The German trial on Aciclovir and Corticosteroids in Herpes-simplex-virus-Encephalitis (GACHE): a multicenter, randomized, double-blind, placebo-controlled trial

Introduction

Comprehensive treatment of Herpes-simplex-virus-encephalitis (HSVE) remains a major clinical challenge. The current therapy gold standard is aciclovir, a drug that inhibits viral replication. Despite antiviral treatment, mortality remains around 20% and a majority of survivors suffer from severe disability. Experimental research and recent retrospective clinical observations suggest a favourable therapy response to adjuvant dexamethasone. Currently there is no randomized clinical trial evidence, however, to support the routine use of adjuvant corticosteroid treatment in HSVE.

Methods

The German trial of Aciclovir and Corticosteroids in Herpes-simplex-virus-Encephalitis (GACHE) studied the effect of adjuvant dexamethasone versus placebo on top of standard aciclovir treatment in adult patients aged 18 up to 85 years with proven HSVE in German academic centers of Neurology in a randomized and double blind fashion. The trial was open from November 2007 to December 2012. The initially planned sample size was 372 patients with the option to increase to up to 450 patients after the second interim analysis. The primary endpoint was a binary functional outcome after 6 months assessed using the modified Rankin scale (mRS 0-2 vs. 3-6). Secondary endpoints included mortality after 6 and 12 months, functional outcome after 6 months measured with the Glasgow outcome scale (GOS), functional outcome after 12 months measured with mRS and GOS, quality of life as measured with the EuroQol 5D instrument after 6 and 12 months, neuropsychological testing after 6 months, cranial magnetic resonance imaging findings after 6 months, seizures up to day of discharge or at the latest at day 30, and after 6 and 12 months.

Results

The trial was stopped prematurely for slow recruitment after 41 patients had been randomized, 21 of them treated with dexamethasone and 20 with placebo. No difference was observed in the primary endpoint. In the full analysis set (n = 19 in each group), 12 patients in each treatment arm achieved a mRS of 0-2. Similarly, we did not observe significant differences in the secondary endpoints (GOS, mRS, quality of life, neuropsychological testing).

Conclusion

GACHE being prematurely terminated demonstrated challenges encountered performing randomized, placebo-controlled trials in rare life threatening neurological diseases. Based upon our trial results the use of adjuvant steroids in addition to antiviral treatment remains experimental and is at the decision of the individual treating physician. Unfortunately, the small number of study participants does not allow firm conclusions.

Trial registration

EudraCT-Nr. 2005-003201-81.

Surface tension determines tissue shape and growth kinetics

The collective self-organization of cells into three-dimensional structures can give rise to emergent physical properties such as fluid behavior. Here, we demonstrate that tissues growing on curved surfaces develop shapes with outer boundaries of constant mean curvature, similar to the energy minimizing forms of liquids wetting a surface. The amount of tissue formed depends on the shape of the substrate, with more tissue being deposited on highly concave surfaces, indicating a mechano-biological feedback mechanism. Inhibiting cell-contractility further revealed that active cellular forces are essential for generating sufficient surface stresses for the liquid-like behavior and growth of the tissue. This suggests that the mechanical signaling between cells and their physical environment, along with the continuous reorganization of cells and matrix is a key principle for the emergence of tissue shape.

Use of a fibrinogen-thrombin sponge in rhinoplasty

BACKGROUND

Although several methods have been described to address nasal dorsum augmentation and smoothing of irregularities in rhinoplasty, establishing the ideal method has proven controversial.

OBJECTIVE

Here, we introduce a novel technique of cartilage grafting for nasal dorsum augmentation by wrapping cartilage in a fibrinogen- and thrombin-coated collagen patch called TachoSil®.

MATERIAL AND METHODS

In a pilot study comprising ten cases, the use of the collagen patch was examined in various indications in rhinoplasty. Patients were clinically monitored for up to 8 months and photometric and sonographic documentation was performed pre- and postoperatively.

RESULTS

In nine patients, the collagen patch was used for fixation of cartilage grafts in different indications: saddle nose deformities (n = 5), open roof (n = 1), nasal dorsum irregularities (n = 3). A diced cartilage graft enclosed by a bilayer of TachoSil® was applied in seven patients. Solid pieces of cartilage were either embedded in a bilayer of the collagen patch (n = 1) or covered by a monolayer (n = 1). Moreover, the collagen patch alone served as a soft tissue support in one patient with thin skin. Six patients were revision cases. All patients had uneventful healing without adverse events such as allergic reactions and infections.

