Use of analgesics in acute stroke patients with inability to self-report pain: a retrospective cohort study

BACKGROUND

Pain is a common and burdensome complication in patients with acute stroke. We assessed the impact of impaired communication in stroke patients on pain assessment and treatment.

METHODS

We included 909 (507 male, mean age 71.8 years) patients admitted to our stroke unit from 01/2015 to 12/2015 in the analysis. Patients were assigned to four groups: able to communicate (AC), not able to communicate prior to index stroke (P-NAC), due to focal symptoms of index stroke (S-NAC), due to a reduced level of consciousness (C-NAC). Pain prevalence, documentation of pain and use of analgesics were evaluated. C-NAC patients were excluded from analyses regarding analgesic treatment due to relevant differences in patient characteristics.

RESULTS

746 patients (82.1%) were classified as AC, 25 (2.8%) as P-NAC, 90 (9.9%) as S-NAC and 48 (5.3%) as C-NAC. Pain was documented on the Numeric Rating Scale and in form of free text by nurses and physicians. Nurses documented pain more frequently than physicians (p < 0.001). Pain prevalence was 47.0% (n.s. between groups). The use of analgesic medication increased from 48.7% in the AC group, to 76.0% in the P-NAC group, and 77.8% in the S-NAC group (p < 0.001). Opioid use was significantly more frequent in NAC patients (p < 0.001). The response to the treatment was poorly documented with significantly lowest rates in S-NAC patients (p < 0.001).

CONCLUSIONS

Our study suggests that post-stroke pain in patients with inability to communicate is not attended enough, not systematically assessed and therefore not sufficiently treated.

Bispectral index monitoring and seizure quality optimization in electroconvulsive therapy

In ECT, the relative timing of seizure induction and anesthesia may critically impact on seizure quality when anesthetic agents with anticonvulsive properties such as barbiturates or propofol are used. Measuring the depth of anesthesia by bispectral index (BIS) monitoring and thereby identifying the optimal moment for seizure induction might enhance seizure quality.Seizures from 869 individual ECT -sessions with thiopental anesthetic from 118 patients were examined in this retrospective study. The associations of the BIS value at the moment of seizure induction with 7 established seizure parameters and with a novel model of seizure quality were tested by regression analyses.BIS value at induction correlated positively with seizure duration, central inhibition, coherence and maximal heart rate, but not with midictal amplitude. Higher seizure quality was related with a higher BIS value at the moment of seizure induction.The BIS value at seizure induction serves as an independent predictor of seizure quality, influencing most other established markers. BIS monitoring appears as a simple tool to identify the optimal moment for seizure induction.

Cannabidiol enhances anandamide signaling and alleviates psychotic symptoms of schizophrenia

Cannabidiol is a component of marijuana that does not activate cannabinoid receptors, but moderately inhibits the degradation of the endocannabinoid anandamide. We previously reported that an elevation of anandamide levels in cerebrospinal fluid inversely correlated to psychotic symptoms. Furthermore, enhanced anandamide signaling let to a lower transition rate from initial prodromal states into frank psychosis as well as postponed transition. In our translational approach, we performed a double-blind, randomized clinical trial of cannabidiol vs amisulpride, a potent antipsychotic, in acute schizophrenia to evaluate the clinical relevance of our initial findings. Either treatment was safe and led to significant clinical improvement, but cannabidiol displayed a markedly superior side-effect profile. Moreover, cannabidiol treatment was accompanied by a significant increase in serum anandamide levels, which was significantly associated with clinical improvement. The results suggest that inhibition of anandamide deactivation may contribute to the antipsychotic effects of cannabidiol potentially representing a completely new mechanism in the treatment of schizophrenia.

Functional Sspects of the Endocannabinoid System in Schizophrenia

Introduction:

The endocannabinoid system represents the target for the hallucinogenic Δ9-Tetrahydrocannabinol. It consists of naturally occurring endocannabinoid lipids (eCBs) - of which anandamide is the first characterized example - and their attending CB1 cannabinoid receptors. Activation of CB1 receptors produces intense emotional and cognitive responses, suggesting that dysfunction in the eCB system may contribute to the pathogenesis of mental disorders.

Methods:

We examined levels of anandamide in cerebrospinal fluid (CSF) and serum of healthy volunteers (n=84) and various groups of patients suffering from acute psychiatric disorders (n=180).

