Eric Lewin Altschuler

Rehabilitation of hemiparesis after stroke with a mirror

2we have now done a larger trial of mirror therapy on patients with hemiparesis following stroke. All patients were at least 6 months post-stroke proven by computed tomography or magnetic resonance imaging (mean 4·8 years post-stroke, SD 8·2 years, range 6 months to 26·25 years), to preclude effects from spontaneous recovery. The patients gave written informed consent. The patients were randomly assigned to spend the first 4 weeks using a mirror or transparent plastic, and then crossed over to the other treatment for the next 4 weeks. We used mirrors sized 1824 inches (45 cm60 cm) made of plastic with a mirror coating, and transparent plastic sheets of the same size. Patients were put on a practice schedule of 15 min, twice a day, 6 days a week, moving both hands or arms symmetrically (moving the affected arm as best they could) while watching the good arm in the mirror, or the paretic arm through the clear plastic (figure). A “bootstrapping” approach was employed in designing regimens for patients, typically moving proximal to distal, working from movements patients could perform to those they could not. The patients were videotaped at 0, 2, 4, 6, and 8 weeks making all of the cardinal movements of the upper limb. Subjective comments were obtained from the patients, and the patients’ progress was assessed from the videotape by two senior neurologists from our team who were unaware of which treatment the patients used first, or the patients’ subjective comments, assessing the change from baseline in patients’ movement ability in terms of range of motion, speed, and accuracy using a ‐3 to +3 scale with 0 representing no change. Subjectively, all the patients liked using a mirror more than the clear plastic and felt that the mirror was more helpful than the plastic. One patient said that while “all my other methods of therapy exercise my muscles, the mirror is the only one which exercises my brain and nerves”. Another said he liked using the mirror and thought it was helpful because while using the mirror “it looks like my bad arm is moving normally,” even though it was not. Another patient characterised working with the mirror as “a blessing.” Both graders found that substantially more patients improved on mirror than on control (7-1 and 4-1, table). The mirror provides patients with “proper” visual input— the mirror reflection of the moving good arm looks like the affected arm moving correctly—and perhaps “substitutes” for the often decreased or absent proprioceptive input. Use of the mirror may also help recruit the premotor cortex to help with motor rehabilitation. 3

The use of visual feedback, in particular mirror visual feedback, in restoring brain function

This article reviews the potential use of visual feedback, focusing on mirror visual feedback, introduced over 15 years ago, for the treatment of many chronic neurological disorders that have long been regarded as intractable such as phantom pain, hemiparesis from stroke and complex regional pain syndrome. Apart from its clinical importance, mirror visual feedback paves the way for a paradigm shift in the way we approach neurological disorders. Instead of resulting entirely from irreversible damage to specialized brain modules, some of them may arise from short-term functional shifts that are potentially reversible. If so, relatively simple therapies can be devised--of which mirror visual feedback is an example--to restore function.

Gastric Helicobacter Pylori Infection as a Cause of Idiopathic Parkinson Disease and Non-Arteric Anterior Optic Ischemic Neuropathy

The mechanisms of pathogenesis for both idiopathic Parkinson disease and non-arteritic anterior optic ischemic neuropathy are unknown. A study has shown that, in both diseases, there is a higher prevalence of gastrointestinal ulcers than in age- and sex-matched controls or than in the reported rates for the general population. It is proposed that gastric Helicobacter pylori infection may be a cause of both these diseases.

Parvovirus B19 and the pathogenesis of rheumatoid arthritis: a case for historical reasoning

4found parvovirus B19 DNA by PCR in the synovium of 75% of patients with rheumatoid arthritis, but in only 17% of controls. Some studies have cast doubt on an association between parvovirus B19 and rheumatoid arthritis. Kerr and co-workers 5 reported parvovirus B19 DNA in the synovium of about 40% of patients with rheumatoid arthritis and in a similar proportion of controls, and Soderlund and colleagues 6 reported the presence of parvovirus B19 in 28% of patients with juvenile chronic

Pet-Facilitated Therapy for Posttraumatic Stress Disorder

It is suggested that pet-facilitated therapy might be a useful adjuvant on treatment of posttraumatic stress disorder. Some motivation and rationale for this idea is given, and a discussion of method of testing it.

