Die Wirkung von Botulinumtoxin A und B auf die vegetative kardiale Innervation

The objective of this study was to examine whether vegetative cardiac innervation is affected by local application of botulinum toxin A and B. For that purpose, heart rate variability (HRV) was measured in 29 patients treated with botulinum toxin A and 26 patients treated with botulinum toxin B both prior to and three weeks following injection. Among the 14 parameters studied, 9 and 10 had significantly changed in terms of decreased HRV following treatment with botulinum toxin A and B, respectively. Obviously, either type of botulinum toxin exerts a systemic effect, although a clear-cut difference between the two preparations was undetectable. By and large, the changes observed tend to be low compared to, for instance, cardiac effects known to occur with tricyclic agents. However, the results might be of relevance for the use of botulinum toxins in patients with a history of cardiac disease since a reduction in HRV correlates with an increased incidence of cardiovascular events. Therefore, an ECG study is advised prior to onset of therapy with botulinum toxin. In addition, nonjudicious use of botulinum toxin outside a defined range of medical indications should be reassessed.

A double-blind randomised placebo-controlled evaluation of three doses of botulinum toxin type A (Dysport) in the treatment of spastic equinovarus deformity after stroke

BACKGROUND/OBJECTIVES

Calf muscle hypertonicity following stroke may impair walking rehabilitation. The aim of this study was to assess botulinum toxin (Dysport) in post-stroke calf spasticity.

METHODS

A prospective, multicentre, double-blind, placebo-controlled, dose-ranging study was performed to evaluate dysport at 500, 1,000 or 1,500 units in 234 stroke patients. They were assessed at 4-week intervals over 12 weeks.

RESULTS

The primary outcome measure, 2-min walking distance and stepping rate increased significantly in each group (p < 0.05, paired test), but there was no significant difference between groups (including placebo). Following dysport treatment, there were small but significant (p = 0.0002-0.0188) improvements in calf spasticity, limb pain, and a reduction in the use of walking aids, compared to placebo. Investigators' and patients' assessments of overall benefit suggested an advantage for dysport over placebo, but this was not significant. Sixty-eight patients reported 130 adverse events, with similar numbers in each group. The few severe events recorded were not considered to be treatment-related.

CONCLUSION

Dysport resulted in a significant reduction in muscle tone, limb pain and dependence on walking aids. The greatest benefits were in patients receiving dysport 1,500 units, but 1,000 units also had significant effects. Dysport 500 units resulted in some improvements. Since few adverse events were reported, this therapy is considered safe and may be a useful treatment in post-stroke rehabilitation of the leg. Possible reasons why functional improvements in gait parameters were not observed are also discussed.

Botulinum toxin for treatment of spasticity in adults

Although a few hundred papers have been published on the treatment of adult spasticity with botulinum toxin, the number of randomized placebo-controlled double-blind studies, by comparison, is relatively small. Criteria of highest evidence classes are met by the following observations: 1) Botulinum toxin improves motor functions (ability to walk and stand in the presence of spastic equinus deformity and knee flexor spasticity, upper-extremity movements). 2) Botulinum toxin makes attendance of spastic adults easier (personal hygiene in patients presenting with severe adductor spasticity; self-care and dressing in the presence of arm spasticity). 3) Early initiation of treatment with botulinum toxin yields better results than delayed institution (hemispasticity).

[Camptocormia--segmental dystonia. Proposal of a new definition for an old disease]

Camptocormia is defined as a forced posture with a forward-bent trunk which appears during standing and sitting. It was first described in 1818 by Brodie. In the last 100 years, numerous cases were observed. A psychogenic origin was presumed in most cases. We describe four patients with typical symptoms of camptocormia who present with the clinical and electromyographical criteria of a segmental dystonia. A new classification of camptocormia is proposed including (1) the primary form, a segmental dystonia of the abdominal wall muscles and (2) secondary forms. Among other conditions (psychogenic disorder, neurosis, myopathy, myositis, Parkinson's disease, multiple-system atrophy, thoracolumbar kyphosis, paraneoplastic syndrome), camptocormia is to be considered in essential tremor. A combination of dystonia of the abdominal wall muscles and essential tremor seems possible.

