25-Hydroxyvitamin D Supplementation and BMI Change: A Meta-Analysis of Randomized Controlled Trials.

The impact of 25-hydroxyvitamin D (25[OH]D) supplementation on weight change remains controversial. The objective of this study was to summarize the effects of 25[OH]D supplementation (cholecalciferol or ergocalciferol) on BMI change through a meta-analysis of published clinical trials. We completed a systematic review of English articles, using MEDLINE (Ovid, Pubmed) from January 1, 1998 through January 1, 2013. The articles selected focused on 25[OH]D supplementation and body mass index (BMI) in randomized controlled trials (RCT's). The association between 25[OH]D and mean BMI change was estimated utilizing a random effects model. A total of 30 studies were reviewed and 9 were included in the meta-analysis. Total participants included 1651 adults (82.6% women and mean age 47.9 years) and mean follow-up ranged between 6 to 196 weeks and mean daily 25[OH]D dose ranged from 200 IU to 1,110 IU. Five of the 9 studies included calcium supplementation in both groups. Average baseline BMI was 30.7 and 30.4 kg/m2 in the intervention and control groups, respectively. Five studies suggested a beneficial effect for 25[OH]D supplementation for BMI change whereas 3 studies showed no effect of 25[OH]D supplementation on BMI change, and one showed a non-perceptible change. Meta-analysis of BMI values at end of trial showed no statistically significant difference in BMI change by use of 25[OH]D supplementation. Based on existing published trials, oral 25[OH]D supplementation does not significantly impact BMI change.

[The rare coincidence of Guillain-Barré syndrome and myelitis]. / Koinzidenz von Guillain-Barré-Syndrom und Myelitis. Eine seltene Kombination.

A 28-year-old male patient developed Guillain-Barré syndrome after a pulmonary infection with typical CSF findings. Five days after the onset, pyramidal signs and spastic increase of muscle tonus in the legs were found. The MRI showed increased signals in the whole spinal cord which were identified as myelitis after review of clinical and neurophysiologic findings. There was a remarkable difference between the dramatic pathologic signals on MRI and the mild clinical symptoms. Four months after onset the patient had no more complaints and presented basically recovered in the clinical examination. The existence of Guillain-Barré syndrome together with myelitis is very rare. A patient with such a good outcome in spite of an extended myelitis is extraordinary.

Intrathecal baclofen therapy for stiff-man syndrome and progressive encephalomyelopathy with rigidity and myoclonus.

We report on eight patients with stiff-man syndrome (SMS) or its "plus" variant, progressive encephalomyelopathy with rigidity and myoclonus (PERM) receiving intrathecal baclofen via pump. In six of the patients, follow-ups continued for approximately 2.5 to 6.5 years after pump implantation. Intrathecal baclofen was an effective last-resort alternative for patients who responded poorly to or did not tolerate oral antispasticity medications. General mobility increased, and spasms and rigidity were reduced; however, no complete remissions were observed either before or after pump implantation. PERM patients showed more severe and rapid progression of symptoms and more attacks of autonomic dysregulation than SMS patients. They also required higher doses and more rapid dosage increases. Complications of intrathecal baclofen therapy included spasm-induced rupture of the catheter, catheter dislocation causing radicular symptoms, and pump malfunction resulting in inaccurate dosage administration. Patients suffered fewer side effects with intrathecal baclofen than with oral medication, but overdose resulted in a transient, comalike state in one patient and sudden dosage reduction due to pump failure was fatal in another.

[Intraoperative monitoring of the recurrent laryngeal nerve. A new method]. / Intraoperatives Monitoring des Nervus laryngeus recurrens. Eine neue Methode.

Injury of the recurrent laryngeal nerve (RLN) is one of the most frequent complications in thyroid surgery. It leads to a significant morbidity of up to 20%, depending on the type of surgery being performed. We present a new device for intraoperative monitoring of the RLN. The new monitoring system was evaluated in piglets. The system is reliable and easy to use. For the first time even imminent injury to the RLN can undoubtedly be demonstrated by signal changes. It will soon be available for use in humans.

