Quality and reporting of guidelines on the diagnosis and management of dystonia

BACKGROUND AND PURPOSE

The quality of clinical practice guidelines on dystonia has not yet been assessed. Our aim was to appraise the methodological quality of guidelines worldwide and to analyze the consistency of their recommendations.

METHODS

We searched for clinical practice guidelines on dystonia diagnosis/treatment in the National Guideline Clearinghouse, PubMed, National Institute for Health and Care Excellence, Guidelines International Network and Web of Science databases. We also searched for guidelines on homepages of international neurological societies. We asked for guidelines from every Management Committee member of the BM1101 Action of the Cooperation between Science and Technology European framework and every member of the International Parkinson and Movement Disorders Society with special interest in dystonia.

RESULTS

Fifteen guidelines were evaluated. Among guidelines on treatment, only one from the American Academy of Neurology could be considered as high quality. Among guidelines on diagnosis and therapy, the guideline from the European Federation of Neurological Societies was recommended by the appraisers. Clinical applicability and reports of editorial independence were the greatest shortcomings. The rigor of development was poor and stakeholder involvement was also incomplete in most guidelines. Discrepancies among recommendations may result from the weight given to consensus statements and expert opinions due to the lack of evidence, as well as inaccuracy of disease classification.

CONCLUSIONS

The quality of appraised guidelines was low. It is necessary to improve the quality of guidelines on dystonia, and the applied terminology of dystonia also needs to be standardized.

Management of dystonia in Europe: a survey of the European network for the study of the dystonia syndromes

BACKGROUND AND PURPOSE

Dystonia is difficult to recognize due to its large phenomenological complexity. Thus, the use of experts in dystonia is essential for better recognition and management of dystonia syndromes (DS). Our aim was to document managing strategies, facilities and expertise available in various European countries in order to identify which measures should be implemented to improve the management of DS.

METHODS

A survey was conducted, funded by the Cooperation in Science and Technology, via the management committee of the European network for the study of DS, which is formed from representatives of the 24 countries involved.

RESULTS

Lack of specific training in dystonia by general neurologists, general practitioners as well as other allied health professionals was universal in all countries surveyed. Genetic testing for rare dystonia mutations is not readily available in a significant number of countries and neurophysiological studies are difficult to perform due to a lack of experts in this field of movement disorders. Tetrabenazine is only readily available for treatment of dystonia in half of the surveyed countries. Deep brain stimulation is available in three-quarters of the countries, but other surgical procedures are only available in one-quarter of countries.

CONCLUSIONS

Internationally, collaboration in training, advanced diagnosis, treatment and research of DS and, locally, in each country the creation of multidisciplinary teams for the management of dystonia patients could provide the basis for improving all aspects of dystonia management across Europe.

The effect of steroid pulse therapy on carbohydrate metabolism in multiple myeloma patients: a randomized crossover observational clinical study

BACKGROUND

Hyperglycemia is a common, but not well-characterized side effect of glucocorticoid treatment.

AIM

To study the effect of pulse dexamethasone treatment on carbohydrate metabolism among multiple myeloma patients.

MATERIAL/SUBJECTS AND METHODS

A randomized crossover observational study in a teaching hospital with nine myeloma patients (one male, two with known type 2 diabetes (KDM), mean age 69.0 ± 6.7 years) were investigated using a standard 75 g Oral Glucose Tolerance Test (patients without KDM) and a 3-day continuous glucose monitoring (CGM--all patients) during and between dexamethasone cycles.

RESULTS

During dexamethasone treatment patients had elevated 2-h postload glucose (12.8 ± 4.7 vs. 8.7 ± 3.2 mmol/L, P = 0.024) but similar fasting glucose (6.3 ± 1.4 vs. 5.1 ± 0.5 mmol/L, P = 0.112). Estimated hourly mean interstitial glucose values based on linear mixed models showed an increase of 0.03 [SE 0.01] mmol/L per hour from 5.0 [0.4] in patients without KDM and followed a quadratic curve from 5.0 [0.4] mmol/L at midnight to 7.5 [0.5] mmol/L at 12:00 h in patients with KDM during control periods. During dexamethasone treatment glucose was similar to control periods between 02:00 and 12:00 h in the non-KDM group, where they followed a cubic trajectory from 5.3 [0.4] mmol/L at 04:00 h to 7.3 [0.4] mmol/L at 18:00 h. In contrast, interstitial glucose was increased by at least 7.9 [0.3] mmol/L throughout the day in KDM patients during dexamethasone treatment and increased from 13.6 [0.5] mmol/L at midnight to 17.5 [0.5] mmol/L at 17:00 h.

CONCLUSIONS

During pulse steroid therapy of myeloma patients without KDM afternoon and evening glucose measurements may be the optimal tools to characterize glucose metabolism.

The effect of paternal and maternal history of diabetes mellitus on the development of gestational diabetes mellitus

BACKGROUND

There is an ongoing debate whether maternal diabetes is a more important risk factor for gestational diabetes (GDM) development than paternal diabetes.

AIM

To describe the risk of GDM associated with paternal and maternal diabetes, and to further characterise GDM women with maternal diabetes.

SUBJECTS AND METHODS

Case-control study within a population-based GDM screening program in an urban area of Hungary in 2002-2003. All GDM women (no.=133) and an age-matched control group (no.=135) with a mean age of 31 years was evaluated. Blood pressure, anthropometric data, and blood glucose values from a 75 g Oral Glucose Tolerance Test (OGTT) were recorded at 24-28 weeks of gestation. Family history data were by self-report.

RESULTS

Known paternal diabetes was not related to GDM risk [odds ratio (OR) 0.83, 95% confidence interval (CI) 0.35-2.00]. Known maternal diabetes (OR 2.90, 95% CI 0.99-8.49) and diabetes in the maternal line (OR 2.83, 95% CI 1.16-6.89) were both related to GDM after adjustment for body mass index (BMI). GDM women with known maternal diabetes had a higher BMI, 31.6 [9.1] kg/m2 median [interquartile range], than GDM women with or without diabetes in the maternal line, 26.1 [4.9] and 26.3 [6.1] kg/m2, respectively, while figures for fasting glucose during OGTT were 5.2 [0.7] vs 4.4 [1.1] vs 4.9 [0.8] mmol/l respectively (all p<0.05).

