Myocardial infarction patients referred to the primary care physician after 1­year treatment according to a guideline-based protocol have a good prognosis.

INTRODUCTION: Identifying ST-elevation myocardial infarction (STEMI) patients who can be referred back to the general practitioner (GP) can improve patient-tailored care. However, the long-term prognosis of patients who are returned to the care of their GP is unknown. Therefore, the aim of this study was to assess the long-term prognosis of patients referred back to the GP after treatment in accordance with a 1-year institutional guideline-based protocol. METHODS: All consecutive patients treated between February 2004 up to May 2013 who completed the 1­year institutional MISSION! Myocardial Infarction (MI) follow-up and who were referred to the GP were evaluated. After 1 year of protocolised monitoring, asymptomatic patients with a left ventricular ejection fraction >45% on echocardiography were referred to the GP. Long-term prognosis was assessed with Kaplan-Meier curves and Cox proportional hazards analysis was used to identify independent predictors for 5­year all-cause mortality and major adverse cardiovascular events (MACE). RESULTS: In total, 922 STEMI patients were included in this study. Mean age was 61.6 ± 11.7 years and 74.4% were male. Median follow-up duration after the 1­year MISSION! MI follow-up was 4.55 years (interquartile range [IQR] 2.28-5.00). The event-free survival was 93.2%. After multivariable analysis, age, not using an angiotensin-converting enzyme (ACE) inhibitor/angiotensin-II (AT2) antagonist and impaired left ventricular function remained statistically significant predictors for 5­year all-cause mortality. Kaplan-Meier curves revealed that 80.3% remained event-free for MACE after 5 years. Multivariable predictors for MACE were current smoking and a mitral regurgitation grade ≥2. CONCLUSION: STEMI patients who are referred back to their GP have an excellent prognosis after being treated according to the 1­year institutional MISSION! MI protocol.

The auditory oddball paradigm in patients with vascular cognitive impairment: a prolonged latency of the N2 complex.

OBJECTIVE: The event-related potential (ERP) evoked by the auditory oddball paradigm has been investigated mainly in patients with Alzheimer's disease and in patients with different causes of subcortical dementia. Subcortical ischemic vascular disease (SIVD) seems to be an important cause of vascular cognitive impairment (VCI) frequently not fulfilling the criteria for dementia. Recognition of VCI is needed in order to provide adequate care and therapy. The aim of this study was to investigate the diagnostic value of the different elements of this response (N(1), N(2) complex and P(3) latencies) in a group of elderly patients with VCI caused by SIVD. METHODS: The study population consisted of patients with a clinical and neuropsychological diagnosis of VCI caused by SIVD (n = 38) and healthy control subjects (n = 53) aged 60 years or older. The mean Mini Mental State Examination score of both groups was 27.6, and the mean HIV Dementia Scale score was 6.1 in the patient group and 12.3 in the control group. In all subjects, the ERP was recorded under standardized conditions, and the latencies and amplitudes of N(1), N(2) and P(3) were analyzed by two clinical neurophysiologists in consensus. Both were blinded to the diagnosis. RESULTS: The N(2) latency was significantly longer in patients with VCI than in age-matched controls, whereas the latencies of the P(3) and N(1) were not significantly different. The peak-to-peak amplitude of the N(2) complex to the P(3) wave was significantly lower in the patient group. White matter abnormalities on MRI were not significantly correlated with the N(2) latency. CONCLUSION: Our findings suggest that the latency of the N(2) complex is prolonged and the peak-to-peak amplitude of the N(2) complex to the P(3) wave is lowered in patients with VCI caused by SIVD.

Emboli rate during and early after carotid endarterectomy after a single preoperative dose of 120 mg acetylsalicylic acid--a prospective double-blind placebo controlled randomised trial.

PURPOSE: To investigate whether a single pre-operative dose of 120 mg acetylsalicylic acid (ASA) decreased either (1) emboli rate, as detected by transcranial Doppler (TCD), during and early after carotid endarterectomy (CEA) and (2) clinical intra- and post-operative signs suggestive of embolism or increased bleeding tendency. DESIGN: Prospective, double-blind placebo controlled trial. PATIENTS AND METHODS: One-hundred consecutive patients were randomised to receive either 120 mg ASA (n = 48) or placebo (n = 49) by suppository on the night before CEA; three patients were excluded. Emboli were counted and expressed as emboli rate (ER). The incidence of bleeding complications was assessed. Surgeons were asked to indicate which patients had received ASA or placebo. RESULTS: There were no significant differences between the ASA and placebo groups in ER in the intraoperative and postoperative periods. ER higher than 0.9 min(-1) was associated with a significantly increased risk of complications (26 vs. 0%, P < 0.01). No extra bleeding complications were observed in the ASA group. Surgeon assessment of whether or not ASA had been administered had a sensitivity of 42% and a specificity of 70%. CONCLUSION: A single pre-operative dose of ASA (120 mg) did not reduce significantly the emboli rate during and after CEA and surgeons could not correctly identify whether or not ASA had been administered.