Results:

Compared to controls, the levels of anandamide in CSF were significantly elevated in acute, antipsychotic-naïve, first-episode schizophrenic patients (n=47) and negatively correlated with psychotic symptoms. This was reversed by the administration of antipsychotics, which antagonize dopamine D2-like receptors (n=37), but not by those, which preferentially antagonize 5HT2A receptors (n=34). In addition, a significant elevation of anandamide was already apparent in a sample of persons clinically at high risk for developing psychosis (prodromal states, n=27). Furthermore, the levels of anandamide in CSF were found significantly lower in antipsychotic-naïve schizophrenic patients reporting more than 20 times of cannabis use in life when compared to those with no more than 5 times.

Conclusion:

Our results suggest that anandamide release in the central nervous system (CNS) may serve as an adaptive mechanism countering neurotransmitter abnormalities in acute schizophrenia. They indicate that frequent cannabis exposure may down-regulate CNS anandamide signaling in schizophrenia and thereby further impact the course of the disease.

HMG CoA reductase inhibition and left ventricular mass in hypertrophic cardiomyopathy: a randomized placebo-controlled pilot study

BACKGROUND

Statins reduce cardiomyocyte hypertrophy in animal models of hypertrophic cardiomyopathy, aortic banding and heart failure after myocardial infarction. We investigated the effect of the hydroxymethylglutaryl coenzyme A reductase inhibitor atorvastatin on left ventricular (LV) mass in patients with hypertrophic cardiomyopathy in a randomized placebo-controlled double-blind pilot study.

MATERIALS AND METHODS

Patients with hypertrophic cardiomyopathy were randomized to be treated once daily by atorvastatin 80 mg or placebo for nine months. LV mass was assessed by serial cardiac magnetic resonance imaging. LV systolic and diastolic function was determined by echocardiography. Markers of collagen metabolism and inflammation were also assessed.

RESULTS

Out of 78 screened patients with hypertrophic cardiomyopathy 28 (2 x 14) patients were eligible for randomization. Eleven patients in each group completed the study with cardiac magnetic resonance imaging assessments meeting the evaluation standards at baseline and at follow-up. Low-density lipoprotein cholesterol levels in the atorvastatin group decreased from 3.24 +/- 1.14 mmol L(-1) (125 +/- 44 mg dL(-1)) at baseline to 1.37 +/- 0.49 mmol L(-1) (53 +/- 19 mg dL(-1)) at follow-up (P < 0.001), but were unchanged in the placebo group. Baseline LV mass was 228 +/- 51 g in the placebo and 232 +/- 67 g in the atorvastatin group. The primary endpoint of change in LV mass from baseline to follow-up was 2 +/- 10% in the atorvastatin group versus 0 +/- 13% in the placebo group (P = NS). Parameters of LV volumes and diameters, systolic and diastolic function, and markers of collagen metabolism were also unchanged in both groups.

CONCLUSION

In patients with hypertrophic cardiomyopathy, this randomized placebo-controlled double-blind pilot study did not demonstrate an effect of 9-month treatment with atorvastatin 80 mg on LV mass reduction.

[Differential diagnosis of dyspnea - significance of clinic aspects, imaging and biomarkers for the diagnosis of heart failure]

Dyspnea is a frequent reason for emergency consultations in hospitals or community medical facilities. Besides heart failure, a wide variety of other disorders may cause this symptom. Thus, early and accurate differential diagnosis is mandatory in order to facilitate rapid institution of appropriate therapy. This CME article elaborates on the specific usefulness of traditional diagnostic tools as history, symptomatology and physical signs along with chest X-ray and ECG and the more recently introduced natriuretic peptides to discriminate heart failure from other causes of dyspnea in the emergency setting. According to a systematic search and meta-analysis of the respective literature, several features from history and physical examination as well as pulmonary congestion on chest X-ray, atrial fibrillation and a high level of confidence of the initial clinical judgment indicate a cardiac cause of dyspnea with high specificity, but less sensitivity. Thus, in patients presenting with one or several of these characteristic features, little further diagnostic yield is to be expected from natriuretic peptides. If, however, the suspicion of heart failure remains unsettled by these means, determination of biomarkers may be helpful, although it needs to be considered that moderately elevated levels have only a limited specificity in particular in elderly patients with comorbidities. As also recognized by the European Guidelines for diagnosis and treatment of chronic heart failure, a BNP level of <100 pg/ml has proven particularly useful for excluding heart failure. Thus, a directed history, symptoms, physical findings, chest-X-ray and ECG remain the diagnostic mainstay. If the diagnosis cannot be established by these traditional tools, BNP or NT-proBNP testing may be very helpful, especially for ruling out heart failure.

