Brie N. Noble

Defining mild cognitive impairment in Parkinson's disease

Our purpose was to characterize a state of mild cognitive impairment (MCI) in Parkinsons disease (PD) (PD‐MCI) that would be analogous to the MCI that is posited as a precursor of Alzheimers disease (AD). We categorized 86 PD subjects in a brain bank population as either cognitively normal (PD‐CogNL), PD‐MCI using criteria that included a 1.5 standard deviation or greater deficit upon neuropsychological testing consistently across at least one cognitive domain without dementia, and PD dementia (PD‐D) using DSM‐IV criteria. Twenty‐one percent of our PD sample met criteria for PD‐MCI, 62% were PD‐CogNL, and 17% had PD‐D. The mean duration of PD and MMSE scores of the PD‐MCI group were intermediate and significantly different from both PD‐CogNL and PD‐D. The cognitive domain most frequently abnormal in PD‐MCI was frontal/executive dysfunction followed by amnestic deficit. Single domain PD‐MCI was more common than PD‐MCI involving multiple domains. We conclude that a stage of clinical cognitive impairment in PD exists between PD‐CogNL and PD‐D, and it may be defined by applying criteria similar to the MCI that is posited as a precursor of AD. Defining PD‐MCI offers an opportunity for further study of cognitive impairment in PD and targets for earlier therapeutic intervention.

Gambling and increased sexual desire with dopaminergic medications in restless legs syndrome

Objectives: Do patients with restless legs syndrome (RLS) report gambling or other abnormal behaviors as previously reported in Parkinson disease. Methods: This survey study was sent to 261 idiopathic RLS patients, and it included the Gambling Symptoms Assessment Scale, Altman Self-Rating Mania Scale, and questions pertaining to sexual activity and novelty-seeking behaviors. Results: Ninety-nine patients responded to the survey, and 77 were actively taking 1 or more dopaminergic medications. Of the 70 respondents who answered the gambling questions, 5 (7%) noted a change in gambling, with 4 (6%; 95% confidence interval, 2%-14%) stating that increased urges and time spent gambling occurred specifically after the use of dopaminergic medications (2 on pramipexole, 1 on ropinirole, and 1 on levodopa and pramipexole). Increased sexual desire was reported by 4 (5%) of the 77 respondents, 3 (4%; 95% confidence interval, 1%-11%) reported that this occurred specifically after the use of dopaminergic medications (1 on pramipexole, 1 on ropinirole, and 1 on levodopa). One patient reported both an increase in gambling and sexual habits. Conclusions: This exploratory survey study revealed the development of gambling and/or increased sexuality in patients with RLS. These data raise the possibility that, as in Parkinson disease, RLS patients should be cautioned about potential behaviors that may occur with the use of dopaminergic medications. Further prospective studies are needed to assess the relationship between these medications and compulsive behaviors associated with the treatment of RLS.

Robotic approach for ovarian cancer: perioperative and survival results and comparison with laparoscopy and laparotomy.

OBJECTIVE Comparison of perioperative outcomes and survival of patients undergoing primary surgical treatment for epithelial ovarian cancer (EOC) by a robotic, laparoscopy, or laparotomy approach. METHODS Retrospective case-control analysis of 25 patients with EOC undergoing robotic surgical treatment between March 2004 and December 2008. Comparison was made with similar patients treated by laparoscopy and laparotomy and matched by age, body mass index (BMI), and type of procedures between January 1999 and December 2006. RESULTS The mean operating times were 314.8, 253.8 and 260.7 min for robotic, laparoscopy and laparotomy patients, respectively (p<0.05); the mean blood loss was 164.0, 266.7, and 1307.0 ml, respectively (p=0.001); the mean length of hospital stay was 4.2, 3.2, and 9.4 days, respectively (p=0.001). The overall survival (OS) for robotics, laparoscopy and laparotomy patients was 67.1%, 75.6% and 66.0%, respectively (p=0.08). Patients were subdivided and compared according to the extent of surgery by the type and number of major procedures. Type I and II debulking patients operated by robotics and laparoscopy had improved perioperative outcomes as compared to laparotomy. For patients undergoing a type III debulking, robotic outcomes were not improved over laparotomy. CONCLUSION Laparoscopy and robotics are preferable to laparotomy for patients with ovarian cancer requiring primary tumor excision alone or with one additional major procedure. Laparotomy is preferable for patients requiring two or more additional major procedures. Survival is not affected by the type of surgical approach.

