Rotational coherent dot movement normalizes spatial disorientation of the subjective visual vertical in patients with rightsided stroke.

Studies in healthy individuals indicate a significant influence of rotating visual motion on judgments of the subjective visual vertical (SVV). Moreover, sensory stimulation manoeuvres like horizontal coherent dot movement significantly modulate horizontal spatial deficits in patients with rightsided stroke. Here, we investigated whether rotational coherent dot movement (RCDM) modulates spatial orientation deficits of the SVV in the roll plane in right hemispheric stroke. We tested the perceptual judgment of the SVV in 20 patients with right-hemispheric, first ever stroke (10 of them with a disorder of the SVV and 10 without a disorder), and 10 healthy, age-matched subjects under three experimental conditions: (1) with a static background of small white dots, (2) with slow clockwise or (3) counterclockwise circular RCDM of these background stimuli. In the baseline condition with static background, the impaired patient group showed a counterclockwise tilt of the SVV. Clockwise RCDM normalized this deficit completely, while with counterclockwise RCDM a slight aggravation was observed. Similar but quantitatively much smaller effects were obtained in the SVV-unimpaired patients and the healthy individuals. These results demonstrate a strong modulatory effect of RCDM on the SVV in patients with a tilt of the SVV due to right-sided stroke. RCDM thus appears to influence higher spatial representations devoted to visuospatial perception of the SVV. Possible mechanisms as well as clinical implications for therapy of visuospatial disorientation (self-orientation in space) after stroke are discussed.

The effect of rotating random dot motion on visuospatial line orientation in patients with right-sided stroke.

Spatial deficits are frequent after brain damage, particularly right hemisphere stroke. Visual judgments of line orientation (LINE) are often impaired after right parietal lesions. Perception of line orientation is an important visuoperceptual component of visuoconstructive capacities. Yet, little is known about modulating factors in LINE and effective treatments are rare for this disorder. Studies in patients with spatial neglect show that horizontal random dot motion (RDM) significantly modulates horizontal spatial disorders, both transiently and permanently after treatment. In the current study, we investigated whether rotational RDM modulates judgements in an oblique LINE task in 20 patients with right-hemispheric first ever stroke (10 of them with a disorder in LINE and 10 without such a disorder), and 10 healthy, age-matched subjects. Subjects were tested under three experimental conditions: (1) with a static background of small white dots, (2) with slow clockwise or (3) counterclockwise circular RDM of these background stimuli, while they performed the LINE task. In the baseline condition with static background, the impaired patient group showed a significant counterclockwise tilt. Clockwise rotating RDM normalized this deficit transiently but completely, while counterclockwise rotating RDM slightly aggravated it, though not significantly. Tilts in the LINE task were significantly correlated with left visuospatial neglect. Similar but much smaller effects were obtained in the spatially unimpaired patients and the normal controls. These results show that rotational RDM modulates deficits of line orientation in patients with right-sided stroke, possibly by influencing higher spatial representations devoted to the perception of oblique lines.

Switching to emtricitabine, tenofovir and rilpivirine as single tablet regimen in virologically suppressed HIV-1-infected patients: a cohort study.

OBJECTIVES: Emtricitabine/tenofovir/rilpivirine as a single-tablet regimen (STR) is widely used without licence in treatment-experienced patients. The purpose of this retrospective observational study was to assess viral suppression of ART-experienced patients switching to STR. METHODS: We assessed 131 pretreated patients switching to STR with HIV RNA <400 HIV-1 RNA copies/mL. The primary outcome measure was the proportion of patients at week 24 with HIV RNA <40 copies/mL. RESULTS: By week 24, eight patients had stopped STR: four because of adverse events and four for other reasons. Three virological failures were observed; among these, at least one patient developed cross-resistance to nucleoside reverse transcriptase inhibitors (NRTIs) and nonnucleoside reverse transcriptase inhibitors (NNRTIs), in particular with the E138K pattern. In intent-to-treat analysis, 92% of participants (120 of 131) achieved HIV RNA <40 copies/mL. Only grade 1 to 2 adverse events were observed, mainly consisting of increased liver enzymes (n=33). Systemic exposure to rilpivirine was above the usually observed steady-state levels for the 18 measurements assessed. CONCLUSIONS: Efficacy and tolerability are similar to those in treatment-naïve patients.

Studies on metabolically depleted erythrocytes.