CONCLUSIONS

Maternal history of diabetes and history of diabetes in the maternal line seems to be a stronger predictor of GDM than paternal history.

Influence of ozone-limonene reactions on perceived air quality

This study conducted short-term assessments of perceived air quality (PAQ) for six different realistic concentrations of ozone and limonene, separately or together, in room air. The impact of filtration and the influence of the ozone generation method were also examined. The evaluations were made in four identical 40 m3 low-polluting test offices ventilated at 1.4 h(-1) or in two identical 30 m3 stainless-steel chambers ventilated at 1.9 h(-1). Concentrations of ozone, total volatile organic compounds and size-fractionated particles were continuously monitored in each experiment. The results indicate that, for each of the six conditions, the PAQ was poorer when ozone and limonene were present together compared with when only ozone or only limonene was present. In the test offices a correlation was observed between the number of secondary organic aerosols produced by a given ozone/limonene condition and the sensory pollution load for that condition. The particles themselves do not appear to be the primary causative agents, but instead are co-varying surrogates for sensory offending gas-phase species.

PRACTICAL IMPLICATIONS

Although the health consequences of long-term exposures to the products of ozone-initiated indoor chemistry remain to be determined, we judge that the sensory offending nature of selected products provides an additional reason to limit indoor ozone levels. Devices that emit ozone at significant rates should not be used indoors. Ozone-filtration of make-up air should also be beneficial in mechanically ventilated buildings located in regions that repeatedly violate outdoor ozone standards. Additionally, the use of limonene containing products should be curtailed during periods when indoor ozone levels are elevated.

Gestational diabetes: current aspects on pathogenesis and treatment

Gestational diabetes (GDM) is a carbohydrate intolerance resulting in hyperglycaemia of variable severity with onset or first recognition during pregnancy. The incidence of GDM is between 0.15-15%, which corresponds to the prevalence of type 2 diabetes and IGT in a given country.--The predominant pathogenic factor in GDM could be the inadequate insulin secretion. If GDM is not properly treated the risk of adverse maternal (preeclampsia) and fetal (large-for-gestational-age infant, macrosomia, birth trauma, cesarean section, still-birth) outcome increases. Hypertension is more prevalent in GDM, and GDM is diagnosed more frequently in women with chronic hypertension.--In order to screen for disturbances of carbohydrate metabolism during pregnancy a simple method suitable for all pregnant women would be desirable, however no such method is available at present. According to the latest WHO recommendation the screening for GDM should be performed universally with the standard 75 g oGTT evaluating only the 2-hour blood glucose values or together with the fasting ones. The latter could provide even an exact diagnosis of the carbohydrate metabolic state.--To manage GDM the first step prompt after diagnosis is to educate adequate dietary needs. If the blood sugar values in spite of an adequate diet exceed the desirable target values, insulin treatment has to be initiated.--GDM is a predictor of diabetes (mainly type 2) later in life. The cumulative incidence of type 2 diabetes is about 50% at 5 years. This review of the current literature including our own experience strongly supposes that prior GDM is also a predictor or even an early manifestation of the metabolic (insulin resistance) syndrome. By all means GDM is a cardiovascular risk factor that could be screened to prevent late complications. The previously presented evidence also strongly suggests that yearly check-ups for women with previous GDM are inevitably important.

Glycaemic control in type 1 diabetic patients using optimised insulin aspart or human insulin in a randomised multinational study

Insulin aspart (IAsp), is a rapid-acting analogue of human insulin (HI), for use in the meal related treatment of diabetes mellitus. The degree of glycaemic control achieved by IAsp in comparison with HI after algorithm-driven dose optimisation was tested over 3 months. The prospective, multicentre, randomised, open-label study with parallel groups was performed in 48 centres in 11 countries and included 423 basal-bolus treated patients with Type 1 diabetes. Main outcome measures were blood glucose control assessed by HbA1c, nine-point self-monitored blood glucose profiles, insulin dose, quality of life, hypoglycaemia and adverse events. An algorithm-driven increase occurred in the dose and number of daily injections of basal insulin, particularly in the IAsp group. After 12 weeks of treatment, HbA1c was significantly lower in IAsp compared to HI treated subjects by 0.17 (95% CI 0.30-0.04) (P<0.05). Comparison of the blood glucose profiles showed lower blood glucose levels with IAsp after breakfast (mean 8.4 vs 10.1 mmol/l; P<0.0001) and dinner (8.2 vs 9.3 mmol/l; P<0.01). There were no differences between treatments in the incidence of hypoglycaemic episodes or in the adverse event profiles. The WHO Diabetes Treatment Satisfaction Questionnaire score for perceived hyperglycaemia was lower with Iasp (P=0.005), and patients found the insulin aspart treatment more flexible (P=0.022). The current study underlines the need for optimising the basal insulin regimen in order to take full advantage of the pharmacodynamics of IAsp.

Beta and gamma frequency synchronization by dendritic gabaergic synapses and gap junctions in a network of cortical interneurons

Distinct interneuron populations innervate perisomatic and dendritic regions of cortical cells. Perisomatically terminating GABAergic inputs are effective in timing postsynaptic action potentials, and basket cells synchronize each other via gap junctions combined with neighboring GABAergic synapses. The function of dendritic GABAergic synapses in cortical rhythmicity, and their interaction with electrical synapses is not understood. Using multiple whole-cell recordings in layers 2-3 of rat somatosensory cortex combined with light and electron microscopic determination of sites of interaction, we studied the interactions between regular spiking nonpyramidal cells (RSNPCs). Random samples of unlabeled postsynaptic targets showed that RSNPCs placed GABAergic synapses onto dendritic spines (53 +/- 12%) and shafts (45 +/- 10%) and occasionally somata (2 +/- 4%). GABAergic interactions between RSNPCs were mediated by 4 +/- 2 axodendritic synapses and phased postsynaptic activity at beta frequency but were ineffective in phasing at gamma rhythm. Electrical interactions of RSNPCs were transmitted via two to eight gap junctions between dendritic shafts and/or spines. Elicited at beta and gamma frequencies, gap junctional potentials timed postsynaptic spikes with a phase lag, however strong electrical coupling could synchronize presynaptic and postsynaptic activity. Combined unitary GABAergic and gap junctional connections of moderate strength produced beta and gamma frequency synchronization of the coupled RSNPCs. Our results provide evidence that dendritic GABAergic and/or gap junctional mechanisms effectively transmit suprathreshold information in a population of interneurons at behaviorally relevant frequencies. A coherent network of GABAergic cells targeting the dendrites could provide a pathway for rhythmic activity spatially segregated from perisomatic mechanisms of synchronization.

