[Possible triggers of decompensated chronic complex tinnitus with a therapeutic approach as relating to treatment of epilepsy]

Coxsackieviruses are responsible for numerable diseases in man. This is also the reason for the high prevalence of endemic infection rates in the population. Our analysis (working hypothesis) will focus on the participation of Coxsackieviruses in chronic decompensated, complex tinnitus. Examination of the Coxsackievirus antibody titers might reveal the extent to which a Coxsackieviruses-triggered disease of the central nervous system participates in the direct sequelae of tinnitus disorders. A spread of Coxsackieviruses to the auditory pathway might lead to an overstimulation of the auditory pathway, comparable to an epileptic lesion. Based on this assumption, treatment with an antiepileptic would make sense. The reasoning behind this working hypothesis is to find a potentially new diagnostic and therapeutic roadmap as a further guide for specialized clinics. The authors are well aware that previous results bear little relevance as they have been based on small case numbers.

[From quality assurance to quality management. Applying data from quality assurance studies]

The realization of internal and external surgical quality assurance is natural for hospital physicians. External influences on the hospital and a changed understanding of organisation demand a development of classical quality assurance. The primary aim is a patient orientated quality assurance related to the medical benefits and the patient individual needs. The active creation and establishing of functional organisation process and interprofessional and interdisciplinary structures in hospital setting is a requirement of time.

C1q: a multifunctional ligand for a new immunoadsorption treatment

C1q is a highly conserved protein with multiple functions involved in innate and adaptive immunity. It plays an important role in the activation of the classical pathway of the complement system to mediate the scavenging of infectious agents, apoptotic products, and immune complexes by the mononuclear phagocyte system (MPS). Exhibiting this function, C1q is able to bind various molecules (complexed IgG, IgM, fibrinogen, fibronectin, lipopolysaccharides, DNA, C-reactive protein [CRP], and viral proteins). Moreover, the collagen-like region of C1q is a target of autoantibodies. Immune complexes and anti-C1q autoantibodies are known to be involved in the pathogenesis of autoimmune diseases. Therefore, C1q is a promising candidate to extract waste material from the circulation. Following the development of the C1q immunoadsorbent, 8 patients with systemic lupus erythematosus (SLE) were treated in a first clinical trial. These preliminary results indicate that C1q immunoadsorption is a safe, compatible, and effective treatment for these patients.

Interleukin-6 and its soluble receptor in serum and cerebrospinal fluid after cerebral trauma

Interleukin-6 (IL-6) and its soluble receptor (sIL-6-R) were measured in cerebrospinal fluid (CSF) and serum of 11 severely head injured patients for up to 3 weeks following trauma. IL-6 increased immediately after injury displaying much higher concentrations in CSF than in serum (n = 11). Differently, median levels of sIL-6-R remained in the normal ranges being 10 times higher in serum than in CSF. However, increased amounts over control levels were found in CSF (n = 7) and intrathecal release of sIL-6-R was also suggested (n = 7). Although no correlation with the extent of cerebral lesion or with clinical outcome was evident, elevation of sIL-6-R in CSF supports a pivotal role for IL-6/sIL-6-R complex in the injured brain.

Preoperative functional magnetic resonance imaging (fMRI) of the motor system in patients with tumours in the parietal lobe

Intracranial lesions may compromise structures critical for motor performance, and mapping of the cortex, especially of the motor hand area, is important to reduce postoperative morbidity. We investigated nine patients with parietal lobe tumours and used functional MRI sensitized to changes in blood oxygenation to define the different motor areas, especially the primary sensorimotor cortex, in relation to the localization of the tumour. Activation was determined by pixel-by-pixel correlation of the signal intensity time course with a reference waveform equivalent to the stimulus protocol. All subjects showed significant activation of the primary sensorimotor cortex while performing a finger opposition task with the affected and unaffected side. In five patients the finger opposition task additionally activated the ipsilateral sensorimotor cortex and the supplementary motor area (SMA). Extension and flexion of the foot, additionally performed in two patients, also activated the sensorimotor cortex, in one case within the perifocal oedema of the tumour. Tumour localization near the central sulcus induced displacement of the sensorimotor cortex as compared to the unaffected side in all patients with a relevant mass effect. The results of our study demonstrate that functional MRI at 1.5 T with a clinically used tomograph can reproducibly localize critical brain regions in patients with intracranial lesions.

