Levent E. Inan

Respiratory muscle training improves cardiopulmonary function and exercise tolerance in subjects with subacute stroke: a randomized controlled trial

Objective: To determine whether two types of exercise — breathing retraining (BRT) and inspiratory muscle training (IMT) — improve on cardiopulmonary functions and exercise tolerance in patients with stroke. Design: A randomized controlled trial. Setting: Education and research hospital. Subjects: Forty-five inpatients with stroke (24 men, 21 women) were recruited for the study. The subjects were randomized into three groups: 15 assigned to receive inspiratory muscle training (IMT); 15 assigned to received breathing retraining, diaphragmatic breathing and pursed-lips breathing (BRT); 15 assigned to a control group. Interventions: All study groups participated in a conventional stroke rehabilitation programme. For the same period, the IMT and BRT groups trained daily, six times a week, with each session consisting of one half-hour of training for six weeks. Main measures: Each subject underwent pulmonary function and cardiopulmonary exercise tests. Subjects were also assessed for exertional dyspnoea, stages of motor recovery, ambulation status, activity of daily living and quality of life. Results: After the training programme, the IMT group had significantly improved forced expiratory volume at 1 second (FEV1), forced vital capacity (FVC), vital capacity (VC), forced expiratory flow rate 25—75% (FEF 25—75%) and maximum voluntary ventilation (MVV) values compared with the BRT and control groups, although there were no significant differences between the BRT and control groups (P<0.01). Peak expiratory flow rate (PEF) value was increased significantly in the BTR group compared with the IMT and control groups. The IMT group also had significantly higher peak oxygen consumption (Vo2peak) than the BRT and control groups, although there were no significant differences between the BRT and control groups (P<0.001). There was a statistically significant increase in maximum inspiratory pressure (PImax) and maximum inspiratory and expiratory pressure (PEmax) in the BRT group and, PImax in the IMT group compared with baseline and the control group. In the IMT group, this was associated with improvements in exercise capacity, sensation of dyspnoea and quality of life. Conclusions: Significant short-term effects of the respiratory muscle training programme on respiratory muscle function, exercise capacity and quality of life were recorded in this study.

Predisposing factors of restless legs syndrome in pregnancy

The occurrence of restless legs syndrome in pregnancy is well known. However, the mechanism of this association is unclear. In this study, we aimed to identify the factors that predispose women to have restless legs syndrome during pregnancy. A total of 146 pregnant women were included in the study. Patients were asked questions regarding demographic characteristics, complications of pregnancy, medical therapy (vitamin and iron intake), sleep disorders, muscle cramps, and excessive daytime sleepiness. Electroneurography, routine blood biochemistry tests, complete blood count, and thyroid function tests were performed and vitamin B12, folic acid, serum iron, iron‐binding capacity, ferritin, iron saturation, prolactin, estradiol, and progesterone were measured. Of the participants, 38 were diagnosed as having restless legs syndrome. In women with restless legs syndrome, additional medical problems, night cramps, and excessive daytime sleepiness were more frequent. In women without restless legs syndrome, serum hemoglobin levels were significantly higher and the use of supplemental iron or vitamins was greater. Among the women with restless legs syndrome, progesterone levels were slightly higher but this difference was not statistically significant. In summary, in this study, lower hemoglobin levels and supplementation deficits of iron and vitamins were found be the risk factors for restless legs syndrome in pregnancy.

Oxidative and nitrosative stress in acute ischaemic stroke

Background: Increased nitric oxide (NO) production may result in further brain damage via nitric oxide synthase uncoupling in patients with acute ischaemic stroke by increasing free radical formation and oxidative stress. In this connection, we measured nitrite and nitrate (NO metabolites), ischaemia-modified albumin (IMA) and thiobarbituric acid-reactive substances (TBARS) in patients with ischaemic stroke. Methods: We studied 41 patients with ischaemic stroke (22 men and 19 women, aged 65-13 years) and 37 age- and sex-matched controls (22 men and 15 women, aged 65-8 years). Blood samples were drawn within the first 24 h from the onset of symptoms in the patient group. Fasting morning samples were used in the control group. Concentrations of nitrite and nitrate were determined by Griess reagent; concentrations of IMA were determined by the albumin cobalt-binding test; and concentrations of TBARS were determined colorimetrically by thiobarbituric acid. Results: Nitrate, IMA and TBARS concentrations were significantly increased compared with controls (P<0.005, P<0.001, and P=0.01, respectively). Conclusions: Patients with acute ischaemic stroke exhibit abnormalities in a range of markers of increased nitrosative and oxidative stress. These abnormalities may contribute to greater brain damage in patients with acute ischaemic stress.

