Effectiveness and side effects of UVB-phototherapy, dithranol inpatient therapy and a care instruction programme of short contact dithranol in moderate to severe psoriasis.

The efficacy of UVB-phototherapy (UVB) and dithranol treatment for psoriasis is well established. However, well-conducted clinical trials on the efficacy of dithranol are not available, making comparison between these time-honoured treatments with currently available therapies impossible. We studied the effectiveness of dithranol in a care instruction programme using short time exposures (short contact treatment), UVB-phototherapy and dithranol treatment in an inpatient setting. In an open randomised study we included 250 patients with moderate to severe psoriasis. The intention to treat group existed of 238 patients. 100 patients were treated with short contact dithranol, 78 Patients were treated with UVB and 60 patients underwent inpatient dithranol treatment. We found UVB and dithranol treatment to be effective and safe in moderate to severe psoriasis. The efficacy of short contact dithranol treatment equals the efficacy of UVB-phototherapy. Dithranol treatment at the inpatient department showed superior efficacy in clinical response rate and treatment duration as compared to UVB and short contact treatment. The median number of days in remission was significantly longer after short contact treatment as compared to inpatient treatment. Although the use of dithranol is hampered by skin irritation and staining, the present study shows that dithranol treatment has an outstanding efficacy and safety profile. Comparison between different antipsoriatic treatments should, besides clearing capacity, reconcile duration of remission, safety, patient acceptability and costs.

Toll-like receptor-4 Asp299Gly polymorphism does not influence progression of atherosclerosis in patients with familial hypercholesterolaemia.

BACKGROUND: Toll-like receptor-4 (TLR4) is a major receptor for inflammatory stimuli potentially involved in the pathogenesis of atherosclerosis, such as lipopolysaccharide (LPS) and heat-shock proteins. The Asp299Gly polymorphism of the TLR4 gene has been associated with a reduced intima-media thickness (IMT) of the common carotid artery in healthy individuals. We have investigated whether the presence of the Asp299Gly polymorphism in patients with familial hypercholesterolaemia (FH) has a similar protective effect, and whether it influences the effects of HMG-CoA reductase treatment. MATERIALS AND METHODS: A cohort of 293 FH patients and 200 healthy volunteers were genotyped for the presence of the Asp299Gly allele using polymerase chain reaction followed by restriction fragment length polymorphism analysis. Intima-media thickness measurements, inflammatory parameters and the effect of HMG-CoA reductase inhibitors were compared between the patients with and without Asp299Gly allele. RESULTS: The Asp299Gly allele was present in 10.6% of the FH patients and 11.0% of the healthy individuals. Whereas the FH patients carrying the Asp299Gly allele displayed a reduced absolute IMT value compared with the FH patients carrying the wild-type allelle, the difference did not reach statistical significance. In addition, the effect of treatment with HMG-CoA reductase inhibitors was not influenced by the presence of Asp299Gly allele. CONCLUSION: The presence of the Asp299Gly allele of the TLR4 gene does not seem to exert a major influence on the progression of atherosclerosis in patients with FH.

Maternal periconceptional biochemical and hematological parameters, vitamin profiles and pregnancy outcome.

OBJECTIVES: To evaluate periconceptional maternal biochemical and hematological parameters and vitamin profiles in relation to the risk of early pregnancy loss and birth weight. DESIGN: Prospective longitudinal study. SETTING: University Medical Centre Nijmegen, Academic Medical Centre, Amsterdam, Maria and Elisabeth Hospitals, Tilburg, and Catharina Hospital, Eindhoven, The Netherlands. SUBJECTS: A cohort of 240 women recruited before pregnancy. INTERVENTIONS: Blood samples were taken preconceptional and at 6 and 10 weeks amenorrhea in which the concentrations of hemoglobin, hematocrit, creatinin, uric acid, total protein, serum iron, total iron-binding capacity, ferritin, and the concentrations of retinol, tocopherol, thiamine, riboflavin, pyridoxal-5'-phosphate, cobalamin and folate were analyzed. MAIN OUTCOME MEASURES: Risk of early pregnancy loss and birth weight. RESULTS: The risk of early pregnancy loss increased with increasing prepregnancy weight, and when the periconceptional decline in hematocrit, creatinin and uric acid was less profound (slope: P<0.01). Maternal smoking was negatively associated with birth weight (mean reduction of 183 g, P<0.05). Maternal age and prepregnancy weight were positively associated with birth weight (P<0.01). No significant associations were found between vitamin concentrations and risk of early pregnancy loss or birth weight. CONCLUSIONS: Several periconceptional biochemical parameters are significantly associated with early pregnancy loss. The effects of maternal periconceptional health on embryonic development and subsequent pregnancy outcome should be further explored. SPONSORSHIP: Dutch Prevention fund, grants no. 28.1358 and 28.1006.

