Ongoing Complaints Research Articles

661 Isolated Lymphoid Aggregates Identified in Non-Inflammatory Bowel Disease (IBD) Patients Are Associated With an Increased Incidence of IBD Development

INTRODUCTION: The Centers for Disease Control and Prevention reports an estimated incidence rate of IBD between 17.7-28.9 cases per 100,000 person years. While IBD is typically associated with visible mucosal abnormalities studies have shown that up to 40% of patients with suspected IBD and normal appearing mucosa have evidence of inflammation on biopsy. Lymphoid aggregates (LA) are often found on histopathology in cases of known or suspected IBD, along with more characteristic findings of chronic inflammation, crypt distortion/abscesses. However, the significance of isolated LA without other abnormal histopathology is unknown. We hypothesized that isolated LA may be a marker of future onset IBD. METHODS: We conducted a retrospective study using a patient database at the Endoscopy Center of Long Island, part of Northwell Health system. A database query was conducted of all colonoscopy reports for adults > 18 years of age during the years of 2006-2011. These reports were reviewed for associated histopathology reports describing LA. Patient were excluded if the histopathology reported any finding suggestive or diagnostic of IBD other than LA. Only patients with a followup colonoscopy were included in final analysis. Patient medical records were further used to exclude those with a documented IBD history or use of IBD medication. A diagnosis of IBD on follow up colonoscopy was determined by endoscopic and microscopic findings. The primary analysis used exact binomial methods to compute an exact 95% CI for IBD diagnosis incidence rate as compared to the CDC estimated IBD incidence rate. RESULTS: 39,680 patients had colonoscopies during the study period. Of these, 767 patients had evidence of LA. 539 (1.36%) demonstrated isolated LA without other evidence of inflammation. Of these, 284 met the requirement of a follow up colonoscopy. 165 were excluded due to documented history of IBD, leaving 119 subjects for analysis. Of these, 5 developed IBD. The median time from initial colonoscopy to diagnosis of IBD was 6.29 years. The observed incidence of IBD in our study group was 654 cases per 100,000 person years, compared to the highest CDC estimated US incidence (P < 0.0001). CONCLUSION: We found that LA in patients is associated with an over twenty fold increased incidence of IBD, and may be an early sign of the disease. Some IBD therapies may be reasonable in select patients with isolated LA, and clinicians should not be hesitant to repeat colonoscopy in those with isolated LA and ongoing complaints.

Possible Role of the Posterior Compartment Peritonectomy, as a Part of the Complex Surgery, Regarding Recurrence Rate, Improvement of Symptoms and Fertility Rate in Patients with Endometriosis, Long-Term Follow-Up

Beside the pain, there are 2 further problems in the management of endometriosis: the high recurrence rate (10% per year) and the high rate of impaired fertility.The objective of this study was to investigate the pathogenesis of these 2 factors. This is a retrospective cohort study, and the aim is to evaluate the complete excision of endometriotic lesions, including the posterior compartment of the peritoneum, with regard to postoperative outcome, focusing on relieving pain, increasing fertility rate, and decreasing recurrence rate. Charité-University Clinic, Department of Gynaecology, Endometriosis research Centre. Fifty-four patients were enrolled in this study, with severe deep infiltrating endometriosis (scored by ENZIAN) and superficial endometriosis, as well as endometriomas (revised American Society for Reproductive Medicine [rASRM] I = 3; II = 15; III = 10; and IV = 26). Posterior compartment peritonectomy (visible endometriotic lesions and inflamed altered peritoneum) was performed in all patients as part of a complex surgery: complete excision of endometriosis. Postoperative outcomes were evaluated, based on the postoperative follow-up (up to 5 years) of 54 investigated patients. In 36 women (66%) preoperative complaints were eliminated. Furthermore, of 28 women seeking improved fertility, pregnancy was reported in 13 cases (46%). In 7 (54%) cases pregnancy occurred spontaneously, and in the remainder with assisted fertilization. In addition, long-term follow-up demonstrated a recurrence rate in 1.8% of patients. Overall, the number of complaints was significantly reduced. Only in the case of reproductive-aged women with ongoing postoperative complaints was it important to preserve the uterus. Although this pilot study on systematic posterior peritonectomy showed improvement in recurrence and fertility rate, the main question remains: will this surgical technique achieve better results and outcomes in the future? This has to be addressed in a prospective randomized study.

