RESUMEN
BACKGROUND & AIMS: The aim of this study was to determine the effect of krill oil supplementation, on muscle function and size in healthy older adults. METHODS: Men and women, aged above 65 years, with a BMI less than 35kg/m2, who participated in less than 1h per week of structured self-reported exercise, were enrolled in the study (NCT04048096) between March 2018 and March 2020. Participants were randomised to either control or krill oil supplements (4g/day) for 6 months in this double blind randomised controlled trial. At baseline, 6 weeks and 6 months, knee extensor maximal torque was measured as the primary outcome of the study. Secondary outcomes measured were grip strength, vastus lateralis muscle thickness, short performance physical battery test, body fat, muscle mass, blood lipids, glucose, insulin, and C-Reactive Protein, neuromuscular (M-Wave, RMS and voluntary activation), and erythrocyte fatty acid composition. RESULTS: A total of 102 men and women were enrolled in the study. Ninety-four participants (krill group (26 women and 23 men) and placebo group (27 women and 18 men)) completed the study (mean (SD): age 71.2 (5.1) years and weight 71.8 (12.3) kg). Six months supplementation with krill oil resulted in, an increase in knee extensor maximal torque, grip strength and vastus lateralis muscle thickness, relative to control (p<0.05). The 6-month treatment effects were 9.3% (95%CI: 2.8, 15.8%), 10.9% (95%CI: 8.3, 13.6%) and 3.5% (95%CI: 2.1, 4.9%) respectively. Increases in erythrocyte fatty acid profile were seen with krill oil for EPA 214% (95%CI: 166, 262%), DHA 36% (95%CI: 24, 48%) and the omega-3 index 61% (95%CI: 49, 73%), relative to control (p < 0.05). Krill oil resulted in an increased, relative to control (p < 0.05), M-Wave of 17% (95%CI: 12.7, 38.1%) but there was no effect of krill oil on RMS, voluntary activation, or on any other secondary outcomes such as performance of the short performance physical battery test or quality of life. CONCLUSION: Krill oil supplementation for 6 months results in statistically and clinically significant increases in muscle function and size in healthy older adults. GOV IDENTIFIER: NCT04048096.
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Euphausiacea , Enfermedades Musculares , Anciano , Animales , Suplementos Dietéticos , Método Doble Ciego , Ácidos Grasos/farmacología , Femenino , Humanos , Masculino , Músculo Esquelético , Calidad de VidaRESUMEN
BACKGROUND: Catheter-related blood stream infections (CRBSI) cause significant morbidity and mortality in patients with hematological malignancies. Previous studies have identified a predominance of gram-positive organisms causing CRBSI but they included both neutropenic and non-neutropenic patients with solid organ and hematological malignancies. The aim of our study was to evaluate the incidence and microbiological profile of CRBSIs in a specific cohort of patients with hematological malignancies in their non-neutropenic phase of illness. METHODS: A detailed retrospective review was done from January 2003 to December 2005 on all patients with hematological malignancies who had double-lumen non-antibiotic impregnated tunneled CVCs (Hickman catheters) inserted in our hospital to identify those fulfilling our criteria for CRBSI episodes. RESULTS: Amongst 273 evaluable patients, 61 developed CRBSI on 70 occasions. In contrast to previous studies, there was a predominance of gram-negative infections (68%). The majority (73%) of initial CRBSI episodes required catheter removal within 7 days of onset. Vancomycin and cefepime was the most common initial antibiotic regimen used. CONCLUSIONS: This study highlights the predominance of gram-negative infections in our cohort of non-neutropenic patients with underlying hematological malignancies who had Hickman catheters whose lines were not salvageable in the majority of cases. Empiric monotherapy with an antimicrobial agent with broad spectrum gram-negative cover needs to be given upfront pending results of the nature and sensitivity of organisms identified.
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Bacteriemia/epidemiología , Catéteres de Permanencia/microbiología , Bacterias Gramnegativas/aislamiento & purificación , Infecciones por Bacterias Gramnegativas/epidemiología , Neoplasias Hematológicas/complicaciones , Adolescente , Adulto , Anciano , Antibacterianos/uso terapéutico , Profilaxis Antibiótica , Bacteriemia/complicaciones , Bacteriemia/microbiología , Cateterismo Venoso Central/efectos adversos , Cefepima , Cefalosporinas/uso terapéutico , Estudios de Cohortes , Femenino , Infecciones por Bacterias Gramnegativas/complicaciones , Infecciones por Bacterias Gramnegativas/tratamiento farmacológico , Neoplasias Hematológicas/sangre , Neoplasias Hematológicas/microbiología , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Neutropenia/complicaciones , Estudios Retrospectivos , Vancomicina/uso terapéutico , Victoria/epidemiologíaRESUMEN
BACKGROUND: Community acquired pneumonia is one of the most common infections for which antibiotics are prescribed in Australia. METHODS: We audited empiric antibiotic prescribing for 392 adults with community-acquired pneumonia. RESULTS: Only 61.9% of patients received empiric antibiotic coverage for both typical and atypical pathogens. Of those who required intensive care unit management, 34.6% did not receive antibiotic cover for atypical pneumonia pathogens within the first 24 h. Approximately 21.9% of patients reporting antibiotic allergies were given antibiotics to which they had a documented allergy. CONCLUSION: Efforts to improve prescribing practices could be focused towards identifying patients with severe illness early and improving recognition of documented allergies.