Natural History of Post-Liver Transplantation Hepatitis C: A Review of Factors That May Influence Its Course

Our aim was to assess long‐term survival in patients transplanted for HCV‐related end‐stage liver disease (ESLD) and evaluate potentially modifiable predictors of survival. We performed a retrospective analysis of adult liver transplants (LT) at our institution for HCV‐related ESLD since the programs inception. Pertinent demographic, clinical, and biochemical information was retrieved from electronic medical records and histological data from 990 per‐protocol liver biopsies were collected. Three hundred eighty LT were performed at our institution during the study period, 206 patients were transplanted for HCV‐related ESLD; 6 died within 30 days of transplantation and were not included. The remaining 200 recipients (DDLT 168 LDLT 32) constituted the evaluable population. The demographics were as follows: 150 males, median age 53 years; median donor age 39 years; hepatocellular carcinoma (HCC) in 26%. Overall 1‐, 5‐, and 7‐year survival: 95%, 81%, and 79%; median survival 43 months, mortality 15%. Significant HCV recurrence (HAI ≥6 and/or fibrosis ≥2) was present in 49%, “early recurrence” (within 1 year of LT) in 30.5% and biopsy‐proven acute rejection was present in 27%. Factors with a significant negative impact on patient survival included: fibrosis stage ≥2 at 12‐month biopsy, advanced donor age, history of HCC and early acute rejection. Survival was similar regardless of the donor type (DDLT vs. LDLT). Early and aggressive HCV recurrence has a very heavy toll on patient survival. Prompt recognition and treatment of “rapid fibrosers” may impart benefit. As has been described before, avoidance of rejection and selection of young donors for HCV‐positive recipients will also improve survival in this population. On the basis of our findings, LDLT is a good option for HCV‐positive recipients. Liver Transpl 15:1872–1881, 2009.

Incidental Lewy body disease: clinical comparison to a control cohort.

Limited clinical information has been published on cases pathologically diagnosed with incidental Lewy body disease (ILBD). Standardized, longitudinal movement and cognitive data was collected on a cohort of subjects enrolled in the Sun Health Research Institute Brain and Body Donation Program. Of 277 autopsied subjects who had antemortem clinical evaluations within the previous 3 years, 76 did not have Parkinsons disease, a related disorder, or dementia of which 15 (20%) had ILBD. Minor extrapyramidal signs were common in subjects with and without ILBD. Cognitive testing revealed an abnormality in the ILBD group in the Trails B test only. ILBD cases had olfactory dysfunction; however, sample size was very small. This preliminary report revealed ILBD cases have movement and cognitive findings that for the most part were not out of proportion to similarly assessed and age‐similar cases without Lewy bodies. Larger sample size is needed to have the power to better assess group differences.

Blood Management in Total Knee Arthroplasty: A Comparison of Techniques

Patients undergoing total knee arthroplasty (TKA) are at high risk for postoperative anemia and allogeneic blood transfusions. Risks associated with allogeneic blood exposure (ie, infection, fluid overload, and longer hospital stays) have prompted alternative blood management strategies. The main goal of this study was to evaluate whether a single change in the clinical blood management of patients undergoing TKA reduced the severity of postoperative anemia or the need for allogeneic blood transfusions. A second goal of this study was to assess the financial impact of the change on the institution. This study compared perioperative cell salvage, preoperative autologous blood donation, and the practice of using allogeneic blood alone in patients undergoing TKA. Clinical and financial data of 154 unique cases of primary TKA at the Mayo Clinic Arizona were retrospectively reviewed. Transfusion rates were 25%, 18%, and 52% respectively for patients in the cell salvage, preoperative autologous blood donation, and allogeneic blood only groups. Respective relative risk reductions were 51.9% (P=.007) and 65.4% (P=.002) with the use of cell salvage or preoperative autologous blood donation versus allogeneic alone. Cell salvage and preoperative autologous blood donation were found to significantly reduce the requirements for allogeneic blood transfusions; these techniques were found to be roughly equivalent in clinical benefit when compared to the use of allogeneic blood alone. The logistical advantages of cell salvage (ie, no preoperative blood donation, no risk of wasting blood units) were associated with greater costs to the institution.

Robotic adnexectomy compared with laparoscopy for adnexal mass.