DALI-the first human whole-blood low-density lipoprotein and lipoprotein (a) apheresis system in clinical use: procedure and clinical results

BACKGROUND

The DALI low-density lipoprotein (LDL) apheresis system is the first whole-blood apheresis system in regular clinical use. DALI stands for direct adsorption of lipoproteins, which describes the basic principle of operation of this newly developed LDL apheresis procedure.

METHODS

The selective removal of LDLs and lipoprotein (a) [Lp(a)] is performed in human whole blood by adsorption onto polyacrylate-coated polyacrylamide beads in an adsorber. This article describes the results of the first open multicentre clinical trial in 14 patients in whom the safety and the efficacy of the system were tested. All patients were treated on average 17 times on a weekly basis. In total, 238 sessions were carried out during the study without severe side-effects. On average, 7675 mL of the patients' whole blood was processed in about 2 h. Anticoagulation in the extracorporeal system was carried out by first giving a heparin bolus followed by continuous addition of an acid citrate dextrose (ACD-A) infusion during the treatment.

RESULTS

The processing of nearly 1.6 times the patient blood volumes resulted in a reduction in the median LDL-cholesterol level by 66-77% (dependent on the system configuration). The Lp(a) concentrations were reduced by 59-73% (dependent on the system configuration). HDL-cholesterol, blood cell count and the other clinical parameters were not significantly affected.

CONCLUSION

Based on this short-term evaluation, the DALI apheresis system is a well-tolerated, effective and simple way of reducing LDL and Lp(a) in human whole blood. The system has been introduced to clinical practice. However, to use the DALI apheresis system in clinical routine, further evaluation of long-term effects is required.

Reduced intracortical facilitation in patients with cerebellar degeneration

OBJECTIVES

Transcranial magnetic stimulation (TMS) was used to study intracortical inhibitory and excitatory phenomena in patients with cerebellar ataxia.

METHODS

Motor evoked potentials (MEP) following single and paired TMS were recorded from the first dorsal interosseus muscle (FDI) in 15 patients with autosomal-dominant or idiopathic cerebellar ataxia and 15 age matched normal controls.

RESULTS

MEP amplitudes after paired TMS with short interstimulus intervals (1-4 ms) showing intracortical inhibition in the control group were not significantly different in the patient group. In contrast, with longer interstimulus intervals (8-20 ms) mean MEP amplitudes were significantly reduced in the patient group, indicating a decrease of intracortical facilitation. The mean postexcitatory inhibition after TMS was also significantly prolonged in the patient group.

CONCLUSION

Our findings support the idea that the cerebellum physiologically exerts a facilitatory influence on the motor cortex which is decreased in patients with a cerebellar degeneration.

Dopa responsive dystonia with Turner's syndrome: clinical, genetic, and neuropsychological studies in a family with a new mutation in the GTP-cyclohydrolase I gene

A 26 year old woman with dopa responsive dystonia and cytogenetically confirmed Turner's syndrome had bilateral globus pallidus hypointensity on brain MRI. Among the living members of a five generation pedigree the patient's mother and the mother's sister also had dopa responsive dystonia; a maternal grandfather had senile parkinsonism, his niece isolated postural tremor. No other family member had Turner's syndrome. A new missense mutation in exon I of the gene of GTP-cyclohydrolase I was found in the three family members with dopa responsive dystonia. With levodopa substitution the patients with dopa responsive dystonia improved clinically as well as in quantitative tests on hand tapping, verbal and performance IQ, concept formation, and set shifting abilities.

LDL hemoperfusion--a new procedure for LDL apheresis: biocompatibility results from a first pilot study in hypercholesterolemic atherosclerosis patients

Current lipid apheresis techniques can remove atherogenic lipoproteins only from plasma. The initial mandatory separation of plasma and blood cells renders the extracorporeal circuit complex. We recently described the first clinical application of a new lipid adsorber that adsorbs low-density lipoprotein (LDL) and lipoprotein (a) (Lp[a]) directly from whole blood. In continuation of our work, this paper describes the clinical biocompatibility of this new LDL hemoperfusion system. In a 2 center phase II clinical trial, 12 hypercholesterolemic patients suffering from overt coronary or peripheral artery disease were treated once with LDL hemoperfusion. The new LDL adsorber (DALI, Fresenius, St. Wendel, Germany) contained 480 ml of polyacrylate coated polyacrylamide gel. The anticoagulation protocol consisted of an initial heparin bolus followed by an acid citrate dextrose-A (ACD-A) infusion during the treatment. One patient blood volume was treated per session. All sessions were clinically uneventful. No signs of hemolysis or extracorporeal clot formation could be detected, and cell counts remained virtually constant. In a subgroup of patients (n = 4-6), further biocompatibility parameters were studied. Activation of leukocytes (elastase release), thrombocytes (beta-thromboglobulin [beta-TG] extrusion), and monocytes (interleukin (IL)-1beta and IL-6) were minimal. Complement activation (C3a and C5a generation) was negligible. The chosen anticoagulation protocol was both safe (constant ionized calcium levels) and effective (low thrombin-antithrombin formation). In summary, within the scope of a first pilot study, this new LDL hemoperfusion procedure combined the features of excellent clinical tolerance, good biocompatibility, and ease of handling. Phase III clinical trials will have to show whether these encouraging preliminary results can be corroborated in a larger patient population.