Expression of CB1 cannabinoid receptor in the anterior cingulate cortex in schizophrenia, bipolar disorder, and major depression

The human endogenous cannabinoid system is an appealing target in the investigation of psychiatric disorders. In schizophrenia, endocannabinoids and their receptors are involved in the pathology of the disease. Previous studies reported an increased radioligand binding to cannabinoid receptors 1 (CB(1)) in schizophrenia, both in the dorsolateral prefrontal cortex and in the anterior cingulate cortex (ACC). We analyzed the expression of the CB(1) receptors in the ACC at the protein level using immunohistochemistry. In a quantitative postmortem study, 60 patients suffering from schizophrenia, bipolar disorder, major depression and controls were included. Numerical densities of neurons and glial cells immunopositive for CB(1) receptors were evaluated. No evidence of an increased or decreased density of CB(1) receptor immunopositive cells in schizophrenia or bipolar disorder was found. In major depression, CB(1) receptor immunopositive glial cells in the grey matter were decreased. Furthermore, our data show that different medications have an impact on the expression of CB(1) receptors in the ACC.

Use of genetic complementation to identify gene(s) which specify species-specific organ tropism of Leishmania

We have employed a genetic complementation screening to identify genetic markers of heat stress tolerance and visceralisation of Leishmania infection. Leishmania major, which has a low thermotolerance and which causes cutaneous lesions, was transfected with a cosmid library of L. donovani DNA. The recombinant parasites were then screened either for thermotolerance or selected by repeated passage in BALB/c mice. Cosmids which conferred selective advantage were isolated. Several strategies were tested to identify the gene(s) within the cosmids responsible for the observed selective advantages. Of the approaches tested, the complete sequence analysis of the cosmids and subsequent screening of defined candidate ORFs proved to be the method of choice. Other approaches, such as creation of sub-libraries or transposon insertion strategies proved to be unsuccessful.

Expression and subcellular localization of cpn60 protein family members in Leishmania donovani

We have identified two diverged members of the cpn60 gene family in Leishmania donovani, causative agent of Indian Kala Azar. One of the genes, cpn60.1, although actively transcribed, is not expressed to detectable levels of protein in cultured L. donovani. The other gene, cpn60.2, which, compared with cpn60.1, shows a higher sequence conservation with the hsp60 genes from Trypanosoma brucei and Trypanosoma cruzi is expressed constitutively in cultured promastigotes. The abundance of the gene product, Cpn60.2, increases by 2.5-fold under heat stress and in axenic amastigotes of L. donovani. Cpn60.2 is also found enriched in mitochondrial cell fractions and localizes to the mitochondrial matrix. We conclude that Cpn60.2 is the major mitochondrial chaperonin in Leishmania.

Leishmania donovani heat shock protein 100. Characterization and function in amastigote stage differentiation

We report the cloning and molecular analysis of the Leishmania donovani clpB gene. The protein-coding region is highly conserved compared with its L. major homologue, while 5'- and 3'-flanking DNA sequences display considerable divergence. The encoded mRNA has an unusually long 5'-leader sequence typical for RNAs, which are translated preferentially under heat stress. The gene product, a 100-kDa heat shock protein, Hsp100, becomes abundant only during sustained heat stress, but not under common chemical stresses. Hsp100 associates into trimeric complexes and is found mostly in a cytoplasmic, possibly membrane-associated, localization as determined by immune electron microscopy. Hsp100 shows immediate early expression kinetics during axenic amastigote development. In its absence, expression of at least one amastigote stage-specific protein family is impaired.

Sequence verification by hybridisation with fluorescent octanucleotides as a first step to a fluorescent sequencing by hybridisation protocol

Three sets of partly overlapping octanucleotides are 5' labelled with derivates of the fluorescence dyes fluorescein-, coumarine- and rhodamine, respectively. Hybridisation conditions are determined, under which all octanucleotides hybridise correctly against complementary target sequences bound on nylon membranes. Target sequences are three synthetic 48-mer oligonucleotides and herring sperm DNA, a positive control containing almost all possible octanucleotides. None of the octanucleotides hybridised to incorrect target sequences. Analysing these results, a given sequence could be unambiguously verified. A feature critical for the accuracy of the hybridisation is the temperature during the last washing step. This temperature can be estimated using the equation T = 19 - 0.4(G + C) + 0.15(G + C)2. Using octanucleotides labelled with three different colors, three hybridisations can be performed simultaneously.

The influence of combined kidney-pancreas transplantation on the progression of diabetic retinopathy. A case series

PURPOSE

To evaluate the impact of combined kidney and pancreas transplantation on the progression of advanced diabetic retinopathy.

