Epidemiologic data of stroke. Data of the WHO-MONICA Project in Germany

Analyses of stroke morbidity or mortality are usually based on official statistics. A reduction in stroke mortality rates has been shown for many countries. It is not clear, however, whether this is due to declining morbidity or case fatality (or both). For this purposes population-based register data are required. Using the standardized methodology of the WHO-MONICA Project, stroke cases were also registered in Germany from 1984 to 1993 (7,435 first-ever and recurrent stroke cases). The data collection was almost restricted to East Germany. The age-specific stroke rates in males/females showed an increase from 9/11 per 100,000 population in the youngest age group (25-34) to 1,005/779 cases per year in the oldest group under study (65-74). If one tries to classify stroke types, which is not always possible in a population-based register, the best estimate for men (women) would be: 63(62%) thromboembolic stroke, 25(22)% intracerebral hemorrhage, and 12(17)% subarachnoid hemorrhage. The 28-day case fatality of the 25-74 year old stroke patients was found to be about 40%. Neither for stroke attacks nor for case fatality was a convincing time trend over the 10-year period found. The very small changes observed over 10 years time should lead to increased attention to strokes, particularly primary and secondary prevention, and this not only in East Germany. This applies also for treatment in the acute phase, because the case fatality before admission in the hospital and during the first few days is still very high. Population-based studies of the long-term prognosis of stroke patients in Germany are also missing, i.e., including the effectiveness of various forms of treatment and rehabilitation. Systematic monitoring of the development in this field is an important part of the assessment of the quality and effectiveness of the health care service.     

Spondylolisthesis in childhood and adolescence

Isthmic spondylolisthesis occurs in 4.4% of children. In general it is a benign condition. The majority of individuals with mild or moderate isthmic vertebral slip remain free of symptoms or get only mild symptoms. In children and adolescents with mild slip, primary treatment of pain symptoms is non-operative. Young children before the growth spurt need radiological follow-up for documentation of possible slip progression. If the slip exceeds 25% in a child, segmental fusion to prevent further progression should be considered. Uninstrumented posterolateral fusion is the method of choice for treatment of pain symptoms not responding to conservative measures in slips up to 50%. In severe slips (> 50%), anterior or combined fusion is necessary to prevent further progression of lumbosacral kyphosis. The clinical and subjective results of in situ fusion in this age group are satisfactory in 80-90% of cases. Slip reduction is possible. It requires internal fixation and is connected with a higher risk of complications. The results of slip reduction have not yet been shown to be superior to results after in situ fusion. It may be performed in cases of spondyloptosis with severe impairment of function and sagittal malalignment of the spine.     

Allergic and systemic contact dermatitis from Matricaria chamomilla tea

A screening programme was carried out among school-going children in Al-Ain, United Arab Emirates (UAE), to identify children with learning disorders. During the course of one academic year, 34 such children were identified. The cause was considered preventable in around half of the cases. In a third of cases with a genetic cause, prevention was possible with existing knowledge and practice.     

The ocular melanoma story. LIII Edward Jackson Memorial Lecture: Part II

PURPOSE: To trace the evolution and status of our knowledge of choroidal melanoma with regard to the nature, cause, and treatment of this tumor. METHODS: Historical materials beginning with Georg Bartisch's contributions in 1583 through to the Collaborative Ocular Melanoma Study and recent basic research are reviewed. RESULTS: Many individuals have made important contributions to our knowledge about this tumor. Basic information, however, regarding the natural history of the tumor, the most effective treatment, and its cause is lacking. CONCLUSION: The Collaborative Ocular Melanoma Study will provide important information regarding the choice of treatment between enucleation and radiotherapy as well as natural history information, quality of life, and definitive pathology findings. Definitive treatment of choroidal melanoma will depend on knowledge of the genetic defects that cause the tumor. Within the next 25 years, it is predicted that genetic defects will be determined and tumor samples will be obtained using small-needle aspiration and DNA probes located on microchips. In addition, treatment will then be based on drugs designed to inhibit molecules related to the genetic defect in the tumor.     