Clinical significance of reverse redistribution on technetium-99m tetrofosmin single-photon emission computed tomography: an 18-month follow-up study.

BACKGROUND: The clinical and prognostic significance of reverse redistribution on technetium-99m (99mTc) single-photon emission computed tomography (SPECT) is unclear. OBJECTIVES: To determine outcomes of chest pain patients showing reverse redistribution after 99mTc tetrofosmin SPECT versus SPECT showing no reverse redistribution. METHODS: Patient outcomes (death, nonfatal myocardial infarction, coronary artery bypass grafting and percutaneous transluminal coronary angioplasty) within 18 months after 99mTc tetrofosmin SPECT were determined in two populations of ambulatory patients, most of whom had been evaluated because of chest pain: a population of 57 patients whose SPECT images showed reverse redistribution without reversible or fixed defects, versus a control population of 98 patients whose SPECT images were normal (no reverse redistribution, no reversible defects, no fixed defects). RESULTS: Stepwise logistic regression analysis showed that the population of patients with reverse redistribution did not have a worse 18-month outcome in comparison with the control population of patients without reverse redistribution (3.5% versus 9.2%, respectively; p=0.15 corrected for age and gender). CONCLUSION: Reverse redistribution on 99mTc tetrofosmin SPECT does not appear to be an unfavourable prognostic factor in ambulatory chest pain patients.

Homocysteine and folate status in methotrexate-treated patients with rheumatoid arthritis.

OBJECTIVE: To study (i) the influence of methotrexate (MTX) therapy on homocysteine and folate metabolism in patients with rheumatoid arthritis (RA), (ii) the influence of the C677T mutation in the methylenetetrahydrofolate reductase gene (MTHFR) on the change in plasma homocysteine levels during MTX treatment, and (iii) the interference of folate and homocysteine metabolism with the efficacy and toxicity of treatment with MTX. METHODS: The 113 patients enrolled in this study were participating in a 48-week, multicentre, double-blind, placebo-controlled study comparing the efficacy and toxicity of MTX treatment with and without folic or folinic acid supplementation. The MTX dose was 7.5 mg/week initially and increased to a maximum of 25 mg/week if necessary. Concentrations of total folate, 5-methyl tetrahydrofolate (in serum and in erythrocytes) and of homocysteine, cysteine and cysteine-glycine and the MTHFR genotype were determined before the start of the study, after 6 weeks, and after 48 weeks or on withdrawal from the study. Blood was drawn from fasting patients at a standardized time in the morning, 16 h after intake of MTX. The laboratory results were related to parameters of efficacy and toxicity of MTX treatment. RESULTS: Baseline values were distributed equally in the three treatment groups. The mean plasma homocysteine level (normal range 6-15 micromol/l) before the start of MTX was relatively high in all groups: 15.4 micromol/l [95% confidence interval (CI) 13.5 to 17.2] in the MTX plus placebo group (n=39), 14.3 micromol/l (95% CI 12.2 to 16.4) in the MTX plus folic acid group (n=35) and 15.9 micromol/l (95% CI 13.7 to 18.1) in the MTX plus folinic acid group (n=39). After 48 weeks of MTX therapy, the mean homocysteine level showed an increase in the placebo group (+3.6 micromol/l, 95% CI 1.7 to 5.6). In contrast, a decrease was observed in the groups supplemented with folic or folinic acid (folic acid, -2.7 micromol/l, 95% CI -1.4 to -4.0; folinic acid, -1.6 micromol/l, 95% CI -0.1 to -3.0). The differences in the change in plasma homocysteine level between the placebo group and each of the two folate-supplemented groups were statistically significant (P<0.0001), contrary to the difference between the folic and folinic acid groups (P=0.26). Linear regression analysis showed that the change in plasma homocysteine level was statistically significantly associated with folic or folinic acid supplementation (P=0.0001) but not with the presence or absence of the C677T mutation in the MTHFR gene. Homozygous mutants had a higher plasma homocysteine concentration at baseline. No relationship was found between the change in disease activity and the change in homocysteine concentration or the mean homocysteine concentration after 48 weeks of MTX therapy. Toxicity-related discontinuation of MTX treatment was not associated with the change in homocysteine concentration. CONCLUSIONS: Low-dose MTX treatment in RA patients leads to an increased plasma homocysteine level. Concomitant folate supplementation with either folic or folinic acid decreases the plasma homocysteine level and consequently protects against potential cardiovascular risks. No relationship was found between the change in homocysteine concentration and the presence or absence of the C677T mutation in the MTHFR gene. Homocysteine metabolism was not associated with efficacy or toxicity of MTX treatment.