METHODS

The changes in diabetic retinopathy severity in patients with insulin-dependent diabetes mellitus who had kidney-pancreas transplantation (n = 51) and in those who had kidney transplantation only (n = 21) were compared. Patients were invited to baseline and 1 year follow-up examinations. Fundus photographs were graded in a masked fashion using standardized protocols.

RESULTS

The mean age and duration of diabetes were similar for both groups. After combined transplantation, none of the patients used insulin, and their mean glycosylated hemoglobin was significantly lower (6.4% versus 10.6%) than those who underwent only kidney transplantation. There was a nonsignificant difference in overall progression of retinopathy for combined transplantation compared with kidney transplantation only (risk ratio = 0.73; 95% confidence interval, 0.31, 1.71).

CONCLUSION

The authors found no evidence that the normalization of glycemia associated with a combined kidney-pancreas transplantation in patients with advanced proliferative diabetic retinopathy (mostly treated with photocoagulation) accelerated retinopathy progression. These data suggest that the normalization of glycemia associated with a combined kidney-pancreas transplantation does not have beneficial influence on the progression of advanced diabetic retinopathy.

Plasma glucocorticoid concentrations in calves as an indicator of stress during parturition

Plasma glucocorticoid concentrations and blood gas values were determined for 6 days in 47 newborn calves that had been subjected to various obstetrical procedures at term. Concentrations of glucocorticoids were uniformly high at birth (70 to 103 ng/ml). Increasing degrees of acidosis were accompanied by increasing glucocorticoid concentrations in plasma. Plasma glucocorticoid concentrations decreased sharply during the first 6 hours after delivery and reached a plateau at 48 hours after birth (14 to 21 ng/ml). The latter was taken as an indication that adaptation had been achieved. Calves subjected to severe pulling had higher glucocorticoid concentrations at birth (110.4 ng/ml) than calves requiring no assistance (88.3 ng/ml), calves requiring only slight assistance (83.8 ng/ml), or calves that had been delivered by cesarean section (82.9 ng/ml).

[Total estrogen concentrations in the blood plasma of calves during the first six days of life]

From 47 mature calves ten blood samples were taken during the first six days of life for determination of total estrogen concentrations. Immediately postnatal concentration of total estrogens in blood plasma was high (1093.2 +/- 452.5 pg/ml blood plasma). Total estrogen values increased towards the sixth hour of life (1789.0 +/- 892.2 pg/ml blood plasma), which is thought to be caused by reabsorption of estrogens released from intracorporeal reservoirs. Towards the 48th hour of life total estrogen values decreased. This decrease indicates a progressive depletion of the reservoirs and also metabolisation and elimination of estrogens by the organism. The fact that total estrogens were nearly unchanged from the 4th day of life onwards reveals the approximative completed elimination of estrogens. At no time significant differences of total estrogen concentrations in blood plasma were found between female and male newborn calves.

Optic disc cupping: prevalence findings from the WESDR

Increased cupping of the optic disc is considered to be an indication of pressure-related damage of the optic nerve. This paper explores the relationship of intraocular pressure and cupping in persons with diabetes mellitus, a group of people whose optic nerves may be more susceptible to the effects of intraocular pressure. Stereoscopic fundus photographs of the seven standard fields were obtained in all persons participating in the Wisconsin Epidemiologic Study of Diabetic Retinopathy at the time of the initial prevalence survey. Measurements of disc and cup diameters in the vertical and horizontal meridia were made by two trained graders. Cup-to-disc ratios were computed for both diameters of each eye and the mean of the two gradings was used. A history of glaucoma was significantly associated with larger cup-to-disc ratios at the prevalence examination. Cup-to-disc ratios were not larger in those with high IOP, nor in those who had panretinal photocoagulation.

Optic disc cupping: four year follow-up from the WESDR

Change in optic disc cupping was evaluated in a 4-year follow-up of a well defined cohort of people with diabetes mellitus. Cup-to-disc ratios were computed for both vertical and horizontal diameters of each eye at the baseline and 4-year follow-up examinations. Graders were masked as to the identity of participants and to the dates of the photographs. Increases of at least 0.1 between baseline and follow-up were used as clinically significant change in the ratios. None of the following factors at baseline were consistent predictors of such a change: intraocular pressure, age, duration of diabetes, hypertension or severity of diabetic retinopathy. People who developed proliferative retinopathy by the follow-up examination were not more likely to have such an increase in ratio at the follow-up. We conclude that clinically significant increases in cup-to-disc ratio cannot be consistently predicted in people with diabetes from the risk factors evaluated with the grading system used in this study.