EEG evidence for shunt requirement during carotid endarterectomy: optimal EEG derivations with respect to frequency bands and anesthetic regimen.

Currently there is no consensus on the derivations that should be used for EEG monitoring during carotid endarterectomy (CEA). The aim of this study was to determine which derivations distinguish the best between patients requiring a shunt and patients who do not need a shunt. Four predefined frequency bands and two regimens for general anesthesia (isoflurane versus propofol) were used. EEG data (16 channels) were obtained from 152 EEGs recorded during carotid endarterectomy. Analog EEG signals of preclamp and clamp periods of 100 seconds were digitized to compute power spectra. Changes in power during clamping were calculated for all possible derivations in four predefined frequency bands and were expressed as Z-scores. For each derivation, the area under the receiver operating characteristics curve was calculated. Derivations with the greatest area under the receiver operating characteristics curve were considered to distinguish the best between the shunt and the nonshunt groups formed in retrospect on the basis of consensus between three independent and experienced board-certified electroencephalographers. The two different anesthetic regimens resulted in different patterns of EEG changes because of clamping. The optimal derivations to differentiate between the shunt and the nonshunt groups also differed for the two anesthetic regimens, although for both conditions, anterior head regions were especially preferred. The optimal derivations are given for each anesthetic regimen.

[Unwanted napping]. / Ongewenste 'siësta'.

Three patients, one woman aged 43, and two men aged 32 and 51, suffered from excessive daytime sleepiness with different causes. The woman experienced nocturnal motor attacks of epileptic origin, responding to carbamazepine. The diagnosis was based on polysomnographic recordings combined with video monitoring. Narcolepsy was diagnosed in the 32-year-old man. He also suffered from cataplexy. The diagnosis was supported by a multiple sleep latency test and HLA-DR2 positivity. He was treated with clomipramine. In the 43-year-old man an obstructive sleep apnoea syndrome was diagnosed by polysomnographic recording. He was treated successfully with continuous positive airway pressure. These patients show that excessive daytime sleepiness is sometimes difficult to recognise and can be a potentially incapacitating symptom of a treatable underlying disorder. Diagnosis is made by careful history taking and through the use of different types of somnographic recordings.

A cross-national study of posttraumatic stress disorder in Dutch-Australian immigrants.

OBJECTIVE: Studying the rates of posttraumatic stress disorder (PTSD) in people who experienced World War II, but who have subsequently lived in different environments is a way of looking at the impact of recovery environment on PTSD. Immigrants had less support in terms of the social cohesion in their home country, but were not subjected to the same triggers of war-related intrusions. METHOD: Posttraumatic stress disorder was investigated in citizens from the Netherlands who emigrated to Australia in the post-World War II years (n = 251). Immigrants born between 1920 and 1930 (n = 171) were compared with a same-aged group living in Holland (n = 1461) for stressful war experiences and the extent of PTSD. RESULTS: Those who had been exposed to the most severe war stress were overrepresented in the immigrant group. Immigrants with current PTSD more often stated that motives for migration were threat of a third world war, disappointment with Dutch society and personal problems. We were unable to demonstrate specific effects of emigration on the prevalence of current PTSD. CONCLUSIONS: This study suggests that exposure to severe war stress promoted the need to emigrate. The comparable PTSD scores of the groups of war victims living in Australia and the Netherlands support the notion that extreme war stress may be considered the primary determining factor in the development of PTSD, and that actual post-war living circumstances are, in the long term, of subordinate importance.

Distal neuralgic amyotrophy.

Neuralgic amyotrophy consists of severe pain around the shoulder and arm followed by weakness in one or several muscles of the same area. We describe four patients with distal neuralgic amyotrophy in whom acute, severe, and transient pain around the shoulder or arm was followed by weakness of the forearm and hand muscles only. Minor sensory symptoms were present in only one patient. The presence of structural lesions causing the extent of the forearm and hand motor deficit was excluded by ancillary examinations. Electrophysiological studies showed a motor axonopathy and minimal sensory axonopathy. A follow-up of 2 years or longer showed either spontaneous improvement or residual motor deficit. Unfamiliarity with a clinically distal localization of neuralgic amyotrophy may result in misdiagnosis of lower cervical (poly)radiculopathy in view of the distal localization of the motor deficit and the high prevalence of coincidental abnormalities of the lower cervical spine on plain radiography, computed tomography, or magnetic resonance imaging.

Prolonged treatment with transdermal fentanyl in neuropathic pain.

