Intravenous thrombolysis for large vessel or distal occlusions presenting with mild stroke severity

BACKGROUND AND PURPOSE

We investigated the effectiveness of intravenous thrombolysis (IVT) in acute ischaemic stroke (AIS) patients with large vessel or distal occlusions and mild neurological deficits, defined as National Institutes of Health Stroke Scale scores < 6 points.

METHODS

The primary efficacy outcome was 3-month functional independence (FI) [modified Rankin Scale (mRS) scores 0-2] that was compared between patients with and without IVT treatment. Other efficacy outcomes of interest included 3-month favorable functional outcome (mRS scores 0-1) and mRS score distribution at discharge and at 3 months. The safety outcomes comprised all-cause 3-month mortality, symptomatic intracranial hemorrhage (ICH), asymptomatic ICH and severe systemic bleeding.

RESULTS

We evaluated 336 AIS patients with large vessel or distal occlusions and mild stroke severity (mean age 63 ± 15 years, 45% women). Patients treated with IVT (n = 162) had higher FI (85.6% vs. 74.8%, P = 0.027) with lower mRS scores at hospital discharge (P = 0.034) compared with the remaining patients. No differences were detected in any of the safety outcomes including symptomatic ICH, asymptomatic ICH, severe systemic bleeding and 3-month mortality. IVT was associated with higher likelihood of 3-month FI [odds ratio (OR), 2.19; 95% confidence intervals (CI), 1.09-4.42], 3-month favorable functional outcome (OR, 1.99; 95% CI, 1.10-3.57), functional improvement at discharge [common OR (per 1-point decrease in mRS score), 2.94; 95% CI, 1.67-5.26)] and at 3 months (common OR, 1.72; 95% CI, 1.06-2.86) on multivariable logistic regression models adjusting for potential confounders, including mechanical thrombectomy.

CONCLUSIONS

Intravenous thrombolysis is independently associated with higher odds of improved discharge and 3-month functional outcomes in AIS patients with large vessel or distal occlusions and mild stroke severity. IVT appears not to increase the risk of systemic or symptomatic intracranial bleeding.

[Preventive contralateral mastectomy despite absence of gene mutation; management and treatment of women with no medical indication]

Recently, there has been an increase in the rate of contralateral prophylactic mastectomies (CPM) as a therapy for breast cancer. The CPM is performed to achieve a reduction in the risk of developing asecond breast cancer. However, evidence is lacking for beneficial survival outcomes after a CPM in patients without a gene mutation, and complications of surgery are inevitable. Currently there are no evidence-based clinical practice guidelines available for clinicians to decide upon the right treatment for patients without a gene mutation. Our hospitals have therefore implemented their own clinical pathway to achieve a comprehensive treatment for this group of patients. In this article we will provide an overview of the existing literature and illustrate our clinical pathway by presenting three patients treated in our hospitals in the last two years.

Proposal for a multidisciplinary approach to the patient with morbid obesity: the St. Franciscus Hospital morbid obesity program

Morbid obesity is a serious disease as it is accompanied by substantial co-morbidity and mortality. The prevalence is increasing to an alarming extent, in Europe as well as in the United States. In the past few decades, bariatric surgery has developed and gained importance. It currently represents the only long-lasting therapy for this group of patients, resulting in an efficient reduction in body weight and obesity-related medical conditions, mostly cardiovascular in nature. The importance of a standardized protocol, the use of selection criteria, and a multidisciplinary approach have been stressed but not yet described in detail. Therefore, in this article, the multidisciplinary approach and the treatment protocol that have been applied in our hospital for more than 20 years are set out in a detailed manner. The application of a strict protocol may help to select and follow-up motivated patients and to organize multidisciplinary research activities.

[Favourable short-term effects of a multidisciplinary, behavioural therapy, group treatment for overweight or obese children]

OBJECTIVE

Evaluate the effect of a multidisciplinary, behavioural therapy, group therapy for obese children.

DESIGN

Descriptive.

METHOD

The treatment consisted of 8 child and 2 parent sessions over a period of 10 weeks, in the Sint Franciscus Gasthuis Hospital in Rotterdam, the Netherlands. Attention was devoted to eating behaviour, physical exercise and psychosocial aspects. Data were collected about children treated in the period 1999-2002. Inclusion criteria were: age 7-14 years, body-mass index (BMI) > or = 25 kg/m2, spoke Dutch, and no problematic behaviour according to the CBCL (total score < 70). Outcome measures were BMI, energy uptake, treadmill endurance time in the Bruce test, and problematic behaviour. There were three measurement points: 3 months before the treatment, immediately before the treatment and immediately after the treatment.

