Botulinum toxin for essential tremor of the voice with multiple anatomical sites of tremor: a crossover design study of unilateral versus bilateral injection

OBJECTIVES/HYPOTHESIS

To evaluate the relative efficacy of unilateral and bilateral injections of botulinum toxin injection (BOTOX) in the treatment of essential tremor of the voice (ETV).

STUDY DESIGN

Prospective open-label crossover study.

METHODS

Patients referred to the Neurolaryngology Clinic at Toronto General Hospital with a diagnosis of ETV were eligible for the study. Patients were sequentially assigned to receive BOTOX as either a bilateral 2.5-U or a unilateral 15-U electromyography-guided injection, followed by the alternative injection 16 to 18 weeks later. Acoustic, aerodynamic, and nasopharyngoscopic data were collected approximately 2, 6, 10, and 16 weeks after each injection. Patients were asked to provide a perceptual evaluation of BOTOX effects at the conclusion of the study.

RESULTS

Three of 10 patients demonstrated an objective reduction in tremor severity with bilateral injection, and 2 of 9 with unilateral injection. However, 8 of 10 patients wished to be re-injected at the conclusion of the study. A reduction in vocal effort appeared to be coincident with reduction in laryngeal airway resistance after BOTOX injection.

CONCLUSIONS

Using objective acoustic measures, only a small proportion of patients achieved benefit from BOTOX injection for ETV. However, a majority of patients in our study benefited from a subjective reduction in vocal effort that may have been attributable to reduced laryngeal airway resistance.

The relative importance of cysteine peptidases in osteoarthritis

OBJECTIVE

To assess the activity of cysteine peptidases in cultured human articular chondrocytes as well as in osteoarthritic (OA) cartilage and subchondral bone, and to interpret their relative importance in cartilage destruction and remodeling of the subchondral region.

METHODS

Intracellular and secreted cysteine peptidase activity was measured in chondrocytes using fluorimetric assays, and enzymes were immunolocalized using monospecific antibodies. Enzyme histochemistry in normal and OA femoral heads was used to characterize enzymatic activity in full thickness samples containing cartilage and subchondral bone. The zonal distribution of cathepsin activity was measured in tissue slices of normal and OA femoral heads cut parallel to the joint surface, using fluorogenic substrates.

RESULTS

Cathepsins B and L were localized by immunohistochemistry with lysosome-like structures in dedifferentiated chondrocytes. Free cysteine peptidase activity (i.e., not requiring prior activation), secreted and intracellularly stored by chondrocytes, was due to cathepsin B, while cathepsin L contributed a minor fraction of the total activity, and was seen only after activation at acidic pH. Histochemistry and activity measurements confirmed cathepsin B as the major, active cysteine peptidase in OA cartilage, particularly at sites where matrix neosynthesis took place. However, free cathepsin L and/or cathepsin K activity was found subchondrally in association with cathepsin B in osteophytes, in zones undergoing bone remodeling, and at sites of inflammation.

CONCLUSION

Cathepsin B, not cathepsin L or cathepsin K, is a candidate for articular cartilage catabolism in OA. While cathepsin K is the major osteoclastic cysteine peptidase, cathepsin L and cathepsin B may also participate in the remodeling processes of bone as well as in bone erosion by inflammatory cells.

[Outpatient treatment of patients with cardiovascular diseases]

In Germany, cardiovascular disturbances belong to the diseases most frequently treated in the offices of general practitioners and internal specialists. With comprehensive monitoring and the taking of adequate therapeutic measures, the average mortality age of the majority of the 18 million patients suffering from circulatory diseases lies at 79.4 years. In the age group of over 70 years, 70 to 80% of the patients receive treatment against cardiovascular disturbances, most of them against hypertension. One of the most important goals of monitoring and intervention in the outpatient sector is the treatment of hypertension, especially in connection with measures taken against disturbances in lipometabolism in order to prevent secondary diseases. The success of treatment is shown by the decreasing age standardized rate of cardiac infarctions, especially among men, and the decreasing mortality rate of patients below 65. The increasing treatment in the outpatient sector is accompanied by additional interventions, especially by bypass surgery in the hospital sector. The concerted actions in both the outpatient and the inpatient sector result in a higher service provision to come to a higher quality of life in the patients and to prevent early death.

