Pyridostigmine bromide versus fludrocortisone in the treatment of orthostatic hypotension in Parkinson's disease - a randomized controlled trial

BACKGROUND AND PURPOSE

Evidence for effective treatment options for orthostatic hypotension (OH) in Parkinson's disease (PD) is scarce. Elevation of cholinergic tone with pyridostigmine bromide has been reported as a way to improve blood pressure (bp) regulation in neurogenic hypotension without causing supine hypertension.

METHODS

This was a double-centre, double-blind, randomized, active-control, crossover, phase II non-inferiority trial of pyridostigmine bromide for OH in PD (clinicaltrials.gov NCT01993680). Patients with confirmed OH were randomized to 14 days 3 × 60 mg/day pyridostigmine bromide or 1 × 0.2 mg/day fludrocortisone before crossover. Outcome was measured by peripheral and central bp monitoring during the Schellong manoeuvre and questionnaires.

RESULTS

Thirteen participants were enrolled between April 2013 and April 2015 with nine participants completing each trial arm. Repeated measures comparison showed a significant 37% improvement with fludrocortisone for the primary outcome diastolic bp drop on orthostatic challenge (baseline 22.9 ± 13.6 vs. pyridostigmine bromide 22.1 ± 17.0 vs. fludrocortisone 14.0 ± 12.6 mmHg; P = 0.04), whilst pyridostigmine bromide had no effect. Fludrocortisone caused an 11% peripheral systolic supine bp rise (baseline 128.4 ± 12.8 vs. pyridostigmine bromide 130.4 ± 18.3 vs. fludrocortisone 143.2 ± 10.1 mmHg; P = 0.01) but no central mean arterial supine bp rise (baseline 107.2 ± 7.8 vs. pyridostigmine bromide 97.0 ± 12.0 vs. fludrocortisone 107.3 ± 6.3 mmHg; P = 0.047). Subjective OH severity, motor score and quality of life remained unchanged by both study interventions.

CONCLUSIONS

Pyridostigmine bromide is inferior to fludrocortisone in the treatment of OH in PD. This trial provides first objective evidence of the efficacy of 0.2 mg/day fludrocortisone for OH in PD, causing minor peripheral but no central supine hypertension. In addition to peripheral bp, future trials should include central bp measurements, known to correlate more closely with cardiovascular risk.

Arabidopsis thaliana transgenics overexpressing IBR3 show enhanced susceptibility to the bacterium Pseudomonas syringae

The gene, indole-3-butyric acid (IBA)-RESPONSE (IBR) 3, is thought to participate in peroxisomal β-oxidation of IBA to indole-3-acetic acid. Here we show that IBR3 may also play a role in Arabidopsis thaliana defence response to microbial pathogens. IBR3 is up-regulated during infection by virulent Pseudomonas syringae pv. tomato (Pst) DC3000 bacteria. Although mutant ibr3-4 did not show a pathogen phenotype, lines overexpressing IBR3 demonstrated enhanced susceptibility to Pst DC3000. Increased susceptibility phenotypes of IBR3 overexpressors were correlated with defective SA defence signalling and impairment of pattern-triggered immunity (PTI) activation. Notably, reactive oxygen species production was reduced in IBR3 overexpressors after treatment with the microbe-associated molecular patterns flg22 and efl26. Later PTI responses, such as accumulation of FRK1 transcripts and callose deposition were also reduced in transgenics overexpressing IBR3 after inoculation with the Type III secretion system deficient bacterial mutant Pst DC3000 hrcC or treatment with flg22 or elf26. Importantly, overexpression of IBR3 did not affect indole-3-acetic acid content or auxin-responsive gene expression. These results suggest a novel role for IBR3 in A. thaliana defence response against bacterial pathogens.

[Pain in multimorbid internistic patients]

Pain and pain management in multimorbid patients is a subject which is mostly unknown. General rules in pain management like the WHO analgesic ladder and its recommendations are to be equally respected as with other patients. As multimorbidity is a common problem especially in the elderly population, some changes in physiology, pharmacodynamics and pharmacokinetics have to be taken into consideration. A careful and slow adoption of dosage leads to more safety and tolerability. Other main problems of multimorbidity are drug-drug, drug-disease or disease-disease interactions, which influence the choice of analgesic medication. As especially the number of drug-drug interactions is endless, available software is a valuable aid to become aware of interactions and help weight the compromises.