Blood pressure response to standing in the diagnosis of autonomic neuropathy: the EURODIAB IDDM Complications Study

Autonomic neuropathy is associated with poor prognosis. Cardiovascular reflexes are essential for the diagnosis of autonomic nerve dysfunction. Blood pressure response to standing is the most simple test for the evaluation of sympathetic integrity, however it is still discussed which diagnostic criteria of abnormal response should be considered as optimal. The EURODIAB IDDM Complications Study involved the examination of randomly selected Type 1 diabetic patients from 31 centres in 16 European counties. Data from 3007 patients were available for the present evaluation. Two tests of autonomic function (response of heart rate /R-R ratio/ and blood pressure from lying to standing) just as the frequency of feeling faint on standing up were assessed. R-R ratio was abnormal in 24% of patients. According to different diagnostic criteria of abnormal BP response to standing (>30 mmHg, >20 mmHg, and >10 mmHg fall in systolic BP), the frequency of abnormal results was 5.9%, 18% and 32%, respectively (p < 0.001). The frequency of feeling faint on standing was 18%, thus, it was identical with the prevalence of abnormal blood pressure response to standing when >20 mmHg fall in systolic blood pressure was considered as abnormal. Feeling faint on standing correlated significantly with both autonomic test results (p < 0.001). A fall >20 mmHg in systolic blood pressure after standing up seems to be the most reliable criterion for the assessment of orthostatic hypotension in the diagnosis of autonomic neuropathy in patients with Type 1 diabetes mellitus.

Targets and reality: a comparison of health care indicators in the U.S. (Pittsburgh Epidemiology of Diabetes Complications Study) and Hungary (DiabCare Hungary)

OBJECTIVE

In the U.S., both primary care and specialist physicians share in the care of type 1 diabetic patients, often in an informal collaboration. In Hungary, however, type 1 diabetic patients are generally managed in special centralized diabetes units. These different treatment settings may lead to different health care practices and outcomes. To determine if this is true, diabetes care indicators and complications were compared across representative study populations from the 2 countries.

RESEARCH DESIGN AND METHODS

The Pittsburgh Epidemiology of Diabetes Complications Study (EDC) is a prospective cohort of childhood-onset type 1 diabetic patients. DiabCare Hungary, a multicenter cross-sectional study, was developed for quality control purposes and provides a nationwide data set of diabetic patients. We identified 2 comparable populations (EDC, n = 416; DiabCare, n = 405) in terms of age (> or =14 years) and age at onset (<17 years).

RESULTS

EDC patients were less likely to receive diabetes education (P<0.0001), see an ophthalmologist (P<0.0001), be treated by diabetologists (P<0.0001), or perform self-monitoring of blood glucose (P<0.0001). They were more likely to use conservative insulin regimens (i.e., 1-2 injections/day, P<0.0001) and have a higher glycated hemoglobin (P< 0.0001). DiabCare patients more often experienced severe hypoglycemia (P<0.01) and had a lower prevalence of proliferative retinopathy (P<0.0001), legal blindness (P<0.05), and albuminuria (> or =30 mg/day P<0.01). No significant differences in macrovascular complications were seen, although rates were generally low

CONCLUSIONS

These data suggest that the 2 populations differ by their diabetes care practices, degree of glycemic control, and microvascular complication status.

Comparison of morbidity of lumbar flank approach and transperitoneal approach for radical nephrectomy

PURPOSE

This is a retrospective study comparing the clinical data and morbidity of transperitoneal radical nephrectomy (TRN) and simple nephrectomy.

MATERIAL AND METHODS

From 1st January, 1989 to 1st January, 1996 a total of 90 simple nephrectomies and from 1st January, 1996 to 1st August, 1999 a number of 85 TRN were performed at the Department of Urology of the Saint Stephen Hospital. The analysis of clinical data included operative time, length of analgesics, postoperative hospital stay and blood loss, as well as morbidity.

RESULTS

The mean operative time for TRN was 170 min., being 95 min. for simple nephrectomy. The mean blood loss for TRN was 250 ml, and 400 ml for simple nephrectomy. There were different types of morbidity for TRN and simple nephrectomy. The complications of TRN mean minimal risk and easy correctibility.

CONCLUSION

Our results demonstrate an overall clear advantage of TRN when compared to simple nephrectomy.

A case of a calcified renal cyst

Authors review a case of a calcified renal cyst. The literary data at hand give evidence that the spreading processes in the kidney can be benign or malignant according to their form of calcification and their localisation. Despite the modern diagnostic techniques, it is not easy to set up the diagnosis or to avoid the need for surgery, as was the case in the present report.

Isolated urethral amyloidosis (case report)

A case of urethral amyloidosis is presented in a 31-year-old male patient. Through this case, authors draw attention to the recommended forms of examination in the event of this illness being suspected, and also discuss problems in differential diagnosis. A reviewed the relevant data in the literature is also provided.

