High dose vitamin E therapy in amyotrophic lateral sclerosis as add-on therapy to riluzole: results of a placebo-controlled double-blind study

Increasing evidence has suggested that oxidative stress may be involved in the pathogenesis of amyotrophic lateral sclerosis (ALS). The antioxidant vitamin E (alpha-tocopherol) has been shown to slow down the onset and progression of the paralysis in transgenic mice expressing a mutation in the superoxide dismutase gene found in certain forms of familial ALS. The current study, a double blind, placebo-controlled, randomised, stratified, parallel-group clinical trial, was designed to determine whether vitamin E (5000 mg per day) may be efficacious in slowing down disease progression when added to riluzole.

METHODS

160 patients in 6 German centres with either probable or definite ALS (according to the El Escorial Criteria) and a disease duration of less than 5 years, treated with riluzole, were included in this study and were randomly assigned to receive either alpha-tocopherol (5000 mg per day) or placebo for 18 months. The Primary outcome measure was survival, calculating time to death, tracheostomy or permanent assisted ventilation, according to the WFN-Criteria of clinical trials. Secondary outcome measures were the rate of deterioration of function assessed by the modified Norris limb and bulbar scales, manual muscle testing (BMRC), spasticity scale, ventilatory function and the Sickness Impact Profile (SIP ALS/19). Patients were assessed at entry and every 4 months thereafter during the study period until month 16 and at a final visit at month 18. Vitamin E samples were taken for compliance check and Quality Control of the trial. For Safety, a physical examination was performed at baseline and then every visit until the treatment discontinuation at month 18. Height and weight were recorded at baseline and weight alone at the follow-up visits. A neurological examination as well as vital signs (heart rate and blood pressure), an ECG and VEP's were recorded at each visit. Furthermore, spontaneously reported adverse experiences and serious adverse events were documented and standard laboratory tests including liver function tests performed. For Statistical Analysis, the population to be considered for the primary outcome measure was an "intent-to-treat" (ITT) population which included all randomised patients who had received at least one treatment dose (n = 160 patients). For the secondary outcome measures, a two way analysis of variance was performed on a patient population that included all randomised patients who had at least one assessment after inclusion.

RESULTS

Concerning the primary endpoint, no significant difference between placebo and treatment group could be detected either with the stratified Logrank or the Wilcoxon test. The functional assessments showed a marginal trend in favour of vitamin E, without reaching significance.

CONCLUSION

Neither the primary nor the secondary outcome measures could determine whether a megadose of vitamin E is efficacious in slowing disease progression in ALS as an add-on therapy to riluzol. Larger or longer studies might be needed. However, administration of this megadose does not seem to have any significant side effects in this patient population.

Durch Zecken übertragene humanpathogene und bisher als apathogen geltende Mikroorganismen in Europa

The importance of tick-borne diseases has significantly increased objectively and subjectively during the last few years. This fact was demonstrated by the description of tick-borne viruses, in particular with respect to tickborne encephalitis published in part I. Here in part II, tick-borne bacteria and parasites will be discussed as well the significance of these agents, their vectors, clinical course, diagnostics, prophylaxis, and therapy. Naturally, Lyme borreliosis, one of the most important tick-borne bacterial illnesses of humans, is the center of our interest. In addition to basic understanding, critical practice-relevant advice regarding all agents is presented. Similarly all tick-borne bacterial diseases such as relapsing fever, tularemia, ehrlichiosis, and rickettsiosis including Q fever will be discussed. Tick-borne zoonotic babesiae are parasites whose veterinary importance has been known for the last 100 years but whose relevance for human medicine only became evident in 1957. The fact that multiple and mixed infections caused by ticks are possible has been known for years. Taking into account such a high prevalence of the infectious agents in ticks, such multiple infections were to be expected. During the last few years it has become evident that double and multiple infections of humans caused by tick bites occur far more frequently than has been known so far. As a result, in cases of unclear anamnesis,new diagnostic and therapeutic approaches should be taken. In general one can say that considerable additional scientific research is necessary to effectively reduce the incidence of tick-borne diseases.

Analysis of gyrA mutations in quinolone-resistant and -susceptible Campylobacter jejuni isolates from retail poultry and human clinical isolates by non-radioactive single-strand conformation polymorphism analysis and DNA sequencing

AIMS

The aims of this study were to characterize the molecular variations in the quinolone resistance-determining region (QRDR) of gyrA among quinolone-resistant and -susceptible Campylobacter jejuni isolates originating from foods of animal origin and human infections and to evaluate the suitability of the single-strand conformation polymorphism (SSCP) method as a screening method for molecular characterization of fluoroquinolone resistance.

