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Biomedical subjects

P Greene

Publications and source records attributed to P Greene.

At least 19 recordsLinked to original sources
PubMed2006

Dietetic guidelines on food and nutrition in the secondary prevention of cardiovascular disease - evidence from systematic reviews of randomized controlled trials (second update, January 2006).

AIM: To update dietetic guidelines based on systematic review evidence on dietary advice to prevent further events in people with existing cardiovascular disease (CVD) (secondary prevention). METHODS: The Cochrane Library, MEDLINE and EMBASE were comprehensively searched to January 2005 for systematic reviews on aspects of diet and heart health. Reviews were included if they searched systematically for randomized controlled trials relating to diet and secondary prevention of CVD. Each review was critically appraised by at least two members of the UK Heart Health and Thoracic Dietitians Group. The quality and results of each review were discussed and summarized at a group meeting. RESULTS: Evidence-based strategies that reduce cardiovascular events in those with CVD include reduction in saturated fat and substitution with unsaturated fats. Individuals who have suffered a myocardial infarction may also benefit from adopting a Mediterranean type diet and increasing intake of omega 3 fats, but it is not clear whether they are beneficial for all patients with CVD. There is no systematic review evidence to support the use of antioxidant vitamins supplements, low glycaemic index diets, or homocysteine lowering therapies in this group. CONCLUSION: There remains good evidence that reducing saturated fat reduces morbidity in patients with CVD. This advice is consistent for most manifestations of CVD, with the addition of Mediterranean dietary advice and increased omega 3 fats for those who have had a myocardial infarction.

Antioxidants↗
PubMed2004

Dietetic guidelines: diet in secondary prevention of cardiovascular disease (first update, June 2003).

AIM: To update dietetic guidelines summarizing the systematic review evidence on dietary advice to prevent further events in people with existing cardiovascular disease (CVD) (secondary prevention). METHODS: The Cochrane Library, MEDLINE and EMBASE were comprehensively searched to November 2002 for systematic reviews on aspects of diet and heart health. Reviews were included if they searched systematically for randomised controlled trials relating to diet and secondary prevention of CVD. Two members of the UK Heart Health and Thoracic Dietitians Group critically appraised each review. The quality and results of each review were discussed and summarized in a meeting of the whole group. RESULTS: Providing evidence-based dietary information (including increasing omega-3 fat intake) to all people who have had a myocardial infarction will save more lives than concentrating dietary advice on just those in need of weight loss or lipid lowering. The practice of prioritizing dietetic time in secondary prevention to those with raised lipids is out of date since the advent of statin therapy. However, effective dietary advice for those with angina, stroke, peripheral vascular disease or heart failure is less clear. CONCLUSION: There is good systematic review evidence that dietary advice to those with coronary heart disease can reduce mortality and morbidity as well as modify some risk factors. Dietary advice that does this most effectively should be prioritized.

Cardiovascular Diseases↗
PubMed2004

Subthalamic nucleus stimulation in advanced Parkinson's disease: blinded assessments at one year follow up.

OBJECTIVE: To measure the effect of deep brain stimulation (DBS) of the subthalamic nucleus in patients with advanced Parkinson's disease. DESIGN: Open label follow up using blinded ratings of videotaped neurological examinations. PATIENTS: 30 patients with advanced Parkinson's disease (19 male, 11 female; mean age 58.8 years; mean disease duration 12.8 years), complicated by intractable wearing off motor fluctuations and dopaminergic dyskinesias. MAIN OUTCOME MEASURES: Unified Parkinson's disease rating scale (UPDRS), part III (motor), score at one year, from blinded reviews of videotaped neurological examinations. Secondary outcomes included the other UPDRS subscales, Hoehn and Yahr scale, activities of daily living (ADL) scale, mini-mental state examination (MMSE), estimates of motor fluctuations and dyskinesia severity, drug intake, and patient satisfaction questionnaire. RESULTS: Subthalamic nucleus stimulation was associated with a 29.5% reduction in motor scores at one year (p<0.0001). The only important predictors of improvement in UPDRS part III motor scores were the baseline response to dopaminergic drugs (p = 0.015) and the presence of tremor (p = 0.027). Hoehn and Yahr scores and ADL scores in the "on" and "off" states did not change, nor did the mean MMSE score. Weight gain occurred in the year after surgery, from (mean) 75.8 kg to 78.5 kg (p = 0.028). Duration of daily wearing off episodes was reduced by 69%. Dyskinesia severity was reduced by 60%. Drug requirements (in levodopa equivalents) declined by 30%. CONCLUSIONS: The 30% improvement in UPDRS motor scores was a more modest result than previously reported. DBS did not improve functional capacity independent of drug use. Its chief benefits were reduction in wearing off duration and dyskinesia severity.