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Antiinfecciosos/uso terapéutico , Infecciones Comunitarias Adquiridas/tratamiento farmacológico , Neumonía/tratamiento farmacológico , Pautas de la Práctica en Medicina , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Infecciones Comunitarias Adquiridas/microbiología , Servicio de Urgencia en Hospital , Femenino , Humanos , Masculino , Auditoría Médica , Persona de Mediana Edad , Neumonía/microbiologíaRESUMEN
The utility of GVHD prophylaxis with cyclosporin, MTX and prednisolone (CSA/MTX/Pred) in allogeneic PBPC transplants is not well described although there are published data using this combination after bone marrow transplants. The effectiveness of this regimen on the prevention of GVHD was assessed in 107 consecutive sibling and less-than-ideal donor transplant recipients over a 5-year period and compared to that observed in 65 patients receiving standard CSA and short-course MTX without prednisolone. Oral prednisolone was commenced on day +14 at 0.5 mg/kg per day, increased to 1 mg/kg per day on day +21 to day +34 then gradually tapered and ceased by day +100. The cumulative incidence of acute GVHD (grades II-IV) to day 100 in those receiving prednisolone prophylaxis was lower (52 versus 76%, P<0.01). The onset of symptomatic GVHD requiring systemic treatment was delayed from a median of 41 days post transplant to 92 days. When assessment of the cumulative incidence of symptomatic GVHD continued to day +180 incidence became similar (74 versus 78%), there was no difference between the two groups in rates of relapse, transplant-related mortality, infections or chronic GVHD. We conclude that the addition of prednisolone to CSA/MTX delays the onset of early acute GVHD in PBPC recipients but has no impact on the overall incidence of GVHD.
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Ciclosporina/uso terapéutico , Enfermedad Injerto contra Huésped/prevención & control , Inmunosupresores/uso terapéutico , Metotrexato/uso terapéutico , Trasplante de Células Madre de Sangre Periférica/métodos , Prednisolona/uso terapéutico , Adolescente , Adulto , Densidad Ósea/efectos de los fármacos , Supervivencia sin Enfermedad , Quimioterapia Combinada , Femenino , Trasplante de Células Madre Hematopoyéticas/métodos , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Trasplante Homólogo , Resultado del TratamientoRESUMEN
Multislice CT coronary angiography (CT-CA) has emerged as a potential imaging method for coronary artery disease. This study aimed to ascertain the accuracy of 16-slice CT in the diagnosis of significant coronary stenosis (>or=50% reduction of lumen diameter). This mixed retrospective/prospective observational study compared 95 paired 16-slice CT-CA and fluoroscopic coronary angiography (FCA) sets. A cardiologist and a radiologist blinded to the FCA findings evaluated CT-CA images independently by visual estimation. Disagreement between these reporters was arbitrated by a third CT reporter (a cardiologist). A separate cardiologist blinded to CT-CA findings assessed FCA by visual estimation. Of 1,161 coronary segments assessable on FCA, 1,103 segments (95%) were assessable on CT-CA. The CT-CA correctly diagnosed 147/180 segments with significant stenoses (sensitivity = 82%) and correctly identified 874/923 coronary segments without significant stenoses (specificity = 95%). The positive and negative predictive values of CT-CA in the diagnosis of coronary segment with significant stenosis were 75 and 96%, respectively. On patient-based analysis, CT-CA correctly identified all 68 studies with at least one vessel with significant stenosis (sensitivity = 100%; specificity = 83%). The positive and negative predictive values of CT-CA in identifying patients with significant coronary stenosis were 94 and 100%, respectively. The 16-slice CT-CA showed moderately good sensitivity but very high specificity and negative predictive value in the diagnosis of significant coronary stenosis. The CT-CA would appear to be a useful 'rule-out' test for patients with low-risk profile for ischaemic heart disease.
