Validation of the Danish SARC-F in Hospitalized, Geriatric Medical Patients

OBJECTIVES

Validation of the Danish version of the SARC-F (Strength, Assistance in walking, Rise from a chair, Climb stairs, and Falls) for hospitalized geriatric medical patients, compared against the original EWGSOP (European Working Group on Sarcopenia in Older People) and revised EWGSOP2 definition for sarcopenia. Additionally, investigation of the ability of SARC-F to individually identify low strength/function and muscle mass.

DESIGN

Cross-sectional analysis of data from an RCT.

SETTING

Hospital, Medical Department.

PARTICIPANTS

122 geriatric medical patients (65.6% women) ≥ 70 years of age with mixed medical conditions.

MEASUREMENTS

SARC-F screening, diagnostic assessment of sarcopenia (hand-grip strength, muscle mass measured by dual-frequency bio-impedance analysis, and 4-m usual gait speed).

RESULTS

The prevalence of risk of sarcopenia (SARC-F ≥ 4) was 48.3%, while it was diagnosed in 65.8% and 21.7%, with EWGSOP and EWGSOP2, respectively. The sensitivity, specificity, positive predictive value, negative predictive value according to EWGSOP were 50.0 %, 53.7 %, 67.2% and 36.1%, while they were 53.8 %, 53.2 %, 24.1% and 80.6%, according to EWGSOP2 (all participants). The ability of SARC-F to predict reduced strength, function, and muscle mass was modest. There was a significant negative linear, yet weak, relationship between total SARC-F score and hand-grip strength (R2=0.033) and 4-m gait speed (R2=0.111), but not muscle mass (R2=0.004).

CONCLUSION

SARC-F does not seem to be a suitable screening tool for identifying and excluding non-sarcopenic geriatric patients. Furthermore, the SARC-F score was more strongly correlated with reduced muscle strength and physical function than with low muscle mass.

Detection of EEG Patterns Related to Nocturnal Hypoglycemia

The aim of the project was to detect specific EEG patterns related to hypoglycemia. EEG analysis was performed using a probabilistic classifier and unsupervised learning for the construction of learning sets for the classifier. Unsupervised learning and additional tools were used in the search for EEG patterns occurring when the blood-glucose level was below the hypoglycemic threshold. The rate of these specific EEG patterns was below 5% in normal nights. In patients who were known to have no or a reduced glucagon response to hypoglycemia, the rate increased to 20-80%.

Abstract P1-01-03: Dynamics of circulating tumor cells during the course of chemotherapy and prognostic relevance across molecular subtypes in high-risk early breast cancer patients – Results from the adjuvant SUCCESS A trial

Background: The presence of circulating tumor cells (CTCs) before chemotherapy is known to be associated with reduced disease free survival (DFS) and overall survival (OS) in early breast cancer (EBC). In addition, recent findings suggest that CTCs persisting after adjuvant chemotherapy indicate poor prognosis. In an explorative analysis of the SUCCESS A trial, we evaluated the prognostic relevance of changes in CTC counts during the course of adjuvant chemotherapy across molecular subtypes to assess whether the prognostic role of persisting CTCs varies according to tumor biology.

Methods: The SUCCESS A trial is a phase III study, where patients with high-risk EBC (stage pN1-3 or pT2-4 or grade 3 or age ≤ 35 or hormone-receptor negative) were randomized to adjuvant chemotherapy with 3 cycles of epirubicin-fluorouracil-cyclophosphamide followed by either 3 cycles of docetaxel or 3 cycles of gemcitabine-docetaxel. CTC enumeration was performed before and after chemotherapy using the FDA-approved CellSearch® System (Janssen Diagnostics, LLC), and CTC positivity was defined as ≥ 1 CTC in 23 ml blood. Molecular subtypes were defined as luminal A like (hormone-receptor positive, grading 1 or 2), luminal B like (hormone-receptor positive, grading 3), triple-negative or HER2-positive. Patient outcome in terms of DFS and OS was analyzed using univariate log-rank tests and Cox regression models (median follow-up time 65.2 months).

