[Telemedicine in acute stroke care--a health economics view]

Specialized stroke units offer optimal treatment of patients with an acute stroke. Unfortunately, their installation is limited by an acute lack of experienced neurologists and the small number of stroke patients in sparsely populated rural areas. This problem is increasingly being solved by the use of telemedicine, so that neurological expertise is made available to basic and regular care. It has been demonstrated by national and international pilot studies that solidly based and rapid decisions can be made by telemedicine regrading the use of thrombolysis, as the most important acute treatment, but also of other interventions. So far studies have only evaluated improvement in the quality of care achieved by networking, but not of any lasting effect on any economic benefit. Complementary to a medical evaluation, the qualitative economic assessment presented here of German and American concepts of telemetric care indicate no difference in efficacy between various ways of networking. Most noteworthy, when comparing two large American and German studies, is the difference in their priorities. While the American networks achieved targeted improvements in efficacy of care that go beyond the immediate wishes of the doctors involved, this was of only secondary importance in the German studies. Also, in contrast to several American networks, the German telemetry networks have not tended to be organized for future growth. In terms of economic benefits, decentralized organized networks offer a greater potential of efficacy than purely local ones. Furthermore, the integration of inducements into the design of business models is a fundamental factor for achieving successful and lasting existence, especially within a highly competitive market.

Sheep category can be classified using machine learning techniques applied to fatty acid profiles derivatised as trimethylsilyl esters

Eruption of permanent incisors (dentition) is used as a proxy for age for defining meat quality in Australian sheep meat. However, this approach may not be reliable. While not presently available, an objective method could be used to determine sheep age, and thus sheep category, which would then potentially remove any inaccuracies that may occur in classifying sheep meat product. Statistical classification algorithms have been successfully used in bioinformatics. In this paper we review the performance of three algorithms (support vector machines, recursive partitioning and random forests) for determining sheep age. The algorithms were applied to the measured fatty acid profiles of fat samples from 533 carcasses; 254 lamb (<1 year old), 131 hogget (~1–2 years old) and 148 mutton (>2 years old) samples. Three data pretreatments (range transformation, column mean centering and range transformation with mean centering) were also examined to determine their impact on the performance of the algorithms. The random forests algorithm, when applied to mean-centred data, gave 100% predictive accuracy when classifying sheep category. This approach could be used for the development of an objective test for determining sheep age and category.

Asthma clinic attendance improves quality of life of Jamaican asthmatic children and their parents

BACKGROUND

With the increasing incidence of paediatric asthma, there has been a corresponding increase in the physical, emotional and financial burden. This has led to a greater interest in determining the impact of asthma and its treatment on many aspects of patient functioning and wellbeing.

AIM

To assess the usefulness of the Asthma Clinic established in Jamaica in 1997 by ascertaining whether there has been improvement in quality of life of children and care-givers who attend the clinic.

METHODS

The quality of life of patients and their parents/care-givers before attending the Asthma Clinic of Bustamante Hospital for Children in Kingston, Jamaica was compared with that of 1 year afterwards. Parents or guardians were interviewed using the Pediatric Asthma Quality of Life Questionnaire which consists of three domains [symptoms (ten questions), emotional (eight questions) and activity (five questions)] and the Pediatric Asthma Caregiver's Quality of life Questionnaire which consist of two domains [emotional (nine questions) and activity (four questions)].

RESULTS

Quality of life improved in patients and their parents/care-givers in all domains.

CONCLUSION

Attendance at an asthma clinic in Jamaica improved the quality of life of asthmatic children and their parents/care-givers.

Idiopathic pustular vulvitis

A 31-year-old woman presented in the 23rd week of her third pregnancy with extremely painful pustular vulvitis, unresponsive to antibiotics. Although the histological findings were was consistent with a diagnosis of hidradenitis suppurativa (HS), bridged comedones, the hallmark of this disease, were absent and there were no dermal sinuses. Incision and drainage of the pustules provided only temporary improvement, which was briefly maintained with oral clindamycin and topical steroids. After the birth, a course of isotretinoin produced almost total clearance, a response not typically found in HS. This patient's condition may represent a variant of HS, and if so, it would be the first case report of de novo HS in pregnancy, but its clinical features and evolution differed so much from those in HS that the possibility of a previously unrecognised condition cannot be excluded.