Combining lesional short-contact dithranol therapy of psoriasis with a potent topical corticosteroid.

BACKGROUND: Since its introduction, the effectiveness of dithranol in treating psoriasis has been unequalled by other topical treatments. Out-patient short-contact dithranol treatment is effective with regard to clinical response rate and relapse rate after 1 year. A drawback, however, is the relatively long treatment duration. OBJECTIVES: To study a dithranol regimen combined with a potent topical corticosteroid with regard to clinical response rate, treatment duration and remission period after clearance. METHODS: Twelve patients with stable psoriasis vulgaris participated in this study. We treated three comparable psoriasis lesions on the extremities for 39 consecutive days. The first lesion was treated daily with short-contact dithranol cream followed by clobetasol-17-propionate ointment 5 days per week. The second lesion was treated daily with short-contact dithranol cream followed by the vehicle of clobetasol-17-propionate ointment. The third lesion was treated with clobetasol-17-propionate ointment 5 days per week. The patients attended on days 1, 4, 9, 12, 15, 18, 22, 25, 32 and 39 during treatment. We assessed lesional severity scores at each visit and registered the baseline area at the first visit. During the follow up at weeks 2, 4, 6, 10, 14, 19 and 23 we assessed lesional sum scores. We also estimated the area involved in recurrence of the lesion as a percentage of the baseline area. The overall differences between the three treatment curves for the treatment period and follow-up period separately were tested with a likelihood ratio test. RESULTS: Differences between the curves of the sum scores during treatment (P < 0.001) were mainly due to the different time-course of dithranol monotherapy, which showed a slower decrease in sum score. Differences between the linear trends of the sum score (P < 0.001) and the area score P < 0.001) during follow up were due to a different time-course of the combination therapy, which started lower and increased more slowly, suggesting a slower relapse rate with combination therapy. When comparing the follow-up data, it must be kept in mind that the three treatments showed an overall significantly different sum and area score at the start of follow up. CONCLUSIONS: Intermittent addition of clobetasol-17-propionate ointment enhanced the antipsoriatic efficacy of short-contact, high-dose dithranol therapy in terms of clearing capacity and treatment duration, without shortening remission duration.

Time from symptom onset to treatment and outcome in prehospital thrombolysis for acute ST-elevation myocardial infarction.