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Angiografía Coronaria/métodos , Estenosis Coronaria/diagnóstico por imagen , Tomografía Computarizada Espiral/métodos , Adulto , Anciano , Anciano de 80 o más Años , Reacciones Falso Positivas , Femenino , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Sensibilidad y EspecificidadRESUMEN
BACKGROUND: This study aimed to evaluate the feasibility and accuracy of 16-slice computed tomography (CT) in the assessment of coronary stent patency. CT coronary angiography (CA) has a high degree of accuracy in the assessment of coronary artery disease compared with invasive selective CA. However, its accuracy in the evaluation of stent patency is not well investigated. METHODS: We conducted a retrospective observational study of paired CT coronary angiography (CT-CA) and invasive fluoroscopic coronary angiography (FCA) in 37 patients with 47 coronary stents. CT-CA was carried out with an electrocardiogram-gated 16-slice CT (LightSpeed-16, General Electric (GE), WI, USA). Two CT reporters, blinded to the FCA findings, assessed CT images for stent patency. A cardiologist blinded to CT findings reported FCA. FCA was regarded as the reference standard. RESULTS: A CT-CA could assess 45 of 47 coronary stents (96%). Non-assessable stents on CT-CA were due to motion artefacts and stent-blooming effects. Of those 45 assessable stents, CT-CA correctly identified five out of seven stents with binary in-stent restenosis (ISR) and 37 of 38 stents without binary ISR. The sensitivity and specificity of 16-slice CT in the evaluation of coronary stents for binary ISR were 71% (95% confidence interval (CI) (29%, 96%)) and 97% (95%CI (86%, 100%)), respectively, exclusive of non-assessable stents. The positive and negative predictive values of 16-slice CT were 83% (95%CI (36%, 100%)) and 95% (95%CI (83%, 99%)), respectively. CONCLUSION: Sixteen-slice CT has a low sensitivity, but very a high specificity when compared with FCA in the evaluation of coronary stents for ISR.
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Angiografía Coronaria/métodos , Reestenosis Coronaria/diagnóstico por imagen , Stents , Tomografía Computarizada por Rayos X/métodos , Anciano , Australia , Estudios de Cohortes , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Stents/normasRESUMEN
PURPOSE: Some patients with temporal lobe epilepsy (TLE) lack evidence of hippocampal sclerosis (HS) on MRI (HS-ve). We hypothesized that this group would have a different pattern of 2-deoxy-2-[F-18]fluoro-D-glucose (FDG)-positron emission tomography (PET) hypometabolism than typical mesial TLE/HS patients with evidence of hippocampal atrophy on magnetic resonance imaging (MRI) (HS+ve), with a lateral temporal neocortical rather than mesial focus. PROCEDURES: Thirty consecutive HS-ve patients and 30 age- and sex-matched HS+ve patients with well-lateralized EEG were identified. FDG-PET was performed on 28 HS-ve patients and 24 HS+ve patients. Both groups were compared using statistical parametric mapping (SPM), directly and with FDG-PET from 20 healthy controls. RESULTS: Both groups showed lateralized temporal hypometabolism compared to controls. In HS+ve, this was antero-infero-mesial (T = 17.13); in HS-ve the main clustering was inferolateral (T = 17.63). When directly compared, HS+ve had greater hypometabolism inmesial temporal/hippocampal regions (T = 4.86); HS-ve had greater inferolateral temporal hypometabolism (T = 4.18). CONCLUSIONS: These data support the hypothesis that focal hypometabolism involves primarily lateal neocortical rather than mesial temporal structures in 'MRI-negative PET-positive TLE.'
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Epilepsia del Lóbulo Temporal/diagnóstico , Hipocampo/patología , Imagen por Resonancia Magnética/métodos , Tomografía de Emisión de Positrones/métodos , Adulto , Estudios de Casos y Controles , Epilepsia del Lóbulo Temporal/diagnóstico por imagen , Femenino , Hipocampo/diagnóstico por imagen , Humanos , Procesamiento de Imagen Asistido por Computador/métodos , Imagen por Resonancia Magnética/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Tomografía de Emisión de Positrones/normas , Tomografía de Emisión de Positrones/estadística & datos numéricos , Radiografía , EsclerosisRESUMEN
Female genital tract graft-versus-host disease (GVHD) is an under-recognized complication of allogeneic stem cell transplantation impacting on quality of life. We describe a prospective surveillance programme for female genital GVHD to better characterize incidence, risk factors and clinical features and the impact of a structured intervention policy. A retrospective audit was conducted on the medical records of all female transplant recipients surviving at least 6 months at a single centre over a 5-year period. Patients commenced topical vaginal oestrogen early post transplant with hormone replacement as appropriate for age, prior menopausal status and co-morbidities. A genital tract management programme included regular gynaecological review and self-maintenance of vaginal capacity by dilator or intercourse. The incidence of genital GVHD was 35% (95% confidence interval (CI) (25, 50%)) at 1 year and 49% (95% CI (36, 63%)) at 2 years. Topical therapy was effective in most cases; no patient required surgical intervention to divide vaginal adhesions. The main risk factor was stem cell source with peripheral blood progenitor cells posing a higher risk than marrow (hazard ratio=3.07 (1.22, 7.73), P=0.017). Extensive GVHD in other organs was a common association. We conclude that female genital GVHD is common, and early detection and commencement of topical immunosuppression with dilator use appears to be highly effective at preventing progression.