Digital selenium radiography: anti-scatter grid for chest radiography in a clinical study

The purpose of this study was to evaluate the diagnostic performance of an additional stationary anti-scatter grid in digital selenium radiography (DSR) compared with images acquired with only an air gap. Chest radiographs were obtained with DSR in 100 patients with and without an anti-scatter grid. Four observers scored 12 anatomical landmarks, catheters and wire cerclages for their visualization in both subsets of images. Statistical analysis was performed using a paired t-test. Anatomical landmarks, catheters and wire cerclages were statistically better visualized in regions of high attenuation when the images were performed with an anti-scatter grid. No statistically significant difference was noted for peripheral regions, nor for sex and weight of the patient between the two modalities. Therefore, an anti-scatter grid is not recommended for chest radiography as it increases the radiation exposure of patients without having a significant impact on visualization for all regions of the chest.

Screening by anti-endomysium antibody for celiac disease in diabetic children and adolescents in Austria

BACKGROUND

Unrecognized celiac disease (CD) may be found in a substantial proportion of patients with type I diabetes mellitus.

METHODS

A cohort of 403 Austrian children and adolescents with type I diabetes mellitus (210 males and 193 females; age range, 1-22 years) was screened for celiac disease using the IgA anti-endomysium antibody test (EMA) and the immunoglobulin (Ig)G anti-gliadin (AGA-IgG) and IgA anti-gliadin (AGA-IgA) antibody test.

RESULTS

Twelve patients' sera (2.98%) yielded positive EMA results and two patients' sera (0.49%) with IgA deficiency had high AGA-IgG values. All but one of these patients underwent intestinal biopsy. Six (1.49%) had clear histologic evidence of CD (flat mucosa), whereas three (0.74%) showed minor histologic changes (increase in intraepithelial lymphocytes) and four (0.99%), including the EMA-negative patients with IgA deficiency, had a normal mucosa. When the cases with silent and potential CD were combined, the overall prevalence in the current cohort was 2.98%. There was no difference in the hemoglobin (Hb)A1c level between antibody-positive and -negative patients, and subsequent gluten-free diet did not change this metabolic parameter.

CONCLUSION

The prevalence of clinically unrecognized CD, found by EMA screening, is much higher in Austrian children with diabetes than in a comparable population without diabetes. The prevalence of CD in diabetic children in Austria is distinctly lower, however, than in several other countries.

Detection of simulated interstitial lung disease and catheters with selenium, storage phosphor, and film-based radiography

PURPOSE

To evaluate the diagnostic performance of storage phosphor and digital selenium radiography (DSR) with asymmetric and symmetric screen-film systems at different speeds in the detection of simulated interstitial lung disease and catheters.

MATERIALS AND METHODS

Patterns of simulated interstitial lung disease and catheters were superimposed over an anthropomorphic chest phantom. Hard-copy images were generated at DSR (200-, 400-, and 600-speed), storage phosphor radiography (200- and 400-speed), and asymmetric (400-speed) and symmetric (200- and 400-speed) screen-film imaging. Surface doses were measured, and receiver operating characteristic analyses were performed.

RESULTS

No statistically significant differences were found between the detector systems with the same speeds for each interstitial pattern. Significantly poorer results were found at 600-speed DSR than at 200-speed DSR. Detection of catheters and nodules over high-attenuation areas was significantly worse with the symmetric screen-film system than with the other detectors. The surface dose with the DSR system, without a grid, was about 50% less than that of the other detector systems, with grids, at the same speed.

CONCLUSION

No significant difference was found in the diagnostic performance at DSR, storage phosphor radiography, and film-based radiography for simulated interstitial lung disease at corresponding speeds; there was a reduction in the surface dose of about 50% with the 400-speed DSR system.