BACKGROUND: Prehospital thrombolysis for acute ST-elevation myocardial infarction shortened treatment by 60 minutes, and created a large patient group who were treated within two hours. OBJECTIVES: We analysed our database of patients undergoing prehospital treatment for acute ST-elevation myocardial infarction in search of characteristics for a better outcome in the early treatment group. METHODS: From 1994 to 2000 a total of 475 patients were treated using prehospital administration of anistreplase (in 407 patients) or reteplase (in 68 patients) after diagnosis was confirmed with transtelephonic transmission of the ECG. There was no age limit. The patient data were divided into two groups: one treated within two hours after onset of pain (291 patients, 62%), and one treated later (171 patients, 37%). Thirty-day mortality, symptoms and clinical signs of heart failure were used as parameters of outcome. Both univariate and stepwise logistic regression analyses were used to test 30-day mortality against age, actual time to treatment, prior myocardial infarction, hypertension, diabetes, anterior myocardial infarction, Killip class, systolic blood pressure and heart rate at presentation. RESULTS: Overall 30-day mortality was 9.1%. Overall heart failure was in 16.6% of patients. Both mortality (5.5% vs. 15.5%, p<0.02) and heart failure (12.7% vs. 23.2%, p<0.02) were significantly lower in the early treatment group compared with the group treated late. Independent parameters showing a relation with 30-day mortality were age, time to treatment, hypertension and prior myocardial infarction. Age, time to treatment, hypertension and hyperlipidaemia were identified as predicting heart failure within the first 30 days. CONCLUSION: With prehospital thrombolysis, both 30-day mortality and heart failure were lower in an early treatment group with acute ST-elevation myocardial infarction. Independent variables for 30-day mortality were age, hypertension, prior myocardial infarction and time to treatment, and age, hypertension, hyperlipidaemia and time to treatment were independent predictors for heart failure.

The C677T mutation in the methylenetetrahydrofolate reductase gene: a genetic risk factor for methotrexate-related elevation of liver enzymes in rheumatoid arthritis patients.

OBJECTIVE: To study the possible relationship between the C677T mutation in the methylenetetrahydrofolate reductase (MTHFR) gene and the toxicity and efficacy of treatment with methotrexate (MTX) in patients with rheumatoid arthritis (RA). METHODS: Genotype analysis of the MTHFR gene was done in 236 patients who started MTX treatment with (n = 157) or without (n = 79) folic or folinic acid supplementation. Outcomes were parameters of efficacy of MTX treatment, patient withdrawal due to adverse events, discontinuation of MTX treatment because of elevated liver enzyme levels, and the total occurrence of elevated liver enzyme levels during the study. Multivariate logistic regression analysis was used to study the relationship between the presence of the MTHFR C677T mutation and toxicity outcomes of MTX treatment. RESULTS: Forty-eight percent of the patients showed the homozygous (T/T) or heterozygous (T/C) mutation. The presence of the C677CT or C677TT genotypes was associated with an increased risk of discontinuing MTX treatment because of adverse events (relative risk 2.01; 95% confidence interval 1.09, 3.70), mainly due to an increased risk of elevated liver enzyme levels (relative risk 2.38; 95% confidence interval 1.06, 5.34). Efficacy parameters were not significantly different between the patients with and those without the mutation. CONCLUSION: The C677T mutation is the first identified genetic risk factor for elevated alanine aminotransferase values during MTX treatment in patients with RA. We postulate that the incidence of clinically important elevation of liver enzyme levels during MTX treatment is mediated by homocysteine metabolism. Supplementation with folic or folinic acid reduced the risk of toxicity-related discontinuation of MTX treatment both in patients with and in patients without the mutation.

Influence of sex, age, and menopausal state on the course of early rheumatoid arthritis.

OBJECTIVE: To investigate the influences of the menopausal state, sex, and age on the course and outcome of rheumatoid arthritis (RA). METHODS: A cohort of patients with early RA (209 female, 123 male) was studied. Sex, age, and menopausal state at baseline, and disease activity, radiographic joint destruction, and physical disability during 6 years of followup were assessed. RESULTS: The Disease Activity Score (DAS) was significantly higher in female compared to male patients at any time point except at the time of inclusion. This was mainly due to postmenopausal patients. Radiographic joint destruction (RJD) was significantly worse in female patients compared to males at the time of inclusion. Postmenopausal patients had significantly higher RJD than premenopausal patients at the time of inclusion and 3 years thereafter. Older male patients showed worse RJD than younger male patients at all time points measured. Physical disability was significantly worse in female compared to male patients, as well as in postmenopausal compared to premenopausal patients, and older male compared to younger male patients. Stepwise regression analysis revealed that at 3 years higher age and female sex were the best predictors for a worse DAS. Higher age and the interaction term between menopausal state and age best predicted higher RJD. Higher age and the interaction term between menopausal state and age best predicted Health Assessment Questionnaire (HAQ) score. CONCLUSION: Higher age at presentation of RA leads to a more severe disease course in terms of DAS, RJD, and HAQ. Although female sex has a deteriorating effect on the DAS, the menopausal state is responsible for the major part of the differences in outcome between men and women. Postmenopausal state in early RA influences future disability and damage, especially in older patients.

