Balance Difficulties Research Articles

Striking the right balance: motor difficulties in children and adults with dyslexia

Balance difficulties are an enduring feature of dyslexia research, however results have been inconsistent. We propose that between-study heterogeneity may be attributable to variability in balance tasks, balance measurement, participant age, and inclusion of comorbid disorders such as ADHD. This study attempted to clarify these issues, employing quantitative, continuous measures of balance and blindfolded balance, and using both adult and child participants without comorbid ADHD. Eighty-seven individuals participated: dyslexic adults (n = 17), matched adult controls (n = 30), dyslexic children (n = 16) and matched child controls (n = 24). The study found significant balance deficits for the child dyslexic group in the eyes-open task and a result approaching significance in the blindfolded task. By contrast, the adult dyslexic group showed significant deficits in the blindfolded task only. This result is interpreted in terms of lack of sensitivity of the non-blindfolded balance task for adults, owing to ceiling effects. This highlights the need for the use of age-appropriate tests, and may explain some of the heterogeneity in the literature. It is concluded that there is a significant incidence of balance difficulties in children and adults with dyslexia, even for those without comorbid attention deficit.

A Gender-Based Analysis of Work Patterns, Fatigue, and Work/Life Balance Among Physicians in Postgraduate Training

To document fatigue in New Zealand junior doctors in hospital-based clinical training positions and identify work patterns associated with work/life balance difficulties. This workforce has had a duty limitation of 72 hours/week since 1985. The authors chose a gender-based analytical approach because of the increasing proportion of female medical graduates. The authors mailed a confidential questionnaire to all 2,154 eligible junior doctors in 2003. The 1,412 respondents were working > or = 40 hours/week (complete questionnaires from 1,366: response rate: 63%; 49% women). For each participant, the authors calculated a multidimensional fatigue risk score based on sleep and work patterns. Women were more likely to report never/rarely getting enough sleep (P < .05), never/rarely waking refreshed (P < .001), and excessive sleepiness (P < .05) and were less likely to live with children up to 12 years old (P < .001). Fatigue risk scores differed by specialty but not by gender.Fatigue risk scores in the highest tertile were an independent risk factor for reporting problems in social life (odds ratio: 3.83; 95% CI: 2.79-5.28), home life (3.37; 2.43-4.67), personal relationships (2.12; 1.57-2.86), and other commitments (3.06; 2.23-4.19).Qualitative analyses indicated a common desire among men and women for better work/life balance and for part-time work, particularly in relation to parenthood. Limitation of duty hours alone is insufficient to manage fatigue risk and difficulties in maintaining work/life balance. These findings have implications for schedule design, professional training, and workforce planning.

Subscribers’ Complaints and Response of the Global Satellite Mobile (GSM) Network Operators in Nigeria

Global Satellite Mobile (GSM) network was introduced into Nigeria in 2001 amidst various challenges that have serious effect on the quality of the services. The most serious among these challenges is the epileptic power supply. The GSM subscribers on their part also face many problems, major of which is constant network failure. Other problems include card recharging problem; checking of balance difficulty and wrong deduction of credit. The study was therefore designed to examine how the GSM Network operators respond to the complaints of the Subscribers. Implications and consequences of the subscribers’ complaints on the providers were discussed. Both primary and secondary sources were used in obtaining relevant data and information. The primary source includes questionnaire and personal interaction. The secondary source includes the historical background of GSM in Nigeria; relevant extracts from current News Magazines and review of related literature. Selected GSM Operators in Nigeria were used as case study. Based on the findings, the paper recommends ways to tackle subscribers’ complaints. These recommendations were categorized into four- To the GSM Providers; To the Government; To the GSM regulatory body in Nigeria; and to the Subscribers.