Decompressive surgery in space-occupying hemispheric infarction: results of an open, prospective trial.

OBJECTIVE: Space-occupying hemispheric infarctions, requiring neurocritical care treatment, demonstrate high mortality and morbidity rates. This study was performed to determine the beneficial effects of decompressive craniotomy on mortality and morbidity rates. DESIGN: Open, nonrandomized, control trial. Outcome was rated at discharge from the hospital (Glasgow Outcome Scale) and at follow-up (Barthel Index, Oxford Handicap Scale). SETTING: Patient recruitment from the Department of Neurology, University of Heidelberg (primary care center) over 65 months. PATIENTS: Thirty-two patients were prospectively selected for surgical treatment; 21 patients were treated conservatively. INTERVENTIONS: Extended craniotomy and dura patch enlargement were performed in all surgically treated patients. MEASUREMENTS AND MAIN RESULTS: At discharge, the outcome of six (18.8%) of 32 surgically treated patients was good compared with 0 (0%) of 21 conservatively treated patients. Fifteen (46.9%) of 32 surgically treated patients were moderately to severely disabled compared with five (23.8%) of 21 conservatively treated patients, and 11 (34.4%) of 32 surgically treated patients died compared with 16 (76.2%) of 21 conservatively treated patients. At follow-up in surgically treated patients, the Barthel Index (mean 62.6) showed an excellent level of daily activity in one patient, minimal assistance (Barthel Index of > or = 60) in 15 patients, and dependency in five patients. The Oxford Handicap Scale indicated no handicap in one patient, moderate handicaps in 15 patients, and moderately severe handicaps in five patients. In the control group, all five surviving patients needed assistance and all but one patient demonstrated a moderately severe handicap. CONCLUSIONS: Hemicraniotomy may improve survival in massive hemispheric stroke victims, decreasing mortality rates to < 35%. The disability rate remains high (24%), although some patients seem to benefit significantly.

[Craniectomy in space-occupying middle cerebral artery infarcts]. / Kraniektomie bei raumfordernden Mediainfarkten.

Space occupying supratentorial ischemic stroke has a high mortality. The benefit of decompressive surgery in these patients is still matter of debate. In a prospective study we performed craniectomy in 37 patients with acute middle cerebral artery infarction and progressive deterioration under conservative antiedematous therapy. Twenty-one patients treated conservatively during the same period served as control group. All survivors were reexamined between one to two years after surgical decompression. In addition, neuropsychological tests were performed, including an Aachener Aphasie Test (AAT) in those patients with infarction of speech-dominant hemisphere. Clinical evaluation was graded using the Barthel index (BI). Mortality rate in the operated group was 37%. Twenty-three patients survived acute stroke and were reexamined. Despite complete hemispheric infarction, no patient suffered from complete hemiplegia or was permanently wheel chair bound. In speech dominant hemispheric infarction (n = 8) only mild to moderate aphasia could be detected. Mean BI was 64. Mortality rate in the conservatively treated group was 76%. The clinical outcome following craniectomy for the treatment of severe ischemic hemispheric infarction is unexpectedly good. Therefore, decompressive surgery should be considered in cases of space-occupying hemispheric infarctions and conservatively uncontrollable intracranial pressure.

Rare diseases mimicking acute vertebrobasilar artery thrombosis.

Acute ischaemia of the vertebrobasilar circulation leads to a variety of clinical manifestation and is mostly due to cardiogenic or artery-to-artery embolism. We describe four neurological emergency situations involving vertebrobasilar artery aclusion of other origins; basilar migraine, extrinsic compression by rheumatoid inflammatory tissue, generalized vasculitis in subacute rheumatic fever and basilar artery dissection. The differential diagnosis of acute vertebrobasilar artery occlusion may have an important impact on patient management.

Intrasubject reliability and validity of somatosensory source localization using a large array biomagnetometer.

