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Background and purpose: In this present study, we tried to find out if there is a subgroup of patients that should not undergo transoesophageal echocardiography (TEE) after an ischaemic stroke or transient ischaemic attack (TIA). Methods: A total of 441 consecutive unselected patients with ischaemic stroke or TIA suitable for anticoagulation were examined with TEE in the acute phase. The patients were divided into five subcategories according to their rhythm, age and the findings in carotid sonography, and into two groups according to the presence of clinical risk factors for ischaemic stroke or TIA. Results: From the 441 studied patients, 60 (14%) had chronic or paroxysmal atrial fibrillation (AF) and 381 (86%) were in sinus rhythm (SR). Of the patients in SR, 46 (12%) were below 50 years old. The carotid sonography was conducted in 240 patients above 50 years old and in SR, and <50% internal carotid artery (ICA) stenosis was found in 194 (81%) patients and ≥50% ICA in 46 (19%) patients. Potential cardiac sources of embolism were found in patients both with AF or in SR (70% versus 46%), both below and above 50-year-old patients in SR (37% versus 47%), both in over 50-year-old patients in SR with <50% ICA stenosis and ≥50% ICA stenosis (41% versus 61%) and in patients in SR either without or with clinical risk factors for ischaemic stroke or TIA (43% versus 51%). On the basis of the TEE study, oral anticoagulation was started in 36 (9%) patients in SR. Conclusion: These results support TEE in patients with ischaemic stroke or TIA who are candidates for receiving oral anticoagulation. [ABSTRACT FROM AUTHOR]

To compare plasma levodopa concentrations after repeated doses of levodopa/carbidopa/entacapone (LCE) and levodopa/carbidopa (LC). Open-label, randomized, two-period, active-controlled, cross-over study with four dosing regimens: groups I and II (healthy volunteers and Parkinson’s disease patients) received levodopa 100 mg or 150 mg four times daily, respectively, and groups III and IV (healthy volunteers) received the same strengths of levodopa five times daily. Pharmacokinetic (PK) parameters determined for levodopa included Cmin, Cmax, Cmax − Cmin, AUC, t1/2, and tmax. In healthy volunteers and PD patients, mean trough levels (Cmin), Cmax, and AUC of levodopa were, in general, significantly higher during LCE compared to LC administration. Compared to Cmin, Cmax, and AUC, differences between the treatments in variability of levodopa concentrations (Cmax − Cmin) were less consistent. The present results on the differences in levodopa PK between LCE and LC provide a basis to evaluate the relationship of levodopa PK and the induction of motor complications in an on-going study in early Parkinson’s disease using similar dosing regimens. [ABSTRACT FROM AUTHOR]

Abstract: Ingestion of windshield washer liquid resulted with an acute severe methanol intoxication in a 49-year old man. He developed optic atrophy with blindness, and an extrapyramidal syndrome. Putaminal injury and hyperintensity in the subcortical white matter was seen in a brain MRI. PET scanning with 6-[18F]fluoro-l-dopa confirmed symmetrical impaired presynaptic dopaminergic activity in the striatum, indicative of functional impairment of dopaminergic nigrostriatal neurons. The striatal uptake was more markedly impaired in the putamina (40% of controls) than in the caudate nuclei (60% of controls). To our knowledge, this is the first report of an 18F-dopa PET scanning result in a case of an acute methanol poisoning. [Copyright &y& Elsevier]

We performed a nation-wide study on geographical variation in the incidence and prevalence of medicated parkinsonism among the Finns aged ≥30 years using Bayesian spatial conditional autoregressive models. Registry of reimbursed medication for parkinsonism and a prescription database of purchase of these drugs were used to identify the study subjects. They were located by the map coordinates of the place of residence and aggregated into regular 100 km2 grid cells. A total of 7,190 incident and 10,616 prevalent cases were found. The age-adjusted annual incidence was 32.6/100,000 (95% HDR 31.8-33.4) during the years 1995 to 2000 and prevalence was 268/100,000 (95% HDR 263-274) in 2000. The male to female ratio was 1.45 (95% HDR 1.39-1.51) in incidence and 1.54 (95% HDR 1.47-1.61) in prevalence. There was strong evidence for geographic variation in incidence and prevalence. A zone with high incidence and prevalence was identified in the eastern and central part of Finland. There was no evidence for difference in incidence and prevalence between urban and rural areas. The marked (more than two-fold) geographic variation can hardly be caused solely by practices of the registration and collection of data on diagnosis or by methodological issues, but rather suggests to geographic variation in protective and predisposing factors of Parkinsonism in Finland. © 2008 Movement Disorder Society [ABSTRACT FROM AUTHOR]