RESULTS

7 of the 78 children who were to participate dropped out. The study cohort consisted of 52 girls and 19 boys with an average age of 10.5 years. In the months prior to the treatment there was no statistically significant change in the outcomes. During the treatment period all of the children lost weight. The mean BMI decreased by 1.7 kg/m2 (-0.3 SDS), the mean daily energy uptake decreased by 1242 kJ and the maximal endurance time increased by 0.8 min (all: p < 0.001). There was no significant decrease in the score for problematic behaviour.

CONCLUSION

For the overweight or obese children who followed the treatment programme the BMI and energy intake decreased during the programme and the fitness increased.

Conformational comparison of five follicular fluid meiosis-activating sterol-related active and inactive compounds

The crystal structures of five follicular fluid meiosis-activating sterol-related Delta(8,14)-sterol compounds are presented. These are 4,4-dimethyl-23-phenyl-24-nor-5alpha-chola-8,14-dien-3beta-ol, C(31)H(44)O, 4,4-dimethyl-22-phenyl-23,24-dinor-5alpha-chola-8,14-dien-3beta-ol, C(30)H(42)O, (20R)-4,4-dimethyl-22-oxa-5alpha,20-cholesta-8,14,24-trien-3beta-ol, C(28)H(44)O(2), 4,4-dimethyl-23-phenyl-22-oxa-24-nor-5alpha-chola-8,14-dien-3beta-ol-water (4/1), 4C(30)H(42)O(2).H(2)O, and 4,4-dimethyl-5alpha-cholesta-8,14-dien-3-one, C(29)H(46)O. Two of the derivatives are inactive and three are active as agonists. Preliminary structure-activity relationship studies showed that the positions of the double bonds in the skeleton and the structures of the side chains are important determinants for activity. The conformations of the skeletons were compared with double-bond isomers retrieved from the Cambridge Structural Database [Allen & Kennard (1993). Chem. Des. Autom. News, 8, 1, 31-37]; no significant differences were found. Thus, conformational changes induced by the double bonds are not discriminative with respect to the activity of the compounds. Comparisons of the side-chain conformations of active and inactive structures revealed that the crystal structures were not conclusive as far as correlation of conformation and activity of the side chains were concerned.

Relation between the molecular electrostatic potential and activity of some FF-MAS related sterol compounds

Follicular Fluid-Meiosis Activating Sterol (FF-MAS) is a compound important for maturation of gametes in mammals. Therefore, it may serve as a lead compound for a novel method of contraception. We studied the Molecular Electrostatic Potential of a series of active and inactive analogues of FF-MAS. We find that double bond configurations required for activity result in a local negative electrostatic potential which is larger as well as more dense compared to those of inactive molecules. We therefore hypothesize that the interaction energy of the double bond system of the MAS compounds with its receptor substantially contributes to the overall interaction energy. This notion is supported by interaction studies of the electrostatic potential originating from the double bonds in crystal structures of cholesterol and four MAS-derived Delta(8,14) structures synthesized and crystallized by us. In addition, we were able to derive a pharmacophore model that relates the local average ESP and its distance to the 3beta-OH oxygen atom to the activity of the molecules.

Toward an unequivocal definition and classification of patient outcomes

PURPOSE

To determine the extent possible of developing an unequivocal formulation of a conceptual, structural, and contextual definition of "patient outcomes," and the possibility of coming to an agreement on the criteria for classification of patient outcomes.

METHODS

An international Delphi survey of 33 experts.

FINDINGS

A conceptual, structural, and contextual definition of patient outcomes and priorities for the characteristics of patient outcome classification.

CONCLUSIONS

The authors recommend the unequivocalness of nursing terminology, not only for reasons of effectiveness and efficiency, but also to clarify the nursing vocabulary for epistemological reasons.

[Patient outcome--towards a definition and classification of nursing care outcome]

Within the context of the desired unambiguousness in definitions and classifications of the nursing terminology, this literature research attempts to inventory the divergent meanings in recent professional nursing literature of the concept 'patient outcome', as well as the classifications used. Data analysis and interpretation was carried out by means of analytic induction. The results clearly show the ambiguousness of the concept. Nursing literature appears to pay little attention to the study of the structure of (the) patient outcome(s). Then, the context in which the patient outcome has to be situated appears to be described in many divergent ways. Finally, classifications of patient outcomes are found in many variants. This report concludes with suggestions for an unequivocal definition of patient outcome, as well as for the construction of (a) classification(s) of patient outcomes.

