[Quality assurance in geriatric rehabilitation hospital treatment. Long-term medical and functional outcome]

Clinical geriatric therapy has shown to be beneficial and cost-effective. However, little is known about its long-term results. Based on GEMIDAS (Geriatric Minimal Data Set), a multicenter-Database of the German Federal Association of 140 Clinical Geriatric Institutions, we conducted a one-year-follow-up pilot study focusing on medical and functional results, including needs of technical aids and nursing. Mortality was 16% at 1 year. Two thirds of the deceased had died during the first half year, many with severe stroke. Among the 840 survivors, 81.1% lived in their private housing, 14.5% in nursing homes, 4.4% were actually hospitalized. 37.3% suffered from recurrent diseases such as stroke (5.2%), bone fractures (4.5%), heart attacks (2.1%), severe infections (1.1%), needing hospitalization in 31.9%, repeatedly in 6.9% of the survivors. Technical aids were regularly used in about 80%. Personal help was often necessary and was provided by relatives (66.9%), professional nursing (39.8%), neighbors (5.7%), only 6% of the patients needed no help. The initial functional gain (mean Barthel-Index from 53.4 to 72.3 points) diminished to 59.6 points during follow-up, with similar patterns for most of the single Barthel-items. Our results confirm the initial benefit and clearly show a significant long-term effect of clinical geriatric rehabilitation. For stabilization and further functional improvement, specific and continuous rehabilitation efforts seem to be crucial.

Women at altitude: carbohydrate utilization during exercise at 4,300 m

To evaluate the hypothesis that exposure to high altitude would reduce blood glucose and total carbohydrate utilization relative to sea level (SL), 16 young women were studied over four 12-day periods: at 50% of peak O(2) consumption in different menstrual cycle phases (SL-50), at 65% of peak O(2) consumption at SL (SL-65), and at 4,300 m (HA). After 10 days in each condition, blood glucose rate of disappearance (R(d)) and respiratory exchange ratio were measured at rest and during 45 min of exercise. Glucose R(d) during exercise at HA (4.71 +/- 0.30 mg. kg(-1). min(-1)) was not different from SL exercise at the same absolute intensity (SL-50 = 5.03 mg. kg(-1). min(-1)) but was lower at the same relative intensity (SL-65 = 6.22 mg. kg(-1). min(-1), P < 0.01). There were no differences, however, when glucose R(d) was corrected for energy expended (kcal/min) during exercise. Respiratory exchange ratios followed the same pattern, except carbohydrate oxidation remained lower (-23.2%, P < 0.01) at HA than at SL when corrected for energy expended. In women, unlike in men, carbohydrate utilization decreased at HA. Relative abundance of estrogen and progesterone in women may partially explain the sex differences in fuel utilization at HA, but subtle differences between menstrual cycle phases at SL had no physiologically relevant effects.

Women at altitude: energy requirement at 4,300 m

To test the hypotheses that prolonged exposure to moderately high altitude increases the energy requirement of adequately fed women and that the sole cause of the increase is an elevation in basal metabolic rate (BMR), we studied 16 healthy women [21.7 +/- 0.5 (SD) yr; 167.4 +/- 1.1 cm; 62.2 +/- 1.0 kg]. Studies were conducted over 12 days at sea level (SL) and at 4,300 m [high altitude (HA)]. To test that menstrual cycle phase has an effect on energetics at HA, we monitored menstrual cycle in all women, and most women (n = 11) were studied in the same phase at SL and HA. Daily energy intake at HA was increased to respond to increases in BMR and to maintain body weight and body composition. Mean BMR for the group rose 6.9% above SL by day 3 at HA and fell to SL values by day 6. Total energy requirement remained elevated 6% at HA [ approximately 670 kJ/day (160 kcal/day) above that at SL], but the small and transient increase in BMR could not explain all of this increase, giving rise to an apparent "energy requirement excess." The transient nature of the rise in BMR may have been due to the fitness level of the subjects. The response to altitude was not affected by menstrual cycle phase. The energy requirement excess is at present unexplained.