Neuromagnetic fields were evoked by tactile stimuli and detected with a multi-channel biomagnetometer through 72 independent repetitive measurements on a single subject. Each measurement consisted of a somatosensory evoked response (N = 256 stimuli) using a single probe placement. These fields were then analyzed for source localization using an equivalent current dipole model and demonstrated highly reliable localizations. The 3 major neuromagnetic somatosensory response components peaking at 35, 65 and 110 msec all localized to the same area of cortex. The relative contributions of intrinsic brain activity, habituation, probe placement, and choice of fiduciary points for headframe determination were quantified. Intrinsic factors were found to constitute the major source of inter-measurement error. Sources localized by magnetic source imaging (MSI) appeared valid relative to neuroanatomical estimation of the central fissure on MRI. Non-invasive presurgical biomagnetic localization of somatosensory cortex produces reliable and valid functional localizations which can be of potential value in risk assessment and may provide a useful guide for invasive functional mapping.

Sensitivity and prognostic value of early CT in occlusion of the middle cerebral artery trunk.

PURPOSE: To investigate the incidence and prognostic value of local brain swelling, the extent of parenchymal hypodensity, and the hyperdense middle cerebral artery sign as shown by CT within the first 5 hours after the onset of symptoms in patients with angiographically proved middle cerebral artery trunk occlusions. METHODS: Fifty-three patients were studied prospectively with CT 46 to 292 minutes (median, 120; mean, 134 +/- 59) after symptom onset and scored clinically at admission and 4 weeks later. All patients were treated with recombinant tissue plasminogen activator (30 to 100 mg). RESULTS: Early CT showed parenchymal hypodensity in 43 patients (81%), local brain swelling in 20 patients (38%), and hyperdensity of the middle cerebral artery trunk in 25 patients (47%). Hypodensity covering more than 50% of the middle cerebral artery territory had an 85%, local brain swelling a 70%, and the hyperdense middle cerebral artery sign a 32% positive predictive value for fatal clinical outcome. Specificity of these findings for fatal outcome was 94%, 83%, and 51%, respectively, and sensitivity was 61%, 78% and 44%, respectively. CONCLUSIONS: Early CT in acute middle cerebral artery trunk occlusion is highly predictive for fatal clinical outcome if there is extended hypodensity or local brain swelling despite aggressive therapeutic attempts such as thrombolysis or decompressive surgery.

Prognostic and clinical relevance of pupillary responses, intracranial pressure monitoring, and brainstem auditory evoked potentials in comatose patients with acute supratentorial mass lesions.

OBJECTIVE: To test the hypothesis that the clinical condition and outcome in patients with acute supratentorial mass lesions can be assessed by determination of pupillary abnormalities, measurement of intracranial pressure, and results of brainstem auditory evoked potentials. DESIGN: Prospective case series of 55 patients presenting with supratentorial mass lesions. SETTING: Neurologic and neurosurgical intensive care unit of a tertiary care center. PATIENTS: Fifty-five comatose patients (26 female/29 male; 9 to 70 yrs of age [mean 44]). INTERVENTIONS: Pupillary abnormalities were rated "normal," "unilaterally enlarged," "unilaterally fixed," and "bilaterally abnormal." The outcome was rated using the Glasgow Outcome Scale. Intracranial pressure values were graded into five categories. Brainstem auditory evoked potentials were rated "bilaterally normal," "unilaterally abnormal," or "bilaterally abnormal," according to normative data. Statistical evaluation was performed by frequency analysis (Fisher's exact test, two-tailed) and calculation of contingency coefficients. MEASUREMENTS AND MAIN RESULTS: Outcome was poor in 24 patients, good in eight patients, and 23 patients were severely disabled. Statistical analysis showed prognostic significance of both pupillary abnormalities (p = .0000542; contingency coefficient = .589) and increased intracranial pressure (p = .0084; contingency coefficient = .352). Brainstem auditory evoked potential categories correlated significantly with pupillary abnormalities (p = .000276; contingency coefficient = .505) and increased intracranial pressure (p = .0301; contingency coefficient = .502) but did not predict outcome (p = .645; contingency coefficient = .321). CONCLUSIONS: Pupillary abnormalities may serve as a reliable parameter, which may even be superior to brainstem auditory evoked potential testing and intracranial pressure monitoring for prediction of outcome in comatose individuals with supratentorial mass lesions. Brainstem auditory evoked potentials can be used to support the clinical relevance of abnormal pupillary status and increased intracranial pressure but are of no prognostic value. Increased intracranial pressure is associated with abnormalities in pupillary status and brainstem auditory evoked potentials. Examination for pupillary abnormalities in combination with intracranial pressure monitoring and brainstem auditory evoked potential testing seems to be a useful strategy in managing patients with supratentorial mass lesions in critical care units.