Results: Data on both molecular subtypes and CTC status before and after chemotherapy were available for 1485 (39.6%) of 3754 patients randomized. This cohort contained 577 (38.9%) luminal A like, 236 (15.9%) luminal B like, 379 (25.5%) HER2-positive and 293 (19.7%) triple negative tumors. Overall, 917 (61.8%) patients were CTC negative before and after chemotherapy (neg/neg), 260 (17.5%) patients had a negative CTC status before and a positive CTC status after chemotherapy (neg/pos), 229 (15.4%) patients converted from positive to negative CTC status (pos/neg), and 79 (5.3%) patients were positive for CTCs at both time points (pos/pos). There were significant differences in DFS and OS among these four groups in patients with luminal A like tumors (log rank test, both p < 0.003) and patients with luminal B like tumors (log rank test, both p < 0.001). In both patients with luminal A like or luminal B like tumors, persistently CTC positive patients had the worst outcome (relative to persistently CTC-negative patients) in terms of DFS and OS. In contrast to luminal-like tumors, no significant differences with regard to DFS or OS were found among the four groups (neg/neg, neg/pos, pos/neg, pos/pos) in patients with HER2-positive or triple-negative tumors (log rank test, all p > 0.13).

Conclusion: The presence of CTCs both before and after adjuvant chemotherapy was associated with poor survival in luminal A like and luminal B like tumors, but not in HER2-positive or triple-negative tumors. Further research is needed to evaluate the effect of chemotherapy on CTC prevalence in different molecular subtypes of EBC.

Citation Format: Tzschaschel MLJ, Rack B, Andergassen U, Friedl TWP, Schneeweiss A, Mueller V, Tanja F, Pantel K, Gade J, Lorenz R, Rezai M, Tesch H, Soeling U, Polasik A, Alunni-Fabbroni M, Trapp EK, Mahner S, Schindlbeck C, Lichtenegger W, Beckmann MW, Fasching PA, Janni W. Dynamics of circulating tumor cells during the course of chemotherapy and prognostic relevance across molecular subtypes in high-risk early breast cancer patients – Results from the adjuvant SUCCESS A trial [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P1-01-03.

Skin-reducing Mastectomy with Primary Implant Reconstruction

Background: We present a series of skin-sparing mastectomies (SSMs) with skin reduction and immediate breast reconstruction to treat large and ptotic breasts. The technique combines oncological mastectomy with immediate subpectoral implant placement as a single-step procedure. Methods: Data was collected from a prospective database from February 2009 to April 2011. A total of 24 patients with macromastia or pronounced ptosis fulfilled the criteria for skin-saving mastectomy. All operations were carried out as a single-step procedure with adaptation of the contralateral breast by reduction mastopexy. Results: A total of 27 SSMs were performed in 24 patients. The mean implant volume was 265 cm³. Immediate reconstruction of the nipple-areola complex was done in 22 patients. The cosmetic and functional results were assessed in all patients 6 months postoperatively; mean follow-up time was 13 months. Mean patient age was 49 years. The cosmetic result was assessed as "very good" or "good" by 22 patients; 2 patients graded the result as "unsatisfactory". There was one local recurrence. Conclusion: Our results support the use of this technique as a safe oncoplastic procedure which is well tolerated by patients.

Bronchial arterial devascularization. An experimental study in pigs

OBJECTIVE

The lungs have dual blood supply: The bronchial and the pulmonary circulation. The importance of bronchial circulation is disputed. The purpose of this study was to establish an experimental model to examine the importance of the bronchial artery.

DESIGN

Comparative porcine experimental study. The surgical technique was evaluated in group A (n = 9). Group B (n = 8) underwent left bronchial arterial devascularization. In group C (n = 9) the left principal bronchus was devascularized, transsected, and reanastomosed. In groups B and C bronchial mucosal blood flow was studied with laser-Doppler velocimetry. Devascularization was controlled by angiography at section, and specimens were examined with conventional histology and scanning electron microscopy. The right bronchus served as control.

RESULTS

In group B devascularization caused considerable, yet insignificant reduction in bronchial mucosal blood flow index (p = 0.1282) postoperatively, and after 1 week (p = 0.0678), insignificant histologic (p > 0.2) changes, and no scanning electron microscopy differences. In group C devascularization with bronchial transsection caused significant reduction in mucosal blood flow index (p = 0.0277) postoperatively and after 1 week (p = 0.0277), significant histologic changes (p = 0.0277), and insignificant (p = 0.069) changes in scanning electron microscopy.

CONCLUSION

Bronchial arterial devascularization with transsection caused significant physiologic and morphologic changes, and a model with bronchial devascularization should include transsection.

