[Will telemonitoring be adopted by patients with chronic heart failure?]

BACKGROUND

Remote Patient Management for chronic heart failure (CHF) is gaining increasing importance in health care. Telemonitoring is defined as daily measuring of health parameters by the patient and their transmission to a telemedical centre. The adherence of this action by the patient can be considered as a measure for RPM adoption.

METHODS

The randomized controlled clinical trial TIM-HF (NCT 00543881) was conducted between 2008 and 2010 with 710 CHF patients with the primary endpoint total mortality for a mean follow-up of 21.5 ± 7.2 months. The non-prespecified analysis of adherence to daily measuring of ECG, blood pressure, weight and self-assessment was focused on sociodemographic and disease-related factors of the 354 RPM patients.

RESULTS

The mean adherence to telemonitoring was more than 80% (absolute adherence: 81.8 ± 22.8%, relative adherence: 88.9 ± 21.5%). From the beginning of treatment 6.5% of the patients (23/354) have shown an adherence below average. The high adherence of the majority of the patients was stable for the entire study duration and irrespective of age, sex, severity of the disease and the presence of mild to moderate depression.

CONCLUSION

A high adherence can be achieved by individual training of the patient regarding the handling of his disease, the use of telemedical devices and an easy-to-use telemonitoring system. The majority of the informed self-determined CHF patients NYHA class II/III are adopting telemonitoring and are adherent in the long term.

Resection of an intramedullary high cervical metastasis from a malignant mixed Muellerian tumour

We present a 66-year-old female patient with a high cervical intramedullary metastasis from a malignant mixed Muellerian tumour (MMMT; carcinosarcoma) with concomitant syringomyelia. She was admitted to our clinic with symptoms of cervical myelopathy. MRI revealed an intramedullary tumour of 2.6cm×1.2cm at the cervical vertebral body C2. We performed a laminectomy on C2 followed by a dorsal median myelotomy from C1 to C3 to resect the tumour. The surgical intervention removed the tumour completely and resolved the syringomyelia. During the 36months of follow-up, the patient presented in a stable condition with no evidence of tumour recurrence. To our knowledge, this is the first report of an intramedullary metastasis of a MMMT.

Calcifying pseudoneoplasms of the neuraxis (CAPNON): clinical features and therapeutic options

INTRODUCTION

Calcifying pseudoneoplasms of the neuraxis (CAPNON) are rare, slow-growing lesions occurring anywhere in the central nervous system (CNS). Since their first description in 1978, only 39 cases have been reported in the literature.

METHODS

The cases of two patients with histopathologically verified diagnoses of CAPNON are presented. Thereafter, we review all reports published so far with respect to study type, number of patients, anatomical area (intracranial, spinal, or both), clinical presentation, radiological presentation, therapy, duration of follow-up, incidence and type of complication, and outcome. Furthermore, current recommendations for the management of spinal and cerebral CAPNON are discussed.

RESULTS

A total of 19 retrospective articles were identified and selected for review: 6 case series (31.6 %) and 13 reports of single cases (68.4 %). The 19 articles and our two additional cases added up to a total of 19 patients with spinal CAPNON and 22 patients with intracranial CAPNON. All patients were treated surgically. A follow-up was provided in 13 patients with spinal (68.4 %) and in 16 patients with intracranial CAPNON (72.7 %), respectively. The follow-up showed no signs of recurrence in 12 of 13 patients with spinal CAPNON (92.3 %) and in 15 of 16 patients with intracranial CAPNON (93.7 %). One-tailed Fisher's exact test revealed no significant difference between complete and incomplete resection in terms of disease recurrence (spinal: p = 0.6842; intracranial: p = 0.3749). Analysis of the literature did not reveal any deaths directly associated with CAPNON.

CONCLUSIONS

Calcifying pseudoneoplasms are rare benign lesions of the CNS of yet unknown origin. Because of the increasing number of reports, this clinical entity should be taken into consideration in the differential diagnosis of intracranial and intraspinal calcified lesions.

Terson haemorrhage in patients suffering aneurysmal subarachnoid haemorrhage: a prospective analysis of 60 consecutive patients

OBJECTIVE

The concomitance of vitreous/subhyaloid haemorrhage (Terson syndrome; TS) and aneurysmal subarachnoid haemorrhage (aSAH) is commonly underestimated. The aim of this study was to determine the incidence of TS and to identify parameters that predispose its development, indicate the severity of the underlying disease, and predict outcome.