The purpose of the present study was to establish how Parkinson's disease (PD) affects working capacity. Altogether, 937 (70%) of 1,343 working-aged members of the Finnish Parkinson Association participated in a questionnaire study. The ages of the subjects were between 29 and 65 years, median 59.0 years; 508 (54%) were men. The median (quartile range) duration of PD symptoms was 7.3 (4.3-11.3) years, and the median self-estimated severity of the disease on the Hoehn & Yahr scale was 2. Only 150 of 937 subjects (16%) were still working: 112 (12%) full-time and 38 (4%) part-time. Among those 343 (37%) who had retired purely because of PD at a median age of 53.4 years, the median working time was 1.7 years after established diagnosis. In part-time work, PD patients had been able to continue for a median of 4.3 years. PD often leads to early retirement; compared with the general Finnish population of similar age, PD patients had retired on the average 6 years earlier. Young age, mild symptoms, and short duration of the disease as well as adjustments enabling easier employment were associated with the possibility to continue longer in the work force. © 2006 Movement Disorder Society [ABSTRACT FROM AUTHOR]

Objective: To study the incidence and risk factors of stroke after coronary artery bypass grafting (CABG) or percutaneous transluminal coronary angioplasty (PTCA). Design: During 1983-1992, coronary revascularization procedures (n = 2160) were recorded in patients aged 35-64 years as part of the population-based FINMONICA Myocardial Infarction Register. The FINMONICA Stroke Register and National Hospital Discharge Register were used to ascertain subsequent stroke events in such patients. Results: During the average follow-up of 5.83 years, 155 patients (7.2%) had a stroke. The cumulative incidence of stroke was 1.55% in the first year after revascularization and varied between 0.8 and 1.4% during subsequent years. In Cox proportional hazard models the relative risk of stroke was 3.01 (p = 0.0007) for a previous stroke, 2.61 (p = 0.0001) for diabetes mellitus, 2.15 (p = 0.007) for low income (compared with high income), 2.06 (p = 0.03) for male sex, and 1.43 (p = 0.02) for a 10-year increment in age. Conclusion: The incidence of stroke during the first year after revascularization was five times higher than among the age- and sex-matched general population. Patients with a previous stroke, diabetes mellitus, advanced age, male sex and low socioeconomic status need special attention because of increased risk of stroke after CABG or PTCA. [ABSTRACT FROM AUTHOR]

Abstract: The objective of this questionnaire study was to assess the effect of cervical dystonia on patients'' working capacity. Of the 303 working-aged members of the Finnish Dystonia Association (N = 433) who participated in the study 247 (82%) had cervical dystonia. Their median age was 50 years, the median duration of CD symptoms was 12.3 years. Most (78%) subjects were on botulinum toxin treatment. Ninety-seven (39%) had retired because of CD at a median age of 48 years; 96 (39%) of the subjects were working: 87 full-time and 9 part-time. The remaining participants were on sick leave, unemployed, studying or retired of other reasons. Retirement occurred more than ten years earlier compared with the general Finnish population. All possibilities to help CD patients to continue longer in work should be considered early. [Copyright &y& Elsevier]

Objective The contribution of genetic causes to Parkinson's disease (PD) is strongest in early-onset cases. We ascertained a nationwide cohort of patients in order to study the genetic epidemiology of early-onset PD (EOPD) in Finland. Methods By means of a search in a national database we ascertained all patients with EOPD. These patients had become eligible for reimbursement of PD drugs between the years 1995–2006 and were <55 years of age at the time of PD diagnosis. A total of 441 patients consented and provided clinical and genealogical information. Results The incidence of EOPD increased 1.7-fold between the years 1995–2006, the mean annual incidence being 3.3/100,000. Fifty-two patients (11.8%) reported an affected first-degree relative. The birthplaces of patients with PD among first-degree relatives were clustered in certain regions in the southwestern and western coastal provinces of Finland and in the eastern province of Savo. Furthermore, the distance between the birthplaces of the patients' parents was smaller for patients, who had first-degree relatives with PD than for patients with no family history of PD. Conclusions Our data suggest that the incidence of EOPD is increasing. The birthplaces of patients with PD among first-degree relatives were clustered in certain provinces of Finland suggesting that monogenic forms of PD or genetic susceptibility of PD are present in the population. [ABSTRACT FROM AUTHOR]