Bronchial transsection and reanastomosis in pigs with and without bronchial arterial circulation

BACKGROUND

The bronchial artery may be vital to the bronchi and lung parenchyma, but results of lung transplantation have raised doubts. This study was performed to examine the effect of bronchial arterial devascularization on bronchial morphology after bronchial transsection and reanastomosis.

METHODS

In 6 pigs (study group), the left main bronchus was transsected, reanastomosed, and devascularized. Six control pigs had the same operation without devascularization. After 1 week, bronchial arterial angiography was performed, and specimens were examined with conventional histology and scanning electron microscopy.

RESULTS

Histology showed significant changes (inflammation, edema, and fibrosis) in bronchi and lung parenchyma of the study group compared with the unoperated side (p = 0.028) and with the control group (p = 0.050). Scanning electron microscopy showed significant ciliary denudation in the study group's left bronchus compared with the unoperated side (p = 0.043) and with the control group (p = 0.0071).

CONCLUSIONS

The loss of cilia of the bronchial epithelium and the occurrence of inflammation, edema, and fibrosis in bronchi and lung parenchyma 1 week postoperatively were significantly related to the absence of the bronchial arterial circulation.

Technical description of the IBIS data library. Improved Monitoring for Brain Dysfunction in Intensive Care and Surgery

The IBIS Data Library (DL) is an annotated data library that contains practically all the monitored data and other clinical information from critically ill patients during surgery and in intensive care. The data have been collected at three sites: the intensive care unit of the Kuopio University Hospital, Finland; Royal Brompton Hospital, London, UK; and St. Bartholomew's Hospital, London, UK. The purpose of the DL is to form the basis for development of biosignal interpretation methods in the Improved Monitoring for Brain Dysfunction in Intensive Care and Surgery project in the European Union (EU) BIOMED2 programme (BMH4-97-2570). The DL contains continuous electroencephalography signals, multimodal evoked potential recordings and diagnostic electrocardiography recorded during intensive care and surgery. In addition, signal types similar to those recorded during an earlier project, the EU-BIOMED1 project IMPROVE, are stored in the DL. In addition, trend data from patient monitors, laboratory data, annotations, nursing actions, and medications recorded and stored by a Patient Data Management System (PDMS) during routine care are included. The data obtained routinely are complemented by special annotations made by a physician who observes the patient during the data collection session. Annotations include, for example, assessment of the awareness of the patient and specific events during surgery not recorded routinely by the PDMS. Inclusion of information about the care plan and the aims of the care make the contents of the DL complete. The present paper describes the technical set-up used for recording of the DL and the contents of the DL. The paper also includes an appendix defining a new data format, the extended evoked potentials format, used for storage of sweep data in the DL.

Glucose uptake is increased in trained vs. untrained muscle during heavy exercise

Endurance training increases muscle content of glucose transporter proteins (GLUT-4) but decreases glucose utilization during exercise at a given absolute submaximal intensity. We hypothesized that glucose uptake might be higher in trained vs. untrained muscle during heavy exercise in the glycogen-depleted state. Eight untrained subjects endurance trained one thigh for 3 wk using a knee-extensor ergometer. The subjects then performed two-legged glycogen-depleting exercise and consumed a carbohydrate-free meal thereafter to keep muscle glycogen concentration low. The next morning, subjects performed dynamic knee extensions with both thighs simultaneously at 60, 80, and until exhaustion at 100% of each thigh's peak workload. Glucose uptake was similar in both thighs during exercise at 60% of thigh peak workload. At the end of 80 and at 100% of peak workload, glucose uptake was on average 33 and 22% higher, respectively, in trained compared with untrained muscle (P < 0.05). Training increased the muscle content of GLUT-4 by 66% (P < 0. 05). At exhaustion, glucose extraction correlated significantly (r = 0.61) with total muscle GLUT-4 protein. Thus, when working at a high load with low glycogen concentrations, muscle glucose uptake is significantly higher in trained than in untrained muscle. This may be due to the higher GLUT-4 protein concentration in trained muscle.

