Somatosensory influence on postural response to galvanic vestibular stimulation

We investigated how postural responses to galvanic vestibular stimulation were affected by standing on a translating support surface and by somatosensory loss due to diabetic neuropathy. We tested the hypothesis that an unstable surface and somatosensory loss can result in an increase of vestibulospinal sensitivity. Bipolar galvanic vestibular stimulation was applied to subjects who were standing on a force platform, either on a hard, stationary surface or during a backward platform translation (9 cm, 4.2 cm/s). The intensity of the galvanic stimulus was varied from 0.25 to 1 mA. The amplitude of the peak body CoP displacement in response to the galvanic stimulus was plotted as a function of stimulus intensity for each individual. A larger increase in CoP displacement to a given increase in galvanic current was interpreted as an increase of vestibulospinal sensitivity. Subjects with somatosensory loss in the feet due to diabetes showed higher vestibulospinal sensitivity than healthy subjects when tested on a stationary support surface. Control subjects and patients with somatosensory loss standing on translating surface also showed increased galvanic response gains compared to stance on a stationary surface. The severity of the somatosensory loss in the feet correlated with the increased postural sensitivity to galvanic vestibular stimulation. These results showed that postural responses to galvanic vestibular stimulus were modified by somatosensory information from the surface. Somatosensory loss due to diabetic neuropathy and alteration of somatosensory input during stance on translating support surface resulted in increased vestibulospinal sensitivity.     

Treatment of acute myeloblastic leukemia in adults: remission induction with a combination of cyclophosphamide,cytarabine and vincristine

A regimen of intravenous cyclophosphamide, cytarabine and vincristine, given over a four-day period and repeated every two to three weeks, was used to treat 33 patients with acute myeloblastic leukemia. Of the 30 evaluable patients 9/18 previously untreated patients achieved complete remission and two others marked improvement, and 4/12 previously treated patients achieved complete remission. Twelve of 16 patients under the median age of 38 responded while only 3/14 patients over this age responded. There was no difference in response between those with elevated muramidase levels and those with normal levels. Three patients developed a previously unrecognized syndorme of fever, malaise, rash and orbital suffusion. Cytarabine was probably responsible.At least four courses of treatment are required before abandoning this regimen of therapy. Patients who achieve a complete remission and live for more than 150 days spend about 25% of their total survival time from diagnosis in hospital.     

CLINICAL EXPERIENCE WITH CHLORPROPAMIDE

Seventy-eight patients with mild diabetes were treated with chlorpropamide in doses up to 1 gm. daily. Eight showed primary failure to respond and two showed an initial but not a sustained response. Patients whose diabetes was of recent onset and who had not been treated with insulin or a sulfonylurea, required smaller doses than the remainder except for a group of patients who had been diabetic for more than 15 years.The average dose for the 64 patients who took chlorpropamide for more than three months was 0.46 gm. per day. Serious side effects were uncommon and disappeared when the drug was stopped. One patient became jaundiced, one had a rash, and one showed granulocytopenia. Changes in liver function tests were seen in 17 out of 56 patients treated for more than three months and were correlated with the dosage of the drug and the duration of treatment.     

Influence Of Diabetes And Hyperglycemia On Duration Of Stay In Patients Hospitalized With Congestive Heart Failure

