Therapeutic singing as an early intervention for swallowing in persons with Parkinson's disease.

OBJECTIVE: For persons with Parkinson's disease (PD), secondary motor symptoms such as swallow impairment impact the quality of life and are major contributors to mortality. There is a present need for therapeutic interventions aimed at improving swallow function during the early stages of PD. The purpose of this pilot study was to examine the effects of a group therapeutic singing intervention on swallowing in persons with PD with no significant dysphagia symptoms. DESIGN: Cohort study. SETTING: University in the United States. PARTICIPANTS: Twenty-four participants with PD. INTERVENTION: Eight weeks of group therapeutic singing. MAIN OUTCOME MEASURES: Electromyography (EMG) was used to assess muscle activity associated with swallow pre and post the group singing intervention. Swallow quality of life (SWAL-QOL) and the Unified Parkinson's Disease Rating Scale (UPDRS) were also obtained pre- and post-intervention. RESULTS: Participants reported minimal difficulty with swallowing, yet results revealed a significant increase in EMG outcome measures, as well as significant improvement in UPDRS total and UPDRS motor scores. No significant differences were revealed for SWAL-QOL. CONCLUSION: Increases in EMG timing measures may suggest that group singing results in the prolongation of laryngeal elevation, protecting the airway from foreign material for longer periods of time during swallow. Combined with the improvement in UPDRS clinical measures, therapeutic singing may be an engaging early intervention strategy to address oropharyngeal dysphagia while also benefiting additional clinical symptoms of PD.

C60 secondary ion mass spectrometry with a hybrid-quadrupole orthogonal time-of-flight mass spectrometer.

A hybrid quadrupole orthogonal time-of-flight mass spectrometer optimized for matrix-assisted laser desorption ionization (MALDI) and electrospray ionization has been equipped with a C 60 cluster ion source. This configuration is shown to exhibit a number of characteristics that improve the performance of traditional time-of-flight secondary ion mass spectrometry (TOF-SIMS) experiments for the analysis of complex organic materials and, potentially, for chemical imaging. Specifically, the primary ion beam is operated as a continuous rather than a pulsed beam, resulting in up to 4 orders of magnitude greater ion fluence on the target. The secondary ions are extracted at very low voltage into 8 mTorr of N 2 gas introduced for collisional focusing and cooling purposes. This extraction configuration is shown to yield secondary ions that rapidly lose memory of the mechanism of their birth, yielding tandem mass spectra that are identical for SIMS and MALDI. With implementation of ion trapping, the extraction efficiency is shown to be equivalent to that found in traditional TOF-SIMS machines. Examples are given, for a variety of substrates that illustrate mass resolution of 12,000-15,600 with a mass range for inorganic compounds to m/ z 40,000. Preliminary chemical mapping experiments show that with added sensitivity, imaging in the MS/MS mode of operation is straightforward. In general, the combination of MALDI and SIMS is shown to add capabilities to each technique, providing a robust platform for TOF-SIMS experiments that already exists in a large number of laboratories.

Deep vein thrombosis assessment clinic: Evaluation of a new working practice.

Suspected deep vein thrombosis (DVT) is a common reason for medical referral to hospital. We evaluated our new approach to assessment of DVT using combined automated strain gauge plethysmography and pretest probability score in comparison with venous ultrasonography in 100 consecutive patients with suspected DVT referred to the nurse-led clinic. The combined plethysmography and pretest probability score produced a negative predictive value of 99%, positive predictive value 53%, sensitivity 94% and specificity 83% for detection of a DVT. We conclude that our new working practice for DVT assessment is both safe and cost effective and can lead to a reduction in venous ultrasonography of approximately 70%.

Maintenance of bone density: outcomes over five years of attendance at an osteoporosis center.

