[Clinical and economic aspects of laparoscopic surgery for acute cholecystitis in delayed presentation]. / Kliniko-ekonomicheskie aspekty laparoskopicheskikh operatsii pri ostrom kholetsistite v usloviyakh pozdnei gospitalizatsii.

OBJECTIVE: To study the clinical and economic features of laparoscopic surgery for acute cholecystitis in delayed presentation. MATERIAL AND METHODS: A prospective non-randomized study (2020-2021) included 101 patients (73.2% (n=74) men and 26.8% (n=27) women, mean age 58±14.9 years) with acute cholecystitis who underwent laparoscopic cholecystectomy. Cost-effectiveness analysis of laparoscopic cholecystectomy at various periods after clinical manifestation was performed. RESULTS: Surgical treatment within 72 hours was performed in 15% (n=16) of cases (group 1), within 4-10 days - in 57.5% (n=58) (group 2), after 10 days - in 26.7% (n=27) of patients (group 3). Overall incidence of postoperative complications was 2.9%, postoperative mortality - 1.9% (two patients died from widespread peritonitis). Surgery time was 70 [65-83], 85 [69-110] and 115 [80-125] min (H=15.55, p<0.001), hospital-stay - 6 [5-7], 9 [7-10] and 11 [7-14] days, respectively (H=21.86, p<0.001). Cost of direct (medical and non-medical) treatment amounted to 29484 [27 509-33 885], 41265 [34 306-48 301] and 50591 [37 069-62 483] rubles, respectively (H=29.71, p<0.001)). CONCLUSION: Delayed hospitalization and surgical treatment of acute cholecystitis after 72 hours are accompanied by higher treatment costs by 29% in the period up to 10 days and by 58% after 10 days. These results require further validation and adjustment in large samples.

Visual evoked potential abnormalities in migraine patients.

BACKGROUND: Visual processing in migraine has been targeted indicating that the visual pathways are involved in the migraine pathophysiology. We aimed to assess the nature of visual evoked potential (VEP) changes in migraine patients and to evaluate the role of VEP in the diagnosis of migraine. MATERIALS AND METHODS: We examined 31 female and 10 male patients with a migraine headache diagnosis according to the criteria of the International Headache Society. Control subjects had neither migraine and other types of primary headache nor familial history. VEP were elicited using a checkerboard by monocular and binocular pattern reversal stimulation. The latencies of N75, P100 and N145 and peak-to-peak amplitude of N75-P100 were measured. We compared VEP latencies and amplitudes of the monocular and binocular stimulation within each population. RESULTS: The N75 and P100 latencies were found to be significantly longer in the study group than the control group (p = 0.014 and p = 0.034, respectively) while the amplitudes in the study group were lower (p = 0.014). N145 latency was found to be longer in patients with longer duration of disease (p < 0.05). P100 latency was found to be significantly longer in patients with aura than the patients without aura (p = 0.029). N75 latency, recorded by left monocular stimulation, was elongated and the amplitude was diminished with left hemicranial headache. CONCLUSION: Measurement of VEP latency and amplitude is a valuable and reliable test for the diagnosis of migraine. Our results reflect a persisting dysfunction of precortical visual processing which might be relevant in the pathogenesis of migraine.

The role of somatosensory evoked potentials in the diagnosis of lumbosacral radiculopathies.

Electrophysiologic studies have an important role in the diagnosis of lumbosacral radiculopathies. Electrophysiologic methods which are used conventionally are needle electromyography (EMG), late responses (F wave and H reflex), and nerve conduction studies. Somatosensory evoked potentials (SEPs) are also important complementary diagnostic methods in the electrophysiologic evaluation of lumbosacral radiculopathies. In this study, we aimed to determine whether SEPs have an advantage over the conventional electrophysiologic methods or whether sensory nerve stimulated SEPs over mixed nerve stimulated ones or the lumbar recordings over the scalp recordings in diagnosing lumbosacral radiculopathies. For this reason, the study included 20 patients with unilateral and unilevel S1 radiculopathy due to intervertebral disc herniation confirmed by clinical examination and magnetic resonance imaging (MRI) as the patient group. And a control group of 18 healthy subjects were also included in the study. Nerve conduction studies, late responses and scalp and lumbar-recorded SEPs after sural and posterior tibial nerve stimulation were studied in both groups, while needle EMG was performed only in the patient group. Patients who manifested abnormal findings on needle EMG or on late responses also showed abnormal findings on at least one type of the SEPs. SEPs detected abnormalities in 5 patients (25%) in whom needle EMG or late responses did not suggest any abnormality. In this study we concluded that SEPs may provide diagnostic information beyond conventional electrodiagnostic methods and that lumbar-recorded SEPs may have an advantage over scalp-recorded ones and sensory nerve stimulated SEPs over mixed nerve stimulated ones.