CONCLUSION

The collagen patch TachoSil® is eligible for various indications in rhinoplasty. It is a useful material predominantly for nasal dorsum augmentation by sandwiching diced or solid cartilage in the collagen patch, leading to better graft fixation and precise profile shaping. At the same time, TachoSil® helps with blood control. Follow-up studies will be performed to assess the material's long-term behavior.

Cross sectional imaging of truncal and quadriceps muscles relates to different functional outcomes in cancer

Introduction

Following the consensus definition of cancer cachexia, more studies are using CT scan analysis of truncal muscles as a marker of muscle wasting. However, how CT-derived body composition relates to function, strength and power in patients with cancer is largely unknown.

Aims

We aimed to describe the relationship between CT truncal (L3) skeletal muscle index (SMI) and MRI quadriceps cross sectional area with lower limb strength, power and measures of complex function.

Methods

Patients undergoing assessment for potentially curative surgery for oesophagogastric or pancreatic cancer were recruited from the regional upper gastrointestinal (UGI) or hepatopancreaticobiliary (HPB) multi-disciplinary team meetings. Maximum Isometric Knee Extensor Strength (IKES) and Maximum Leg Extensor Power (Nottingham Power Rig) (LEP) were used as measures of lower limb performance. Both Sit to Stand (STS) and Timed Up and Go (TUG) were used as measures of global complex muscle function. Muscle SMI was measured from routine CT scans at the level of the third lumbar vertebrae (L3) and MRI scan was used for the assessment of quadriceps muscles. Linear regression analysis was performed for CT SMI or MRI quadriceps as a predictor of each measure of performance.

Results

Forty-four patients underwent assessment. Height and weight were significantly related to function in terms of quadriceps power, while only weight was associated with strength (P < 0.001). CT SMI was not related to measures of quadriceps strength or power but had significant association with more complex functional measures (P = 0.006, R² = 0.234 and 0.0019, R² = 0.175 for STS and TUG respectively). In comparison, both gross and fat-subtracted measures of quadriceps muscle mass from MRI were significantly correlated with quadriceps strength and power (P < 0.001), but did not show any significant association with complex functional measures.

Conclusion

CT SMI and MRI quadriceps have been shown to reflect different aspects of functional ability with CT SMI being a marker of global muscle function and MRI quadriceps being specific to quadriceps power and strength. This should therefore be considered when choosing outcome measures for trials or definitions of muscle mass and function.

Resource-directed foraging of the Neotropical mistletoe Struthanthus flexicaulis (Loranthaceae)

Some parasitic plants are capable of vegetative propagation, which allows them access to new hosts and improves nutrient availability. We aimed to determine what factors positively influence this propagation in the xylem-tapping Struthanthus flexicaulis, focusing on the use of directed foraging as a means of optimising access to resources. The study site was a rupicolous plant community in southeast Brazil. We evaluated how the success of branch propagation (by contagion) of the mistletoe is influenced by the crown height and density of its main host, the legume Mimosa calodendron. Oriented foraging was tested through comparing the response of mistletoe branches toward a potential host (resources) or a plastic net (no resources). Successful contagion was related to high density and the departure height of a branch from a host crown. In a high-density area, 89% of branches reached a new host versus 21% in a low-density area. Formation of an appressorium on either the plastic nets or hosts elicited branch growth reorientation towards it, as well as development of new branches. These responses were significantly stronger towards hosts than nets, and attributed to effective xylem tapping. The foraging strategy of S. flexicaulis benefits from branch response (growth and reorientation) to the development of appressoria and their resulting haustoria. The growth of appressoria on non-resource substrates and the ensuing response optimises the mistletoe spread by allowing these substrates to act as physical support for spreading branches and to infect a host that was previously out of reach.

[Telescience : Feasibility studies, definition and a fair answer to the scientific brain drain]

BACKGROUND

What is telescience? Is it feasible to transfer academic information with the help of telematics to educate and teach young scientists over large distances? The term telescience has so far not been defined but covers a variety of possibilities, which could be successfully implemented worldwide. This article gives examples and highlights the feasibility analysis of telescience.