The porcine bronchial artery. Anastomoses with oesophageal, coronary and intercostal arteries

Information about the existence and anatomy of arterial anastomoses with the porcine bronchial artery is lacking in the literature. Prior to basic physiological investigations in a porcine model related to lung transplantation with bronchial artery revascularisation, this study was designed to examine the anatomy of systemic arterial anastomoses with the bronchial artery system. Twenty pigs were studied in 3 groups. In 2 groups the heart-lung block was removed with all mediastinal structures. One group served for investigation of coronary-bronchial artery anastomoses and one for investigation of oesophageal-bronchial artery anastomoses. The systemic arteries to be examined were cannulated. The inflated heart-lung block was examined macroscopically with Evans blue, and radiographically after contrast injection. In the 3rd group intercostobronchial artery anastomoses were studied radiographically with the heart-lung block in situ. Coronary-bronchial artery anastomoses were demonstrated in 3 of the 5 pigs with an aortic 'pouch' technique, but contrast was very limited in 2 of these 3. Oesophageal arterial anastomoses with bronchial arterial branches and/or the pulmonary veins were demonstrated in 6 of the 7 pigs and more markedly than the coronary-bronchial anastomoses. Intercostobronchial artery anastomoses could not be demonstrated angiographically. It was concluded that the existence of coronary-bronchial and oesophageal-bronchial artery anastomoses in the pig appear to establish an arterial net between the base of the heart and the distal oesophagus. The resemblance to human oesophageal-bronchial artery anastomoses supports use of a porcine model for experimental studies.

Two evolutionarily closely related ABC transporters mediate the uptake of choline for synthesis of the osmoprotectant glycine betaine in Bacillus subtilis

Biosynthesis of the compatible solute glycine betaine in Bacillus subtilis confers a considerable degree of osmotic tolerance and proceeds via a two-step oxidation process of choline, with glycine betaine aldehyde as the intermediate. We have exploited the sensitivity of B. subtilis strains defective in glycine betaine production against glycine betaine aldehyde to select for mutants resistant to this toxic intermediate. These strains were also defective in choline uptake, and genetic analysis proved that two mutations affecting different genetic loci (opuB and opuC) were required for these phenotypes. Molecular analysis allowed us to demonstrate that the opuB and opuC operons each encode a binding protein-dependent ABC transport system that consists of four components. The presumed binding proteins of both ABC transporters were shown to be lipoproteins. Kinetic analysis of [14C]-choline uptake via OpuB (K(m) = 1 microM; Vmax = 21 nmol min-1 mg-1 protein) and OpuC (K(m) = 38 microM; Vmax = 75 nmol min-1 mg-1 protein) revealed that each of these ABC transporters exhibits high affinity and substantial transport capacity. Western blotting experiments with a polyclonal antiserum cross-reacting with the presumed substrate-binding proteins from both the OpuB and OpuC transporter suggested that the expression of the opuB and opuC operons is regulated in response to increasing osmolality of the growth medium. Primer extension analysis confirmed the osmotic control of opuB and allowed the identification of the promoter of this operon. The opuB and opuC operons are located close to each other on the B. subtilis chromosome, and their high sequence identity strongly suggests that these systems have evolved from a duplication event of a primordial gene cluster. Despite the close relatedness of OpuB and OpuC, these systems exhibit a striking difference in substrate specificity for osmoprotectants that would not have been predicted readily for such closely related ABC transporters.

The porcine bronchial artery: surgical and angiographic anatomy

The pig is often used in experimental studies on the significance of bronchial artery circulation, but the anatomy of this artery is only poorly described. The purpose of this study was to improve the anatomical basis for experimental studies on the porcine bronchial artery circulation. The origin of the artery from the aorta is described in 32 pigs. Heart-lung blocks were perfused with saline and removed in 16 pigs, and the broncho-oesophageal orifice was identified and cannulated. In these 16 specimens the intrapulmonary ramification was studied by angiography, and the extrapulmonary distribution and supply area by injection of Evans Blue. The broncho-oesophageal artery originated from the aorta as a single trunk in 91%. Angiography showed that each principal bronchus was accompanied by 2 bronchial artery branches far into the lung parenchyma. The central branching pattern of the artery between the aorta and the principal bronchi was divided into 3 subtypes. Evans Blue showed communication with the whole mediastinum. The anatomical relations are described. It is concluded that the broncho-oesophageal artery divides to follow each bronchus with 2 bronchial branches. A nomenclature for these branches is suggested. The pig anatomy is suited for experimental investigations on the bronchial circulation.