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Enfermedades de los Genitales Femeninos/tratamiento farmacológico , Enfermedades de los Genitales Femeninos/etiología , Enfermedad Injerto contra Huésped , Administración Tópica , Adulto , Trasplante de Médula Ósea/efectos adversos , Manejo de la Enfermedad , Femenino , Enfermedad Injerto contra Huésped/tratamiento farmacológico , Enfermedad Injerto contra Huésped/etiología , Enfermedad Injerto contra Huésped/patología , Trasplante de Células Madre Hematopoyéticas/efectos adversos , Trasplante de Células Madre Hematopoyéticas/métodos , Humanos , Inmunosupresores/administración & dosificación , Incidencia , Persona de Mediana Edad , Trasplante de Células Madre de Sangre Periférica/efectos adversos , Vigilancia de la Población , Guías de Práctica Clínica como Asunto , Estudios Retrospectivos , Factores de Riesgo , Trasplante HomólogoRESUMEN
We prospectively investigated the short-term effects of intravenous methyl-prednisolone (IVMP) on cerebral volume in patients suffering a multiple sclerosis (MS) relapse. Ten patients underwent MRI brain studies immediately before and after IVMP treatment, and 4 and 8 weeks later. Whole brain volumes decreased significantly over the 8-week period. The greatest change occurred during IVMP administration. This has implications for MS treatment trials using cerebral atrophy as an endpoint.
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Antiinflamatorios/uso terapéutico , Corteza Cerebral/efectos de los fármacos , Metilprednisolona/uso terapéutico , Esclerosis Múltiple Recurrente-Remitente/tratamiento farmacológico , Adulto , Femenino , Humanos , Imagen por Resonancia Magnética/métodos , Masculino , Persona de Mediana Edad , Esclerosis Múltiple Recurrente-Remitente/patología , Estudios Prospectivos , Factores de TiempoRESUMEN
Methotrexate (MTX), used as a graft-versus-host disease (GvHD) prophylactic agent in hematopoietic stem cell transplantation (HSCT), exerts its effect via folate cycle inhibition. A critical enzyme involved in folate metabolism is 5,10-methylenetetrahydrofolate reductase (MTHFR). We examined the association of a single nucleotide polymorphism (SNP) at position 677 in the MTHFR gene on GvHD outcomes in allogeneic HSCT patients administered MTX. MTHFR genotyping was performed by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) on 193 HSCT patients and donors. A total of 140 patients were transplanted with an HLA-matched related donor and 53 with an unrelated donor. GvHD outcomes were compared between genotypes by univariate and multivariate analysis. The combined donor 677CT and TT genotypes were associated with a decreased incidence of GvHD (acute and chronic combined) in HSCT recipients with an HLA-matched related donor (75% at 1 year in the CT and TT group compared with 91% in the wild type CC group, P=0.01), increased time to onset of first GvHD (P=0.001) and time to first GvHD treated with systemic therapy (P=0.022). Unrelated donor MTHFR genotype was not associated with outcome parameters and no associations of recipient genotype in either related or unrelated donor cohorts were observed.