ObjectiveTo analyze the influence of diabetes and hyperglycemia on duration of stay in patients hospitalized with congestive heart failure (CHF).MethodsWe conducted a retrospective review of data for patients admitted during a 6-month period with CHF to a community teaching hospital in Baltimore, Maryland. Patients were divided into diabetic and nondiabetic groups, and patients with diabetes were stratified by mean fasting plasma glucose levels into the following groups: < 110 mg/dL, 110 to 180 mg/dL, and > 180 mg/dL. The primary outcome was duration of hospitalization. Other variables included sex, age, ejection fraction, admission glucose, brain natriuretic peptide, creatinine, and other comorbidities.ResultsThe study cohort consisted of 142 patients, 49% of whom had diabetes. The duration of hospitalization was 3.23 days in the patients with diabetes versus 3.11 days in those without diabetes (P = .875). Patients with diabetes were significantly younger (71.8 versus 76.6 years; P = .027) and had a higher baseline mean creatinine level (1.4 versus 1.2 mg/dL; P = .010). Patients with diabetes in the 110 to 180 mg/dL blood glucose group had shorter hospitalizations than did those in the < 110 mg/dL group (2.94 versus 3.41 days; P = .259). Only 9 patients had blood glucose levels > 180 mg/dL, and these patients had the longest hospitalizations (mean duration, 3.78 days).ConclusionThe prevalence of diabetes was higher in our study than in previously published studies of patients with CHF. Although patients with diabetes did not have significantly longer hospitalizations than those without diabetes, they were significantly younger and had higher baseline creatinine values. Hyperglycemia was an infrequent phenomenon among patients without diabetes. The patients with diabetes in the 110 to 180 mg/dL blood glucose group had shorter hospitalizations than did those in the < 110 mg/dL group, although this difference did not reach statistical significance. Many of the initial studies of tight glucose control were conducted in the surgical intensive care unit, but recently published evidence has raised doubt about applying these results to medical patients. We conclude that there may be no significant benefit in terms of duration of hospitalization in assigning patients with diabetes who have CHF exacerbations to tight glucose control regimens. A more liberal approach of maintaining glucose levels at 110 to 180 mg/dL may be acceptable. (Endocr Pract. 2008;14:691-696)     

Characteristics and Outcomes among Older HIV-Positive Adults Enrolled in HIV Programs in Four Sub-Saharan African Countries

Background

Limited information exists on adults ≥50 years receiving HIV care in sub-Saharan Africa.

Methodology

Using routinely-collected longitudinal patient-level data among 391,111 adults ≥15 years enrolling in HIV care from January 2005–December 2010 and 184,689 initiating ART, we compared characteristics and outcomes between older (≥50 years) and younger adults at 199 clinics in Kenya, Mozambique, Rwanda, and Tanzania. We calculated proportions over time of newly enrolled and active adults receiving HIV care and initiating ART who were ≥50 years; cumulative incidence of loss to follow-up (LTF) and recorded death one year after enrollment and ART initiation, and CD4+ response following ART initiation.

Findings

From 2005–2010, the percentage of adults ≥50 years newly enrolled in HIV care remained stable at 10%, while the percentage of adults ≥50 years newly initiating ART (10% [2005]-12% [2010]), active in follow-up (10% [2005]-14% (2010]), and active on ART (10% [2005]-16% [2010]) significantly increased. One year after enrollment, older patients had significantly lower incidence of LTF (33.1% vs. 32.6%[40–49 years], 40.5%[25–39 years], and 56.3%[15–24 years]; p-value<0.0001), but significantly higher incidence of recorded death (6.0% vs. 5.0% [40–49 years], 4.1% [25–39 years], and 2.8% [15–24 years]; p-valve<0.0001). LTF was lower after vs. before ART initiation for all ages, with older adults experiencing less LTF than younger adults. Among 85,763 ART patients with baseline and follow-up CD4+ counts, adjusted average 12-month CD4+ response for older adults was 20.6 cells/mm³ lower than for adults 25–39 years of age (95% CI: 17.1–24.1).

Conclusions

The proportion of patients who are ≥50 years has increased over time and been driven by aging of the existing patient population. Older patients experienced less LTF, higher recorded mortality and less robust CD4+ response after ART initiation. Increased programmatic attention on older adults receiving HIV care in sub-Saharan Africa is warranted.     

Distinct Clinical and Experimental Characteristics in the Patients Younger than 60 Years Old with Myelodysplastic Syndromes

