Prediction of underlying atrial fibrillation in patients with a cryptogenic stroke: results from the NOR-FIB Study

BACKGROUND

Atrial fibrillation (AF) detection and treatment are key elements to reduce recurrence risk in cryptogenic stroke (CS) with underlying arrhythmia. The purpose of the present study was to assess the predictors of AF in CS and the utility of existing AF-predicting scores in The Nordic Atrial Fibrillation and Stroke (NOR-FIB) Study.

METHOD

The NOR-FIB study was an international prospective observational multicenter study designed to detect and quantify AF in CS and cryptogenic transient ischaemic attack (TIA) patients monitored by the insertable cardiac monitor (ICM), and to identify AF-predicting biomarkers. The utility of the following AF-predicting scores was tested: AS5F, Brown ESUS-AF, CHA₂DS₂-VASc, CHASE-LESS, HATCH, HAVOC, STAF and SURF.

RESULTS

In univariate analyses increasing age, hypertension, left ventricle hypertrophy, dyslipidaemia, antiarrhythmic drugs usage, valvular heart disease, and neuroimaging findings of stroke due to intracranial vessel occlusions and previous ischemic lesions were associated with a higher likelihood of detected AF. In multivariate analysis, age was the only independent predictor of AF. All the AF-predicting scores showed significantly higher score levels for AF than non-AF patients. The STAF and the SURF scores provided the highest sensitivity and negative predictive values, while the AS5F and SURF reached an area under the receiver operating curve (AUC) > 0.7.

CONCLUSION

Clinical risk scores may guide a personalized evaluation approach in CS patients. Increasing awareness of the usage of available AF-predicting scores may optimize the arrhythmia detection pathway in stroke units.

Underlying causes of cryptogenic stroke and TIA in the nordic atrial fibrillation and stroke (NOR-FIB) study - the importance of comprehensive clinical evaluation

BACKGROUND

Cryptogenic stroke is a heterogeneous condition, with a wide spectrum of possible underlying causes for which the optimal secondary prevention may differ substantially. Attempting a correct etiological diagnosis to reduce the stroke recurrence should be the fundamental goal of modern stroke management.

METHODS

Prospective observational international multicenter study of cryptogenic stroke and cryptogenic transient ischemic attack (TIA) patients clinically monitored for 12 months to assign the underlying etiology. For atrial fibrillation (AF) detection continuous cardiac rhythm monitoring with insertable cardiac monitor (Reveal LINQ, Medtronic) was performed. The 12-month follow-up data for 250 of 259 initially included NOR-FIB patients were available for analysis.

RESULTS

After 12 months follow-up probable stroke causes were revealed in 43% patients, while 57% still remained cryptogenic. AF and atrial flutter was most prevalent (29%). In 14% patients other possible causes were revealed (small vessel disease, large-artery atherosclerosis, hypercoagulable states, other cardioembolism). Patients remaining cryptogenic were younger (p < 0.001), had lower CHA₂DS₂-VASc score (p < 0.001) on admission, and lower NIHSS score (p = 0.031) and mRS (p = 0.016) at discharge. Smoking was more prevalent in patients that were still cryptogenic (p = 0.014), while dyslipidaemia was less prevalent (p = 0.044). Stroke recurrence rate was higher in the cryptogenic group compared to the group where the etiology was revealed, 7.7% vs. 2.8%, (p = 0.091).

CONCLUSION

Cryptogenic stroke often indicates the inability to identify the cause in the acute phase and should be considered as a working diagnosis until efforts of diagnostic work up succeed in identifying a specific underlying etiology. Timeframe of 6-12-month follow-up may be considered as optimal.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT02937077, EudraCT 2018-002298-23.

Safety and efficacy of tenecteplase in patients with wake-up stroke assessed by non-contrast CT (TWIST): a multicentre, open-label, randomised controlled trial

BACKGROUND

Current evidence supports the use of intravenous thrombolysis with alteplase in patients with wake-up stroke selected with MRI or perfusion imaging and is recommended in clinical guidelines. However, access to advanced imaging techniques is often scarce. We aimed to determine whether thrombolytic treatment with intravenous tenecteplase given within 4·5 h of awakening improves functional outcome in patients with ischaemic wake-up stroke selected using non-contrast CT.

METHODS

TWIST was an investigator-initiated, multicentre, open-label, randomised controlled trial with blinded endpoint assessment, conducted at 77 hospitals in ten countries. We included patients aged 18 years or older with acute ischaemic stroke symptoms upon awakening, limb weakness, a National Institutes of Health Stroke Scale (NIHSS) score of 3 or higher or aphasia, a non-contrast CT examination of the head, and the ability to receive tenecteplase within 4·5 h of awakening. Patients were randomly assigned (1:1) to either a single intravenous bolus of tenecteplase 0·25 mg per kg of bodyweight (maximum 25 mg) or control (no thrombolysis) using a central, web-based, computer-generated randomisation schedule. Trained research personnel, who conducted telephone interviews at 90 days (follow-up), were masked to treatment allocation. Clinical assessments were performed on day 1 (at baseline) and day 7 of hospital admission (or at discharge, whichever occurred first). The primary outcome was functional outcome assessed by the modified Rankin Scale (mRS) at 90 days and analysed using ordinal logistic regression in the intention-to-treat population. This trial is registered with EudraCT (2014-000096-80), ClinicalTrials.gov (NCT03181360), and ISRCTN (10601890).