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Genotipo , Trasplante de Células Madre Hematopoyéticas/métodos , Metotrexato/uso terapéutico , Metilenotetrahidrofolato Reductasa (NADPH2)/genética , Donantes de Tejidos , Adolescente , Adulto , Anciano , Estudios de Cohortes , ADN/química , Femenino , Ácido Fólico/metabolismo , Enfermedad Injerto contra Huésped , Humanos , Masculino , Persona de Mediana Edad , Modelos Estadísticos , Análisis Multivariante , Mutación , Reacción en Cadena de la Polimerasa , Polimorfismo de Longitud del Fragmento de Restricción , Polimorfismo de Nucleótido Simple , Modelos de Riesgos Proporcionales , Trasplante de Células Madre , Células Madre/citología , Factores de Tiempo , Acondicionamiento Pretrasplante , Trasplante Homólogo , Resultado del TratamientoRESUMEN
BACKGROUND: Several severity scores have been proposed to predict patient outcome and to guide initial management of patients with community acquired pneumonia (CAP). Most have been derived as predictors of mortality. A study was undertaken to compare the predictive value of these tools using different clinically meaningful outcomes as constructs for "severe pneumonia". METHODS: A prospective cohort study was performed of all patients presenting to the emergency department with an admission diagnosis of CAP from March 2003 to March 2004. Clinical and laboratory features at presentation were used to calculate severity scores using the pneumonia severity index (PSI), the revised American Thoracic Society score (rATS), and the British Thoracic Society (BTS) severity scores CURB, modified BTS severity score, and CURB-65. The sensitivity, specificity, positive and negative predictive values were compared for four different outcomes (death, need for ICU admission, and combined outcomes of death and/or need for ventilatory or inotropic support). RESULTS: 392 patients were included in the analysis; 37 (9.4%) died and 26 (6.6%) required ventilatory and/or inotropic support. The modified BTS severity score performed best for all four outcomes. The PSI (classes IV+V) and CURB had a very similar performance as predictive tools for each outcome. The rATS identified the need for ICU admission well but not mortality. The CURB-65 score predicted mortality well but performed less well when requirement for ICU was included in the outcome of interest. When the combined outcome was evaluated (excluding patients aged >90 years and those from nursing homes), the best predictors were the modified BTS severity score (sensitivity 94.3%) and the PSI and CURB score (sensitivity 83.3% for both). CONCLUSIONS: Different severity scores have different strengths and weaknesses as prediction tools. Validation should be done in the most relevant clinical setting, using more appropriate constructs of "severe pneumonia" to ensure that these potentially useful tools truly deliver what clinicians expect of them.
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Neumonía Bacteriana/diagnóstico , Índice de Severidad de la Enfermedad , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Infecciones Comunitarias Adquiridas/diagnóstico , Infecciones Comunitarias Adquiridas/mortalidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Neumonía Bacteriana/mortalidad , Pronóstico , Estudios Prospectivos , Sensibilidad y EspecificidadRESUMEN
BACKGROUND: An inverse relation exists between smoking and coffee intake and Parkinson's disease (PD). The present study explored whether this is explained by low sensation seeking, a personality trait believed to characterise PD. METHODS: A total of 106 non-demented patients with PD and 106 age and sex matched healthy controls completed a short version of Zuckerman's Sensation Seeking Scale (SSS), the Geriatric Depression Scale, and the Trait Anxiety Inventory. Data were collected on past and current cigarette smoking, and participants also completed food frequency questionnaires to estimate current caffeine and alcohol intake. RESULTS: Patients with PD had lower sensation seeking and higher depression and anxiety scores. They were also less likely to have ever smoked, and had lower caffeine and alcohol intakes. Analysis of the data using conditional logistic regression suggested that the inverse association of PD risk with sensation seeking was independent of smoking, and caffeine and alcohol intake. Moreover, low sensation seeking explained some of the apparent effect of caffeine and alcohol intake on PD. However, the effect of smoking was weakened only slightly when SSS was included in the regression model. CONCLUSION: This study raises the possibility that there is a neurobiological link between low sensation seeking traits--which might underlie the parkinsonian personality--and the hypothetical protective effect of cigarette smoking and caffeine consumption on PD.
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Consumo de Bebidas Alcohólicas/psicología , Cafeína/administración & dosificación , Conducta Impulsiva/psicología , Enfermedad de Parkinson/psicología , Sensación , Fumar/psicología , Anciano , Anciano de 80 o más Años , Consumo de Bebidas Alcohólicas/epidemiología , Nivel de Alerta , Estudios Transversales , Femenino , Humanos , Conducta Impulsiva/epidemiología , Masculino , Persona de Mediana Edad , Enfermedad de Parkinson/diagnóstico , Enfermedad de Parkinson/epidemiología , Trastornos de la Personalidad/diagnóstico , Trastornos de la Personalidad/epidemiología , Trastornos de la Personalidad/psicología , Inventario de Personalidad , Factores de Riesgo , Fumar/epidemiología , Estadística como Asunto , Reino UnidoRESUMEN
BACKGROUND: Elevated hematocrit (Hct) contributes to blood viscosity and has an adverse effect in acute stroke. The authors investigated the influence of Hct on tissue fate using serial MRI in acute stroke patients. METHODS: The effects of Hct on reperfusion, penumbral salvage, and infarct expansion in 64 patients presenting within 24 hours of stroke onset were measured. MRI was performed at baseline (< 24 hours), days 3 to 5, and 90 days from stroke onset. RESULTS: Median Hct was 42% with a bimodal distribution. There was a strong inverse relationship between Hct and reperfusion (Spearman rho = -0.74, p < 0.0001). The odds of major reperfusion (> 50% resolution of the baseline perfusion-weighted imaging deficit) were significantly lower with increasing Hct (odds ratio [OR] = 0.53; 95% CI = 0.97 to 1.00), independent of age, perfusion, and diffusion lesion volumes and recombinant tissue plasminogen activator (rtPA) administration. There was a trend toward reduced penumbral salvage at days 3 to 5 with increasing Hct (p = 0.06, 95% CI = -4.76 to 0.14). An increasing Hct was a significant predictor of infarct growth (OR = 1.26, 95% CI = 1.00 to 1.59), independent of baseline perfusion and diffusion volumes and glucose. The effect of Hct on reperfusion and infarct expansion was similar irrespective of rtPA administration (p = 0.31) and independent of smoking status. CONCLUSIONS: Higher hematocrit (Hct) values have a significant independent association with reduced reperfusion and greater infarct size after ischemic stroke. An elevated Hct may also be a potential physiologic determinant of reduced penumbral salvage.