Erythrocytes kept outside the blood circulation undergo progressive changes in metabolism, shape and function, which was the topic of this study. For that purpose, blood anticoagulated with either heparin, citrate or EDTA was incubated at temperatures of 5°C, 22°C or 37°C for 0 h, 24 h and 48 h, respectively. A temperature- and time-dependent decrease of glucose and ATP and increase of lactate and LDH were observed. An erythrocyte swelling and echinocytic shape transformation, which was also time- and temperature-dependent, was seen. Density-separated young and old erythrocytes behaved similarly. The degree of echinocytic shape transformation correlated with the increase in blood viscosity at high shear rate. Echinocytosis was partially reversible when erythrocytes were suspended in buffer containing 0.2% albumin. This phenomenon is specific for albumin, since molecules with a similar molecular weight (dextran 70, heat shock protein, protein C) had no effect. These finding may have an impact on blood banking and transfusion medicine.

Limb activation ameliorates body-related deficits in spatial neglect.

Many neglect patients show deficits in the mental representation of their contralesional body side or body parts, termed personal neglect. These deficits include impairments in identifying body parts on schematic drawings of human bodies. Limb activation and alertness cues have been shown to modulate neglect transiently, and are effective treatments for several symptoms of the neglect syndrome. Here, we tested on eight patients with right-hemispheric stroke and left-sided spatial neglect whether these two techniques modulate deficits in the mental representation of hands, assessed with a hand-test in which the subjects had to decide whether a depicted schematic hand belongs to the left or right side of the human body. The results showed that neglect patients made marginally significant (p = 0.065) more errors in left-hand-decisions than right-hand-decisions, indicating a neglect-specific disorder. Moreover, we found that left-sided limb activation but not non-lateralized alertness cueing (a loud noise immediately before patients made their perceptual decision) significantly reduced misidentifications for depicted left hands as compared to baseline. No effect of any intervention was observed on error rates for depicted right hands. We conclude that the amelioration of the performance in the hand task is modulated by the activation of the body schema or other body representations through left-sided limb activation.

Contralesional spatial bias in chronic hemianopia: the role of (ec)centric fixation, spatial cueing and visual search.

Patients with homonymous hemianopia often show a contralesional shift towards their blind field when bisecting horizontal lines ('hemianopic line bisection error', HLBE). The reasons for this spatial bias are not well understood and debated. Eccentric fixation and adaptive orienting of eye movements towards the blind field have been suggested as hypothetical explanations but were not tested experimentally yet. Moreover, the role of spatial attention and visual search in the blind field are unsettled issues. Here, we tested in 20 stroke patients with chronic homonymous hemianopia (10 left-sided, 10 right-sided) without visual neglect, 10 healthy control subjects and 10 neurological control patients without hemianopia whether the HLBE is related to (a) eccentric fixation and (b) is influenced by spatial-attentional cueing (left, right) and (c) related to the degree of oculomotor compensation in the blind field. Perimetric mapping of the blind spot in the ipsilesional eye was performed in 39/40 subjects. Both hemianopic patient groups showed the typical HLBE towards their blind field, while the two control samples showed only a small but significant leftward shift known as pseudoneglect. The horizontal and vertical position of the blind spot in the ipsilesional eye was within normal limits in 38 out of 40 subjects, and did not differ significantly between the four samples. Moreover, the HLBE was not significantly correlated to the horizontal or vertical position of the centre of the blind spot, thus excluding eccentric fixation as an explanation for this spatial error. Furthermore, spatial cueing by manipulating the starting position of the bisection cue (left, right) did not affect the HLBE, arguing against attentional cueing effects well known from the line bisection error in patients with spatial neglect. Finally, the size of the saccadic search field in the scotoma was not significantly correlated to the HLBE in hemianopia. We conclude that eccentric fixation, contralesional hyperattention or ipsilesional hypoattention, or good or poor oculomotor compensation of the field loss itself are not likely causes of the HLBE in chronic homonymous hemianopia. Implications of these findings and alternative explanations are discussed.

Does spatial cueing affect line bisection in chronic hemianopia?