Levetiracetam monotherapy for late poststroke seizures in the elderly

Stroke is the most common cause of seizures in the elderly. Antiepileptic drugs are used to treat most patients with late poststroke seizures. The aim of this study was to evaluate the efficacy and tolerability of levetiracetam (LEV) in patients aged 60 or older with late-onset poststroke seizures. This prospective study evaluated patients 60 years of age or older, who had at least two late-onset poststroke seizures and were given LEV monotherapy. Demographic data and seizure and stroke characteristics were recorded. Outpatient visits were made after 2, 4, 6, 9, and 12 months and every 3 months thereafter, and the effectiveness and tolerability of LEV were investigated. Thirty-four patients with a mean age of 69.76+/-6.41 were included in this study. Average seizure frequency before treatment was 3.61+/-3.02/month. Mean follow-up time was 17.68+/-3.24 months. At daily doses of 1000-2000 mg, 82.4% of the patients were seizure free, and 7 patients (20.6%) had side effects. LEV was discontinued in one patient because of severe somnolence. Two patients were switched to another antiepileptic drug because of uncontrolled seizures despite an increase in dose up to 3000 mg/day. LEV monotherapy can be effective and well tolerated in elderly patients with late-onset poststroke seizures.

Intravenous theophylline decreases post-dural puncture headaches.

Post-dural puncture headache (PDPH) is a common complication of lumbar puncture. As invasive treatments for PDPH have known complications, pharmacologic management may be preferable. The aim of this study was to evaluate and to compare the efficacy of intravenous theophylline treatment for PDPH, in comparison with a placebo. We found that intravenous theophylline infusion was effective for decreasing the painfulness of PDPH compared with the control group. The mean visual analogue scale (VAS) value was 7.05+/-1.47 before the theophylline infusion and 2.88+/-2.31 after infusion. An average of 59.1% relief of pain was obtained in the group treated with theophylline infusion. The improvement in VAS in the study group was significant (p < 0.001), whereas that in the control group was not (p = 0.15). The mean VAS decrease after theophylline infusion was 4.17+/-2.03 in the study group and 0.41+/-0.71 in the control group; the difference in improvement between the groups was significant (p < 0.001). Intravenous theophylline infusion is an easy, rapid, minimally invasive, an effective treatment for PDPH. It may be attempted in PDPH patients before invasive techniques are used. To the best of our knowledge, this is the first report on the effect of intravenous infusion of theophylline compared with a placebo in the treatment of PDPH.

Peripheral nervous system involvement in patients with Behçet disease.

Background:Central nervous system involvement in Behçet disease (BD) has been well documented, but studies evaluating peripheral nervous system involvement are relatively uncommon. Objective:The aim of this study is to evaluate the frequency and characteristics of peripheral nervous system involvement in BD. Methods:Sixty-nine BD patients (36 women, 33 men) followed by neurology and dermatology outpatient clinics between October 1999 and October 2004 were enrolled into study. A careful history was taken and physical and neurologic examinations were done. All other medical causes that may be related to peripheral nervous system involvement were studied. All patients underwent nerve conduction studies using standard electrophysiologic procedures. Results:Peripheral nervous system involvement was detected in 13 patients. There was no sign and symptom related to peripheral nervous system involvement in these patients. Causes other than BD were found in 5 patients with polyneuropathy. Asymptomatic delay in conduction velocities of the median nerves was detected in 3 patients. In 5 patients with clinically evident peripheral nerve involvement due to BD, 3 had sensorimotor and 2 had sensory axonal neuropathies. Conclusion:Axonal type polyneuropathy may be seen in BD patients. Peripheral involvement may be detected by electrophysiological examinations in asymptomatic BD patients.

Headaches in the different phases of relapsing-remitting multiple sclerosis: a tendency for stabbing headaches during relapses.

Introduction:Primary headaches are known to be associated with multiple sclerosis. We aimed to determine headaches using ICHD-II in different phases of relapsing-remitting multiple sclerosis, and the correlation between headaches and several features of the disease. Results:Migraine (41.2%) and tension-type headaches (20.6%) were the most common headaches in remission, and primary stabbing headache (PSH) (27.8%) was common in the relapsing phase. Although headaches seemed to occur independently of disease duration, extended disability status scale, beck depression inventory scores, and treatments, the total number of headaches was correlated with periventricular lesions (P = 0.03) and tension-type headaches were correlated with spinal lesions in remission (P = 0.02). Total number of headaches was correlated with brain stem lesions in the relapsing phase (P = 0.05). Conclusion:The high frequency of PSHs in relapse was notable, and, to the best of our knowledge, PSH was not reported in relapsing-remitting multiple sclerosis before. Further studies with larger samples are recommended.