Parkinsonism and cognitive decline in a fragile X mosaic male

Parkinsonism and cognitive decline in a fragile X mosaic male

Persistent Increase of Cardiac Troponin I in Plasma without Evidence of Cardiac Injury

A 69-year-old man with diabetes mellitus type II, hypertension, dyslipidemia, and prior ischemic strokes presented to the emergency department with complaints of balance difficulties and inability to stand unassisted of 2 weeks’ duration. The patient’s home medication regimen included atenolol, lisinopril, amlodipine, metformin, and glipizide. He is a retired chef and a former smoker (20 pack-years). He has 2 brothers, both of whom had myocardial infarctions in their 50s. The patient’s physical examination was remarkable for frequent premature contractions, left lower extremity weakness, and impaired coordination. His electrocardiogram revealed sinus rhythm with frequent premature ventricular contractions and diffuse nonspecific T-wave abnormalities. Results of a comprehensive metabolic chemistry panel were within the reference intervals except for increases in glucose (158 mg/dL; reference interval, 74–99 mg/dL) and creatinine (1.5 mg/dL; reference interval, 0.7–1.3 mg/dL). The hemoglobin A1c value was 7.4% (reference interval, <6.0%). Cardiac troponin I (cTnI)1 concentrations were increased at 0.27, 0.22, and 0.25 μg/L (Abbott Architect assay; 99th percentile, <0.03 μg/L) over a span of approximately 8 h. The patient was admitted to the cardiology service on the basis of these abnormal results. A transthoracic echocardiogram revealed a preserved left ventricular systolic function with evidence of impaired diastolic filling. A cardiac catheterization evaluation revealed an ulcerated plaque in the left anterior descending artery with >70% stenosis, which was treated with a bare-metal stent. The presenting symptom of balance difficulty failed to resolve after the coronary intervention, and the patient remained unable to stand unassisted. A neurologic evaluation included magnetic resonance imaging, which found no evidence of an acute stroke. He was discharged with a diagnosis of orthostatic hypotension. Three months later, the patient presented to the emergency department with several days of balance difficulty. The initial cTnI value was increased at 0.10 μg/L, prompting admission to the cardiology …

Correlação entre equilíbrio e ambiente domiciliar como risco de quedas em idosos com acidente vascular encefálico

INTRODUÇÃO: Os idosos acometidos pelo acidente vascular encefálico (AVE) com presença de alterações de equilíbrio estão mais suscetíveis a quedas, podendo estar envolvidos fatores de riscos ambientais em sua etiologia. OBJETIVO: Correlacionar o equilíbrio e o ambiente domiciliar como risco de quedas em idosos acometidos pelo AVE. METODOLOGIA: Estudo descritivo, transversal, quantitativo, cuja amostra foi de 25 idosos, com 60 anos ou mais, de ambos os sexos, com história prévia de AVE, residentes na comunidade e atendidos em dois centros e duas unidades de saúde do município de Jequié-BA, selecionados intencionalmente. RESULTADOS: O grupo estudado apresentou uma média de 28,96 (± 15,65) segundos no Timed Up and Go Test, variando de 8 a 70 segundos, sendo que 36% dos indivíduos realizaram o teste em 30 segundos ou mais, apresentando alto risco de quedas. Na Escala Ambiental de Risco de Quedas Adaptada, os domicílios avaliados apresentaram média de 20,12 (± 4,79) pontos, variando de 9 a 27 pontos, em que se verificou que 56% apresentaram pontuação maior que 20, demonstrando alto risco de quedas para os idosos. A correlação entre o equilíbrio dos idosos acometidos pelo AVE com o ambiente domiciliar mostrou-se positiva e estatisticamente significativa (p = 0,039) CONCLUSÃO: A dificuldade de equilíbrio apresentada pelos idosos com AVE associada à alta prevalência de fatores de riscos encontrados no ambiente domiciliar remete a um quadro preocupante, tornando-se necessária a criação de medidas que visem à prevenção das quedas, com o intuito de melhorar a qualidade de vida dessa população.