METHODS AND RESULTS

Alterations in QRDR of gyrA from 182 C. jejuni isolates were determined by nonradioisotopic SSCP analysis and direct sequencing. A total of 13 types of nucleic acid sequence combinations within the QRDR of the gyrA gene resulted in 11 different SSCP patterns. All nalidixic acid resistant strains possessed nucleotide substitution at either codon Thr-86 or Asp-90. Silent mutations were detected additionally. Thr-86 to Ile mutation was detected in all 139 ciprofloxacin resistant strains, which showed cross-resistance to nalidixic acid.

CONCLUSIONS

The SSCP method is suitable for a molecular screening of quinolone resistant C. jejuni isolates and in combination with DNA sequencing suitable to detect genetic variations of the QRDR of gyrA.

SIGNIFICANCE AND IMPACT OF STUDY

This study provides data of the genetic variations of the QRDR of gyrA from C. jejuni isolates of foods and human beings.

Topoisomerase IIα expression in mantle cell lymphoma: a marker of cell proliferation and a prognostic factor for clinical outcome

Mantle cell lymphoma (MCL) is a malignant lymphoma associated with a relatively aggressive clinical course and a median overall survival time of 3-4 years. Treatment usually consists of combination chemotherapy, often including topoisomerase (topo) inhibitors such as doxorubicin, etoposide and mitoxantrone. Topo IIalpha is an enzyme that is needed whenever uncoiling of DNA is necessary during the cell cycle. The enzyme is a marker of cell proliferation. We analyzed the expression of topo IIalpha in relation to Ki-67 and the clinical outcome in patients with MCL. Biopsy specimens from 95 untreated patients enrolled in two multicenter trials (1975-1985) were investigated immunohistochemically with monoclonal antibodies against topo IIalpha (Ki-S4) and Ki-67 (Ki-S5). Patients with low (0-10%) topo IIalpha expression had a median overall survival time of 49.0 months, compared to 17.0 months for patients with high (more than 10%) topo IIalpha expression. The Kaplan-Meier analysis showed a significant difference in the overall survival time related to the percentage of topo IIalpha (P<0.001) and Ki-67 (P<0.001) positive tumor cells. Multivariate Cox regression analysis revealed the expression of topo IIalpha as the most important prognostic factor (P<0.001) in MCL superior to the international prognostic index (IPI), the Ki-67 index and other clinical characteristics.

Durch Zecken �bertragene humanpathogene und bisher als apathogen geltende Mikroorganismen in Europa

The importance of tick-borne encephalitis (TBE) and Lyme borreliosis-the main European tick-borne diseases-is steadily growing. This fact is due to many different factors including climate changes. However, across Europe many other human pathogenic viruses, bacteria, and parasites are found in ticks. This article gives an overview of tick-borne human pathogenic viruses present in Europe as well as those considered nonpathogenic. It also deals with the various species of vector-competent ticks. Among these ticks, viruses from 6 families encompassing 8 genera and 35 species are found,whereby the families Flaviviridae, Bunyaviridae, and Reoviridae with the genera flavivirus, nairovirus, and orbivirus are the most prevalent. Because of their special importance Omsk hemorrhagic fever, louping-ill disease, tick-borne encephalitis, and Crimean-Congo hemorrhagic fever are discussed in detail. Although West Nile virus is mainly transmitted to man by mosquitoes, it is discussed in detail, because West Nile fever has become a good example for a new and rapidly spreading vector-borne disease in the USA and for a recurrent one in Europe. Secondly, besides the mosquito-bird cycle an interesting tick--bird cycle is emerging. The overview clearly demonstrates that in Europe (particularly in Germany) tick-borne viruses, with the exception of TBE, constitute an extremely ignored research subject. This lack of attention is in contrast to their importance and results in a lack of necessary scientific data.

Value of micro-CT as an investigative tool for osteochondritis dissecans

PURPOSE

To evaluate micro computed tomography (micro-CT) for the assessment of osteochondritis dissecans in comparison with histology.

MATERIAL AND METHODS

Osteochondritis dissecans lesions of 3 patients were evaluated using micro-CT (0.125 mA, 40 keV, 60 microm slice thickness, 60 microm isotropic resolution, entire sample) and light microscopy (toluidine blue, 3-5 microm slice thickness). The methods were compared regarding preparation time, detectability of tissue types and morphologic features of bone and cartilage.

RESULTS

Non-destructive micro-CT imaging of the entire sample was faster than histologic preparation of a single slice for light microscopy. Morphologic features of bone and cartilage could be imaged in a comparable way to histology. It was not possible to image cells or different tissue types of bone and cartilage with micro-CT.

CONCLUSION

Micro-CT is a fast, non-destructive tool that may be a supplement or, if detailed histologic information is not necessary, an alternative to light microscopy for the investigation of osteochondritis dissecans.