Neurophysiological basis, aetiology and clinical aspects of hypersensitive teeth

Dentine hypersensitivity is a common cause of dental pain. The sensitivity has been shown in clinical studies to vary greatly. The response to the treatment of hypersensitive teeth varies. It has been observed that while the treatment might be effective in some teeth, it is not so in other teeth. In some hypersensitive teeth spontaneous reduction in the hypersensitivity has been observed, while in other teeth, the sensitivity has persisted even for years. It seems probable that the hydrodynamic mechanism is the one operating in dentine sensitivity and the condition of dentine, with either blocked or open dentinal tubules, is a decisive factor in the degree of dentine sensitivity. In hypersensitive dentine the dentinal tubules are open and the pulp is inflammed. In cases where treatment is effective, probably the dentinal tubules are successfully blocked and the inflammation is resolved. If the process is not successful the teeth will be resistant to treatment. The correct therapeutic approach should aim at blocking the dentinal apertures and resolving pulpal inflammation. In addition, clinicians should be aware of clinical procedures which might result into dentine hypersensitivity.     

New approach to classifying non-Hodgkin's lymphomas: clinical features of the major histologic subtypes. Non-Hodgkin's Lymphoma Classification Project

Increasing knowledge about the biology of the non-Hodgkin's lymphomas has led to new approaches in classification. Rather than grouping lymphomas simply based on cell size, cell shape, and growth pattern, it is now possible to identify distinctive clinicopathologic entities. In many cases, the existence of specific immunologic and/or genetic features has confirmed the existence of these distinctive types of lymphoma. Since patients will be given these diagnoses by pathologists, it is important that clinicians be knowledgeable with regard to their clinical characteristics. The findings for the 13 most common lymphoma types that will be encountered in clinical practice are presented here.     

Attitudes of 47 mothers of pediatric oncology patients toward genetic testing for cancer predisposition

PURPOSE: To assess attitudes toward testing for cancer susceptibility genes, we interviewed mothers of pediatric oncology patients about their cancer causation theories, interest in hypothetical predisposition testing for themselves and their healthy children, and anticipated impact of testing. PATIENTS AND METHODS: The subjects were 47 mothers of two or more living children, one of whom was 6 to 24 months postdiagnosis of cancer. Potential risks and benefits of hypothetical genetic predisposition testing for cancer susceptibility were described. A semistructured interview assessed the following: (1) recall of discussions with the pediatric oncologist about the possible role of heredity in causing the child's cancer; (2) mothers' personal theories of the etiology of their child's cancer; (3) family cancer history; (4) interest in genetic predisposition testing for themselves and unaffected (cancer-free) children; and (5) expected sequelae of testing. RESULTS: If genetic cancer predisposition tests were available, 51% of mothers would test themselves and 42% would test healthy children, even with no medical benefit. With established medical benefit, an additional 36% of mothers would seek testing for themselves and another 49% would test their healthy children. Interest in cancer predisposition testing among mothers extended far beyond those with significant family histories of cancer. Most mothers would consider minor children's wishes in the decision about testing and would tell children under age 18 their test results. CONCLUSION: As increasing numbers of cancer susceptibility genes are identified, parents of pediatric oncology patients may be receptive to opportunities to test themselves and their healthy children. Counseling will be important to aid in decisions about testing. Research is essential to evaluate the long-term impact of predisposition testing.     

What's new in stroke?

More than 30,000 strokes occur each year in Texas, even though most strokes can be prevented by currently available and well-tolerated therapies. Antiplatelet therapy with aspirin or ticlopidine reduces stroke by about 25% in many patients with transient ischemic attack or initial stroke. Warfarin should not be used routinely for primary cerebrovascular disease but is useful to prevent cardioembolic stroke. Carotid endarterectomy is highly beneficial for patients with symptomatic, high-grade carotid stenosis, but its value for lesser degrees of symptomatic carotid plaque and for asymptomatic stenosis is less clear. Patients with nonvalvular atrial fibrillation have a substantial risk for stroke; most should be treated with warfarin. Risk-factor management (eg, control of hypertension, cessation of smoking, and treatment of hyperlipidemia) is as important as antithrombotic or surgical therapies for most patients with threatened stroke. Treating isolated systolic hypertension in elderly patients reduces stroke risk. Determining the cause of threatened stroke strongly influences preventive management. The tools are at hand to prevent most strokes; the challenge remains to apply them optimally.     