Activities of Daily Living↗
PubMed2003

Cognition following bilateral implants of embryonic dopamine neurons in PD: a double blind study.

OBJECTIVES: To determine if bilateral transplantation of embryonic mesencephalic dopamine cells into the putamen of patients with PD significantly affected their cognitive functioning when compared with patients receiving sham surgery and to examine the effect of age on cognitive performance after implantation. METHODS: Forty patients (19 women, 21 men; age 34 to 75 years) with idiopathic PD of at least 7 years' duration (mean 14 years) who had disabling motor signs despite optimal drug management were randomly assigned to tissue implants or sham craniotomies in a double-blind design. Neuropsychological tests assessing orientation, attention, language, verbal and visual memory, abstract reasoning, executive function, and visuospatial and construction abilities were administered before and 1 year after surgery. Treatment groups did not differ at baseline in demographic, neuropsychological, motor, depression, or levodopa equivalent measures. RESULTS: Postsurgical change in cognitive performance was not significantly different for real or sham surgery groups. Performance in both groups remained unchanged at follow-up for most measures. CONCLUSIONS: Embryonic dopamine producing neurons can be implanted safely into the putamen bilaterally without impairing cognition in patients with PD, but within the first year, improved cognition should not be expected.

Adult↗
PubMed2001

Blinded positron emission tomography study of dopamine cell implantation for Parkinson's disease.

We assessed nigrostriatal dopaminergic function in Parkinson's disease (PD) patients undergoing a double-blind, placebo-controlled surgical trial of embryonic dopamine cell implantation. Forty PD patients underwent positron emission tomography (PET) imaging with [18F]fluorodopa (FDOPA) prior to randomization to transplantation or placebo surgery. The 39 surviving patients were rescanned one year following surgery. Images were quantified by investigators blinded to treatment status and clinical outcome. Following unblinding, we determined the effects of treatment status and age on the interval changes in FDOPA/PET signal. Blinded observers detected a significant increase in FDOPA uptake in the putamen of the group receiving implants compared to the placebo surgery patients (40.3%). Increases in putamen FDOPA uptake were similar in both younger (age < or = 60 years) and older (age > 60 years) transplant recipients. Significant decrements in putamen uptake were evident in younger placebo-operated patients (-6.5%) but not in their older counterparts. Correlations between the PET changes and clinical outcome were significant only in the younger patient subgroup (r = 0.58). The findings suggest that patient age does not influence graft viability or development in the first postoperative year. However, host age may influence the time course of the downstream functional changes that are needed for clinical benefit to occur.

Adult↗
PubMed2001

Community supports for individuals with challenging behavior after brain injury: an analysis of the New York state behavioral resource project.

OBJECTIVE: To articulate a framework for supporting individuals with behavioral challenges following brain injury, to describe a state-funded clinical intervention program established to provide community support to individuals with challenging behaviors following brain injury using such a framework, to present data from which it can be concluded that such a program is cost-effective, and to offer policy recommendations. DESIGN: Retrospective analysis of cost data and living arrangements for individuals with behavioral challenges served for a period of 3-4 years through the New York State Home and Community-Based Services Traumatic Brain Injury (HCBS-TBI) Waiver program and the State Behavioral Resource Project. SUBJECTS: 80 individuals with TBI and severe behavioral challenges that included criminal behavior, physical threats, assault and physical aggression, sexually inappropriate behavior, substance abuse, refusal to participate in intervention programs, and psychiatric disturbances, all of whom were at least 2 years postinjury (X = 7.33 years postinjury). RESULTS: The majority of individuals (82% of the 1996 cohort; 89% of the 1997 cohort) with challenging behaviors were living successfully in their home communities 3-4 years after the initiation of behavioral supports. In addition, the costs of serving these individuals decreased in the first year of community integration and for that last year that a cost analysis was completed. CONCLUSIONS: Many individuals with behavioral impairments can be supported successfully in community settings, so long as those supports are flexibly implemented to meet the changing needs of those individuals. Moreover, even with intensive supports, it is cost-effective to serve this population in the community.

Brain Injuries↗
PubMed2000

Knowledge, attitudes, and behaviors of Alabama's primary care physicians regarding cancer genetics.