Use of a closed set questionnaire to measure primary and secondary effects of neurofibromatosis type 2

To identify the greatest difficulties reported by people affected by neurofibromatosis type 2, and to determine the relationship between the primary and secondary effects of the disease. Postal questionnaire study. Questionnaire sent to subjects' home addresses. Eighty-seven adult patients under the care of the Manchester multidisciplinary neurofibromatosis type 2 team were invited to take part. The response rate was 62 out of 87 (71 per cent). Respondents' answers emphasised that their greatest problem was deafness, which resulted in communication difficulties with social contacts, close partners, family and friends. Correlation coefficients indicated a relationship between general mood changes and hearing difficulties, social communication problems, balance difficulties and mobility problems. Self-confidence was significantly related only to social communication problems. The use of a closed set neurofibromatosis type 2 questionnaire identified hearing problems and subsequent communication difficulties as the main problems faced by people with this condition.

Einfluss des Skischuhs auf das Gleichgewichtsverhalten

Modern ski carving technique demands that skiers have a strong sense of balance and edge their skis with precision and feeling. Stiff ski boots facilitate the transfer of power to the ski but increase the difficulty of balancing. The aim of this study was to analyse the influence of ski boots on balance performance of alpine skiers. 76 experienced skiers (female 33/male 43) and 76 ski racers of the Skigymnasium Stams (female 31/male 45) were tested on the MFT S 3 Check with and without ski boots. Ski boots significantly influenced balance. There were also significant differences between experienced skiers and ski racers, but gender differences were minimal. In addition to general conditioning, skiers should utilise general and ski-specific balance and sensomotor training which could help in ski injury prevention, especially knee injuries.

Application of a Tracer Aerosol Technique Using Atomized Sodium Chloride Particles for Measuring Ventilation Rates in a Naturally Ventilated Azrom-Type Greenhouse in Zimbabwe

In this study ventilation rates for a naturally ventilated Azrom-type greenhouse in Zimbabwe were determined by both a tracer aerosol technique using atomized NaCl particles as the tracer and an integrating nephelometer to monitor the decay of the aerosol particles' concentration in the greenhouse and the water vapor balance method. Comparison of the results showed that, although the tracer aerosol method suffers from some of the typical problems of tracer techniques in general (like the need for uniform concentration of the tracer), it gave comparable results with the water vapor balance method, while overcoming the difficulty of the water vapor balance of scaling up from single (or few) plant(s) to whole canopy transpiration. The M903 Radiance Research portable nephelometer is a lightweight, low-power instrument, and costs about US$7,000, while the nebulizer costs less than US$1,000. In comparison with the high cost of gas analyzers (up to US$30,000 for most CO2 and N2O analyzers) and the additional high costs and unavailability of the tracers, the method offers a cost-effective way of measuring ventilation rates in a greenhouse. For measuring leakage ventilation rates, however, the tracer aerosol technique failed to provide useful results.

Change of Body Movement Coordination during Cervical Proprioceptive Disturbances with Increased Age

Background: To date, there are very few studies on postural stability in older adults using body movement recordings to capture the postural movement pattern. Moreover, the importance of proprioception at key areas such as the calf or neck on the postural movement pattern in older adults has rarely been investigated. Objective: To investigate whether the body movement coordination strategy to calf or neck vibration was affected by aging. Methods: Body movement measurements were taken at five locations (ankle, knee, hip, shoulder and head) from 18 younger (mean age 29.1 years) and 16 older (mean age 71.5 years) adult subjects using a 3D movement measuring system while subjected to 50 s of pseudo-random calf or neck vibratory stimulation pulses with eyes open or closed. The positions from the knee, hip, shoulder and head markers were correlated against one another to give an indication of the body coordination. Results: During quiet standing, older adults had greater correlation between the head and trunk than the young. There was an age effect in the body movement coordination strategy. Older adults had a different movement pattern with neck vibration involving mainly more independent knee movements, indicating balance difficulty. Conclusions: Neck vibration affects the movement pattern in older adults more compared with younger adults and calf vibration, suggesting that, the regulation of body orientation in older adults is more difficult, especially during cervical proprioceptive disturbances.