LDL hemoperfusion--a new procedure for LDL apheresis: first clinical application of an LDL adsorber compatible with human whole blood

To date, lipid apheresis procedures can remove low-density lipoprotein (LDL) cholesterol (LDL-C) only from plasma. Thus, initially plasma has to be separated from the blood cells, which increases the costs and complexity of the extracorporeal circuit. This paper describes the first clinical application of a new LDL adsorber that eliminates LDL directly from whole blood. The goal of this pilot study was to test the efficacy, safety, and feasibility of direct lipoprotein adsorption in patients. In a 2 center Phase II clinical trial, 12 hypercholesterolemic patients suffering from overt coronary or peripheral artery disease were treated once with LDL hemoperfusion. The new LDL adsorber (DALI, Fresenius, St. Wendel, Germany) contained 480 ml of polyacrylate coated polyacrylamide gel. The anticoagulation consisted of an initial heparin bolus followed by an acid citrate dextrose (ACD)-A infusion during the treatment. The processing of nearly 1 patient blood volume resulted in a reduction of LDL-C by 45 +/- 8% and triglycerides by 23 +/- 20%. HDL-C, fibrinogen, and cell counts were not significantly influenced. In a subgroup of 5 patients who exhibited elevated lipoprotein (a) (Lp[a]) levels, Lp(a) reduction was 43 +/- 15% (all results corrected for plasma volume shifts). The sessions were clinically uneventful; the system was technically safe and easily handled. In conclusion, short-term LDL hemoperfusion by the DALI proved to be a safe, effective, and simple procedure for the treatment of patients suffering from symptomatic recalcitrant hypercholesterolemia. The present study represents a solid basis for the clinical long-term evaluation of this new technique in the future.

[CADASIL: 2 case reports of hereditary multi-infarct dementia]

Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is a hereditary stroke disease linked to chromosome 19 q 12. We report on two families affected by this disease, which is characterised by recurrent subcortical ischaemic strokes, progressive pseudobulbar palsy, and presenile dementia. Neuroimaging revealed multiple deep infarcts and diffuse leukoencephalopathy. Diagnosis of CADASIL based on the typical clinical feature without vascular risk factors, the neuroradiological signs of extensive leukoencephalopathy, and the autosomal dominant pattern of inheritance. CADASIL might be an underestimated cause of familial stroke and should be considered in the differential diagnosis of hereditary stroke.

Enhancement of inhibitory mechanisms in the motor cortex of patients with cerebellar degeneration: a study with transcranial magnetic brain stimulation

The excitatory state of the primary motor cortex can be studied by measuring either the postexcitatory inhibition after transcranial magnetic single stimulation (pI-S) or the refractory period with magnetic double stimulation (rP-D). The cerebellum may influence the excitability of the motor cortex by cerebellar inputs and outputs from side loops of transcortical projections. Therefore, we studied pI-S and rP-D in 24 patients with autosomal dominant cerebellar ataxia or idiopathic cerebellar ataxia, who were allocated to one group (Group A) with mild to moderate ataxia (n = 11) and to another group (Group B) with severe ataxia (n = 13). The results were compared with those obtained in 21 normal age-matched control subjects. The central motor conduction time (CMCT) was delayed in approximately half of the patients, demonstrating that the degenerative process, beyond the cerebellum, also affects the pyramidal tract. Mean CMCT was significantly delayed only in patients of Group B. pI-S was prolonged in 10 of our 24 patients; incidence of pathology in pI-S did not differ between the two patient groups. In 5 patients with normal CMCT, pathological pI-S results were found. Mean pI-S was prolonged in the whole patient group and in both subgroups as well. rP-D was prolonged in two patients of Group B only, but mean rP-D was significantly prolonged in the whole patient group. Prolonged postexcitatory inhibition and refractory period may be a consequence of a transient facilitation of cortical inhibitory interneurons, which results in a decreased excitability of primary motor cortex in patients with cerebellar degeneration.

