Diurnal variations of short-term variation and the impact of multiple recordings on measurement accuracy.

OBJECTIVE: Short-term variation (STV) from computerized cardiotocogram heart rate analysis is a parameter that complements decision making, regarding the delivery of fetuses in several high-risk situations. Although studies on the effects of gestational age and fetal pathology are convincing, there is a lack of data exploring diurnal variation and the adequacy of a single measurement. STUDY DESIGN: In this prospective observational study, fetal STV was monitored with the AN24 fetal ECG monitor (Monica Healthcare) each hour for at least 10 h in total, beginning at different times. This resulted in data covering all 24 h of the day. Seventy fetuses, low risk with respect to conditions accessible to heart rate monitoring (median 37th week of gestation) were monitored for an average of 12 h. Results of STV per hour were categorized as 'compromised' (STV<4 ms) or 'healthy', (STV⩾4 ms) to calculate the model of predictability. RESULTS: The model proposed (STV of 'healthy' fetuses: 9.6±2.6 ms, 'compromised' fetuses 3.0±0.5 ms, prevalence 1%) leads to a positive predictive value of 39%, which increased to 68 or 80% given two or three pathological (STV<4 ms) measurements, respectively. Diurnal variation was not observed. CONCLUSIONS: Single pathological STV values should be corroborated by further measurements in a 24-h interval in otherwise low-risk fetuses before inducing delivery. This may help to avoid unnecessary early births and give the fetus valuable days for intrauterine maturity.

[The Meaning of Neurological and Psychiatric Disease and Addiction for Pregnancy Outcome: A Case-control Study of the Birth Cohort 2010-2012]. / Die Bedeutung neurologischer, psychiatrischer und Suchterkrankungen für den Schwangerschaftsausgang: Fall-Kontroll-Studie der Geburtsjahrgänge 2010-2012.

BACKGROUND AND AIMS: The worldwide prevalence of neurological and psychiatric illnesses is steadily increasing. Consequently women of childbearing age are concerned as well. This survey examines the question of what kind of effects these illnesses have prenatally on mother and child. METHODS: In a case-control study, differences in pregnancy, birth process, and birth outcome were associated with a neurological or psychiatric illness of the expectant mother. 325 pregnant women with 331 born children were identified as cases, which were compared to 5 103 non diseased pregnant women with 5 195 born children. RESULTS: The age of the mother for admission was significantly lower in the case group than in the control group. The number of previous gestations and the number of previous induced abortion were significantly higher in the case group. Also the BMI before pregnancy and the length of stationary stay showed significantly higher values in the case group. Children belonging to the case group were born significantly earlier, had a lower birth weight, height, and head circumference. Furthermore Apgar scores were significantly lower in the case group. The frequency of postpartum stationary stay in a children's clinic as well as the length of stationary stay were also significantly higher when the mother suffered from a neurological or a psychiatric illness. CONCLUSION: The present results point out the correlation between most of the tested parameters and a neuropsychiatric illness of the newborn's mother. The interdisciplinary collaboration between gynecologists and pediatricians, as well as neurologists and psychiatrists should be strengthened to guarantee the best possible medical care.

[Q fever : A rare differential diagnosis of granulomatous disease]. / Q-Fieber : Eine seltene Differenzialdiagnose granulomatöser Erkrankungen.

Q fever is a worldwide distributed zoonotic disease with a mostly benign course, which regularly reoccurs in Germany. This report is about a patient with sporadic serologically proven Q fever, which also showed typical histopathological findings with nonspecific granulomatous hepatitis, usually seen in acute disease. The bone marrow biopsy revealed so-called doughnut granulomas, which are not pathognomonic but a typical finding in Q fever. This case report impressively underlines that the histomorphological findings can make a decisive contribution to the clarification by extended differential diagnostics, even though it plays a subordinate role in the routine diagnostics of disseminated Q fever.

Carnitine status of pregnant women: effect of carnitine supplementation and correlation between iron status and plasma carnitine concentration.

BACKGROUND/OBJECTIVES: It has been shown that plasma carnitine concentrations markedly decline during gestation in women. The reason for this, however, is unknown. One objective of this study was to investigate the effect of carnitine supplementation on plasma carnitine concentrations in pregnant women. The second objective was to investigate the hypothesis that reduced plasma carnitine concentrations during gestation are caused by a reduced carnitine synthesis because of a diminished iron status. SUBJECTS/METHODS: Healthy pregnant women (n=26) were randomly assigned in two groups receiving either a L-carnitine supplement (500 mg L-carnitine per day as L-carnitine L-tartrate) (n=13) or placebo (n=13) from the 13th week of gestation to term. RESULTS: In the control group, there was a marked reduction of plasma carnitine concentration from the 12th week of gestation to term. This reduction was prevented by the supplementation of carnitine. In the control group, there was a positive relationship between the parameters of iron status (mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH) and ferritin) and plasma concentration of carnitine (P<0.05). Moreover, there were inverse correlations between the concentrations of ferritin and the carnitine precursor gamma-butyrobetaine in plasma, and between gamma-butyrobetaine and carnitine in plasma (P<0.05). CONCLUSIONS: This study confirms that plasma carnitine concentrations decline in the course of pregnancy, an effect that can be prevented by the supplementation of carnitine. Data of this study, moreover, suggest that the decline of plasma carnitine concentration during pregnancy could be caused by a reduced rate of carnitine biosynthesis, possibly because of an inadequate iron status.