Prospective, randomised trial of sleep deprived versus rested surgeons

1studied the proficiency and speed of surgeons using a virtual reality laparoscopic surgery system. They found that surgeons who had been deprived of sleep made about 20% more errors and took about 14% longer, than when rested. Unfortunately, these findings and those of other research 2 of negative effects of sleep deprivation have failed to curtail this common, and correctable, current medical practice. The work of Taffinder and colleagues can be considered as invitro evidence that a current medical practice—using surgeons who have not had much sleep—may be potentially hazardous. Furthermore, they provide a potential method to improve care, namely letting surgeons rest. However, the question remains of whether sleep deprivation causes worse clinical outcomes. Thus, following standard practice in other areas of medical research, a proper prospective trial should be done to study the question. Consider the following trial: “A

Compensational Strategies for a Merchant After Stroke With Anosognosia for Alexia Without Agraphia

We report the first case, to our knowledge, of successful return to work of a patient with alexia without agraphia. This case is also interesting as it is the first report of which we are aware of anosogosia for alexia without agraphia: the patient confabulated when asked to read English text, but immediately stated that he could not read Chinese text because he did not know that language. The selective nature of this confabulation would not be inconsistent with anosognosia being one of the brain’s responses to absence of afferent information.

Bupropion for Blau syndrome

Blau syndrome (BS) is an autosomal dominantly inherited disease characterized by granulomas and arthritis. The gene mutated in BS was recently found to be CARD15. Mutations in this gene also occur in about 20% of patients with Crohns disease (CD), though with different mutations than in the Crohns patients. We are not aware of any cure or specific treatment for BS. We have found that bupropion is effective for CD, and we now suggest that bupropion be considered for treatment of BS.

Mycophenolate mofetil, Crohn's disease, measles?

nancy (2–4). Our colleague Dr. Nimura and we have a lot of experience with extended hepatic resection for biliary tract cancer of the hepatic hilus (2). Moreover, we have adopted a policy of resecting all gross tumors, even though major hepatic resection along with pancreatoduodenectomy was necessary in patients with advanced carcinoma of the biliary tract involving adjacent vascular structures and intestinal organs, and have achieved unexpectedly good results (3, 4). We do not agree that the patient presented by Kadayifci et al. was diagnosed as having far advanced unresectable biliary cancer merely because the cholangiography-guided brush cytology disclosed cancer cells. A gallbladder cancer patient with direct hilar bile duct invasion is a good candidate for surgical treatment. Cytologically proven cancer cells should be considered as indicating the mere fact of the presence of the bile duct malignancy. It can never reveal the extent of the bile duct tumor spread, and gives us little information about its resectability. We use percutaneous transhepatic cholangioscopy (PTCS) and direct biopsy after bilateral percutaneous transhepatic biliary drainage (PTBD) for precise and careful histological diagnosis of the progress of cancer to each segmental duct, preoperatively, in every individual case (2). Moreover, the former method is useful to avoid unnecessary surgical intervention for nonmalignant lesions of the biliary tract, such as gallstones and intramural cysts (5). As regards our case (1), we must admit that the patient with gallbladder cancer combined with extrahepatic bile duct metastasis has a dismal prognosis, and that the operation had no effect on the patient’s survival. However, we believe that we improved her quality of life, as she could enjoy her remaining life without the biliary drainage tube connected to a collection system. Even if the placement of internal biliary stenting were possible in our patient, we could not resolve her right upper quadrant pain and fever, caused by cholecystitis resulting from the cystic duct obstruction. Although Dr. Kadayifci has suggested the usefulness of the brush cytology for our patient, we would not abandon the resection of the lesion regardless of the results of the cytological study. Extrahepatic bile duct cancer combined with acute cholecystitis can never be distinguished from metastatic bile duct tumor based on brush cytology. We regard the former as a good candidate for surgical resection. Although the extended operations for advanced biliary tract cancers are still challenging, we believe that operation indications for carcinoma of the biliary tract should be carefully re-examined, taking into consideration the fact that aggressive surgery could offer unexpectedly long survival.

Can You Do This? Extremely Difficult Interbodypart Coordination Tasks and Implications for Central Limitations on Control of Coordination:

We have recently noticed our own inability to perform a number of interbodypart coordination tasks. The inability to perform these tasks indicates an intriguing central processing limitation on movement control, and study of these tasks should be helpful in understanding the neural mechanisms of motor control.