Abstract: A malfunctioning heater caused a severe carbon monoxide (CO) intoxication leading to unconsciousness and predominantly right-sided extrapyramidal syndrome in a 29-year-old man. Follow-up included thorough clinical monitoring, and brain MRI and PET studies. Nine days after the poisoning, brain MRI showed symmetrical necrosis in the globus pallidi, but no abnormality was found in the substantia nigra. In addition, white matter periventricular lesions were seen. In a control scan 14 months later the white matter changes had subsided but small necrotic lesions were still noted bilaterally in the globus pallidi. A 6-[18F]fluoro-l-dopa PET examination performed 5 weeks after the intoxication revealed impaired presynaptic dopaminergic function in the left putamen whereas in the right putamen the dopaminergic activity was within normal limits. [11C] raclopride PET imaging 4 months after the poisoning showed no abnormality in postsynaptic D2 binding in the striatum. Clinically, the parkinsonian symptoms resolved 1.5 years after the poisoning. The final outcome of the recovery was excellent, and the patient returned to work. This is the first case reported where unilateral presynaptic, dopaminergic hypofunction in putamen could be confirmed with fluoro-l-dopa PET imaging on a patient with extrapyramidal syndrome caused by CO poisoning. Our results emphasize that CO intoxication can lead to striatal dopaminergic hypofunction, and that PET is a sensitive tool in evaluating extrapyramidal system after sudden neurotoxic insult. [Copyright &y& Elsevier]

Summary: We conducted a search for white matter changes (WMCs) in 13 Unverricht-Lundborg disease patients and compared the prevalence of WMCs in these patients to age-matched long-term epileptics and healthy controls. ULD patients had significantly more T2-weighted high-intensity signals on MRI than control subjects, due to the increased prevalence of these signals in the basal ganglia. Interestingly, ULD patients with the basal ganglia changes were overweight. Basal ganglia T2-weighted high-intensity signals are novel findings in ULD. [Copyright &y& Elsevier]

Sixteen subjects with de novo Parkinson's disease (PD) underwent three 6-[18F]fluoro-L-dopa (Fdopa) positron emission tomography (PET) scans during a follow-up time of 5 years (mean +/- SD 5.5 +/- 0.4 years) to study the progression of striatal dopaminergic hypofunction. Throughout the study, the smallest Fdopa uptake values were found in the dorso-caudal part of the putamen contralateral to the side with dominant motor symptoms. The rate of decline in Fdopa uptake in the contralateral putamen was faster in the beginning of the disease and slowed down as the disease progressed. The annual decline in Fdopa influx constant (Ki, unit x 10(-3) min(-1)) was on average 0.5 during the first 2 years and 0.2 during the subsequent 3 years (P = 0.002) in the contralateral putamen. In caudate, the rate of decline in Fdopa values was slower than in the putamen and did not change significantly during the follow-up time, annual decline in the contralateral caudate being 0.1 between baseline and 2 years and 0.3 between 2 and 5 years (P = 0.4). These results suggest that progression of putaminal dopaminergic hypofuncion in PD follows a nonlinear pattern at least in the contralateral side being faster in the beginning of the disease. [ABSTRACT FROM AUTHOR]

Sixteen subjects with de novo Parkinson's disease (PD) underwent three 6-[18F]fluoro-L-dopa (Fdopa) positron emission tomography (PET) scans during a follow-up time of 5 years (mean ± SD 5.5 ± 0.4 years) to study the progression of striatal dopaminergic hypofunction. Throughout the study, the smallest Fdopa uptake values were found in the dorso-caudal part of the putamen contralateral to the side with dominant motor symptoms. The rate of decline in Fdopa uptake in the contralateral putamen was faster in the beginning of the disease and slowed down as the disease progressed. The annual decline in Fdopa influx constant (Ki, unit × 10−3 min−1) was on average 0.5 during the first 2 years and 0.2 during the subsequent 3 years ( P = 0.002) in the contralateral putamen. In caudate, the rate of decline in Fdopa values was slower than in the putamen and did not change significantly during the follow-up time, annual decline in the contralateral caudate being 0.1 between baseline and 2 years and 0.3 between 2 and 5 years ( P = 0.4). These results suggest that progression of putaminal dopaminergic hypofuncion in PD follows a nonlinear pattern at least in the contralateral side being faster in the beginning of the disease. © 2009 Movement Disorder Society [ABSTRACT FROM AUTHOR]