FINDINGS

From June 12, 2017, to Sept 30, 2021, 578 of the required 600 patients were enrolled (288 randomly assigned to the tenecteplase group and 290 to the control group [intention-to-treat population]). The median age of participants was 73·7 years (IQR 65·9-81·1). 332 (57%) of 578 participants were male and 246 (43%) were female. Treatment with tenecteplase was not associated with better functional outcome, according to mRS score at 90 days (adjusted OR 1·18, 95% CI 0·88-1·58; p=0·27). Mortality at 90 days did not significantly differ between treatment groups (28 [10%] patients in the tenecteplase group and 23 [8%] in the control group; adjusted HR 1·29, 95% CI 0·74-2·26; p=0·37). Symptomatic intracranial haemorrhage occurred in six (2%) patients in the tenecteplase group versus three (1%) in the control group (adjusted OR 2·17, 95% CI 0·53-8·87; p=0·28), whereas any intracranial haemorrhage occurred in 33 (11%) versus 30 (10%) patients (adjusted OR 1·14, 0·67-1·94; p=0·64).

INTERPRETATION

In patients with wake-up stroke selected with non-contrast CT, treatment with tenecteplase was not associated with better functional outcome at 90 days. The number of symptomatic haemorrhages and any intracranial haemorrhages in both treatment groups was similar to findings from previous trials of wake-up stroke patients selected using advanced imaging. Current evidence does not support treatment with tenecteplase in patients selected with non-contrast CT.

FUNDING

Norwegian Clinical Research Therapy in the Specialist Health Services Programme, the Swiss Heart Foundation, the British Heart Foundation, and the Norwegian National Association for Public Health.

Atrial fibrillation in cryptogenic stroke and TIA patients in the nordic atrial fibrillation and stroke The Nordic Atrial Fibrillation and Stroke (NOR-FIB) Study: Main results

Introduction:

Secondary stroke prevention depends on proper identification of the underlying etiology and initiation of optimal treatment after the index event. The aim of the NOR-FIB study was to detect and quantify underlying atrial fibrillation (AF) in patients with cryptogenic stroke (CS) or transient ischaemic attack (TIA) using insertable cardiac monitor (ICM), to optimise secondary prevention, and to test the feasibility of ICM usage for stroke physicians.

Patients and methods:

Prospective observational international multicenter real-life study of CS and TIA patients monitored for 12 months with ICM (Reveal LINQ) for AF detection.

Results:

ICM insertion was performed in 91.5% by stroke physicians, within median 9 days after index event. Paroxysmal AF was diagnosed in 74 out of 259 patients (28.6%), detected early after ICM insertion (mean 48 ± 52 days) in 86.5% of patients. AF patients were older (72.6 vs 62.2; p < 0.001), had higher pre-stroke CHA₂DS₂-VASc score (median 3 vs 2; p < 0.001) and admission NIHSS (median 2 vs 1; p = 0.001); and more often hypertension ( p = 0.045) and dyslipidaemia ( p = 0.005) than non-AF patients. The arrhythmia was recurrent in 91.9% and asymptomatic in 93.2%. At 12-month follow-up anticoagulants usage was 97.3%.

Discussion and conclusions:

ICM was an effective tool for diagnosing underlying AF, capturing AF in 29% of the CS and TIA patients. AF was asymptomatic in most cases and would mainly have gone undiagnosed without ICM. The insertion and use of ICM was feasible for stroke physicians in stroke units.

Potentiation of GM-CSF or GCSF Induced Mobilization of Circulating Progenitor Cells by Pretreatment with IL-3 and Harvest by Apheresis

Recombinant human colony-stimulating factors (CSFs) are increasingly used for mobilizing progenitor cells in the peripheral blood (PB). 7 patients were treated with GM-CSF or GCSF at a dose of 5μg/kg/d for 5 days and after a treatment free interval received another cycle of the same cytokine after pretreatment with IL-3. Pretreatment with 5μg/kg/d of IL-3 for 7 days did not mobilize by itself but significantly potentiated GM-CSF or GCSF induced mobilization of PB progenitor cells in all 5 patients tested. As compared to the mobilization capacity of GM-CSF or GCSF alone, 7 day IL-3 pretreatment potentiated maximum values of CFU-GM by 3.7-6.3 fold in patients receiving GM-CSF (n=2) and by 1.8-3.3 fold in patients receiving GCSF leading to a 10-23 fold increase in numbers of circulating CFU-GM by the combination IL-3/GM-CSF, and a 26-101 fold increase by IL-3/GCSF, respectively. Stem cell apheresis in patients treated with IL-3 + GCSF or GM-CSF yielded enough PB-stem cells to ensure complete engraftment after ablative chemotherapy.

Alignment of D-state Rydberg molecules

We report on the formation of ultralong-range Rydberg D-state molecules via photoassociation in an ultracold cloud of rubidium atoms. By applying a magnetic offset field on the order of 10 G and high resolution spectroscopy, we are able to resolve individual rovibrational molecular states. A full theory, using a Fermi pseudopotential approach including s- and p-wave scattering terms, reproduces the measured binding energies. The calculated molecular wave functions show that in the experiment we can selectively excite stationary molecular states with an extraordinary degree of alignment or antialignment with respect to the magnetic field axis.

Prenatal adversity: a risk factor in borderline personality disorder?

BACKGROUND

Patients with borderline personality disorder (BPD) show a high prevalence of early adversity, such as childhood trauma. It has also been reported that prenatal adverse conditions, such as prenatal maternal stress, drug taking, tobacco smoking or medical complications, may be associated with an increased risk of mental disorders in the offspring. Prenatal adversity is investigated here for the first time as a potential risk factor in the diagnosis of BPD. Method A total of 100 patients with a DSM-IV diagnosis of BPD and 100 matched healthy controls underwent semi-structured interviews about the course of pregnancy, maternal stressors, birth complications and childhood trauma. Further information was obtained from the participants' mothers and from prenatal medical records.