Relaxation and exercise in lymphoma survivors (REIL study): a randomised clinical trial protocol

BackgroundLymphoma survivors commonly report ongoing complaints including fatigue, pain, depression and decreased quality of life (QoL) following treatment. Although evidence suggests that both relaxation and exercise can significantly improve such symptoms, there is no consensus on which intervention is more effective. This paper presents the REIL (Relaxation and Exercise In Lymphoma) Study protocol. The REIL study aims to compare the effect of two home-based interventions – relaxation and exercise – on QoL in lymphoma survivors.MethodsEligible participants (n = 36) will be randomised to a relaxation or exercise programme to perform at least three times per week. The primary outcome measure is QoL, assessed by the European Organisation for Research and Treatment of Cancer QoL Questionnaire Core 30 (EORTC QLQ-C30). Secondary outcome measures include body composition, cardiovascular status, pulmonary function, grip strength, functional exercise capacity (six minute walk test), well-being assessed by the FACT-Lym questionnaire, and psychological status assessed by the Hospital Anxiety and Depression Scale. Total duration of the study will be twelve weeks and outcome measures will be assessed at baseline, six weeks and at the end of the study.DiscussionIt is anticipated that results from this preliminary study will begin to highlight effective pathways to improve QoL following chemotherapy for this population. This will better inform healthcare professionals to optimise QoL of lymphoma patients, and enable a smooth transition from being a cancer patient to survivor.Trial registrationThe REIL study has been registered on a publicly accessible database, ClinicalTrials.gov, Registration Number: NCT02272751, October 2014.

Abdominal aortic pseudoaneurysm as a complication of lumbar disc surgery

Background: Iatrogenic vascular injury during lumbar discectomy is a rare but serious and life threatening complication. The pituitary rongeur is the usual cause of injury during the disc surgery. A deep bite can injure the major vessels, especially the abdominal aorta or the common iliac arteries. Case Presentation: We present a 33-year-old female patient with complaints of continuous abdominal pain and difficulty in walking. Her complaints began a couple of days before her admittance to our clinic. In the medical history, the patient had undergone a lumbar discectomy operation due to L4–L5 disc hernia 4 months ago. Her follow-up physical examinations were uneventfully in the first and third month of the lumbar disc surgery. The patient had no any chronic diseases in her medical history. Computed tomographical angiography revealed a 57 × 42 mm pseudoaneurysm formation from the abdominal aorta arising closely from the abdominal aortic bifurcation level. A primary repair for the posterior abdominal aortic defect and a patchplasty for the aortotomy was performed. Conclusion: Clinician should suspect of vascular complications in terms of ongoing complaints, such as abdominal pain or a pulsatile mass in the abdominal region after lumbar disc surgery. In such cases, the clinical evaluation and imaging procedures must be done carefully.

Bony deviations revealed by cone beam computed tomography of the temporomandibular joint in subjects without ongoing pain.

To assess the prevalence of temporomandibular joint (TMJ) bony changes in cone beam computed tomography (CBCT) images of adult subjects without ongoing orofacial pain or complaints from the TMJ. The study included 84 TMJs from 28 men and 14 women (mean age [± SD]: 51 ± 11 years) without orofacial pain or TMJ complaints who were participants in a study of patients with obstructive sleep apnea. They were examined before any treatment with the Research Diagnostic Criteria for Temporomandibular Disorders and with CBCT (NewTom VGi; 15 × 15 cm, exposure time 18 seconds, axial thickness 0.3 mm). Osseous TMJ deviations were assessed blindly and classified. Degenerative changes were noted in the CBCT images of 33 (39.3%) of the TMJs, of which 21 were classified as osteoarthritic alterations and 12 as indeterminate changes of osteoarthritis. Two TMJs were clinically classified as osteoarthrosis and 6 as disc displacement with reduction. The CBCT images of the 2 TMJs with a clinical diagnosis of osteoarthrosis showed also bony changes, but the CBCT images also revealed osteoarthritic bony changes in the 18 TMJs without any clinical diagnosis. CBCT images of asymptomatic adult TMJs commonly show degenerative bony alterations. Accordingly, such radiographic findings should be used with care and only as a supplement to clinical assessment.

Nurses as substitutes for doctors in primary care.

Nurses as substitutes for doctors in primary care.