METHODS

We have carried out feasibility analyses for neurological functional diagnostics, an epidemiological cross-sectional study as well as a laboratory study for detection of thrombocyte function during dengue fever with the help of telemedicine. The basis for all these projects was a telemedical transcontinental cooperation over a distance of 12,000 km.

RESULTS

All performed studies demonstrated the feasibility. With the help of telematics the laboratory techniques, planning, conduction and interpretation of results as well as publication skills can be transferred.

DISCUSSION

Telescience is feasible. Our studies showed that telescience is a very promising option to transfer knowledge, which will help to enable professional expertise to be transferred directly to the region/country without a brain drain. All too often young motivated scientists are enticed to move to well-known institutions, which involves the danger of a brain drain. Brain drain can be avoided in favor of local implementation of scientific projects. Our results illustrate that it is feasible to educate and guide scientists with the help of telematics infrastructures.

Setting up a Neuroscience Stroke and Rehabilitation Centre in Brunei Darussalam by a transcontinental on-site and telemedical cooperation

Due to the world-wide aging population, there is a need for specialist neurological knowledge, treatment and care. Stroke treatment is effective in reducing mortality and disability, but it is still not available in many areas of the world. We describe the set-up process of a specialized Neuroscience, Stroke and Rehabilitation Centre in Brunei Darussalam (BNSRC) in cooperation with a German hospital. This study details the setup of a stroke-, neurological intensive care- and neurorehabilitation unit, laboratories and a telemedical network to perform all evidence-based stroke treatments. All neurological on-site services and the telemedical network were successfully established within a short time. After setup, 1386 inpatients and 1803 outpatients with stroke and stroke mimics were treated. All evidence-based stroke treatments including thrombolysis and hemicraniectomy could be performed. It is possible to establish evidence-based modern stroke treatment within a short time period by a transcontinental on-site and telemedical cooperation.

[Therapy Goals for Children and Adolescents with ADHD and their Primary Caregivers. A Content Analysis and Examination of Agreement of ADHD Patients and their Primary Caregivers]

OBJECTIVE

The aim of this study was to identify individual therapy goals (ITGs) of children and adolescents with ADHD and their primary caregivers.

METHODS

Within the evaluation of the selective contract for children and adolescents with ADHD in Bremerhaven, Germany, ITGs of 42 study participants (aged 8-17) and their primary caregivers were collected with the psychotherapy basis documentation for children and adolescents (Psy-BaDo-KJ). ITGs were analysed following the classification of categories for individual therapy goals (KITZ) and their modification for children and adolescents. Analysis focused on the most frequently named ITGs and the agreement of patients and primary caregivers ITGs on the individual level.

RESULTS

235 ITGs were named. The greatest proportion of ADHD patients and their caregivers (47%) focused on interactional, psychosocial conflicts. In 19% of the cases (n=8) patients and their caregivers had the same main goal. 38% of patients and of caregivers (n=16) named the other ones main goal in one of his/her ITGs as well.

CONCLUSIONS

ADHD patients and their primary caregivers both pursue ITGs related to ADHD symptoms. Few ITGs address medication related aspects. In case of differences in the ITGs of a patient and his/her primary caregivers, therapists should check whether differing ITGs address the same problem from different perspectives.

Induction of M2-macrophages by tumour cells and tumour growth promotion by M2-macrophages: a quid pro quo in pancreatic cancer

INTRODUCTION

More effective therapies are required to improve survival of pancreatic cancer. Possible immunologic targets include tumour associated macrophages (TAMs), generally consisting of M1- and M2-macrophages. We have analysed the impact of TAMS on pancreatic cancer in a syngeneic orthotopic murine model.

METHODS

6606PDA murine pancreatic cancer cells were orthotopically injected into C57BL6 mice. Tumour growth was monitored using MRI. Macrophages were depleted by clodronate liposomes. Tumours including microvessel density were evaluated using immunohistochemistry, immunofluorescence and/or cytometric beads assays. Naïve macrophages were generated employing peritoneal macrophages. In vitro experiments included culturing of macrophages in tumour supernatants as well as tumour cells cultured in macrophage supernatants using arginase as well as Griess assays.

