Role of endotoxin in the pathogenesis of critical illness polyneuropathy

Critical illness polyneuropathy (CIP) occurs in association with sepsis and multiple organ failure; however, little is known about the pathomechanisms of CIP and its therapy. In order to determine the parameters which interfere with development of CIP, electrophysiological investigations of peripheral nerves and biochemical measures were correlated to each other. The present study includes 20 consecutive patients in an intensive care unit developing severe sepsis or septic shock. Nerve conduction studies and electromyography were performed with occurring sepsis (day 1, 7, 14) and neurophysiological parameters were correlated with biochemical measures, especially indicators of infection and inflammation. It was found that all patients developed neurophysiological signs of axonal motor polyneuropathy. There was a significant correlation between serum concentrations of endotoxin and interleukin-2 receptors (IL2-R) and reduction of the amplitude of the compound motor action potentials. Other clinical and biochemical parameters showed no significant correlations with neurophysiological data. This finding apparently indicates that endotoxin damages nerve axons directly or indirectly, e.g. by activation of inflammatory cascades (IL2-R). Endotoxin appears to be an essential factor in the pathogenesis of CIP in sepsis, and therapeutic options neutralizing endotoxin may prevent development of CIP.

Electrodiagnostic criteria for diagnosis of ALS

A consensus meeting was held to determine the best use and interpretation of electrophysiological data in the diagnosis of ALS. The utility of needle EMG and nerve conduction studies was affirmed. It is recommended that electrophysiological evidence for chronic neurogenic change should be taken as equivalent to clinical information in the recognition of involvement of individual muscles in a limb. In addition, in the context of a suspected clinical diagnosis of ALS, fasciculation potentials should be taken as equivalent to fibrillation potentials and positive sharp waves in recognising denervation. The importance of searching for instability in fasciculation potentials and in motor unit potentials in ALS is stressed. These changes in the interpretation of electrophysiological data render obsolete the category Probable Laboratory-Supported ALS in the modified El Escorial diagnostic criteria for ALS. Methods for detection of upper motor neuron abnormality appear sensitive but require further study, particularly regarding their value when clinical signs of upper motor neuron lesion are uncertain.

Good practice in the management of amyotrophic lateral sclerosis: clinical guidelines. An evidence-based review with good practice points. EALSC Working Group

The evidence base for diagnosis and management of ALS is still weak, and curative therapy is lacking. Nonetheless, early diagnosis and symptomatic therapy can profoundly influence care and quality of life of the patient and relatives, and may increase survival time. This review addresses the current optimal clinical approach to ALS. The literature search is complete to December 2006. Where there was lack of evidence but consensus was clear we have stated our opinion as good practice points. We conclude that a diagnosis of ALS can be achieved by early examination by an experienced neurologist. The patient should be informed of the diagnosis by the consultant. Following diagnosis, a multi-diciplinary care team should support the patient and relatives. Medication with riluzole should be initiated as early as possible. PEG is associated with improved nutrition and should be inserted early. The operation is hazardous in patients with VC <50%: RIG may be a better alternative. Non-invasive positive pressure ventilation improves survival and quality of life but is underused in Europe. Maintaining the patient's ability to communicate is essential. During the course of the disease, every effort should be made to maintain patient autonomy. Advance directives for palliative end of life care are important and should be discussed early with the patient and relatives if they so wish.

Monitoring of circulating tumor cells during systemic therapy allows distinguishing breast cancer patients at risk for relapse

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Background: Recent refinement of methods, allowing detection of minimal numbers of residual cells from malignant tumors have reactivated the debate, to what extent single tumor cells in lymph nodes, bone marrow and peripheral blood can be considered as “micrometastases”. The presence of such cells, indeed, reflects only the first step in the metastatic process, dissemination, and the formation of metastases from such cells seems to be quite ineffective. If, however these cells react to therapy in an identical way as the tumor itself, these cells can be used to monitor therapy response very early during primary systemic (neoadjuvant) therapy, during adjuvant therapy, where no other target is available to control therapy success and already during therapy initiation in metastatic disease. Methods: Circulating epithelial cells were enumerated from 1 ml of anticoagulated blood after red blood cell lysis, staining of live cells with a fluorochrome labeled anti-epithelial antibody and automated microscopy before and after each chemotherapy cycle for monitoring of therapy success. Results: The response of the peripherally circulating cells of 35 patients with breast cancer treated with neoadjuvant chemotherapy varied from marginal (less than tenfold) to highly responsive (more than thousand fold) already during the first three to four courses and showed identical response to therapy as the whole tumor with a correlation of p > 0.9. The method was subsequently applied to monitor the response of such cells in the adjuvant treatment. In the first 25 patients with a follow up of more than 4 years, an increase in cell numbers already from the begin of therapy or following an initial response was observed in 20% of patients and all of these patients have subsequently relapsed (p<0,0001). These results have now been corroborated in a total of 148 patients, confirming a hazard ratio of 25 for relapse in the following 5 years for patients with increasing cell numbers during therapy independent of therapy regimen and a significance of p<0.0001. Conclusions: Quantitative monitoring of circulating tumor cells can be used as a tool for therapy survey in breast cancer in the absence of manifest tumor.

No significant financial relationships to disclose.