[Studies on the importance of tick-borne encephalitis in Rhineland-Pfalz]

Within the scope of a prospective clinical study during 2001 in Rhineland-Palatinate specimen from sera and cerebrospinal fluids of 163 patients with suspected meningitis were controlled in an enzyme immunoassay concerning a TBE infection. Questionable results were checked via a neutralisation test. In no case such an infection was confirmed. No virus specific nucleic acids could be detected in 998 nymphs and adults of Ixodes ricinus in an additional investigation in 2000. Therefore Rhineland-Palatinate has to be considered as a region with low virus prevalence. A general recommendation for vaccination is not necessary.

Effects of subthalamic nucleus (STN) stimulation on motor cortex excitability

BACKGROUND

Deep brain stimulation of the internal global pallidus (GPi) and the subthalamic nucleus (STN) has become a treatment alternative in advanced PD. Although the effects of GPi stimulation have been examined recently, little is known about STN stimulation effects on motor cortex excitability.

METHODS

The effects of STN stimulation were studied in eight patients with advanced PD using paired-pulse transcranial magnetic stimulation (TMS) in comparison with healthy control subjects. Motor evoked potentials following paired-pulse TMS (interstimulus interval 3 ms to test for corticocortical inhibition vs 13 ms for facilitation) have been recorded from the extensor carpi radialis and its functional antagonist, the flexor carpi radialis muscle. Silent period (SP) was also determined. Patients were examined under four conditions: medication "off"/stimulator "off" vs medication "on"/stimulator "off" vs medication "off"/stimulator "on" vs medication "on"/stimulator "on."

RESULTS

Although the mean values for intracortical inhibition (ICI) were not significantly different, data variation was smaller and levels of significance higher with the STN stimulator switched "on," suggesting that ICI was more consistent. SP during stimulator "on"/medication "on" was longer than during stimulator "off"/medication "off." Motor performance as indicated by a finger-tapping test and Unified PD Rating Scale III was significantly better with dopaminergic medication and further improved with stimulator "on."

CONCLUSIONS

Results suggest an effect of subthalamic nucleus stimulation on intracortical inhibitory mechanisms. This hypothesis could at least partially explain a more consistent depression of motor evoked potentials following inhibiting paired-pulse transcranial magnetic stimulation, a longer silent period (under stimulator "on"/medication "on"), and a reduction of akinesia and rigidity leading to a better motor performance in subthalamic nucleus-stimulated patients.

Annual and seasonal variation of tick-borne encephalitis virus (TBEV) prevalence in ticks in selected hot spot areas in Germany using a nRT-PCR: results from 1997 and 1998

The prevalence of tick-borne encephalitis virus (TBEV) in Ixodes ricinus tick populations in endemic areas of Germany with the highest TBE risk is unknown. Annual and seasonal differences in TBEV prevalence have also not been studied. Against this background, in May 1997 we started a systematic virus surveillance programme in ticks collected in locations known to have a high incidence of autochthonous TBE cases. These were 5 locations in Baden-Württemberg (Black Forest) and 8 locations in Bavaria (surrounding Passau). Field-collected ticks were randomly assigned to pools of 10 adults or 20 nymphs, respectively. The tick pools were tested for the presence of TBEV-RNA using a newly developed, sensitive nested reverse transcriptase polymerase chain reaction assay (nRT-PCR). The primer pairs were selected from the 5'-terminal noncoding region, a highly conserved part of the virus. The specificity was tested by computer homology searches of sequences, as well as by sequencing of the first and the second amplificates, by Southern blot hybridisation with a DIG-labelled oligonucleotide probe, and by restriction enzyme analysis. The method has proved to be very sensitive, with a detection limit of 20 fg of TBEV RNA per PCR run, or a single positive tick. Based on biostatistical considerations a sample size of at least 1000 ticks per estimation point was chosen. The estimated TBEV prevalence and confidence intervals (CI) were calculated from the nRT-PCR results of pooled samples (10 adults or 20 nymphs) using appropriate formulae for pooled testing. In order to identify the estimated TBEV prevalence as well as to assess the influence of annual and seasonal factors on TBEV prevalence, ticks were sampled twice a year (May and September) in 1997 and 1998 at exactly identical sites. These sites were selected because they were known to have had the highest incidence of autochthonous TBE cases during the previous 10 years. On sampling days, relevant local meteorological data were also noted. In total, 8500 I. ricinus ticks were investigated in this study, 4270 (3540 nymphs, 730 adults) from the Black Forest habitats, and 4230 (3680 nymphs, 550 adults) from the Bavarian locations. In the foci near Freiburg (Black Forest), the estimated virus prevalence was relatively high in the whole tick population, during 1997 with only slight seasonal differences [3.4% (confidence interval, CI, 2.3-4.8%) in May and 2.9% (CI 1.7-4.5%) in September]. In contrast, in 1998, in the same foci the estimated TBEV prevalence was considerably lower [1.1% (CI 0.5-2.0%) in May and 0.6% (CI 0.2-1.4%) in September]. Thus, while the seasonal differences again remained low, the annual variation was marked. In the Bavarian foci in 1997, the estimated virus prevalence of the whole tick population studied was lower than in the Black Forest foci and the seasonal fluctuations were low: in May 1997 0.9% (CI 0.4-1.8%) of the ticks were positive, in September 1.1% (CI 0.5-1.9%). In 1998, in May 2.0% (CI 1.1-3.3%) of the ticks were positive, and in September 1.1% (CI 0.5-2.1%). For the whole study period, every 50th to 100th I. ricinus nymph or adult in the Passau region was calculated to give a positive signal in the nRT-PCR. The TBEV prevalence data indicate that residents and visitors of areas in Germany known for high endemic activity take a significant risk of contracting TBEV infection, if bitten by ticks. In addition, the data suggest that annual fluctuations may exist in the whole tick population studied. Seasonal fluctuations of the virus prevalence in ticks were small.

