our goal was to test the feasibility of having patients answer the DLQI in a busy dermatology clinic and to find out to what extent results vary from those published in Wales. We also wanted to examine the validity of the index in terms of the correlation between DLQI scores and stage of illness (disease severity). METHODS: We administered the DLQI to 200 consecutive patients who were seen in a dermatology clinic at Indiana University Medical Center. Results were examined in light of results found by those who originated the DLQI. A pilot group of patients were given the DLQI and rated for severity of disease by means of the Dermatology Index of Disease Severity (DIDS). RESULTS: Overall, the DLQI is easy to administer and can be completed within 3 minutes. The scores in our study were compatible with those previously reported by the DLQI originators. There was a "ceiling" effect in that 11% of the patients indicated no quality of life impairment on the DLQI rating. This index shows stratification with severity of disease. CONCLUSION: The DLQI is an easy and efficient instrument for assessing quality of life in dermatology patients. Patients needed minimal assistance with the form. Our results were similar to those of the DLQI originators, and this further shows reliability and validity of the DLQI. In addition, this study further supports the use of DLQI as a quality of life instrument suitable for use in international studies.

Neurourologic findings in patients with traumatic thoracolumbar vertebra junction lesions.

OBJECTIVE: To investigate neurourologic involvement in injuries to the thoracolumbar vertebra junction with magnetic resonance imaging (MRI) and electrophysiologic and urodynamic measurements and to characterize the neurogenic mechanisms of voiding dysfunctions. DESIGN: Baseline comparisons among 3 anatomic groups before neural repair. SETTING: Tertiary care center. PATIENTS: Thirty-five T11 to L2 spinal cord injury patients consecutively admitted to a rehabilitation unit. Eight patients (Group 1) had above-conus lesions without denervation and polyphasic waves revealed in the anal sphincter electromyography; 13 patients (Group 2) had conal and/or above-conus lesions and anal sphincter electromyographic abnormalities; and 14 patients (Group 3) had below-conus lesions and anal sphincter electromyographic abnormalities. MAIN OUTCOME MEASURES: Comparison of features identified on pudendal nerve terminal motor latency, urethral pressure profiles, and multichannel voiding pressure-flow study. RESULTS: The pudendal nerve terminal motor latency in Group 3, showing a significantly higher abnormal ratio (100%; p =.011, Fisher's exact test), indicated that cauda equina lesions might be the cause. Urodynamic data from Group 3 showed a significant decrease in maximal urethral closure pressure (48 +/- 17cm H2O, p =.0022, analysis of variance [ANOVA], repeated measure) and an increase in bladder capacity (429 +/- 194mL, p =.037, ANOVA, repeated measure). There were no significant changes in the other groups. CONCLUSION: Neurourologic abnormalities are less predictable with injuries to thoracolumbar junction, except in patients with cauda equina lesions.

The specialty of the treating physician affects the likelihood of tumor-free resection margins for basal cell carcinoma: results from a multi-institutional retrospective study.

BACKGROUND: Basal cell carcinoma (BCC) is the most common cutaneous malignancy. Surgical experience and physician specialty may affect the outcome quality of surgical excision of BCC. METHODS: We performed a multicenter retrospective study of BCC excisions submitted to the respective Departments of Pathology at 4 major university medical centers. Our outcome measure was presence of histologic evidence of tumor present in surgical margins of excision specimens (incomplete excision). Clinician experience was defined as the number of excisions that a clinician performed during the study interval. The analytic sample pool included 1459 tumors that met all inclusion and exclusion criteria. Analyses included univariate and multivariate techniques involving the entire sample and separate subsample analyses that excluded 2 outlying dermatologists. RESULTS: Tumor was present at the surgical margins in 243 (16.6%) of 1459 specimens. A patient's sex, age, and tumor size were not significantly related to the presence of tumor in the surgical margin. Physician experience did not demonstrate a significant difference either in the entire sample (P <.09) or in the subsample analysis (P >.30). Tumors of the head and neck were more likely to be incompletely excised than truncal tumors in all the analyses (P <.03). Compared with dermatologists, otolaryngologists (P <.02) and plastic surgeons (P <.008) were more likely to incompletely excise tumors; however, subsample analysis for plastic surgeons found only a trend toward significance (P <.10). Dermatologists and general surgeons did not differ in the likelihood of performing an incomplete excision (P >.4). CONCLUSION: The physician specialty may affect the quality of care in the surgical management of BCC.

The frequency of histologically dysplastic nevi in 199 pediatric patients.

Many uncertainties surround the definition, frequency, and significance of dysplastic nevi in children. Consequently the management of dysplastic nevi in the pediatric population has been largely derived from the studies of adults. Biopsies are usually performed on this young age group because of lesion change or abnormal appearance. One might therefore assume that the frequency of histologically diagnosed dysplastic nevi would be higher in children than in adults. We decided to attempt to verify this assumption by determining the frequency of dysplastic nevi diagnosed histologically in the pediatric population. To do this we reviewed 199 cutaneous pathology reports of nevi removed from patients less than 18 years old and submitted to a community-based dermatopathology laboratory. The diagnosis of dysplastic nevus was made based on histologic criteria recommended by the World Health Organization Melanoma Program. We found that 3 of 199 nevi submitted for histologic analysis met the histologic criteria for dysplastic nevus. There were no melanomas. Our data suggest that there is an extremely low frequency of histologically confirmed dysplastic nevi within the general pediatric population.