PURPOSE: To determine Alabama's primary care physicians' knowledge, attitudes, and behaviors regarding cancer genetics. METHOD: A questionnaire was mailed to a random sample of 1,148 physicians: family and general practitioners, internists, and obstetrician-gynecologists. RESULTS: Of the surveyed physicians, 22.1% responded. Of the respondents, 63% to 85% obtained family histories of cancer from 76% to 100% of their patients. Obstetrician-gynecologists referred more patients for cancer genetic testing (p = .008) and were more confident in their abilities to tailor preventive recommendations based on the results (p = .05) than were the other physicians. Primary care physicians were more likely than were obstetrician-gynecologists to identify lack of time during the patient visit as hindering efforts to do genetic counseling (p = .01). Physicians in practice for ten years or less were more confident in explaining genetic test results than were those in practice for more than 20 years (p = .01). CONCLUSION: These data validate gaps in primary care practices in obtaining family history of cancer, as well as lack of confidence in explaining genetic test results and in tailoring recommendations based on the tests.

Adult↗
PubMed1998

Current concepts on the clinical features, aetiology and management of idiopathic cervical dystonia.

Idiopathic cervical dystonia (ICD) is the most common form of adult-onset focal dystonia. Previously, disagreement existed about whether ICD was a psychiatric illness, but the disorder is now viewed as a neurological illness and large clinical series have clarified the clinical features of the disease. At the time of diagnosis, extracervical dystonia is found in approximately 20% of patients, and there may be a concomitant head or hand tremor. Importantly, adult-onset ICD does not become generalized, although there may be segmental spread and pain may increase independently of the dystonia. While 10-20% of patients may experience remission, nearly all patients relapse within 5 years and are left with persistent disease. The aetiology of ICD is unknown, but there has been much progress in clarifying the genetic abnormality in families with inherited adult-onset cervical dystonia; linkage to chromosome 18p has been demonstrated in one family, and the DYT1 locus has been excluded in two other families. Painful trauma may be involved in the pathogenesis of ICD. Painful stimuli are received and processed by the basal ganglia, and the synaptic changes provoked by pain may lead to the abnormal physiology underlying dystonia. Consistent with this idea are experiments which demonstrate that altered sensory input leads to plasticity of the motor cortex, and those that explore the 'tonic vibration reflex' in patients with dystonia. Another theory suggests that a primary vestibular abnormality is responsible for ICD. Botulinum toxin is the most effective treatment for ICD. Roughly 75% of patients improve, and a response is generally seen within the first week. However, many questions remain regarding the optimal technique of administration. The development of neutralizing antibodies occurs in at least 5-10% of patients, and appears to be related both to dosage and to the interval between treatments. Side-effects are generally mild and result from the action of the toxin in the periphery. If the response to botulinum toxin is not adequate, anticholinergics, benzodiazepines, baclofen and other medications are used as adjunctive therapy. Surgical therapies are available for the treatment of ICD but are reserved for patients refractory to conservative measures.

Diagnosis, Differential↗
PubMed1998

Outcome of selective ramisectomy for botulinum toxin resistant torticollis.

OBJECTIVE: To investigate the long term outcome of selective ramisectomy denervation in patients with botulinum toxin resistant spasmodic torticollis. BACKGROUND: The published surgical series of ramisectomy treatment for torticollis do not provide systematic information on patients who develop resistance to the current standard of treatment-botulium toxin injections. Moreover, there is little information on surgical outcome using rating scale measurements of torticollis, or assessments of functional and occupational capacity. METHODS: Using a structured interview format and videotape assessments of severity of dystonia in a retrospective fashion, detailed follow up information was obtained on 16 patients who underwent open label selective denervation for severe, disabling torticollis, refractory to injections of botulinum toxin. RESULTS: Of 16 patients with disabling torticollis followed up postoperatively for a mean of 5 years, six (37.5%) had a moderate or complete return of normal neck function, as determined using functional capacity scales, whereas 10 had only minimal relief of dystonia or gain in function. Six of the 16 patients (37.5%) underwent a second peripheral denervation operation, and one required a third. Of 11 patients working outside the home before surgery, nine were disabled by dystonia, and only one continued to work after surgery. Dystonia rating scale scores of videotaped examinations using a modification of the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) improved in 12 of 14 patients (85.7%) who underwent selective ramisectomy. When patients with primary botulinum toxin resistance were excluded, the magnitude of benefit for this subgroup was 31.9% of the baseline dystonia score (p<0.0002), comparable with the degree of improvement in a group of control patients receiving botulinum toxin treatment for torticollis. CONCLUSION: About one third of patients with torticollis resistant to injections of botulinum toxin may derive modest long term functional improvement from selective denervation, with a reduction in dystonia by about 30%, but remain unable to work.

Adult↗
PubMed1996

Delayed-onset cerebellar syndrome.