Physicians' abdominal auscultation. A multi-rater agreement study

BACKGROUND

Abdominal auscultation has an important position in the physical examination of the abdomen. Little is known about rater agreement. The aim of this study was to describe rater agreement and thus, indirectly, the value of the examination.

METHODS

In a semi-virtual setup 12 recordings of the intestinal sounds from 8 patients with acute abdominal pain and 4 healthy volunteers were presented to 100 physicians. The physicians were asked to characterize the intestinal sounds as normal or pathologic. Fisher's exact test was used for comparison between groups of physicians.

RESULTS

Overall, 72% of the answers with regard to healthy volunteers concluded that the sounds were normal (equalling agreement), whereas 64% of answers with regard to intestinal obstruction concluded that the sounds were pathologic (but agreement was higher due to agreement on wrong diagnosis in one case). Bowel sounds from colonic obstruction were diagnosed as pathologic in 94 of 100 answers. In peritonitis disagreement dominated. Specialists in gastrointestinal medicine diagnosed bowel obstruction significantly more poorly than non-specialists in gastrointestinal surgery (P < 0.05).

CONCLUSION

Rater agreement in normal subjects and in patients with intestinal obstruction was acceptable for a clinical examination. Abdominal auscultation is a helpful clinical examination in patients with acute abdominal pain.

Digital archival and exchange of events in a simple format for polygraphic recordings with application in event related potential studies

This paper describes a simple method of event encoding as an extension to a previously defined standard format, the European Data Format (EDF). The specification ensures full backward compatibility with the existing definition. By using this extension, the format can be used to store both continuous recordings and selected epochs of recordings. The encoding is performed in a channel of event-codes or in a pseudo-channel for annotations. Standardisation of event encoding is discussed. Decoding of events or annotations from the extended format is implemented at the application level. Existing programs that do not support the new encoding scheme still operate correctly and can simply ignore the new channels in processing 'extended' data files. The event encoding is also compatible with EDF's capability to encode channels of different sampling frequency.

Lipoprotein from the osmoregulated ABC transport system OpuA of Bacillus subtilis: purification of the glycine betaine binding protein and characterization of a functional lipidless mutant

The OpuA transport system of Bacillus subtilis functions as a high-affinity uptake system for the osmoprotectant glycine betaine. It is a member of the ABC transporter superfamily and consists of an ATPase (OpuAA), an integral membrane protein (OpuAB), and a hydrophilic polypeptide (OpuAC) that shows the signature sequence of lipoproteins (B. Kempf and E. Bremer, J. Biol. Chem. 270:16701-16713, 1995). The OpuAC protein might thus serve as an extracellular substrate binding protein anchored in the cytoplasmic membrane via a lipid modification at an amino-terminal cysteine residue. A malE-opuAC hybrid gene was constructed and used to purify a lipidless OpuAC protein. The purified protein bound radiolabeled glycine betaine avidly and exhibited a KD of 6 microM for this ligand, demonstrating that OpuAC indeed functions as the substrate binding protein for the B. subtilis OpuA system. We have selectively expressed the opuAC gene under T7 phi10 control in Escherichia coli and have demonstrated through its metabolic labeling with [3H]palmitic acid that OpuAC is a lipoprotein. A mutant expressing an OpuAC protein in which the amino-terminal cysteine residue was changed to an alanine (OpuAC-3) was constructed by oligonucleotide site-directed mutagenesis. The OpuAC-3 protein was not acylated by [3H]palmitic acid, and part of it was secreted into the periplasmic space of E. coli, where it could be released from the cells by cold osmotic shock. The opuAC-3 mutation was recombined into an otherwise wild-type opuA operon in the chromosome of B. subtilis. Unexpectedly, this mutant OpuAC system still functioned efficiently for glycine betaine acquisition in vivo under high-osmolarity growth conditions. In addition, the mutant OpuA transporter exhibited kinetic parameters similar to that of the wild-type system. Our data suggest that the lipidless OpuAC-3 protein is held in the cytoplasmic membrane of B. subtilis via its uncleaved hydrophobic signal peptide.