METHODS

Sixty consecutive patients suffering from aSAH were included in this study. The admitting Glasgow Coma Scale scores (GCS), Hunt & Hess (H&H) and Fisher grades were documented. All participants were ophthalmologically examined. The outcome at discharge was estimated using the Glasgow Outcome Scale (GOS).

RESULTS

Of the 60 patients admitted for aSAH, eleven (18.3%) displayed TS within 24h after aneurysm rupture. Statistical analysis revealed a significant relation between TS and either high Fisher- (3.0 vs. 2.32; p=0.008) or H&H- (4.09 vs. 2.69; p=0.001) and low GCS- (5.55 vs. 12.87; p<0.001) scores. Compared with the non-TS group, patients with TS displayed generally worse outcomes (mean GOS 2.09 vs. 3.53; p=0.007), including a significantly higher mortality (36.4 vs. 10.2%; p=0.028).

CONCLUSION

Terson syndrome is likely to occur in severe aSAH with poor admission scores and indicates a worse functional outcome. An ophthalmological examination is strongly recommended in aSAH patients with poor admission scores.

Successful resection of the recurrence of a cavernous malformation of the optic chiasm

The case of a 33-year-old female who suffered from a recurrence of an intrachiasmatic cavernous malformation is presented. She had already undergone surgery in 1991 and 2001 and was admitted to our hospital with reduced vision in the right eye. After MRI, and diagnosis of recurrence of the cavernoma, a neurosurgical operation was performed using the pterional approach. The intraoperative situation was documented with micro photographs. The postoperative course was uneventful. The female described a minimal improvement of her vision. No postoperative complications were observed. To our knowledge, microsurgically complete extirpation of a recurrence of an intrachiasmatic cavernoma has not yet been reported in the literature.

[The intracranial meningioma - therapeutic possibilities and limitations]

Meningiomas are common intracranial tumours that arise from arachnoidal cells. Clinically they often manifest by headache, focal or generalized seizures, or neurologic deficits as a result of brain compression. More than 90 percent of these mostly slow growing meningiomas are benign. In symptomatic patients a resection should be performed with the intention to cure or at least alleviate symptoms. In cases of subtotal resection an adjuvant radiotherapy should be deliberated. Stereotactic radiotherapy as initial treatment is an effective alternative for meningiomas, especially in patients not suitable for surgery due to various reasons. In patients that are refractory to treatment or with unresectable disease a hormonal- or chemotherapy can be considered.

Percutaneous placement of pedicle screws in the lumbar spine using a bone mounted miniature robotic system: first experiences and accuracy of screw placement

STUDY DESIGN

A prospective analysis.

OBJECTIVE

The idea of this study was to evaluate a new miniature robotic system providing passive guidance for pedicle screw placement at the lumbar spine. Special focus was laid on the postoperative accuracy of screw placement.

SUMMARY AND BACKGROUND DATA

Recent technical developments lead to a minimization of pedicle screw fixation techniques. However, the use of navigational techniques is still under controversy.

METHODS

Patients selected for a minimal invasive posterior lumbar interbody fusion received a spiral computer tomographic scan before surgery. The miniature hexapod robot was mounted to the spinous process and the system moves to the exact entry point according to the trajectory of the surgeon's preoperative plan. After minimal invasive screw placement all patients received routinely a postoperative spiral computer tomographic scan. Screws placed exactly within the pedicle were evaluated as group A, screws deviating <2 mm were evaluated as group B, > or =2 mm to <4 mm (group C); > or =4 mm to <6 mm (group D); and more than 6 mm (group E).

RESULTS

Thirty-one patients received a PLIF with percutaneous posterior pedicle screw insertion using the bone mounted miniature robotic device. A total of 133 pedicle screws were placed. The majority of the screws were placed in L5 (58 screws; 43.6%). In axial plane, 91.7% of the screws were evaluated as group A and 6.8% were evaluated as group B. In longitudinal plane, 81.2% of the screws were evaluated as group A and 9.8% were evaluated as group B. In 1 screw (L5 right) the postoperative evaluation was done as group C (axial plane) and D (longitudinal plane). In 29/31 cases the integration of the miniature robotic system was successful.

CONCLUSION

In our study the first clinical assessment of a new bone mounted robot system guiding percutaneous pedicle screw placement was done. A deviation <2 mm to the surgeon 's plan in 91.0% to 98.5% verifies the system's accuracy.

Schmerzreduktion nach Operation an der Halswirbelsäule

AIM

Surgery in cervical spine disease using titanium cages is a common procedure to reduce the pain and neurological deficits. This study was aimed to evaluate the results in pain reduction using the wing cage intraoperatively.