RESULTS

Clodronate treatment depleted macrophages by 80% in livers (p = 0.0051) and by 60% in pancreatic tumours (p = 0.0169). MRI revealed tumour growth inhibition from 221.8 mm(3) to 92.3 mm(3) (p = 0.0216). Micro vessel densities were decreased by 44% (p = 0.0315). Yet, MCP-1-, IL-4- and IL-10-levels within pancreatic tumours were unchanged. 6606PDA culture supernatants led to a shift from naïve macrophages towards an M2-phenotype after a 36 h treatment (p < 0.0001), reducing M1-macrophages at the same time (p < 0.037). In vivo, M2-macrophages represented 85% of all TAMs (p < 0.0001). Finally, culture supernatants of M2-macrophages induced tumour growth in vitro by 63.2% (p = 0.0034).

CONCLUSIONS

This quid pro quo of tumour cells and M2-macrophages could serve as a new target for future immunotherapies that interrupt tumour promoting activities of TAMs and change the iNOS-arginase balance towards their tumoricidal capacities.

Myrmecofauna of ironstone outcrops: composition and diversity

The Iron Quadrangle in the state of Minas Gerais, Brazil, harbors ironstone outcrops locally known as cangas, which are historically under great anthropic pressure. The functions performed by ants in environments with severe edapho-climatic conditions, such as cangas, are poorly known. Considering the lack of studies and the potential role of ants in cangas, this study aimed to identify the taxonomic composition of the myrmecofauna that occurs in the soil of two campo rupestre areas (rupestral plant communities) on cangas under different anthropic impacts and evaluate the influence of seasonality and degree of degradation on the diversity and composition of the myrmecofauna. This is the first study to systematically investigate ant fauna collected with baits on ironstone outcrops. Sardine and honey baits were used in dry and rainy periods. Fourteen species distributed among ten genera belonging to five subfamilies were found. The total number of baits visited in the dry season was lower than in the rainy season. Both habitats had a reasonable similarity in their composition (Jaccard similarity index = 0.571). Multivariate analyses suggest a greater similarity between areas than seasons. The diversity of ants in the cangas is low compared to other Cerrado environments where more than 20 species are frequently collected in these types of study. This low richness may be related to the adverse conditions characteristic of ironstone outcrops. We hope our data will help to expand the actions to manage and preserve cangas in the Iron Quadrangle.

Work status and health-related quality of life following multimodal work hardening: a cluster randomised trial

BACKGROUND

Systematic reviews have confirmed the effectiveness of work-related rehabilitation with significant cognitive-behavioural components for patients with musculoskeletal disorders (MSDs). In Germany, however, work-related rehabilitation focuses mainly on functional capacity training and less on psychosocial work demands.

OBJECTIVE

To evaluate the efficacy of multimodal work hardening (MWH) with a cognitive-behavioural approach.

METHODS

Patients with MSDs resulting in severe restriction of work ability were randomly assigned to treatment by either MWH or conventional musculoskeletal rehabilitation (controls). The primary outcome was work status. The work status at 6 months of follow-up was defined as positive if the patient was working and had ≤ 6 weeks of sick leave, and that at 12 months was defined as positive if the patient was working and had ≤12 weeks of sick leave. Follow-up data were collected by postal questionnaires.

RESULTS

236 patients consented to participate. Follow-up data were obtained from 169 (71.6%) participants at 6 months and 146 (61.9%) participants at 12 months. At 6 months, participants in the MWH group had a 2.4 times higher chance of a positive work status than the controls (OR=2.363; 95% CI: 1.266 to 4.410; p=0.007). At 12 months, the chances of a positive work status were still higher, but this difference was not statistically significant (OR=1.914; 95% CI: 0.849 to 4.317; p=0.118). Significance of the interaction term of treatment and time indicated more favourable outcomes for depression and anxiety, mental and physical health-related quality of life, and pain management in the MWH group.

CONCLUSIONS

MWH improves health-related quality of life and is able to enhance the mid-term chances of work-life participation.

[Topical cyclosporine A 0.05% in the treatment of keratoconjunctivitis sicca]

BACKGROUND

The current understanding of the pathogenesis of dry eye disease has proceeded to recognition of inflammation as the key pathogenetic mechanism. The purpose of this study was to evaluate the effect of cyclosporine 0.05% eye drops on subjective symptoms and objective signs of patients with keratoconjunctivitis sicca.