Cellular localization of human relaxin-like factor in the cyclic endometrium and placenta.

We have studied the cellular localization of the relaxin-like factor (RLF) in the histologically normal cyclic endometrium collected from days 3--26 of the menstrual cycle. RLF transcripts and protein were detected in the luminal and glandular epithelium and in stromal cells at all stages of the cyclic endometrium. Increased expression of RLF was observed in endometrial tissues in the proliferative as compared to the secretory phase, suggesting that oestrogens affect RLF gene activity in the human endometrium. The cellular localization of RLF transcripts and protein was also determined in first trimester placental tissues obtained from normal and ectopic tubal implantation sites and in third trimester placentae of normal and pre-eclamptic pregnancies. In first trimester placenta, weaker expression of RLF was observed in the syncytiotrophoblast as compared to the underlying cytotrophoblast. Extravillous trophoblast cells constitutively expressed RLF. Trophoblast cells were the main source of RLF in the human placenta and trophoblastic RLF gene activity was unaffected by either the site of implantation or the invasive properties of the cytotrophoblast as demonstrated by samples from patients with tubal implantation and pre-eclampsia respectively. Decidual cells weakly expressed RLF. The presence of unprocessed and cleaved immunoreactive RLF in term placenta was determined by Western analysis. The above results suggest a functional role for both RLF isoforms within normal placental tissue.

[Pelvic organ prolapse]. / Deszensus und Prolaps.

Pelvic organ prolapse of the female is a common disease with age dependent increase in incidence. The committee for standardisation of the International Continence Society recently suggested to avoid classical terms such as cystocele, rectocele or enterocele for the description of prolapse and to replace them by defined landmarks. The "Pelvic Organ Prolapse Quantification" (POPQ) was developed and five different grades of prolapse were defined. This is a true gain for scientific documentation but needs some effort to be implemented in routine practical work. Previous normal vaginal delivery is statistically highly correlated with prolapse, followed by climacteric involution, constitutional factors, physical work, chronic bronchitis, and overweight respectively. The diagnosis is confirmed by clinical examination. Defects of the supportive structures can be precisely assessed with dynamic magnetic resonance imaging. Time will show whether this costly method will become part of routine diagnostic procedures. A patient with moderate prolapse or few complaints may be treated conservatively with pelvic floor training or electrotherapy. Modern pessaries are tried as first line therapy or for patients unwilling to undergo surgery. Local estrogen application should routinely be prescribed for perimenopausal patients. In the last decade laparoscopic techniques have been established in addition to standard methods of pelvic floor reconstruction. These techniques do not follow a new surgical strategy but realise the minimal invasive approach to established methods of pelvic floor reconstruction. Of note, laparoscopic fixation is very convenient for young women who want to preserve their uterus. Long time follow up is not available for most techniques.

Apolipoprotein E and functional recovery from brain injury following postacute rehabilitation.

OBJECTIVE: APOE epsilon4 has been associated with late-onset familial and sporadic AD and delayed recovery from head injury. The authors examined the relationship between functional recovery of patients with head injury and the APOE alleles. METHODS: Thirty-one patients with head injury who had completed the Acute Neurorehabilitation Program at Helen Hayes Hospital were evaluated for presence of APOE epsilon4 and assessed for recovery based on Functional Independence Measures (FIM). RESULTS: Analysis of covariance (using coma days as the covariate to control for differences in initial severity of injury between subjects with and without APOE epsilon4) revealed a significant difference for both total FIM and motor FIM scores between the subjects with and without APOE epsilon4. Specifically, there were lower scores for total FIM (df = 30; F = 3.341; p = 0.05) and motor FIM (df = 30; F = 4.189; p = 0.026) in APOE epsilon4 carriers. No difference was found for the cognitive portion of the FIM. CONCLUSIONS: The data suggest that the presence of the lipoprotein APOE epsilon4 adversely affects rehabilitation outcome for traumatic brain injury survivors.

Arylhydrocarbon receptor expression in the human endometrium.

OBJECTIVE: To determine the expression and localization of the arylhydrocarbon (dioxin) receptor in human endometrium throughout the normal menstrual cycle. DESIGN: Retrospective immunohistochemical and in situ hybridization study. SETTING: Academic research unit. PATIENT(S): Premenopausal women (n = 86), aged 25 to 45 years, with histologically normal endometrium undergoing curettage or hysterectomy. INTERVENTION(S): Endometrial samples were collected from days 3 to 26 of the cycle by superficial scrapings of the uterine cavity or by hysterectomy. MAIN OUTCOME MEASURE(S): Expression of arylhydrocarbon receptor mRNA and protein. RESULT(S): Arylhydrocarbon receptor was expressed in 43% of the endometria studied and was correlated with the day of the cycle. The maximum of immunopositive endometria was found around the time of ovulation. Immunostaining decreased with increasing age of the patients. The receptor protein was localized exclusively in the apical part of the cytoplasm in the epithelial cells of the endometrial glands. In women positive for arylhydrocarbon receptor, arylhydrocarbon receptor mRNA was expressed in the cytoplasm of endometrial epithelial cells. CONCLUSION(S): Our results describe the expression of the arylhydrocarbon receptor in human endometrium and indicate a possible involvement of this transcription factor in endometrial function in women during the reproductive phase.