Effect of folic or folinic acid supplementation on the toxicity and efficacy of methotrexate in rheumatoid arthritis: a forty-eight week, multicenter, randomized, double-blind, placebo-controlled study.

OBJECTIVE: To study the effect of folates on discontinuation of methotrexate (MTX) as single-drug antirheumatic treatment due to toxicity, to determine which type of adverse events are reduced, to study the effects on the efficacy of MTX, and to compare folic with folinic acid supplementation in a 48-week, randomized, double-blind, placebo-controlled trial. METHODS: Patients with active RA (n = 434) were randomly assigned to receive MTX plus either placebo, folic acid (1 mg/day), or folinic acid (2.5 mg/week). The initial MTX dosage was 7.5 mg/week; dosage increases were allowed up to a maximum of 25 mg/week for insufficient responses. Folate dosages were doubled once the dosage of MTX reached 15 mg/week. The primary end point was MTX withdrawal because of adverse events. Secondary end points were the MTX dosage and parameters of efficacy and toxicity of MTX. RESULTS: Toxicity-related discontinuation of MTX occurred in 38% of the placebo group, 17% of the folic acid group, and 12% of the folinic acid group. These between-group differences were explained by a decreased incidence of elevated liver enzyme levels in the folate supplementation groups. No between-group differences were found in the frequency of other adverse events or in the duration of adverse events. Parameters of disease activity improved equally in all groups. Mean dosages of MTX at the end of the study were lower in the placebo group (14.5 mg/week) than in the folic and folinic acid groups (18.0 and 16.4 mg/week, respectively). CONCLUSION: Both folate supplementation regimens reduced the incidence of elevated liver enzyme levels during MTX therapy, and as a consequence, MTX was discontinued less frequently in these patients. Folates seem to have no effect on the incidence, severity, and duration of other adverse events, including gastrointestinal and mucosal side effects. Slightly higher dosages of MTX were prescribed to obtain similar improvement in disease activity in the folate supplementation groups.

Cognitive behaviour therapy for chronic fatigue syndrome: a multicentre randomised controlled trial.

BACKGROUND: Cognitive behaviour therapy (CBT) seems a promising treatment for chronic fatigue syndrome (CFS), but the applicability of this treatment outside specialised settings has been questioned. We compared CBT with guided support groups and the natural course in a randomised trial at three centres. METHODS: Of 476 patients diagnosed with CFS, 278 were eligible and willing to take part. 93 were randomly assigned CBT (administered by 13 therapists recently trained in this technique for CFS), 94 were assigned the support-group approach, and 91 the control natural course. Multidimensional assessments were done at baseline, 8 months, and 14 months. The primary outcome variables were fatigue severity (on the checklist individual strength) and functional impairment (on the sickness impact profile) at 8 and 14 months. Data were analysed by intention to treat. FINDINGS: 241 patients had complete data (83 CBT, 80 support groups, 78 natural course) at 8 months. At 14 months CBT was significantly more effective than both control conditions for fatigue severity (CBT vs support groups 5.8 [2.2-9.4]; CBT vs natural course 5.6 [2.1-9.0]) and for functional impairment (CBT vs support groups 263 [38-488]; CBT vs natural course 222 [3-441]). Support groups were not more effective for CFS patients than the natural course. Among the CBT group, clinically significant improvement was seen in fatigue severity for 20 of 58 (35%), in Karnofsky performance status for 28 of 57 (49%), and self-rated improvement for 29 of 58 (50%). Prognostic factors for outcome after CBT were a higher sense of control predicting more improvement, and a passive activity pattern and focusing on bodily symptoms predicting less improvement. INTERPRETATION: CBT was more effective than guided support groups and the natural course in a multicentre trial with many therapists. Our study showed a lower proportion of patients with improvement than CBT trials with a few highly skilled therapists.

Longitudinal vitamin and homocysteine levels in normal pregnancy.