[Identification and clinical use of the Metabolic Syndrome]

The Metabolic Syndrome is characterised by the following components: atherogenic dyslipidemia, elevated blood pressure, elevated glucose and abdominal obesity. 22% of 415 patients of an outpatient clinic in internal medicine fulfilled the criteria of a Metabolic Syndrome. The most common components were abdominal obesity, elevated blood pressure and elevated triglyceride. Only one in five treating physicians diagnosed a Metabolic Syndrome. Our data show that the concept of the Metabolic Syndrome has limited utility in clinical practice.

Determination of effective tip geometries in Kelvin probe force microscopy on thin insulating films on metals

In scanning probe techniques, accurate height measurements on heterogeneous surfaces are a major requirement. Different electrostatic potentials of various materials have a significant influence on the measured force/current and therefore a direct influence on the tip-sample distance. Kelvin probe force microscopy (KPFM) is based on a dynamic compensation of the electrostatic force while performing non-contact atomic force microscopy measurements. Thus, the influence of the electrostatic potentials can be minimized and accurate height measurements become possible. Here, the study of ultra-thin alkali halide films on Cu(111) investigated by KPFM is presented. This work is focused on the interface between areas of bare Cu(111) and the first layers of salt. The compensation of the electrostatic potential allow us to determine layer heights with high accuracy. The second objective was to elaborate on the characterization of tip geometries across suitable nanostructures. Simulations of measured images are performed with different input parameters, which gives a direct estimation of the effective tip radius and geometry used for the measurements.

[Non-controllable blood pressure peaks--pheochromocytoma?]

A 59-year old patient presented with a history of arterial hypertension, refractory to combined antihypertensive treatment with ACE-inhibitors, diuretics, calcium channel blockers and beta blockers. Blood pressure values ranged from 180/100mmHg to 90mmHg systolic after medication intake. Diagnostic work-up revealed renal artery stenosis on duplexsonography that was treated by percutaneous transluminal angioplasty and stent implantation. After the intervention, blood pressure values remained normal even without antihypertensive treatment.

[Premature coronary disease]

The family history in a sportive 49 year old patient with coronary artery disease reveals several members with cardiovascular events. The diagnosis of dyslipidemia could be made in all the patient's children. Genetic analysis of the patient shows a heterozygous mutation of the apolipoprotein B-100 genotype. An accurate family history and screening for cardiovascular risk factors are mandatory in all patients with a history of premature coronary artery disease.

[Hypertension and hyperhidrosis. Pheochromocytoma]

A 39-year-old woman was referred to our hypertension clinic with refractory hypertension. The patient history gave certain clues for pheochromocytoma. The diagnosis was proven with elevated metanephrines and computer tomography. The tumor was surgically removed.

[Update on tuberculosis: interferon-gamma assays]

Until recently, skin testing with purified protein derivative of tuberculin was the only practical way of detecting latent tuberculosis infection (LTBI). However, the tuberculin skin test (TST) is subject to considerable variations and other limitations. PPD is a mixture of more than 200 mycobacterial antigens also present in nontuberculous mycobacteria and in the Bacille Calmette-Guérin (BCG) vaccine strains. Therefore false-positive testing results were common. Recently, peripheral blood-derived T-cell interferon-gamma responses to M.tuberculosis-specific antigens have been investigated for the management of tuberculosis. The results suggest that interferon-gamma assays may have advantages over the TST, in terms of higher specificity, better correlation with exposure to M.tuberculosis, and less cross-reactivity due to BCG vaccination and non-tuberculous mycobacterial infection. Furthermore, the interferon-gamma assays are less subject to reader bias and error and can be accomplished after a single patient visit. However, there is inadequate evidence on the value of interferon-gamma assays in the management of immunocompromised individuals for whom an alternative assay to the TST would be of great value.