Brainstem auditory evoked potentials and middle latency auditory evoked potentials in patients with impaired glucose tolerance.

AIMS: The aim was to investigate the effects of impaired glucose tolerance (IGT) on the central nervous system via brainstem auditory evoked potentials (BAEPs) and middle latency auditory evoked potentials (MLAEPs), and on the peripheral nervous system via nerve conduction studies (NCS). METHODS: Thirty patients with IGT and 20 control subjects underwent NCS, BAEPs and MLAEPs. RESULTS: Tibial distal motor latencies were significantly prolonged in the IGT group; no differences in other parameters, including BAEPs and MLAEPs, were observed between the IGT and control subjects. CONCLUSION: Brainstem involvement may not be seen in IGT patients as in DM. The was no obvious electrophysiological finding indicating peripheral nervous system disfunction in our patients.

The effect of piracetam on ataxia: clinical observations in a group of autosomal dominant cerebellar ataxia patients.

OBJECTIVES: Autosomal dominant cerebellar ataxias are clinically and genetically heterogeneous neurodegenerative disorders. There is no known treatment to prevent neuronal cell death in these disorders. Current treatment is purely symptomatic; ataxia is one of the most disabling symptoms and represents the main therapeutic challenge. A previous case report suggesting benefit from administration of high dose piracetam inspired the present study of the efficacy of this agent in patients with cerebellar ataxia. Piracetam is a low molecular weight derivative of gamma-aminobutyric acid. Although little is known of its mode of action, its efficacy has been documented in a wide range of clinical indications, such as cognitive disorders, dementia, vertigo and dyslexia, as well as cortical myoclonus. The present report investigated the role of high dose piracetam in patients with cerebellar ataxia. METHODS: Eight patients with autosomal dominant cerebellar ataxia were given intravenous piracetam 60 g/day by a structured protocol for 14 days. The baseline and end-of-the study evaluations were based on the International Cooperative Ataxia Rating Scale. RESULTS: Statistical analysis demonstrated a significant improvement in the patients' total score (P = 0.018) and a subscale analysis showed statistical significance for only the posture and gait disturbances item (P = 0.018). CONCLUSION: This study is providing good clinical observation in favour of high dose piracetam infusion to reduce the disability of the patients by improving their gait ataxia.

A comparison of sural nerve conduction studies in patients with impaired oral glucose tolerance test.

OBJECTIVE: Monitoring of the sural nerve is a sensitive method for detection of neuropathies. We examined different methods of studying sural nerve conduction in a group of patients with impaired glucose tolerance (IGT) in the same study. MATERIALS AND METHODS: Several parameters of sural nerve were investigated in 20 patients. First, sensory nerve conduction studies of the sural nerve were performed on the distal-leg and the proximal-leg segments. Second, dorsal sural nerve studies were conducted. Third, the sural/radial sensory nerve action potential (SNAP) amplitude ratios were calculated. The results were compared with those obtained from 21 healthy controls. RESULTS: Abnormal results revealing peripheral neuropathy were found in only one patient and dorsal sural SNAP was absent in another patient (5%). Although the results of nerve conduction studies were within normal ranges except the patient with peripheral neuropathy, the lower extremity nerves and especially sural nerves have been found to be more affected and the parameters revealed large differences between groups (P < 0.05). Only dorsal sural nerve latency related to fasting blood glucose level in patients (<0.05). DISCUSSION AND CONCLUSIONS: Sural nerve studies should be of value to determine neuropathy in IGT patients. This study supported the idea that IGT is a transitional state before diabetes and also the importance of the dorsal sural nerve latencies for early detection of neuropathy.

Neuromuscular status of thyroid diseases: a prospective clinical and electrodiagnostic study.