Urinary 8-hydroxy-2′-deoxyguanosine level and plasma paraoxonase 1 activity with Alzheimer’s disease

Abstract Background: Alzheimer’s disease (AD) is the most frequent cause of dementia and age is the most important risk factor for AD. Aging is associated with increased free radical production and oxidative stress plays an important role in the pathogenesis of AD. 8-Hydroxy-2′-deoxyguanosine (8-OHdG) is a biomarker indicating oxidative DNA damage. Paraoxonase 1 (PON1) is a high-density lipoprotein (HDL)-associated antioxidant enzyme and prevents especially oxidation of low-density lipoproteins. The aim of this study is to measure urinary 8-OHdG levels and serum PON1 activity in patients with AD. Methods: A total of 21 elderly patients diagnosed with moderate AD (10 men and 11 women, aged 76±7.8 years) were included in the study. A total of 20 healthy elderly volunteers (11 men and nine women, aged 81±7.2 years) were enrolled as a control group. Levels of urinary 8-OHdG, serum PON1 activity and lipid profile were determined in patients and controls. Results: Urinary 8-OHdG levels were significantly increased, but serum PON1 activity was significantly decreased in patients compared to controls. Lipid profile did not show a difference between the groups. There was a negative correlation between 8-OHdG levels and PON1 activity only in the patient group (r=–0.536). Analytical performance characteristics of the methods used were satisfactory. Conclusions: In this study, evidence of increased oxidative DNA damage was determined in AD patients as well as decreased serum PON1 activity. Oxidant stress and oxidative DNA damage are important pathological processes in AD. The biomarkers, urinary 8-OHdG level and serum PON1 activity can be used to determine and monitor the status of patients with AD.

Different clinical manifestations of hyperammonemic encephalopathy

Valproate is an effective anticonvulsant. Although it is usually well tolerated, it has been associated with many neurological, hematopoietic, hepatic, and digestive system side effects. Among these side effects, hyperammonemia without clinical or laboratory evidence of hepatotoxicity is rare and is an important clinical consideration. The aim of this article was to evaluate the reasons for the unexpected symptoms observed in seven patients with epilepsy patients during valproate treatment. We evaluated seven adult patients with localization-related epilepsy who presented with different acute or subacute neurological symptoms related to valproate-induced hyperammonemic encephalopathy. Four of the seven patients had acute onset of confusion, decline in cognitive abilities, and ataxia. Two had subacute clinical symptoms, and the other patient had symptoms similar to those of acute toxicity. These unusual clinical symptoms and similar cases had not been reported in the literature before. Serum ammonia levels were elevated in all seven patients. After discontinuation of valproate, complete clinical improvement was observed within 5-10 days. On the basis of our work, we suggest that the ammonia levels of a patient who has new neurological symptoms and has been taking valproate must be checked. Clinicians should be aware that these clinical symptoms may be related to valproate-induced hyperammonemic encephalopathy. The symptoms have been observed to resolve dramatically after withdrawal of the drug.

Greater occipital nerve blockade in migraine, tension-type headache and cervicogenic headache

Abstract The blockade of the greater occipital nerve (GON) has been used in the treatment of migraine without aura (MWOA), tension-type headache (TTH) and cervicogenic headache (CH). There have been only a few reports about the effectiveness of the GON blockade in patients with MWOA and TTH and it has not yet been clarified whether or not it is a diagnostic tool for CH. In this study, we therefore investigated the diagnostic value of GON blockade in patients with CH, MWOA and TTH. Sixty patients who were affected by TTH, MWOA and CH participated in the study. They were divided into three main groups, each of which consisted of 20 patients with TTH, MWOA and CH respectively. Each group was then divided into two sub-groups with 10 patients, ten of whom were injected with 1 ml 2% prilocaine, and the other ten with 1 ml physiological saline (PS). Our results showed that GON blockade reduced pain in the orbitofrontal (OF) and orbitonuchal (ON) areas in patients with CH. In MWOA and TTH patients, GON blockade reduced pain only in the ON area. In the light of these findings, we may conclude that GON blockade is a diagnostic tool if it is effective in the ON and OF areas.