RESULTS

Borderline patients were significantly more often exposed to adverse intrauterine conditions, such as prenatal tobacco exposure (p=0.004), medical complications (p=0.008), prenatal maternal traumatic stress (p=0.015), familial conflicts (p=0.004), low social support (p=0.004) and partnership problems during pregnancy (p=0.014). Logistic regression analyses revealed that the reported prenatal risk factors accounted for 25.7% of the variance in BPD. Prenatal tobacco exposure [odds ratio (OR) 3.37, 95% confidence interval (CI) 1.49-7.65, p=0.004] and medical complications (OR 2.87, 95% CI 1.29-6.38, p=0.010) emerged as important predictors. After controlling for childhood adversity and parental socio-economic status (SES), prenatal risk factors predicted relevant borderline subdomains, such as impulsivity, affective instability, identity disturbance, dissociation and severity of borderline symptoms.

CONCLUSIONS

This study provides evidence of an association between prenatal adversity and the diagnosis of BPD. Our findings suggest that prenatal adversity may constitute a potential risk factor in the pathogenesis of BPD.

[Technique of the urethral anastomosis in orthotopic neo-bladder following robot-assisted radical cystectomy (RARC)]

The urethral anastomosis in extracorporeally constructed orthotopic neo-bladder following robot-assisted radical cystectomy (RARC) remains a challenge. In principle either pre-posi-tioned single sutures or robotic continuous suture techniques can be applied. In the literature the different techniques are most often not described in detail. In the present work one example for each technique is given and the advantages and disadvantages of both methods are discussed.

[The urethral anastomosis in orthotopic neobladder following robot-assisted radical cystectomy (RARC) at German-speaking centres]

INTRODUCTION

Following robot-assisted radical cystectomy (RARC) and extracorporeal reconstruction, robotic continuous suture techniques and those using open or robotically pre-positioned single sutures are used for the urethroneovesical anastomosis.

METHODS

62 German-speaking robotic centres were asked in an online questionnaire whether they carried out RARC. Following an affirmative answer further questions were put to the form of the neobladder and the technique of the urethrovesical anastomosis.

RESULTS

80% of the online questionnaires were answered. 44% (n=22) of these centres perform the RARC. According to the answers, given all of the centres but one perform an extracorporeal construction of the neobladder [Studer bladder 73% (n=16), Hautmann bladder 18% (n=4), others 9% (n=2)]. After reconstruction 36% (n=8) of the teams perform a completely open surgical anastomosis with pre-positioned sutures, 24% (n=5) close the anastomosis in a single knot technique using robotically pre-positioned sutures and 40% (n=9) use continuous sutures during the intracorporeal reconstruction or after re-docking the robot.

CONCLUSION

According to this questionnaire to German-speaking centres the most common anastomotic technique following extracorporeal reconstruction, mostly a Studer bladder, is that of the pre-positioned single knot sutures. This offers the advantage that a re-docking of the robotic cart is unnecessary. In contrast, however, to robotically performed suturing, there must be enough space in the open procedure to surgically tie-off the sutures of the anastomosis.

Quality of life survey after endovascular abdominal aortic aneurysm repair in octogenarians

AIM

The aim of this study was to assess health-related quality of life (HRQOL) after endovascular abdominal aortic aneurysm (AAA) repair in octogenarians compared to younger patients. In addition, a possible association between HRQOL, duration of hospitalisation and preoperative serum C-reactive protein (CRP) was studied.

METHODS

270 consecutive patients (249 men, mean age 73 years, range 52-89 years) with elective endovascular repair of AAA had been retrospectively evaluated. The Nottingham Health Profile (NHP) score was used to assess health related quality of life in 20 patients 80 years or older and in 25 younger patients.

RESULTS

The only difference in the NHP score between the two groups was found in physical abilities, where octogenarians had a significant lower score (79.9%, range 32.8-100%) than the younger group (92.2%, range 36.8-100%, P=0.0003). The mean AAA diameter of the octogenarians was 6.4 cm (range 4.1-13.0 cm) and was significantly larger than in non-octogenarians (5.8 cm, range 3.6-12.5 cm, P=0.017). Duration of hospitalisation, CRP-level and prevalence of CAD and PAD were not different in the two groups. Higher preoperative CRP was associated with longer hospital stay.

CONCLUSION

Perceived HRQOL in patients undergoing endovascular repair of AAA is equally good in octogenarians and non-octogenarians, however only the score for physical ability is lower in the older group.

The potential effect of population development, smoking and antioxidant supplementation on the future epidemiology of age-related macular degeneration in Switzerland

BACKGROUND

Due to the predicted age shift of the population an increase in the number of patients with late AMD is expected. At present smoking represents the only modifiable risk factor. Supplementation of antioxidants in patients at risk is the sole effective pharmacological prevention. The aim of this study is to estimate the future epidemiological development of late AMD in Switzerland and to quantify the potential effects of smoking and antioxidants supplementation.

METHODS

The modelling of the future development of late AMD cases in Switzerland was based on a meta-analysis of the published data on AMD-prevalence and on published Swiss population development scenarios until 2050. Three different scenarios were compared: low, mean and high. The late AMD cases caused by smoking were calculated using the "population attributable fraction" formula and data on the current smoking habits of the Swiss population. The number of potentially preventable cases was estimated using the data of the Age-Related Eye Disease Study (AREDS).

RESULTS

According to the mean population development scenario, late AMD cases in Switzerland will rise from 37 200 cases in 2005 to 52 500 cases in 2020 and to 93 200 cases in 2050. Using the "low" and the "high" scenarios the late AMD cases may range from 49 500 to 56 000 in 2020 and from 73 700 to 118 400 in 2050, respectively. Smoking is responsible for approximately 7 % of all late AMD cases, i. e., 2600 cases in 2005, 3800 cases in 2020, 6600 cases in 2050 ("mean scenario"). With future antioxidant supplementation to all patients at risk another 3100 cases would be preventable until 2020 and possibly 23 500 cases until 2050.

CONCLUSION

Due to age shift in the population a 2.5-fold increase in late AMD cases until 2050 is expected, representing a socioeconomic challenge. Cessation of smoking and supplementation of antioxidants to all patients at risk has the potential to reduce this number. Unfortunately, public awareness is low. These data may support health-care providers and public opinion leaders when developing public education and prevention strategies.