Myelodysplastic syndromes (MDS) mainly occur in elderly individuals in Western countries. However, MDS is commonly found in young individuals (<60 years) in Asia. The reason for the high incidence in younger individuals is still unclear, and the differences in disease features between young and elderly patients with MDS have been not well recognized. To explore these issues, in this study, we analyzed the clinical and experimental characteristics of MDS in the patients younger and older than 60 years old and characterized the potential age-associated differences. The results showed that over half of the patients with MDS (61.9%) were younger than 60 years old upon the first diagnosis. The younger patients were more likely to be female, who have lower risk and less advanced MDS. The occurrence of trisomy 8 and bone marrow failure were more frequent in the younger patients than the older ones. The marrow CD34+ cells in the younger patients showed lower proliferation and higher apoptosis in comparison with that in the older ones. Obvious amplification of T cells and low CFU formation could be found in the younger patients. CFU formation was significantly increased in the younger patients after the removal of activated T cells. In addition, the younger patients had a lower frequency of p15^INK4B methylation, longer survival expectancy and less AML transformation. In summary, the younger patients with MDS in China may show more benign disease features than the older ones. Enhanced immunological response may be involved in the pathogenesis of MDS in the patients younger than 60 years.     

Effect of streptomycin on the hearing function]

One of the main problems of the modern medicines within the last 10-15 years has been so-called drug disease. Toxic effect of the aminoglucoside antibiotics and streptomycin on the vestibular and auditory analysers is one of frequent and severe complications of their use. According to the author's observations treatment of 200 patients with streptomycin resulted in affection of their hearing in 40 to 80 cases. The ototoxicity was confirmed by audiograms, while the level of clinical signs and subjective complains did not always coincided with the audiograms. Audiometry should be performed at the beginning of the treatment and before the repeated courses of streptomycin therapy, and later it should be repeated during the treatment course every 10-15 days. Under the experimental conditions low doses of streptomycin used at early stages induced fine damages in the sensor cells of the cochlea which could be detected only histochemically.     

Plasma lipids and lipoprotein patterns in angiographically graded atherosclerosis of the legs and in coronary heart disease.

The prevalence and type of plasma lipoprotein abnormalities were determined in 114 French-Canadian patients with angiographically proven peripheral vascular disease (PVD). The severity of atherosclerosis was positively correlated with plasma triglyceride concentration, especially in the younger patients (r = 0.29, P less than 0.05), and (not significantly) with plasma cholesterol concentration. Of the risk factors believed to predispose individuals to atherosclerosis, cigarette smoking was the most frequently found in the PVD patients (72.8%), especially among the men. Combination of two or more risk factors was the rule. Findings were compared with those in 114 patients who had undergone coronary angiography for suspected coronary heart disease (CHD). The CHD patients were, on average, younger by 10 years. Hyperlipidemia was present in 58.8% of CHD patients, compared with 43.9% of PVD patients. A far higher proportion of CHD patients showed the type II plasma lipoprotein pattern (24.6% v. 7.9%), although the type IV pattern was more common in both groups (31.6% and 28.9%, respectively). A high proportion of all patients (56.1% with PVD and 41.2% with CHD) showed a normal lipoprotein pattern on paper electrophoresis.     

Brain Infarction and Hemorrhage in Young and Middle-aged Adults

Of 131 young (17 to 44 years) and middle-aged (45 to 55 years) adults who had brain infarction or hemorrhage, the most common etiologic factors were rheumatic heart disease, migraine and oral contraceptive use among the younger group. In contrast, atherosclerotic, hypertensive and diabetes-associated cerebrovascular were the most common causes in the middle-aged group. Patients who have a stroke before age 45 should have prompt, complete laboratory and radiologic testing to define a possible treatable cause.     

Streptidine, a metabolic derivative produced after administration of streptomycin in vivo, is vestibulotoxic in rats