With this study, it has been intended to evaluate the neuromuscular symptoms and findings observed in patients with the diagnoses of hyperthyroidism and hypothyroidism. This study included 21 patients with hyperthyroidism, 19 patients with hypothyroidism and a control group comprised of 29 healthy persons. In the patient group with hypothyroidism, the increase in the median motor distal latency and the median sensorial distal latency (p < 0.0001), the reduction in the median sensory action potential amplitude (p < 0.01) and the slowing in the velocity of nerve conduction (p < 0.01) were found significantly different when compared to the control group. H-reflex latencies were determined to be significantly longer bilaterally (p < 0.01). In the patient group with hyperthyroidism, only the reduction in the median sensory action potential amplitude and the prolongation in the distal latency (p < 0.05) were significant. As for the lower extremities, the slowing in the velocity of the nerve conduction of bilateral peroneal (p < 0.0001), the prolongation in the peroneal F-wave latency (p < 0.01), the slowing in the velocity of the nerve conduction of bilateral tibial nerve (p < 0.05), the prolongation in the tibial F-wave latency (p < 0.01), the prolongation in the sural nerve distal latency (p < 0.0001) and the reduction in the sensory action potential amplitude (p < 0.05) were determined to be significantly different compared to the control group. Among the thyroid patients, 17 (42.5%) patients were diagnosed with mononeuropathy and polyneuropathy. Entrapment neuropathy was observed in 30% and diffuse neuropathy in 10% of the patients. Mypopathy findings were observed in 2 patients.

Median sep and blink reflex in thyroid diseases.

Pathological disturbances of thyroid hormones is associated with central and peripheral nervous system disturbances. The aim of this study is to evaluate median nerve stimulated somatosensory evoked potential (SEP) and blink reflex of thyroid patients (hypo and hyperthyroidism). Median SEP was performed in 40 patients (21 with hyperthyroidism and 19 with hypothyroidism). We evaluated the latencies of N9, N11, N13, P9, P11, P14, N20 and P25 waves and the N9-N20, N9-N13, N13-N20 and P14-N20 interpeak latencies. We compared the results of patients with the control group (26 persons). We found that the N20 latency was longer in patients with hyperthyroidism than in the control group and the difference was statistically significant. There was not any statistically significant difference regarding the N9, N11, N13, P9, P11, P14, N20 and P25 latencies and the N9-N20, N9-N13, N13-N20 and P14-N20 interpeak latencies between hypothyroid patients and controls. We performed the blink reflex study in 28 of 40 patients (14 patients with hyperthyroidism and 14 patients with hypothyroidism). Comparing the R1, R2, CR2 (contralateral R2) latencies and durations of the patients and controls, we found that R2 and CR2 duration was shorter in patients with hyperthyroidism. This difference was statistically significant.

The electrophysiological findings of subclinical neuropathy in patients with recently diagnosed type 1 diabetes mellitus.

To assess the prevalence of subclinical neuropathy within the first year of type 1 diabetes mellitus, 30 patients and 14 healthy subjects have been studied prospectively. The patients whose diabetes duration was longer than 1 year have been excluded from the study. Control group consisted of healthy volunteers. Subjective neuropathy symptoms, neurological examination, and electrophysiological findings were evaluated. All patients were clinically asymptomatic. At least two abnormal independent neurophysiological nerve parameters, which were required as the criterion of the peripheral nervous system subclinical involvement, were found as in 96.6% of diabetic patients in the first years. The percentages of abnormal electrophysiological parameters in different motor and sensory nerves were 86.7% in sural nerve, 83.3% in peroneal motor nerve, 73.3% in posterior tibial motor nerve, 66.7% in median motor nerve, 63.3% in ulnar motor nerve, 60% in median sensory nerve, and 46.7% in ulnar sensory nerve. While distal motor latency, F conduction time, and minimum F latency were the most frequent abnormal parameters in the upper extremity electrophysiological study; conduction velocity, minimum and mean F latencies, F conduction time were the most frequent abnormal parameters in the lower extremity. In all sensory nerve conduction studies, the most frequent abnormal parameter was the onset latency. In the autonomic sympathetic nerve electrophysiological study, plantar SSR latency was found significantly longer than the control group. In the lower extremity generally somatic motor fibres, sensory large fibres and sympathetic autonomic nerve fibres were found to be more affected. There is a correlation between HbA1c levels and nerve conduction velocity in posterior tibial and peroneal nerves. However, upper extremity nerve conduction dysfunction was not correlated with HbA1c value. Neither the duration of disease nor the age of the subject correlated with the nerve dysfunction.

Ulnar nerve entrapment at wrist associated with carpal tunnel syndrome.