METHOD

In this prospective study demographic data were noted, whereas special emphasis was placed on pain, which was noted using a visual pain scale and the prolo score, neurological deficits and the causing pathology. Furthermore, questions about the use of analgesics and the duration of pain were asked. After operation with insertion of a wing cage instead of the disk, a neurological investigation 6, 12 and 24 months later was done to evaluate the postoperative status.

RESULTS

54 patients underwent a cervical discectomy in 64 segments as therapy for neck pain or a radiculopathy caused by osteochondrosis or disc disorder. Patients with brachialgia profited most from the operation. Less improvement was seen in cases of osteochondrosis or combined pathology.

CONCLUSION

Patients with pain caused by discs in the cervical spine, have better improvement than patients with other pathologies. This should be taken into account when choosing the mode of therapy.

The spliceosomal snRNP core complex of Trypanosoma brucei: cloning and functional analysis reveals seven Sm protein constituents

Each of the trypanosome small nuclear ribonucleoproteins (snRNPs) U2, U4/U6, and U5, as well as the spliced leader (SL) RNP, contains a core of common proteins, which we have previously identified. This core is unusual because it is not recognized by anti-Sm Abs and it associates with an Sm-related sequence in the trypanosome small nuclear RNAs (snRNAs). Using peptide sequences derived from affinity-purified U2 snRNP proteins, we have cloned cDNAs for five common proteins of 8.5, 10, 12.5, 14, and 15 kDa of Trypanosoma brucei and identified them as Sm proteins SmF (8.5 kDa), -E (10 kDa), -D1 (12.5 kDa), -G (14 kDa), and -D2 (15 kDa), respectively. Furthermore, we found the trypanosome SmB (T. brucei) and SmD3 (Trypanosoma cruzi) homologues through database searches, thus completing a set of seven canonical Sm proteins. Sequence comparisons of the trypanosome proteins revealed several deviations in highly conserved positions from the Sm consensus motif. We have identified a network of specific heterodimeric and -trimeric Sm protein interactions in vitro. These results are summarized in a model of the trypanosome Sm core, which argues for a strong conservation of the Sm particle structure. The conservation extends also to the functional level, because at least one trypanosome Sm protein, SmG, was able to specifically complement a corresponding mutation in yeast.

Factors influencing shunt dependency after aneurysmal subarachnoid haemorrhage

In this retrospective analysis of 138 patients treated for ruptured aneurysms the development of shunt dependent hydrocephalus was evaluated regarding possible predictive factors. In 15 patients (11%) ventriculo-atrial shunt was implanted due to hydrocephalus. One predictive factor was the localisation of aneurysms as patients with hydrocephalus had PcoA aneurysms in 40% compared to 20% in the group of patients without hydrocephalus and only 7% compared to 28% MCA aneurysms. An other predictive factor was the severity of the subarachnoid haemorrhage (SAH) as 7 patients out of the 15 were graded Fisher IV on admission. Furthermore, an important predictive factor was the presence of acute hydrocephalus as 13 out of the 15 patients (87%) with shunt dependent hydrocephalus had acute hydrocephalus requiring external ventricular drainage. An other possible factor was the intraoperative opening of the lamina terminalis as in 73% of the patients with shunt dependent hydrocephalus compared to 82% in the group of patients without hydrocephalus this procedure was performed during surgery. The results suggest that shunt dependency is more likely after severe SAH especially in the presence of an acute hydrocephalus and in patients with aneurysms located in the basal cisterns. Therefore treatment of the acute hydrocephalus and possible the opening of the lamina terminalis could have a positive effect on the development of shunt dependent hydrocephalus after SAH.

Trans mRNA splicing in trypanosomes: cloning and analysis of a PRP8-homologous gene from Trypanosoma brucei provides evidence for a U5-analogous RNP

In trypanosomes all mRNAs are generated through trans mRNA splicing, requiring the functions of the small nuclear RNAs U2, U4 and U6. In the absence of conventional cis mRNA splicing, the structure and function of a U5-analogous snRNP in trypanosomes has remained an open question. In cis splicing, a U5 snRNP-specific protein component called PRP8 in yeast and p220 in man is a highly conserved, essential splicing factor involved in splice-site recognition and selection. We have cloned and sequenced a genomic region from Trypanosoma brucei, that contains a PRP8/p220-homologous gene (p277) coding for a 277 kDa protein. Using an antibody against a C-terminal region of the trypanosomal p277 protein, a small RNA of approximately 65 nucleotides could be specifically co-immunoprecipitated that appears to be identical with a U5 RNA (SLA2 RNA) recently identified by Dungan et al. (1996). Based on sedimentation, immunoprecipitation and Western blot analyses we conclude that this RNA is part of a stable ribonucleoprotein (RNP) complex and associated not only with the p277 protein, but also with the common proteins present in the other trans-spliceosomal snRNPs. Together these results demonstrate that a U5-analogous RNP exists in trypanosomes and suggest that basic functions of the U5 snRNP are conserved between cis and trans splicing.