Fatigue in pediatric patients with familial Mediterranean fever

Objectives: Familial Mediterranean fever (FMF) is characterized by recurrent, self-limited attacks of fever with serositis involving the peritoneum, pleura and joints. Fatigue is a common problem in many pediatric rheumatic diseases; however, has not been evaluated systematically in FMF patients. Accordingly, the aim of this study was to evaluate fatigue and its possible allied factors in patients with FMF.Methods: Patients with FMF, aged between 10 and 21 years, were assessed by completed validated fatigue questionnaire (Checklist Individual Strength-20). As a control group, patients with chronic rheumatic diseases and healthy children without any chronic disease were included.Results: The study group comprised 111 patients with FMF, 54 with other chronic rheumatic diseases and 79 healthy subjects. While the CIS-20 total score and subscale scores (including subjective experience of fatigue) were similar between patients with FMF and those with other chronic rheumatic diseases (p > .05); both groups had significantly higher scores when compared with healthy subjects (p < .05). FMF patients with musculoskeletal complaints had significantly higher scores of subjective experiences of fatigue when compared to those without those complaints.Conclusions: Fatigue is a common but unrecognized complaint in patients with FMF. Familial Mediterranean fever seems to be a chronic disease with inter attack ongoing complaints.

Ambivalent gentleman-thieves and ‘the Dutch Conan Doyle’: British-based detective fiction in the Netherlands at the start of the twentieth century

This article explores the content and reception of two kinds of British-based detective fiction that were widely-read in the Netherlands at the start of the twentieth century: serialized international pulp fiction (the Lord Lister series) on the one hand, and domestic novels (from the Dutch writer Ivans) on the other. The Lord Lister series was generally regarded as the lowest part of popular culture and as very dangerous because the ambivalent ‘gentleman-thief’ Lord Lister, the criminal hero of the series, could influence young people to confuse right and wrong. The novels by the popular Dutch writer Ivans, ‘the Dutch Conan Doyle’, were received more positively. Ivans, who explicitly positioned himself between ‘low’ and ‘high’ culture, countered the ongoing complaints against popular fiction by offering novels that defended moral and societal norms and strived towards a harmonious balance between human emotions and rational thinking. His attempt to provide a ‘healthier’ and national kind of detective fiction was in line with the wishes of critics who functioned as mediators between contemporary literature and the common reader and were concerned with the social and mental effects of reading too much (imported) popular fiction.

Surgery versus conservative management for recurrent and ongoing left-sided diverticulitis (DIRECT trial): an open-label, multicentre, randomised controlled trial

Patients with recurrent or persisting complaints after an episode of left-sided diverticulitis are managed with either conservative measures or elective sigmoidectomy. To date, there are no data from randomised trials. We aimed to establish which treatment leads to a better quality of life for patients with diverticulitis. We did an open-label, multicentre, randomised controlled trial (DIRECT trial) in 24 teaching and two academic hospitals in the Netherlands. Patients aged 18-75 years presenting with either recurrent (three or more presentations with clinical signs of acute diverticulitis within 2 years) or persistent abdominal complaints (ongoing lower left abdominal pain or persistent change in bowel habits for ≥3 months) after an episode of left-sided diverticulitis, confirmed by CT, ultrasound, or endoscopy, were included. Patients were excluded if they had previous elective or emergency surgery for acute sigmoid diverticulitis, an absolute operation indication, suspicion of a colorectal malignancy, with a preoperative or postoperative risk greater than III (on the American Society of Anesthesiologists classification), or were unable to complete questionnaire or follow-up. Patients were randomly assigned (3:3) to receive conservative management or elective (laparoscopic) sigmoidectomy using a digital randomisation system, stratified by type of disease and centre, with a block size of six. Patients, physicians, and researchers were not masked to treatment allocation. Our primary endpoint was health-related quality of life, measured by the Gastrointestinal Quality of Life Index (GIQLI) at 6 months after inclusion or surgery, depending on randomisation group. This trial is registered with trialregister.nl, number NTR1478, and is closed for inclusion. Between July 1, 2010, and April 1, 2014, we randomly assigned 109 patients to receive surgical treatment (resection; n=53) or conservative management (n=56), after which the Data Safety and Monitoring Board prematurely terminated the trial because of increasing difficulties in recruitment. 47 (89%) of 53 patients received surgical treatment and 43 (77%) of 56 patients received conservative management. The GIQLI score at 6 months' follow-up was significantly higher in patients randomly assigned to receive surgical treatment (mean 114·4 [SD 22·3]) than conservative management (100·4 [22·7]; mean difference 14·2, 95% CI 7·2-21·1, p<0·0001). 43 (38%) of 109 patients had a severe adverse event in the first 6 months after treatment (18 [34%] of 53 patients in the surgical treatment group vs 23 [40%] of 57 patients in the conservative treatment group). Seven (15%) patients who received surgical treatment developed anastomotic leakage. Of the 56 patients assigned to be treated conservatively, 13 (23%) ultimately underwent elective resection due to ongoing abdominal complaints, with no anastomotic leakage. We recorded no patient deaths. Elective sigmoidectomy, despite its inherent risk of complications, results in better quality of life than conservative management in patients with recurrent and persisting abdominal complaints after an episode of diverticulitis. Netherlands Organisation for Health Research and Development.