Slower fatigue and faster recovery of the adductor pollicis muscle in women matched for strength with men

In previous gender comparisons of muscle performance, men and women rarely have been closely matched, absolute force has not been equalized, and rates of fatigue and early recovery have not been determined. We compared adductor pollicis muscle performance at a similar absolute force development in healthy men and women (both n=9) matched for adductor pollicis maximal voluntary contraction (MVC) force (132 +/- 5 N for women and 136 +/- 4 N for men, mean +/- SE, P > 0.05). Subjects repeated static contractions at a target force of approximately 50% of MVC force of rested muscle (68 +/- 3 N or 51.9 +/- 1.0% MVC for women and 72 +/- 2 N or 53.0 +/- 2.0% MVC for men, P > 0.05) for 5 s followed by 5 s rest until exhaustion, i. e. inability to maintain the target force for 5 s. MVC force was measured following each minute of exercise, at exhaustion, and after each minute for 3 min of passive recovery. For women compared with men: MVC force fell less after 1 min of exercise (to 93 +/- 1% vs. 80 +/- 3% of MVC force of rested muscle, respectively, P < 0.05); MVC force (N min-1) fell approximately 2-fold slower (P < 0.05); and endurance time to exhaustion was nearly two times longer (14.7 +/- 1. 6 min vs. 7.9 +/- 0.7 min, P < 0.05). After declining to a similar level of MVC force of rested muscle at exhaustion (56 +/- 1% for women and 56 +/- 3% for men), MVC force rose faster in women than in men (to 71 +/- 2% vs. 65 +/- 3% of MVC force of rested muscle, respectively; P < 0.05) during the first minute of recovery. The findings are consistent with the hypothesis that slower adductor pollicis muscle fatigue in women is linked with differences between men and women both in impairment of force generating capacity, per se, and in rates of recovery between contractions.

Basal ganglia alterations and brain atrophy in Huntington's disease depicted by transcranial real time sonography

OBJECTIVES AND METHODS

Transcranial real time sonography (TCS) was applied to 49 patients with Huntington's disease and 39 control subjects to visualise alterations in the echotexture of the basal ganglia. For comparison T1 weighted, T2 weighted, and fast spin echo MRI was performed in 12 patients with Huntington's disease with and in nine patients without alterations of the basal ganglia echotexture as detected by TCS and T1 weighted, T2 weighted, and fast spin echo MRI. Furthermore, the widths of the frontal horns, third ventricle, and the lateral ventricles were depicted in TCS examinations and correlations examined with corresponding CT slices.

RESULTS

Eighteen out of 45 (40%) of the patients with Huntington's disease with adequate insonation conditions showed hyperechogenic lesions of at least one basal ganglia region. In 12 patients TCS depicted hyperechogenic lesions of the substantia nigra; in six patients the head of the caudate nucleus was affected. The lentiform nucleus (n=3) and the thalamus (n=0) were less often affected or spared. Hyperechogenic lesions were significantly more frequent in patients with Huntington's disease than in 39 control subjects, who had alterations of the echotexture in 12.8% (4/39) of the examinations. The number of CAG repeats and the clinical status correlated with the identification of hyperechogenic lesions of the substantia nigra (p<0.01). Hyperechogenic lesions of the caudate nucleus were associated with an increased signal intensity in T2 weighted MR images (p<0.05). All TCS parameters indicating brain atrophy correlated with CT findings (p<0.0001).

CONCLUSIONS

TCS detects primarily abnormalities of the caudate nucleus and substantia nigra in Huntington's disease. These changes in the echotexture may represent degenerative changes in the basal ganglia matrix and are partially associated with CAG repeat expansion and the severity of clinical findings.

Contrast-enhanced transcranial color-coded sonography in acute hemispheric brain infarction

PURPOSE

The aim of the present study was to investigate the diagnostic potential of contrast-enhanced transcranial color-coded real-time sonography (CE-TCCS) in otherwise ultrasound-refractory acute stroke patients with an ischemia in the territory of the middle cerebral artery (MCA). Furthermore, correlations of CE-TCCS findings with clinical, angiographic, and CT results were investigated.

METHODS

In 90 acute stroke patients with inadequate insonation conditions in unenhanced transcranial color-coded real-time sonography (TCCS) examinations, CE-TCCS, clinical, angiographic, and CT examinations were performed within 12 hours, 36 hours (CE-TCCS only), and 1 week after onset of clinical symptoms. A CT angiography (CTA) as reference method was available in 39 individuals. After application of a galactose-based echo-enhancing agent, the portion of conclusive ultrasound examinations of the MCA, as manifested by an MCA occlusion, decreased or increased flow velocity (FV), and symmetrical MCA FV, was evaluated. CE-TCCS findings on admission and during follow-up were correlated with infarction size as demonstrated on follow-up CT, and clinical findings were assessed by use of the European Stroke Scale.