Anatomic variations in patients operated for bladder substitution

Authors review the anatomic variations observed throughout orthotopic ileal neobladder formation in 38 cases following radical cystectomy. A part of the variations was necessitated because of deviation from the classic Hautmann-type surgical technique: in 6 cases the site of ileal resection was modified due to abnormal mesenterial art. course, on 2 occasions Meckel diverticules were detected while cutting the ileal neobladder, in 13 cases the laterally adhered sigma bladder necessitated the left-sided ureter to be pulled through beneath the mesosigma for the purpose of making sure the ureter--ileal neobladder anastomosis became free of any tension, while on 1 occasion the left ureteral preparations went with some injury. Since the left ureter became short, ureter replacement variation was needed, similar to the Studer method of ileal neobladder formation. All these variations, however, did not implicate the essence of the Hautmann technique. Follow-up of the patients did not reveal high frequency of occurrence of any complications.

Metabolic consequences of orthotopic ileal neobladder

PURPOSE

Orthotopic ileal bladder substitution is a well accepted form of urinary diversion providing high quality of life. However, potential metabolic consequences remain a serious problem. These complications are discussed in the present article.

MATERIAL AND METHODS

Authors review the metabolic complications of 45 orthotopic ileal neobladder cases.

RESULTS

Insufficient absorption (malabsorption) associated with ileal resection is quite rare, while hyperchloremic metabolic acidosis after ileal neobladder is a rather common phenomenon (55%).

CONCLUSION

Authors suggest careful patient selection, correct operative technique and vigilant follow-up for successful treatment of metabolic complications.

Proximally targeted GABAergic synapses and gap junctions synchronize cortical interneurons

Networks of GABAergic interneurons are implicated in synchronizing cortical activity at gamma frequencies (30-70 Hz). Here we demonstrate that the combined electrical and GABAergic synaptic coupling of basket cells instantaneously entrained gamma-frequency postsynaptic firing in layers 2/3 of rat somatosensory cortex. This entrainment was mediated by rapid curtailment of gap junctional coupling potentials by GABAA receptor-mediated IPSPs. Electron microscopy revealed spatial proximity of gap junctions and GABAergic synapses on somata and dendrites. Electrical coupling alone entrained postsynaptic firing with a phase lag, whereas unitary GABAergic connections were ineffective in gamma-frequency phasing. These observations demonstrate precise spatiotemporal mechanisms underlying action potential timing in oscillating interneuronal networks.

[Detection of antibodies against pancreatic islet cells in clinical practice]

Development of diabetes mellitus caused by pancreatic beta-cell destruction of autoimmune origin is the result of a long lasting process. The most easily examinable feature of this stage is the occurrence of the islet cell antibodies. The sera which are positive for islet cell cytoplasmic antibodies (ICA), examined by indirect immunofluorescence, contain a mixture of antibodies. The glutamic acid decarbocylase (GAD), the tyrosin phosphatase (IA2), the insulin, and the GM2-1 glycolipid can be the targets of these antibodies. One can routinely examine the ICA, the GADA, the IA2 antibodies. The detection of antibodies against insulin (IAA) and GM-2-1 glycolipid is not invented in the routine laboratory work. The aim of the authors was the evaluation of clinical significance of occurrence of islet cell antibodies: one hundred and eighteen nondiabetic children an adult human being without known diabetic first degree relatives and 366 type 1 diabetic children and adult patients served as controls. The authors evaluated the predictive value of the different islet cell antibodies to the development of type 1 diabetes mellitus in 596 nondiabetic children with type 1 diabetic first degree relatives. The authors looked for markers of beta-cell destruction among sera of 320 diabetics manifested after 30 years of age with at least half a year of non-insulin-dependency and in the sera of 68 females suffered from gestational diabetes after 0-14 years of the index pregnancy. Finally the authors report 7 cases in which the examination of islet cell antibodies helped the diagnosis and classification of diabetes mellitus. Indirect immunofluorescence method was used for the detection of ICA, radioimmunoassay for that of GADA and IA2 antibodies. There was no positive reaction for ICA and GADA in the nondiabetic population without diabetic first degree relatives. Among the freshly diagnosed type 1 diabetic children 39% were positive for only ICA, 44% for only GADA and 80% for any antibodies. Among the freshly manifested type 1 diabetic adults ICA positivity only was observed in 21%, GADA positivity only in 7.1% and 93% for any antibodies. From the 595 nondiabetic children with type 1 diabetic first degree relatives 23 were positive for ICA, from whom 5 became diabetic during a two years observation period. These diabetic children had multiplex autoantibodies besides ICA. One child from this group, who was negative for ICA became diabetic, too. Among type 2 diabetic patients 13% were positive for ICA alone, 17% were positive for GADA alone and 27% were positive for any antibodies. The insulin dependency manifested in a short time was associated with antibody positivity. Among the gestational diabetics 10 were found positive for ICA. From them, 7 were type 1 diabetics, and 3 were type 2 diabetics at the time of the detection of antibodies. The authors suggest the need of determination of islet cell antibodies in the group of nondiabetic first degree relatives of type 1 diabetic patients (ICA, GADA, IA2 and IAA), in the group of non-insulin-dependent diabetics (ICA and GADA) as a screening for later insulin dependency, and in gestational diabetes after delivery (ICA) as screening for type 1 diabetes mellitus.

Experiences of 25 orthotopic ileal neobladders

Authors report on their results obtained from orthotopic ileal neobladders following 25 cases of radical cystectomy. Analysis is given of the possible complications, their prevention, as well as of surgical techniques. It is determined that orthotopic ileal neobladder is one of the best bladder substitution methods, giving the patient a chance for a high quality of life.

Experiences on 25 cases of radical cystectomy

Authors review their early experiences and the oncopathological relations in respect to 25 cases of radical cystectomy involving orthotopic bladder substitution. The difficulties of diagnostics and indication are discussed. Attention is drawn to the fact that pathological "staging", "grading" are not entirely exact and reliable, though surgical indication is positioned on these. It is the opinion of authors that in case of TIG3 radical surgery is indicated. Due to the shortness of the follow-up periods, no studies on survival were performed. It remains an open question whether radical cystectomy is indicated as opposed to the possible choice of organ-preserving surgery.