Defective bronchus-associated lymphoid tissue in long-term surviving rat lung allografts

In a previous study we found that a local immune response did not develop in the bronchus-associated lymphoid tissue (BALT) of infected rat allografts. We hypothesized that the BALT in rat lung allografts was damaged after allotransplantation. Therefore, we investigated three prerequisites for a normal function of the BALT, i.e., its structure, the uptake of antigens, and the lymphocyte migration to the BALT in three groups of rats (n = 10 each): (1) Brown Norway(BN)-to-Lewis (LEW) allografts; (2) LEW-to-LEW isografts; and (3) normal LEW rats. All rats were immunosuppressed with CsA (injected on days 2 and 3). Six mo after transplantation the structure of the BALT and the uptake of intrabronchially injected carbon particles in the BALT were determined histologically; the migration of intravenously injected, fluoroscein-isothiocyanate labeled lymphocytes to the BALT was determined immunohistochemically. In the allografts the BALT was defective in all three investigated aspects. It was reduced in size and lymphocyte density and was largely replaced by fibrous tissue. Twenty-four h after administration no carbon particles and only a few labeled lymphocytes were found in the BALT. In contrast, in the syngeneically transplanted and nontransplanted lungs the BALT consisted of a large and dense collection of lymphocytes. In these BALTs large numbers of carbon particles and labeled lymphocytes were found. In conclusion, after allogeneic transplantation the BALT in the lung becomes defective in structure and function. The BALT is most likely damaged by rejection, since the BALT is syngeneic lung transplants was perfectly normal.

Inadequate antibody response against respiratory viral infection in long-surviving rat lung allografts

Lung transplant recipients suffer from a high number of viral infections. It has been suggested that the defense against viral infections is impaired in lung transplants. Therefore, we investigated in rat lung transplants whether antibody responses against an intrapulmonary viral infection were impaired in 3 groups of rats with: (1) BN-to-LEW allogeneic lung transplants, (2) LEW-to-LEW syngeneic lung transplants, and (3) nontransplanted LEW lungs. All rats (including those with nontransplanted, normal lungs) were treated with cyclosporine on days 2 and 3 after operation; this treatment is adequate to induce permanent graft acceptance of the allografts. Six months after transplantation, viral infections with Sendai virus (parainfluenza type I) were induced intratracheally. At day 0, immediately before infection, and at days 4, 7, 21, and 56 after infection, 4 rats in each group were killed for histological evaluation of the lungs. The number of antibody-positive cells in the bronchus-associated lymphoid tissue (BALT) in the lungs and in the spleen, and presence of the virus in the lungs were determined by immunohistology. Serum antibody titers were followed for 56 days after infection. The allogeneically transplanted lungs failed to respond adequately against the virus: the number of antibody-positive cells in the BALT did not increase after infection, serum antibody titers were hardly detectable, and virus was present in the airways of the lungs up to day 21 after infection. In contrast, in the syngeneically and nontransplanted lungs, the number of antibody-forming cells in the BALT increased steeply until day 7, serum antibody titers rose until day 14, and virus could be detected only on day 4 after infection. This study shows that in rat lung allografts, both the local antibody production in the BALT and the systemic antibody response against a respiratory viral infection are inadequate. As a consequence, the virus is present longer in these allografted lungs and can exert its damaging effect over a longer period of time. These results may explain why lung transplants are so susceptible to viral infections.

Respiratory viral infections aggravate airway damage caused by chronic rejection in rat lung allografts

Airway damage resulting in bronchiolitis obliterans occurs frequently in patients after heart-lung and lung transplantation. Generally, chronic rejection is assumed to be the most important cause of bronchiolitis obliterans. However, viral infections might also be potential causes of airway damage after lung transplantation. In the present study, we investigated whether viral infections could induce airway damage in rat lung transplants in the absence or presence of chronic rejection. We compared the histopathology of the airways in 3 groups of rats: (1) nontransplanted LEW lungs, (2) LEW-to-LEW syngeneic lung transplants, and (3) BN-to-LEW allogeneic lung transplants. Nontransplanted and transplanted rats were treated with CsA to induce permanent graft acceptance of the allografts. Six months after transplantation, 4 noninfected rats of each group were killed for histological investigation (another 4 noninfected allografted rats were killed 56 days later). The remaining 16 rats in each group were infected with Sendai virus (parainfluenza type 1) intratracheally. These rats were killed for histological investigation 4, 7, 21, and 56 days after infection. In the lungs of the noninfected rats of the nontransplanted and syngeneically transplanted groups, airway changes were absent. After viral infection in these lungs, mild inflammation developed in the airways that was transient and completely resolved by day 56 after infection. In contrast, in the allogeneically transplanted lungs the viral infection caused severe and permanent damage of the airways. In the bronchioles and the large airways throughout the allogeneic lung transplants, inflammation with epithelial necrosis and formation of granulation tissue was present. On day 56 after infection, the bronchioles showed scarring in the submucosa and obliteration of the lumen, typical features of bronchiolitis obliterans. This study shows that a respiratory viral infection aggravates the airway damage in rat lung allografts with chronic rejection. The findings suggest that viral infections and chronic rejection play a synergistic role in the development of bronchiolitis obliterans after human heart-lung and lung transplantation: the virus infection may stimulate chronic rejection and rejection may hamper the local defense against the virus.