Step-by-step description of a rotary root canal preparation technique

CLINICAL TECHNIQUE: Since the introduction of nickel-titanium in endodontics, several canal preparation techniques involving the use of rotary instruments have become popular. Such engine-driven rotary instruments rotate between 150 and 2000 r.p.m. and may be high or low torque orientated. This paper describes one such engine-driven system called the ProFile technique. The instruments are of a different specification to that used for conventional endodontic files and reamers. This paper describes a technique employed by the Division of Endodontology, Zurich Dental School, in a step-by-step procedure using primarily photographs of radiographs. The intention is to give any interested clinician a better idea of the technique using radiographs taken from both the buccolingual (clinical) perspective and the mesiodistal projection. Basically, the technique involves preparing the coronal portion of the root canal using Gates-Glidden burs and the ProFile instruments. Only when any constricting coronal parts of the canals have been removed is the working length established using conventional files. Finally, the apical part of the canal is prepared using only the ProFile instruments. Three clinical cases are also briefly described, in order to illustrate the potential of the technique in cases treated generally by clinicians.

A nested RT-PCR for the detection of tick-borne encephalitis virus (TBEV) in ticks in natural foci

We have developed a sensitive nested reverse-transcriptase polymerase chain reaction assay (n RT-PCR) for the detection of the tick-borne encephalitis virus (TBEV) RNA, especially in ticks. The primer pairs were selected from the 5'-terminal noncoding region, a highly conserved part of the virus. The specificity was tested by computer homology searches of sequences as well as by the sequencing of the first and second amplificate, by Southern blot hybridization with a DIG-labelled oligonucleotide probe, and by restriction enzyme analysis. The method has proved to be very sensitive. The detection limit is about 20 fg of TBEV RNA per PCR run (25 microliters), or a single positive tick, i.e. (adult or nymph). The method can be used for comparative studies of the epidemiological situation, as well as for the screening of natural foci for the presence and circulation of TBEV or for the detection of TBEV-genome-sequences in clinical materials.

Evaluating the sizes of Lightspeed instruments

The diameters of six different sized Lightspeed cutting heads were measured using a modified optical micrometer. Six specimens of instrument sizes 20, 22.5, 27.7, 30, 32.5 and 45 were examined. Except for one cutting head of size 30, all the recorded diameters were oversized compared to the expected diameter and the permitted tolerance (+/- 0.005 mm). Perfectly machined instruments would increase by 12.5%, 9.09% and 8.3% from instrument sizes 20-22.5, 27.5-30 and 30-32.5, respectively. Under the conditions of this study, the corresponding increases were 7.1%, 6.75% and 8.54%. Instrument size 20 had the widest range and is the smallest instrument in the Lightspeed set. The largest differences between the recorded and expected means were registered for the size 45 group. An earlier study using a different measuring method reported that Lightspeed instruments were mostly undersized.

Viral zoonosis from the viewpoint of their epidemiological surveillance: tick-borne encephalitis as a model

Tick-borne encephalitis (TBE) is a vector borne and, more rarely, a food (milk, milk products) borne disease of humans. For further characterization of the virus activity in natural foci of TBE more than 32,000 unengorged wild ticks were caught in low and high virus active foci in Germany (Mecklenburg-Western Pomerania, Saxony, Brandenburg, Thuringia, Bavaria, Baden-Württemberg, Saarland). The ticks were examined by RT-PCR and Southern blot hybridization as well as by classical virological methods. The dynamics of such natural foci of TBE in the last 35 years were discussed. Also nucleotide sequence data of parts of the virus genome (5'-non coding region) of 16 European and some Far East subtype strains were compared.