Patients with homonymous hemianopia often show a contralesional shift towards their blind field when bisecting horizontal lines ("hemianopic line bisection error", HLBE). The reasons for this spatial bias are not well understood and debated. Cueing of spatial attention modulates line bisection significantly in patients with visuospatial neglect. Moreover, recent evidence showed that attention training significantly improves deficits of visual search in hemianopia. Here, we tested in 20 patients with chronic homonymous hemianopia (10 left-sided, 10 right-sided) without visual neglect, 10 healthy control subjects, 10 neurological control patients, and 3 patients with left visuospatial neglect and leftsided hemianopia whether spatial cueing influences the HLBE. Subjects indicated verbally the midpoint of horizontal lines in a computerized line bisection task under four experimental cue positions (cue far left, mid-left, mid-right or far-right within the horizontal line). All 20 hemianopic patients showed the typical HLBE towards their blind field, while the two control samples showed only a small but significant leftward shift (pseudoneglect). None of the 4 cueing manipulations had a significant effect on the HLBE in the hemianopic patients. Moreover, no differential effects of cueing on line bisection results were obtained when analyzed in lesion subgroups of hemianopic patients with circumscribed occipital lesions (N=8) as contrasted with patients having more extended (occipito-temporal or temporal) lesions (N=12). This null-effect contrasts with marked cueing effects observed in 3 neglect patients with left hemianopia in the same tasks, showing the principal efficacy of our cueing manipulation. These results argue against attentional explanations of the HLBE.

Recovery from auditory and visual neglect after optokinetic stimulation with pursuit eye movements--transient modulation and enduring treatment effects.

Optokinetic stimulation (OKS) modulates many facets of the neglect syndrome. This sensory stimulation technique is known to activate multiple brain regions (temporo-parietal cortex, basal ganglia, brain stem, cerebellum) some of which are involved in auditory and visual space coding. Here, we evaluated whether OKS modulates auditory neglect transiently and induces a sustained effect (Study 1), and whether repetitive OKS permanently recovers auditory neglect (Study 2). In Study 1, 20 patients with visuospatial neglect and auditory neglect in an auditory midline task following rightsided stroke were randomly allocated to an experimental and a control group matched for neglect severity and socio-demographic factors. Both groups showed a stable, pathological shift of their auditory subjective median plane (ASMP) in front space to the right side. During leftward OKS the experimental group showed a complete normalization of the shift of the ASMP, which endured until 30 min poststimulation, and returned almost to baseline values 24h after OKS. In contrast, the control group who viewed the identical but static dot pattern, showed neither change in their ASMP during this condition, nor any significant change at 30 min or 24h poststimulation. In Study 2, we show in two samples of neglect patients (N = 3 each) that repetitive leftward OKS with smooth pursuit eye movements as a therapy induces lasting improvements in auditory (the ASMP) and visual neglect while visual scanning therapy yielded no measurable effects on auditory and significantly smaller effects on visual neglect. In conclusion, the experiments show that a single session of OKS induces rapid though transient recovery from auditory neglect including a sustained effect after termination of stimulation, while repetitive OKS therapy yields enduring and multimodal recovery from auditory and visual neglect. OKS therapy with pursuit eye movements therefore represents a multimodally effective and easily applicable technique for the treatment of auditory and visual neglect.

The GAIN (Geriatric Anorexia Nutrition) registry: the impact of appetite and weight on mortality in a long-term care population.

PURPOSE: To investigate nursing home residents at high nutritional risk to determine: 1) which baseline nutrition or health status indicators correlated with subsequent weight gain or appetite improvement; and, 2) whether a continued weight loss correlated with higher mortality. METHODS: At study entry, nutritional, health status, and demographic data were extracted from the nursing home chart or the MDS. Each subject was tracked for 6 months with survival, weight gain of 5%, and appetite improvement the primary outcome measures. RESULTS: During the 6-month study, younger age was the strongest correlate of appetite improvement. The odds of gaining weight were negatively correlated with BMI, age, and feeding dependency. Subjects who were receiving appetite stimulants (orexigenics) at study entry had a 70% greater probability of gaining weight than those who were not. A weight loss during the 6-month period was associated with a nearly two-fold increase in the likelihood of dying (adjusted RR: 1.95, 95% CI 1.43 to 2.66). CONCLUSION: The course of nutritional problems within nursing homes is highly variable. Continued weight loss, however, appears to have ominous implications for mortality. Younger residents who are not dependent on others for feeding assistance, and who receive orexigenics tend to experience weight gain.

Managed care at Eisenhower Army Medical Center: an initial experience.