Prospective evaluation of the prognostic significance of evoked potentials in acute basilar occlusion.

OBJECTIVE: To establish valid prognostic parameters in patients with acute basilar artery occlusive disease. DESIGN: A prospective study. SETTING: Neurocritical care unit at the University of Heidelberg. PATIENTS: Twenty-three patients (12 male, 11 female; 32 to 69 yrs of age, median 54) with acute basilar occlusions. INTERVENTIONS: Angiography, brainstem auditory and somatosensory evoked potentials. MEASUREMENTS AND MAIN RESULTS: Clinical and electrophysiologic data were obtained before angiography and thrombolytic therapy. Outcome was classified according to a slightly modified Glasgow Outcome Scale at discharge from the intensive care unit (ICU). Level of consciousness was determined in four classes: awake (n = 4); somnolence (n = 7); stupor (n = 4); and coma (n = 8). Bilateral recordings of brainstem auditory and somatosensory evoked potentials were ranked in three categories: normal; one side normal; and both sides abnormal. Of 23 sets of evoked potential recordings, brainstem auditory evoked potentials were normal in seven patients, one side abnormal in four patients, and both sides abnormal in 12 patients. Somatosensory evoked potentials were normal in eight patients, one side abnormal in eight patients, and both sides abnormal in seven patients. A combination of both evoked potential modalities demonstrated normal results in three patients, one side abnormal recordings in six patients, and both sides abnormal findings in 14 patients. Outcome was ranked in three groups: five individuals had a good recovery or moderate disability; two patients remained severely disabled; and 16 patients persisted either in a locked-in state or died. Statistical analysis using Fisher's exact test demonstrated a significant correlation between the initial brainstem auditory evoked potential findings and outcome (p < .005), while for the initial somatosensory evoked potentials a significant correlation with outcome was not identified (p = .089). All patients with normal brainstem auditory and somatosensory evoked potential findings did well, whereas all patients with bilateral (both sides) abnormal brainstem auditory evoked potential and bilateral abnormal somatosensory evoked potential remained locked-in or died. CONCLUSION: Initial brainstem auditory evoked potential and somatosensory evoked potential testing are valid prognostic parameters on which to base therapeutic decisions in patients with acute basilar occlusion.

Monitoring therapeutic efficacy of decompressive craniotomy in space occupying cerebellar infarcts using brain-stem auditory evoked potentials.

Brain-stem auditory evoked potentials (BAEPs) have been used to gauge effects of brain-stem dysfunction in humans and animal models. The purpose of this study was to evaluate the usefulness of BAEP in monitoring patients undergoing decompressive surgery of the posterior fossa for space occupying cerebellar infarcts. We report on serial BAEP recordings in 11 comatose patients with space occupying cerebellar infarcts undergoing decompressive craniotomy. BAEP studies were performed within 12 h after admission, 24 h following surgery and prior to extubation. BAEP signals were analyzed using latency determination and cross-correlation. Following surgery, 9 patients regained consciousness; 2 patients persisted in a comatose state and died subsequently. BAEP interpeak latency (IPL) I-V assessed prior to surgery exceeded normal values in all patients in whom it could be reliably measured (N = 9). Following decompressive surgery BAEP wave I-V IPL normalized in 5 patients, but remained prolonged despite dramatic clinical improvement in 4 patients. We prospectively computed the coefficient of cross-correlation (MCC) of combined ipsilateral BAEP trials after right and left ear stimulation. In all patients increasing MCC was associated with clinical improvement. Unchanging or decreasing MCC indicated poor outcome. We conclude that serial BAEP studies are an appropriate perioperative monitoring modality in patients with space occupying cerebellar infarcts undergoing decompressive surgery of the posterior fossa. Our study suggests advantages of cross-correlation analysis as an objective signal processing strategy; relevant information can be extracted even if BAEP wave discrimination is impossible due to severe brain-stem dysfunction.