Drug Burden Index and physical function in older Australian men

This study evaluated the associations of physical performance and functional status measures with the Drug Burden Index in older Australian men. The Drug Burden Index is a measure of total exposure to anticholinergic and sedative medications that incorporates the principles of dose-response and maximal effect. A cross-sectional survey was performed on community-dwelling older men enrolled in The Concord Health and Ageing in Men Project, Sydney, Australia. Outcomes included chair stands, walking speed over 6 m, 20-cm narrow walk speed, balance, grip strength and Instrumental Activities of Daily Living score (IADLs). The study population consisted of 1705 men (age 76.9 +/- 5.5 years). Of the 1527 (90%) participants who reported taking medications, 21% were exposed to anticholinergic and 13% to sedative drugs. The average Drug Burden Index in the study population was 0.18 +/- 0.35. After adjusting for confounders (sociodemographics, comorbidities, cognitive impairment, depression), Drug Burden Index was associated with slower walking speed (P < 0.05), slower narrow walk speed (P < 0.05), balance difficulty (P < 0.01), grip weakness (P < 0.01) and poorer performance on IADLs (P < 0.05). Associations with physical performance and function were stronger for the sedative than for the anticholinergic component of the Drug Burden Index. Higher Drug Burden Index is associated with poorer physical performance and functional status in community-dwelling older Australian men. The Drug Burden Index has broad applicability as a tool for assessing the impact of medications on functions that determine independence in older people.

Post-traumatic pneumocephalus

A 79-year-old male presented to the emergency department after a facial trauma because of a mechanical fall 3 h prior with no history of loss of consciousness. The patient had Parkinson’s disease and atrial fibrillation (AF), and was on treatment with acetylsalicylic acid for AF. The family reported that he was dependent for all basic daily activities and had mild cognitive deterioration. Physical examination showed that he was lethargic, but oriented, bradykinetic, and had gait and balance difficulty. No headache or confusion was reported. All cranial nerves were intact, and there were no motor or sensory deficits. He had superficial lacerations in the nasal and frontal regions. Nasal and ocular orbit X-rays were taken, showing nasal fracture and pneumocephalus (Fig. 1). Computed tomography scan confirmed pneumocephalus and multiple craniofacial fractures (Fig. 2). After a week of observation and prophylactic antimicrobial therapy during which there was no clinical deterioration, the patient was discharged. At follow-up 5 weeks later, the patient was at his clinical baseline. Repeated imaging showed progressive resolution. Fig. 1 X-ray showing nasal and orbital fractures and pneumocephalus Fig. 2 Large right pneumocephalus compressing right frontal lobe and widening interhemispheric space. There are also air bubbles in basal cisterns and cerebellar fissures bilaterally Pneumocephalus is the presence of air in the cranial vault. It is usually associated with neurosurgery, barotrauma, basilar skull fractures, sinus fractures, nasopharyngeal tumor invasion and meningitis [1, 2]. Headache and altered consciousness are the most common symptoms [3]. Tension pneumocephalus can occur and is a neurosurgical emergency [4]. Plain X-rays can diagnose pneumocephalus, but CT scan is the diagnostic modality of choice [5]. A classical CT sign of tension pneumocephalus is the “Mount Fuji sign”: the massive accumulation of air that separates and compresses both frontal lobes and mimics the profile of the large volcano in Japan. In our case, the air only compressed the right frontal lobe. Most cases of pneumocephalus resolve spontaneously, and conservative management should be provided. Nonoperative management involves oxygen therapy, keeping the head of the bed elevated, prophylactic antimicrobial therapy (especially in post-traumatic cases), analgesia, frequent neurologic checks and repeated CT scans.