Treatment of diabetic polyneuropathy with the antioxidant thioctic acid (alpha-lipoic acid): a two year multicenter randomized double-blind placebo-controlled trial (ALADIN II). Alpha Lipoic Acid in Diabetic Neuropathy

Short-term trials with the antioxidant thioctic acid (TA) appear to improve neuropathic symptoms in diabetic patients, but the long-term response remains to be established. Therefore, Type 1 and Type 2 diabetic patients with symptomatic polyneuropathy were randomly assigned to three treatment regimens: (1) 2 x 600(mg of TA (TA 1200), (2) 600)mg of TA plus placebo (PLA) (TA 600) or (3) placebo and placebo (PLA). A trometamol salt solution of TA of 1200 or 600 mg or PLA was intravenously administered once daily for five consecutive days before enrolling the patients in the oral treatment phase. The study was prospective, PLA-controlled, randomized, double-blind and conducted for two years. Severity of diabetic neuropathy was assessed by the Neuropathy Disability Score (NDS) and electrophysiological attributes of the sural (sensory nerve conduction velocity (SNCV), sensory nerve action potential (SNAP)) and the tibial (motor nerve conduction velocity (MNCV), motor nerve distal latency (MNDL)) nerve. Statistical analysis was performed after independent reviewers excluded all patients with highly variable data allowing a final analysis of 65 patients (TA 1200: n = 18, TA 600: n = 27; PLA: n = 20). At baseline no significant differences were noted between the groups regarding the demographic variables and peripheral nerve function parameters for these 65 patients. Statistically significant changes after 24 months between TA and PLA were observed (mean +/- SD) for sural SNCV: +3.8 +/- 4.2 m/s in TA 1200, +3.0+/-3.0m/s in TA 600, -0.1+/-4.8m/s in PLA (p < 0.05 for TA 1200 and TA 600 vs. PLA); sural SNAP: +0.6+/-2.5 microV in TA 1200, +0.3+/-1.4 microV in TA 600, -0.7 +/- 1.5 microV in PLA (p = 0.076 for TA 1200 vs. PLA and p < 0.05 for TA 600 vs. PLA), and in tibial MNCV: +/- 1.2 +/- 3.8 m/s in TA 1200, -0.3 +/- 5.2 m/s in TA 600, 1.5 +/- 2.9 m/s in PLA (p < 0.05 for TA 1200 vs. PLA). No significant differences between the groups after 24 months were noted regarding the tibial MNDL and the NDS. We conclude that in a subgroup of patients after exclusion of patients with excessive test variability throughout the trial, TA appeared to have a beneficial effect on several attributes of nerve conduction.

CT scanning of the paranasal sinuses: axial helical CT with reconstruction in the coronal direction versus coronal helical CT

Paranasal sinuses of 52 patients with sinusitis, tumours or fibrous dysplasia were scanned. Axially acquired spiral data were obtained and reconstructed coronally. Four radiologists compared the two sets of images. They evaluated the diagnostic quality for visualization of the ostiomeatal unit, infundibulum, infraorbital canal, inflammatory disease, fine osseous lamellae and presence of amalgam or step artefacts. Two test phantoms were scanned for both techniques and lens dose was measured. Statistical significant differences in the diagnostic quality of the representation of the fine osseous structures in the paranasal sinuses, attributable to step artefacts were found in the coronally reconstructed images (p < 0.001). However, there was no amalgam and almost no motion artefacts in the reconstructed images. Interobserver correlation was r = 0.953 versus 0.956 for inflammatory disease, r = 0.816 versus 0.852 for artefacts, and r = 0.596 versus 0.547 for fine osseous lamellae in coronally acquired or axially acquired and reconstructed images, respectively. Lens dose was measured between 11.8 mGy and 13.8 mGy for axially acquired and reconstructed images. The advantage of axially acquired, coronally reconstructed images is the absence of artefacts attributable to amalgam and fewer motion artefacts. Axially acquired, coronally reconstructed images are inferior to coronal helical CT images, because of step artefacts, when it comes to evaluating the resolution of fine osseous structures. Nevertheless, reconstructed images are suitable as a investigatory procedure for patients with inflammatory disease who cannot maintain the prone position.