Cholinergic activation and tonic excitation induce persistent gamma oscillations in mouse somatosensory cortex in vitro

1. Concomitant application of the cholinergic agonist carbachol and nanomolar doses of kainate can elicit persistent gamma frequency oscillations in all layers of the mouse somatosensory cortex in vitro. Receptor pharmacology with bath-applied antagonists indicated that oscillatory network activity depended crucially on the participation of cholinergic muscarinic, (S)-alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA)/kainate and GABAA receptors. 2. The timing of action potentials and the occurrence of excitatory as well as inhibitory postsynaptic events was highly correlated with the phasic change of extracellularly recorded population activity. Firing probability was lowest during the peak negativity of IPSPs and gradually increased during their ensuing decay. In conjunction with the effect of a barbiturate to decrease the frequency of gamma oscillations, this suggests a crucial role of IPSPs in phasing the suprathreshold activity of principal neurons. 3. At nearby (< 1 mm) sites contained within any given cortical layer, oscillatory extra- and intracellular activity was highly synchronous with no apparent phase lag. However, interlaminar mapping experiments demonstrated a phase reversal of both extra- and intracellularly recorded activity near the lower border of thalamo-recipient layer 4, thus corroborating findings that have been obtained in vivo. 4. In conclusion, a modest increase of tonic excitatory drive in conjunction with the activation of cholinergic muscarinic receptors can elicit persistent gamma frequency network oscillations in the rodent somatosensory cortex. These findings (re)emphasize the role of the cholinergic ascending system in the cortical processing of sensory information.

Differentially interconnected networks of GABAergic interneurons in the visual cortex of the cat

Networks of GABAergic neurons have been implicated in neuronal population synchronization. To define the extent of cellular interconnections, we determined the effect, number, and subcellular distribution of synapses between putative GABAergic neurons in layers II-IV of the cat visual cortex using paired intracellular recordings in vitro followed by correlated light and electron microscopy. All neurons having interneuronal electrophysiological properties were classified by their postsynaptic target profile and were identified as basket (BC; n = 6), dendrite-targeting (DTC; n = 1), and double bouquet (DBC; n = 2) cells. In four out of five anatomically fully recovered and reconstructed cell pairs, synaptic connections were found to be reciprocal. Generally BCs established synaptic junctions closer (21 +/- 20 micron) to postsynaptic somata than did DBCs (43 +/- 19 micron; p < 0.01). The unitary number of synapses (n values, 10, 7, and 20) in each of three BC-to-BC pairs was higher than that in three BC-to-DBC (n values, 1, 2, and 2) and three DBC-to-BC (n values, 1, 4, and 4) connections (p < 0.05). A BC innervated a DTC through two synaptic junctions. Unitary postsynaptic effects mediated by five BCs could be recorded in two BCs, two DBCs, and a DTC. The BCs elicited short-duration fast IPSPs, similar to those mediated by GABAA receptors. At a membrane potential of -55.0 +/- 6.4 mV, unitary IPSPs (n = 5) had a mean amplitude of 919 +/- 863 microV. Postsynaptic response failures were absent when an IPSP was mediated by several release sites. Thus, distinct GABAergic interneurons form reciprocally interconnected networks. The strength of innervation and the proximal placement of synapses suggest a prominent role for BCs in governing the activity of intracortical GABAergic networks in layers II-IV.

Spontaneous (renal) pelvic rupture. Two cases cured by conservative therapy

Two cases of spontaneous pelvic rupture are presented. In Case 1 (female, 49 years) and Case 2 (male, 63 years) the rupture was due to obstruction and tumorous compression of the ureter, respectively. Authors deal with the diagnostic difficulties and the possibility of a cure without open surgery. Conservative therapy (double-J ureteral catheter and pigtail catheter) was successful in both cases. The pertinent literature is briefly reviewed.

Salient features of synaptic organisation in the cerebral cortex

The neuronal and synaptic organisation of the cerebral cortex appears exceedingly complex, and the definition of a basic cortical circuit in terms of defined classes of cells and connections is necessary to facilitate progress of its analysis. During the last two decades quantitative studies of the synaptic connectivity of identified cortical neurones and their molecular dissection revealed a number of general rules that apply to all areas of cortex. In this review, first the precise location of postsynaptic GABA and glutamate receptors is examined at cortical synapses, in order to define the site of synaptic interactions. It is argued that, due to the exclusion of G protein-coupled receptors from the postsynaptic density, the presence of extrasynaptic receptors and the molecular compartmentalisation of the postsynaptic membrane, the synapse should include membrane areas beyond the membrane specialisation. Subsequently, the following organisational principles are examined: 1. The cerebral cortex consists of: (i) a large population of principal neurones reciprocally connected to the thalamus and to each other via axon collaterals releasing excitatory amino acids, and, (ii) a smaller population of mainly local circuit GABAergic neurones. 2. Differential reciprocal connections are also formed amongst GABAergic neurones. 3. All extrinsic and intracortical glutamatergic pathways terminate on both the principal and the GABAergic neurones, differentially weighted according to the pathway. 4. Synapses of multiple sets of glutamatergic and GABAergic afferents subdivide the surface of cortical neurones and are often co-aligned on the dendritic domain. 5. A unique feature of the cortex is the GABAergic axo-axonic cell, influencing principal cells through GABAA receptors at synapses located exclusively on the axon initial segment. The analysis of these salient features of connectivity has revealed a remarkably selective array of connections, yet a highly adaptable design of the basic circuit emerges when comparisons are made between cortical areas or layers. The basic circuit is most obvious in the hippocampus where a relatively homogeneous set of spatially aligned principal cells allows an easy visualization of the organisational rules. Those principles which have been examined in the isocortex proved to be identical or very similar. In the isocortex, the basic circuit, scaled to specific requirements, is repeated in each layer. As multiple sets of output neurones evolved, requiring subtly different needs for their inputs, the basic circuit may be superimposed several times in the same layer. Tangential intralaminar connections in both the hippocampus and isocortex also connect output neurones with similar properties, as best seen in the patchy connections in the isocortex. The additional radial superposition of several laminae of distinct sets of output neurones, each representing and supported by its basic circuit, requires a co-ordination of their activity that is mediated by highly selective interlaminar connections, involving both the GABAergic and the excitatory amino acid releasing neurones. The remarkable specificity in the geometry of cells and the selectivity in placement of neurotransmitter receptors and synapses on their surface, strongly suggest a predominant role for time in the coding of information, but this does not exclude an important role also for the rate of action potential discharge in cortical representation of information.

