REM sleep behaviour disorder in Parkinson's disease: a questionnaire-based study.

The aim of the study was to determine the clinical frequency and features of REM sleep behaviour disorder (RBD) in a large population of Parkinson's disease (PD) patients using defined diagnostic criteria both for RBD and PD. Six trained neurologists used a semistructured questionnaire based on ICSD-R diagnostic criteria for RBD to evaluate 200 PD patients and their caregivers. Interobserver reliability for the diagnosis of RBD was "substantial" (Kappa 0.65). Five patients were excluded from the study because of an MMSE lower than 25. The demographic and PD clinical features were compared in the clinically defined RBD group and in those without RBD (NRBD). Then the RBD features during the last year were analysed in the affected group. Out of 195 patients, 66 fulfilled the ICSD-R criteria for RBD; 62 patients reported RBD during the last year (frequency 31.8%). RBD features: two or more episodes per week in 35.5%; upper limb movements in 87%; lower limb movements in 79%; vocalisations during events in 85%. RBD onset was before PD in 27% of patients; 69% of the RBD group had injured themselves or their caregivers during sleep. According to multivariate analysis, RBD was associated with male gender, age and PD duration. Brief training and the use of a semistructured questionnaire may help the neurologist in dealing with sleep disturbances in PD patients. The search for RBD symptoms in PD is highly recommended, especially in patients with a long disease duration, the risk of sleep-related injuries being high.

Validation of symptoms related to excessive daytime sleepiness.

The aim of this study was to validate some recurring definitions of excessive daytime sleepiness (EDS) obtained from descriptive epidemiological studies. We devised questions concerning concepts such as "tiredness", "resistible sleepiness", "irresistible sleepiness" and "sudden sleep attacks". The validation was done by comparing the answers with the results of the Multiple Sleep Latency Test (MSLT), considered the gold standard, or criterion measure, for the diagnosis of EDS. The sample study comprised 73 subjects, 57 outpatients referred to our Sleep Center complaining of daytime sleepiness, snoring or sleep apnea and 16 inpatients admitted to our Neurological Institute for causes other than sleep disorders. A moderate correlation (p = -0.38, 95% confidence interval -0.57 to -0.19) was found between "irresistible sleepiness" and mean sleep latency (MSL). The best combinations of sensitivity and specificity in identifying EDS, for 5- and 8-min MSL cutoffs, were observed for the questions concerning "sudden sleep attacks" and "irresistible sleepiness" (areas under the receiver-operating characteristic curves = 66 and 67%, respectively). The subitems exploring the frequency and situations of occurrence of these symptoms improved the validity in identifying EDS. The items regarding "tiredness" and "resistible sleepiness" were not related to the results of the MSLT. In subgroup analysis, irresistible sleepiness failed to identify pathologic MSLT in sleep-disordered breathing subjects. According to previous observations, we suggest that the concept of sleepiness includes various domains heterogeneously related with MSL and that questionnaires must be tailored to the different populations studied.

Pseudoexfoliation syndrome: a cohort study on intraoperative complications in cataract surgery.

Our aim was to determine the rate of intraoperative complications induced by pseudoexfoliation syndrome (PSX) in cataract surgery. We report our experience regarding 1,052 consecutive patients who underwent phacoemulsification. Exact logistic regression was used to examine the role of PSX in intraoperative complications. Odds ratio for intraoperative complications (vitreous loss, capsular break, zonular break) was estimated to be 5.1 for PSX present as compared to when it is absent. PSX was associated with a statistically significant increase in intraoperative complications during cataract surgery (p<0.0001).

Systemically circulating oxidative species in human deep venous thrombosis.

To investigate the hypothesis that plasmatic changes of lipoperoxidative markers are associated with deep venous thrombosis (DVT), peripheral venous blood samples were obtained from 10 patients with venographically proven DVT before starting anticoagulant therapy, and 36+/-3 and 60+/-3 hours later. Values of myeloperoxidase (MPO), 4-hydroxynonenal (HNE) and malondialdehyde (MDA) were compared with those of 10 age-matched control subjects. Despite individual variations, mean plasma MPO level was higher in the DVT group (p < 0.01), as were average plasma MDA (p < 0.001) and HNE (p < 0.01) levels. Separate analysis of the DVT cases showed that higher values of MDA, HNE and MPO were found in patients with either co-morbid diseases or clinically silent pulmonary embolism (PE). Good evidence exists for considering DVT a condition associated with an apparently excessive free radical production not buffered by efficient defence systems. A role of DVT itself cannot be excluded, but PE or other co-morbid diseases may participate in the oxidative stress. If confirmed in a larger series of patients, these findings could shed new light on the plasmatic changes associated with the propagation and complications of DVT, which in turn could have therapeutic implications.

