Lege Artis Medicinae

[Let’s balance!]

NEMESÁNSZKY Elemér

OCTOBER 19, 2008

Lege Artis Medicinae - 2008;18(10)

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Clinical Neuroscience

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MAIHOUB Stefani, MOLNÁR András, CSIKÓS András, KANIZSAI Péter, TAMÁS László, SZIRMAI Ágnes

[Background – Dizziness is one of the most frequent complaints when a patient is searching for medical care and resolution. This can be a problematic presentation in the emergency department, both from a diagnostic and a management standpoint. Purpose – The aim of our study is to clarify what happens to patients after leaving the emergency department. Methods – 879 patients were examined at the Semmel­weis University Emergency Department with vertigo and dizziness. We sent a questionnaire to these patients and we had 308 completed papers back (110 male, 198 female patients, mean age 61.8 ± 12.31 SD), which we further analyzed. Results – Based on the emergency department diagnosis we had the following results: central vestibular lesion (n = 71), dizziness or giddiness (n = 64) and BPPV (n = 51) were among the most frequent diagnosis. Clarification of the final post-examination diagnosis took several days (28.8%), and weeks (24.2%). It was also noticed that 24.02% of this population never received a proper diagnosis. Among the population only 80 patients (25.8%) got proper diagnosis of their complaints, which was supported by qualitative statistical analysis (Cohen Kappa test) result (κ = 0.560). Discussion – The correlation between our emergency department diagnosis and final diagnosis given to patients is low, a phenomenon that is also observable in other countries. Therefore, patient follow-up is an important issue, including the importance of neurotology and possibly neurological examination. Conclusion – Emergency diagnosis of vertigo is a great challenge, but despite of difficulties the targeted and quick case history and exact examination can evaluate the central or peripheral cause of the balance disorder. Therefore, to prevent declination of the quality of life the importance of further investigation is high.]

Clinical Neuroscience

Vestibular evoked myogenic potential responses in Parkinson’s disease

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Background - Our objectives were to determine the differences in the vestibular evoked myogenic potential (VEMP) responses in patients diagnosed with early staged idiopathic Parkinson’s disease (PD) compared to the normal population and evaluate the vestibular system disorder causing balance-posture disorders. Second aim of this study was to investigate caloric test responses particularly in early staged PD compared to normal popu­lation. Material and methods - Thirty patients (14 females and 16 males; mean age, 60.6 ± 13.1 years) diagnosed with idiopathic PD and 28 healthy subjects (20 males and 8 females; mean age, 59.1 ± 6.4 years) were included. The patient and control groups were subdivided according to their age, gender and the patient group was subdivided according to onset time of the Parkinson symptoms, Hoehn-Yahr staging. The subgroups were compared for VEMP and caloric test responses. Results - There were no significant differences between the study and control groups for right and left VEMP measurements. Patients over 60 years and under 60 years did not show significant differences in terms of right and left mean VEMP measurements. However, P1 amplitude was significantly lower in patients over 60 years old (P = .004). Gender, disease duration, BERG balance scale and Hoehn-Yahr stage had no effect on the VEMP amplitudes. There was no significant correlation with the side of Parkinsonian symptoms to the side of canal paresis (P = .566) and the side on which no VEMP response was obtained in caloric test. Conclusion - VEMP responses were not different between PD and healthy subjects. VEMP P1 amplitude was decreased with age in PD group. Canal paresis and symptoms side were not statistically correlated in caloric test.

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[Cholesterol-lowering statins are the most tested medications in respect of the effects and side-effects. Based on these, we can safely claim that most of the negative opinions about cholesterol-lowering are not realistic. It is not a panacea, but it is proven that around a 30% of cardio- and cerebrovascular risk reducation can be achieved by their regular taking, while the incidence of side effects and risks are at least one order of magnitude lower in each patient groups. For cholesterol, there is no “normal” lab threshold or low level, only “target values”, since the mean value in the general population is high in regard of atherosclerosis (the values measured at birth and among natural people can be considered normal). Let us appreciate the cholesterol- lowering medications because we do not have a large armamentarium!]

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[The balance parameters and the loading symmetry was assessed in a subject with anterior cruciate ligament deficiency. A 14 days intensive training was performed mainly with eyes closed in closed kinematic chain exercises, loading the affected limb. Stabilometry and the assessment of loading symmetry was performed. The sway path was calculated in two direction. The sway path comparisons did not revealed significant differences only a tendency of decrease in anteroposterior direction. Interestingly we found an increased loading of the affected limb after our intensive training, with a mismatch between the subjective perceived symmetry and the objective symmetry data. The changed symmetry perception might be explained with the change in proprioceptive information processing induced by the training. In the future further examinations with higher case number are necessary to support this result. ]

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[How to evaluate clinical trials?]

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[Data from a clinical study should be always viewed with great care, and is recommended to examine and evaluate the data in-depth. First of all should be determined the evidence level of the trial’s results and what recommendations can be made based on them. The study’s type and the study design, the number of participating patients, statistical power, randomisation, stratifi cation, the balance between study arms, the endpoints and the adequacy of follow-up time should be examined. In addition the importance of the observed statistical signifi cance, the clinical relevance of the data and the real magnitude of the detected differences, and the time-dependent variables are worth to consider because these factors can determine the impact of the given clinical trial on the every-day clinical practice. In the era of the “creative study plans” a critical attitude is necessary to be convinced that the study does not contain any typical bias that could infl uence the real value and actual results of the trial.]