Streptomycin is the treatment of choice in developing countries for patients suffering from tuberculosis or other infectious diseases. However, it produces incapacitating vestibular symptoms whose onset is delayed and gradual. This observation led to the notion that a streptomycin metabolic derivative and not the antibiotic itself is the damaging agent for the inner ear. To study further the existence of this ototoxic metabolite, chronic treatment with streptomycin or its putative derivative streptidine was carried out in young male Long Evans rats. The presence of streptomycin or streptidine in the blood of animals of either experimental group was assessed by high performance liquid chromatography and analysis of swimming behavior was used to evaluate vestibular damage. Features of the sensory epithelium and quantification of hair cells were attained in sections of the utricular organ of all groups by light microscopy. After 25, 35 and 45 days of treatment with streptomycin, a metabolite with the same chromatographic properties as the streptidine standard run in parallel was identified in the blood of rats. Concentrations of the metabolite were 2.26 microg/ml on the 25th day and around 8.0 microg/ml in both the 35th and the 45th day of treatment, while streptomycin was below its detection level at either period. In streptidine-treated rats, the concentration of this compound was 1.0, 1.84 and 4.94 microg/ml on the 25th, 35th and 45th treatment days, respectively. Treatment with either streptomycin or streptidine resulted in similar abnormal swimming patterns and histological alterations of the utricular epithelium. Loss of hair cells was roughly equivalent even though streptidine was administered in a dose 90% lower than streptomycin. The gradual appearance of streptidine as a metabolic derivative of the antibiotic in the blood of rats or the administration of this compound alone, causing similar functional and structural vestibular deterioration seen in streptomycin-treated animals, supports the notion that streptidine is a potential contributor to ototoxicity after prolonged antibiotic administration.     

Drug resistance in Shigella dysenteriae,S flexneri and S boydii in England and Wales: increasing incidence of resistance to trimethoprim.

A total of 2753 strains of shigella belonging to subgroups A, B, and C that were isolated from patients in England and Wales during the period from 1979 to mid-1983 were studied. Of these, 1690 (61%) were from patients recently returned from abroad or in contact with recent travellers, and 760 (45%) of these affected travellers from the Indian subcontinent. The number of strains resistant to sulphonamides and streptomycin remained at a high level throughout (average 76% and 72% respectively). Resistance to tetracyclines, ampicillin, and chloramphenicol rose, reaching 63%, 51%, and 48%, respectively, in 1982. Strains resistant to trimethoprim were seen in substantial numbers for the first time and increased from 1.3% of all strains in 1979 to 9.9% in 1982 and 16.8% in the first half of 1983. The proportion of patients with recent foreign contact was notably smaller among those with strains resistant to trimethoprim than among those with strains sensitive to trimethoprim. The increase in resistance to trimethoprim might partly result from the use in Britain of compounds containing trimethoprim for the treatment of shigellosis.     

The Role of Cervical and Ocular Vestibular Evoked Myogenic Potentials in the Assessment of Patients with Vestibular Schwannomas

Objectives

To investigate the clinical utility of VEMPs in patients suffering from unilateral vestibular schwannoma (VS) and to determine the optimal stimulation parameter (air conducted sound, bone conducted vibration) for evaluating the function of the vestibular nerve.

Methods

Data were obtained in 63 patients with non-operated VS, and 20 patients operated on VS. Vestibular function was assessed by caloric, cervical and ocular VEMP testing. 37/63 patients with conclusive ACS ocular VEMPs responses were studied separately.

Results

In the 63 non-operated VS patients, cVEMPs were abnormal in 65.1% of patients in response to AC STB and in 49.2% of patients to AC clicks. In the 37/63 patients with positive responses from the unaffected side, oVEMPs were abnormal in 75.7% of patients with ACS, in 67.6% with AFz and in 56.8% with mastoid BCV stimulation. In 16% of the patients, VEMPs were the only abnormal test (normal caloric and normal hearing). Among the 26 patients who did not show oVEMP responses on either side with ACS, oVEMPs responses could be obtained with AFz (50%) and with mastoid stimulation (89%).

Conclusions

The VEMP test demonstrated significant clinical value as it yielded the only abnormal test results in some patients suffering from a unilateral vestibular schwannoma. For oVEMPs, we suggest that ACS stimulation should be the initial test. In patients who responded to ACS and who had normal responses, BCV was not required. In patients with abnormal responses on the affected side using ACS, BCV at AFz should be used to confirm abnormal function of the superior vestibular nerve. In patients who exhibited no responses on either side to ACS, BCV was the only approach allowing assessment of the function of the superior vestibular nerve. We favor using AFz stimulation first because it is easier to perform in clinical practice than mastoid stimulation.     