Transcranial Doppler ultrasound and magnetoencephalography in migraine.

Eighty subjects--30 migraineurs during the attack, 30 patients in the interictal period, and 20 healthy volunteers--were studied using two technologies for functional assessment: transcranial Doppler ultrasound and magnetoencephalography. Transcranial Doppler studies showed an increased mean flow velocity at rest (p less than 0.05) in the middle cerebral artery on the side of the headache and a decreased vasomotor response to CO 2 (p less than 0.001) on the same side compared to control subjects. Biomagnetic measurements of somatosensory evoked fields of 11 patients and 11 control subjects in this study did not demonstrate differences between migraineurs and the control group in current flow or latency measures. The data from this study tend to support the hypothesis of vascular disease as a primary underlying deficit in migraine.

[Acute myoglobinuric kidney failure in McArdle's syndrome. The diagnostic significance of 31P nuclear magnetic resonance spectroscopy]. / Myoglobinurisches akutes Nierenversagen bei McArdle-Syndrom. Diagnostische Bedeutung der 31P-Kernspinspektroskopie.

A 44-year-old man developed acute renal failure, associated with reddish brown urine, after severe physical exertion. Since childhood his physical capacity was known to be limited. Muscular indurations, cramps and pains had occurred after muscular work. Serum creatinine level on the day before hospitalization was 10.0 mg/dl, creatine-kinase activity 3,790 U/l, lactate dehydrogenase activity 670 U/l, myoglobin level 701 ng/ml. Cause of the rhabdomyolysis was thought to be McArdle's disease (glycogen storage disease type V: abnormal skeletal muscle glycogen utilization). 31P-magnetic resonance spectroscopy, which gives characteristic spectra with anaerobic muscle work, provided the diagnosis, which was confirmed by measurement of myophosphorylase activity in a muscle biopsy (zero activity). After two dialysis sessions and alkalinization of the urine diuresis again occurred and the retention indicators fell to normal in the course of the subsequent 18 months. Creatinine kinase activity remained elevated.

[Noninvasive temporary cardiac pacemaker in neurologic intensive care patients]. / Nichtinvasiver temporärer Herzschrittmacher bei neurologischen Intensivpatienten.

The need for temporary cardiac pacing is not unusual in neurocritical patients, due either to disorders of the autonomic nervous system or to concomitant cardiac disease. Mostly, intravenous devices are used. However, intravenous pacing is not without risks, and requires skill and experience when done in emergency cases. We therefore tried a technique of non-invasive, transcutaneous cardiac stimulation on eight patients, for all of whom it proved safe and effective. The only observed side-effect was minor discomfort in conscious patients.

Clotting properties in diverse valve prostheses.

With regard to both hemolysis and thrombophilia the St. Jude Medical prosthesis shows only minor alterations in comparison to normals. The most significant alterations concerning platelets and hemolysis have been found in patients with Starr-Edwards prostheses. Even in tissue valves, major alterations of the clotting system and chronic intravascular hemolysis were found. For long-term anticoagulation in mechanical prostheses--even with sinus rhythm--vitamin K antagonists should be preferred. During the first months of gravidity only heparin can be recommended. In St. Jude Medical valves anticoagulation with dicumarolum must be recommended; whether antiaggregation drugs can be recommended is not yet proved. Anticoagulation may be discontinued three months after tissue valve implantation if there are no additional risk factors. Diminishing platelet adhesivity in tissue valves may support these conclusions.