In this study, ulnar nerve entrapments at the wrist were investigated using nerve conduction studies in cases with established diagnosis of carpal tunnel syndrome (CTS). Cases with cervical radiculopathy and polyneuropathy as well as patients with ulnar nerve entrapment at elbow were excluded from the study. Fifty-three cases (46 females, seven males) whose ages ranged between 20 and 72 years (mean: 49.31 +/- 13.78) were evaluated. Among 53 cases, 12 (22.6%) bilateral and 41 (77.3%) unilateral CTS were detected. Totally 65 wrists evaluated and prolongation of median nerve wrist-3rd digit distal sensory latencies (DSL; N: 59; 90.7%) and wrist-abductor pollicis brevis distal motor latencies (N: 48; 73.8%) were seen. In six wrists, diagnoses were established with the detection of an increase in the differences between wrist-4th digit DSL of median and ulnar nerve. This test was used if other test results were in normal limits. Prolongation of ulnar nerve wrist-5th digit DSL were found in 12 wrists (18.4%) in cases with CTS. Among these 12 wrists mild (N: 2), moderate (N: 7) and severe (N: 3) CTS were detected. Ulnar nerve motor conduction studies provided normal results. In conclusion, we are in the opinion that for the detection of associated ulnar nerve wrist entrapments, ulnar nerve conduction studies paying special attention to DSL convey importance in established cases with CTS.

Sympathetic skin response and R-R interval variation in cases with rheumatoid arthritis.

To investigate the autonomic nervus system involvement in cases with rheumatoid arthritis (RA) by assesing sympathetic skin response (SSR) and R-R interval variation (RRIV), 14 healthy women and 10 women with RA, all of them without clinic dysautonomies were examined. SSR's were recorded palmar surface of both hands and soles of both feet, after stimulating median and tibial nerves individually. RRIV's were assessed at rest and during six deep breathing in one minute with electrodes placed on dorsal surfaces of both hands. SSR could not be obtained from lower extremities of one case with RA. We could not find any significant difference between two groups in terms of SSR latencies. RRIV values obtained during deep breathing to those recorded at rest (D%/R%) was found to be significantly lower in RA cases than healthy controls. RRIV values increased with deep breathing in healthy subjects, while they decreased in 50% of the RA cases. We conclude that assessment of SSR and RRIV are valuble methods for revelation of subclinical autonomic involvement in cases with RA.

A-waves and electrophysiologically established diagnoses.

The aim of this study was to investigate the presence of A-waves in cases referred to our electromyography laboratory with various diagnoses and documentation of electrophysiologic diagnoses with A-waves. In cases where at least 3 motor nerves were analysed, during F response studies, A-waves having stabile latencies and amplitudes from minimum one third of submaximal and supramaximal stimuli were evaluated. Electrophysiologic diagnoses and the related nerves of cases with A-waves were recorded. A-waves were obtained from 38 out of 1604 cases (2.36%). Most of the cases (57.8%) with established A-waves consisted of patients with radiculopathies. A-waves were detected mostly in tibial nerve. Electrophysiologic analysis of 5 cases with A-waves has given normal results. Although mechanism of A-waves is not known completely, we suggest when obtained it must be remarked during routine electrophysiologic examination.

Evaluation of autonomic nervous system functions in post-stroke patients.

OBJECTIVE: In this study, we aimed to investigate whether there is a sympathetic and parasympathetic system dysfunction in hemiplegic or hemiparetic patients after a cerebrovascular accident. DESIGN: Sympathetic skin response and R-R interval variation were evaluated in a total of 65 subjects: 37 hemiparetic or hemiplegic patients due to a cerebrovascular accident, seven acute (<30 days) and 30 chronic, with a mean age of 59.16 yr (32-76 yr), and 28 healthy subjects with a mean age of 57.07 yr (45-75 yr). Disease duration was 6.89 mo (1-32 mo) in the patient group. Bilateral sympathetic skin responses were recorded with stimulation of median nerves in both affected and unaffected sides. R-R interval variation was evaluated at rest (R%) and during deep breathing (DB%) at six times per minute. RESULTS: Although there was no significant difference between sympathetic skin response latencies of the patient and the control groups, the amplitude values of sympathetic skin response in patients were significantly lower than those in controls (P < 0.05). Both R% and DB% in patients significantly increased as compared with controls (P < 0.001 and P < 0.05, respectively). CONCLUSION: In conclusion, our results suggest that both sympathetic and parasympathetic functions in post-stroke survivors were partially inhibited, and this finding may be useful in the prediction of possible complications during rehabilitation.

Anterior tarsal tunnel syndrome.