Longitudinal study of pressed glass-ceramic inlays for four and a half years.

STATEMENT OF PROBLEM: Some restorative materials used in the posterior region of the mouth present conventional problems, such as microleakage, recurrent caries, wear, and poor color stability. PURPOSE: This study determined the reliability of the IPS Empress ceramic material for fabricating inlays and onlays in the posterior region of the mouth. MATERIAL AND METHODS: A total of 125 IPS Empress pressed glass ceramic inlays were placed for 29 patients in a private practice. The restorations were observed for a period of 7 to 56 months, with a mean of 40.3 months. All inlays were constructed in the same dental laboratory and the restorative materials used according to the manufacturers' instructions. The restorations were evaluated clinically according to modified U.S. Public Health Service criteria at the time of insertion and at periodic recall appointments. Kaplan-Meier statistics were used to calculate survival rates. RESULTS: Clinical evaluation revealed that pressed glass ceramic inlays, with the exception of four fractured restorations, were rated from Alpha to Bravo for each criteria. Marginal discoloration recorded the lowest percentage of alpha ratings (65.3%). The estimated survival rate after approximately a 4.5-year follow-up period was 95.63% (95% confidence interval; 90.77% to 99.95%).

Plasma lipoperoxidative markers in ischaemic stroke suggest brain embolism.

Plasma activity of myeloperoxidase (MPO), malondialdehyde (MDA) and 4-hydroxynonenal (HNE) was measured prior to any treatment in 50 consecutive stroke patients with acute cerebral ischaemia, as well as in 14 healthy control subjects. Mann-Whitney-Wilcoxon test for unpaired data showed greater values of MPO (p < 0.01), MDA (p < 0.01) and HNE (p < 0.05) in stroke patients compared with controls. Considering as covariates the level of consciousness (GCS < 9 vs > or = 9), possible sources of emboli (yes vs no), leukocyte count (< 10 x 10(9)/1 vs > or = 10 x 10(9)/1) and relevant comorbid diseases (yes vs no), exact multiple logistic regression analysis indicated that only the presence of possible cardiac sources of emboli was associated with changes in by-products of lipid peroxidation. If confirmed in a larger series of subjects, our results could have therapeutic implications, providing more support for the use of free radical scavengers in the acute care of stroke patients with a possible cardioembolic aetiology.

Variables associated with hospital arrival time after stroke: effect of delay on the clinical efficiency of early treatment.

BACKGROUND AND PURPOSE: A limiting criterion for the eligibility of patients in clinical trials investigating acute stroke therapies is that time between onset of symptoms and arrival in the hospital should fall within the "therapeutic window." The aims of this study were to estimate hospital arrival time in an unselected sample of stroke patients, to assess the association with some clinical and demographic variables, and to evaluate the effects of the delay on the clinical efficiency of an effective treatment. METHODS: We evaluated the delay in hospital arrival time in 189 patients (84 men, 105 women; mean age, 76.5 years) prospectively collected in the S Orsola-Malpighi Community Teaching Hospital in Bologna, Italy. Cutoffs of 2 and 5 hours were chosen to allow for hypothetical treatment within 3 and 6 hours, respectively. Exact multiple logistic regression was used to predict the delay as a function of dichotomized age, sex, symptoms on awakening, day of the week, hour of the day, area of residence, level of consciousness, and level of motor power defect. We then projected the effectiveness of tissue plasminogen activator (TPA) on disability as estimated with the aid of the odds ratio from the National Institute of Neurological Disorders and Stroke (NINDS) rt-PA Stroke Trial onto our unselected sample to evaluate clinical efficiency of treatment as a function of arrival time and of hypothetical effects of educational efforts to reduce it. RESULTS: The mean interval between onset of symptoms and hospital arrival was 680 minutes; 59 patients (31%) arrived within 2 hours and 100 (53%) within 5 hours. Onset of symptoms when awake, drowsiness or coma, and paralysis of at least one limb were the only independent predictors of hospital arrival within 2 and 5 hours in both the total sample and the subgroup of patients who were awake at stroke onset. The effectiveness of 17%, extrapolated with the aid of the odds ratio of 1.6 of having a favorable outcome (Barthel Index > or = 95 at 3 months) in treated versus untreated patients in the NINDS rt-PA Stroke Trial, corresponded to a projected clinical efficiency of 5%. This could be doubled by hypothesizing a 100% effect of educational efforts in reducing the delay in hospital arrival time. CONCLUSIONS: Patients with milder symptoms, for whom treatment might be more effective, were less likely to arrive in time for therapy. The proposed model of the relationship between the delay in hospital presentation after a stroke and the clinical efficiency of a given treatment might be useful for planning future clinical trials on early stroke treatment and predicting the impact of an educational program aimed at shortening arrival time.