Bilateral ureteric replacement with ileum

In connection with a report of a case, authors discuss in outline the possibilities of ureter replacement. If both the ureters are injured, they can be substituted with one single segment of the intestine, as it happened in their case. Authors raise the idea that a longer segment of the intestine used for substitution provides sufficient capacity and isoperistaltic function, and this may protect from the negative effects of possible vesicoileal reflux. In this case, the reflux does not spread to the kidneys even if the ureteroileal was not made with anti-reflux technique.

Massive autaptic self-innervation of GABAergic neurons in cat visual cortex

Autapses are transmitter release sites made by the axon of a neuron on its own dendrites. We determined the numbers and precise subcellular position of autapses on different spiny and smooth dendritic cell types using intracellular biocytin filling in slices of adult neocortex. Potential self-innervation was light microscopically assessed on 10 pyramidal cells, 7 spiny stellate cells, and 41 smooth dendritic neurons from cortical layers II-V. Putative autapses occurred on each smooth dendritic neuron and on seven pyramids, but not on spiny stellate cells. However, electron microscopic examination of all light microscopically predicted sites on pyramids (n = 28) showed only one case of self-innervation with two autapses on dendritic spines. Interneurons were classified by postsynaptic target distribution () and all putative autapses of seven basket, three dendrite-targeting, and three double bouquet cells were scrutinized. All basket and dendrite-targeting cells established self-innervation, the number of autapses being 12 +/- 7 and 22 +/- 12 (mean +/- SD), respectively; only one of the double bouquet cells formed autapses (n = 3). Basket cell autapses (n = 74) were closer to the soma (12.2 +/- 22.3 microm) than autapses established by dendrite-targeting cells (51.8 +/- 49.9 microm; n = 66). The degree of self-innervation is cell type-specific. Unlike on spiny cells, autapses are abundant on GABAergic basket and dendrite-targeting interneurons, with subcellular location similar to that of synapses formed by the parent cell on other neurons. The extensive self-innervation may modulate integrative properties and/or the firing rhythm of the neuron in a manner temporally correlated with its own activity.

Synaptic effects of identified interneurons innervating both interneurons and pyramidal cells in the rat hippocampus

GABAergic interneurons sculpt the activity of principal cells and are themselves governed by GABAergic inputs. To determine directly some of the sources and mechanisms of this GABAergic innervation, we have used dual intracellular recordings with biocytin-filled microelectrodes and investigated synaptic interactions between pairs of interneurons in area CA1 of the adult rat hippocampus. Of four synaptically-coupled interneuron-to-interneuron cell pairs, three presynaptic cells were identified as basket cells, preferentially innervating somata and proximal dendrites of pyramidal cells, but one differing from the other two in the laminar distribution of its dendritic and axonal fields. The fourth presynaptic interneuron was located at the border between strata lacunosum moleculare and radiatum, with axon ramifying within stratum radiatum. Action potentials evoked in all four presynaptic interneurons were found to elicit fast hyperpolarizing inhibitory postsynaptic potentials (mean amplitude 0.35 +/- 0.10 mV at a membrane potential of -59 +/- 2.8 mV) in other simultaneously recorded interneurons (n=4). In addition, three of the presynaptic interneurons were also shown to produce similar postsynaptic responses in subsequently recorded pyramidal cells (n=4). Electron microscopic evaluation revealed one of the presynaptic basket cells to form 12 synaptic junctions with the perisomatic domain (seven somatic synapses and five synapses onto proximal dendritic shafts) of the postsynaptic interneuron in addition to innervating the same compartments of randomly-selected local pyramidal cells (50% somatic and 50% proximal dendritic synapses, n=12). In addition, light microscopic analysis also indicated autaptic self-innervation in basket (12 of 12) and bistratified cells (six of six). Electron microscopic investigation of one basket cell confirmed six autaptic junctions made by five of its boutons. Together, these data demonstrate that several distinct types of interneuron have divergent output to both principal cells and local interneurons of the same (basket cells) or different type. The fast synaptic effects, probably mediated by GABA in both postsynaptic interneurons and principal cells are similar. These additional sources of GABA identified here in the input to GABAergic cells could contribute to the differential temporal patterning of distinct GABAergic synaptic networks.

Effect, number and location of synapses made by single pyramidal cells onto aspiny interneurones of cat visual cortex