BACKGROUND: Delayed-onset involuntary movements, including dystonia and myoclonus, have been reported after stroke or head trauma. Moreover, there have been reports of delayed-onset isolated intention tremor and, in several of these cases, gait ataxia. OBJECTIVE: To further define the clinical features of a delayed-onset cerebellar syndrome. DESIGN: Subjects with cerebellar tremor and either head trauma or stroke were identified using a computerized database, providing detailed demographic and clinical information of 4002 patients with involuntary movements other than Parkinson's disease seen at our center between 1983 and 1995. Medical records and videotaped neurological examinations were retrospectively reviewed. SETTING: The Center for Parkinson's Disease and Other Movement Disorders at Columbia-Presbyterian Medical Center, New York, NY. PATIENTS: Five patients with delayed-onset cerebellar syndromes. RESULTS: Five patients with stroke or head trauma developed a cerebellar syndrome 3 weeks to 2 years after the initial insult. The syndrome, characterized by intention tremor, ataxic dysarthria, nystagmus, dysmetria, dysdiadochokinesis, and gait ataxia, was progressive in at least one patient. In four patients, lesions were present on neuroimaging in the thalamus or brain stem (especially in the midbrain). CONCLUSIONS: A delayed-onset cerebellar syndrome may follow head trauma or stroke. The syndrome is sometimes progressive and often disabling. The delayed onset implies that the syndrome is not caused by the initial lesion itself but may be caused by development of post-synaptic supersensitivity or secondary reorganization of involved pathways.

Adolescent↗
PubMed1996

Approach to the treatment of limb disorders with botulinum toxin A. Experience with 187 patients.

OBJECTIVE: To determine the dosing, response expectation, efficacy, and most rational strategy for using intramuscular injections of botulinum toxin A (BTX) for limb disorders. DESIGN: Open-label prospective analysis of outcome after BTX treatment in patients with limb disorders. PROCEDURE: Botulinum toxin A prepared from lyophilized botulinum toxin was injected into selected upper and lower limb muscles under electromyographic guidance. Booster injections were given every 10 to 14 days during the first month (if needed) until optimal effects were achieved. Clinical data and muscle strength testing were obtained before the first injections and repeated at each visit. Level of disability, global functional improvement, and relief of pain were evaluated 6 to 8 weeks after the first set of injections. Practical and meaningful BTX doses by muscle, limb, or condition according to specified levels of efficacy were developed. MAIN OUTCOME MEASURES: Botulinum toxin A efficacy was calculated as an arithmetic combination of changes in the 3 clinical ratings before and after administration of BTX. RESULTS: Botulinum toxin A injections were given to 187 patients with limb disorders during an 8-year period (136 with dystonia, 37 with parkinsonian, essential, and cerebellar tremors, and 14 with spasticity). Four overall outcomes from no effect to almost complete improvement in the use of the limb or relief of pain were found, and determined the strategy for follow-up injections. Average BTX efficacy for all patients was 65% and ranged from 83.5% for focal hand dystonia to 35.7% for parkinsonian tremor. Botulinum toxin A injections relieved pain, independent of motor function, in 82.7% of patients with painful muscle spasms. CONCLUSIONS: Botulinum toxin A was found to be a safe and useful treatment of various limb conditions. Botulinum toxin A was significantly more effective when only a few muscles needing low doses were injected, and tended to be more useful in dystonia and spasticity than tremor. Candidates for BTX injection could be categorized functionally into 3 groups independent of the underlying disorders. The only significant adverse effect of BTX injection in limbs was transient weakness in injected or neighboring muscles.

Adolescent↗
PubMed1996

Use of intrathecal baclofen in the treatment of patients with dystonia.

BACKGROUND: Continuous infusion of intrathecal (IT) baclofen is a highly effective standard therapy for severe spasticity of spinal origin. By contrast, there is limited clinical experience regarding the use of IT baclofen in treating patients with dystonia, and little is known regarding the indications for treatment, efficacy, and safety of IT baclofen in this disorder. OBJECTIVE: To study retrospectively the effects of IT baclofen in treating 25 patients with severe segmental or generalized dystonia. SETTING: Neurological Institute, Columbia-Presbyterian Medical Center, New York, NY. PATIENTS: Twenty-five patients with severe segmental or generalized dystonia that was refractory to oral medications underwent IT baclofen test dosing. In addition to dystonia, 17 patients had spasticity or painful spasms. Thirteen of 25 patients responded to the test doses of IT baclofen, according to unblinded neurological assessments that included the patient's subjective report; all 13 underwent implantation of a pump for continuous IT baclofen infusion. RESULTS: In contrast to reports of patients with spasticity of spinal origin, those with dystonia in the present series had a lower response rate to bolus IT baclofen doses and a smaller degree of clinical improvement. For 10 of the 13 responders to the test doses of IT baclofen, dystonia rating scale scores of videotaped examinations by blinded observers detected no significant change (P < .07) in severity of dystonia. Retrospective data from 11 of 13 patients with implantable pumps, followed up for a mean interval of 21 months after pump insertion, showed continuing efficacy in 6 individuals (55%), based on a determination of patient satisfaction; however, only 3 patients (27%) reported a sustained improvement in functional capacity. Five (38%) of the 13 patients with implantable pumps experienced severe complications that required hospitalization. CONCLUSIONS: Despite recent reports that have described the benefit in small numbers of patients with dystonia, we concluded that the role of IT baclofen in treating severe dystonia remains uncertain. Intrathecal baclofen may be more effective when dystonia is associated with spasticity or pain. In the present series, we detected no significant difference in the response to IT baclofen in patients with or without spasticity or pain, perhaps owing to the small sample size.