Anatomical and functional aspects of the septo-hippocampal projections

The origins, distribution, and cellular targets of the septo-hippocampal projections are reviewed. It appears that the distribution of acetylcholinesterase-positive neurons in the medial septum and diagonal bands and those cells labelled after injections of horseradish peroxidase into the hippocampus coincide; however, the possibility of a non-acetylcholinesterase septal projection remains. Good agreement is found between the distribution of hippocampal acetylcholinesterase and the patterning of silver grains after injection of [3H]leucine into the medial septum. A major target of septal efferents to the hippocampus is the interneuron population; the possibility of septal mediation of intrahippocampal circuitry via this anatomical arrangement is discussed.

Role of controlled trials in evaluating preventive medicine procedures

A number of large controlled trials evaluating methods of preventing cardiovascular disease are reviewed, mainly for their methodological lessons. They include trials of treatment for hypertension (Veterans Administration, Australian, and the Hypertension Detection and Follow-up Program); of coronary heart disease prevention by drugs (post-infarction beta-blockers, the WHO trial of clofibrate, and the Lipid Research Clinics Program); and of health education (the Multiple Risk Factor Intervention Trial and the WHO European Multifactorial Trial). Although important evidence has emerged, expectations from large trials of this kind are now more sober. Their findings have to be considered alongside the rest of the evidence, and preventive policy can only be based on a best judgment. Any hope of 'proof' is naive.

Implications of genetic research for control measures

Coronary heart disease and hypertension are 'mass' diseases to which nearly all individuals are in varying degree susceptible. Incidence rates, population differences and time trends are determined by environment and lifestyle. Within populations the different levels of precursors in individuals are probably genetically determined to a large degree. Genetic and environmental approaches to research are interdependent, but the contribution of genetic advances to control measures is currently confined to less common conditions or to individuals at exceptionally high risk.

The efficacy and safety of tigecycline in the treatment of skin and skin-structure infections: results of 2 double-blind phase 3 comparison studies with vancomycin-aztreonam

Two phase 3, double-blind studies in hospitalized adults with complicated skin and skin-structure infections (cSSSI) determined the safety and efficacy of tigecycline versus that of vancomycin-aztreonam. Patients received tigecycline (100 mg, followed by 50 mg intravenously twice daily) or vancomycin (1 g intravenously twice daily) plus aztreonam (2 g intravenously twice daily) for up to 14 days. Populations were as follows: 1116 patients (566 treated with tigecycline, and 550 treated with vancomycin-aztreonam) constituted the modified intent-to-treat (mITT) population, 1057 patients (538 treated with tigecycline, and 519 treated with vancomycin-aztreonam) constituted the clinical mITT (c-mITT) population, and 833 patients (422 treated with tigecycline, and 411 treated with vancomycin-aztreonam) constituted the clinically evaluable population. Clinical responses to tigecycline and vancomycin-aztreonam at test-of-cure were similar: c-mITT, 79.7% (95% confidence interval [CI], 76.1%-83.1%) versus 81.9% (95% CI, 78.3%-85.1%) (P = .4183); and clinically evaluable, 86.5% (95% CI, 82.9%-89.6%) versus 88.6% (95% CI, 85.1%-91.5%) (P = .4233). Adverse events were similar, with increased nausea and vomiting in the tigecycline group and increased rash and elevated hepatic aminotransferase levels in the vancomycin-aztreonam group. Tigecycline monotherapy is as safe and efficacious as the vancomycin-aztreonam combination in treating patients with cSSSI.