The effect of human chorionic gonadotropin on plasma steroid levels in young and old men

Seven men, 21–30 years old, and six men, 72–90 years old, were given human chorionic gonadotropin (HCG), 3,000 units a day for four days. The concentration of 17β-estradiol (1), estrone and testosterone were measured in plasma samples drawn before and during the course of HCG administration. The administration of HCG resulted in higher levels of both 17β-estradiol and testosterone in the younger as compared to the older men although the percentage increases over baseline levels were similar in both groups. HCG administration resulted in similar, absolute and relative increases of estrone in both young and old men. The levels of 17β-estradiol were higher on day 3 as compared to day 5 in young men. The relative ability to respond to exogenous gonadotropins appears to be preserved despite ageing and loss of libido and potentia. The absolute response is, however, somewhat less in old men as compared to young.     

Facial nerve palsy in the newborn: incidence and outcome

This study retrospectively identifies and characterizes patients with facial palsy related to birth trauma and describes the natural history of this disorder. The records of infants born with facial weakness or paralysis over a 5-year period at Brigham and Women's Hospital were reviewed, and criteria were defined to assign a diagnosis of acquired facial palsy based on birth history and documented physical examinations. The majority of patients were followed up by interview with a family member. Among 44,292 infants born between October 1, 1982 and July 31, 1987, there were 92 recorded cases of congenital seventh nerve palsy. Of these, 81 were acquired, for an incidence of 1.8 per 1000. Seventy-four of the 81 (91 percent) were associated with forceps delivery. By contrast, obstetric forceps were used in 19 percent of all deliveries during the period of the study. The average weight of subjects was 3.55 kg, versus a mean overall birth weight of 3.23 kg. Fifty-nine percent of mothers of affected children and 37 percent of controls were prima gravidas. Forceps delivery, birth weight of 3500 gm or more, and primiparity were all significant risk factors for acquired facial palsy. The incidence of additional birth injuries also was substantially higher among affected subjects than among the general population of newborns. Sixty-six of 81 patients had adequate follow-up. Recovery has been complete for 59 patients (89 percent) and incomplete for the remaining 7 (mean follow-up 34 months). In summary, congenital traumatic facial palsy has definable risk factors and a predictably favorable outcome.     

Multiple myeloma.

Multiple myeloma occurs in over 2000 new patients in England and Wales each year. It presents most frequently as bone pain and patients tend to become dehydrated and may develop renal failure. No available treatment is curative, but about two thirds of patients achieve a stable response with low dose combination chemotherapy. Combination chemotherapy including doxorubicin and carmustine with the alkylating agents cyclophosphamide and melphalan achieve a higher stable response rate than conventional treatment with melphalan and prednisone without additional haematological toxicity. These responses are associated with loss of bone pain and patients remain symptom free for months without further treatment. Relapse occurs on average in a little under two years and, though second responses are frequently obtained, the disease eventually becomes refractory. This paper looks at who should be treated and the benefits that may be expected from the treatments available.     

Ontogeny of the insulin response to glucose in fetal and adult sheep

The purpose of the present experiments was to examine in sheep whether the fetal insulin response to glucose was present by day 110 (d110) of pregnancy and whether the magnitude of the fetal insulin response changed between d110 and d145 (term). We also compared the responses observed in fetuses to those of adult nonpregnant sheep. Basal concentrations of glucose measured in plasma collected from the fetal femoral artery rose progressively between d110 and d145 of gestation, but did not attain the plasma glucose concentrations measured in adult sheep. Peak glucose concentrations in fetuses were achieved 10 min following the bolus injection of glucose (0.8 g/kg estimated fetal body weight) into the fetal femoral vein, and peak values increased with gestational age. Significantly higher peak glucose concentrations were achieved in adult sheep. The concentration of insulin rose rapidly in fetuses at d110, and a similar time course of insulin release in plasma was seen at all gestational ages. The peak plasma insulin concentrations were achieved at 20 min and were significantly greater in older (d140-145) than younger (d125-130) fetuses (p less than 0.05). Peak insulin values in fetuses were much less than in adult sheep. In adult sheep glucose and insulin concentrations remained elevated at 120 min following the injection of glucose, whereas in the fetus the concentration of insulin had returned to preinjection values by 60 min. The insulin/glucose ratio did not change in fetal lambs over the last one third of gestation and was not different from the adult sheep.(ABSTRACT TRUNCATED AT 250 WORDS)     