RESULTS

Adequate diagnosis was achieved in 74 of 90 patients (82%) by the use of echo contrast agents. MCA occlusion or reduction of MCA FV was found in 20 and 27 patients, respectively. MCA occlusion was confirmed by CTA in 17 cases. In one individual, false-positive diagnosis of MCA occlusion was made according to ultrasound criteria. In 5 patients with MCA occlusion, vessel recanalization was observed during follow-up; 15 of 27 patients with decreased flow velocities showed normalization after the third examination that was associated with a significantly better clinical outcome (P<0.0001). Furthermore, MCA occlusion or decreased FV in the first 12 hours were associated with significantly larger infarctions in the MCA territory compared with normal CE-TCCS findings (P<0.0001).

CONCLUSIONS

CE-TCCS enables adequate diagnosis in approximately 80% of acute hemispheric stroke patients with insufficient unenhanced TCCS examinations. It is a reliable diagnostic tool regarding MCA mainstem and branch occlusions. Because this method conveys useful information concerning cerebral tissue and clinical prognosis, it may be useful to identify those patients who benefit most from local or intra-arterial thrombolytic therapy.

[Neurocardiogenic syncopes in patients with implanted pacemakers]

BACKGROUND AND OBJECTIVE

Recently the tilting table test (tilting up to 70 degrees angle) has established itself for the diagnosis of neurocardiogenic syncope (NS). Usually patients with bradycardic arrhythmias or asystole are treated by pacemaker implantation. But if the syncope is of neurocardiogenic aetiology other therapeutic alternatives must be chosen. We here report on seven patients in whom a pacemaker had been implanted in the treatment of syncopes, in ignorance of their neurocardiogenic aetiology, yet they had recurred.

PATIENTS AND METHODS

Pacemakers had been implanted in eight patients: two with sick sinus syndrome, three with sinus bradycardia, one with brady-tachyarrhythmia, one with asystole and one with Mobitz-type 2 degrees AV block. All patients continued to have syncopes, when sitting or standing, months to years after the pacemaker implantation. The tilting table test (up to 30 min at an angle of 70 degrees) was positive in all patients. There was no case of pacemaker malfunction.

RESULTS

One patient declined further treatment. The remaining seven patients were symptom-free in the tilting table test on various medications: theophylline up to 2 x 350 mg, metoprolol up to 2 x 100 mg or disopyramide 3 x 100 mg.

CONCLUSION

Patients with syncope while sitting or standing should undergo the tilting table test to determine whether the cause is neurocardiogenic so that pacemaker implantation can be avoided. The majority of patients with NS can be successfully treated by drugs. But in some patients pacemaker implantation may have to considered if drug treatment has failed.

Mutational analysis of subunit i beta2 (MECL-1) demonstrates conservation of cleavage specificity between yeast and mammalian proteasomes

Proteasomes are the major protein-degrading complexes in the cytosol and regulate many cellular processes. To examine the functional importance of the MC14/MECL-1 proteasome active site subunits, cell lines expressing a catalytically inactive form of MECL-1 were established. Whereas mutant MECL-1 was readily incorporated into cytosolic proteasomes, replacing the constitutive MC14 subunit, removal of the prosequence was incomplete indicating that its processing required autocatalytic cleavage. Functional analyses showed that the absence of the MC14/MECL-1 active sites abrogated proteasomal trypsin-like activity, but did not affect other catalytic activities. Our data demonstrate a conservation of cleavage specificity between mammalian and yeast proteasomes.