PATIENTS AND METHODS

In this clinical trial 62 patients with severe keratoconjunctivitis sicca (DEWS grade 3) were included. Over a time period of 3 months all patients received treatment with preservative-free hyaluronic acid artificial tears at one drop 5 times per day and in addition 31 patients received one drop of cyclosporine 0.05% twice daily. Screening parameters were LIPCOF, tear break-up time (BUT), fluorescein and rose bengal staining, the intraocular pressure (IOP) and the OSDI score.

RESULTS

In the cyclosporine A group BUT, Jones test and OSDI score improved significantly after 3 months in contrast to the controls. Moreover the values of BUT and Jones test in the cyclosporine A group were significantly higher after 3 months compared to the healthy controls. Fluorescein and rose bengal staining improved only in the cyclosporine A group after 3 months.

CONCLUSION

Anti-inflammatory therapy with cyclosporine A 0.05% eye drops as off label use significantly improves subjective symptoms and objective signs in patients with severe dry eye disease providing a good safety profile. These findings suggest a widespread use of cyclosporine A 0.05% eye drops in patients with moderate to severe keratoconjunctivitis sicca.

Who is really at risk? Identifying risk factors for subthreshold and full syndrome eating disorders in a high-risk sample

BACKGROUND

Numerous longitudinal studies have identified risk factors for the onset of most eating disorders (EDs). Identifying women at highest risk within a high-risk sample would allow for focusing of preventive resources and also suggests different etiologies.

METHOD

A longitudinal cohort study over 3 years in a high-risk sample of 236 college-age women randomized to the control group of a prevention trial for EDs. Potential risk factors and interactions between risk factors were assessed using the methods developed previously. Main outcome measures were time to onset of a subthreshold or full ED.

RESULTS

At the 3-year follow-up, 11.2% of participants had developed a full or partial ED. Seven of 88 potential risk factors could be classified as independent risk factors, seven as proxies, and two as overlapping factors. Critical comments about eating from teacher/coach/siblings and a history of depression were the most potent risk factors. The incidence for participants with either or both of these risk factors was 34.8% (16/46) compared to 4.2% (6/144) for participants without these risk factors, with a sensitivity of 0.75 and a specificity of 0.82.

CONCLUSIONS

Targeting preventive interventions at women with high weight and shape concerns, a history of critical comments about eating weight and shape, and a history of depression may reduce the risk for EDs.

Modeling the potential distribution of the invasive golden mussel Limnoperna fortunei in the Upper Paraguay River system using limnological variables

The invasive golden mussel, Limnoperna fortunei (Dunker, 1857), was introduced into the La Plata River estuary and quickly expanded upstream to the North, into the Paraguay and Paraná rivers. An ecological niche modeling approach, based on limnological variables, was used to predict the expansion of the golden mussel in the Paraguay River and its tributaries. We used three approaches to predict the geographic distribution: 1) the spatial distribution of calcium concentration and the saturation index for calcium carbonate (calcite); 2) the Genetic Algorithm for Rule-Set Production (GARP) model; and the 3) Maximum Entropy Method (Maxent) model. Other limnological variables such as temperature, dissolved oxygen, pH, and Total Suspended Solids (TSS) were used in the latter two cases. Important tributaries of the Paraguay River such as the Cuiabá and Miranda/Aquidauana rivers exhibit high risk of invasion, while lower risk was observed in the chemically dilute waters of the middle basin where shell calcification may be limited by low calcium concentrations and carbonate mineral undersaturation.

[Vasculitis of the nervous system in infectious diseases]

Vasculitis and vasculopathies of the central and peripheral nervous system can be caused by infectious diseases. Vasculitis can lead to stenosis, occlusion and aneurysm formation of blood vessels which may result in stroke or cerebral haemorrhage. In cases of peripheral nervous system involvement mononeuritis multiplex and symmetric peripheral neuropathy are possible. The diagnosis is based on clinical presentation, serology, cerebrospinal fluid analysis and neuroradiologic examinations. In cases of peripheral neuropathy neurophysiologic examinations and biopsy of the sural nerve can lead to the diagnosis. A fast and efficient antimicrobial therapy is the most important treatment option. In cases of peripheral neuropathies short-term treatment with corticosteroids and plasma exchange may be helpful.