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Isquemia Encefálica/fisiopatología , Infarto Cerebral/fisiopatología , Policitemia/complicaciones , Daño por Reperfusión/fisiopatología , Accidente Cerebrovascular/fisiopatología , Adulto , Anciano , Anciano de 80 o más Años , Viscosidad Sanguínea , Encéfalo/irrigación sanguínea , Encéfalo/patología , Encéfalo/fisiopatología , Causalidad , Arterias Cerebrales/fisiopatología , Infarto Cerebral/diagnóstico , Circulación Cerebrovascular , Progresión de la Enfermedad , Hematócrito , Humanos , Modelos Logísticos , Imagen por Resonancia Magnética , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Accidente Cerebrovascular/diagnósticoRESUMEN
BACKGROUND AND PURPOSE: The Echoplanar Imaging Thrombolysis Evaluation Trial (EPITHET) tests the hypothesis that perfusion-weighted imaging (PWI)-diffusion-weighted imaging (DWI) mismatch predicts the response to thrombolysis. There is no accepted standardized definition of PWI-DWI mismatch. We compared common mismatch definitions in the initial 40 EPITHET patients. METHODS: Raw perfusion images were used to generate maps of time to peak (TTP), mean transit time (MTT), time to peak of the impulse response (Tmax) and first moment transit time (FMT). DWI, apparent diffusion coefficient (ADC), and PWI volumes were measured with planimetric and thresholding techniques. Correlations between mismatch volume (PWIvol-DWIvol) and DWI expansion (T2(Day 90-vol)-DWI(Acute-vol)) were also assessed. RESULTS: Mean age was 68+/-11, time to MRI 4.5+/-0.7 hours, and median National Institutes of Health Stroke Scale (NIHSS) score 11 (range 4 to 23). Tmax and MTT hypoperfusion volumes were significantly lower than those calculated with TTP and FMT maps (P<0.001). Mismatch > or =20% was observed in 89% (Tmax) to 92% (TTP/FMT/MTT) of patients. Application of a +4s (relative to the contralateral hemisphere) PWI threshold reduced the frequency of positive mismatch volumes (TTP 73%/FMT 68%/Tmax 54%/MTT 43%). Mismatch was not significantly different when assessed with ADC maps. Mismatch volume, calculated with all parameters and thresholds, was not significantly correlated with DWI expansion. In contrast, reperfusion was correlated inversely with infarct growth (R=-0.51; P=0.009). CONCLUSIONS: Deconvolution and application of PWI thresholds provide more conservative estimates of tissue at risk and decrease the frequency of mismatch accordingly. The precise definition may not be critical; however, because reperfusion alters tissue fate irrespective of mismatch.