Crystallization and preliminary diffraction analysis of a DsbA homologue from Wolbachia pipientis

alpha-DsbA1 is one of two DsbA homologues encoded by the Gram-negative alpha-proteobacterium Wolbachia pipientis, an endosymbiont that can behave as a reproductive parasite in insects and as a mutualist in medically important filarial nematodes. The alpha-DsbA1 protein is thought to be important for the folding and secretion of Wolbachia proteins involved in the induction of reproductive distortions. Crystals of native and SeMet alpha-DsbA1 were grown by vapour diffusion and belong to the monoclinic space group C2, with unit-cell parameters a = 71.4, b = 49.5, c = 69.3 A, beta = 107.0 degrees and one molecule in the asymmetric unit (44% solvent content). X-ray data were recorded from native crystals to a resolution of 2.01 A using a copper anode and data from SeMet alpha-DsbA1 crystals were recorded to 2.45 A resolution using a chromium anode.

Expression and crystallization of DsbA from Staphylococcus aureus

Bacterial Dsb proteins catalyse the in vivo formation of disulfide bonds, a critical step in the stability and activity of many proteins. Most studies on Dsb proteins have focused on Gram-negative bacteria and thus the process of oxidative folding in Gram-positive bacteria is poorly understood. To help elucidate this process in Gram-positive bacteria, DsbA from Staphylococcus aureus (SaDsbA) has been focused on. Here, the expression, purification, crystallization and preliminary diffraction analysis of SaDsbA are reported. SaDsbA crystals diffract to a resolution limit of 2.1 A and belong to the hexagonal space group P6(5) or P6(1), with unit-cell parameters a = b = 72.1, c = 92.1 A and one molecule in the asymmetric unit (64% solvent content).

Integration von PACS und KIS in den Workflow einer nuklearmedizinischen Abteilung

Ziel: Die Entwicklung neuer Diagnoseverfahren und Implementierung eines modernen Qualitätsmanagements bedingen die permanente Anpassung vorhandener EDVStrukturen an den Arbeitsablauf in einer nuklearmedizinischen Abteilung. Die gesetzliche Pflicht zur Patientendatensicherung und ein schneller Datenzugriff mittels Vernetzung, wird durch ein PACS mit Anschluss an das KIS ermöglicht bzw. wesentlich erleichtert. Ziel dieser Arbeit ist deshalb den Aufbau, die Struktur und Ergebnisse eines derartigen Systems darzustellen und zu bewerten. Methode: Initial wurde der Workflow der Nuklearmedizin analysiert und den einzelnen Systemkomponenten der Abteilung zugeordnet. Die im Klinikum eingesetzte, auf den Standardverfahren SAP R/3 und IS-H bzw. IS-H*med basierende Software zur Patientenverwaltung, wurde entsprechend den Bedürfnissen der Nuklearmedizin angepasst. Die Vernetzung der bildgebenden Systeme erfolgte durch die Integration eines PACS. Im letzten Schritt erfolgte die Anbindung des PACS an das KIS mit der Möglichkeit dem schriftlichen Befund die entsprechenden Bildbefunde anzuhängen. Ergebnisse, Schlussfolgerung: Durch Vernetzung des KIS mit dem nuklearmedizinischen PACS konnte der Workflow wesentlich verbessert werden. Der Datenfluss kann von der Anmeldung, über die Akquisition, bis zum Abruf von schriftlichem und bildlichem Befund transparent nachvollzogen werden. Eine wesentliche Kostenreduktion, sowie ein schnellerer Zugang zu schriftlichem Befund und Bilddaten von Seiten der anfordernden Abteilungen ist festzuhalten. Die Integration von PACS und KIS in den Workflow der Nuklearmedizin dient auch unter Berücksichtigung der kritischen Aspekte, wie permanenter Systempflege oder regelmäßiger Aktualisierung, trotzdem der Effizienzsteigerung und Kostenersparnis. Das Patientenmanagement und die Nachvollziehbarkeit des Datenflusses werden erheblich verbessert.

Parkin gene variations in late-onset Parkinson's disease: comparison between Norwegian and German cohorts

OBJECTIVES

Mutations in the Parkin gene can cause autosomal recessive early-onset Parkinson's disease (PD). Recently, Parkin mutations were also suggested to play a role in the commoner late-onset forms of PD.

METHODS

We compared a German cohort of PD patients (95) with a Norwegian cohort of PD patients (96). Both cohorts have predominant late-onset form of PD. Mutation and polymorphism frequencies were compared via single-strand conformation polymorphism and sequence analyses.

RESULTS

Three heterozygous missense mutations (Arg256Cys, Arg402Cys and Thr240Met) were found in late-onset PD patients in the German patient cohort (1.6%). A missense mutation (Arg402Cys) was also found in one of 149 healthy control subjects (0.3%). Only one heterozygous missense mutation (Arg256Cys) was identified in a Norwegian patient suffering from late-onset PD (0.5%). The frequencies of four known single nucleotide polymorphisms significantly differ between the two distant European populations.

CONCLUSION

The results support the hypothesis that heterozygous mutations in the Parkin gene may act as susceptibility alleles for late-onset forms of PD in rare cases.

[Integration of PACS and HIS into the workflow of a nuclear medicine department. Experience in Regensburg]

AIM

The development of new diagnostic techniques and the implementation of a modern quality control management system requires the continuous adaptation of existing data processing tools to the nuclear medicine diagnostic workflow. Furthermore, PACS connected to HIS facilitates and enhances the transfer of data and pictures, and satisfies the legal requirements for data retention as regulated by law. Therefore, the aim of this work is to present the architecture, structure and results of such a system newly installed in a department of nuclear medicine.