Na,K-ATPase and V-ATPase in ovarian follicles of Drosophila melanogaster

Uncovering the cause and meaning of bioelectric phenomena in developing systems requires investigations of the distribution and activity of ion-transport mechanisms. In order to identify and localize ion pumps in ovarian follicles of Drosophila, we used immunofluorescence microscopy, immunoelectron microscopy, subcellular fractionation, immunoblots, and acridine-orange staining. We applied various antibodies directed against the Na,K-pump (Na,K-ATPase) and against vacuolar-type proton pumps (V-ATPase). During all phases of oogenesis, Na,K-ATPase were found in apical and lateral follicle-cell membranes and, during rapid follicle growth (beginning with stage 10), also in nurse-cell membranes and in the oolemma. V-ATPase were detected in various cytoplasmic vesicles and in yolk spheres and, beginning with stage 10, also in apical follicle-cell membranes and in the oolemma. Given these and earlier results, we propose that: 1) V-ATPase coupled to secondary active antiporters represent the ouabain-intensitive potassium pumps described previously; 2) both Na,K-ATPase and V-ATPase are involved in bioelectric phenomena as well as in osmoregulation and follicle growth, especially during stages 10-12; 3) organelle-associated V-ATPase play a role in vesicle acidification and in yolk processing; and 4) the channel-forming protein ductin is a component of both V-ATPase and gap junctions in ovarian follicles of Drosophila.

[Strategy for identification of new neuropeptides]

Neuropeptides play a crucial role in cell communication as neurotransmitters, neuromodulators or neurohormones, and are involved in a number of biological activities including neuroendocrine regulations, control of neurovegetative functions, trophic effects and modulation of the immune response. The number of neuropeptides that have been fully characterized so far is rather limited, as compared to the number of precursor proteins that are actually expressed in nerve cells. Owing to the development of powerful analytical and structural identification methods, and the rapid advance in molecular biology techniques, a number of novel neuropeptides have been characterized during the last decade, in both vertebrates and invertebrates. The aim of the present review is to provide a comprehensive coverage of the different approaches which are currently used to identify novel neuropeptides.

Women at altitude: changes in carbohydrate metabolism at 4,300-m elevation and across the menstrual cycle

We hypothesized that, in women, the blood glucose response to a meal (BGR) would be lower after exposure to 4,300 m compared with sea level (SL) and that BGR would be reduced in the presence of estrogen plus progesterone (E+P) relative to estrogen alone (E). Sixteen women were studied in both the E and E+P conditions at SL and in either the E or E+P condition at 4,300 m. On day 9 in each condition, blood was sampled before, and every 30 min for 2 h after, the subjects ate a high-carbohydrate meal. At 4,300 m, BGR peaked at a lower value (5.73 +/- 0.94 mM) than at SL (6.44 +/- 1.45 mM) and returned to baseline more slowly (P < 0.05). Plasma insulin values were the same but C peptide was slightly higher at 4,300 m (P < 0. 05). At SL, BGR returned to baseline more slowly in E+P condition (5. 13 +/- 0.89 and 5.21 +/- 0.91 mM at 60 and 90 min, respectively) relative to E condition (4.51 +/- 0.52 and 4.69 +/- 0.88 mM, respectively) (P < 0.05). Insulin and C peptide were not different between E and E+P conditions. The data indicate that BGR is lower in women at high altitude compared with the SL, possibly due to greater suppression of hepatic glucose production or stimulation of peripheral glucose uptake by insulin. BGR was lower in E condition relative to E+P condition at SL and possibly at 4,300 m, but the relative concentrations of ovarian hormones do not appear to alter the magnitude of the change in BGR when women are exposed to high altitude.

Echo contrast-enhanced three-dimensional power Doppler of intracranial arteries

The purpose of this study was to evaluate the potential of contrast-enhanced three-dimensional (3-D) power Doppler (CE3DPD) in the assessment of intracranial vascular structures, and to compare the results with unenhanced 3-D power Doppler (3DPD) and magnetic resonance angiography (MRA) findings. We insonated 25 patients without cerebrovascular diseases through the temporal bone window using 3DPD and CE3DPD; for comparison, 13 patients underwent MRA. Identification rates of vascular segments and of small branches of intracranial vessels were evaluated by two independent investigators blinded to MRA results. In 21 patients with adequate insonation conditions, CE3DPD significantly improved identification rates compared to 3DPD for the complete visualization of the P1 segment (80.9 vs. 19.0%, p < 0.005, P2 segment (80.9 vs. 42.8%, p < 0.05 and A1 segment (85.7 vs. 38.1%, p < 0.005). Furthermore, CE3DPD depicted, in significantly more examinations, branches of the middle (MCA) and posterior cerebral artery (PCA). Interobserver agreement was higher than 95% for the main intracranial segments and branches of the MCA, but relatively low (80.1-85.7%) for branches of the PCA. In comparison to CE3DPD, MRA identified only parieto-occipital branches of the PCA, temporal branches of the MCA, frontal branches of the anterior cerebral artery and the MCA bifurcation more frequently and accurately. In 4 patients with inadequate acoustic temporal bone windows, the application of a galactose-based microbubble suspension allowed clear 3-D visualization of almost all major intracranial vascular segments and some branches of the large arteries. In conclusion, CE3DPD is a more sensitive ultrasonic tool compared to unenhanced 3-D reconstructions. It makes 3-D ultrasound imaging of the basal cerebral circulation easier to perform and interpret, by providing an improved spatially oriented display of image position. As such, this method may increase operator diagnostic confidence level under pathologic conditions.