1. Dual intracellular recordings were made from synaptically coupled pyramidal cell-to-interneurone pairs (n = 5) of the cat visual cortex in vitro. Pre- and postsynaptic neurones were labelled with biocytin, followed by correlated light and electron microscopic analysis to determine all sites of synaptic interaction. 2. Pyramidal neurones in layers II-III elicited monosynaptic EPSPs in three distinct classes of smooth dendritic local-circuit neurones, namely basket cells (n = 3), a dendrite-targeting cell (n = 1) and a double bouquet cell (n = 1). Unitary EPSPs in basket cells were mediated by one, two, and two synaptic junctions, whereas the pyramid-to-dendrite-targeting cell and pyramid-to-double bouquet cell interaction were mediated by five and seven synaptic junctions, respectively. Recurrent synaptic junctions were found on all somato-dendritic compartments, with a tendency to be clustered close to the soma on the double bouquet and dendrite-targeting cells. The latter interneurones were reciprocally connected with pyramidal cells. 3. Unitary EPSPs had an average peak amplitude of 1005 +/- 518 microV, fast rise times (10-90%; 0.67 +/- 0.25 ms) and were of short duration (at half-amplitude, 4.7 +/- 1.0 ms). Their decay was monoexponential (tau = 7.8 +/- 4.3 ms) at hyperpolarized membrane potentials and appeared to be shaped by passive membrane properties (tau = 9.2 +/- 8.5 ms). All parameters of concomitantly recorded spontaneous EPSPs were remarkably similar (mean amplitude, 981 +/- 433 microV; mean rise time, 0.68 +/- 0.18 ms; mean duration, 4.7 +/- 1.7 ms). 4. In all three pyramidal-to-basket cell pairs, closely timed (10-50 ms) pairs of presynaptic action potentials resulted in statistically significant paired-pulse depression, the mean of the averaged second EPSPs being 80 +/- 11% of the averaged conditioning event. The overall degree of paired-pulse modulation was relatively little affected by either the amplitude of the preceding event or the inter-event interval. 5. The probability density function of the peak amplitudes of the unitary EPSPs could be adequately fitted with a quantal model. Without quantal variance, however, the minimum number of components in the model, excluding the failures, exceeded the number of electron microscopically determined synaptic junctions for all five connections. In contrast, incorporating quantal variance gave a minimum number of components which was compatible with the number of synaptic junctions, and which fitted the data equally well as models incorporating additional components but no quantal variance. For this model with quantal variance with the minimum number of components the estimate of the quantal coefficient of variation ranged between 0.33 and 0.46, and the corresponding quantal sizes ranged between 260 and 657 microV. The peak EPSP amplitudes in two of the four connections with more than one synaptic junction could be adequately described by a uniform binomial model for transmitter release. 6. In conclusion, at least three distinct interneurone classes receive local excitatory pyramidal cell input which they relay to different compartments on their postsynaptic target neurones. The reliability of transmission is high, but the fast time course of the EPSPs constrains their temporal summation. Due to the relatively small amplitude of unitary EPSPs several convergent inputs will therefore be required to elicit suprathreshold responses.

Fast IPSPs elicited via multiple synaptic release sites by different types of GABAergic neurone in the cat visual cortex

1. The effects of synapses established by smooth dendritic neurones on pyramidal and spiny stellate cells were studied in areas 17 and 18 of the cat visual cortex in vitro. Paired intracellular recordings with biocytin-filled electrodes and subsequent light and electron microscopic analysis were used to determine the sites of synaptic interaction. 2. All smooth dendritic cells established type II synapses previously shown to be made by terminals containing GABA, therefore the studied cells are probably GABAergic. Three classes of presynaptic cell could be defined, based on their efferent synaptic target preference determined from random samples of unlabelled postsynaptic cells. (a) Basket cells (n = 6) innervated mainly somata (49.9 +/- 13.8%) and dendritic shafts (45.2 +/- 10.7%) and, to a lesser extent, dendritic spines (4.9 +/- 4.6%). (b) Dendrite-targeting cells (n = 5) established synapses predominantly on dendritic shafts (84.3 +/- 9.4%) and less frequently on dendritic spines (11.2 +/- 6.7%) or somata (4.5 +/- 4.7%). (c) Double bouquet cells (n = 4) preferred dendritic spines (69.2 +/- 4.2%) to dendritic shafts (30.8 +/- 4.2%) as postsynaptic targets and avoided somata. 3. Interneurones formed 5240 +/- 1600 (range, 2830-9690) synaptic junctions in the slices. Based on the density of synapses made by single interneurones and the volume density of GABAergic synapses, it was calculated that an average interneurone provides 0.66 +/- 0.20% of the GABAergic synapses in its axonal field. 4. The location of synaptic junctions on individual, identified postsynaptic cells reflected the overall postsynaptic target distribution of the same GABAergic neurone. The number of synaptic junctions between pairs of neurones could not be predicted from light microscopic examination. The number of electron microscopically verified synaptic sites was generally smaller for the dendritic domain and larger for the somatic domain than expected from light microscopy. All presynaptic cells established multiple synaptic junctions on their postsynaptic target cells. A basket cell innervated a pyramidal cell via fifteen release sites; the numbers of synapses formed by three dendrite-targeting cells on pyramidal cells were seventeen and eight respectively, and three on a spiny stellate cell; the interaction between a double bouquet cell and a postsynaptic pyramidal cell was mediated by ten synaptic junctions. 5. All three types of interneurone (n = 6; 2 for each type of cell) elicited short-latency IPSPs with fast rise time (10-90%; 2.59 +/- 1.02 ms) and short duration (at half-amplitude, 15.82 +/- 5.24 ms), similar to those mediated by GABAA receptors. 6. Average amplitudes of unitary IPSPs (n = 6) were 845 +/- 796 microV (range, 134-2265 microV). Variability of IPSP amplitude was moderate, the average ratio of IPSP and baseline noise variance was 1.54 +/- 0.96. High frequency activation of single presynaptic dendrite-targeting cells led to an initial summation followed by use-dependent depression of the averaged postsynaptic response. Double bouquet cell-evoked IPSPs, recorded in the soma, had a smaller amplitude than those evoked by the other two cell types. In all connections, transmission failures were rare or absent, particularly when mediated by a high number of release sites. 7. The results demonstrate that different types of neocortical GABAergic neurones innervate distinct domains on the surface of their postsynaptic target cells. Nevertheless, all three types of cell studied here elicit fast IPSPs and provide GABAergic input through multiple synaptic release sites with few, if any, failures of transmission.

[Use of sodium diclofenac in acute renal colic]

31 patients with symptoms of acute renal colic were treated with diclofenac natrium. According to preliminary results this drug is more effective for relieving pain of acute renal colic than the traditional combination of spasmolytics and analgetics. This might be due to the blocking effect of diclofenac natrium on the renal PG synthesis and release, thus decreasing the diuresis. Side effects were minimal, as nausea, vomiting etc. Authors highly recommend this drug as the first choice of treatment in acute renal colic.