OBJECTIVE: To evaluate whether the application of robotic technology in the performance of adnexectomy resulted in benefits for the patient when compared with patients operated by laparoscopy. METHODS: Evaluation of 85 patients undergoing robotic adnexectomy and comparison with a group of 91 patients operated on by laparoscopy during the same period of time and by the same surgeons. Patients were compared by age, body mass index (BMI), American Society of Anesthesiologists (ASA) physical status classification, indications, unilateral compared with bilateral adnexectomy, adhesions, size or weight or both of the adnexal mass, and previous abdominal or pelvic surgery. Univariate and multivariate analysis was used to determine factors favorable to each technique. Comparison between the groups was evaluated using the Fisher exact test from a one-way analysis of variance. RESULTS: The robotic group had an increased number of obese (BMI 30 or more) and higher anesthetic risk (ASA classification 2 and 3) patients as compared with laparoscopy patients. The mean operating time was 12 minutes longer in the robotic group (P=.01). The mean blood loss (80 mL robotic, 71 mL laparoscopic), length of hospital stay (0.15 days robotic, 0.28 days laparoscopic), intraoperative complications (1% robotic, 2% laparoscopic), and postoperative complications (12% robotic, 11% laparoscopic) were similar in both groups. CONCLUSION: Laparoscopy and robotics provided similar results for the performance of adnexectomy, with similar blood loss, intraoperative and postoperative complications, and length of hospital stay. Robotics mean operating time was 12 minutes longer. LEVEL OF EVIDENCE: II

Developing a Reproductive Life Plan

The purpose of this article is 2-fold: to emphasize the importance of a reproductive life plan and to define its key elements. We review the 2006 recommendations from the Centers for Disease Control and Prevention (CDC) regarding ways to improve the delivery of preconception health care to women in the United States, with particular focus on encouraging individual reproductive responsibility throughout the life span and on encouraging every woman to develop a reproductive life plan. We propose recommendations for the content of a reproductive life plan and explore ways to incorporate the guidelines from the CDC into clinical practice. By encouraging women to consider their plans for childbearing before they become pregnant, clinicians have the opportunity to influence behavior before pregnancy, which may decrease the incidence of unintended pregnancies and adverse pregnancy outcomes.

Hypoxia-induced changes in standing balance.

BACKGROUND A few studies in the literature have reported postural changes with hypoxia, but none have quantified the magnitude of change. Further understanding of this condition could have implications for patients at risk for falls, individuals undergoing acute altitude exposure, and pilots and commercial passengers. The objective of this study was to evaluate the effect of different levels of hypoxia (oxygen nitrogen mixtures) on postural standing balance using the computerized dynamic posturography (CDP) system. This improves upon previous protocols by manipulating vision and standing balance with a sway-referenced visual field and/or platform. Additionally, normative data were available for comparison with the cumulative test scores and scores for each condition. METHODS Altitude hypoxia was simulated by use of admixing nitrogen to the breathing gas to achieve equivalent altitudes of 1524 m, 2438 m, and 3048 m. Subjects were evaluated using the CDP system. RESULTS Subjects showed an overall trend toward decreased performance at higher simulated altitudes consistent with the initial hypothesis. Composite standing balance sway scores for the sensory organization subtest of CDP were decreased compared to baseline for simulated altitudes as low as 2438 m (mean sway scores: 81.92 at baseline; 81.85 at 1524 m; 79.15 at 2438 m; 79.15 at 3048 m). Reaction times to unexpected movements in the support surface for the motor control subtest (MCT) increased compared to baseline (mean composite scores: 133.3 at baseline; 135.9 ms at 1524 m; 138.0 ms at 2438 m; 140.9 ms at 3048 m). CONCLUSIONS The CDP testing provided a reliable objective measurement of degradation of balance under hypoxic conditions.

Insulation failure in robotic and laparoscopic instrumentation: a prospective evaluation

OBJECTIVE The purpose of this study was to detect the incidence, prevalence, and location of insulation failures (IFs) in laparoscopic and robotic instruments. STUDY DESIGN In phase A, a total of 78 robotic and 298 laparoscopic instruments were tested at 20 W and 2.64 kV at Mayo Clinic in Arizona. In phase B, 60 robotic and 308 laparoscopic instruments were tested at 20 W/1 kV and 20 W/4.2 kV, respectively. RESULTS In phase A, the robotic group showed a higher prevalence (25/78; 32%) and incidence of IFs after 10 uses (35/44 instruments; 80%) when compared with laparoscopy (prevalence, 39/298 [13%]; incidence, 68/189 [36%]; P<.05). In phase B, IFs were detected in 81.7% of the robotic instruments and in 19.5% of the laparoscopic instruments (P<.005). CONCLUSION There is a high incidence and prevalence of IF in endoscopic instrumentation that is more common in the robotic group.