Purpose: Unverricht-Lundborg disease (ULD) is currently classified as progressive myoclonus epilepsy. Myoclonus, the characteristic symptom in ULD, suggests that dopamine neurotransmission may be involved in the pathophysiology of ULD. Our purpose was to examine brain dopaminergic function in ULD patients. Methods: Four genetically and clinically diagnosed ULD patients and eight healthy controls were scanned with [11C]raclopride-PET. PET images were coregistered to individual 1.5T MR images and region-of-interest analysis was performed for the striatum and thalamus. Standardized uptake values and individual voxel-wise binding potential maps of the patients and controls were also analyzed. Results: ULD patients had markedly higher (31–54%) dopamine D2-like receptor availabilities than healthy controls in both the striatum and the thalamus. The proportionally highest binding potentials were detected in the thalamus. There were no significant differences in the cerebellar uptake of [11C]raclopride in ULD patients versus healthy controls. Voxel-based results were in accordance with the region-of-interest analysis. Conclusions: These results suggest that dopaminergic modulation at the level of the striatum and thalamus could be a crucial factor contributing to the symptoms of ULD. In the light of our data, we propose that ULD with dopamine dysfunction and dyskinetic symptoms shares certain pathophysiological mechanisms with classical movement disorders. Future studies are therefore warranted to study the effect of dopaminergic pharmacotherapy in ULD. [ABSTRACT FROM AUTHOR]

Abstract: Introduction: Baseline severity and clinical stroke syndrome (Oxford Community Stroke Project, OCSP) classification are predictors of outcome in stroke. We used data from the ‘Tinzaparin in Acute Ischaemic Stroke Trial’ (TAIST) to assess the relationship between stroke severity, early recovery, outcome and OCSP syndrome. Methods: TAIST was a randomised controlled trial assessing the safety and efficacy of tinzaparin versus aspirin in 1484 patients with acute ischaemic stroke. Severity was measured as the Scandinavian Neurological Stroke Scale (SNSS) at baseline and days 4, 7 and 10, and baseline OCSP clinical classification recorded: total anterior circulation infarct (TACI), partial anterior circulation infarct (PACI), lacunar infarct (LACI) and posterior circulation infarction (POCI). Recovery was calculated as change in SNSS from baseline at day 4 and 10. The relationship between stroke syndrome and SNSS at days 4 and 10, and outcome (modified Rankin Scale at 90 days) were assessed. Results: Stroke severity was significantly different between TACI (most severe) and LACI (mildest) at all four time points (p <0.001), with no difference between PACI and POCI. The largest change in SNSS score occurred between baseline and day 4; improvement was least in TACI (median 2 units), compared to other groups (median 3 units) (p <0.001). If SNSS did not improve by day 4, then early recovery and late functional outcome tended to be limited irrespective of clinical syndrome (SNSS, baseline: 31, day 10: 32; mRS, day 90: 4); patients who recovered early tended to continue to improve and had better functional outcome irrespective of syndrome (SNSS, baseline: 35, day 10: 50; mRS, day 90: 2). Conclusions: Although functional outcome is related to baseline clinical syndrome (best with LACI, worst with TACI), patients who improve early have a more favourable functional outcome, irrespective of their OCSP syndrome. Hence, patients with a TACI syndrome may still achieve a reasonable outcome if early recovery occurs. [Copyright &y& Elsevier]