Psycho-motor re-education for children with reading difficulties.

Psycho-motor re-education is a specialized pedagogical treatment based on movement. There are many instances in which a psychomotor re-education is indicated. We will deal today with the cases of children suffering of reading difficulties and a way in which psychomotor re-education can help these children. The objective of psycho-motor re-education is to give by true concrete approach an occasion to the child of experimenting and developing his motricity, his body image and his spatial organization. In those cases in which psycho-motor troubles have been directly or indirectly the cause of learning disabilities, this method of re-education has proven itself valuable, especially if integrated in a body of treatments. Its usefulness comes from the fact that the re-education attacks directly the psycho-motor difficulties and thus allows a motor and spatial reorganization, thus is prevented the existence of "holes" which have to be patched continuously when more scholarly treatment is undertaken. It also allows through a narrow cooperation with corrective teaching the facilitation of constant references to actual learning experiences on the concrete level. There are still of course many unknowns, but we believe that the inter-disciplinary dialogue will be evermore in a position to answer them and to discover them. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

From psychosomatic disorder to autoimmune disease--50 years urticaria and Quincke edema

While the hereditary angioneurotic edema is a rare but serious disorder 10 to 25% of the population experience urticaria during a lifetime. Urticaria is for the patient a very impressive disease. He therefore has a great desire to know its cause. In acute urticaria this is usually possible since drugs or specific foods are the most common triggers. In chronic urticaria the search for a cause is much more difficult and successful only in 20 to 30% of cases. Over the past years it has been proven that about 30% of patients with chronic urticaria have antibodies against the high affinity Fc-receptor of mast cells. Thus a fraction of patients with chronic urticaria formerly often associated with psychosomatic illness suffer in fact from an autoimmune disorder.     

Stroke: a stranger among the people

INTRODUCTION: Lack of awareness of warning signs of stroke is a factor that contribute to late patient arrival to the emergency department. OBJECTIVE: The goal of this pilot study was to determine the baseline knowledge of stroke among the population (terminology, signs-symptoms, risk factors and attitude) prior to educational campaigns. PATIENTS AND METHODS: A population-based interview using closed-ended questions was conducted by neurologists among 100 users of the Vall d'Hebron's Primary Health Center, randomly sampled. RESULTS: In our population a 9% unknowns totally the disease, of the remainder, 42% has a good knowledge of signs-symptoms and 46% of risk factors. Only 22% of the sample has good global knowledge of the disease. If suffering a stroke this population should seek medical attention through 911 (46.2%) or come directly to the emergency department (50.5%). If symptoms were gone away, transient ischemic attack (TIA), appears a trend to contact primary physicians (59.3%). Respondents aged > 65 years were less likely to recognize symptoms (p = 0.001) and to consider stroke as an emergency. Respondents with an affected relative (50.5%) tend to locate more exactly the disease at the brain (p = 0.05) and to arrive earlier to the emergency department (p = 0.045), than those with non-affected relatives. CONCLUSIONS: Less than a quarter of our population have a good knowledge of the disease. Stroke is considered an emergency unlike TIA. The information about stroke is theoretically associated with early presentation to the emergency department. These results permit a redesign of the questionnaire to conduct a second phase of the study and generalize them for the Spanish population.     

Illicit drug-associated ischemic stroke in the Baltimore-Washington Young Stroke Study

BACKGROUND: Limited information exists on the frequency, trends in occurrence, risk factors, mechanisms, and outcome of ischemic stroke associated with illicit drug use among young adults in a geographically defined population. METHODS: We reviewed ischemic stroke in young adults (aged 15 to 44 years) in 46 regional hospitals for 1988 and 1991. We examined stroke mechanisms and outcome in patients with recent drug use. RESULTS: Recent illicit drug use was noted in 51/422 (12.1%) stroke patients. Patients with drug use were more likely than other stroke patients to be black (p=0.01), aged 25 to 39 years (p=0.004), and smokers (p=0.006), and were less likely to have hypertension (p=0.004) or diabetes mellitus (p=0.004). Drug use was the probable cause of stroke in 20 (4.7%) patients. Among 31 (7.3%) patients with drug use as a possible stroke mechanism, more likely diagnoses included cardioembolic stroke in 18, hematologic/collagen vascular in 6, nonatherosclerotic vasculopathy in 5, and atherosclerosis in 3. There was no difference in outcome between drug-associated and non-drug associated stroke. CONCLUSIONS: Recent illicit drug use occurs in 12.1% of young adult stroke patients. Drug-associated young adult stroke seems to relate to vascular mechanisms other than those related to hypertension or diabetes. Case-control studies are needed.     