Fever in acute stroke worsens prognosis. A prospective study.

BACKGROUND AND PURPOSE: No definitive data are yet available on the effects of body temperature on neurological damage after cerebral ischemia in humans. Experimental animal models have provided much evidence, but to our knowledge, only two studies on the relationship between fever and prognosis of stroke in humans have been published. The aim of our study was to investigate the prognostic role of fever in the first 7 days of hospitalization in a cohort of patients admitted to our hospital for acute stroke. METHODS: We analyzed the data of 183 patients included in a prospective observational prognostic study. Vital status at 30 days was considered the main outcome and was obtained for all patients. Age, level of consciousness, and glycemia at the time of hospitalization were considered covariates for an exact logistic regression analysis. The maximum temperature recorded during the first 7 days dichotomized as "no or low fever" versus "high fever" was added to the model. Death within 10 days, taken as a secondary outcome suggestive of death from neurological causes, was analyzed with exact permutation tests. RESULTS: Of the 183 patients analyzed in this study, 43% had fever during the first 7 days after hospitalization. The mean value of the maximum temperature recorded during the first 7 days in the 78 febrile patients was 38.3 degrees C, and the median was 37.9 degrees C. Onset of fever occurred in only 15% of febrile patients during the first day and in 49% on the second. The prognostic roles of age, level of consciousness, and glycemia were confirmed by exact logistic regression. Degree of consciousness impairment was the strongest prognostic variable, with an odds ratio (OR) of 11.4 (95% confidence interval [CI], 4.4 to 31.6). High fever (maximum temperature recorded during the first 7 days > or = 37.9 degrees C) was an independent factor for a worse prognosis, with an OR of 3.4 (95% CI, 1.2 to 9.5). The OR of dying within 10 days versus dying between 11 and 30 days was 4.9 (95% CI, 1.2 to 25.2) in patients with high fever with respect to all other patients. CONCLUSIONS: Fever in the first 7 days was an independent predictor of poor outcome during the first month after a stroke. No data were available on the underlying causes of fever, but the higher risk of death in the first 10 days, most frequently attributed to neurological mechanisms, suggested that high temperature was an independent component of poor prognosis and not only an epiphenomenon of other complications in the course after a stroke. In agreement with animal studies, we found that patients with higher temperature had a worse stroke outcome.

Severity scores in respiratory intensive care: APACHE II predicted mortality better than SAPS II.

BACKGROUND: In recent years several scoring systems have been developed to describe the severity of illness, to establish the individual prognosis, and to group adult ICU patients by predicted risk of mortality. In addition, these scores can be used to measure and/or compare the quality of care in different ICUs. We compared the mortality predictions of the Acute Physiology and Chronic Health Evaluation (APACHE II) score and a new Simplified Acute Physiology Score (SAPS II) in patients with respiratory disease who require intensive care. PATIENTS & METHODS: We prospectively studied all 306 admissions from January 1, 1992 through December 31, 1994. McNemar and Hosmer-Lemeshow tests, and receiver operating characteristic (ROC) curves were used to describe and analyze our data. RESULTS: The average APACHE II score was 17.5 (SD 6.0), corresponding to a mean predicted death rate of 24.9% (SD 17.2%) as compared to an observed overall RICU mortality rate of 21.6%. The average SAPS II score was 39.1 (SD 11.1) corresponding to a mean predicted death rate of 26.0% (SD 18.4%). The ratio between the actual and predicted hospital mortality was 86% for APACHE II and 83% for SAPS II. Survivors had a significantly lower predicted risk of death than nonsurvivors (p < 0.0001) with both indices, and a higher Glasgow coma scale score (p < 0.0001). The ROC-curve analysis suggested the superior predictive ability of APACHE II in our patients. Area under the APACHE II ROC curve was 80.88% (standard error [SE] 2.89%), significantly larger (p < 0.01) than that found for SAPS II (73.52%, SE 3.61%). CONCLUSIONS: The APACHE II score was a good predictor of hospital outcome and better than SAPS II in our population.

