Biomedical subjects
Publications and source records attributed to E Goldenberg.
An oligoclonal IgG pattern was found in the CSF of a patient who is known to suffer from progressive familial myoclonus. In view of this finding the possibility arises that immunological mechanisms participate in the etiopathogenesis of this disease.
A case of probable herpetic viral encephalitis is presented. The clinical picture following the acute phase of disease was dominated by severe fluent aphasia, prominent oral tendencies, visual agnosia, and a decrease in fear reactions. Most of these symptoms, with the obvious exception of aphasia, are similar to those observed by Kluver and Bucy in rhesus monkeys that underwent bitemporal lobectomy. These manifestations may be explained by the tendency of the herpes simplex virus to invade the temporal lobes. "Agnosia" in the auditory field and changes in vocal behavior were observed by H. Kluver and P. C. Bucy (1939, Archives of Neurology and Psychiatry, 42, 949-1000) in some of their bitemporal monkeys. The association of sensory aphasia, as observed in this case, with the auditory "agnosia" observed in some bitemporal monkeys, is discussed.
In a study of 272 patients with myocardial infarction (MI) the 68 who died within 1 year had significantly higher levels of factor VIIIR:Ag, factor VIII:C, fibrinogen, alpha 1 antitrypsin and alpha 2 macroglobulin than those who survived. The mean white cell count (WCC) and peak creatine kinase (CK) were also significantly higher in those who died compared with the survivors. There was considerable intercorrelation between many of the haemostatic variables, WCC and CK as well as between many of the clinical predictors of outcome and the laboratory variables. The differences in haemostatic variables between those who died and those who survived may merely reflect the size of the infarct; alternatively, the haemostatic system may influence prognosis following an MI.
The increasingly accurate prediction of survival and functional recovery in patients with stroke will be of value in planning both their individual management and the health and social services needed. To establish the independent predictive effects of a range of personal and clinical characteristics, data on 900 patients admitted to Northwick Park Hospital with stroke were analysed by stepwise multiple regression. Older patients who lose consciousness at the outset and show signs of multiple neurological deficits, abnormal pupils, and conjugate deviation of the eyes are more likely to die within a year than those without these characteristics. Those who survive the acute episode and are discharged alive are more likely to die within a year if they are old and have sensory loss with severe physical disability. Older female patients who are incontinent, lose consciousness at the onset of stroke, sustain extensive motor deficits in combination with other neurological deficits, and have residual disabilities from previous strokes are particularly likely to be severely disabled on discharge from hospital. Routinely collected clinical data enable useful forecasts about mortality and disability after stroke. The accuracy of these forecasts can probably be improved further.
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Of 1094 patients with a confirmed stroke admitted to Northwick Park, a district general hospital, 364 (33%) died while in hospital, 215 (20%) were fully recovered when discharged, and 329 (30%) were too frail or too ill from diseases other than stroke to be considered for active rehabilitation. Only 121 (11%) were suitable for intensive treatment. They and 12 patients referred direct to outpatients were allocated at random to one of three different courses of rehabilitation. Intensive was compared with conventional rehabilitation and with a third regimen which included no routine rehabilitation, but under which patients were encouraged to continue with exercises taught while in hospital and were regularly seen at home by a health visitor. Progress at three months and 12 months was measured by an index of activities of daily living. Improvement was greatest in those receiving intensive treatment, intermediate in those receiving conventional treatment, and least in those receiving no routine treatment. Decreasing intensity of treatment was associated with a significant increase in the proportions of patients who deteriorated and in the extent to which they deteriorated. Probably only a few stroke patients, mostly men, are suitable for intensive outpatient rehabilitation, but for those patients the treatment is effective and realistic.
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Recordings were made from 43 poor sleepers between the ages of 20 and 30 for at least 4 consecutive nights. Three subject groups were formed on the basis of the awakenings occurring up to the sixth hour of sleep. The first group, with an average of 61 min wakefulness, is characterized by the abundance of long-lasting waking periods. The second group, with 18 min average wakefulness, showed the highest absolute number of awakenings, almost all of which were very brief. The third group, with 6 min average wakefulness, showed a slightly lower number of awakenings, but these were almost exclusively micro-waking periods. The temporal distribution of the waking periods was also different in the first group, in which the longest waking periods occur during the first hour of sleep and remain elevated until the fifth hour of sleep. The latency for falling asleep is particularly high for this group. A correlation exists between the amount of time awake up until the sixth hour of the night and the subject's anxiety level and the neuroticism index. 65% of the subjects obtained pathological scores on one or more MMPI scales. According to the order of frequency these were scales Sc, Pd and Pt. No preferential profile was found.
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In order to measure disability in a randomised controlled trial of different intensities of rehabilitation following stroke, a modification of existing methods has been developed; it makes use of 17 items of activities of daily living (ADL) which are rated on a three-point scale, and it has been subjected to tests of repeatability and validity. While some activities (e.g. use of taps, ascending or descending stairs) are either redundant or repetitive, others provide independent measures of disability. There was no significant inter-observer variability; the assessors disagreed on 78 (3.7%) out of a total of 2,125 paired observations. In a study of short-term within-patient variability, different scores were assigned on 49 (14.4%) out of a total of 340 observations made on two separate occasions. Minor differences (mainly in activities involving equipment e.g. cookers) emerged when scores obtained in hospital were compared with those obtained at home, but the two sets of scores were still highly correlated (r = 0.962. There was, however, considerable discrepancy between the hospital scores and those derived from the patients' own estimates of their activities at home, the latter falling below actual capabilities as indicated by the hospital scores. A clinical validation of the index showed a significant association between the hospital ADL scores and the extent of cerebral lesions determined by the number of neurological deficits. This modified ADL index is sufficiently repeatable and valid for the assessment of patients with moderate disability as a result of stroke and other chronic diseases; in most circumstances, it can probably be simplified to include only five or six items.
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Observation of the four cases reported and a review of the published literature suggest that spinal column lipomas can produce two entirely unrelated types of radiological image. 1. An image of cord-like appearance and variable width which joins the filum terminale to the sacrum, and is usually associated with enlargement of the spinal cord at the same level. This image can be demonstrated by both gas myelography and opaque myelography, and is produced by a lipoma of the filum terminale. The cord image is either that of an ectopic spinal cord or that of the lipomatous tumor itself, which joins the filum terminale to the sacrum. A spina bifida is often associated with these tumors, which can be intradural alone, which is very rare, or both intradural and epidural, and are often associated with enlargement of the spinal canal. 2. A fairly specific blocking-type of image which can be seen by opaque myelography, and consists of fringed bands which become progressively shorter from above downwards until being completely blocked. This appearance, which is extremely rare, is peculiar to intramedullary lipomas, the image probably corresponding to the dissociation of the medullary fiber bundles by the tumoral cords.
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