Because enteroviruses can be detected in various clinical samples during enteroviral meningitis, we analyzed the combined diagnostic utility of polymerase chain reaction (PCR) of cerebrospinal fluid (CSF), feces, and serum for detection of enterovirus in specimens obtained from adults with aseptic meningitis or encephalitis. PCR results were analyzed for 34 adults for whom enteroviral meningitis was diagnosed on the basis of virus isolation and antibody detection in our hospital during 1999-2003. PCR results were also analyzed for 77 adults with meningitis or encephalitis of another defined cause for whom this assay was used for diagnostic evaluation during that period. Twenty-six (76%) of 34 CSF samples and 24 (96%) of 25 fecal samples collected from patients with enteroviral meningitis had positive PCR results. The diagnostic yield of the test was lower for CSF specimens obtained >2 days after clinical onset, compared with CSF collected &les;2 days after onset. Instead, PCR of feces was highly useful also later, because 12 of the 13 fecal specimens obtained 5-16 days after clinical onset had positive test results. None of 75 CSF samples and 2 of 48 fecal samples obtained from patients with nonenteroviral infection had positive PCR results. All serum samples were PCR negative. PCR of fecal specimens obtained throughout the course of enteroviral meningitis had the highest clinical sensitivity for detecting enterovirus. It is recommended that, in addition to performance of CSF PCR, fecal samples collected from patients with suspected enteroviral meningitis should be tested by PCR, especially when the duration of symptoms is >2 days. [ABSTRACT FROM AUTHOR]

Background: Low-molecular-weight heparins and heparinoids are superior to unfractionated heparin in the prevention and treatment of venous thromboembolism, but their safety and efficacy in acute ischaemic stroke are inadequately defined.Methods: This randomised, double-blind, aspirin-controlled trial tested the safety and efficacy of treatment with high-dose tinzaparin (175 anti-Xa IU/kg daily; 487 patients), medium-dose tinzaparin (100 anti-Xa IU/kg daily; 508 patients), or aspirin (300 mg daily; 491 patients) started within 48 h of acute ischaemic stroke and given for up to 10 days. Primary intracerebral haemorrhage was excluded by computed tomography. Outcome was assessed, with treatment allocation concealed, by the modified Rankin scale at 6 months (independence [scores 0-2] vs dependence or death [scores 3-6]).Findings: Of 1486 randomised patients, two did not receive treatment and 46 were lost to follow-up. The proportions independent at 6 months were similar in the groups assigned high-dose tinzaparin (194/468 [41.5%]), medium-dose tinzaparin (206/486 [42.4%]), or aspirin (205/482 [42.5%]). There was no difference in effect in any predefined subgroup, including patients with presumed cardioembolic stroke. Other outcome measures were similar between the treatment groups (disability, case-fatality, and neurological deterioration rates). During the in-hospital treatment period no patient assigned high-dose tinzaparin developed a symptomatic deep-vein thrombosis compared with nine assigned aspirin. Conversely, seven patients assigned high-dose tinzaparin developed symptomatic intracerebral haemorrhage compared with one in the aspirin group.Interpretation: Treatment with tinzaparin, at high or medium dose, within 48 h of acute ischaemic stroke did not improve functional outcome compared with aspirin. Although high-dose tinzaparin was superior in preventing deep-vein thrombosis, it was associated with a higher rate of symptomatic intracranial haemorrhage. [ABSTRACT FROM AUTHOR]

SummaryWe have assessed the ability of xeroderma pigmentosum and normal keratinocytes grown out from skin biopsies to undergo apoptosis after irradiation with ultraviolet B. Keratinocytes have been studied from xeroderma pigmentosum complementation groups A (three biopsies), C (three biopsies), D (one biopsy), xeroderma pigmentosum variant (two biopsies), and Cockayne syndrome (one biopsy). The three xeroderma pigmentosum group A and the xeroderma pigmentosum group D samples were at least six times more sensitive than normal cells to ultraviolet B-induced apoptosis. The xeroderma pigmentosum variant samples showed intermediate susceptibility. Xeroderma pigmentosum group C samples proved heterogeneous: one showed high sensitivity to apoptosis, whereas two showed near normal susceptibility. The Cockayne syndrome sample showed the high susceptibility of xeroderma pigmentosum groups A and D only at a higher fluence. These results suggest that the relationships between repair deficiency, apoptosis, and susceptibility to skin cancer are not straightforward. Ultraviolet B-induced skin cancer is also thought to be due in part to ultraviolet B-induced impairment of immune responses. The release of the inflammatory cytokines interleukin-6 and tumor necrosis factor-α from cultured xeroderma pigmentosum keratinocytes tended to occur at lower fluences than in normals, but was less extensive, and was more readily inhibited at higher fluences of ultraviolet B. [ABSTRACT FROM AUTHOR]