Recalcitrant Gastroesophageal Reflux Disease in the Setting of a Gastroesophageal Junction Mass

In this case study, a sixty-three year old African American female with significant past medical history postsurgical hypothyroidism, hypertension, gastroesophageal reflux disease (GERD) presented with ongoing complaints of severe retrosternal burning associated with regurgitation. She had severe typical GERD symptoms despite twice a day PPI therapy. She had pH impedance testing on therapy which revealed abnormal esophageal acid exposure on therapy(>2.4% total esophageal acid exposure time). She underwent esophagogastroduodenoscopy (EGD) to evaluate for a source for her symptoms which revealed a freely prolapsing mass at the gastroesophageal junction. The location and dimension of the mass compromised the lower esophageal sphincter (LES) leading to her recalcitrant GERD. The patient was scheduled for laparoscopic Nissen fundoplication with transgastric resection of the gastric mass. Pathology of the intra gastric mass indicated benign sub-epithelial simple cyst. Overlying squamocolumnar junction mucosa with changes suggestive of GERD. At two weeks post op, she was significantly better. She had resolution of her previous symptoms and was no longer taking her PPI. She reported no significant dysphagia and no abdominal pain.Figure 1Discussion: Recalcitrant GERD is a common diagnostic dilemma that gastroenterologist evaluate. This case illustrates a novel cause of recalcitrant GERD secondary to benign sub-epithelial simple cyst creating lower esophageal sphincter incompetence which improved after resection. This case underscores the importance of EGD in patients who fail medical therapy.

Anti-N-Methyl-D-Aspartate Receptor Encephalitis: A Review and Neuropsychological Case Study

Objective: Anti-N-Methyl-d-Aspartate Receptor (NMDAR) Encephalitis is an autoimmune-mediated encephalitis, which may be associated with a tumor, which occurs when antibodies bind central NMDA receptors. Although typically diagnosed in women, approximately 20% of cases have been males. Due to the challenges with identification, imaging, and diverse symptom presentation, this syndrome is often misdiagnosed. Accurate diagnosis may provide an opportunity for introduction of disease-modifying therapies, which may alter disease trajectory. Moreover, neuropsychology has yet to fully clarify the pattern of impairments expected with this disorder. Methods: This manuscript reviews a single case study of a 42-year-old male diagnosed with NMDAR encephalitis. Neuropsychological evaluation was completed subsequent to diagnosis, treatment, and rehabilitation. Ongoing patient complaints, approximately six months post diagnosis, included reduced sustained attention, poor word retrieval, and daily forgetfulness. Adaptive skills were improved following rehabilitation. Results: Direct testing revealed mildly impaired sustained attention, processing speed, oral word fluency, and executive functioning. All other cognitive domains were within estimated premorbid range, low average to average. Conclusions: Neuropsychological deficits were consistent with mild frontal brain dysfunction and continued recovery. This case illustrates the need for medical and psychological practitioners to understand NMDAR encephalitis, its symptom presentation, and related neuropsychological impact; particularly with the potential for misdiagnosis.