Evidence of the impact of maternal nutritional status on pregnancy outcome is increasing. However, reference values for vitamin and homocysteine concentrations in maternal blood during normal pregnancy are scarce, and are lacking for the preconceptional period and early pregnancy. Thus, in a longitudinal study we evaluated vitamin and homocysteine concentrations in 102 nulliparous women with an uneventful singleton pregnancy and normal outcome not using supplements. The physiological changes in vitamin and homocysteine concentrations in blood were determined from the preconceptional period throughout pregnancy until 6 weeks post-partum. The vitamins evaluated comprised retinol, thiamin, riboflavin, pyridoxal 5'-phosphate, folate in serum and erythrocytes, vitamin B12 and alpha-tocopherol. The plasma homocysteine concentration was also measured, considering the essential roles of folate, vitamin B6 and vitamin B12 in homocysteine metabolism. The concentrations of retinol, thiamin, pyridoxal 5'-phosphate serum folate and vitamin B12 decreased during pregnancy. In contrast, the concentrations of riboflavin, alpha-tocopherol, and folate in erythrocytes increased or showed only minor changes. Homocysteine concentrations also remained approximately constant during pregnancy. These observations emphasize the importance of preconceptional and post-partum concentrations of vitamins in the evaluation of pregnancy-induced changes. These data have provided valuable reference values for vitamins and homocysteine before, during and after pregnancy in order to contribute to better diagnosis of maternal deficiencies and to study further the relationship between maternal vitamin status and adverse course and outcome of pregnancy.

Intima-media thickness of peripheral arteries in asymptomatic cigarette smokers.

BACKGROUND AND PURPOSE: Although it is known that smoking is associated with an increase in arterial wall thickness, most studies have been performed in heterogeneous groups of older age, already suffering from atherosclerotic diseases or having additional cardiovascular risk factors. The purpose of this study is to assess the effect on arterial wall thickness of the carotid and femoral artery in cigarette smokers. METHODS: In a cross-sectional study, intima-media thickness of the common and internal carotid artery, carotid bulb and common femoral artery was determined with the use of a B-mode ultrasound device, in 184 (44.3+/-9.0 years) cigarette smokers for whom smoking is the single cardiovascular risk factor. Comparisons were made with 56 non-smokers, matching in age and gender. RESULTS: The posterior walls of both carotid bulbs (right: P=0.0005; left: P=0.02) and of the internal carotid arteries (right: P=0.004; left: P=0.003) as well as the posterior wall of the right common carotid artery (P=0.02) and of the right common femoral artery (P<0.0001) were thicker in smokers. CONCLUSIONS: Cigarette smoking as the single cardiovascular risk factor causes wall thickening of the carotid and femoral arteries, which indicates that early atherosclerosis is already present in smokers entering middle age.

Evaluation of three methods to rate impairment in patients with complex regional pain syndrome I of one upper extremity.

OBJECTIVE: To gain insight into the best way of obtaining an impairment rating in complex regional pain syndrome I (CRPS I) of the upper extremity. This syndrome can potentially result in permanent impairment. DESIGN: Comparison of three evaluation methods to obtain impairment scores. Each patient was seen by one tester; two testers in total participated in the research. SETTING: Outpatient clinic of a university hospital. SUBJECTS: Seventy-four patients (27 men, 47 women, mean age 52 years) with CRPS I of one upper extremity. MAIN OUTCOME MEASURES: Methods I and II were conducted according to the American Medical Association's Guides to the evaluation of permanent impairment method I according to the general guidelines, and method II according to the methodology specificially described for CRPS I. Method III was developed by the Dutch Association of Neurologists. For comparison, differences between methods were plotted against their mean ratings, with the limits of agreement. Also the paired t-statistics were calculated (alpha = 0.05/3). RESULTS: The mean difference between methods I and II was -0.7% whole body impairment, between methods II and III 8.1% and between methods I and III 7.3%. Outcomes obtained with method III differed significantly from the other outcomes. CONCLUSIONS: Method I most accurately and objectively reflected the permanent impairment level resulting from CRPS I.

Venous reflux has a limited effect on calf muscle pump dysfunction in post-thrombotic patients.