Clinical relevance of in vitro drug resistance testing in childhood acute lymphoblastic leukemia: the state of the art

Nowadays about two-thirds of children with acute lymphoblastic leukemia (ALL) can be cured with chemotherapy, but one-third die from the disease. The clinical response of leukemic cells to chemotherapy is roughly due to two factors: the effective drug levels reaching the cells and the resistance of these cells to the drugs. The clinical value of cellular drug resistance in children with ALL is not known. We developed an in vitro assay to study drug resistance in these children. In this article, the main results obtained with this MTT assay on samples from 137 children with ALL are summarized: (1) patients whose cells are resistant to several drugs at initial diagnosis have a poor prognosis; (2) relapsed leukemias show a considerable drug resistance which might partly explain the poor prognosis. Relapsed cases differ in their type and degree of resistance; (3) the poor outcome of high risk groups as defined by age and immunophenotype can partly be explained by specific patterns of drug resistance; (4) P-glycoprotein-mediated multidrug resistance is not an important cause of resistance in childhood ALL; and (5) no relation exists between the activities of the purine enzymes HGPRT, 5'NT, ADA, and PNP and drug resistance in childhood ALL. The conclusion is that in vitro drug resistance data have clinical relevance and can be used to develop more effective and less toxic treatment strategies in childhood ALL.     

Filial therapy into the 21st century.

Discusses filial therapy (FT) which might seem new to many child and family therapists. Yet training parents to play therapeutically using this child-centered approach with their children has a long track record that demonstrates it is an effective way to work with children and their parents together. It is noted that while the method was waiting to gain broader recognition and acceptance by practicing play and family therapists, advocates in academic settings were testing its efficacy. As FT is becoming more known and widely used by practitioners, it has attained the status of an "empirically supported" or "evidence based" or "empirically validated" treatment. All of these terms mean the same thing: a treatment that rests on good research, with results that show its efficacy, one that can be replicated by practitioners who can achieve comparable positive effects using it. Such terms concern anyone familiar with issues related to health care insurance. The slow start of FT, then, has become an advantage for the therapy and its users. Only rarely does a treatment arrive already backed by empirical support of efficacy. The remainder of this article will explain how this desirable state has come about. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Hyperlipidaemia and atherosclerotic cerebrovascular disease

Controversies exist concerning the role of hypercholesterolaemia as a risk factor for nonhaemorrhagic stroke because intracranial arteries seem to be more resistant than coronary arteries to cholesterol-induced endothelial damage. Only very high levels of serum cholesterol seem to be a significant risk factor. It is possible that coronary heart disease may occur earlier in life than cerebrovascular atherosclerosis, and it could then become the cause of stroke. In our view, the causal relationship between very low levels of serum cholesterol and haemorrhagic stroke is unlikely, and cholesterol-lowering treatment appears to be safe. New studies should consider the particular metabolic aspects of intracranial arteries and the independent role of lipoprotein (a), apolipoprotein E phenotypes and other molecular and genetic mechanisms involved in atherosclerotic cerebrovascular disease.     

The intertrochanteric osteotomy in the treatment of congenital dysplasia of the hip

The dysplastic acetabulum develops to normal shape only if the head of the femur is in central position in the articualr cavity correct according to biomechanics of the hip joint. Anterior rotation of the neck of the femur should be reduced operatively to neutral position as soon as possible if joint congruity cannot be achieved by conservative treatment. The indication for an intertrochanteric derotation osteotomy is made in cases demonstrating a roof inclination less than 30 degrees in children age 1 1/2 to three. After the third year of age, the mutual growth-stimulating effect of the articular bodies is not important enough to be useful in treatment of dysplasia. The femoral osteotomy has to be performed intertrochanterically. If articular congruity cannot be achieved by intertrochanteric osteotomy only, an additional innominate osteotomy of the pelvis is indicated at the same stage. The results of 435 cases demonstrated a good development of the acetabular roof if the intervention was performed early, according to correctly specified indications. In cases with insufficient growth potential of the acetabular roof, resulting in an increased inclination, an additional reconstruction of the acetabular cavity is required.     