Forty-eight patients with noncancer neuropathic pain who had participated in a randomized controlled trial with intravenous fentanyl (FENiv) infusions received prolonged transdermal fentanyl (FENtd) in an open prospective study. Pain relief, side effects, tolerance, psychological dependence, mood changes, and quality of life were evaluated. The value of clinical baseline characteristics and the response to FENiv also was evaluated in terms of the outcome with long-term FENtd. Eighteen patients stopped prematurely because of insufficient pain relief, side effects, or both. Among the remaining 30 patients completing the 12-week dose titration protocol, pain relief was substantial in 13 and moderate in five. Quality of life improved (23%, P < 0.01). Psychological dependence or the induction of depression was not observed. In only one patient did tolerance emerge. There was a significant positive correlation between the pain relief obtained with FENiv and that with prolonged FENtd (r = 0.59, P < 0.0001). We conclude that (1) long-term transdermal fentanyl may be effective in noncancer neuropathic pain without clinically significant management problems and (2) A FENiv-test may assist in selecting neuropathic pain patients who might benefit from prolonged treatment with FENtd.

Reported physical health in resistance veterans from World War II.

Male Dutch Resistance veterans from World War II who reported on chronic diseases were compared with subjects from a population survey. Resistance veterans in general reported significantly more disease. Veterans with symptoms of posttraumatic stress disorder reported more disease than those who had none. Furthermore, 13 specific disease categories were more prevalent in the Resistance veterans than in the general population. In the Resistance veterans total number of reported diseases was significantly correlated with anxiety, depression, and posttraumatic stress disorder. In Resistance veterans weekly tobacco use was comparable to that of the control subjects, but alcohol consumption was significantly less.

Influence of caffeine and caffeine withdrawal on headache and cerebral blood flow velocities.

Caffeine consumption may cause headache, particularly migraine. Its withdrawal also produces headaches and may be related to weekend migraine attacks. Transcranial Doppler sonography (TCD) has shown changes in cerebral blood flow velocities (BFV) during and between attacks of migraine. In order to examine whether headache and changes in BFV could develop from controlled caffeine alterations, 20 healthy volunteers without a headache history, underwent clinical evaluation, TCD and serum caffeine measurements on four occasions, comparing conditions of regular caffeine intake, caffeine withdrawal and "re-caffeination". After 24 h of complete caffeine abstinence, 10 suffered from moderate to severe headaches with complete recovery within 1 h after caffeine intake. The BFVs in both middle cerebral, both posterior cerebral and basilar arteries were higher following the withdrawal period, reaching statistical significance in the left middle cerebral basilar and both posterior cerebral arteries. BFVs decreased significantly within half an hour after caffeine intake in all subjects, and were similar to baseline values after 2 h. Our results emphasize the relationship between caffeine withdrawal, the development of headache and alterations in cerebral blood flow velocities. Also, these findings indicate that accurate interpretation of TCD measurements should account for the influence of caffeine on BFVs.

Normal values of patellar and ankle tendon reflex latencies.

The clinical value of latency measurement of tendon reflexes in neurological patients has been reported by several authors. However, normal values are not readily comparable. In the present study, latencies and amplitudes of patellar (PTR) and ankle tendon reflexes (ATR) were measured at rest and after facilitation in 102 normal controls. A manually operated reflex hammer, tipped with electrically conductive rubber, ensured an immediate start of the sweep of the oscilloscope. Latencies showed a significant correlation with height (r = 0.70 for PTR and r = 0.72 for ATR, P < 0.0001) and to a lesser degree with age (r = 0.16 and r = 0.30, P < 0.0001). While amplitudes were highly variable, rendering them less useful for diagnostic purposes, latencies showed minimal intra-individual variability (CV 1.5 and 0.8%, respectively). Correlation of ATR-latency with the H-reflex latency of the soleus muscle was very high (r = 0.97, P < 0.0001). Comparison with three other hammer types yielded corresponding results with a hammer supplied with a piezo-electric element; however, significantly shorter latencies were found with a hammer with a microswitch, and with another hammer with a spring-contact, due to a delay from the tap on the tendon until the start of the sweep of the monitor.

Prevalence and course of posttraumatic stress disorder in Dutch veterans of the civilian resistance during World War II: an overview.

This study concerns the prevalence of current and lifetime Posttraumatic Stress Disorder (PTSD) in various groups of officially recognized Veterans of the Dutch civilian Resistance against the Nazi occupation during World War II. In total, 1046 Resistance veterans living in The Netherlands and 52 who immigrated to the United States after the war were examined. Between four and five decades after the end of WW II, between 25 and 50% were suffering from current PTSD. The life-time prevalence is estimated to be substantially higher. The course of PTSD proved highly variable. There had often been a delay of several decades between the end of the war and reoccurrence or first onset of posttraumatic symptoms. The prevalence of PTSD in Resistance veterans who emigrated to the United States was hardly different from that of the veterans still living in The Netherlands.