Synaptic target selectivity and input of GABAergic basket and bistratified interneurons in the CA1 area of the rat hippocampus

To assess the position of interneurons in the hippocampal network, fast spiking cells were recorded intracellularly in vitro and filled with biocytin. Sixteen non-principal cells were selected on the basis of 1) cell bodies located in the pyramidal layer and in the middle of the slice, 2) extensive labeling of their axons, and 3) a branching pattern of the axon indicating that they were not axo-axonic cells. Examination of their efferent synapses (n = 400) demonstrated that the cells made synapses on cell bodies, dendritic shafts, spines, and axon initial segments (AIS). Statistical analysis of the distribution of different postsynaptic elements, together with published data (n = 288) for 12 similar cells, showed that the interneurons were heterogeneous with regard to the frequency of synapses given to different parts of pyramidal cells. When the cells were grouped according to whether they had less or more than 40% somatic synaptic targets, each population appeared homogeneous. The population (n = 19) innervating a high proportion of somata (53 +/- 10%, SD) corresponds to basket cells. They also form synapses with proximal dendrites (44 +/- 12%) and rarely with AISs and spines. One well-filled basket cell had 8,859 boutons within the slice, covering an area of 0.331 mm2 of pyramidal layer tangentially and containing 7,150 pyramidal cells, 933 (13%) of which were calculated to be innervated, assuming that each pyramidal cell received nine to ten synapses. It was extrapolated that the intact axon probably had about 10,800 boutons innervating 1,140 pyramids. The proportion of innervated pyramidal cells decreased from 28% in the middle to 4% at the edge of the axonal field. The other group of neurons, the bistratified cells (n = 9), showed a preference for dendritic shafts (79 +/- 8%) and spines (17 +/- 8%) as synaptic targets, rarely terminating on somata (4 +/- 8%). Their axonal field was significantly larger (1,250 +/- 180 microns) in the medio-lateral direction than that of basket cells (760 +/- 130 microns). The axon terminals of bistratified cells were smaller than those of basket cells. Furthermore, in constrast to bistratified cells, basket cells had a significant proportion of dendrites in stratum lacunosum-moleculare suggesting a direct entorhinal input. The results define two distinct types of GABAergic neuron innervating pyramidal cells in a spatially segregated manner and predict different functions for the two inputs. The perisomatic termination of basket cells is suited for the synchronization of a subset of pyramidal cells that they select from the population within their axonal field, whereas the termination of bistratified cells in conjunction with Schaffer collateral/commissural terminals may govern the timing of CA3 input and/or voltage-dependent conductances in the dendrites.

The use of Voltaren (diclofenac sodium, Ciba) in acute renal colic

Thirty-one patients with acute renal colic were treated with Voltaren (Diclofenac Sodium, Ciba). The drug proved to be suitable for relieving, and stopping pain. Adverse effects were observed but in few cases. For this reason authors suggest a more extensive use of the drug.

The effect of somatostatin in dumping syndrome after gastric surgery

The effect of somatostatin on early and late dumping syndrome was studied in 12 patients with gastric resection. Each patient underwent two glucose challenges with 75 gram of glucose administered orally. In the control study isotonic sodium chloride was given, while in the other study cyclic somatostatin in a dose of 80 ng/kg/min was given for a period of 270 minutes. In the control study all patients showed subjective symptoms of the early dumping syndrome with significant (p < 0.001) increases in pulse rate, hematocrit, and vasoactive intestinal polypeptide. Ten patients showed asymptomatic hypoglycemia, as a sign of the late dumping syndrome associated with a significant (p < 0.001) increase of insulin, gastric inhibitory peptide and glucagon levels. During the administration of somatostatin these changes failed to develop. The difference between the results of the two challenges are significant. These results indicate that somatostatin alleviates the symptoms both of early and late dumping syndrome partly by inhibiting the vasoactive intestinal polypeptide, gastric inhibitory peptide and insulin release, which are increased in dumping syndrome and may, therefore, be implicated as to have an etiological role.

Occurrence of oral leukoplakia and lichen planus in diabetes mellitus

The occurrence of oral leukoplakia and lichen planus in 1600 patients with diabetes mellitus (815 type 1: insulin-dependent, 761 type 2: non-insulin-dependent)-under care at the International Medicine Department-was studied. Precancerous lesions and conditions were diagnosed and grouped according to internationally accepted criteria. The prevalence of oral leukoplakia in diabetic patients was 6.2%, as compared to 2.2% in the healthy controls, that of oral lichen was 1.0% in the test-, and 0.0% in the control group. Leukoplakia and lichen both showed the highest occurrence in the second year of established diabetes, and their prevalence was higher among insulin-treated diabetics. Smokers were more often affected, by both kind of lesions, oral lichen showed a more frequent association with candidiasis. The prevalence of oral leukoplakia and lichen in diabetes mellitus patients was higher, than average ratios in population samples from the same country.

[Relationship between the caries status and metabolic imbalance in diabetics]

The dental clinical examination of 1600 (815 insulin dependent of type 1 and 761 non-insulin dependent of type 2 respectively) patients cared of because of diabetes mellitus was carried out and an answer to the question was sought for whether the condition of the teeth does change according to he type of the metabolic disturbance of the diabetic, the time of its manifestation, its setting, the manner of therapy, the family occurrence of the illness and the mouth hygiene, respectively. According to examination results, greater edentulousness with diabetes over 30 years showed a positive interdependence according to the confirmance time of diabetes. On the other hand, with diabetic of better setting there were less teeth with caries or removed ones and the DMF-T average was lower than with patients with worse diabetes setting. No independence was found in the development of the DMF-T average and the caries conditions, respectively, if diabetes occurred in the family history and according to the type of diabetes.

[The effect of somatostatin in dumping syndrome]

The effect of cyclic somatostatin on early and late dumping syndrome was studied in 12 patients with gastric resection. Each patient underwent two glucose challenges with 75 grams of glucose administered orally. In the control study isotonic sodium chloride was given, while in the other study cyclic somatostatin in a dose of 250 micrograms bolus injection followed by infusion of 80 ng/kg/min for a period of 270 minutes. In the control study all patients showed subjective symptoms of the early dumping syndrome with significant increases in pulse rate, hematocrit, and vasoactive intestinal polypeptide. Ten patients showed asymptomatic hypoglycemia, as a sign of the late dumping syndrome associated with a significant increases of insulin, gastric inhibitory peptide and glucagon levels. During the administration of somatostatin these changes failed to develop. These results indicate that somatostatin alleviates the symptoms of early and late postprandial dumping syndrome.