The risk of Guillain-Barré syndrome after tetanus-toxoid-containing vaccines in adults and children in the United States

OBJECTIVES: This study examined whether there is a risk that tetanus-toxoid-containing vaccines could cause Guillain-Barré syndrome and, if so, how large the risk is. METHODS: This study was based on previous active surveillance epidemiological studies of Guillain-Barré syndrome and vaccination history. RESULTS: A background rate of 0.3 cases of Guillain-Barré syndrome per million person-weeks has been estimated. By chance, 2.2 people with the syndrome would have received tetanus-toxoid-containing vaccine within the 6 weeks before onset, yet only 1 person had done so. Data on children show similar results. CONCLUSIONS: If an association exists, it must be extremely rare and not of public health significance.     

Usefulness of ictal and interictal 99mTc ethyl cysteinate dimer single photon emission computed tomography in patients with refractory partial epilepsy

OBJECTIVE: The aim was to investigate the feasibility of recording the electrical auditory brain stem response (EABR) evoked by electrical stimulation at the promontory (Prom-EABR) as a tool to assist selection of the ear for cochlear implantation in young children. STUDY DESIGN: The study group consisted of young children for whom the decision to proceed with implantation with the Nucleus mini 22-channel cochlear implant (Cochlear (UK) Ltd., London, UK) had already been made. SETTING: The Prom-EABR was recorded after the children had been anesthetised, but before the start of surgery. PATIENTS: A group of 25 children (11 boys and 14 girls), whose age at implantation ranged from 2 years 11 months to 6 years 8 months (mean age, 4 years 5 months), were investigated. INTERVENTION: Recordings of the Prom-EABR were used to determine which ear would receive the cochlear implant, providing there were no preexisting contraindications regarding selection of the ear. MAIN OUTCOME MEASURE: It has been suggested from earlier studies that the characteristics of the amplitude input/output (I/O) function of the EABR are related to neuronal survival. If the ear with the "better" I/O function is chosen for implantation, it might be expected that these children will perform better on average than those in whom the ear has been selected at random. RESULTS: Reliable recordings of the Prom-EABR were achieved in 40 ears (80%) of the 50 ears in the study. In 20 of the 25 children the technique was actively employed for selection of the ear for implantation. CONCLUSIONS: Recording of the Prom-EABR in the operating theater is a viable technique. Future analysis of long-term outcome measures of performance with the implant will confirm or dispute the benefit of ear selection using the Prom-EABR.     

Clinicopathological study on patients with renal cell carcinoma according to whole area histological sections

BACKGROUND: We tried to establish new classification of histological grade and indication of elective nephron-sparing surgery (ENSS) in renal cell carcinoma (RCC), and studied histological changes according to tumor size. METHODS: We made whole area histological sections on 142 cases with RCC and investigated histological aspects and prognosis. RESULTS: (1) To classify the grade of the cases, the worst grade which occupied more than 10% of the tumor provided most appropriate prognosis. (2) In 144 cases (kidneys), satellite tumor lesions (STL) were observed in 69 cases (47.9%), and the cases with vein invasion were observed in 75 cases (51.4%). Incidence of these two factors increased with tumor size. (3) From the point of view of location of STL and vein invasion, ENSS was possible with taking more than 2 cm surgical margin in the cases with less than 4 cm in size and slow growing type. But indication of ENSS should not be decided with ease. (4) Incidence of the cases with multiple structural and cell types and grades increased with tumor size. (5) Incidence of the cases with solid structure, spindle or pleomorphic cell type and high grade increased with tumor size. (6) It was supposed that tumor heterogeneity and progression could be associated with tumor growth in each cases. CONCLUSION: These results suggest the necessity of treatment of the cases with RCC as small as possible. If the tumor is less than 4 cm, prognosis tends to be good, and ENSS might be possible in some cases.