[Ligamentum arcuatum syndrome: color doppler ultrasound diagnosis in abdominal pain of unknown origin in young patients]

PURPOSE

To assess the diagnostic potential and accuracy of CDS in the diagnosis and management of visceral artery stenosis in young patients with abdominal pain.

METHOD

126 patients < 45 y with abdominal pain were examined by CDS. Other diseases were excluded before. Systolic (Vmax.sys.) and end diastolic (Vmax.diast.) peak velocities in exspiration and inspiration were measured in the celiac (CA) and superior mesenteric artery (SMA). Vmax.syst. > 1.8 m/s in exspiration and inspiration was regarded as a respiratory fixed stenosis. This was followed by intraarterial digital subtraction angiography (i.a. DSA) including visualization of the pancreaticoduodenal artery (PDA), and, if fixed stenosis was confirmed, by operation. CDS was again performed in the follow-up.

RESULTS

CA stenosis were found in 19 patients (mean age 28.9 y). 4 were respiratory fixed, 2 combined with SMA stenoses or occlusion, all proved by i.a. DSA. The others had no evidence of fixed CA stenoses. The 4 operated patients were postoperatively immediately well. One with intermediate pain again had a stenosis in the SMA-bypass which was successfully treated by PTA. The others were treated with dietary procedures and regularly controlled by CDS.

CONCLUSION

Ligamentary CA stenosis in young patients is rare, but may lead to considerable abdominal pain and weight loss. Hemodynamicly significant stenoses are proved by CDS with respiratory fixed Vmax.syst. > 1.8 m/s and Vmax.diast. > or = 1 m/s; i.a. DSA often shows a retrograde perfusion of the PDA. Such patients should be treated surgically. CDS should be performed in the follow-up.

["Repeating" the transference? The central relationship conflict topic of the 290th session--questions, problems, results]

The following text sums up the results of an examination of a therapeutic session in which a psychoanalyst treated a patient suffering from neurotic depression. We employed the CCRT method which was applied at various levels of abstraction and in two steps of evaluation. The standard evaluation procedure allows for both a more thorough evaluation of "self-relationship episodes" and episodes involving other objects. An integration of "tailor-made" formulations allowed us to analyse another set of "relationship-patterns": namely, those which, in contrast to those most often found in conflict themes, contain positive traits. These results were then discussed clinically to examine these in light of the therapeutic conception of depression. In this context, the question arose as to whether the classic CCRT method can be fruitfully applied in long-term analysis and if this notion should be modified in order to examine the analysis of depression more effectively. A first attempt at such a modification was undertaken in the hope it would allow us to evaluate both the relevance of meaning passages contained in the clinical data and the visible processes of change.

Organization of the cord blood bank in Warsaw, Poland: current status and future prospects

The preliminary results of the currently established cord blood bank in Warsaw, Poland have been reported. 163 cord blood samples (mean volume 102 ml) were collected during/or after delivery of the placenta. Average cell numbers per sample were as follows: WBC 13.4 x 10(8); BFU-E 5.7 x 10(4); GM-CFC 4.1 x 10(5); CD34+ 4.5 x 10(6). The quantities and quality of collected cells are suitable for their use for clinical transplantation.

[Puerperal sepsis caused by streptococcus group A with a severe form of progression like "toxic shock-like syndrome"]

HISTORY AND CLINICAL FINDINGS

A previously healthy 32-year-old woman was admitted with shock symptoms 5 days after an uneventful home delivery. She developed a fever up to 39.5 degrees C during the days after delivery with sore throat, diarrhoea and muscle aches in all limbs. On physical examination there were swellings of the arms and lower legs as well as macular and vesicular erythrodermia, especially of the trunk.