Sonographic long-term study: paediatric growth charts for single kidneys

AIMS

To explore the clinical course of children with "single kidney" (defined as either a solitary or single functioning kidney) with reference to renal function (glomerular filtration rate (GFR) and proteinuria), body height and particularly sonomorphological features.

PATIENTS AND METHODS

This retrospective monocentric study evaluated 119 children with a solitary or single functioning kidney (>90% unilateral function on isotope scan) between 1997 and 2007. Patients were followed for 6.3 years (median, range 1-17) and had at least three renal ultrasound examinations (median 8). During recruitment six children were identified with chronic kidney disease (CKD) stage III or worse. These patients were analysed separately.

RESULTS

The aetiology of "single kidney" was attributed to contralateral multicystic dysplastic kidney (26%), tumournephrectomy (24%), renal agenesis (18%), hypo/dysplasia (11%) and obstructive or refluxive uropathy (18%). Irrespective of aetiology, the sonographic dimensions of "single kidneys" were in the upper range of normal paired kidneys and showed adequate growth. Compensatory renal hypertrophy (defined as >95% CI on two or more recent measurements) occurred in a third of patients. All six patients with CKD and GFR less than 60 ml/minute per 1.73 m(2) had pathological sonomorphology of their "single kidney" with inadequate renal growth (6/6), abnormal echogenicity (5/6), hypo/dysplasia (5/6). In addition, proteinuria (5/6) and short stature (3/6) were found.

CONCLUSIONS

New reference centiles were generated to assess renal size of "single kidneys" in paediatric patients. These charts will facilitate counselling of patients and parents. Further evidence for a benign clinical course of children with "single kidney" and absent additional pathology of the remnant kidney is presented.

Prospective combined brain and spinal cord MRI in clinically isolated syndromes and possible early multiple sclerosis: impact on dissemination in space and time

BACKGROUND

The diagnosis of multiple sclerosis (MS) is based on dissemination in space (DIS) and time (DIT). The aim of the study was to assess the impact of spinal cord (SC) imaging on the evidence of DIS and DIT.

METHODS

Thirty-five treatment-naive patients with a first clinical symptom suggestive of MS were examined in a 2-year prospective longitudinal follow-up assessment. Brain and SC magnetic resonance imaging (MRI), Expanded Disability Status Scale and multiple sclerosis functional composite were analysed at baseline and after 1 and 2 years.

RESULTS

At study entry, 21 patients were classified as clinically isolated syndrome suggestive of MS (CIS) and 14 patients as possible early MS. SC lesions were detected at baseline in 14 CIS patients (67%, median: 1.0, enhancing 29%) and in 11 patients with possible early MS (79%, median: 2.0, enhancing 29%). DIS as depicted by additive SC imaging was detected in two additional individuals according to the revised versus the 2001 McDonald criteria. All patients with emerging cord lesions showed new brain lesions. Five individuals developed clinically asymptomatic cord lesions.

CONCLUSIONS

Spinal cord abnormalities are frequent in CIS patients and in patients with possible early MS. SC imaging slightly improved the establishment of DIS, but had no impact on the evidence of DIT.

Quantitation of intrathecal antibodies in cerebrospinal fluid of subacute sclerosing panencephalitis, herpes simplex encephalitis and multiple sclerosis: discrimination between microorganism-driven and polyspecific immune response