The job satisfaction of UK architects and relationships with work‐life balance and turnover intentions

PurposeThere is evidence that those working within the construction industry are exposed to a number of stressors which potentially negatively impact well‐being, namely; long working hours, high workload, poor work‐life balance, low sense of professional worth and lack of job security. Additionally there is some evidence architects may also be vulnerable to an erosion of professional status, low pay and limited scope to use their creative skills. This paper aims to explore the job satisfaction of architects who are currently employed within the UK.Design/methodology/approachA questionnaire is used to elicit data from 110 practising architects on their occupational well‐being and work‐life balance.FindingsThe results reveal that between 20 and 40 percent of respondents are dissatisfied with their rate of pay, practice management, promotion prospects, working hours and opportunity to use their abilities. Additionally the majority of respondents report some work‐life balance difficulties and approximately one‐third were considering leaving their current employer. The causes of poor well‐being are associated with organisational factors rather than factors intrinsic to the work of an architect. Further analysis demonstrates that those who are self employed may experience better occupational well‐being.Research limitations/implicationsThe small sample size means that any generalisations to the entire architectural profession should be treated with caution. A cross‐sectional approach can only highlight the existence of relationships between variables; it cannot comment on their exact nature.Originality/valueThe implications for the profession are discussed and tentative recommendations put forward as to how the profession may address the situation.

Falls in older people: Risk factors and strategies for prevention (2nd edn) ‐ by Stephen Lord, Catherine Sherrington, Hylton Menz, and Jacqueline Close

Falls in older people: Risk factors and strategies for prevention (2nd edn) Lord, Stephen, Sherrington, Catherine, Menz, Hylton, and Close, Jacqueline . Cambridge University Press , Cambridge, UK , 2007 . 395p . A$130.00 (soft cover) . The first edition of Falls in older people was published in 2001 and was intended as a review of research on fall prevention strategies for elderly people published in the final 20 years of the twentieth century. This second edition includes new research in this field published over the last 7 years. The authors use a chart to demonstrate the increase in research output on falls from 1986 to 2004; the increase over the last 4 years is double the number of publications from the preceding 16 years. This increase in attention to falls is not surprising as falling has been recognised as a major health risk for older people. Older people who lie for an hour or more after falling are less likely than those who get up or are helped up to make a good recovery. More than 50% of those who remain on the floor for over an hour will die within 6 months, even though not directly injured by the fall. Each chapter of the text is specific in focus, citing population studies and other research (both with and without the use of matched controls) to identify factors that increase the likelihood of falls. Good use is made of diagrams and tables to illustrate the text. The final chapters of the book include a review of assessments used to assist in identifying potential fallers. The authors recommend exercise and balance training programs to assist older people who have been identified as potential fallers to improve their stability and reduce the likelihood of a fall, and remedial actions such as cataract removal. The last chapter suggests further areas of research in seeking causes for fall likelihood, and further preventative strategies. An integral feature of the text is well-designed tables listing research done, numbers of participants and types of assessments carried out. Every chapter has a lengthy bibliography and there is an excellent index. This is an outstanding resource for professional carers of older people in medical and allied health positions. It was interesting to learn that someone suffering from lowered balance, eye problems or vestibular difficulties will function better on a surface such as carpet or a wooden floor. I would intuitively have thought that a soft surface would help to prevent the serious effect of a fall, such as a broken hip, arm or leg. Floor coverings must be maintained in good condition. An obvious recommendation was to use walking aids such as a stick or trolley to assist in maintaining independence. However, unfortunately, many older people will object to this suggestion. My elderly parent at the age of 87 insisted that he was not going to be seen using a stick like an old man. This is a very scholarly and well-prepared text and something that would be of use to any person involved in the fields of gerontology or orthopaedic care. It is not a text for the average family carer.

Gait and balance in essential tremor: Variable effects of bilateral thalamic stimulation