Assessment of emphysema using high resolution CT, CT expiratory density mask, and plain chest films.

Pulmonary function tests (diffusing capacity for carbon monoxide of the lungs) and radiological imaging (plain chest film, high resolution computed tomography (CT) and CT expiratory density mask) were compared in the assessment of 29 patients with suspected airways obstruction. Conventional roentgenogram showed a good agreement with the diffusing capacity of the lungs and proved to be useful in predicting the presence of severe emphysema, but the extension of the disease was more precisely assessed by computed tomography. A good agreement was found between high resolution CT and density mask CT, although the "subjective" high resolution identified more patients with mild emphysema than the "automated" density mask. In conclusion, although the plain chest film is useful in the diagnosis of severe emphysema, CT (especially when high resolution is used) is helpful in identifying cases of mild disease and in diagnosing the type of emphysema.

Fibrin sealant in laparoscopic adhesion prevention in the rabbit uterine horn model.

OBJECTIVE: To assess the effects of fibrin sealant on adhesions after laparoscopic surgery. DESIGN: Standardized surgical trauma was induced in 60 female rabbits. The animals were randomized in three groups for different adhesion prevention treatment. SETTING: University research laboratory. INTERVENTIONS: After standardized trauma was induced, group 1 (n = 20) received no treatment, group 2 animals (n = 20) were injected in the abdominal cavity with 60 mL of Ringer's lactate, and human fibrin sealant was applied on the surgical lesions under laparoscopic vision in group 3 (n = 20). MAIN OUTCOME MEASURES: Five weeks after laparoscopy, a laparotomy was performed, and the adhesions were scored. RESULTS: Fourteen of 20 rabbits in the control group (70%) presented postoperative adhesions, 11 of 20 (55%) in the Ringer's group, and 5 of 20 (25%) in the fibrin sealant group. High-score adhesions were seen in 15% of cases in control and Ringer's group and in 5% of cases in the fibrin sealant group. CONCLUSIONS: When used during laparoscopic surgery, fibrin sealant has a preventive effect on de novo postsurgical adhesions. To assess the efficacy in reproductive surgery, a trial on recurrent postsurgical adhesions is required.

Effect of single dose of oral erythromycin on gastric and gallbladder emptying. Simultaneous assessment by ultrasound.

To evaluate the effects of a single oral dose of erythromycin on gastric and gallbladder emptying, 10 volunteers, without a known history of gastrointestinal disease, were investigated. Erythromycin stearate (500 mg) or placebo was given on separate mornings 30 min before a standard solid meal in a randomized, double-blind, crossover study. Gastric and gallbladder emptying rates were simultaneously evaluated by means of real-time ultrasonography. Gastric antral area and gallbladder volume were determined before the meal and 30, 60, 120, 180, 240, and 300 min after commencing eating. Erythromycin, compared to placebo, significantly accelerates and increases the degree of both gastric and gallbladder emptying. As previously reported for intravenous and chronic oral assumption, also a single dose of oral erythromycin is able to accelerate gastric and gallbladder emptying in normal human subjects.

[Angiographic aspects of unstable angina]. / Aspetti angiografici dell'angina instabile.

One-hundred and ninety-four patients with unstable angina pectoris (91 "in crescendo" angina and 103 new onset angina) underwent coronary angiography. The angiographic data from both groups were compared in order to discover whether angiographic aspects were related to the various clinical symptoms of coronary artery disease. Patients with recent onset angina had a significant increase (p less than 0.0001) of mono-vessel disease, whereas multi-vessel disease was prevalent in patients with "in crescendo" angina pectoris. Higher prevalence of coronary collaterals was observed in patients with "in crescendo" angina (p less than 0.005). No significant difference was observed in ejection fraction of the two groups. A further analysis was performed in 100 patients with unstable angina pectoris but without prior myocardial infarction (42 "in crescendo" angina and 58 recent onset angina). Also in these patients were found the same results; with the exception of ejection fraction which was more slight in patients with "in crescendo" angina (p less than 0.01). These data confirm that patients with unstable angina are an heterogeneous group in which comparison is unreliable and that the severity of clinical symptoms is not related to the degree of angiographic coronary lesions.