[Chronic fatigue. IV--Assessment of a 40-year-old patient]

A forty year old patient was referred by the federal insurance for medical assessment. His presenting complaint was chronic fatigue. The patient had been an intravenous drug user for years and had been infected with hepatitis C. He was treated with interferon. The patient history showed that he also suffered from anaemia and depression. He participated in a methadone substitution program. Our diagnostic procedures showed that he also has Hashimoto's thyroiditis.

[Muscle pain. De Quervain throiditis]

A 62-year-old female patient presents with myalgia, dysphagia and daytime fatigue. Clinical examination is normal. Laboratory results show a hyperthyroidism and an increased erythrocyte sedimentation rate. Clinical presentation, an ultrasound and further examinations suggest a thyroiditis de Quervain. A treatment with NSAR is started. After eight weeks the thyroid hormones return to normal and the patient is asymptomatic.

[Orthostatic hypotension and hypertension lying down: a clinical dilemma. 56-year-old patient with multiple system atrophy]

A 56-year-old patient with multisystem atrophy of Parkinson type presents himself with severe, symptomatic and orthostatic hypotension and concomitant arterial hypertension while in a recumbent position. Etiology and pathophysiology of orthostatic hypotension and concomitant hypertension in recumbent position is discussed as it relates to this specific patient. Specific indications for antihypertensive therapies and other potential therapeutic options are also discussed.

New Technologies and Concepts for Rehabilitation in the Acute Phase of Stroke: A Collaborative Matrix

The process of developing a successful stroke rehabilitation methodology requires four key components: a good understanding of the pathophysiological mechanisms underlying this brain disease, clear neuroscientific hypotheses to guide therapy, adequate clinical assessments of its efficacy on multiple timescales, and a systematic approach to the application of modern technologies to assist in the everyday work of therapists. Achieving this goal requires collaboration between neuroscientists, technologists and clinicians to develop well-founded systems and clinical protocols that are able to provide quantitatively validated improvements in patient rehabilitation outcomes. In this article we present three new applications of complementary technologies developed in an interdisciplinary matrix for acute-phase upper limb stroke rehabilitation - functional electrical stimulation, arm robot-assisted therapy and virtual reality-based cognitive therapy. We also outline the neuroscientific basis of our approach, present our detailed clinical assessment protocol and provide preliminary results from patient testing of each of the three systems showing their viability for patient use.

[Check-up-examinations in internal medicine]

A growing body of evidence supports or rejects preventive interventions in asymptomatic adults. Thus, counseling for smoking cessation and some immunizations have been shown to be cost-effective. Evidence supports screening for body weight (obesity), hypertension, hyperlipidemia, cervical cancer, colorectal cancer and breast cancer. Screening for lung, pancreatic and ovarian cancer has no effect on outcome and should not be performed. Controversial preventive interventions include general screening for diabetes mellitus in the young adult, thyroid disorders and prostate cancer. Physicians should be aware of a possible hidden agenda in patients presenting for a check-up.

Value of gonadotropin-releasing hormone testing in the differential diagnosis of androgen deficiency in elderly men

Elderly men with low testosterone (T) levels are increasingly diagnosed to have partial androgen deficiency of the aging male (PADAM). Frequently, magnetic resonance imaging is performed to exclude pituitary adenoma. The value of GnRH testing to differentiate PADAM from secondary hypogonadism is unknown. Serum levels of T as well as LH and FSH at baseline and after GnRH were evaluated in the following groups: 1) 24 elderly men with low serum T (<11.7 nmol/liter), 2) 25 elderly men with normal serum T levels (>11.7 nmol/liter), 3) 10 men with primary hypogonadism, 4) 24 men with secondary hypogonadism, and 5) 13 healthy young volunteers. In elderly men, T levels were lower (P < 0.001) and gonadotropin levels higher (P = 0.03) compared with younger controls. LH and FSH response to GnRH was higher in elderly men with low T levels (PADAM) compared with elderly men with normal T levels (P = 0.02 and P < 0.001) in the presence of similar basal gonadotropin levels. To differentiate secondary hypogonadism from PADAM with a sensitivity of 100%, a T less than 10 nmol/liter had a specificity of 50%. This specificity was improved to 75% by using a cutoff of less than or equal to 15 mU/liter increase of LH upon GnRH stimulation. Overall, decreased T levels and increased LH levels in elderly men suggest a primary Leydig cell dysfunction. In the subgroup of elderly men with low T levels, an increased LH response to GnRH with normal basal LH levels suggests additional, possibly hypothalamic changes. To exclude secondary hypogonadism in PADAM, diagnostic accuracy can be improved by using GnRH testing.