BACKGROUND: This is a longitudinal analysis of the data from women who visited the Osteoporosis Prevention Center for at least five years. The study is part of an ongoing evaluation of the results of the Center visits. METHODS: A random sample of 100 women who had attended the clinic for more than five years and were not referred for a definite medical diagnosis was pulled from the records. Descriptive statistics were compiled on this sample. Seventy-five women were postmenopausal and over 49 years of age. This subgroup was studied for change in bone mineral density (BMD) over the five years. RESULTS: The BMD change was 0.03 gm/cm2 in the spine, -0.01 gm/cm2 in the femoral-neck. and -0.008 gm/cm2 at the radius over the five years. CONCLUSION: Attendance at the Osteoporosis Prevention Center was associated with maintenance of bone density in the spine over a five-year period.

Management of patients treated with aspirin or warfarin and evaluation of haemostasis prior to prostatic biopsy: a survey of current practice amongst radiologists and urologists.

AIM: To document current practice concerning the management of patients taking aspirin or warfarin and the evaluation of haemostatic function prior to prostatic biopsy. METHOD: A postal survey was performed with typed questionnaires being sent to 275 urology and 275 radiology centres. RESULTS: A high proportion of radiology departments in particular (83%) had protocols in place concerning the management of aspirin or warfarin prior to prostatic biopsy. A significant proportion of both radiologists and urologists have postponed biopsies due to patients unexpectedly taking these medications. Few of the respondents reported the use of pre-biopsy screening blood tests. Fifty-two percent of radiologists and 27% of urologists terminated aspirin prior to prostatic biopsy, although the urologists stopped aspirin for a long time period. Ninety-five percent of radiologists and 84% of urologists terminated warfarin prior to prostatic biopsy, although again the urologists stopped warfarin at an earlier stage. Most of those respondents who stopped warfarin prior to biopsy, also checked the INR. The urologists generally stated a higher threshold (INR) which would be considered too high to proceed. CONCLUSION: There are wide variations in practice both within and between the radiology and urology groups. This is unsurprising, since there is conflicting advice in the relevant literature.

Herniography in the investigation of groin pain in adults.

Herniography is a useful investigation in adults with unexplained groin pain in whom there is no clinical evidence of a hernia, thus ensuring appropriate surgery. The technique is described, normal anatomy and different types of hernias illustrated.

Lemierre syndrome: a complication of acute pharyngitis.

Lemierre syndrome, otherwise known as postanginal sepsis or necrobacillosis, is an illness that originates as an acute pharyngitis or tonsillitis which progresses to sepsis, usually fusobacterial, due to suppurative thrombophlebitis of the internal jugular vein. Septic thromboemboli then seed various organs, resulting in multiple organ system pathology, most commonly affecting pulmonary and hepatic systems and joints. Although rare in the age of antibiotics, this disease typically affects previously healthy adolescents with varied clinical manifestations depending upon organ system involvement (A. Lemierre, Lancet March (1936) 701-703; J. Barker, H.T. Winer-Muram, S. Grey, Southern Med. J. 89 (1996) 1021-1023). Prompt diagnosis based on clinical presentation, radiologic findings, particularly CT scanning with contrast and a high index of suspicion, is necessary in order to institute often life saving therapy (J. Barker, H.T. Winer-Muram, S. Grey, Southern Med. J. 89 (1996) 1021-1023). We will present two cases of Lemierre syndrome, review it's clinical presentation, anatomic considerations, particularly it's relationship to the parapharyngeal space, radiographic findings, potential life threatening complications and finally, a unique approach to therapy.

Enterocele revealed by simultaneous evacuation proctography and peritoneography: does "defecation block" exist?