[Clinical characteristics and prognostic factors in chronic heart failure secondary to primary dilated cardiomyopathy and ischemic heart disease]. / Caratteristiche cliniche e fattori prognostici dello scompenso cardiaco cronico secondario a miocardiopatia dilatativa primitiva ed a cardiopatia ischemica.

Natural history and prognostic factors in chronic congestive heart failure were investigated in 141 patients (100 males and 41 females), aged 58 +/- 14.5 years, who were hospitalized between 1981-1985. Heart failure was due to idiopathic dilated cardiomyopathy in 79 patients and ischemic heart disease in 62 patients. The following parameters were examined: sex, age, etiology, NYHA functional class, mean arterial blood pressure, heart rate, presence of 3rd heart sound, atrial fibrillation and left ventricular conduction delay, plasma sodium, echocardiographic shortening fraction, and treatment with vasodilators. Mean follow-up was 31 +/- 19 months. Overall survival was 83% at 1 year, 58% at 3 years and 49% at 5 years. No difference in mortality was evident between the two etiological groups, while the data on the cause of death showed a significant difference: sudden death was prevalent in the patients with ischemic disease (50% vs 24%), intractable heart failure predominated in patients with idiopathic dilated cardiomyopathy (69.7% vs 42.8%) (p less than 0.05). The multivariate analysis with the Cox model resulted in a negative prognostic significance of the male sex (p less than 0.02), III and IV NYHA functional class (p less than 0.04), heart rate at rest greater than 85 b/min (p less than 0.002) and the presence of left ventricular conduction delay on standard ECG (p less than 0.001).

Ambulatory blood pressure and assessment of pacemaker function.

Ten patients in sinus rhythm with ventricular demand (VVI) pacemakers implanted for the sick sinus syndrome underwent 24 hour ambulatory blood pressure and electrocardiographic recording by a modified version of the Oxford system. Five patients had symptoms of dizziness or presyncope at the time of study and five were symptom free. The onset of pacing was associated with a fall in arterial blood pressure in both groups which was larger in the patients with symptoms, and in these patients the blood pressure recovery consequent on baroreflex activation was delayed by up to fifteen beats. In three of the patients with symptoms the original pacemaker was replaced by an atrioventricular pacing (DVI) device. This abolished symptoms and the initial fall and delayed recovery of blood pressure. Thus it appears that the development of symptoms of hypotension after the onset of ventricular pacing is determined by the rate of the baroreflex response. These symptoms and the haemodynamic consequences may be alleviated by dual chamber pacing.

Perception of emotions in borderline hypertensive patients and normal subjects.

The ability to recognize the facial expressions of emotions was investigated in 30 borderline hypertensive patients, 16 with high intralymphocytic sodium content (ILSC) and 14 with normal ILSC, and in 34 normotensive matched controls. To this aim, 48 slides with the facial expressions of emotions and with neutral expressions were shown to the subjects by means of a tachistoscope. Two brief questionnaires, the Affective Communication Test and the Dimensions Rating Scale, were used to assess the ability to express emotions and the intensity of emotional experience in the subjects. Results show in borderline hypertensives a difficulty in recognizing emotions, with differences between the two subgroups of patients.

Comparison of three devices for measuring blood pressure.

Blood pressure measurement with two automatic devices, Dinamap 845 and Sentry, was compared with the standard mercury sphygmomanometer, by means of a 3-period crossover experiment. Both automatic devices read diastolic pressure considerably lower than the mercury sphygmomanometer (about 7 mmHg on average); agreement was better for systolic pressure. Device differences in individual patients were often much higher. To assess the patient's emotional pressor response during manual measurement, Dinamap was used to monitor blood pressure before, during and after measurement with the mercury sphygmomanometer. No rise in pressure was found. It is concluded that the three devices can often give different values, and that the physician's involvement cannot explain these differences.