The purpose of the present study was to evaluate the relationship between calf muscle pump dysfunction (CMD) and the presence and location of valvular incompetence. Deep vein obstruction might influence CMD, and so venous outflow resistance (VOR) was measured. VOR and calf muscle pump function were measured in 81 patients, 7-13 years after venographically confirmed lower-extremity deep venous thrombosis. The supine venous pump function test (SVPT) measures CMD, and the VOR measures the presence of venous outflow obstructions, both with the use of strain-gauge plethysmography. Valvular incompetence was measured using duplex scanning in 16 vein segments of one leg. Venous reflux was measured in proximal veins using the Valsalva manoeuvre, and in the distal veins by distal manual compression with sudden release. Abnormal proximal venous reflux was defined as a reflux time of more than 1 s, and abnormal distal venous reflux as a reflux time of more than 0.5 s. No statistically significant relationship was found between the SVPT and either the location or the number of vein segments with reflux. Of the 81 patients, only nine still had an abnormally high VOR, and this VOR showed no relationship with the SVPT. In conclusion, venous reflux has a limited effect on CMD, as measured by the SVPT. The presence of a venous outflow obstruction did not significantly influence the SVPT. Duplex scanning and the SVPT are independent complementary tests for evaluating chronic venous insufficiency.

Adjuvant physical therapy versus occupational therapy in patients with reflex sympathetic dystrophy/complex regional pain syndrome type I.

OBJECTIVE: To investigate the effectiveness and cost of physical therapy (PT) or occupational therapy (OT) in patients with reflex sympathetic dystrophy (RSD). DESIGN: Prospective randomized controlled trial, with 1 year follow-up. SETTING: Two university hospitals. PATIENTS: One hundred thirty-five patients who had been suffering from RSD of one upper extremity for less than 1 year. INTERVENTIONS: Patients were assigned to PT, OT, or a control group (social work). MAIN OUTCOME MEASURES: Improvement in impairment level sumscore (ISS) over 1 year (Student's t test). A difference of 5 ISS points between the groups was defined as being clinically relevant. Furthermore, severity of disability and handicap was measured and tested exploratively (Wilcoxon; alpha = .05), and cost-effectiveness of the groups was calculated. RESULTS: PT and, to a lesser extent, OT resulted in a significant and also more rapid improvement in the ISS as compared with controls (6 and 4 ISS points, respectively). On a disability level, a positive trend was found in favor of OT. On a handicap level, no differences were found between the groups. PT had an advantage over OT regarding the cost-effectiveness ratio. CONCLUSION: In different ways PT and OT each contribute to the recovery from RSD of the upper extremity.

Do physical therapy and occupational therapy reduce the impairment percentage in reflex sympathetic dystrophy?

Reflex sympathetic dystrophy (RSD) is a disorder that can potentially result in permanent impairment. Because there are no adequate comparative studies regarding the additional value of physical therapy (PT) or occupational therapy (OT) for reducing the severity of permanent impairment in RSD, we prospectively investigated their effectiveness. At two university hospitals, we randomly assigned 135 patients with RSD of one upper limb, existing for <1 yr, to PT, OT, or control therapy (CT). One year after inclusion, impairment percentages were calculated according to the general method of the American Medical Association's Guides to the Evaluation of Permanent Impairment. For statistical evaluation, the Wilcoxon's signed-rank test (two-sided; alpha = 0.05) was used. The mean whole body impairments were as follows: PT, 21.6% and 19.1%; OT, 22.8% and 22.1%; CT, 22.0% and 22.1% (intention-to-treat and per protocol analysis, respectively). There were no significant differences between the groups. We conclude that impairment percentages in RSD patients treated with PT or OT did not differ significantly from those treated with CT at 12 months after inclusion.

Pain and reduced mobility in complex regional pain syndrome I: outcome of a prospective randomised controlled clinical trial of adjuvant physical therapy versus occupational therapy.