Modelling techniques and their application for monitoring in high dependency environments--learning models

This paper reviews the use of learning models including Bayesian classifiers and artificial neural networks in monitoring and interpreting biosignals. Generally learning models applied for analysis of biosignals are "black-box' types trained on the basis of measured signals. It is illustrated that the training and application of learning models more or less follow the same sequences. The main focus is the interpretation of electrical signals from the brain (electroencephalogram (EEG) and evoked potentials (EP)). Current analysis of these signals often reveals sudden changes in the EEG or evoked potentials to be the earliest discernible signs of inadequate perfusion of the brain. They may reflect problems such as systemic arterial oxygen desaturation or hypotension arising from other body system failures during critical illness. It is suggested that these brain signals should be recorded in the critical care unit, and that they should form part of the annotated database of biosignals established during the IMPROVE project. This would allow for the development of new methods for on-line warning of impending damage to the central nervous system, such that corrective actions could be taken before permanent damage occurred.

The treatment of ureteric calculi before and after the introduction of extracorporeal shockwave lithotripsy

Indications and treatment results of ureteric calculi one year before and one year after the introduction of ESWL were analysed in 169 consecutive patients. Sex, age, former stone operation, stone localisation and stone size were not significantly different in the two groups. Before ESW1 47% of the patients received treatment against 54% after the introduction (p > 0.3). There was no tendency towards treatment of smaller calculi. Expectedly, the number of endoscopies and ureterolithotomies was significantly reduced (p < 0.05). The treatment period (from first contact till final control) was longer with ESWL, but not significantly. Judged from the length of the hospital stay there was no major economic benefit from ESWL. In conclusion, ESWL with a second generation lithotriptor is suitable for in situ treatment of ureteric calculi. It should be first choice for ureteric calculi.

Sleep intensity in fibromyalgia: focus on the microstructure of the sleep process

Alpha electroencephalography (EEG) predominance has been described during sleep in patients suffering from the fibromyalgia syndrome (FMS). However, EEG power density in the lower frequency bands probably better reflects the restorative functions of sleep. This study was conducted to describe the energy in all frequency bands in the sleep EEG. Ambulatory sleep recordings were performed on 12 women with FMS and 14 control women. Epochs were classified according to standard criteria. Moreover, all 2-s segments (n = 287,355) of the EEG in non-rapid-eye-movement (NREM) 2-4 sleep were subjected to frequency analysis using autoregressive modelling. Frequency bands were: delta (0.5-3.5 Hz), theta (3.5-8 Hz), alpha (8-12 Hz), sigma (12-14.5 Hz) and beta (14.5-25 Hz). In patients with FMS, there was a predominance of EEG power in the higher frequency bands [two-way analysis of variance (ANOVA), alpha: P = 0.043; sigma: P = 0.004] at the expense of the lower frequencies (ANOVA, delta: P = 0.005; theta: P = 0.008). The same trends were obtained for the individual sleep cycles. The calculations of total delta power in the time domain showed an exponentially declining curve in healthy subjects, but a flatter decline in FMS. The decreased power in the low-frequency range might reflect a disorder in homoeostatic and circadian mechanisms during sleep and may contribute to daytime symptoms in patients with fibromyalgia.

The upper arm arterio-venous fistula--an alternative for vascular access in haemodialysis

Forty-eight consecutive arteriovenous fistulae of the upper arm constructed in 44 patients between 1983 and 1987 were reviewed. The median observation time was 8.5 months (range 1 day-65 months). The overall patency rate for fistulae used for haemodialysis (early failures excluded) was 50% after one year and 38% after two years. However, only six (18.7%) of the used fistulae stopped because of thrombosis. The total number of thromboses was nine (19.6%). The main cause of discontinuance of fistulae was a high number of deaths (n = 22), presumably a result of a high median age of 62 years. Early failure rate was seven of 46 (15.2%); in three cases (6.5%) this was caused by thrombosis. The results are compared to other alternatives for radiocephalic fistulae and the difficulties of comparisons are discussed. It is concluded that the upper arm arteriovenous fistula can serve as a second choice, when a radio-cephalic fistula fails.

Pleurodesis with polidocanol in pigs. An experimental study

Polidocanol was instilled in five pleural cavities of three pigs. Adhesions formed in all. Adhesion distribution varied from covering a minor part to most of the lung, depending on the amount of polidocanol. One control cavity treated with sodium chloride was unaffected. Microscopy showed fibrous bridges between the pleural layers and mild submesothelial fibrosis and inflammation.