[Expectations of psychiatric patients from their outpatient and inpatient treatment]

OBJECTIVE

This study describes patient evaluations about treatment interventions and the subjective value of specific treatment expectations.

METHOD

A random sample of 425 out-patients and in-patients was assessed to evaluate importance of treatment interventions and specific expectations of psychiatric treatment.

RESULTS

Preferences regarding treatment interventions varied among diagnostic groups. Psychiatric patients ranked medication and supporting therapeutic conversations the highest. Sociodemographic characteristics, numbers of previous hospitalizations, quality of life and social abilities influenced treatment expectations. A patient's perception of dissatisfying quality of life and high social vulnerability increased the need for social assistance.

CONCLUSION

Subjective treatment expectations of psychiatric patients should be the start-out for every treatment-regime. Socially vulnerable patients should be identified and specific treatment plans should be developed at treatment-start.

Wild-type p53 suppresses angiogenesis in human leiomyosarcoma and synovial sarcoma by transcriptional suppression of vascular endothelial growth factor expression

Our recent studies (R. Pollock et al., Clin. Cancer Res., 4: 1985-1994, 1998; M. Milas et al., Cancer Gene Ther., in press, 2000) have shown that the restoration of wild-type (wt) p53 enhances cell cycle control in vitro and inhibits the growth of human soft-tissue sarcoma in severe combined immunodeficient mice. We hypothesized that the antitumor effect of wt p53 overexpression in sarcoma cells is attributable not only to enhanced cell cycle control but also to inhibition of angiogenesis. We evaluated the effect of restoring wt p53 function on angiogenesis in human soft-tissue sarcoma harboring mutant p53. Restoration of wt p53 expression in human leiomyosarcoma SKLMS-1 cells that contain mutant p53 markedly inhibited angiogenesis induced by tumor cells in vivo. Angiogenesis assays using an in vivo Matrigel plug assay demonstrated that less neovascularization in severe combined immunodeficient mice was observed with conditioned medium (CM) from human synovial sarcoma cells expressing wt p53 compared with CM from human synovial sarcoma cells expressing mutant p53. Microvessel density and microvessel counts were lower in tumor xenografts from cells containing wt p53 than in tumor xenografts from cells containing mutant p53. The growth and migration of murine lung endothelial cells were decreased when cells were treated with CM from sarcoma cells expressing wt p53 compared with CM from sarcoma cells expressing mutant p53. The introduction of wt p53 into sarcoma cells containing mutant p53 significantly reduced the expression of vascular endothelial growth factor (VEGF), which is a key mediator of tumor angiogenesis. Stimulation of endothelial cell migration by CM from cells expressing mutant p53 was significantly reduced after anti-VEGF neutralizing antibody was added to the CM. Using luciferase as the reporter of VEGF promoter activity, we found that wt p53 inhibited VEGF promoter activity in SKLMS-1 cells. Deletion analysis defined an 87-bp region (bp -135 to -48) in the VEGF promoter that is necessary for inhibiting VEGF promoter activity by wt p53. The transcription factor Sp1 may be involved in the repression of VEGF promoter activity by wt p53 in SKLMS-1 cells. These data indicated that wt p53 can suppress angiogenesis in human soft-tissue sarcomas by transcriptional repression of VEGF expression.

Nuclear factor kappaB in proliferation, activation, and apoptosis in rat hepatic stellate cells

BACKGROUND/AIMS

Activation of the transcription factor NFkappaB has been demonstrated in activated hepatic stellate cells (HSCs). We investigated the role of NFkappaB in proliferation, in activation, and in TNFalpha-induced apoptosis of HSCs.

METHODS

NFkappaB activation was inhibited using an adenovirus expressing an IkappaB dominant negative protein (Ad5IkappaB) in both quiescent and activated HSCs. Quiescent HSCs were infected with Ad5IkappaB or an adenovirus expressing beta-galactosidase (Ad5LacZ). The cells were cultured for 7 days. HSCs activation was determined by cell morphology, smooth muscle alpha-actin (alpha-sma) expression, and steady-state mRNA levels of alpha1(I) collagen as assessed by Western blot and RNase protection assay, respectively. Proliferation was determined in culture-activated HSCs by 3H-thymidine incorporation and direct cell counting. Apoptosis was analyzed by infecting quiescent or activated HSCs with Ad5IkappaB or Ad5LacZ, and then treating with TNFalpha. Apoptosis was demonstrated by determining cell number, assessing nuclear morphology, TUNEL assay and caspase 3 activity.