Managed care is receiving a great deal of attention in the health care industry. In today's cost-conscious economic environment, managed care has been developed in an attempt to maximize quality of health care while minimizing the cost of providing that care. The purposes of this article are to (1) review the principles of clinical case management; (2) describe the implementation of clinical case management and critical paths at Dwight David Eisenhower Army Medical Center; (3) elaborate on successful strategies employed; and (4) address difficulties encountered. Finally, the study that is currently underway at the facility will be briefly discussed.

Characterization of carrier females and affected males with X-linked recessive nephrolithiasis.

X-linked recessive nephrolithiasis (XRN) was described in a large kindred in which nephrolithiasis; proximal tubular dysfunction, proteinuria, nephrocalcinosis, and renal failure occur only in males. Carrier females are asymptomatic, but formal studies of them have not been done. The gene for XRN has been mapped to the pericentromeric region of the X chromosome, close to the loci for several eye disease genes. We studied six affected males, 13 carrier females, and 25 normal members of this family including 7 females whose genetic haplotype predicted them to be carriers. Studies were done in the Clinical Research Unit on a diet containing 400 mg of calcium and 2 g of sodium, and by an additional outpatient urine collection was obtained on a 1-g calcium intake. Hypercalciuria occurred in five of six affected males, 4 of 12 carrier females, and three of seven predicted carriers. Significant proteinuria was present in all affected males and in no other subjects. Low-molecular-weight proteinuria was present in all affected males: the excretion of alpha 1-microglobulin exceeded normal by 3- to 14-fold, of beta 2-microglobulin exceeded normal by 100- to 400-fold, and of retinol-binding protein exceeded normal by 1,000- to 3,000-fold. The excretion of these proteins was less strikingly elevated in carrier females, but the excretion of alpha 1-microglobulin was abnormal in 9 of 15 carriers, beta 2-microglobulin was abnormal in 12 of 15, and retinolbinding protein in was abnormal 12 of 13, and this pattern was similar in predicted carriers. The urinary concentrating ability was abnormal in four affected males with renal insufficiency but normal in all other subjects. Urinary wasting of potassium, phosphorous, and glucose occurred infrequently, and no subject was hypouricemic. Formal ophthalmologic studies were normal in five affected males. Thus, the most consistent urinary abnormalities in XRN are hypercalciuria and low-molecular-weight proteinuria, the latter of which appears to be a marker for the carrier state.

Somatosensory evoked potential. Monitoring during spinal surgery.

Somatosensory evoked potentials (SSEPs) have been used to help minimize neurologic morbidity during spinal surgery. While this is a sensory test it has been used as an inference of motor function. The failure to always achieve the latter goal has resulted in some pessimism regarding the value of this test. In this series of 161 operations in 150 patients, it was demonstrated that SSEPs were recordable under anesthesia in 87% of patients. Of these patients, 12% had their spinal surgery interrupted due to significant neurophysiologic changes; of these patients, 18% had new neurologic deficits postoperatively. There were no cases with new neurologic deficits who had no changes in their SSEPs. It was concluded that SSEP monitoring may be helpful in identifying potentially neurologically threatening surgical maneuvers in a significant number of patients.

Acute interstitial nephritis with renal failure associated with propylthiouracil therapy.

Propylthiouracil therapy is associated with a variety of adverse reactions. Renal involvement, although rare, has occurred, but neither acute interstitial nephritis nor severe acute renal failure has been reported previously. We report a case of fulminant acute interstitial nephritis with renal failure following treatment with propylthiouracil.

Economic assessment of ketorolac versus narcotic analgesics in postoperative pain management.

The medical records for 174 patients who underwent cholecystectomy (n = 52) or hip/knee replacement (n = 122) at four community-based medical centers were retrospectively reviewed to determine if using a nonnarcotic alternative to morphine sulfate and/or meperidine as a primary postoperative analgesic could reduce resource costs per patient. Two cohorts were constructed: 87 patients received either morphine sulfate or meperidine as the primary postoperative analgesic, and 87 patients received ketorolac. Ketorolac patients undergoing cholecystectomy were associated with lower per case costs in inpatient care (length of stay), direct nursing labor, PRN (as required) procedures, and medications relating to emesis and to gastrointestinal distress. Higher per case costs were recorded for the primary analgesic (study drug) and for supplemental pain medications. In contrast to substantial differences in the acquisition cost of ketorolac versus morphine sulfate/meperidine, the ketorolac cholecystectomy group was associated with lower overall resource costs per patient. In joint replacement procedures, however, the ketorolac group was associated with higher overall resource costs per patient, attributable primarily to a slightly higher postoperative length of stay.