Characterization of a bidirectional promoter shared between two human genes related to aging: SIRT3 and PSMD13

The human SIRT3 gene contains an intronic VNTR enhancer whose variability is correlated with life span. The SIRT3 5' flanking region encompasses the PSMD13 gene encoding the p40.5 regulator subunit of the 26S proteasome. Proteasome is a multicatalytic proteinase whose function declines with aging. SIRT3 and PSMD13 are linked in a head-to-head configuration (788-bp intergenic region). The molecular configuration of two genes that are both related to aging prompted us to search for shared regulatory mechanisms between them. Transfection experiments carried out in HeLa cells by deletion mutants of the PSMD13-SIRT3 intergenic region showed a complex pathway of coregulation acting in both directions. Furthermore, linkage disequilibrium (LD) analyses carried out in a sample of 710 subjects (18-108 years of age) screened for A21631G (marker of PSMD13), and for G477T and VNTR(intron5) (markers of SIRT3), revealed high LD, with significantly different PSMD13-SIRT3 haplotype pools between samples of centenarians and younger people.

Adult xanthogranulomatous disease of the orbit and ocular adnexa: new immunohistochemical findings and clinical review

BACKGROUND/AIMS

Adult xanthogranulomatous disease involving the ocular tissues is rare and poorly understood. Adult onset xanthogranuloma (AOX), adult onset asthma and periocular xanthogranuloma (AAPOX), necrobiotic xanthogranuloma (NBX), and Erdheim-Chester disease (ECD) are the four syndromes within this disorder, which is diagnosed by characteristic histopathology. Experience with eight cases prompted a multi-institutional effort to study the histopathology, immunohistochemistry, clinical findings, and systemic associations in this disorder.

METHODS

22 cases, including histopathological slides, were compiled. Published reports were identified by an English language Medline search (1966-2005) and review of reference citations. Each case in this series and the literature was classified as one of four syndromes and then analysed for age onset, sex, skin xanthoma, orbital location, immune dysfunction, internal organ and bone lesions, treatment, and outcome. The histopathology in each of these cases was reviewed by two pathologists. Immunhistochemical stains (CD3, CD4, CD8, L26) were performed in 14 cases where unstained slides were available.

RESULTS

137 cases were compiled. There was no sex or age difference between syndromes. AOX, AAPOX, NBX affect the anterior orbit, ECD tends to be diffuse and intraconal. Skin lesions are found in all the syndromes. Immune dysfunction was noted in all cases of AAPOX and NBX; 11% of NBX and all ECD patients had internal organ disease. Treatment included surgery, corticosteroids, other chemotherapeutic agents, radiotherapy, and combinations of these. No AOX or AAPOX deaths occurred; 66% of ECD patients died. All 22 cases had xanthoma cells; most had Touton giant cells. Lymphocytes were present in all cases and occurred as aggregates (mostly in AAPOX) or diffuse populations mixed with fibroblasts (mostly in ECD). Immunohistochemistry revealed the majority of these to be CD8+. Necrosis was most marked in NBX.

CONCLUSION

Adult xanthogranuloma of the orbit is rare, making prospective evaluation or meta-analysis impossible. The best treatment is unknown but seems to be with multiagent chemotherapy guided by histopathological, immunohistochemical, and systemic findings.

Increase in slow afterhyperpolarization led to learning delay in DBA mice

We showed that differences in learning capacity between DBA and C57Bl/6 mice correlates with differences in slow afterhyperpolarization amplitude in hippocampal CA1 pyramid neurons. In DBA mice learning capacity is lower, but the amplitude of slow afterhyperpolarizations higher than in C57Bl/6 mice.

Biopsy-confirmed spontaneous resolution of orbital langerhans cell histiocytosis

A 17-year-old boy presented with a left upper lid swelling, headaches and diplopia. An orbital computerized tomography (CT) scan showed a mass in the left lacrimal fossa eroding bone and extending into the temporalis fossa and intracranially. An urgent biopsy without curettage was carried out and showed Langerhans cell histiocytosis. He was otherwise well and no other lesion was found. He was therefore observed and reviewed regularly. During follow-up it was noted that the mass was reducing in size. Five months after the initial biopsy a further procedure, involving curettage and an intralesional steroid, was carried out at a tertiary referral center. Histology of the material obtained showed no remaining evidence of Langerhans cell histiocytosis. Spontaneous resolution of orbital Langerhans cell histiocytosis has been described clinically and radiologically. This is the first case of spontaneous resolution to be confirmed histologically.