Reduced antibody responses after immunization in rat lung transplants

Pulmonary infections occur so frequently in recipients of lung transplants as well as of combined heart and lung transplants that it has been suggested that the function of the defense system in lung transplants is impaired. Therefore, we investigated in rats whether antibody responses against intrapulmonary antigens were impaired at various time points after transplantation. Antibody responses were induced in lungs of four experimental groups. Group 1: normal lungs (LEW); Group 2: hilar-stripped (sham-operated) lungs (LEW); Group 3: syngeneic lung transplants (LEW-to-LEW); Group 4: allogeneic lung transplants (BN-to-LEW). The operations were performed on the left lungs. All rats (including those with normal lungs) were treated with cyclosporine on Days 2 and 3 after operation, which treatment is adequate to induce permanent graft acceptance of the allografts. Rats were immunized 7, 10, 14, 21, and 28 days and at 6 months after operation with sheep red blood cells, injected selectively into the bronchus of the left lung. The resulting serum antibody titers were detected with a hemolysis assay. After immunization on Day 7, no antibody responses could be detected in all hilar-stripped and transplanted rats, whereas responses were normal in two allografted rats immunized in the nontransplanted right lung. After immunization on Day 14, responses had returned to normal in hilar-stripped rats, whereas they were still impaired in the transplanted rats. After immunization on Day 28, responses were almost normal in all rats and remained so until 6 months after transplantation.(ABSTRACT TRUNCATED AT 250 WORDS)

The human prostatic carcinoma cell line LNCaP and its derivatives. An overview

The FGC (fast growing colony) line, a derivative of the LNCaP cell line shares all the main characteristics, including its androgen dependence, described for the original LNCaP cultures. A number of sublines originated from the FGC line which were characterized with respect to their response to steroid-depleted serum and to the synthetic androgen, R1881. After subcloning the FGC line a series of clones was isolated with distinct patterns of androgen-responsiveness. Among the sublines and clones studied, the FGC, FGC-JB and FGC clone-9 were androgen-dependent, whereas subline LNO, R and presumably also FGC clone-22 were androgen-independent. Distinct morphological differences were observed between the cells of the various sublines and between clone-9 and 22. The LNCaP cell line, its descending sublines and clonal derivatives provide a suitable in vitro model for studying different aspects of androgen-responsiveness of human prostate cancer.

Transplantable human prostatic carcinoma (PC-82) in athymic nude mice. III. Effects of estrogens on the growth of the tumor tissue

The transplantable human prostatic tumor model (PC-82) in nude mice was used to evaluate the indirect and possibly direct effects of estrogens on the growth of prostatic tumor tissue. High (pharmalogical) doses of plasma estradiol (E2) were achieved in tumor-bearing mice by using E2-containing Silastic implants of different lengths. In comparison with the situation in men, in mice much higher concentrations of circulating E2 (exceeding 3 nmol/liter) were necessary to attain (near)-castrate levels of plasma testosterone (T). Treatment of tumor-bearing mice with a high dose of E2 resulted in tumor growth arrest and a subsequent decline of the tumor volume, which equals the effects of castration. No evidence was found that either of the two doses of E2 applied had any additive inhibitory effect on tumor growth when compared to castration alone. It was inferred from these findings that in the PC-82 tumor model, estrogens, rather than having a direct effect on the tumor tissue, mainly act indirectly by their suppressive effect on T secretion in the host animal. A different and unexpected result was obtained in castrated tumor-bearing mice treated with a combination of E2 and T. With both doses of E2 this type of treatment led to a smaller increase of the tumor volume compared with mice receiving T only, the result of the high dose being statistically significant. This antagonistic effect of the two steroids on the PC-82 tissue was paradoxically associated with a sharp increase of nuclear androgen receptor levels and a higher concentration of dihydrotestosterone in the tumor tissue. Plasma and tissue concentrations of T appeared to be unaltered. The present study of the PC-82 prostate tumor shows that only by careful monitoring of plasma steroid levels in tumor-bearing mice can conclusions about the effectiveness of hormonal treatment regimens, such as estrogen therapy, be drawn.