Essential tremor (ET) is a multi-faceted condition best known for postural and action tremor but also may include disordered gait and postural instability. Deep brain stimulation (DBS) of the ventral intermediate nucleus (VIM) of the thalamus provides substantial tremor reduction yet some patients with bilateral VIM DBS have gait and balance impairment. This study examines gait and balance performance in 13 participants with ET who have bilateral VIM DBS compared with a matched control group. Participants with ET were tested with their stimulators off (DBS OFF) and on (DBS ON). For both standard and tandem walking, participants with ET walked significantly more slowly than controls, with significantly lower cadence, spending a lower percentage of the gait cycle in single limb support and a higher percentage in double support compared with controls. Participants with ET also had significantly lower tandem and one leg stance times, Berg balance scores, balance confidence, and required significantly greater time to perform the Timed Up-and-Go relative to controls. There were no significant differences in any gait or balance measures in the DBS OFF versus DBS ON conditions, but the effects of DBS on gait and balance were highly variable among individuals. Future studies are needed to determine why some individuals experience gait and balance difficulties after bilateral thalamic DBS and others do not. A better understanding of the mechanisms underlying gait and balance impairments in those with bilateral DBS is critical to reduce falls and fractures in this group.

PSYCHOMOTOR DEVELOPMENT IN PREMATURE INFANTS UNTIL THE END OF THEIR THIRD YEAR OF LIFE

Received: 20. 04. 2009 Accepted: 18. 05. 2009 Original article Abstract Psychomotor development in premature infants has specific characteristics with increased tendency towards neuro-developmental difficulties, such as the fact that certain percent of the developmentally challenged people belongs in this category of children. Many factors contribute to the neuro-developmental difficulties in premature infants. A large number of studies have shown that the birth weight (BW) and gestational age (GA) have strong correlation with the neuro-developmental outcome. In order to establish the general developmental outcome and the developmental outcome in specific areas of early development, that is the first three years of life in preemies, we have conducted a research on our own population. We conducted a longitudinal study on 20 premature newborns with very low birth weight (VLBW), with a follow-up period from 4 weeks CGA until 36 weeks GA. The research results showed that the largest difference in developmental areas between the group of premature infants with VLBW and the control group is present at the end of the 36th month of life and the general development quotient (GDQ) in the premature group was significantly lower during the whole follow-up period, except at the end of month 4 - in different developmental areas. We also concluded that 20% of the premature infants with VLBW have developmental difficulties and severe difficulties in their motor development. Key words: premature infants with VLBW, Griffiths Mental Development Scales, GDQ, developmental areas. (ProQuest: ... denotes non-US-ASCII text omitted.) Introduction Neuro-developmental Characteristics of Premature Newborns The neurological system of the preemie, as a result of its immaturity, is exposed to constant danger in an anatomical, chemical and physical manner. The uncompleted maturity of its organism accounts for the difficult adaptation to the outer environmental stress, which, on the other hand, contributes to bleeding and PVL malations in the CNS - the biggest issue of neuro-developmental difficulties in this group of high-risk infants. The white brain matter is especially sensitive to this kind of problems. These afflictions are strongly associated with motor problems. Preemies are a vulnerable group of children and their development in large extent depends on their maturity, the birth conditions and the support given during the early developmental period. The baby's adaptive ability is underdeveloped in the new environment as a result of its immature organism. Since its birth the baby is exposed to plenty of tactile stimuli, many of which are painful. During the last three decades, neonatal mortality notes dramatic fall, especially in preemies with GA lower than 32 GW and in extreme preemies (GA lower than 28 GW). This condition raises another issue: Does the mortality decrease or increase the number of developmentally challenged persons? The answer should be looked in the longitudinal research. Prematurity is often related to longer periods of hospitalization, separation from the parents, and deprivation of parental touch. It is also related to fear for life and consequences on the development, which results in anxiety at parents and taking protective attitude towards the child. In early diagnostics, 40-80% of premature infants are diagnosed with transitory neurological difficulties accompanied by hypotonic or hypertonic signs that should disappear in the first 3-9 months of life. In two thirds of the preemies with very low birth weight (VLBW) the transitory neurological difficulties should disappear with continuous development of the infant. Some of these children have motor balance and coordination difficulties for a longer period of time. Studies show that premature infants with VLBW (.1500gr.) in their early developmental period suffer from severe developmental difficulties such as Cerbral Palsy, mental handicap, etc. …

Impairment of short‐term memory and Korsakoff syndrome are common in AIDS patients with cytomegalovirus encephalitis