METHODS

Initially, the nuclear medicine workflow was carefully analyzed and each step was correlated to the corresponding module. The standard SAP R/3 and IS-H/IS-H(*)med based software used for patient administration at the University of Regensburg Hospital was adapted to the needs of the Nuclear Medicine Department. The networking of the imaging systems was done by integration of a PACS. Finally, the PACS was connected to the HIS to allow the attachment of images to the medical report.

RESULTS, CONCLUSION

By connecting the HIS to the nuclear medicine PACS, the workflow was significantly improved. The data management sequence starting at the reception desk, continuing through the nuclear medical examination, to the physician's final written and image report is clearly structured. Although high demands exist on technical support and administration the integration of PACS and HIS into the nuclear medicine workflow leads to enhanced efficiency and reduction in hospital costs. Patient and data management are considerably improved in this way.

Gender differences in health-related quality of life on admission to a maintenance treatment program

We compared the gender differences in health-related quality of life (QOL) on admission to a maintenance program. 103 opioid users (65 men and 38 women) admitted to a maintenance treatment program during 2000-2002 were studied. During this period we assessed the QOL status using the German version ('Berlin Quality of Life Profile') of the Lancashire Quality of Life Profile. Physical symptoms were measured using the Opioid Withdrawal Scale. 312 urine screening tests were carried out to evaluate consumption. The female group showed significantly less additional consumption of other opiates (p = 0.043) compared with the male group. The male group showed significantly better QOL scores in self-esteem (p = 0.015), psychical health (p = 0.027), and law and security (p = 0.008). The outcome measures for withdrawal scores showed significantly less symptoms for males in twitching of muscles (p = 0.034), vomiting (p = 0.002), depressions (p = 0.004) and poor appetite (p = 0.008). In summary, both genders showed only a few significant differences on admission in terms of QOL and physical symptoms. The predominant effects of drug use appear to eclipse the gender-related role pattern. Further exploration of gender and QOL could have important theoretical and treatment implications.

[Central anticholinergic syndrome and apnea after general anaesthesia. A rare manifestation of the central anticholinergic syndrome]

The central anticholinergic syndrome (CAS) is a rarely observed condition after general anaesthesia. There are no definitive criteria to set the diagnosis of CAS. The syndrome may manifest in clinical neurological signs, such as hyperactive states or a depressed CNS state. The diagnosis usually depends on a process of exclusion of other conditions and is confirmed after rapid recovery following administration of physostigmine. We report on a 34-year-old patient who suddenly lost consciousness and developed respiratory arrest 1 h after general anesthesia and normal postoperative recovery. CAS was considered, although apnea has not been reported as a clinical symptom of this disease up to now and no peripheral signs of CAS were observed. After the administration of 1 mg physostigmine the symptoms resolved immediately and the patient started sufficient spontaneous breathing. However, corresponding to the plasma elimination half-life of the drug, further comatose episodes with apnea occurred. Therefore, the patient was admitted to the ICU and an infusion of physostigmin at a rate of up to 5 mg/h was started. Due to this therapy the patient's state became stable and 15 h after the first manifestation of CAS the infusion of physostigmin was discontinued. The following postoperative course was uneventful. In case of reduced vigilance with apnea after general anaesthesia, central anticholinergic syndrome should be considered. For diagnostic and therapeutic purposes the administration of physostigmine should be attempted.

Buprenorphine versus methadone maintenance treatment in an ambulant setting: a health-related quality of life assessment

BACKGROUND

To compare the effects on quality of life (QOL) of oral methadone with sublingual buprenorphine.

METHODS

We performed an open-label, non-randomized, two-site (methadone-buprenorphine) study. During 6 months we assessed the quality of life status of 53 opioid-dependent patients admitted to a methadone or buprenorphine maintenance programme using the German version (Berlin Quality of Life Profile) of the Lancashire Quality of Life Profile. Physical symptoms were measured using the Opioid Withdrawal Scale. Five hundred and thirty urine screening tests were carried out randomly to detect additional consumption.

RESULTS

Sixty-seven opioid-dependent subjects (38 on methadone and 29 on buprenorphine) were enrolled in the study, and 53 completed it (30 subjects treated with buprenorphine and 23 subjects with racemic methadone). The subjects were comparable on all baseline measures. At the first follow-up (week 8), the buprenorphine-maintained group showed significantly less additional consumption of opioids (P = 0.013) compared with the methadone group. Patients retained in the buprenorphine or methadone programme (week 24) showed no significant differences in all quality of life scores. At the end of the study period, the buprenorphine-maintained group showed significantly less additional consumption of opioids (P = 0.001) and cocaine (P = 0.018) compared with the methadone group. The outcome measures for withdrawal symptoms after 24 weeks of treatment with buprenorphine showed slight advantages in stomach cramps, fatigue or tiredness, feelings of coldness and heart pounding.

CONCLUSIONS

These results suggest that buprenorphine treatment is as effective as methadone regarding effects on quality of life and withdrawal symptoms. Buprenorphine has the potential to reduce the harm caused by drug abuse. Further research is needed to determine if buprenorphine is more effective than methadone in particular subgroups of patients.

Familial Parkinson's disease: a community-based study

Genetic factors seem to be important in the pathogenesis of Parkinson's disease (PD). It is however, still controversial whether these factors also are reflected in a familial aggregation of PD. The aim of this study was to investigate the frequency of PD patients with a positive PD family history compared with two control groups. The included 245 PD patients were examined by neurologists and information was obtained through a semi-structured interview. The patients and the control groups were examined for the frequency of PD and dementia in their families. The 245 patients with PD were included in this study. A positive PD-family history could be obtained in 53 (21.6%) patients. The frequency was three- and four-fold increased as compared with the control groups (P < 0.001). Age at onset of disease was not different among patients with and without PD in the family. The frequency of dementia did not differ in the family of individuals with and without PD (P > 0.1). As a conclusion our study of PD in a community based population supports previous reports of a three- to fourfold increased risk for PD in the families of patients with the disease. Our results indicate that the familial aggregation of the disease is independent of the age of the proband.