Recurrences and Ongoing Complaints of Diverticulitis; Results of a Survey among Gastroenterologists and Surgeons

Objective: This study aims to investigate the current opinion of gastroenterologists and surgeons on treatment strategies for patients, with recurrences or ongoing complaints of diverticulitis. Background: Treatment of recurrences and ongoing complaints remains a point of debate. No randomized trials have been published yet and guidelines are not uniform in their advice. Design: A web-based survey was conducted among gastroenterologists and GE-surgeons. Questions were aimed at the treatment options for recurrent diverticulitis and ongoing complaints. Results: In total, 123 surveys were filled out. The number of patients with recurrent or ongoing diverticulitis who were seen at the outpatient clinic each year was 7 (0-30) and 5 (0-115) respectively. Surgeons see significantly more patients on an annual basis 20 vs. 15% (p = 0.00). Both surgeons and gastroenterologists preferred to treat patients in a conservative manner using pain medication and lifestyle advise (64.4 vs. 54.0, p = 0.27); however, gastroenterologists would treat patients with mesalazine medication, which is significantly more (28%, p = 0.04) than in the surgical group. Surgeons are inclined more towards surgery (31.5%, p = 0.02). Conclusions: Both surgeons and gastroenterologists prefer to treat recurrent diverticulitis and ongoing complaints in a conservative manner. Quality of life, the risk of complications and the viewpoint of the patient are considered important factors in the decision to resect the affected colon.

Dobar efekat niskih doza blokatora kalcijumskih kanala kod bolesnice sa idiopatskom plućnom hipertenzijom

Introduction: Pulmonary arterial hypertension is defined by hemodynamic and pathophysiological changes of increased resting mean pulmonary arterial pressure ≥ 25mmHg estimated by right heart catheterisation. Case report: We describe a 44-year-old woman who presented for evaluation 13 years after being diagnosed with primary pulmonary hypertension. Over that extended period of time, she did not develop any changes in her coronary or pulmonary vascular measurements as documented by repeat catheterization. She did not have signs of systemic connective tissue disease. Throughout this time, she was managed with continuous medical treatment of low-doses of a Ca-channel antagonist (nifedipine 10mg twice per day) along with oral anticoagulant therapy. Her ongoing complaints were of fatigue when engaged in heavy physical activity, but there was no progression of symptoms. She also occasionally felt symptoms of increased heart rate and syncope. Auscultation revealed a systolic murmur along the left parasternal edge and an accented second sound of the pulmonary artery. Electrocardiography showed sinus rhythm and incomplete right bundle branch block. Echocardiography was consistent with signs of pulmonary hypertension. Conclusion: A small number of patients with pulmonary hypertension have a good prognosis with treatment with modest doses of calcium blockers as seen in our patient who has had a stable course of disease for many years.

Post-chikungunya rheumatic disorders in travelers after return from the Caribbean.

Due to increasing concerns about post-chikungunya (pCHIK) rheumatic disorders in Latin America we aimed to evaluate its occurrence in travelers returning to NYC from the Caribbean. Patients diagnosed with chikungunya (CHIK) during 2014 at the Bronx-Lebanon Hospital Center (Bronx, NewYork) were identified by reviewing laboratory and electronic medical records. Patients and caregivers of pediatric patients were interviewed by phone ≥9 months after the CHIK diagnosis to survey for chronic symptomatology and current health care needs. Reported chronic musculoskeletal complaints were categorized according to validated criteria. A total of 28 patients (54% females, median age [range] of 51.5 [0, 88] years) diagnosed with CHIK at our center were identified. Most (82%) had returned from the Dominican Republic. Nineteen (68%) patients were successfully contacted at a median (range) of 13 (9, 16) months since the acute diagnosis. A third (37%) reported ongoing complaints related to CHIK including joint pain (32%), muscle pain (32%), and joint swelling (26%). A presumptive diagnosis of pCHIK chronic inflammatory arthritis (n = 4) and pCHIK musculoskeletal disorder (n = 3) was established. A third of travelers with CHIK acquired in the Caribbean may be at risk for developing persistent symptoms suggestive of pCHIK rheumatic disorder.

Evaluation of a hybrid treatment for Veterans with comorbid traumatic brain injury and posttraumatic stress disorder: Study protocol for a randomized controlled trial

Comorbidity of posttraumatic stress disorder (PTSD) and history of traumatic brain injury (TBI) is high among Veterans of Operation Iraqi Freedom/Enduring Freedom/New Dawn (OIF/OEF/OND). Cognitive processing therapy (CPT) is empirically supported for the treatment of PTSD, but it is not specifically designed to accommodate the memory, attention, or problem solving deficits that are experienced by many Veterans with comorbid PTSD and TBI. Compensatory cognitive rehabilitation, including cognitive symptom management and rehabilitation therapy (CogSMART), is effective for cognitive deficits stemming from a variety of etiologies, including TBI. We have integrated components of CogSMART into CPT in order to address the unique challenges faced by Veterans with ongoing cognitive complaints related to PTSD and a history of mild TBI. Here we describe an ongoing randomized controlled trial investigating the efficacy of our novel hybrid treatment, SMART-CPT, as compared to standard CPT, for OIF/OEF/OND Veterans with PTSD and a history of mild to moderate TBI. We describe the development of this hybrid treatment as well as implementation of the randomized controlled trial.