Administration of an LHRH-antagonist to male mice: effects on in vivo secretion of hormones and on the growth of a transplantable human prostatic carcinoma

The potent luteinizing hormone releasing hormone (LHRH) antagonist [N-Ac-D-p-Cl-Phe1,2,D-Trp3,D-Arg6,D-Ala10]-LHRH was chronically administered to male nude mice bearing the transplantable human hormone-dependent prostatic adenocarcinoma PC-82. Treatment of tumor-bearing male mice with a daily dose of 100 micrograms (4 mg/kg b w.) for 21 days did not significantly affect the growth of the PC-82 tumor tissue, or the weights of ventral prostate, seminal vesicles and testes. At 24 hours after the last dose of the antagonist the mean plasma-testosterone (T) value in these animals was not different from the control level. Administration of similar doses of the antagonist to intact normal immunocompetent male mice significantly reduced plasma LH concentrations and suppressed plasma-T to near-castrate levels, when blood was taken 2 hours after the last injection. At 24 hours after the last dose, however, plasma concentrations of LH and T had returned to control levels. This time-dependent pattern of T suppression by the antagonist was confirmed by a time-course experiment in animals receiving a single dose of the compound. These data demonstrate that a daily high dose of this antagonist cannot effectively suppress plasma-T in male mice. Therefore, the mouse may not be a suitable model for the investigation of the "castration-like" effect of LHRH-antagonists on androgen-dependent prostate xenografts.

Biological effects of hormonal treatment regimens on a transplantable human prostatic tumor line (PC-82)

The effects of hormonal manipulation on the growth of a transplantable human prostatic carcinoma line (PC-82) were studied. The histological pattern of the PC-82 tumor, which still closely resembles the original tumor material, and the tumor growth rate did not change during the subsequent mouse passages. Growth of PC-82 tumor tissue on female and castrated male mice did not occur. Castration of tumor-bearing mice resulted in a cessation of tumor growth, after which the tumor volume decreased 50 +/- 27 per cent within 6 weeks after castration. Hormone-independent regrowth of the tumor tissue was not observed after long-term withdrawal of androgens. After a period of 10 weeks following tumor growth arrest, administration of testosterone almost directly resulted in regrowth of the tumor. Hormones, testosterone and estradiol, were administered by silastic implants. Intact male nude mice were shown to have highly fluctuating levels of testosterone. Implantation with testosterone resulted in constant levels of circulating testosterone, which could be maintained for at least 10 weeks, while the mean concentration of plasma testosterone was not different from that in control male mice. The doubling time of tumors grown on testosterone-substituted intact female and intact and castrated male mice was significantly shorter than that of tumors grown on intact male mice. Histologically the tumors grown on androgen-substituted mice were similar to those grown on untreated mice; the mitotic index, however, was much higher in the testosterone treated animals. Implantation of intact male mice with estradiol suppressed plasma testosterone to a mean level of 1 ng. per ml. and prevented the growth of PC-82 tumor tissue almost completely. Treatment of tumor-bearing mice with an estradiol implant following androgen withdrawal did not result in a further decrease of the tumor volume compared to the mice without additional estradiol implantation.

The use of steroid-containing Silastic implants in male nude mice: plasma hormone levels and the effect of implantation on the weights of the ventral prostate and seminal vesicles

The effects of implantation of steroid-containing capsules into male nude mice on steroid concentrations in plasma and weight of accessory sex organs were studied. Intact male nude mice had plasma levels of testosterone (T) of 8.0 +/- 2.4 ng/ml, while T implantation (length 1.0 cm) of a group with castrated male mice resulted in a mean level of 8.1 +/- 0.3 ng/ml. This level was reached within 2 days after implantation and lasted for at least 40 days. After longer periods of application (up to 75 days) physiological levels could still be attained. Treatment of intact male nude mice with estradiol (E2)-containing implants (length 0.5 cm) resulted in constant levels of plasma-E2 (250 pg/ml) also lasting for at least 32 days. This treatment resulted in a mean plasma-T level of 1.0 +/- 0.2 ng/ml, which was still significantly higher than that obtained after castration (0.14 +/- 0.03 ng/ml). Up to 16 days after implantation E2 did not cause a decrease of the weights of the accessory sex glands in intact male mice, while after 32 days a significant reduction (50% of the control animals) of the organ weights was observed. The present data obtained with T and E2 implantation show that this route of administration of hormones is also very applicable in the nude mouse model.