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Imagen de Difusión por Resonancia Magnética/métodos , Imagen Eco-Planar/métodos , Angiografía por Resonancia Magnética/métodos , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/patología , Anciano , Isquemia Encefálica/patología , Arterias Cerebrales/patología , Infarto Cerebral , Circulación Cerebrovascular , Difusión , Humanos , Procesamiento de Imagen Asistido por Computador , Persona de Mediana Edad , Perfusión , Terapia Trombolítica , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: Clinical practice guidelines in general (General-CPG) may reduce variation in clinician performance and improve patient outcomes. Short-term evaluation is now routine, but demonstration of early successful implementation does not necessarily ensure longer-term effectiveness. AIM: To assess adherence to chronic obstructive pulmonary disease (COPD)-CPG recommendations at the Royal Melbourne Hospital (RMH), 2 years after successful implementation. To identify barriers to sustained success of General-CPG. METHODS: A multi-faceted evaluation was performed to document: (i) current adherence to COPD management recommendations (medical record audit); (ii) awareness of attitudes towards and barriers for the use of COPD-CPG and General-CPG (staff survey, focus groups and key informant interviews) and (iii) access to and quality of available General-CPG (internet review and random sample General-CPG evaluation. RESULTS: Adherence to COPD-CPG recommendations was highly variable. Adherence was higher in the Emergency Department than the general wards and for specific therapeutic recommendations. It was lower for non-pharmacological therapy and for recommendations relating to processes of care. Most health professionals were in favour of General-CPG. Barriers to use of General-CPG were in keeping with previous literature reports. Organizational issues including high levels of staff turnover and lack of integration of General-CPG into hospital quality frameworks were highlighted as major barriers. Hospital intranet access and presentation of General-CPG identified lack of consistency in terminology and presentation. CONCLUSION: Short-term effectiveness of COPD-CPG implementation did not ensure sustained success. Departmental organizational behaviours and organizational system barriers are major factors influencing durability.
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Competencia Clínica , Adhesión a Directriz , Conocimientos, Actitudes y Práctica en Salud , Guías de Práctica Clínica como Asunto , Anciano , Femenino , Humanos , Masculino , Rol del Médico , Pautas de la Práctica en Medicina , Enfermedad Pulmonar Obstructiva Crónica/terapia , Encuestas y CuestionariosRESUMEN
Most patients with non-lesional temporal lobe epilepsy (NLTLE) will have the findings of hippocampal sclerosis (HS) on a high resolution MRI. However, a significant minority of patients with NLTLE and electroclinically well-lateralized temporal lobe seizures have no evidence of HS on MRI. Many of these patients have concordant hypometabolism on fluorodeoxyglucose-PET ([18F]FDG-PET). The pathophysiological basis of this latter group remains uncertain. We aimed to determine whether NLTLE without HS on MRI represents a variant of or a different clinicopathological syndrome from that of NLTLE with HS on MRI. The clinical, EEG, [18F]FDG-PET, histopathological and surgical outcomes of 30 consecutive NLTLE patients with well-lateralized EEG but without HS on MRI (HS-ve TLE) were compared with 30 consecutive age- and sex-matched NLTLE patients with well-lateralized EEG with HS on MRI (HS+ve TLE). Both the HS+ve TLE group and the HS-ve TLE patients had a high degree of [18F]FDG-PET concordant lateralization (26 out of 30 HS-ve TLE versus 27 out of 27 HS+ve TLE). HS-ve TLE patients had more widespread hypometabolism on [18F]FDG-PET by blinded visual analysis [odds ratio (OR = + infinity (2.51, -), P = 0.001]. The HS-ve TLE group less frequently had a history of febrile convulsions [OR = 0.077 (0.002-0.512), P = 0.002], more commonly had a delta rhythm at ictal onset [OR = 3.67 (0.97-20.47), P = 0.057], and less frequently had histopathological evidence of HS [OR = 0 (0-0.85), P = 0.031]. There was no significant difference in surgical outcome despite half of those without HS having a hippocampal-sparing procedure. Based on the findings outlined, HS-ve PET-positive TLE may be a surgically remediable syndrome distinct from HS+ve TLE, with a pathophysiological basis that primarily involves lateral temporal neocortical rather than mesial temporal structures.
Asunto(s)
Epilepsia del Lóbulo Temporal/patología , Hipocampo/patología , Imagen por Resonancia Magnética/métodos , Tomografía Computarizada de Emisión/métodos , Adulto , Electroencefalografía/métodos , Epilepsia del Lóbulo Temporal/fisiopatología , Epilepsia del Lóbulo Temporal/cirugía , Salud de la Familia , Femenino , Hipocampo/fisiopatología , Hipocampo/cirugía , Humanos , Masculino , Persona de Mediana Edad , Pruebas Neuropsicológicas , Estudios Retrospectivos , Esclerosis , Convulsiones/patología , Convulsiones/fisiopatología , Resultado del TratamientoRESUMEN
Using serial magnetic resonance imaging (MRI), we investigated the relationship between diffuse cerebral atrophy, T1 and T2 lesion volumes, mean thalamic volumes and clinical progression in patients with established multiple sclerosis (MS). Eleven patients were included in this prospective serial study. Cerebral volumes, T1 hypointense lesion volumes, and T2 hyperintense lesion volumes at baseline and at up to 3 years follow-up were assessed on MRI brain scans. As a putative measure of cerebral atrophy mean thalamic volumes were also obtained. The outcome measures were the MRI parameters and disability on Kurtzke's expanded disability status scale (EDSS). Of the 11 patients 6 worsened clinically as measured by an increase of 0.5 or more on the EDSS. Cerebral atrophy occurred in 91% of patients and was independent of changes in lesion volumes and was not associated with disease progression as determined by the EDSS.