Effects of treatment with the antioxidant alpha-lipoic acid on cardiac autonomic neuropathy in NIDDM patients. A 4-month randomized controlled multicenter trial (DEKAN Study). Deutsche Kardiale Autonome Neuropathie

OBJECTIVE

To evaluate the efficacy and safety of oral treatment with the antioxidant alpha-lipoic acid (ALA) in NIDDM patients with cardiac autonomic neuropathy (CAN), assessed by heart rate variability (HRV).

RESEARCH DESIGN AND METHODS

In a randomized, double-blind placebo-controlled multicenter trial (Deutsche Kardiale Autonome Neuropathie [DEKAN] Study), NIDDM patients with reduced HRV were randomly assigned to treatment with daily oral dose of 800 mg ALA (n = 39) or placebo (n = 34) for 4 months. Parameters of HRV at rest included the coefficient of variation (CV), root mean square successive difference (RMSSD), and spectral power in the low-frequency (LF; 0.05-0.15 Hz) and high-frequency (HF; 0.15-0.5 Hz) bands. In addition, cardiovascular autonomic symptoms were assessed.

RESULTS

Seventeen patients dropped out of the study (ALA n = 10; placebo n = 7). Mean blood pressure and HbA1 levels did not differ between the groups at baseline and during the study, but heart rate at baseline was higher in the group treated with ALA (P < 0.05). RMSSD increased from baseline to 4 months by 1.5 ms (-37.6 to 77.1) [median (minimum-maximum)] in the group given ALA and decreased by -0.1 ms (-19.2 to 32.8) in the placebo group (P < 0.05 for ALA vs. placebo). Power spectrum in the LF band increased by 0.06 bpm2 (-0. 09 to 0.62) in ALA, whereas it declined by -0.01 bpm2 (-0.48 to 1.86) in placebo (P < 0.05 for ALA vs. placebo). Furthermore, there was a trend toward a favorable effect of ALA versus placebo for the CV and HF band power spectrum (P = 0.097 and P = 0.094 for ALA vs. placebo). The changes in cardiovascular autonomic symptoms did not differ significantly between the groups during the period studied. No differences between the groups were noted regarding the rates of adverse events.

CONCLUSIONS

These findings suggest that treatment with ALA using a well-tolerated oral dose of 800 mg/day for 4 months may slightly improve CAN in NIDDM patients.

Increased incidence of DNA double-strand breaks and anti-ds DNA antibodies in blood of workers occupationally exposed to asbestos

Asbestos, proven to be carcinogenic in humans and animals, is reported to have no genotoxic effect. Asbestos workers have an increased risk of lung cancer, mesothelioma, and other tumours. Earlier findings showed that crocidolite can induce DNA strand breaks in cultured rat embryo cells as assessed by nick translation. We investigated DNA double-strand breaks in white blood cells (WBC) of ten workers occupationally exposed to asbestos. According to our results, obtained with neutral filter elution, individuals who had been exposed to asbestos fibres showed two to four times more DNA double-strand breaks (dsb) in white blood cells than ten non-exposed persons. The induced DNA fragments are of about 250 kb (compared to chromosomal DNA of Saccharomyces cerevisiae standard marker). Using additionally the chromosomal DNA protective method of agarose-plugs, DNA fragments in the range of 200 to 1000 kb have been found in the white blood cells of the same ten workers occupationally exposed to asbestos. In the white blood cells of non-exposed subjects no DNA fragments could be detected with this method. Compared to 51 non-exposed persons, elevated anti-ds DNA antibody concentrations were found in ten workers occupationally exposed to asbestos. The fact that workers occupationally exposed to asbestos have distinctly more double-strand breaks and anti-ds DNA antibodies could mean that an increased incidence of DNA-fragments may be an important indicator in the chronic effect of asbestos-associated carcinogenesis. Apparently, the chronic effects of asbestos observed here do not seem to be identical with that of previously reported acute in vitro effects.