OBJECTIVE: Pelvic floor weakness may allow prolapse of the bowel into the rectogenital space, forming an enterocele. Enteroceles are believed to obstruct defecation by rectal compression and are therefore considered an abnormal finding on evacuation proctography. With a technique combine evacuation proctography and peritoneography, we prospectively studied constipated patients to reveal the pelvic peritoneal recesses during evacuation and to determine if enterocele actually impairs rectal emptying. SUBJECTS AND METHODS: Fifty constipated patients were studied prospectively, Using 20 ml of water-soluble contrast medium, we performed peritoneography, then evacuation protography with 120 ml of intrarectal paste. Lateral evacuation and posteroanterior stress views were analyzed by computerized video capture. Anatomic features and functional measurements of rectal emptying were noted. Posteroanterior views were compared with views in 31 subjects undergoing peritoneography for investigation of groin pain. RESULTS: Technical failure in three patients left 47 for analysis. A deep rectogenital pouch was seen in 36 patients (77%). Of these, 12 (58%) contained viscera that formed an enterocele, but the remaining 15 patients (42%) showed no visceral filling. Most pouches were apparent only during straining (31 cases, 86%). Peritoneal descent was greater than in controls (p < .0001), of whom only three had small rectogenital pouches. Patients with enterocele were compared with those who had a rectogenital pouch but no visceral filling and those who had no pouch. Standard anatomic measurements by evacuation proctography were not significantly different, but patients with enterocele evacuated more rapidly (p = .008) and completely (p = .021) than did the other two groups. CONCLUSION: Combined evacuation proctography and peritoneography is a new technique to diagnose pelvic hernias that occur during evacuation. This technique has shown that a deep rectogenital pouch is common in constipated patients and that just over half such pouches fill with viscera. However, because an enterocele does not impair rectal evacuation, this proctographic finding should be interpreted with caution.

Osteonecrosis of the humeral head in sickle cell disease.

To determine the effects of sickle cell disease on the glenohumeral joint, 28 shoulders in 14 patients with SS sickle cell hemoglobinopathy were studied clinically and roentgenographically. patients were randomly selected; their mean age was 46 years (range, 22 to 63 years). Pain, stability, and function of the shoulders were assessed, and roentgenograms were evaluated for osteonecrosis. All 28 shoulders had some degree of pain with activity, but functional range of motion was maintained despite symptoms. Seventy-one percent of the patients had had total hip arthroplasty and 21% had had total knee arthroplasty for osteonecrosis; there was a mean of 1.5 previous joint implants per patient. Our study results show that, in patients with sickle cell hemoglobinopathy, symptoms of humeral head osteonecrosis are better tolerated than those of osteonecrosis in the lower extremities, delaying the need for surgical intervention. With severe pain and functional limitations, shoulder arthroplasty is the procedure of choice in this patient population. However, the risks are greater for patients with sickle cell disease than for other patients who have humeral head osteonecrosis, and thorough preoperative medical and anesthesia evaluations are necessary. These patients require perioperative transfusion or plasmapheresis and sufficient intraoperative hydration and oxygenation to avoid precipitating a sickle cell crisis; in addition, use of methyl methacrylate should be avoided.

Evaluation of herniography in the diagnosis of an occult abdominal wall hernia in symptomatic adults.

Outpatient herniography as a means of confirming or refuting the presence of an occult abdominal wall hernia was performed in 50 symptomatic patients, including 13 who had previously undergone hernia repair. Altogether 30 occult hernias were detected in 27 patients, only one of which was considered to be unrelated to the presenting symptoms. On the basis of herniography, 17 patients were spared surgical exploration and, of these 17, 16 obtained a good result. One further patient with a clinically apparent hernia on one side but with contralateral symptoms was spared unnecessary surgery because the contralateral side was radiologically normal. There was one false negative and no false positive examinations. There were three minor complications: two cases of sigmoid colon puncture and one of abdominal wall haemorrhage (all managed conservatively). There were two technical failures. These results support the Scandinavian experience that herniography has a useful role in the management of patients who may have occult hernias as the underlying cause of abdominal wall symptoms.

Diffuse "encephalitic" cerebral toxoplasmosis in AIDS. Report of four cases.

Four patients with AIDS presented with a rapidly fatal global neurological illness. CT did not show any focal lesion and gross post mortem examination of the brain was normal in three of the four cases. Microscopic examination revealed numerous widespread microglial nodules in the brain parenchyma, most containing central toxoplama cysts or free tachyzoites. Such diffuse, non-necrotic, "encephalitic" forms of cerebral toxoplasmosis appear unique to AIDS and, to our knowledge, have not been documented previously. They represent a treatable, often misdiagnosed cause of diffuse neurological involvement in AIDS patients.