Donepezil medicated memory improvement in traumatic brain injury during post acute rehabilitation.

Memory dysfunction is a recognized and difficult to treat complication of traumatic brain injury (TBI). Since medial-temporal lobe injury is a frequent contributor to memory dysfunction in TBI, it is likely that an acetylcholine deficit contributes to memory dysfunction in this population. Recently, Donepezil, an acetylcholine-esterase inhibitor which has demonstrated a high selectivity for neural Ach-esterase (with minimal side effects), was approved for use in dementia in Alzheimer's patients. Due to its promising results in Alzheimer's patients, and reports in the literature describing the use of physostigmine (an anti-cholinesterase with significant cardiovascular and autonomic side effects) to treat memory deficits in closed head injury, we decided to begin a trial of Donepezil in two patients with TBI who were experiencing long term static memory dysfunction refractory to conventional treatment. Both patients were admitted to our facility for physical and cognitive rehabilitation, and were started on a trial of Donepezil. Modified memory tests and subjective observations by both family and staff pointed to an improvement in memory within three weeks of starting Donepezil. Should these initial results be supported in larger trials, Donepezil may prove to be a valuable tool for the treatment of memory dysfunction in TBI.

Heart-rate variability in chronic traumatic brain injury.

Heart-rate variability (HRV), a measure of fluctuation around the mean heart rate, reflects the sympathetic and parasympathetic balance of the autonomic nervous system, and is an excellent technique to study cardiovascular tone in patients with neurological injuries. The purpose of this study was to determine whether abnormal HRV is present in patients with traumatic brain injury (TBI) during the post-acute recovery phase. Using a prospective, case/control design, we performed 24-h ambulatory ECG monitoring in seven TBI patients and in seven controls (C). There was a significant difference in root mean squared successive difference of RR intervals (C 40.4 +/- 10.3, TBI 23.3 +/- 16.5, p = 0.04) between TBI and C. Four patients with TBI (compared to one control) had abnormal standard deviation of the RR interval. When these four patients were compared to their matched controls, significant differences were found in frequency domain measure (In total power: TBI 4.4 +/- 0.9 ms2, C 7.1 +/- 1.4 ms2, In low frequency: TBI 3.3 +/- 1.1 ms2, C 6.4 +/- 1.4 ms2; In high frequency TBI 2.0 +/- 1.0 ms2, C 4.8 +/- 1.3 ms2, all p < 0.05). Thus, abnormalities in both time and frequency domains of HRV are present in TBI during the post-acute recovery phase.

Amphetamine in recovery from brain injury.

A chart review of dextroamphetamine treatment in 27 traumatic brain injury patients during rehabilitation therapy suggests that amphetamine treatment enhanced the recovery and functional status of 15 patients.

Irish brogue after stroke.

BACKGROUND: We describe a patient who presented a unique variation of the previously described acquired foreign accent syndrome. CASE DESCRIPTION: A 65-year-old women developed an Irish brogue immediately after a deep left hemisphere stroke. The newly accented speech possibly represented a previously learned speech pattern. CONCLUSIONS: Suppressed prosodic speech patterns may reemerge in the setting of brain injury.

Fluoxetine improves emotional incontinence.

Emotional incontinence is a behavioural syndrome characterized by involuntary weeping, grimacing, and/or laughter. We investigated the efficacy of fluoxetine in 13 patients with emotional incontinence. All 13 patients demonstrated dramatic improvement in emotional lability within 3 to 14 days.

Word deafness in head injury: implications for coma assessment and rehabilitation.

Pure word deafness, usually involving left hemisphere focal lesions that destroy Heschl's gyrus and/or isolate auditory association cortex, may be rare, but cases with additional perceptual or cognitive symptoms may not be. Word deafness can be transient or evolving, and has been seen in various conditions without identifiable focal lesions. Only two closed head injury cases with focal contusions have been reported; we report two more, with diffuse damage and no focal signs. One patient's symptoms evolved soon after they were recognized. The other patient's unresponsiveness to spoken verbal stimuli persisted despite relatively preserved reading and speech, in a context of poor initiation and moderately severe cognitive impairment. Unrecognized, word deafness following head injury could lead to overestimation of coma duration if transient, and impede rehabilitation if chronic.

Neurological improvement following respiratory support in syringomyelia: case report.

Respiratory failure in syringomyelia has rarely been reported. We report a patient with syringomyelia who showed some neurological improvement after intermittent respiratory support with negative and positive pressure ventilation.