Three hundred twenty patients complaining of pain and/or numbness of their feet were evaluated in our Clinical Neurophysiology Laboratory. Nerve conduction studies of deep peroneal, superficial peroneal, sural and posterior tibial nerves were studied bilaterally. Needle electromyography (EMG) of anterior tibial, long peroneal, abductor hallucis longus, extensor hallucis longus, gastrocnemius and extensor digitorum brevis muscles were examined bilaterally. Nerve conduction studies of 25 healthy volunteer subjects (16 female, 9 male, age range 36-70, mean age 52.82 +/- 8.8) with no complaint composed the control group. Fourteen of these patients (8 female, 6 male, age range 40-70, mean age 55.73 +/- 12.04) were found to have anterior tarsal tunnel syndrome (anterior TTS) bilaterally or unilaterally. In the patients with anterior TTS, the nerve conduction studies revealed deep peroneal nerve distal latency as 6.5 +/- 1.9 msec; the amplitude as 1.8 +/- 1.3 mV at the ankle level; and the conduction velocity as 41.5 +/- 5.9 m/sec in the distal segment. When these values were compared with the control group statistically, results were found highly significant (p < 0.005). Needle EMG findings in the anterior TTS group showed only in the extensor digitorum brevis muscle. Other nerves and muscles were normal. All patients with anterior TTS were performing Namaz for years, and none of them had the predisposing factor which may cause entrapment neuropathy. So, we suggest that chronic prolonged stretching of the deep peroneal nerve on the dorsum of the foot during Namaz may cause anterior TTS.

Normative data of sympathetic skin response and RR interval variation in Turkish children.

Sympathetic skin response (SSR) and RR interval variation (RRIV) are used commonly for the assessment of sympathetic and parasympathetic nervous system function, respectively. We determined the normal values of SSR and RRIV in 23 (14 females, nine males) Turkish children aged 5 to 14 (mean 9.86, SD 2.48) years. SSR was recorded on the hands and feet during the electrical stimulation of both median and posterior tibial nerves, respectively. Similar response was elicited on both feet during the stimulation of the right median nerve. RRIV testing was performed during rest on the supine position and deep inspiration at a frequency of 6 times/min. The SSR was elicited in all children. The mean SSR latencies recorded on the feet during the stimulation of median or posterior tibial nerve were significantly more prolonged than those recorded at the hands (P < 0.001). There was no significant difference between the mean latencies of SSR recorded at the ipsilateral and contralateral palms or soles. The mean latencies recorded at the sole during stimulation of the median nerve were not significantly different compared to those that recorded at the sole during the posterior tibial nerve (P > 0.05). The SSR amplitudes were not assessed because of great variability and rapid habituation. The mean RRIV (46.54+/-11.29%) during deep breathing was significantly increased as compared to that (35.90+/-10.63%) during rest (P < 0.003). As a result, SSR and RRIV are preferred non-invasive tests for evaluation of autonomic nervous system in children. The SSR is useful and reliable if it is obtained in the optimum technical conditions. Further research is necessary to establish strict criteria for abnormality.

Magnetic stimulation in the determination of lumbosacral motor radiculopathy.

Magnetic stimulation was utilised to diagnose lumbosacral motor radiculopathy non-invasively. Magnetic coil stimulation estimated peripheral motor nerve conduction time (MNCT) which, used in combination with F response, allowed calculation of "motor root conduction time (MRCT)," response being recorded from abductor hallucis. Twenty-five normal controls and 26 patients with lumbar spondylosis were studied. The mean interside difference (left minus right) of MRCT in the control was +0.06 msec (range: -0.88 to +0.74 msec). On clinical and radiological grounds, patients with spondylosis were grouped into those with: (I) no lumbosacral root compression, (II) root compression without motor sign, and (III) root compression with motor deficit. All patients in group III and 36% of cases of group II had MRCT significantly prolonged on the affected side.

Intrathecal synthesis of beta-2-microglobulin in multiple sclerosis and aseptic meningo-encephalitis.

Beta-2-microglobulin (beta 2m) levels were studied in the cerebrospinal fluid (CSF) and plasma of 52 patients with clinically definite multiple sclerosis (MS) and of 14 with aseptic meningo-encephalitis (AM). Reference values for beta 2m were defined in 72 subjects of different age groups with tension headache (TH). Plasma levels of beta 2m increased with age in TH controls, particularly in the older age group, while no significant age variation could be detected for CSF beta 2m. Increased levels of beta 2m were found in the CSF and plasma of AM patients and in the CSF in MS. Calculations of CSF/plasma beta 2m ratios showed higher values in AM, reflecting intrathecal beta 2m synthesis, while only borderline alterations were evident in MS. Demonstration of intrathecal production of beta 2m is an additional CSF finding that may be useful in evaluating, among others, inflammatory nervous system disorders, but it has limited importance in the study of MS patients.

Recurrent multiple cranial nerve palsies (Tolosa-Hunt plus?).

Twelve patients with recurrent cranial nerve palsies in whom no focal cause was found were seen during a period of 4 years. The literature is reviewed, and the relationship and similarity to Tolosa-Hunt syndrome is discussed. Early recognition is important since the response to steroids, although not specific, is rapid in most patients, and the prognosis for complete recovery is relatively good.