Detection of EEG patterns related to nocturnal hypoglycemia

The aim of the project was to detect specific EEG patterns related to hypoglycemia. EEG analysis was performed using a probabilistic classifier and unsupervised learning for the construction of learning sets for the classifier. Unsupervised learning and additional tools were used in the search for EEG patterns occurring when the blood-glucose level was below the hypoglycemic threshold. The rate of these specific EEG patterns was below 5% in normal nights. In patients who were known to have no or a reduced glucagon response to hypoglycemia, the rate increased to 20-80%.

Cognitive function in type 1 (insulin-dependent) diabetic patients after nocturnal hypoglycaemia

Eight Type 1 (insulin-dependent) diabetic patients with no diabetic complications were studied on two consecutive and one subsequent overnight occasions. The aim was to evaluate the influence of nocturnal hypoglycaemia on neuropsychological and reaction time tests the following morning. Hypoglycaemia was induced by i.v. insulin infusion, blood glucose nadir was 1.5 +/- 0.3 mmol/l. Duration of hypoglycaemia (blood glucose less than 3 mmol/l) was 101 +/- 38 min. Whole night sleep statistics for all patients showed no statistical differences between the normoglycaemic and hypoglycaemic nights, however, there was a tendency of prolongation of the second sleep cycle in the nights with hypoglycaemia. Each patient was used as his own control and periods with blood glucose concentration less than 3 mmol/l were compared to exactly the same periods in nights with blood glucose level over 5 mmol/l. During hypoglycaemia the amount of deep sleep was reduced and replaced by superficial sleep and arousals of short duration. Further, the reduction in deep sleep was replaced later at night. Neuropsychological test scores and reaction time measurements in the morning showed no differences between the normoglycaemic and hypoglycaemic nights.

IN CONCLUSION

despite sleep disturbances, nocturnal hypoglycaemia did not impair cognitive function the following morning in Type 1 (insulin-dependent) diabetic patients.

A simple format for exchange of digitized polygraphic recordings

A simple digital format supporting the technical aspects of exchange and storage of polygraphic signals has been specified. Implementation of the format is simple and independent of hard- or software environments. It allows for any local montages, transducers, prefiltering, sampling frequencies, etc. At present, 7 laboratories in various countries have used the format for exchanging sleep-wake recordings. These exchanges have made it possible to create a common database of sleep records, to compare the analysis algorithms local to the various laboratories to each other by applying these algorithms to identical signals, and to set up a computer-aided interlaboratory evaluation of manual and automatic analysis methods.

Sleep disturbances in IDDM patients with nocturnal hypoglycemia

Eight insulin-dependent diabetic patients were studied to evaluate sleep patterns during normoglycemia and spontaneous and insulin-induced hypoglycemia. Two channels of electroencephalogram (EEG), electromyogram and actooculogram were recorded. The signals were analyzed off-line, using a polygraphic sleep analysis system. The scoring was mainly based on the color density spectral array of the EEG. Blood glucose and growth hormone were measured serially. Asymptomatic, spontaneous nocturnal hypoglycemia occurred in 38% of the nights. Conventional sleep analysis showed a tendency toward prolongation of the two first rapid eye movement cycles on hypoglycemic nights, although it was insufficient to explain the activities seen during hypoglycemia. Blood glucose values below 2.0 mmol/l were observed in some of the patients accompanied by EEG changes with increased theta and delta activity.

Nocturnal electroencephalogram registrations in type 1 (insulin-dependent) diabetic patients with hypoglycaemia

Eight Type 1 (insulin-dependent) diabetic patients with no diabetic complications were studied overnight for two consecutive and one subsequent night with continuous monitoring of electroencephalogram and serial hormone measurements. The aims were: 1) to evaluate the influence of spontaneous and insulin-induced hypoglycaemia on nocturnal electroencephalogram sleep-patterns and, 2) to evaluate counter-regulatory hormone responses. Spontaneous hypoglycaemia occurred on six nights (38%) with blood glucose concentrations less than 3.0 mmol/l and on four nights less than 2.0 mmol/l. All the patients experienced insulin-induced hypoglycaemia with a blood glucose nadir of 1.6 (range 1.4-1.9) mmol/l. The electroencephalogram was analysed by a new method developed for this purpose in contrast to the traditional definition of delta-, theta-, alpha- and beta-activity. The blood glucose concentration could be correlated to the rank of individual electroencephalogram-patterns during the whole night, and specific hypoglycaemic amplitude-frequency patterns could be assigned. Three of the eight patients showed electroencephalogram changes at blood glucose levels below 2.0 (1.6-2.0) mmol/l. The electroencephalogram classes representing hypoglycaemic activity had peak frequencies at 4 and 6 Hz, respectively, clearly different from the patients' delta- and theta-activity. The changes were not identical in each patient, however, they were reproducible in each patient. The changes were found equally in all regions of the brain. The three patients with electroencephalogram changes during nocturnal hypoglycaemia could only be separated from the other five patients by their impaired glucagon responses. Against this background the possibility of protection by glucagon, against neurophysiologic changes in the brain during hypoglycaemia may be considered.

