Successful Closed Reduction of a Jeffery Type 2 Radial Head Epiphysiolysis -A Case Report with Literature Review.

INTRODUCTION: Radial neck fractures in children are rare injuries, accounting for approximately 5-8.5% of all pediatric elbow fractures; even rarer is the Jeffery type 2 injury, which was described by Jeffery in 1950 and occurs during the automatic reduction of a previous posterior elbow subluxation or dislocation. Only few cases and case small series have been reported on this rare injury, but there is no report on the achievement of closed reduction of the radial head. In all the reported cases, open surgery was essential to achieve adequate reduction of the fracture, except for two cases where percutaneous reduction was achieved using a pin. CASE REPORT: We present a 10-year-old female patient with a Jeffery type 2 fracture who was treated successfully with closed reduction. We describe a detailed closed reduction method to treat the fracture, providing a brief literature review for this rare injury. The clinical outcome of our patient was excellent without any complications. CONCLUSION: Jeffery's type 2 injury is a rare, but potential devastating lesion of the elbow, especially if left undiagnosed or inadequately treated. Adequate knowledge of the mechanism and presentation of the injury is mandatory for early diagnosis. Closed or percutaneous reduction is not only difficult but also preferable due to better functional outcomes. Awareness is needed to recognize early complications ("upside-down" radial head) after the external manipulation.

Expert Consensus Group report on the use of apomorphine in the treatment of Parkinson's disease--Clinical practice recommendations.

Extensive published evidence supports the use of subcutaneously-administered apomorphine as an effective therapy for Parkinson's disease (PD) but to date no consensus recommendations have been available to guide healthcare professionals in the optimal application of apomorphine therapy in clinical practice. This document outlines best-practice recommendations for selecting appropriate candidates for apomorphine intermittent injection (the pen-injection formulation) or apomorphine continuous infusion (the pump formulation), for initiating patients onto therapy and for managing their ongoing treatment. Apomorphine is a suitable therapeutic option for PD patients who experience troublesome 'off' periods despite optimized treatment with oral PD medications. Due to its speed of onset, apomorphine injection is particularly suited to those patients requiring rapid, reliable relief of both unpredictable and predictable 'off' periods, those who require reliable and fast relief when anticipating an 'off', those with levodopa absorption or gastric emptying problems resulting in delayed or failed 'on', or for rapid relief of early morning dystonia or akinesia. Apomorphine infusion(1) is suited for patients whose 'off' periods can no longer be adequately controlled by standard oral PD treatment or for those in whom rescue doses of apomorphine injection are effective but either needed too frequently (more than 4-6 times per day), or are associated with increasing dyskinesia. In addition to treating motor fluctuations, there is evidence that apomorphine infusion may be effective for the management of specific non-motor symptoms of PD associated with 'off' periods. Apomorphine infusion is less invasive than other non-oral treatment options for advancing disease, intrajejunal levodopa infusion and deep-brain stimulation.

Clinical characteristics of Parkinson's disease patients in Greece: a multicenter, nation-wide, cross-sectional study.

Parkinson's disease is a neurodegenerative disease, with a constantly increasing prevalence and a high global financial impact arising from direct and indirect costs. Large-scale, observational studies provide data that support the better comprehension of disease aspects, constitute a baseline reference for future studies and assist comparisons among different patient populations, allowing the recognition of distinctive characteristics and special needs. The present study is the first to depict the clinical characteristics and their interplay in a large sample of Parkinson's disease (PD) patients in Greece. Nine hundred eighty six consecutive PD outpatients were recruited from 17 centers around Greece in the time period from 8/2007 to 7/2009 and were examined and interviewed by movement disorders experts. Multiple clinical characteristics were recorded including age at diagnosis, disease severity, patients' self classification of PD symptoms and their relevance to physician's global clinical impression, smoking, alcohol consumption, presence of family history for PD, dementia, depression, hypertension, cancer and other comorbidities. Associations of high clinical significance were found between certain clinical characteristics.

Morphologic changes and functional retinal impairment in patients with Parkinson disease without visual loss.

PURPOSE: To investigate the anatomic and electrophysiologic changes of the macula and the optic nerve in patients with Parkinson disease (PD) without visual impairment. METHODS: Thirty-two eyes of 16 patients with PD (group A) without visual impairment were tested. Visual acuity was 20/20 or better and visual fields as well as color vision testing results were normal. Also, no retinal lesions were assessed. Patients in group B (40 eyes of 20 patients) were age- and sex-matched control subjects. All study participants underwent a comprehensive ophthalmic examination, multifocal electroretinogram (mfERG) recording, and optical coherence tomography (OCT) scan. Thickness of retinal nerve fiber layer (RNFL) along a 3.4-mm-diameter circle centered on the optic nerve head was evaluated using third-generation OCT. RESULTS: The mean P1-response density amplitude of ring 1 of mfERG was 136.69 nV/deg2 in patients with PD and 294 nV/deg2 in control subjects and the difference was highly significant. On the contrary, these values in ring 2 and 3 did not differ statistically between controls and patients with PD. The mean inferior and temporal RNFL thickness was significantly lower in patients with PD than in control subjects (p<0.0001 and p=0.0045, respectively). CONCLUSIONS: In patients with PD with normal vision, we found a decrease in the electrical activity of the fovea as well as in the thickness of the RNFL. Multifocal electroretinogram and OCT scan objectively detect early subclinical PD-associated visual functional impairment.