The detection of intrathecal antibody synthesis by qualitative methods or the Antibody-Index (AI) is a relevant tool for diagnosis of inflammatory neurological diseases. An increased AI can be observed for a causative antigen as well as part of a polyspecific immune response. The quantitation of the intrathecal antibody fraction in cerebrospinal fluid (CSF), F(S), helps to discriminate both cases. In contrast to AI, F(S) needs an absolute antibody concentration detected in the ELISA in mg/L. The intrathecally synthesized, "local" antibody concentration in CSF (AB(Loc)) is expressed as the specific fraction of the intrathecally synthesized total IgG (IgG(Loc)) in CSF with F(S)=AB(Loc)/IgG(Loc) x 100 in %. F(S) for HSV or measles has about 20- to 60-fold higher values in virus-caused antibody synthesis in acute herpes simplex encephalitis (mean HSV-F(S)=8.9%) or subacute sclerosing panencephalitis (mean measles-F(S)=18.8%) compared to the polyspecific immune response against these antigens e.g., in multiple sclerosis (0.14% or 0.52%, correspondingly). F(S) helps also to avoid misinterpretations of an increasing AI in cases of therapy control, and allows direct comparison of relative antibody concentrations (R(S)) in blood and intrathecally synthesized fractions in CSF (F(S)): In multiple sclerosis patients F(S):R(S) has a mean ratio of about 3 for the measles, rubella and VZV antibodies. Together with the large variability we find by ranking that about two third of MS patients have no direct correlation of the relative concentrations in serum and intrathecal synthesis. So this concept gains increasingly relevance for analysis of the polyspecific immune response in brain.

[Left flank tumor of fluctuating size in a 5-week-old boy: perirenal urinoma caused by urethral valves]

BACKGROUND

Flank swelling and pseudotumors of the kidney are unusual manifestations of obstructive uropathies in small children. Our case illustrates typical problems and briefly reviews management options.

CASE REPORT

A 5-week-old boy presented with a large, palpable urinoma due to posterior urethral valves. Sonography and voiding cystourethrogram led to the diagnosis and immediate suprapubic transcutaneous urinary diversion was performed. However, the urinoma did not resolve. Thus, in addition to suprapubic urinary diversion, indirect drainage - instead of percutaneous puncture - was performed by retrograde insertion of a double-J catheter. Urethral valves were resected 4 weeks later and follow-up demonstrated an uneventful further development with normal renal function as assessed by regular ultrasound studies, a repeat cystourethrogram and a renal scan.

CONCLUSION

Perirenal urinomas may be the first symptom in patients with posterior urethral valves. Drainage via double-J stenting offers a promising alternative to percutaneous puncture. A renoprotective "pop-off" mechanism by which intrarenal pressure may be relieved is discussed.

Neuromyelitis optica (Devic's syndrome) as first manifestation of systemic lupus erythematosus

Neurologic symptoms rarely occur as presenting feature of systemic lupus erythematosus (SLE). We describe a 37-year old woman who presented with several episodes of transverse myelitis and optic neuritis. Clinical, radiologic and laboratory findings were compatible with neuromyelitis optica (NMO). Seven years after disease onset clinical and laboratory findings were diagnostic for SLE. This case illustrates that NMO may represent a first manifestation of SLE for many years.

Subarachnoid hemorrhage due to Borrelia burgdorferi-associated vasculitis

We report the case history of a patient who suffered a subarachnoid hemorrhage (SAH) in association with early Lyme neuroborreliosis. After a tick bite, this patient developed erythema chronicum migrans and complained of stinging radicular pain in both legs. A computed tomography (CT) scan was performed because of acute headache and nuchal rigidity, which revealed an occipital SAH. Cerebrospinal fluid analysis provided further evidence of acute neuroborreliosis. Digital substraction angiography showed irregularities in the right posterior cerebral artery, which might be due to vasculitis, but no aneurysms.

Neuromyelitis optica (Devic's syndrome) as first manifestation of systemic lupus erythematosus

Neurologic symptoms rarely occur as presenting feature of systemic lupus erythematosus (SLE). We describe a 37-year old woman who presented with several episodes of transverse myelitis and optic neuritis. Clinical, radiologic and laboratory findings were compatible with neuromyelitis optica (NMO). Seven years after disease onset clinical and laboratory findings were diagnostic for SLE. This case illustrates that NMO may represent a first manifestation of SLE for many years.

Das Chediak-Higashi-Syndrom

Chediak-Higashi syndrome (CHS) is a rare autosomal recessive lysosomal disorder characterized by frequent infections, oculocutaneous albinism, high bleeding tendency, and various neurological symptoms. Onset in early childhood mostly leads to lymphohistiocytic infiltration into multiple organs, which is usually lethal without bone marrow transplantation. The adult form of CHS has a milder course, no lymphohistiocytic infiltration, and is characterized by neurological manifestations such as polyneuropathy, parkinsonism, dementia, and ataxia. In young adults, a combination of these defects with oculocutaneous albinism or recurrent infections should bring CHS into consideration. Diagnosis is established by the presence of characteristic eosinophilic peroxidase-positive giant granules in leukocytes. This article summarizes current knowledge about the pathogenesis, clinical course, and therapy of CHS and reports on experience with two adult CHS patients.