[Early changes in magnetic resonance tomography in adrenoleukomyeloneuropathy]

In this case report we describe the MRI findings of a 24-year-old male with adrenoleukomyeloneuropathy, an intermediate form of X-linked adrenoleukodystrophy and adrenomyeloneuropathy. At the onset of illness MRI revealed circumscribed lesions of tracts and fiber systems of the CNS. One year later MRI showed progressive demyelination of the parietal and occipital medullary layer corresponding to the clinical deterioration. Such a progression of MRI findings has not previously been reported in the literature.

[Neurologic complications in hypereosinophilia syndrome--a case report]

The idiopathic hypereosinophilic syndrome (HES) is a rare disease characterised by prolonged eosinophilia of undetectable cause and by the presence of varying internal symptoms and frequent neurological signs. We report on a 43-year old man with HES who developed cerebral infarction and organic psychosyndrome. Chemotherapy resulted in lower eosinophil counts and marked improvement of central nervous system dysfunction. We comment on possible pathophysiologic mechanisms of central nervous system involvement in HES.

Artificial liver

Without transplantation, approximately 90% of patients with fulminant hepatic failure die. If patients receive a liver transplant, there is often a lag between the need for and the availability of a donor liver. Therefore, there is a definite need for a liver support system to support the patient's own liver function in fulminant hepatic failure and while awaiting transplantation. We have developed an artificial liver system that not only eliminates lipophilic toxins such as phenols, fatty acids, and mercaptans, but also hydrophilic ones such as ammonia. This artificial liver system consists of a monitor, an extracorporeal blood circuit that uses a hydrophilic polysulfone high-flux dialyzer to remove water-soluble metabolites, and a novel hydrophilic liquid membrane filter to remove lipophilic toxins. In more than 100 in vitro experiments using porcine (5 I) blood, the system was evaluated for its ability to remove toxins that are normally increased in hepatic failure. We found that phenol, cresol, and short- and medium-chain fatty acids can be almost completely eliminated from the blood within 5 h. In animal experiments using pigs, we also found no significant changes of blood gases, liver parameters, electrolytes, and blood cell counts.

[Changes in the urinary protein pattern in SDS polyacrylamide gel electrophoresis in normal and hypertensive pregnancies]

The urinary protein pattern was determined in 46 healthy male and female subjects, 64 patients with an uncomplicated course of pregnancy and 88 hypertensive pregnant women by use of a special urine preparation and a modified SDS-polyacrylamide gel electrophoresis (SDS-PAGE). There were no differences in the protein electrophoresis pattern between the control subjects, independent of sex and age, and the pregnant women. The number of protein bands did not change in the course of pregnancy and in the post partum period. In both groups, an intensively stained protein band with an apparent molecular weight of 105 kD was detected. In 71 of the 88 hypertensive pregnant women we found a marked reduction in intensity or complete disappearance of the 105 kD protein band. Follow-up analysis in 30 of these pregnant women showed, that in 24 cases disappearance of the 105 kD band occurred simultaneously with and in 6 women before clinical manifestation of the disease. There were no differences in the protein electrophoresis pattern between patients with preexisting renal or hypertensive disease and hypertensive women without a complicated history. In 49 of the 52 hypertensive pregnant women complete reappearance of the 105 kD band was observed 2 to 14 days after delivery. By using silver staining and Western blot, the 105 kD band was identified as Tamm-Horsfall protein. Our findings may reflect a transitory tubular dysfunction in cases of preeclampsia and support the hypothesis of an immunological pathogenesis of the disease.

Intracellular localisation of phytochrome and ubiquitin in red-light-irradiated oat coleoptiles by electron microscopy

The intracellular localisation of phytochrome and ubiquitin in irradiated oat coleoptiles was analysed by electron microscopy. We applied indirect immunolabeling with polyclonal antibodies against phytochrome from etiolated oat seedlings or polyclonal antibodies against ubiquitin from rabbit reticulocytes, together with a goldcoupled second antibody, on serial ultrathin sections of resin-embedded material. Immediately after a 5-min pulse of red light-converting phytochrome from the red-absorbing (Pr) to the far-redabsorbing (Pfr) form-the label for phytochrome was found to be sequestered in electron-dense areas. For up to 2 h after irradiation, the size of these areas increased with increasing dark periods. The ubiquitin label was found in the same electrondense areas only after a dark period of 30 min. A 5 min pulse of far-red light, which reverts Pfr to Pr, given immediately after the red light did not cause the electron-dense structures to disappear; moreover, they contained the phytochrome label immediately after the far-red pulse. In contrast, after the reverting far-red light pulse, ubiquitin could only be visualised in the electron-dense areas after prolonged dark periods (i.e. 60 min). The relevance of these data to light-induced phytochrome pelletability and to the destruction of both Pr and Pfr is discussed.