The ice pack test in the differential diagnosis of myasthenic diplopia.

PURPOSE: To investigate the diagnostic value and to establish threshold criteria for the ice pack test as an office preliminary test in the differential diagnosis of myasthenic diplopia in comparison with blepharoptosis. DESIGN: Prospective, comparative cohort study. PARTICIPANTS: Eighty-nine patients with a recent onset of diplopia, blepharoptosis, or both were evaluated with orbital cooling in a prospective manner. Forty-eight patients presented with diplopia, 25 patients with both blepharoptosis and ophthalmoplegia and 16 patients with blepharoptosis. TESTING: All patients had the ice pack applied for 5 minutes on both eyelids at the initial orthoptic evaluation. Increasing the duration of cooling to 10 minutes was investigated in 36 diplopic patients. A complete diagnostic work-up was ordered and patients were followed up for a minimum of 6 months before diagnosis of myasthenia gravis was ascertained. MAIN OUTCOME MEASURES: Difference in cover test measurements in primary position or marginal reflex distance before and after the application of the ice pack, specific cause for diplopia and blepharoptosis. RESULTS: Fifteen patients were diagnosed as myasthenic. The optimal cutoff point for a positive response to the ice pack test proved to be a reduction in ocular deviation in primary position by 50% or by 10 prism diopters (PD) or more for presenting deviations larger than 20 PD. By this criterion, sensitivity for the detection of myasthenic diplopia was 76.9% (95% confidence interval [CI], 49.06%-92.50%) for the 5-minute application, compared with 92.3% (95% CI, 63.5%-98.9%) sensitivity demonstrated for blepharoptosis. Increasing the time of application to 10 minutes did not improve the diagnostic value of the test. Specificity was high (98.3%; 95% CI, 90.3%-99.9%) and was demonstrated even in patients with coexisting myasthenic and dysthyroid ophthalmopathy. Patients with oculomotor nerve paresis and Horner syndrome invariably were nonresponsive to the test. CONCLUSIONS: The ice pack test demonstrated high specificity and an acceptable sensitivity in the differential diagnosis of myasthenic diplopia. Data from this series suggest that a partial rather than a complete response to the ice pack test may be expected for myasthenic diplopia. Standardization of the method of application of the ice pack is critical for the interpretation of its effect.

Role of the H1 haplotype of microtubule-associated protein tau (MAPT) gene in Greek patients with Parkinson's disease.

BACKGROUND: The extended tau haplotype (H1) that covers the entire human microtubule-associated protein tau (MAPT) gene has been implicated in Parkinson's disease (PD). Nevertheless, controversial results, such as two studies in Greek populations with opposite effects, have been reported. Therefore, we set out to determine whether the H1 haplotype and additional single nucleotide polymorphisms (SNPs) included in H1 are associated with PD in a sample of Greek patients. METHODS: We analysed MAPT haplotypes in cohorts of 122 patients and 123 controls of Greek origin, respectively. SNP genotyping was performed with Taqman assays and genotyping results were confirmed by sequencing. RESULTS: The presence of the H1 haplotype was significantly associated with PD (odds ratio for H1H1 vs. H1H2 and H2H2: 1.566; 95% CI: 1.137-2.157; P = 0.006) and remained so after adjustment for sex. Further analysis of H1 sub-haplotypes with three single nucleotide polymorphisms (rs242562, rs2435207 and rs3785883) demonstrated no significant association with PD. CONCLUSION: Our data support the overall genetic role of MAPT and the H1 haplotype for PD susceptibility in Greek patients. However, the previously supported association of H1 sub-haplotypes with PD could not be confirmed in our study.

A voxel-by-voxel parametric fMRI study of motor mental rotation: hemispheric specialization and gender differences in neural processing efficiency.

Differences between men and women in brain size, cognitive performance and lateralization of brain activation have been perennial and controversial issues. Here we show that in a motor mental rotation task where women and men performed equally well, the slope of the functional magnetic resonance imaging (fMRI) blood oxygenation level dependent (BOLD) signal per degree of mental rotation was overall 2.4x higher in men than in women. This was attributed to the much more inefficient engagement (i.e. higher slopes) of the right hemisphere by men (mainly the frontal lobe). These findings indicate that women process information much more efficiently than men, which could offset smaller brain size.