Early intervention strategies in substance abuse

Since the mid-eighties many efforts have been made to develop spezialized intervention strategies and interview techniques aiming at harm reduction and motivational enhancement in patients with substance related disorders. Firstly, the "Transtheoretical Model of Change" by Prochaska and DiClemente, which defines motivation as a dynamic process with several stage dependent intervention possibilities. Secondly, the "Motivational Interviewing" technique by Miller and Rollnick, who strongly suggest an empathic communication style deriving from humanistic psychology. It has been shown that especially persons in early stages of substance related disorders profited very well from such early interventions. Psychiatric institutions not involved in specialized addiction treatment have to face frequent comorbid substance abuse among their patients. Findings of the efficacy of early interventions in general psychiatry are encouraging. Despite there is strong evidence of efficacy of early and motivational intervention strategies in several medical fields, their implementation tends to be very difficult.

cDNA - protein fusions: covalent protein - gene conjugates for the in vitro selection of peptides and proteins

We report a method for the synthesis of covalent cDNA-protein fusions for protein display applications. A branched mRNA template was developed which carries a peptidyl acceptor and a reverse transcription primer at the 3'-end. Translation in vitro followed by reverse transcription produced a protein covalently bonded to its encoding cDNA. Both single- and double-stranded cDNA-protein fusions were prepared. cDNA-protein fusions are stable in alkali and resistant to ribonucleases. Their simple preparation and their resistance towards degradation should make cDNA-protein fusions a useful tool for the in vitro selection and evolution of high affinity ligands from large libraries of polypeptides.

Cephaibols, new peptaibol antibiotics with anthelmintic properties from Acremonium tubakii DSM 12774

Two groups of new peptaibol-type antibiotics termed cephaibols have been isolated from the fungus Acremonium tubakii, DSM 12774. These 16- or 17-unit straight-chain peptides, whose structures were characterized by amino acid analyses, 2-D NMR experiments, and by mass spectrometric sequencing, have a high content of the unusual amino acids aminoisobutyric acid and isovaline. The principal constituent of the novel peptaibol mixture is cephaibol A, which is formed in abundance in cultures of the wild strain. The striking biological property of cephaibol A is its pronounced anthelmintic action and activity against ectoparasites.

Platelet-reactive HLA antibodies associated with low posttransfusion platelet increments:a comparison between the monoclonal antibody-specific immobilization of platelet antigens assay and the lymphocytotoxicity test

BACKGROUND

Platelet-reactive HLA antibodies are a major reason for low posttransfusion platelet increments. The clinical importance and value of the test systems for their in vitro determination is still controversial.

STUDY DESIGN AND METHODS

A prospective analysis of HLA antibodies was performed in sera obtained once a week for at least 4 consecutive weeks from 55 patients (female/male, 28/27; age: median, 49 years; range, 18-69) undergoing intensive chemotherapy and in need of prophylactic platelet transfusions. All sera (n = 330) were analyzed by the monoclonal antibody-specific immobilization of platelet antigens (MAIPA) assay and by the standard lymphocytotoxicity test (LCT).

RESULTS

In the MAIPA, 24.5 percent of sera (81/330) obtained from 22 patients contained HLA antibodies. These were detected significantly more often by the MAIPA assay than by the LCT (24.5% vs. 8.2%). Fifty-five sera (20 patients) were positive in the MAIPA assay only. In 15 patients, HLA antibodies were transient. In 3 patients, HLA antibodies were detected earlier by the MAIPA assay than by the LCT. Significantly more sera obtained at the time of low posttransfusion platelet increments were positive in MAIPA alone, rather than in both MAIPA and the LCT (44% vs. 17%).

CONCLUSION

The MAIPA assay is more sensitive than the standard LCT in detecting platelet-reactive HLA antibodies. These MAIPA-positive/LCT-negative HLA antibodies affect the posttransfusion platelet increment.

The chemical structure of mumbaistatin, a novel glucose-6-phosphate translocase inhibitor produced by Streptomyces sp. DSM 11641

The characterization of the structure of mumbaistatin (1), an effective inhibitor of the glucose-6-phosphatase system (EC 3.1.3.9), is reported. Isolation of mumbaistatin from cultures of Streptomyces sp. DSM 11641 was achieved by anion-exchange and reversed-phase chromatography. The acid-labile inhibitor was methylated for the structure determination. Single-crystal X-ray structure analysis of a triply methylated dehydration product, C31H24O11, revealed the structure of an aromatic dispirodiketal (2), a compound containing a previously undescribed ring system. Extensive 2D-NMR experiments with mumbaistatin and with the methylation products showed that mumbaistatin itself possesses the hydroxydiketodicarboxylic acid structure 1, C28H20O12, which, in the presence of acid or upon activation through methyl ester formation, undergoes self-condensation with loss of water to the dispirodiketal form (2). Mumbaistatin is an anthraquinone derivative, whose open-chain diketo form acts as a specific and powerful inhibitor of glucose-6-phosphate translocase: IC50=5 nM. The activity towards the same enzyme of the cyclized dispirodiketal derivatives is roughly one thousand times lower.