RESULTS

After 7 days in culture no differences were noted between the Ad5IkappaB- and the Ad5LacZ-infected cells in the morphology, alpha-sma expression or in alpha1(I) collagen mRNA levels. Ad5IkappaB infection did not modify proliferation in activated HSCs. TNFalpha induced apoptosis only in Ad5IkappaB-infected activated, but not quiescent HSCs. Apoptosis was initially demonstrated 12 h after exposure to TNFalpha. Twenty-four h after the TNFalpha treatment, 60% of the activated HSCs were apoptotic.

CONCLUSION

NFkappaB activity is not required for proliferation or activation of HSCs; however, NFkappaB protects activated HSCs against TNFalpha-induced apoptosis.

[Quality of life of the mentally ill]

Object of this research project was to study the subjective quality of life of psychiatric patients. The vulnerability of 424 out- and inpatients was assessed. The Vulnerability Index, composed of: marital status, income, health, life conditions, occupation, and risk factors in childhood was used. According to their vulnerability, two groups of patients were differentiated: patients with high and low vulnerability. We compared these objective criteria of vulnerability with the subjective quality of life (Q-LES-Q). Quality of life was also compared with diagnosis, severity of illness, and treatment (first contact/long-term contacts). Quality of life of 250 patients was analysed after one year follow up. Patients with a low vulnerability score are more satisfied with 'social relations' than patients with a high vulnerability score. In-patients are more satisfied with 'social relations' than out-patients. Out-patients are more satisfied with their 'physical health', 'subjective feelings', 'leisure time activities', and 'overall life satisfaction' than in-patients. Patients with a mild affective disorder have a better 'life satisfaction' than patients with severe affective disorder. Quality of life of schizophrenics and of patients with anxiety and adjustment disorders has improved significantly after one year.

[Helicobacter pylori and coronary heart diseases--hypotheses and facts]

In 1994 Mendall et al. (9) have suggested that there might be a correlation between Helicobacter pylori (HP) infection and coronary heart disease (CHD), mediated by a chronic low-grade acute phase reaction with mildly raised serum or plasma concentrations of C-reactive protein and fibrinogen. According to this hypothesis, a gastric HP colonization might be an additional risk factor for CHD. In the meantime, 35 studies have examined whether HP seropositivity is associated with CHD occurrence. However, in 8 publications only CHD was definitively proven (in CHD+ patients) or excluded (in the corresponding control groups) by coronary artery angiography, and in only 2 of them (1 abstract, 1 full-length publication) a significant association between HP positivity (serologically proven) and CHD was ascertained. Additionally, a metaanalysis of 18 studies including 10,000 patients could not demonstrate any correlations between HP seropositivity and different acute phase proteins (66). Thus, a positive correlation between gastric HP colonization and CHD is far from being proven. Further proposed links between HP infection and CHD such as hyperhomocysteinemia (67) or autoimmune mechanisms (71) due to cross-reacting antibodies to HP HSP60/65 (heat shock protein) with human endothel-derived HSP60/65 need further confirmation.