Baclofen↗
PubMed1996

Oral and genital pain syndromes in Parkinson's disease.

Painful sensory complaints are known to occur in Parkinson's disease, but painful oral or genital syndromes have not been described. We report seven individuals with presumed idiopathic Parkinson's disease and one with atypical parkinsonism who experienced chronic severe oral or genital pains that appeared to be examples of a primary sensory disturbance related to the underlying parkinsonism. In each case, the pain syndrome overshadowed the other features of the parkinsonism. Five patients experienced oral pain and three patients, all women, had genital pain. No other definable organic cause was detected to explain the symptoms in any case. The genital pain tended to fluctuate in severity with the motor manifestations of the parkinsonism and could be abolished or reduced by levodopa. The recognition of painful oral or genital sensations in patients with parkinsonism should lead to further study regarding the prevalence, neurochemical basis, and treatment for these disabling symptoms.

Aged↗
PubMed1996

Use of research-based practices by oncology staff nurses.

PURPOSE/OBJECTIVES: To determine the extent to which oncology staff nurses adopted eight specific research-based practices and the impact of demographic and resource factors on adoption of these practices. DESIGN: Cross-sectional mail survey. SETTING: National. SAMPLE: 1,100. METHODS: Network sampling techniques: 2,000 Oncology Nursing Society (ONS) staff nurses were randomly and proportionally selected from seven practice setting categories; each ONS nurse was asked to recruit a non-ONS staff nurse colleague. Both groups completed the Oncology Nursing Practice Questionnaire, which measures adoption of eight research-based practices. MAIN RESEARCH VARIABLES: Extent of adoption, including awareness, persuasion, and implementation of eight specific practices; nurse demographics; and work-related resources. FINDINGS: Awareness was high, with 53%-96% of nurses reporting awareness of the eight practices. Overall, 28% were aware of all practices while 10% were aware of half or fewer. Less-aware nurses differed from other nurses in demographics and resources. Computed "extent of adoption" scores showed that almost 90% of aware nurses used seven of the practices at least sometimes. CONCLUSIONS: Oncology staff nurses with awareness of a practice were implementing the practice in their organization. IMPLICATIONS FOR NURSING PRACTICE: The findings establish a need for developing educational programs to enhance awareness of specific practices and to creatively reach nurses who are unlikely to seek programs outside their employing agencies.

Adult↗
PubMed1995

Spread of symptoms in idiopathic torsion dystonia.

We reviewed the histories of 115 patients who had idiopathic dystonia and who were 21 years of age and younger at onset of symptoms and 472 patients with onset older than age 21. Patients with onset in the lower extremities tended to be younger at onset (mean age 8.4 years), have rapid spread of symptoms to other body parts, and to develop generalized dystonia. Patients with onset in the upper extremities tended to be older at onset (mean age 11.2 years) and were less likely to develop generalized dystonia, but were more likely to experience spread of symptoms many years after the disease began. Almost 20% of patients younger than age 22 began with torticollis, and 67% of these remained focal after a mean 14.9 years. In adults, dystonic symptoms remained focal in the majority, but approximately 15-30% of patients presenting with blepharospasm, torticollis, laryngeal or brachial dystonia eventually experienced dystonia outside the initially involved segment. Almost 50% of children and adolescents with dystonia reported a family history of dystonia, compared with approximately 10-13% of patients with torticollis, laryngeal or brachial dystonia. Less than 3% of patients with blepharospasm reported a family history of dystonia. There were only minor differences in the pattern of spread of dystonic symptoms between Jewish and non-Jewish patients. Although younger patients were more likely to report a family history of dystonia, patterns of spread were the same for familial and sporadic patients in the same age range.

Adolescent↗