Reduction mammaplasty using the inferior glandular "pyramid" pedicle: experiences with 300 patients

A comprehensive review of 300 patients undergoing reduction mammaplasty (576 breasts) based on an inferior glandular pedicle is presented. The average age was 31.7 years, weight 146.6 lbs., and the amount of tissue removed 1313.6 gm. No deepithelialization of the skin was performed, and average operating time was 174 minutes. The average distance the nipple-areola complex was moved was 12 cm, with the longest being 22.5 cm. Fifty-seven percent had fibrocystic mastopathy on histologic analysis, and no malignancies were found, even in patients who had undergone a previous mastectomy for breast carcinoma. The most common complication (3.1 percent) was minor suture line necrosis along the infra-mammary crease. All healed without intervention. There was no necrosis or sensory loss to the nipple-areola complex in any patient, and cosmesis was excellent. The analysis also showed that the use of epinephrine, injected subcutaneously just prior to the operation, significantly decreased intraoperative blood loss (p less than 0.0005), regardless of the amount of tissue removed, and eliminated the need for transfusions.     

Intermittent Chemotherapy for Tuberculosis in an Urban Community

A regimen designed for effective foolproof antituberculosis treatment, acceptable on a routine basis, was applied to all patients newly diagnosed at the Chest Clinic, Hammersmith Hospital, in 1963, 1964, and 1965. During the first three months of treatment patients received daily (six days a week) streptomycin 0.75 g. plus isoniazid 300 mg. plus sodium para-aminosalicylate (P.A.S.) 12 g. The P.A.S. was usually stopped when bacterial sensitivity reports made this possible. For a further 15 months streptomycin 1 g. plus isoniazid 600 mg. was given on three alternate days each week to complete a total of 18 months'' treatment.Of the total of 140 patients (66% sputum-positive) 112 (80%) completed the planned 18 months with intermittent streptomycin plus isoniazid and a further eight completed treatment on alternative regimens (a total of 85%). The equivalent figures for one year are 88% and 94%. Excellent clinical and radiological results, together with sputum conversion, were achieved in 138 of the 140 patients (99%). Only two patients were lost from surveillance, because of failure to co-operate, before quiescence was obtained.It is concluded that the total efficiency of supervised intermittent treatment is greater than that of unsupervised daily regimens. Since 100% arrest of tuberculosis is possible with co-operative patients, less should not be accepted in developed countries.     

Higher Calorie Content Preserves Myocardial Electrical Activity During Very-Low-Calorie Dieting

We investigated the effect of calorie and protein content of very-low-calorie diets for weight loss upon myocardial electrical activity. Patients were followed on very low calorie diets for up to 20 weeks. Study No. 1 had 16 obese patients (4 men and 12 women). Study No. 2 had 113 obese women. Both study groups were consecutive samples with patients who had BMI >30. In Study No. 1 patients were given 400 kcaVd with 50 gm of protein and 45 gm of carbohydrates over 12 weeks. In Study No. 2 patients were given either Metabolic Nutrition Program? (MNP?) which contained 600 kcal/d with 70 gm protein and 70 gm carbohydrates, or Optifast-70® which contained 420 kcaVd with 70 gm protein and 32 gm carbohydrates, for up to 20 weeks. Electrocardiograms were obtained at baseline and during the third month in Study No. 1, and monthly in Study No. 2. The sum of the voltage in leads I+II+III and the length of the QT interval were derived from the electrocardiograms. In Study No. 1 the QRS voltage decreased from 2.77 ± .18 mv to 2.45 ± .17 mv (p<.02). Patients lost 18.1 kg ± 4 kg and the QT interval remained unchanged. In Study No. 2 at 20 weeks the QRS voltage decreased on Optifast-70® (p<001) in comparison to MNP?, in which the QRS voltage remained unchanged. Patients on Optifast-70® lost 17.5 ± .53 kg, patients on MNP? lost 18.5 ± .66 kg and the QT interval in both groups remained unchanged. The formula diets tested of less than 600 kcaVd were associated with a decrease in electrocardiographic voltage>.