Identification of the bile acid-binding site of the ileal lipid-binding protein by photoaffinity labeling, matrix-assisted laser desorption ionization-mass spectrometry, and NMR structure

The ileal lipid-binding protein (ILBP) is the only physiologically relevant bile acid-binding protein in the cytosol of ileocytes. To identify the bile acid-binding site(s) of ILBP, recombinant rabbit ILBP photolabeled with 3-azi- and 7-azi-derivatives of cholyltaurine was analyzed by a combination of enzymatic fragmentation, gel electrophoresis, and matrix-assisted laser desorption ionization (MALDI)-mass spectrometry. The attachment site of the 3-position of cholyltaurine was localized to the amino acid triplet His(100)-Thr(101)-Ser(102) using the photoreactive 3,3-azo-derivative of cholyltaurine. With the corresponding 7,7-azo-derivative, the attachment point of the 7-position could be localized to the C-terminal part (position 112-128) as well as to the N-terminal part suggesting more than one binding site for bile acids. By chemical modification and NMR structure of ILBP, arginine residue 122 was identified as the probable contact point for the negatively charged side chain of cholyltaurine. Consequently, bile acids bind to ILBP with the steroid nucleus deep inside the protein cavity and the negatively charged side chain near the entry portal. The combination of photoaffinity labeling, enzymatic fragmentation, MALDI-mass spectrometry, and NMR structure was successfully used to determine the topology of bile acid binding to ILBP.

Serial granulocytapheresisunder daily administration of rHuG-CSF: effects on peripheral blood counts, collection efficiency, and yield

BACKGROUND

An option for treatment of severe infections in neutropenic patients is the transfusion of granulocytes from donors stimulated with rHuG-CSF. The schedule of rHuG-CSF-stimulated granulocyte donations and the quality of the components remain controversial. This study was done with the intention of ensuring daily granulocyte support with therapeutic cell numbers, while keeping the patients' allogeneic exposure as low as possible.

STUDY DESIGN AND METHODS

Granulocyte collection with multiple consecutive leukapheresis procedures under daily rHuG-CSF administration and with hydroxyethyl starch as sedimenting agent were prospectively studied. Complete blood counts of the donors, collection yield, and efficiency were analyzed.

RESULTS

Products (n = 259) from 76 donors were examined. The median peripheral blood WBC and neutrophil counts were 28.1 g per L and 24.1 g per L, respectively, and they were significantly higher on Day 5 of collections than on Days 1 to 3. Platelet counts and Hb levels decreased steadily. Collection yields increased over time from 4.9 to 6.7 x 10(10) neutrophils. Side effects of cytokines and aphereses did not exceed World Health Organization grade II status.

CONCLUSION

Repetitive daily rHuG-CSF administration-even under daily leukapheresis procedures-results in a continuing increase in WBC and neutrophil levels and thus leads to increased collection yields. Side effects are tolerable, although Hb and platelet levels should be monitored closely.

Selection bias in clinical trials with antipsychotics

Although the selection of patients is known to be a powerful factor affecting the results of clinical trials, little is known about recruitment issues. Many patients with schizophrenia who are screened for a clinical trial of an investigational antipsychotic are ultimately not included in the study. Therefore, the question arises of whether the results obtained by studying a selected group of patients are really representative of the general population of patients with schizophrenia. The authors studied possible reasons for selective sampling in 200 patients who were consecutively admitted to inpatient units of Innsbruck's Department of Psychiatry with a diagnosis of schizophreniform or schizophrenic disorder over a time period of 33 months. Apart from demographic data and a psychopathologic rating (using the Brief Psychiatric Rating Scale), the authors recorded whether or not a patient was included in a phase III study and whether or not those were not included would have theoretically been eligible for such a study. Twenty-seven patients were finally recruited for a clinical trial. These patients were younger, on average, had a more recent onset of illness, and had experienced fewer psychotic episodes in the past. A history of noncompliance with previous treatment and the refusal of consent were the most common reasons for not including theoretically eligible patients in a clinical trial.

A cell-kinetic model of CD34+ cell mobilization and harvest: development of a predictive algorithm for CD34+ cell yield in PBPC collections

BACKGROUND

Mobilization and homing of PBPCs are still poorly understood. Thus, a sufficient algorithm for the prediction of PBPC yield in apheresis procedures does not yet exist.

STUDY DESIGN AND METHODS

The decline of CD34+ cells in the peripheral blood during apheresis and their simultaneous increase in the collection bag were determined in a prospective study of 18 consecutive apheresis procedures. A cell-kinetic, four-compartment model describing these changes was developed. Retrospective data from 136 apheresis procedures served to further improve this model. A predictive algorithm for the yield was developed that considered the sex, weight, and height of the patient, the number of CD34+ cells in peripheral blood before apheresis, the inlet flow, and the duration of the apheresis. The accuracy of this algorithm was evaluated by comparison of the predicted and the observed yields of CD34+ cells in 105 prospective autologous and 148 retrospective allogeneic apheresis procedures.

RESULTS

The correlation between predicted and observed yields was good for the autologous and allogeneic groups with a correlation coefficient (r) of 0.8979 and 0.8311 (p<0.0001), respectively. The regression is described by the equations log (measured value [m]) = 1.0118 + 0.8595 x log (predicted value [p]) for the autologous and log (m) = 2.226 + 0.7559 x log (p) for the allogeneic group. The respective equations for the zero-point regression are log (m) = 1.014 x log (p) and log (m) = 1.026 x log (p). The probability that the measured value was 90 percent or more of the predicted value was 83.8 percent for the autologous and 90.5 percent for the allogeneic apheresis procedures.

CONCLUSION

The predictive accuracy of the algorithm and the slope of the zero-point regression curve were higher for allogeneic than autologous PBPC collections. The predictive algorithm may be a useful tool in PBPC harvest, enabling the adaptation of the size of the apheresis to the needs of each patient.

Drug-phospholipid conjugates as potential prodrugs: synthesis, characterization, and degradation by pancreatic phospholipase A(2)

The aim of the present study was the synthesis of phospholipids containing a drug molecule instead of a fatty acid. Valproic acid and ibuprofen served as model compounds. The target molecules were synthesized either starting from sn-glycero-3-phosphocholine (1) or using (S)-2-O-benzyl-1-O-tritylglycerol (11) and (R)-2-O-benzyl-1-O-tert-butyldiphenylsilylglycerol (12), respectively, as key intermediates. With respect to the surface properties and the aggregation behavior, the drug-phospholipid conjugates resembled natural phosopholipids. Upon incubation with porcine pancreatic phospholipase A(2), only compounds with a fatty acid in the sn-2 position of the glycerol backbone were degraded. Derivatives with either ibuprofen in the sn-2 position or displaying the unnatural S-configuration were resistant to enzymatic in vitro hydrolysis.