Adenovirus-mediated p53 gene therapy inhibits human sarcoma tumorigenicity

Mutations of the p53 tumor-suppressor gene are the most frequent genetic abnormality in soft tissue sarcomas. Because these rare tumors also respond poorly to standard chemotherapy and bear a 50% 5-year mortality rate, we investigated the possible therapeutic benefits of p53 gene restoration in sarcomas. We constructed Ad5p53, which is an E1A-deleted, replication-deficient adenovirus expressing a cytomegalovirus promoter-driven wild-type p53 cDNA with a Flag sequence tag. SKLMS-1 human leiomyosarcoma cells containing a mis-sense p53 point mutation were effectively transduced with Ad5p53. Increasing levels of Flag-p53 protein, as well as dose-dependent p21Cip1 induction, were observed through a dose range of 10-500 plaque-forming units (PFU)/cell. In vitro administration of Ad5p53 as a single 100 PFU/cell dose caused 40-60% growth inhibition of SKLMS-1 cells at posttreatment days 4, 6, and 8 compared with untreated or viral control treated-cells (P < .05, Student's t test). Relative to these same controls, in vivo treatment of SKLMS-1-bearing severe combined immunodeficient mice with 6 x 10(9) PFU of Ad5p53 by intratumoral injection resulted in a 35-day tumor growth delay and complete tumor regression in 40% of mice (P < .05, Student's t test). The expression of virally derived p53 mRNA in Ad5p53-treated tumor tissues was detected in treated tumor specimens by reverse transcriptase polymerase chain reaction. Reduced intratumoral cellularity and the presence of p53 staining in adjacent normal tissue, consistent with delivery of exogenous p53 to the tumor target, were evident only in Ad5p53-treated tumors after immunohistochemical staining for p53. These results indicate that wild-type p53 gene restoration in sarcomas retards tumor growth and may come to be usefully applied to the clinical treatment of this disease as a single regimen or in combination with conventional therapies.

[Initial effects of the 1998 revised narcotic law in substitute drug treatment of narcotic dependent patients--results of a physician survey]

To study the consequences of the last revision of the German narcotics act (1998, which forbids prescribing codeines as substitutes), a survey was carried out several months after implementation with 639 physicians, who gave substitution treatment. It could be determined how far codeine patients were ready to change their substitute, how content physicians said their patients were after changing the substitute and which were the attitudes of physicians to the revision in question.

RESULTS

The majority of patients (70%) who were formerly substituted by means of codeine accepted methadone as a substitute. After the method of substitution had been changed, 51% of patients had been classified as "very content" and 35% as "reasonably content". Especially those physicians who prescribed codeines in the past, unlike physicians who used methadone for substitution treatment only, criticised the revision in question and feared that many patients should be without medical care as a consequence of the new situation.

[Assisted living for former long-term hospitalized psychiatric patients]

OBJECTIVES

The aim of the study is the evaluation of essential characteristics of patients who entered the sheltered group homes of the Psychosozialen Dienst (PSD) in the city of Vienna after the establishment of sectorized psychiatric out-patient care facilities.

METHOD

Eighty patients who lived in these group homes on the first key day, June 30th 1993, were investigated. Any change in their living situation and rate of hospitalization was ascertained at follow-up, 3.5 years after the first key day.

RESULTS

The patients had an average period of hospitalization of 240.5 days per year before entry to a group home, which decreased to 12.4 days per year after entry to a sheltered group home. At follow-up more than half of all patients (65%) were still able to live in the community successfully. The number and the length of hospitalizations between the first key day and the follow-up were lowest for patients who had moved to private homes.

CONCLUSIONS

Sheltered group homes play an essential role in the process of rehabilitation towards independent living within the community. The results demonstrate that rehabilitation in private apartments can be possible even after 5.7 years of residence in sheltered group homes.

Response types in Collembola towards copper in the microenvironment

Laboratory studies were carried out to cast light on differences in density responses among collembolan species to copper (Cu)-polluted environments. In a recolonisation experiment, mesofauna originating from a copper (Cupolluted arable field were allowed to colonise defaunated Cu-contaminated and uncontaminated soil cores for 3 months. The abundances of Pseudosinella alba and gamasid mites were higher in the uncontaminated soil, whereas the majority of other collembolans tended to be more abundant in the Cu-enriched soil. Behavioural experiments were conducted to test the ability of single Collembola species to distinguish between filter paper and food soaked in water, Cu, and calcium (Ca) solutions. Onychiurus armatus avoided both Cu and Ca, whereas Folsomia quadrioculata and Folsomia manolachei showed a significant preference for Cu. Isotomurus palustris was not able to distinguish between Cu and water. The results are compared and discussed with regard to other studies on the occurrence and behaviour of Collembola in Cu-contaminated environments. We suggest that microsite selection according to preference or avoidance of high salinity of pore water may partly explain the community structure of Collembola in Cu-polluted soils which are characterised by an increase of euedaphic species. More studies have to be carried out to generalise this concept and to explore to what extent reduced predation by gamasid mites contribute to the success of certain Collembola in Cu-contaminated sites.