Intralesional Cryotherapy versus Excision with Corticosteroids or Brachytherapy for Keloid Treatment

INTRODUCTION: Keloids are a burden for patients due to physical, aesthetic and social complaints. Treatment remains a challenge because of therapy resistance and high recurrence rates. Decision making in keloid treatment is difficult due to heterogeneity of the condition and the lack of comparative studies with informative outcomes. The main goal of treatment is to improve the patients’ quality of life (QoL); this implies that, apart from surgical outcomes, patient-reported outcome measures (PROMs) need to be taken into account. MATERIAL AND METHODS: This is a multicenter randomized controlled open trial that compares intralesional cryotherapy versus excision with corticosteroids or brachytherapy. The primary outcome is the patient and observer scar assessment scale (POSAS) consisting of 12-items. Secondary outcomes are recurrence rates, volume reduction, Skindex-29 scores, SF-36 scores and complication rates.1 During the study we added an outcome measure ‘patient satisfaction’ defined as; patients not seeking further medical treatment for their keloid. RESULTS: There were 179 keloid patients with surgical indication seen during the inclusion period. Seventy-four of them were eligible by our inclusion criteria, unfortunately only 26 patients gave informed consent for randomization. Due to the small study group statistical analysis of our planned outcome measures will not be possible.1 We saw comparable patient satisfaction between cryotherapy and excision with corticosteroids, but lower patient satisfaction with cryotherapy than with excision and additional brachytherapy treatment (p<.05). Most patients (9 out of 14) that underwent cryotherapy asked for excision with additional brachytherapy due to inadequate volume reduction, hypopigmentation or ongoing pain complaints (Figure 1 and 2).Figure 1: Keloid around the left scapula after trauma.Figure 2: Keloid around the left scapula 54 weeks after first and 38 weeks after second cryotherapy treatment.DISCUSSION: Intralesional cryotherapy did not give as good results previously reported, at least not for the keloid patients in this study.2,3 The previous studies (cohort studies) might have selected patients with keloids well suitable for intralesional cryotherapy. Besides, in this randomized trial patients were eligible and informed about another treatment option, which might have influenced their search for further treatment. For future research on keloid treatment we advise to look for study designs other than randomized controlled trials in order to improve inclusion and generalizability of the results.

Extension and flexion in the upper cervical spine in neck pain patients

Neck pain is a common problem in the general population with high risk of ongoing complaints or relapses. Range of motion (ROM) assessment is scientifically established in the clinical process of diagnosis, prognosis and outcome evaluation in neck pain. Anatomically, the cervical spine (CS) has been considered in two regions, the upper and lower CS. Disorders like cervicogenic headache have been clinically associated with dysfunctions of the upper CS (UCS), yet ROM tests and measurements are typically conducted on the whole CS. A cross-sectional study assessing 19 subjects with non-specific neck pain was undertaken to examine UCS extension-flexion ROM in relation to self-reported disability and pain (via the Neck Disability Index (NDI)). Two measurement devices (goniometer and electromagnetic tracking) were employed and compared. Correlations between ROM and the NDI were stronger for the UCS compared to the CS, with the strongest correlation between UCS flexion and the NDI-headache (r = −0.62). Correlations between UCS and CS ROM were fair to moderate, with the strongest correlation between UCS flexion and CS extension ROM (r = −0.49). UCS flexion restriction is related to headache frequency and intensity. Consistency and agreement between both measurement systems and for all tests was high. The results demonstrate that separate UCS ROM assessments for extension and flexion are useful in patients with neck pain.