[Vertigo of several seconds duration. 73-year-old pensioned chemical laboratory worker]

Entscheidend in der Differentialdiagnose des Schwindels ist die Anamnese, der Status bestätigt oft die Diagnose. Die Mehrheit der Patienten mit Schwindel leidet an Vertigo, gefolgt von unspezifischem Schwindel und Gleichgewichtsstörungen. Präsynkope gehört zu den selteneren Ursachen von Schwindel, ist aber umso wahrscheinlicher, wenn die Betroffenen über Beinahe-Ohnmacht berichten. Die meisten Ursachen der Dreh- und ungerichteten Schwindel sind benigne und selbstlimitierend.

Comparison of different methods for the measurement of serum testosterone in the aging male

BACKGROUND

Circulating testosterone (T) levels, mainly non-SHBG bound fractions, decline with advancing age. Free (FT) and bioavailable (BT) testosterone levels have been suggested to represent more reliably the bioactive hormone at the tissue level as compared to total testosterone (TT) levels. However, there is an ongoing controversy as to which T assay is most appropriate in defining T deficiency in the aging male.

METHODS

In a prospective observational study, TT, FT and BT levels were measured in 51 elderly men (55 to 70 years). TT levels were determined on two different days using 2 different assays. FT was calculated using TT, albumin and SHBG levels as well as measured directly by radioimmunoassay. The free androgen index (FAI) was calculated using the formula 100 x TT/SHBG. BT was obtained by precipitation of SHBG-bound T with ammonium sulphate.

RESULTS

We found good correlations within different assays for TT (r = 0.87 to 0.91, p <0.001) and between TT and calculated FT (r = 0.66 to 0.84, p <0.001). In contrast, the correlation between TT and BT was poor (r = 0.17 to 0.19, p = ns). TT was equivalent to calcFT and was better in mirroring clinical sings of androgen deficiency in elderly men as compared to BT. The intra-individual day-to-day variance of TT levels was 14.8% (range 0.1-79%) with a coefficient of variance of 12.6%.

CONCLUSION

Serum TT and the calculated FT fraction correlated well with each other and were superior in defining a group of elderly men with suspected androgen deficiency. In contrast, FT measured by direct RIA and BT reflected gonadal function poorly. Our data favour the repetitive use of TT when screening for androgen deficiency in elderly men.

[Joint pain and clubbed fingers. 62-year-old machinist]

Die hypertrophe Osteoarthropathie ist charakterisiert durch die Trias Trommelschlegelfinger, Arthritis und Periostitis. Meist tritt die Erkrankung als paraneoplastisches Syndrom in Erscheinung, das sich häufig vor der klinischen Manifestation des malignen Grundleidens ausprägt und deshalb zur intensiven Ursachensuche veranlassen muss.

Comparison of different methods for the measurement of serum testosterone in the aging male

BACKGROUND

Circulating testosterone (T) levels, mainly non-SHBG bound fractions, decline with advancing age. Free (FT) and bioavailable (BT) testosterone levels have been suggested to represent more reliably the bioactive hormone at the tissue level as compared to total testosterone (TT) levels. However, there is an ongoing controversy as to which T assay is most appropriate in defining T deficiency in the aging male.

METHODS

In a prospective observational study, TT, FT and BT levels were measured in 51 elderly men (55 to 70 years). TT levels were determined on two different days using 2 different assays. FT was calculated using TT, albumin and SHBG levels as well as measured directly by radioimmunoassay. The free androgen index (FAI) was calculated using the formula 100 x TT/SHBG. BT was obtained by precipitation of SHBG-bound T with ammonium sulphate.