Das trockene Auge

The etiology of dysfunctional tear syndrome ("dry eye") is multifactorial and complex. Recent evidence suggests an important role of androgens in regulating tear film secretion onto the ocular surface. In addition, inflammatory processes of the ocular surface seem to be the common final pathway of all chronic forms of dry eye. Novel concepts of pathogenesis and state-of-the-art diagnostic tools are discussed. In vivo confocal microscopy allows quantification of ocular surface inflammatory cells. This is of increasing importance for evaluation of anti-inflammatory treatments in dry eye patients.

Aktuelle Therapie des trockenen Auges

The therapy of dry eye disease as a chronic problem necessitates a long-term therapeutic association between patient and ophthalmologist. The aim of therapy is to relieve symptoms and improve vision as far as possible with an acceptable level of effort on the part of the patient. Therapy of dry eye follows a staged concept including tear replacement, serum eye drops, punctum plugs, novel anti-inflammatory drugs (cyclosporin A), and surgical procedures. Interdisciplinary care, especially of patients with autoimmune disease, is recommended and is best provided in a specialized dry eye outpatient clinic with quality control.

Hemorrhagic acoustic schwannoma: radiological and histopathological findings

A 49-year-old man on anticoagulation treatment with phenprocoumon presented with acute right sided 7th and 8th cranial nerve palsy, acute hearing loss, headache, vertigo, and vomiting. CT and MRI revealed a cerebellopontine angle tumor 15mm in diameter and acute intratumoral hematoma. A cellular schwannoma composed predominantly of Antoni A tissue with dilated thin-walled vessels, surrounded by old hemorrhage with hemosiderin-laden macrophages was found histologically.

Cerebrovascular manifestations of Takayasu arteritis in Europe

OBJECTIVES

Takayasu arteritis is well known as a cause of stroke in Asia but has rarely been described in the Western world. Here we report the clinical and neuroimaging follow-up of a series of patients with Takayasu arteritis from Europe.

METHODS

Seventeen consecutive patients who fulfilled the diagnostic criteria for Takayasu arteritis of the American College of Rheumatology were evaluated on follow-up by standardized neurological examination, sonography and MRI.

RESULTS

At follow-up almost 20 yr after onset of symptoms, the subclavian artery and the common carotid artery were often affected. In addition, evidence of intracranial pathology was found in seven patients. In contrast to the severe vessel involvement, the neurological state was stable. Two patients had suffered from stroke before the diagnosis was made and therapy was initiated, and one patient had recurrent transient ischaemic attacks. Intermittent dizziness was associated with pathology of the vertebral and basilar arteries. However, clinical symptoms of subclavian steal syndrome were rare.

CONCLUSION

This case series shows that the clinical neurological course of Takayasu arteritis on treatment is benign in most cases despite the severe vascular involvement.

Immunoglobulins and virus-specific antibodies in patients with Creutzfeldt-Jakob disease

OBJECTIVES

Cerebrospinal fluid (CSF) pattern in patients with neuropathologically diagnosed Creutzfeldt-Jakob disease was analyzed.

MATERIAL AND METHODS

Routine tests included white blood cells count, protein, albumin, immunoglobulins and the presence of oligoclonal immunoglobulin G (IgG) in the CSF as well as the calculation of intrathecal synthesis of immunoglobulins by standard methods. In addition, antibodies against neurotropic viruses such as measles, rubella, varicella zoster and herpes simplex were measured and the specific antibody index was calculated.

RESULTS

A blood-CSF barrier dysfunction was observed in six of 25 cases. In CSF/serum quotient diagrams, no patient had intrathecally synthesized immunoglobulins, but in two of 25 patients oligoclonal bands were detected. Two patients had intrathecally synthesized antibodies against varicella zoster and three against herpes simplex virus.

CONCLUSION

In conclusion, in the routine diagnosis, the CSF in CJD is normal in most cases. In some patients, abnormalities include the blood-CSF barrier dysfunction, mild pleocytosis, oligoclonal bands and intrathecally synthesized viral antibodies.