Spliced leader RNA of trypanosomes: in vivo mutational analysis reveals extensive and distinct requirements for trans splicing and cap4 formation

In trypanosomes mRNAs are generated through trans splicing. The spliced leader (SL) RNA, which donates the 5'-terminal mini-exon to each of the protein coding exons, plays a central role in the trans splicing process. We have established in vivo assays to study in detail trans splicing, cap4 modification, and RNP assembly of the SL RNA in the trypanosomatid species Leptomonas seymouri. First, we found that extensive sequences within the mini-exon are required for SL RNA function in vivo, although a conserved length of 39 nt is not essential. In contrast, the intron sequence appears to be surprisingly tolerant to mutation; only the stem-loop II structure is indispensable. The asymmetry of the sequence requirements in the stem I region suggests that this domain may exist in different functional conformations. Second, distinct mini-exon sequences outside the modification site are important for efficient cap4 formation. Third, all SL RNA mutations tested allowed core RNP assembly, suggesting flexible requirements for core protein binding. In sum, the results of our mutational analysis provide evidence for a discrete domain structure of the SL RNA and help to explain the strong phylogenetic conservation of the mini-exon sequence and of the overall SL RNA secondary structure; they also suggest that there may be certain differences between trans splicing in nematodes and trypanosomes. This approach provides a basis for studying RNA-RNA interactions in the trans spliceosome.

Isolation and sequence analysis of the fatty acid synthetase FAS2 gene from Penicillium patulum

The fatty acid synthetase complex of Penicillium patulum was isolated and shown to be structurally similar to other known fungal fatty acid synthetases. It is composed of two subunit, alpha and beta, each with a molecular mass of about 200 kDa. P. patulum genomic and cDNA libraries were constructed in lambda gt11 and EMBL3 vectors. From these libraries, the P. patulum FAS2 gene together with its flanking DNA was isolated. The cloned genomic DNA was sequenced over a length of 6357 base pairs. The coding sequence of fatty acid synthetase subunit alpha, being 5571 nucleotides long, was identified within this DNA segment. The FAS2 gene is a mosaic of three exons (514, 4949 and 108 base pairs) and two introns, each of 54 base pairs in length. Both introns were absent in the corresponding cDNA sequences. Like other fungal introns both contain an internal CTAAC sequence, located 10 base pairs upstream of their 3'-exon/intron boundaries. In addition, they have, at their ends, the GTCAAGT and TAG consensus sequences characteristic of all eucaryotic introns. Furthermore, two pairs of direct repeats, of as yet unknown significance, were found in the two P. patulum introns. The P. patulum FAS2 gene encodes a protein of 1857 amino acids and 204.5 kDa molecular mass. It is 90 nucleotides shorter than the corresponding S. cerevisiae gene. In both organisms, the FAS2 genes and their products exhibit a high degree of overall sequence similarity at both the DNA (63%) and protein (68%) levels. Therefore, the fatty acid synthetase alpha subunits of P. patulum and S. cerevisiae obviously contain the same catalytic domains in an identical sequential order.

Abnormal myomuscular junctions and AChE in a congenital neuromuscular disease

We studied a patient with a congenital neuromuscular disease clinically characterized by ophthalmoplegia, slight limb muscle weakness, and normal electromyography. In the muscle biopsy, there were frequent examples of interdigitation of areas of muscle and extracellular spaces giving a fragmented appearance to muscle fibers. These structures resemble myomuscular junctions; acetylcholinesterase activity was present in the vicinity of these structures and on the muscle cell surface.

Carnitine deficiency of skeletal muscle: report of a treated case

We studied a 10-year-old girl with an insidious muscle disease beginning at age 7. Muscle biopsy showed that the majority of type I fibers were vacuolated and contained lipid excess. Carnitine deficiency was found in skeletal muscle. The patient was treated with 3.0 gm L-carnitine per day and with a medium-chain triglyceride diet. She showed a rapid improvement and recovery of strength. A muscle biopsy 8 months later showed a decreased lipid content. Oral carnitine replacement represents an effective treatment for the disease.