RESULTS

We found good correlations within different assays for TT (r = 0.87 to 0.91, p <0.001) and between TT and calculated FT (r = 0.66 to 0.84, p <0.001). In contrast, the correlation between TT and BT was poor (r = 0.17 to 0.19, p = ns). TT was equivalent to calcFT and was better in mirroring clinical sings of androgen deficiency in elderly men as compared to BT. The intra-individual day-to-day variance of TT levels was 14.8% (range 0.1-79%) with a coefficient of variance of 12.6%.

CONCLUSION

Serum TT and the calculated FT fraction correlated well with each other and were superior in defining a group of elderly men with suspected androgen deficiency. In contrast, FT measured by direct RIA and BT reflected gonadal function poorly. Our data favour the repetitive use of TT when screening for androgen deficiency in elderly men.

[Polyneuropathy seropositive for anti-Hu antibodies]

Wir berichten über einen 51-jährigen Patienten mit einer Neuropathie, bei welchem wegen falsch positiven Anti-Hu-Ak eine ausgedehnte Tumorsuche durchgeführt wurde. Eine stufenweise Abklärung bei Polyneuropathien wird kurz dargestellt.

[Bilateral lacrimal gland inflammation in a 42-year-old entrepreneur]

Eine Tränendrüsenschwellung als Erstmanifestation einer Sarkoidose tritt in weniger als 1% der Fälle auf. Im Rahmen dieser Systemerkrankung werden die verschiedenen Augenabschnitte und die Adnexe unterschiedlich isoliert oder kombiniert betroffen. Unser Fallbericht zeigt, dass die Diagnostik bei einer Tränendrüsenschwellung schwierig sein kann und dass eine konklusive Diagnose eventuell erst im weiteren Krankheitsverlauf einer Multisystemerkrankung gestellt werden kann.

[Increased dyspnea. Mediastinal B-cell non-Hodgkin lymphoma with bilateral chylous pleural effusion]

Der Chylothorax ist durch einen milchig-trüben Pleuraerguss charakterisiert. Die häufigste nichttraumatische Ursache ist ein Lymphom. Wir beschreiben eine Patientin, bei der im Verlauf der Abklärungen eines Chylothorax ein Non-Hodgkin-Lymphom gefunden wurde.

[Teenager with fatigue and hepatosplenomegaly. A 15-year-old secondary school student]

Während die meisten EBV-Infektionen bei Säuglingen und Kleinkindern asymptomatisch verlaufen, äussert sich die Infektion bei Adoleszenten und Erwachsenen oft als infektiöse Mononukleose. Letztere ist charakterisiert durch die Trias von Fieber, Pharyngitis und Lymphadenopathie. Über einen Zusammenhang zwischen chronic fatigue syndrome und EBV-Infektion wurde häufig spekuliert, eine eigentliche Korrelation besteht jedoch nicht.

[Glomerulonephritis in systemic vasculitis. Microscopic polyangiitis]

Die mikroskopische Polyangiitis (MPA) ist eine seltene Vaskulitis, welche definiert ist als Kleingefässvaskulitis ohne Granulombildung mit immunhistochemisch weitgehend fehlenden Immunkomplexablagerungen. Die MPA betrifft beide Geschlechter gleich häufig und tritt hauptsächlich in der fünften und sechsten Lebensdekade auf. Wir beschreiben eine Patientin mit diesem Krankheitsbild.

[Recurrent painful cyanosis of fingers and palm. Recurrent paroxysmal finger hematoma (Achenbach syndrome)]

Das paroxysmale Fingerhämatom (Achenbach-Syndrom) ist ein wenig beschriebenes Krankheitsbild ungeklärter Ätiologie. Spontan oder nach geringen Traumata treten Hämatome an der Volarseite der Finger auf, welche von Schmerzen, Fingerschwellung und Parästhesien begleitet sind. Wir beschreiben eine Patientin mit diesem Krankheitsbild.

beta-Aminobutyric acid-induced protection of Arabidopsis against the necrotrophic fungus Botrytis cinerea