Syndrome of diminished vasodilator reserve of the coronary microcirculation (microvascular angina or syndrome X): diagnosis by combined atrial pacing and thallium 201 imaging--a case report.

Patients with angina-like chest pain without evidence of epicardial coronary artery disease or coronary arterial vasospasm are becoming increasingly recognized. These are often related to noncardiac causes including esophageal, musculoskeletal, and hyperventilatory or panic states. However, recently a subgroup of such patients are being recognized as having true myocardial ischemia and chest pain on the basis of diminished coronary microvascular vasodilatory reserve (microvascular ischemia or Syndrome X). The authors describe such a patient who was found to have replication of anginal pain associated with a reversible ischemic defect on thallium 201 imaging during atrial pacing, suggesting ischemia in this myocardial segment. Resolution of angina and ST segment electrocardiographic changes of ischemia occurred with cessation of pacing. We believe this is the first report of a patient with this form of myocardial ischemia diagnosed by this method and should be considered in patients with anginal chest pain after significant coronary artery disease and coronary vasospasm have been excluded.

Static exercise with congestive heart failure and the response to vasodilating drugs.

The hemodynamic response to static exercise in 28 patients with congestive heart failure (CHF) was compared with that in 8 control subjects. Static handgrip exercise at 50% of the maximal voluntary contraction was performed to fatigue. In patients with CHF, pulmonary arterial wedge pressure increased from 20 +/- 18 to 31 +/- 10 mm Hg (p less than 0.001) (mean +/- standard deviation) and systemic vascular resistance increased from 1,730 +/- 454 to 2,151 +/- 724 dynes s cm-5 (p less than 0.001). Although cardiac index did not change significantly, stroke volume index and stroke work index decreased from 24 +/- 6 to 20 +/- 6 ml/m2 (p less than 0.001) and 28 +/- 11 to 25 +/- 12 g-m/s2 (p less than 0.05), respectively. In control subjects, pulmonary arterial wedge pressure did not change significantly; cardiac index increased from 3.6 +/- 0.3 to 4.0 +/- 0.4 liters/min/m2 (p less than 0.05) and systemic vascular resistance increased slightly, from 1,011 +/- 186 to 1,106 +/- 180 dynes s cm-5 (p less than 0.05). The effects of arterial dilation with hydralazine on the response to static exercise were assessed in 10 of the patients with CHF. Compared with predrug exercise, cardiac index increased 68% (p less than 0.01), stroke volume index increased 76% (p less than 0.01) and systemic vascular resistance decreased 47% (p less than 0.01) after administration of hydralazine. Thus, static exercise can have adverse effects on cardiac performance in patients with CHF.(ABSTRACT TRUNCATED AT 250 WORDS)

An acute hypertensive response after intravenous use of a new pentazocine formulation.

We present the case of a 27-year-old woman with a history of drug abuse. Following her routine intravenous (IV) injection of solubilized pentazocine and tripelennamine tablets ("Ts and Blues"), the patient developed severe hypertension, a finding not characteristic of either drug alone or of the combination. The manufacturers of Talwin (pentazocine) recently have added naloxone to the tablets to discourage IV abuse of this oral preparation. Our patient unknowingly had injected the new pentazocine formulation, and she subsequently developed narcotic withdrawal symptoms. Her hypertension was treated, and she was discharged from the emergency department. We report the case as an "unusual reaction" that may develop in frequent abusers of pentazocine and its combinations.

The epidemiology of spina bifida in south-western Ohio--1970-1979.

Multiple epidemiological variables of 131 children with spina bifida born during 1970 and 1979 in a seven-county urban/rural region of south-western Ohio were analyzed retrospectively via personal interviews, hospital and clinic records, and birth and stillbirth certificates. The estimated incidence of spina bifida was 0.69/1000. It did not vary over the 10 years, seasonally, or in the urban vs. rural areas. The incidence for whites was three times that for non-whites. Reporting of spina bifida on the birth certificate was found for 52 per cent. Fetal loss in the children's mothers was similar to that for controls. However, there was a high number of therapeutic abortions just prior to the conception of the child with spina bifida. Oral contraceptives were used in the early months of the affected pregnancy more frequently than in controls. Recurrence risk was 3.2 per cent. Almost 12 per cent of the children with spina bifida had other major malformations. Even when the deceased probands were discounted, the malformation rate was higher than in the general population. Siblings of affected children had a less impressive but still increased rate of malformations.