Net mass transfer of plasma cholesteryl esters and lipid transfer proteins in normolipidemic patients with peripheral vascular disease

The role of plasma cholesteryl ester transfer and lipid transfer proteins in atherosclerosis is unclear. Recent data suggest both antiatherogenic and atherogenic properties for cholesteryl ester transfer protein (CETP). The overall effect of CETP on atherosclerosis may thus vary depending on individual lipid metabolism. To test whether lipid transfer parameters are of importance even in patients without major lipid risk factors for atherosclerosis, CETP mass and activity, net mass transfer of cholesteryl esters between endogenous lipoproteins (CET), and phospholipid transfer protein (PLTP) activity were determined in plasma from 18 normolipidemic male patients with peripheral vascular disease and 21 controls. Furthermore, lecithin: cholesterol acyltransferase (LCAT) activity was tested. The results show that CETP mass, CETP activity, and LCAT activity are not different between patients and controls. However, specific CETP activity (CETP activity/CETP mass) is lower in the patients (P < .02). On the contrary, higher CET is observed in patients' plasma (P < .001). Increased plasma PLTP activity (P = .052) is demonstrable in the patients. If the data of all subjects are combined, CET correlates positively with triglycerides ([TG], r = .45, P < .001) and with PLTP activity (r = .32, P < .05) but negatively with specific CETP activity (r = -.37 P < .05). CET and specific CETP activity remain significantly different in TG-matched patients and controls and are more strongly interrelated (r = -.71, P < .001), suggesting a higher and selective influence of lipid transfer inhibitor(s) on CET and CETP activity in the patients. CET allows the best discrimination between patients and controls in univariate and multivariate analysis. Eighty-eight percent of the subjects are correctly classified by CET as a single parameter. The results suggest that increased CET in the patients may reflect atherogenic alterations in TG metabolism and/or in lipid transfer protein activities despite normal fasting lipoprotein levels.

[Consensus on the diagnosis of multi-system atrophy]

We report the results of a consensus conference on the diagnosis of multiple system atrophy. We describe the clinical features of the disease, which include four domains: autonomic failure/urinary dysfunction, parkinsonism and cerebellar ataxia, and corticospinal dysfunction. We set criteria to define the relative importance of these features. The diagnosis of possible multiple system atrophy requires one criterion plus two features from separate domains. The diagnosis of probable multiple system atrophy requires the criterion for autonomic failure/urinary dysfunction plus poor levodopa responsive parkinsonism or cerebellar ataxia. The diagnosis of definite multiple system atrophy requires pathological confirmation.

Coagulation factor IXa: the relaxed conformation of Tyr99 blocks substrate binding

BACKGROUND

Among the S1 family of serine proteinases, the blood coagulation factor IXa (fIXa) is uniquely inefficient against synthetic peptide substrates. Mutagenesis studies show that a loop of residues at the S2-S4 substrate-binding cleft (the 99-loop) contributes to the low efficiency. The crystal structure of porcine fIXa in complex with the inhibitor D-Phe-Pro-Arg-chloromethylketone (PPACK) was unable to directly clarify the role of the 99-loop, as the doubly covalent inhibitor induced an active conformation of fIXa.

RESULTS

The crystal structure of a recombinant two-domain construct of human fIXa in complex with p-aminobenzamidine shows that the Tyr99 sidechain adopts an atypical conformation in the absence of substrate interactions. In this conformation, the hydroxyl group occupies the volume corresponding to the mainchain of a canonically bound substrate P2 residue. To accommodate substrate binding, Tyr99 must adopt a higher energy conformation that creates the S2 pocket and restricts the S4 pocket, as in fIXa-PPACK. The energy cost may contribute significantly to the poor K(M) values of fIXa for chromogenic substrates. In homologs, such as factor Xa and tissue plasminogen activator, the different conformation of the 99-loop leaves Tyr99 in low-energy conformations in both bound and unbound states.

CONCLUSIONS

Molecular recognition of substrates by fIXa seems to be determined by the action of the 99-loop on Tyr99. This is in contrast to other coagulation enzymes where, in general, the chemical nature of residue 99 determines molecular recognition in S2 and S3-S4. This dominant role on substrate interaction suggests that the 99-loop may be rearranged in the physiological fX activation complex of fIXa, fVIIIa, and fX.