The non-protein amino acid beta-aminobutyric acid (BABA) protects numerous plants against various pathogens. Protection of Arabidopsis plants against virulent pathogens involves the potentiation of pathogen-specific defense responses. To extend the analysis of the mode of action of BABA to necrotrophs we evaluated the effect of this chemical on Arabidopsis plants infected with the gray mold fungus Botrytis cinerea. BABA-treated Arabidopsis were found to be less sensitive to two different strains of this pathogen. BABA protected mutants defective in the jasmonate and ethylene pathways, but was inactive in plants impaired in the systemic acquired resistance transduction pathway. Treatments with benzo-(1,2,3)-thiadiazole-7-carbothioic acid S-methyl ester, a functional analog of salicylic acid (SA), also markedly reduced the level of infection. Moreover, BABA potentiated mRNA accumulation of the SA-associated PR-1, but not the jasmonate/ethylene-dependent PDF1.2 gene. Thus, besides jasmonate/ethylene-dependent defense responses, SA-dependent signaling also contributes to restrict B. cinerea infection in Arabidopsis. Our results also suggest that SA-dependent signaling is down-regulated after infection by B. cinerea. The observed up-regulation of the PDF1.2 gene in mutants defective in the SA-dependent signaling pathway points to a cross-talk between SA- and jasmonate/ethylene-dependent signaling pathways during pathogen ingress.

Potentiation of pathogen-specific defense mechanisms in Arabidopsis by beta -aminobutyric acid

The nonprotein amino acids gamma-aminobutyric acid (GABA) and beta-aminobutyric acid (BABA) have known biological effects in animals and plants. Their mode of action has been the object of thorough research in animals but remains unclear in plants. Our objective was to study the mode of action of BABA in the protection of Arabidopis plants against virulent pathogens. BABA protected Arabidopsis against the oomycete pathogen Peronospora parasitica through activation of natural defense mechanisms of the plant such as callose deposition, the hypersensitive response, and the formation of trailing necroses. BABA was still fully protective against P. parasitica in transgenic plants or mutants impaired in the salicylic acid, jasmonic acid, and ethylene signaling pathways. Treatment with BABA did not induce the accumulation of mRNA of the systemic acquired resistance (SAR)-associated PR-1 and the ethylene- and jasmonic acid-dependent PDF1.2 genes. However, BABA potentiated the accumulation of PR-1 mRNA after attack by virulent pathogenic bacteria. As a result, BABA-treated Arabidopsis plants were less diseased compared with the untreated control. In the case of bacteria, BABA protected mutants insensitive to jasmonic acid and ethylene but was not active in plants impaired in the SAR transduction pathway. Thus, BABA protects Arabidopsis against different virulent pathogens by potentiating pathogen-specific plant resistance mechanisms. In addition, we provide evidence that BABA-mediated papilla formation after P. parasitica infection is independent of the SAR signaling pathway.

Risk factor control and perceptions of risk factors in patients with coronary heart disease

Treatment of hypertension and hyperlipidaemia improves cardiovascular and overall mortality in patients with coronary heart disease. Adequate awareness of atherogenic risk factors is a key first step that enables patients to address their risk factors. In a recently completed study in coronary heart disease patients at coronary angiography and 18 months later, we found that skewed views about atherogenic risk factors in general were expressed. In addition, awareness of the patients' own hypercholesterolaemia or diabetes mellitus was often inadequate or lacking, in contrast to their awareness of blood pressure or bad smoking habits. Awareness of risk factors had only marginally improved 18 months after the initial investigation. Smoking habits, total cholesterol, and HDL values had improved over 18 months but lipid values were far from reaching target values of accepted guidelines. A majority of our patients remained with at least one treatable and insufficiently controlled atherogenic risk factor, usually hypercholesterolaemia. Interestingly, higher awareness of risk factors correlated with better risk factor control. These observations suggest that systematic interventions are necessary to further ameliorate secondary prevention in coronary heart disease. Successful standardized programmes of high or perhaps medium intensity, that include systematic screening of risk factors, reasoned educational interventions, and methodical management of treatable atherogenic risk factors according to accepted, guidelines, therefore require further attention in daily medical practice.