EMG before and after cervical anterior discectomy.

INTRODUCTION: In patients with cervical root syndromes, the relation between clinical findings and EMG results, the value of the registration of the H-reflex latency of the flexor carpi radial muscle (HFCR) and the rate of recovery of EMG abnormalities following surgery are unclear. METHODS: In 68 patients with cervical radicular syndromes caused by intervertebral disc lesions, EMG was made shortly before anterior cervical discectomy and four months later. EMG consisted of needle myography and bilateral determination of the HFCR. RESULTS: Results of HFCR were unrelated to findings on needle myography. Preoperative EMG abnormalities were related to more severe clinical and myelographic findings. A preoperative abnormal HFCR correlated with good clinical outcome. No relation was found between the clinical outcome and EMG-findings during follow-up. CONCLUSION: Determination of HFCR is a useful EMG-test, but further comparison to tendon reflexes is necessary. EMG identifies patients with more severe root lesions, but cannot be used for evaluation of persistent complaints within the first half year following surgery.

Posttraumatic stress disorder in male and female Dutch Resistance veterans of World War II in relation to trait anxiety and depression.

In this study, 680 male and 144 female Dutch Resistance veterans of World War II were evaluated on Posttraumatic Stress Disorder, trait anxiety, and depression. Approximately 27% of these men and 20% of these women showed current Posttraumatic Stress Disorder. Resistance veterans, as a group, appeared comparable to the controls from Dutch validation studies on trait anxiety and depression. Gender differences were not observed. Veterans with current PTSD symptoms scored higher on trait anxiety and depression than the remaining veterans and were comparable on trait anxiety and depression to psychiatric patients. Correlational analyses showed that there was a strong association between trait anxiety and depression. Posttraumatic Stress Disorder correlated highly with trait anxiety and depression.

Somatosensory evoked potentials after iohexol myelography.

Tibial nerve and S1 dermatome somatosensory evoked potentials (SSEPs) were recorded before and after iohexol lumbar myelography in order to evaluate possible neurotoxic effects of this contrast medium. No significant change in SSEP latencies nor amplitudes was noted after iohexol myelography, supporting the low neurotoxic profile of this contrast agent. Results were compared to those of a control group of patients before and after lumbar puncture (LP), without injection of contrast agent. In this group also no significant change in SSEP components was found, indicating that a preceding LP does not affect this electrophysiological examination.

A self-rating scale for the assessment of posttraumatic stress disorder in Dutch Resistance veterans of World War II.

The present study reports on the development of a Dutch PTSD scale based on the DSM-III criteria for PTSD. Test-retest reliability was .91. The scale showed an internal consistency with a coefficient alpha of .88. Factor analysis on a large sample of Resistance veterans (N = 967) yielded six factors, which represent intrusive thoughts, physiological reactions, detachment, rage, active confrontation, and guilt.

Snoring and anxiety dreams.

In a group of elderly males who had been exposed to excessive stress during World War II, 56% of whom suffered from current post-traumatic stress disorder, a significant association was found between snoring and the occurrence of anxiety dreams, independent of the use of sedatives, antidepressants, smoking and alcohol and coffee consumption. Anxiety dream incidence was highest when snoring was accompanied by respiratory pauses. The underlying pathophysiologic mechanisms are thought to be hypercapnia and autonomic-vegetative arousal, resulting from obstructive sleep apneic episodes in heavy snoring. Polysomnographic sleep studies are needed to confirm this hypothesis.

Neurometrics in cerebral ischemia and uremic encephalopathy.

The neurometric method as introduced by John was used to study three groups of patients with cerebral ischemia, three groups of patients with renal disease and an additional normal control group. The traditional neurometric approach was slightly modified: relative band power values were not expressed as a percentage of the total power per derivation but as a percentage of the "global power"; frequency matrices were used in addition to power matrices. From the study of the three groups of patients with one-sided supratentorial ischemia it appeared that sensitivity and specificity are completely satisfactory when using neurometrics in patients with severe ischemia in the middle cerebral artery territory studied within 48 hours of the onset of the stroke. However, in ischemia patients with less pronounced clinical signs and especially in patients without persistent neurological deficit the sensitivity is much lower. In studying dialysed and non-dialysed renal patients signs of an (often subclinical) encephalopathy could be detected in approximately 37% of all patients. Follow-up studies of the ischemia patients and the renal patients over a period of several years revealed a parallelism between clinical scores and qEEG scores in the ischemia patients; almost all qEEG improvement occurred in the first three months after the stroke. The qEEG profile of the groups of dialysed patients tended to be more or less stable over a period of several years.