The Effects of Betahistine and Dimenhydrinate on Caloric Test Parameters; Slow-Phase Velocity of Nystagmus

OBJECTIVE: The aim of this study is to determine the effects of betahistine and dimenhydrinate on the slow phase velocity. MATERIALS and METHODS: Forty patients with complaints of vertigo and dizziness volunteered to be included in the study. All patients who were included the study were treated at the other medical centers. The patients were divided into two Groups. Patients in the first Group were given betahistine 24 mg three times per day. During this treatment, caloric testing was performed, and the dose was increased to 48 mg three times a day due to ongoing complaints. The test was then repeated four weeks after using this higher dosage. Patients in the second Group had caloric testing while using and four weeks after stopping dimenhydrinate. RESULTS: The study Group was comprised of 40 patients; 20 patients (13 female, 7 male, 18-68 years, median age 46) in the betahistine Group and 20 patients (14 female, 6 male, 24-74 years, median age 44.5) in the dimenhydrinate Group. The average slow phase maximum velocity in the first Group of patients was 18 -/+ 8.2 and 21.1 -/+ 10.8 deg/s at 24 mg betahistine three times a day and 48 mg three times a day, respectively. In the second Group of patients, the average slow phase velocity was 13.4 -/+ 5.1 and 18.2 -/+ 7.5 deg/s during and after stopping the treatment of dimenhydrinate, respectively. The caloric test-induced slow-phase velocity was decreased with dimenhydrinate and increased with the higher dosage of betahistine. CONCLUSION: To our knowledge, this is the first study to demonstrate that betahistine increases caloric-induced slow-phase velocity in humans. Dimenhydrinate and betahistine should not be used together because of their opposite effects on the vestibular system. Dimenhydrinate can be used to treat acute episodes of vertigo, whereas betahistine should not be used during the episode but may be used in the period between the attacks to stimulate the vestibular system.

Testing the effectiveness of group-based memory rehabilitation in chronic stroke patients

Memory complaints are common after stroke, yet there have been very few studies of the outcome of memory rehabilitation in these patients. The present study evaluated the effectiveness of a new manualised, group-based memory training programme. Forty outpatients with a single-stroke history and ongoing memory complaints were enrolled. The six-week course involved education and strategy training and was evaluated using a wait-list crossover design, with three assessments conducted 12 weeks apart. Outcome measures included: tests of anterograde memory (Rey Auditory Verbal Learning Test: RAVLT; Complex Figure Test) and prospective memory (Royal Prince Alfred Prospective Memory Test); the Comprehensive Assessment of Prospective Memory (CAPM) questionnaire and self-report of number of strategies used. Significant training-related gains were found on RAVLT learning and delayed recall and on CAPM informant report. Lower baseline scores predicted greater gains for several outcome measures. Patients with higher IQ or level of education showed more gains in number of strategies used. Shorter time since onset was related to gains in prospective memory, but no other stroke-related variables influenced outcome. Our study provides evidence that a relatively brief, group-based training intervention can improve memory functioning in chronic stroke patients and clarified some of the baseline factors that influence outcome.

Bupropion XL Use in Comorbidity of Depression and Restless Leg Syndrome: A Case Report

Restless leg syndrome (RLS) is a sensorimotor disorder with symptoms including uncomfortable subjective sensations in the legs and the urge to move them. This common disorder affects 10% of the population and may reduce quality of life. The pathophysiology of RLS is not well understood but dysfunction of dopaminergic pathways is the most prominent theory. Antidepressants, especially SSRIs, can aggravate the symptoms of RLS. Here we present a 42 year old woman diagnosed with major depressive disorder and comorbid RLS and who had been treated with paroxetine 20 mg/day for 2 months who benefited from switching to bupropion treatment. In this case the RLS symptoms had existed for approximately 3 years but were milder before paroxetine treatment. The patient met the diagnostic criteria for RLS. We used the International Restless Legs Scale (IRLS) and Montgomery-Asberg Depression Rating Scale (MADRS) to measure the patient’s symptom severity. The severity of her depressive symptoms was similar to baseline despite the two month paroxetine treatment. Due to symptoms of RLS and her ongoing depressive complaints, we decided to switch from paroxetine to bupropion. With 150 mg/day bupropion XL treatment, her RLS symptoms improved substantially at a one month follow-up while her depression severity was not changed significantly. Due to inadequate response for depression, bupropion XL was titrated to 300 mg/day. Her depressive symptoms improved significantly at a further one month follow-up. Comorbidity of RLS and depression was found to be as a frequent occurence reported in the literature. We concluded that bupropion, as a selective noradrenergic-dopaminergic reuptake inhibitor can be a good alternative to the SSRIs for patients, who suffer from both depression and RLS.