Intracellular localisation of phytochrome in oat coleoptiles by electron microscopy

We have analysed the intracellular localisation of phytochrome in oat coleoptile cells by electron microscopy and confirm and extend light-microscopical findings of previous authors. We used indirect immuno-labeling with polyclonal antibodies against 60-KDa phytochrome from etiolated oat seedlings, and a gold-coupled second antibody, on ultrathin sections of LR-white-embedded material. In dark-grown seedlings, phytochrome-labeling is distributed diffusely throughout the cytoplasm. Organelles and membranes are not labeled. After photoconversion of the red-absorbing form of phytochrome to the far-red absorbing form (Pfr) (5-min red light; 660 nm), the label is sequestered uniquely in electron-dense areas within the cytoplasm. These areas are irregularly shaped, are often located in the vicinity of the vacuole, are not surrounded by a membrane, exclude cellular organelles and ribosomes and are not found in dark-grown material; an immediate 5-min farred light pulse after the red light does not cause these structures to disappear. After a dark period of 3-4 h following red-light irradiation, these electron-dense structures disappear together with any specific labeling. We suggest a Pfr-induced aggregation of an unknown, phytochrome-binding protein or proteins.

Cysteine transport and sulfite reductase activity in a germination-defective mutant of Histoplasma capsulatum

A mutant of the dimorphic, zoopathogenic fungus Histoplasma capsulatum, defective in the ability of its blastospores to germinate, was used to show that the nutritional requirement for cysteine and the expression of sulfite reductase activity are temperature dependent and not related to the growth form the fungus, whereas the kinetics of cysteine transport depend on both temperature and the form of the fungus.

Experiments on lymphocyte-mediated cellular immunity in murine histoplasmosis

Peritoneal exudate cells from immunized mice inhibit the intracellular growth of Histoplasma capsulatum. The lymphocyte is the mediator cell of this phenomenon. Lymphocytes from immunized animals are highly activated cells. Supernatants from cultures of immune lymphocytes or from cultures of mitogen-stimulated lymphocytes did not arm macrophages from normal animals to inhibit the intracellular growth of H. capsulatum.

Mycological culture media and its quality control

The need for control of the quality of media used in the isolation and identification of fungi is an important aspect of the overall quality control of laboratory culture media; however, guidelines for such controls have not been available. In this paper, primary isolation media with and without appropriate drugs are suggested for use on a variety of specimens. Positive and negative quality control organisms that indicate clear-cut postiive and negative results on the fungal media to be tested are listed. Several alternative procedures for maintenance of fungi are discussed.

Further studies on the intracellular behavior of Torulopsis glabrata

The growth of Torulopsis glabrata was inhibited in glucose-peptone broth containing 10 to 20% normal human serum. Addition of iron to the medium diminshed the fungistatic effect. The intracellular growth of T. glabrata was remarkably restricted within mouse macrophages maintained in vitro, but this growth restriction was not caused by the limitation of iron imposed by the serum in the medium. The intracellular growth of T. glabrata within a very small percentage of the macrophages was not obviously related to the failure of lysosomal fusion to the phagosomes in those cells. The studies did not permit definite conclusions regarding the viability of the inhibited yeasts, but results suggested that a large portion of them survived. Potentially misleading artifacts of the technique for assessment of the intracellular behavior of the fungus were detected and are discussed.

Lymphocyte-mediated cellular immunity in histoplasmosis

Mononuclear phagocytes freshly harvested from immunized animals restrict the intracellular growth of Histoplasma capsulatum, whereas the same cells maintained in culture for 48 hr do not. Experiments established that within the mixed cell population of the mouse peritoneal cavity the lymphocyte was the most likely mediator of the intracellular growth restriction observed. Partially purified lymphocytes, from the peritoneal cavity of mice immunized by sublethal infection, mediated the suppression of intracellular growth of the fungus in normal mouse macrophages in cell culture.