INVESTIGATIONS

Abnormal laboratory findings were thrombocytopenia (20,000/microliters), increased serum concentrations of fibrin breakdown products (102 mg/dl) and of C-reactive protein (> 200 mg/dl), increased creatine kinase (5700 U/l), transaminases (GOT 220 U/l, GPT 52 U/l), creatinine (2.0 mg/dl) and urea (114 mg/dl). Streptococcus pyogenes was grown on blood culture and from vaginal smear. Sonography, echocardiography and radiological examinations failed to demonstrate a septic focus.

TREATMENT AND COURSE

Mechanical ventilation was required for 7 days because of respiratory failure and shock symptoms (toxic shock-like syndrome, TSLS). Penicillin G and tobramycin were given after the bacteriological diagnosis. Severe consumption coagulopathy was successfully treated with antithrombin III and platelet concentrates. After extubation she was found to have a flaccid tetraparesis, especially of the right and of the legs, due to soft-tissue necrosis and damage to peripheral nerves. An embolic occlusion of the right brachial artery 4 weeks after onset of the disease required upper-arm amputation.

CONCLUSION

One of the decisive factors for the prognosis of TSLS is early antibiotic treatment. The prodromal symptoms in this case underline the necessity of early recognition and treatment to prevent a full-blown picture of the syndrome.

Diagnosis and monitoring of middle cerebral artery occlusion with contrast-enhanced transcranial color-coded real-time sonography in patients with inadequate acoustic bone windows

Transcranial color-coded real-time sonography (TCCS) is an emerging diagnostic technique that allows noninvasive imaging of intracranial vessels within parenchymal structures. However, in some patients, transcranial ultrasound is particularly hindered by insufficient ultrasound penetration through the temporal bone. The present study evaluates whether or not application of an echo-contrast agent in ultrasound-refractory patients with middle cerebral artery (MCA) trunk occlusion enhances image acquisition enough to yield accurate diagnoses. Contrast-enhanced (CE) TCCS examinations, computed tomography scans and angiographic studies were performed in 20 patients with clinical symptoms suggestive of MCA occlusion within 12 h of the onset of symptoms. For comparison, 20 control persons without history or clinical signs for cerebrovascular diseases were examined using CE-TCCS. In none of the patients or control subjects did unenhanced TCCS investigations depict any color-coded vascular signal of an intracranial vessel. After application of 9 mL of 400 mg/mL galactose-based microbubbles, CE-TCCS was performed. In subjects with MCA occlusion, CE-TCCS examinations were repeated within 24 h, 48 h and 5 days after stroke. In stroke patients (n = 20), CE-TCCS showed an occluded MCA main stem in 11 patients, and this vessel was clearly demonstrable on the unaffected side. On the affected side, the posterior cerebral artery (PCA) and anterior cerebral artery (ACA) could be visualized in 8 of 11 subjects; in 3 patients, at least 1 of these vessels was detectable. Angiographic studies confirmed the diagnosis of MCA trunk occlusion in all 11 individuals. In follow-up investigations, 3 stroke patients had angiographic and CE-TCCS examinations consistent with vessel reperfusion. Nine stroke patients had a patent MCA shown in angiographic and CE-TCCS examinations. In the control group, the MCA trunk could be visualized in all subjects by CE-TCCS. CE-TCCS is a sensitive and specific ultrasound method for the diagnosis of MCA trunk occlusion that overcomes the anatomical hindrance of inadequate acoustic bone window. This technique may help to identify patients suitable for thrombolytic therapies and monitor their response.

Capillary electrophoresis of DNA restriction fragments: effect of polymer properties

The mechanism of DNA separation by dilute polymer solutions in capillary electrophoresis is not well understood. To provide information on the effect of polymer properties on DNA separations, four polymers that differ in size, shape and stiffness were examined. Hydroxyethylcellulose of high molecular weight provides excellent separation of large DNA fragments (2027 bp - 23,130 bp). Polyvinylpyrrolidone separates DNA from 72 bp to 23 kbp; star-poly(ethylene oxide) and linear poly(ethylene oxide) provide separation of fragments to 1353 bp.