Magnetoencephalographic (MEG) changes in cortical activity were studied in a chronic Finnish-speaking deep dyslexic patient during single-word and sentence reading. It has been hypothesized that in deep dyslexia, written word recognition and its lexical-semantic analysis are subserved by the intact right hemisphere. However, in our patient, as well as in most nonimpaired readers, lexical-semantic processing as measured by sentence-final semantic-incongruency detection was related to the left superior-temporal cortex activation. Activations around this same cortical area could be identified in single-word reading as well. Another factor relevant to deep dyslexic reading, the morphological complexity of the presented words, was also studied. The effect of morphology was observed only during the preparation for oral output. By performing repeated recordings 1 year apart, we were able to document significant variability in both the spontaneous activity and the evoked responses in the lesioned left hemisphere even though at the behavioural level, the patient's performance was stable. The observed variability emphasizes the importance of estimating consistency of brain activity both within and between measurements in brain-damaged individuals. [ABSTRACT FROM AUTHOR]

The ability of echocardiography to diagnose sources of embolism and the role of the examination in the prediction of thromboembolism are reviewed. In addition, the yield of transthoracic (TTE) and transoesophageal echocardiography (TEE) is analysed in patients with suspected embolism and guidelines are proposed for performing echocardiography in this setting. In general, echocardiography is reliable for diagnosing sources of embolism and this applies in particular to TEE in the case of atrial, valvular, and aortic abnormalities. However, the method is useful for predicting embolism in a few cases only. There is a substantial risk in the event of mobile or protruding thrombi, but screening for these and other markers of thromboembolism seems to be unproductive in most groups of risk patients. Yet, in the presence of atrial fibrillation, echocardiography may be helpful in defining patients with an otherwise normal heart and low risk of embolism - and in defining the relatively rare patient with a clinically low-risk profile but moderate-to-severe left ventricular systolic dysfunction and a high risk of embolism. TEE-guided conversion of atrial fibrillation without weeks of preceding anticoagulation may prove useful, after further investigation. The risk of embolism in relation to the size and mobility of valvular vegetations has remained controversial. In patients with suspected recent embolism, TTE results in less than 5% new therapeutic consequences. In those with a normal TTE, the yield of TEE seems to be equally low. We therefore recommend a selective strategy: TTE and TEE can be omitted when a cardiac source of embolism appears from the clinical setting and in most patients with an obvious predisposition to cerebrovascular disease. However, in the latter cases TTE should be performed if indicated by the clinical situation, e.g. in the presence of fever and murmur. TTE is also recommended when there are no obvious markers of primary vascular disease. To preclude very rare sources of embolism (e.g. atrial thrombi despite sinus rhythm), supplementary TEE is recommended in younger patients in whom primary vascular disease is very unlikely. The diagnosis by TEE of common conditions such as atrial septal aneurysms and patent foramen ovale cannot, however, be taken as proof of the mechanism of a systemic arterial occlusive event; thus it is difficult to change therapy on the basis of such diagnoses. [ABSTRACT FROM AUTHOR]

Comments on several issues related to medicine in Great Britain. Breakfast habits of patients with Crohn's disease; Effects of withholding notifications of abortion; Advantages of dealing with natural human diabetes.

Balo's concentric sclerosis is a severe demyelinating disease with poor prognosis. To date, nothing is known about the effects of pregnancy on the course of Balo's disease. We describe here the first successful pregnancy of a patient with Balo's concentric sclerosis. Upon neurological worsenings during pregnancy, our patient was treated with high-dose methylprednisolone and plasma-exchange. Intravenous immunoglobulin and inerferon-beta-la were given postpartum. At the last follow-up visit 2.5 years after the delivery the patient had only minor residual symptoms. [ABSTRACT FROM AUTHOR]

The article presents a case report regarding the effect of ventriculoatrial shunts on patients who pass through neurosurgical treatment. It highlights the case of a 46-year-old man who undergone medical treatment due to progressive subcutaneous swelling of the area of the right mastoid process. The researchers unveiled that shunt malfunction is possible, but the migration of a shunt catheter to distal organs is uncommon.