The diagnosis of cytomegalovirus encephalitis (CMV-E) in AIDS patients is challenging as other illnesses may obscure the symptoms. Here, we characterize the clinical symptoms of CMV-E and link them to post-mortem findings. Patients and methods In 254 homosexual men with AIDS, followed from HIV diagnosis to death before the antiretroviral combination therapy era, CMV-E was suspected in 93 cases. All were CMV-positive in blood. Neurological examination, including cognitive testing was performed in 34 of them within 6 months before death. CMV-E was diagnosed by CMV-PCR in cerebrospinal fluid (n = 24) or by post-mortem (n = 24). The majority complained of forgetfulness (91%), balance difficulties (85%) and impotence (85%). Impaired short-term memory was present in 29 patients. It was extreme in 17, justifying the diagnosis of Korsakoff's syndrome. This was often associated with infectious CMV in blood (P = 0.01). Brainstem symptoms were found in 19 patients. Post-mortem examination often revealed ventriculoencephalitis. CMV was found primarily around the ventricles and in other structures, described in Korsakoff's syndrome. The location of CMV in the brain corresponded well to the clinical findings, demonstrating the close relationship between the neurological symptoms and the neuroanatomical lesions.

POLYCYTEMIA VERA PRESENTING AS SUDDEN‐ONSET COGNITIVE IMPAIRMENT

To the Editor: A 67-year-old woman was presented at our outpatient clinic for analysis of recent-onset cognitive impairment. Her medical history was unremarkable, and except for sporadic acetaminophen, she did not use any medication. Until 2 months before presentation, she had lived independently and enjoyed her work serving coffee at an auction. Over several weeks, she developed rapid progressive cognitive impairment with loss of memory and the inability to perform activities of daily living, including her job. She met the criteria for clinical dementia. Her son and daughter also noticed agitation and trivialization. In the previous 2 months, she had fallen occasionally during biking because of “balance difficulties.” Upon questioning, she reported generalized itching complains. She did not suffer from fatigue, headaches, lightheadedness, burning sensation of the palms or soles, visual disturbances, gout, or gastrointestinal complaints. Upon physical examination, her attention was neither diminished nor fluctuating. There was a remarkable redness of the face, with strong red-injected conjunctivae. Her skin showed generalized scratch marks, and her fingertips were cyanotic. Physical examination of heart, lungs, and abdomen was unremarkable. Neurological examination revealed a slight gait disturbance (widened base) but no focal abnormalities. Laboratory results showed prominent erythrocytosis: hemoglobin (Hb) 22.05 g/dL, mild leukocytosis (9.2×109/L), and no thrombocytosis (198×109/L). Her general practitioner had also found erythrocytosis (Hb 20.64 g/dL) 4 months earlier. Magnetic resonance imaging of her cerebrum showed extensive generalized white matter lesions and several hemorrhagic infarct lesions in the anterior and posterior border zones of both hemispheres, with cortical necrosis (Figure 1). Duplex testing of her carotid arteries was normal. Fluid-attenuated inversion recovery image of the brain, showing bilateral, symmetric white matter hyperintensities (leukoaraiosis) and bilateral infarcts in the parietal lobes in the watershed territories of the posterior and middle cerebral arteries. Neuropsychological testing was performed, with a Mini-Mental State Examination score of 12 out of 30 (normal≥25), a Cambridge Cognitive Examination score of 47 out of 101 (normal>80), and an inability to perform the Trails Making Tests. There were no signs of delirium. The clinical diagnosis of cognitive dysfunction due to watershed infarction caused by polycythemia vera (PV) was confirmed by genetic screening for the JAK2 mutation, low serum erythropoietin level, and tri-linear hyperplasia of the three different cell lines in her bone marrow, in the absence of stainable iron. She was treated immediately with frequent phlebotomies and started taking acetylcystein 100 mg once daily. After the first phlebotomy, pruritus disappeared, as did congestion of the face, conjunctivae, and finger tips. After 6 weeks of treatment, global cognitive function and executive function improved, and she was able to perform her daily tasks at a reasonable, although not the preexisting, level. Long-term follow-up will show to what extend cognitive symptoms are fully reversible. Watershed infarctions of the cerebral cortex occur at the intersection of the outflow trajectories of two major cerebral arteries. These infarctions are usually secondary to stenosis of the carotid artery or to cardiac arrest.1 Watershed infarction due to hyperviscosity caused by PV is a rare medical condition, and sudden cognitive impairment is even less often reported. Improvement of cognitive impairment in patients with PV after phlebotomies has been described, but these patients did not suffer from stroke.2 Focal cognitive and behavioral dysfunction are often seen after watershed infarctions. The precise pathophysiology of these neuropsychiatric symptoms remains unclear but may be the result of disruption of cortical projection pathways, impairment of cortical blood flow, or both.3 Other typical neurological presentations include hemiparesis, sparing the face, and mood disturbances such as apathy or euphoria in non-dominant hemisphere anterior lesions. In posterior watershed infarctions, hemi-anopsia is common. Watershed infarctions in the bilateral frontal lobes can cause severe dementia.4 PV is a chronic, myeloproliferatieve disorder, predominantly presenting in elderly patients with an incidence rate of 23.5 per 100,000 person-years.5 Symptoms are due to hyperviscocity. A feared complication of PV is thrombosis (venous or arterial). Together with transformation into myelofibrosis, acute leukemia, or both, thrombosis is the main cause of death.6 The median survival of treated patients exceeds 10 year.7 This case history illustrates that an unusual course of cognitive impairment necessitates in-depth clinical investigation. We thank Professor R. G. J. Westendorp for thoroughly reading this manuscript. We also thank Dr. L. van der Wiel, neuropsychologist, Dr. W. Bollen, clinical neurologist, and Professor M. A. van Buchem, neuroradiologist, for their contributions. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this letter. Author Contributions: Both authors contributed equally to the preparation of this letter. Sponsor's Role: None.