There are no adequate comparative studies on physical therapy (PT) versus occupational therapy (OT) in patients with complex regional pain syndrome I (CRPS I). Therefore, we conducted a prospective randomised clinical trial to assess their effectiveness. The outcomes regarding reducing pain and normalising active range of motion (AROM) are discussed. Included in the study were 135 patients who had been suffering from CRPS I of one upper extremity for less than one year. They were randomly assigned to one of three groups: PT, OT, or control (social work, CT). Measurements were taken at base-line (t0), after 6 weeks, and after 3, 6 and 12 months (t1 to t4). Pain was measured on four visual analogue scales (VAS) and the McGill Pain Questionnaire, Dutch Language Version (MPQ-DLV). The AROM was recorded relative to the contralateral side. Explorative statistical evaluations were performed (Wilcoxon; alpha=0.05). PT and to a lesser extent OT, resulted in more rapid improvement in the VAS scores than CT, especially for the VAS during or after effort (P<0.05 at t1 to t3). PT was superior to CT and OT according to the MPQ-DLV particularly at t4. Improvement on the MPQ-DLV over the year was significantly greater for PT than for OT and CT (P<0.05). PT -and to a lesser degree OT- led to better results than CT for the AROM of the wrist, fingers and thumb at t1 to t3 (most-times P<0.05 for PT), but the improvements over the year were not significantly different. Our results indicated that PT, and to a lesser extent OT, were helpful for reducing pain and improving active mobility in patients with CRPS I of less than one year duration, localised in one upper extremity.

Signs and symptoms in complex regional pain syndrome type I/reflex sympathetic dystrophy: judgment of the physician versus objective measurement.

OBJECTIVE: To assess the relation between the subjectively assessed and objectively measured diagnostic signs and symptoms in complex regional pain syndrome type I (CRPS I) and to quantify their severity. DESIGN: Diagnostic signs and symptoms were recorded in patients suffering from CRPS I of one upper extremity for less than 1 year. Independent assessors measured (a) pain by using four visual analog scales (VAS) and the McGill Questionnaire list of adjectives (MPQ), (b) edema with a hand volumeter, (c) skin temperature with an infrared thermometer, and (d) active range of motion (AROM) with goniometers. SETTING: Two university hospitals. PATIENTS: Ninety-five women and 40 men with CRPS I of one upper extremity. RESULTS: Four signs and symptoms were diagnosed in 50 patients, and five in the remaining 85 patients. The mean score for present pain intensity was 31.5 mm and that for pain resulting from exertion of the affected extremity was 71.9 mm. A median of 11.5 words was chosen from the MPQ, with the highest number from its evaluative part. The difference in volume between both hands was 30.4 ml. The mean difference in temperature between the two hands was 0.78 degrees C dorsally and 0.66 degrees C palmarly. The largest decrease in mobility was seen in the wrist and fingers; the thumb was relatively less affected and the little finger relatively more affected than the other fingers. CONCLUSIONS: Bedside evaluation of CRPS I with Veldman's criteria was in good accord with psychometric or laboratory testing of these criteria.

Photorefractive keratectomy with an ablatable mask for myopic astigmatism.

PURPOSE: To evaluate efficacy, safety, and stability of photoastigmatic keratectomy (PARK) carried out with a Summit Apex Plus laser using an ablatable mask. METHODS: Forty-one eyes of 41 patients with myopic astigmatism with follow-up of 12 months were evaluated. Treatment efficacy was compared in groups with high (>6.00 D) versus low (< or =6.00 D) preoperative spherical equivalent subjective manifest refraction, in groups with high (>2.00 D) versus low (< or =2.00 D) preoperative cylindrical component and in groups divided according to preoperative axis of cylinder. RESULTS: At 12 months after surgery, mean spherical equivalent manifest refraction in all 41 eyes was -0.30 +/- 0.90 D. Mean cylinder component was 0.60 +/- 0.70 D. Mean reduction in astigmatic component was 67 +/- 47%. Uncorrected visual acuity of 0.5 or more was achieved in 79% of eyes; 71% of eyes achieved 0.8 or more. At 1 month after surgery, 49% of eyes had a loss of 2 or more lines of spectacle-corrected visual acuity. This loss was restored at 12 months. No statistically significant differences were found between the different subgroups. CONCLUSION: Photoastigmatic keratectomy with ablatable mask gives satisfactory results. No relation in efficacy was found when taking into account the amount of preoperative spherical component, the cylindrical component, or the cylinder axis direction.