Stimulation of angiogenesis through cathepsin B inactivation of the tissue inhibitors of matrix metalloproteinases

The tissue inhibitors of matrix metalloproteinases (MMPs), TIMP-1 and TIMP-2, are also angiogenesis inhibitors. Cathepsin B and MMPs are found at sites of neovascularization in pathologies such as cancer and osteoarthritis. Treatment of TIMP-1, TIMP-2, and of a mixture of both inhibitors from human articular chondrocytes with cathepsin B resulted in their fragmentation, whereby they lost their MMP-inhibitory and anti-angiogenic activities. Our data suggest that, besides directly participating in tissue destruction, cathepsin B can be harmful for two further reasons: it raises the activity of the MMPs also in the absence of mechanisms up-regulating these enzymes, and it stimulates angiogenesis. This is a prerequisite for blood vessel invasion in a variety of pathological situations of which cancer and osteoarthritis are prominent examples.

Analysis of edge glare phenomena in intraocular lens edge designs

PURPOSE

To determine the image and relative intensity of reflected glare images from 4 commonly used intraocular lens (IOL) edge designs to assess the potential for noticeable postoperative edge glare.

SETTING

University of Texas Medical School, Houston, Texas, USA.

METHODS

The interaction of light rays from 4 common IOL edge designs were examined in an eye model using the OptiCAD 3-D radiometric ray-tracing program (Opticad Corp.). Comparison of the potential of the 4 edge designs to produce visual sensations was derived from plots of the spatial location and energy distribution of rays forming the retinal image.

RESULTS

Edge designs with no anterior and posterior dioptric powers at the lens periphery (lenticular) and rounded corners distributed the edge glare rays over a large retinal area. Edge designs with sharp edges formed by "cropping" the anterior and posterior optic zones focused edge glare rays into distinct arc-shaped images. The peak intensity of the arc-shaped image was 8 to 10 times stronger than the peak intensity of the diffuse image formed by lenses with rounded edges.

CONCLUSIONS

Rounded IOL edges distribute reflected glare image over a significantly greater area than sharp edges. Rounded edges reduce the potential for edge glare phenomena that appear to the patient as a thin crescent or partial ring.

Management of Parkinson's disease a review of current and new therapies

The management of Parkinson's disease has undergone recent changes with the advent of new therapies, both pharmacotherapy and surgery. Available interventions are discussed. Levodopa remains the mainstay of therapy. New drugs include the dopamine agonists and COMT inhibitors. New dopamine agonists which may have a levodopa "sparing effect;" it has been suggested that some of the drugs should be considered as first line treatments for newly diagnosed Parkinson's disease patients. We review roles of these drugs. The concept of neuroprotection in neurodegenerative disorders such as Parkinson's disease became popular in the mid 1980s and it is hoped that eventually therapy will be directed at slowing progression of the disease. A great deal more work needs to be done before a suitable agent is identified as being neuroprotective. Potential neuroprotective agents are reviewed. Surgical therapies for Parkinson's disease consisting of various forms of lesion surgery as well as stimulation procedures are reviewed. Complications of drug therapy include motor problems such as motor response fluctuations, as well as psychiatric complications including levodopa-induced psychosis. Atypical neuroleptic agents and ECT for psychiatric syndromes associated with Parkinson's disease are discussed. Algorithms for the management of early disease as well as the management of psychosis in Parkinson's disease are included. Treatment options for advanced disease are tabulated.

[Meningococcal sepsis in 3 young men]

HISTORY AND CLINICAL FINDINGS

Three young men became ill one after the other with fever, headaches, vomiting, arthralgias and muscle pain. One day after beginning of symptoms all three patients developed a haemorrhagic rash with petechial and ecchymotic lesions most intense on distal extremities. 24 hours later patient no. 1 and 3 were in septic shock.

INVESTIGATIONS

Laboratory tests showed signs of systemic infection, disseminated intravascular coagulation and renal failure. On the day of admission to the hospital blood cultures showed Neisseria meningitidis in patient no. 1 and 3. In patient no. 2 blood cultures were negative.