Dietary guidance for older patients with diabetes mellitus and their primary caregivers using a Model Nutritional Balance Chart

AbstractAim: Dietary control of diabetes mellitus becomes hard in care‐dependent older patients staying at home due to the difficulty of understanding nutritional balance by their primary caregivers. In the present study, an easily handled Model Nutritional Balance Chart (MNBC) for care‐dependent older patients with diabetes mellitus and their primary caregivers was investigated.Methods: Nine care‐dependent older patients with diabetes mellitus and their primary caregivers received dietary guidance using the MNBC once per month for 6 months. Nine control care‐dependent older patients with diabetes mellitus and their primary caregivers did not receive dietary guidance but cooperated in providing data once per month. The medicines for the patients were kept the same during the entire length of the study. The effectiveness of the program was judged by changes in nutritional balance and hemoglobin A1c (HbA1c) values.Results: Improvements in nutritional balance were observed in relation to fish, fruit, oil, and sugar. The HbA1c values significantly decreased after 6 months in the intervention group, while the HbA1c values in the control group did not change.Conclusion: Our guidance method seems to be useful for care‐dependent older patients with diabetes mellitus who are staying at home with their primary caregivers.

Perceived imbalance and risk of Parkinson's disease.

We prospectively examined associations between perceived imbalance and Parkinson's disease (PD) risk in the Health Professional Follow-up Study (HPFS), and Nurses' Health Study (NHS). We included 39,087 men and 82,299 women free of PD at baseline (1990) in the current analyses. We documented 449 incident PD cases during 12 years follow-up. Subjects who reported difficulty with balance before 1990 (baseline) were 1.8 more times likely to develop PD, relative to those who reported no balance difficulty (pooled multivariate RR = 1.8; 95% CI: 1.3, 2.5; P < 0.0001). When we further examined associations between perceived imbalance at baseline and PD onset during different time periods, we found a significant elevation of PD risk only during the first 4 years of follow-up. This result suggests that the imbalance may in some cases be an early sign of PD, and may represent the onset of motor symptoms although they have not been clinically recognized.