[Lung function and normal values]

Interindividual derived predicted values of lung function are not suitable for detection of early changes of lung function. Intraindividual values show variability, which should be considered. Many of the very common obstructive lung diseases start with small variations of the individual values of lung function, long time before clinical manifestation takes place. Followup of the most useful measurements (FEV1, MEF 50%, Rt und IGV%) show reliable early changes, important for preventive therapeutic intervention. Strong variability of the individual values argue for hyperreagibility of the airways, even as a risk factor for manifestation of obstructive airway diseases.

[The inhalation 1 concentration test for the assessment of bronchial reactivity]

An unspecific bronchial provocation challenge with a 1-concentration test is a reliable method to distinguish between normal and hyperreactive persons. The patient inhales a bronchoconstricting substance such as methacholine. A significant change of lung function, for example an increase of airway resistance, characterizes a hyperreactive bronchial system. The continuous registration of transcutaneous oxygen pressure is helpful concerning a strong reaction or a peripheral airway obstruction. An exaggerated increase of airway resistance after provocation test can be treated rapidly by inhalation of sympathicomimetics. No complications were registered. Comparative studies showed a good reproducibility of this method. Summarizing, the 1-concentration test is simple, easy to perform and suitable especially for investigations in occupational medicine or epidemiology.

[Changes in the pleura of subjects occupationally-exposed to asbestos: radiological study technique, spectrum, etiological classification and coding according to the ILO classification]

Pleural abnormalities of 119 occupationally asbestos-exposed with prominent internal stripe of the lateral thoracic wall were radiodiagnostically analysed by plain films of the thorax in four views and by computed tomography in the course of medical expert's certification. Abnormalities were coded according to 1980 ILO international classification of pneumoconioses. Hardly half of the patients had pleural abnormalities caused by asbestos exposure: Pleural plaques, "diffuse" pleural fibrosis, pleural effusions, organized pleural effusions and pleural tumors. The other half of the patients had pleural involvement of pulmonary and chest wall abnormalities or variations of the lateral thoracic wall not related to asbestos exposure. The 1980 ILO classification of pneumoconioses proved to be inadequate for complete coding of the abnormalities, since only the postero-anterior plain film of the thorax must be used, since the normal appearance of the pleura is insufficiently defined and since the entity of organized pleural effusion is lacking.

[Asbestos-induced bronchopulmonary diseases]

Asbestos is a collective term for fibrous crystalline silicate minerals, which can be used to produce technically useful fibers. The various types of asbestos, such as chrysotile, crocidolite and amosite, may induce not only fibrotic changes in the pleura and lungs, but also carcinomas and mesotheliomas. The increasing industrial use of asbestos has led to a marked increase in bronchopulmonary diseases, which can be shown to be caused by occupational exposure to fine asbestos dust. In this overview, the pathological anatomy, differential diagnosis and occupational-medical assessment of the various conditions induced by asbestos are discussed.

[Sweat glands in pseudohypoaldosteronism]

Pseudohypoaldosteronism is a rare syndrome occurring during early infancy, which is mainly characterized by salt-depletion crises. Sodium chloride is lost via the kidneys resulting in a reduced sodium level and raised potassium level in the serum, leading to life-threatening disturbances of water and acid-base concentration. The excessive sodium loss seems to be caused by an unresponsiveness of the renal tubules to endogenous and exogenous mineralocorticoids. The colon, salivary and sweat glands, which are also involved in sodium reabsorption, may likewise be affected by the disease. We describe skin changes in two siblings suffering from pseudohypoaldosteronism, who developed seborrheic dermatitis, folliculitis or miliaria rubra-like lesions during salt-depletion crises. Biochemical analysis revealed a highly increased sodium-chloride concentration in the sweat, saliva, urine and stool of both patients. Destructive inflammatory reactions could be demonstrated histologically within and around the dermal sweat glands, thus indicating the important role of the sweat system in the pathogenesis of skin lesions in pseudohypoaldosteronism.