TREATMENT AND COURSE

Intravenous antibiotic therapy was started immediately after admission. In patient no. 1 and 3 purpura fulminans with multiple organ failure demanded intensive care treatment. Patient no. 1 recovered. Necrotic toes made amputations necessary. Patient no. 2 was never critically ill. Patient no. 3, whose course was complicated by a long lasting disseminated intravascular coagulation, died from massive cerebral bleeding 6 days after admission. Patient no. 2, who was treated with ciprofloxacin after symptoms began was never critically ill.

CONCLUSION

Neisseria meningitidis sepsis has a high mortality rate. Rapid admission to the hospital and beginning of an antibiotic therapy with penicillin G or a third-generation cephalosporin is a priority when meningococcal disease is suspected. Chemoprophylaxis should be offered to close contacts of patients.

Gene regulation in hepatic stellate cell

Hepatic stellate cells are now recognized as the major source of extracellular matrix in hepatic fibrosis. Following liver injury the hepatic stellate cell changes from a quiescent to an activated cell. The activation process includes an increased proliferation rate, a phenotypic change to a myofibroblast-like cell, loss of vitamin A stores, increased extra-cellular matrix protein synthesis and contractility. Furthermore, hepatic stellate cells have been implicated in hepatic inflammation through their ability to secrete cytokines and chemokines. Here, we review the literature on the molecular pathogenesis of hepatic stellate cells activation with emphasis on the most recent findings. The reviewed topics include transcriptional and post-transcriptional regulation of the genes encoding type I collagen in hepatic stellate cells; the role of the transcription factor nuclear factor Kappa B in the hepatic stellate cell activation; focal adhesion kinase and integrin-mediated signal transduction in hepatic stellate cell, and apoptosis in hepatic stellate cells. New insight into hepatic stellate cell activation and death may lead to the development of novel therapies for hepatic fibrosis.

Consensus statement on the diagnosis of multiple system atrophy. American Autonomic Society and American Academy of Neurology

We report the results of a consensus conference on the diagnosis of multiple system atrophy (MSA). We describe the clinical features of the disease, which include four domains: autonomic failure/urinary dysfunction, parkinsonism and cerebellar ataxia, and corticospinal dysfunction. We set criteria to define the relative importance of these features. The diagnosis of possible MSA requires one criterion plus two features from separate domains. The diagnosis of probable MSA requires the criterion for autonomic failure/urinary dysfunction plus poor levodopa responsive parkinsonism or cerebellar ataxia. The diagnosis of definite MSA requires pathological confirmation.

A concept analysis of parent-infant attachment

A concept analysis, the clarification of a concept, is the first step towards building the foundations of nursing theory, research and practice. As a relevant concept for nurses working with childbearing families, parent-infant attachment is an important part of the body of nursing knowledge. Wilson's method of concept analysis was used to generate antecedents, critical attributes and consequences of parent-infant attachment, highlighting the need to refine measurements of this concept.

Efficacy and toxicity of 2-Chlorodeoxyadenosine (Cladribine)--2 h infusion for 5 days--as first-line treatment for advanced low grade non-Hodgkin's lymphoma

2-Chlorodeoxyadenosine (Cladribine) is a new purine analogue with high activity in pretreated low grade non-Hodgkin's lymphoma (NHL). To evaluate the efficacy of this drug in untreated patients with advanced NHL, we performed a prospective multicentre trial. Cladribine (0.12 mg/kg) was administered intravenously daily for 5 consecutive days in an out-patient setting. The treatment was repeated every 28 days for four cycles. Included were patients with a histological diagnosis of low grade NHL according to the Kiel classification and stage III or IV disease. Stage II patients were included when radiotherapy had failed. 55 patients were entered into the study. 50 patients were evaluable. The remission rate was 44/50 (88%; 95% confidence interval 82-100%), including complete remissions (CR) in 14 (28%) patients. Only 2 patients showed progression while on Cladribine treatment. The estimated overall survival, and time to treatment failure (TTF) were 85% and 51%, respectively, after a median observation time of 92 weeks. 11 (22%) patients showed grade 3 or 4 toxicity according to the WHO grading. Haematological toxicity was responsible for 86% of the overall toxicity and 100% of grade 3 and 4 toxicity. 7 patients (14%) had an infection, two of which were opportunistic. 12 (24%) patients did not experience any toxicity during the treatment. The results of this study clearly demonstrate the safety and considerable activity of this regimen. Cladribine is very effective even at lower doses than have been used so far.