Asunto(s)
Encéfalo/patología , Imagen por Resonancia Magnética , Esclerosis Múltiple/complicaciones , Esclerosis Múltiple/patología , Adulto , Atrofia/etiología , Encefalopatías/etiología , Encefalopatías/patología , Evaluación de la Discapacidad , Progresión de la Enfermedad , Femenino , Humanos , Procesamiento de Imagen Asistido por Computador , Masculino , Persona de Mediana Edad , Proyectos Piloto , Estudios ProspectivosRESUMEN
OBJECTIVE: To compare the relative proportions of varicella zoster virus (VZV) and herpes simplex viruses in specimens obtained from the genital lesions of adults presenting with presumed genital herpes infection. METHODS: Swabs of genital lesions from 6210 patients attending general practices, infectious diseases clinics within hospitals, or sexual health centres for treatment of their genital lesions were tested using polymerase chain reaction (PCR) technology. The multiplexed PCR was capable of detecting herpes simplex virus types 1 and 2 (HSV-1, HSV-2), VZV, and cytomegalovirus in a single sample. RESULTS: A total of 2225 patients had viruses detected by PCR. HSV-1 was detected in 36%, HSV-2 in 61%, and VZV in 2.9% of PCR positive samples. Of the 65 patients with VZV genital infection, many were thought to have HSV infection before laboratory testing. CONCLUSIONS: The finding of VZV in nearly 3% of virus positive genital specimens demonstrates that this virus needs to be considered as a differential diagnosis for genital herpetic lesions. Advice provided to patients with VZV genital infection regarding the source of infection, likelihood of recurrence, and potential for transmission of the virus will be different from that given to patients with HSV infection.
Asunto(s)
Varicela/diagnóstico , Herpesvirus Humano 3/aislamiento & purificación , Adolescente , Adulto , Anciano , Varicela/virología , Niño , Preescolar , Citomegalovirus/aislamiento & purificación , ADN Viral/análisis , Femenino , Herpesvirus Humano 1/aislamiento & purificación , Herpesvirus Humano 2/aislamiento & purificación , Humanos , Lactante , Recién Nacido , Masculino , Persona de Mediana Edad , Reacción en Cadena de la Polimerasa/métodosRESUMEN
Magnetic resonance images (MRI) were collected in a sample of 28 apes, 16 Old World monkeys and 8 New World monkeys. The length of the sylvian fissure (SF) and the superior temporal sulcus (STS) was traced in each hemisphere from three regions of the cerebral cortex. These three regions were labeled according to their position on the sagittal plane as lateral, medial and insular. It was hypothesized that the length and asymmetry of these fissures would be dependent on the region of measurement and that a leftward asymmetry in the SF and STS would be more robust in the great ape sample than for the monkeys. The results indicated within the ape sample a population-level leftward asymmetry in the medial and insular regions of the SF. Within the Old and New World monkey samples, the SF was leftward in the medial region at the population level, but not at the insular region. Additionally, the Old World monkeys exhibited a population-level rightward lateral SF and a rightward lateral STS. No other families exhibited population-level asymmetries in the lateral region of the SF or in any region of the STS. These results are consistent with findings reported in apes and, to a lesser extent, monkeys. MRI has excellent potential for comparing neuroanatomy across taxonomic families that will help future investigations.
Asunto(s)
Encéfalo/anatomía & histología , Encéfalo/fisiología , Lateralidad Funcional/fisiología , Imagen por Resonancia Magnética , Animales , Femenino , Masculino , Primates , Lóbulo Temporal/anatomía & histología , Lóbulo Temporal/fisiologíaRESUMEN
The planum temporale (PT), a portion of Wernicke's area, is important for linguistic functions in humans and is larger in the left compared to the right hemisphere. In this study, we assessed the presence and size of the PT in a sample of non-human primates including 21 great apes, four lesser apes, 11 Old World monkeys and eight New World monkeys using magnetic resonance imaging. The PT was measured in both the sagittal and coronal planes by use of multiplanar reformatting software. The PT could only be identified in the sample of great apes and not in the remaining non-human primate species. Within the great ape sample, the PT was larger in the left hemisphere than in the right in a statistical majority of the subjects. These results are consistent with the notion that the PT evolved as a definable structure about 15 million years ago and may have arisen as a result for selection for greater cortical folding which in turn led to greater gyrification in larger brains.