[McArdle's syndrome--undiagnosed for 17 years despite medical check-ups]

The clinical picture is characteristic with muscular pain on exertion and subsequent stiffness and possible reddish discolouration of the urine (myoglobinuria). The therapeutic possibilities are reviewed. The most important is avoidance of exertion as myoglobin is nephrotoxic.

[Sperm granulomata]

Sperm granulomata are rare without prior surgical intervention but constitute a common complication of vasectomy and affect 35 and 42% with the conventional methods. Refertilizing and sperm quality are better in cases of sperm granulomata and, as opposed to previous assumptions, reduced fertility is not found in cases of sperm granulomata in patients with sperm antibodies. Fewer complaints are observed after open end vasectomy despite the particularly high incidence of sperm granulomata. Unfortunately, the literature does not appear to contain randomized investigations as guidelines for the choice of surgical method for vasectomy.

Paraghurt for patients with irritable bowel syndrome. A controlled clinical investigation from general practice

A comparison of Paraghurt tablets (freeze-dried culture of Streptococcus faecium) and placebo was carried out in patients with irritable bowel syndrome in a double-blind trial in Danish general practices. Fifty-four patients (42 females and 12 males) with an average duration of the disease of seven years were treated for four weeks. The clinical symptoms were registered prior to the treatment and after two and four weeks. The clinical effect was assessed according to changes in number of abdominal symptoms, the patients' registrations on rating scales, and the physicians' overall estimations. According to all three parameters a markedly better effect of Paraghurt was seen. Thus, after four weeks 81% of the Paraghurt- and 41% of the placebo-treated patients had improved according to the physicians' overall assessment (p = 0.002). The result of the trial suggests that Paraghurt is a valuable alternative in the treatment of irritable bowel syndrome.

A comparison of human muscarinic cholinergic receptor properties subsequent to alcohol abuse and senescence

Neuropsychiatric impairment during senescence and consequent to alcohol abuse demonstrates several parallels in the areas of short-term memory and sensorimotor skills. In this study high-affinity binding of the muscarinic cholinergic antagonist quinuclidinyl benzilate (QNB) was determined with post-mortem human brain tissue from normal young adults, age-matched ethanol abusers, and nondemented senior adults without histories of substance abuse. Hippocampus was chosen because of its high-density cholinergic innervation and probable role in the mnemonic process. A statistical significance emerged between nonalcoholic young adults and both ethanol abusers and seniors in reference to cooperative binding interactions (Hill coefficient, nH) amongst the latter two groups. Analysis of the respective receptor affinities (KD) revealed a significant difference between each group. A trend toward an increased KD occurred from nonalcoholic young adults to alcoholic young adults to nonalcoholic seniors. Concerning the density of receptor sites (Bmax) no difference emerged between alcoholic or nonalcoholic young adults. However nonalcoholic seniors manifest a statistically significant reduction in Bmax; this feature is consistent with the reports of several other investigators. Amongst subjects with a pathologic history of ethanol abuse, a premature senescence along parameters of nH and KD emerged, albeit not including the apparent age-dependent decline in Bmax.

[Impulse cytophotometry in neoplasm prevention. The behavior of normal vaginal smears in the impulse cytophotometric histogram]

Evaluation of histograms of normal cervical and vaginal smears, produced by ""rapid flow through'' cytophotometry. Normal cytological cervical and vaginal smears were examined for their appearance in histograms in order to find criteria for the classification of ""normal non-pathological'' cytological slides. Simultaneously, the reliability of the standardized method for preparation of vaginal and cervical smears was checked. The diagrams and data produced by the histograph were also coded on line and analyzed by a computer; thus obtaining an objective mathematical analysis and avoiding errors due to subjective visual analysis of the histograms. The objective interpretation of histograms of normal vaginal smears is an important step to the realisation of automatic pre-screening.