Psoralen photo-crosslinked mRNA-puromycin conjugates: a novel template for the rapid and facile preparation of mRNA-protein fusions

We describe the synthesis of a novel type of mRNA template and its use in the preparation of mRNA-protein fusions. A light-induced psoralen crosslinking reaction was used to attach a puromycin-containing oligonucleotide to the 3'-end of an mRNA template. The photo-crosslinked template was found to undergo efficient mRNA-protein fusion formation in rabbit reticulocyte lysate. Fusion formation was subsequently tested with templates carrying puromycin linkers of different length and chemical composition. Short linkers with multiple triethyleneglycol phosphate building blocks allowed the most efficient fusion formation under a wide range of salt conditions. The present method simplifies the preparation of mRNA-protein fusions and thus significantly accelerates the in vitro protein evolution procedure which involves repetitive cycles of fusion production and selection.

Friulimicins: novel lipopeptide antibiotics with peptidoglycan synthesis inhibiting activity from Actinoplanes friuliensis sp. nov. II. Isolation and structural characterization

Four novel lipopeptide antibiotics, friulimicins A, B, C, and D, were isolated from cultures of Actinoplanes friuliensis HAG 010964 after fermentation in different nutrient media. The new compounds were separated by ion-exchange chromatography from the acidic lipopeptides of the amphomycin type also present in the culture fluid, compounds A-1437 A, B, E, and G. The principal constituent friulimicin B, C59H94N14O19, was structurally characterized by mass spectrometric investigations of its hydrolysis and partial degradation products and by sequencing of the cyclic acyl peptide. The NMR data of friulimycin B and the amphomycin constituent A-1437 B were completely assigned by a variety of 2-D experiments, and confirmed the structures determined by mass spectrometry. All 8 lipopeptides possess an identical peptide macrocycle as their central element, linked via a diaminobutyric acid N-terminal either to an acylated asparagine residue or, in the case of the amphomycin series, to an acylated aspartic acid residue. The structures of the amphomycins have now been revised to take account of the peptide framework described herein and the determined cis-configuration of the exocyclic double bond. As a consequence of their higher isoelectric points, the new compounds friulimicin A, B, C, and D have different properties than the amphomycins.

Regeneration of erythropoiesis after related- and unrelated-donor BMT or peripheral blood HPC transplantation: a major ABO mismatch means problems

BACKGROUND

Blood group incompatibility in allogeneic BMT is common but does not appear to affect the outcome in terms of incidence of graft rejection or delayed engraftment. However, major ABO incompatibility may be associated with prolonged erythroid aplasia.

STUDY DESIGN AND METHODS

In a retrospective analysis of 286 allogeneic transplant recipients, the prevalence of prolonged erythroid aplasia, including pure RBC aplasia, was determined.

RESULTS

Patients receiving major ABO-incompatible grafts showed a significant delay in reticulocyte engraftment (median, 32 days; range, 12-347) from that in patients receiving ABO-identical (20; 10-152) or minor ABO-incompatible (21; 12-47) grafts. Pure RBC aplasia occurred in 7 (3%) of 240 evaluable recipients and was observed only in the major ABO-incompatible group (7/43, 16%). Treatment of pure RBC aplasia consisted of either plasma exchange, which resulted in a response within 16 to 68 days, or immunoadsorption, in which the response occurred between Days 119 and 204 after initiation of treatment.

CONCLUSION

Major ABO incompatibility may lead to delayed reticulocyte engraftment, resulting in prolonged transfusion dependency and increased risks of transmission of infection and iron overload. Therefore, therapeutic strategies should be taken into consideration to allow erythroid reconstitution in these patients.

Autologous blood donation for surgery in inflammatory bowel disease--a report of six cases

BACKGROUND

Surgery in inflammatory bowel disease (IBD) is frequently associated with need for perioperative blood transfusions carrying the potential risk of infection. Autologous blood donation is often limited by IBD-associated anemia which is reversible by intravenous iron and erythropoietin. We therefore tested the feasibility of autologous blood donation in IBD.

METHODS

Six patients (five Crohn's disease, one ulcerative colitis) with indication for elective bowel resection were treated after informed consent was obtained. Two to four blood donations were scheduled during four weeks prior to surgery. Once a week 350-450 ml of blood were collected from patients with a hemoglobin level above 11.0 g/dl. After each donation 200 mg of iron saccharate diluted in 0.9% saline were given to all patients intravenously as substitute for donation-related iron loss. Patients with preexisting anemia or C-reactive protein above 2.0 mg/dl received concomitant erythropoietin.

RESULTS

The scheduled number of packed red cells was donated successfully by four patients. Due to low hemoglobin levels two patients donated one unit less than intended. Four patients received autologous blood transfusions intra- or postoperatively. No patient needed homologous blood. No serious adverse events were observed during blood donations, perioperatively, and during the one year follow-up period.

CONCLUSION

Preoperative autologous blood donation is save and feasible in IBD patients with elective bowel resection.

Five-year-survey of invasive aspergillosis in a paediatric cancer centre. Epidemiology, management and long-term survival

The epidemiology, management, and long-term survival of invasive aspergillosis was assessed in a prospective, 5-year observational study in 346 unselected paediatric cancer patients receiving dose-intensive chemotherapy for newly diagnosed or recurrent malignancies. Invasive aspergillosis occurred exclusively in the context of haematological malignancies, where it accounted for an incidence of 6.8% (n = 13 of 189). The lung was the primary site in 12 cases, and dissemination was present in three of those. Prior to diagnosis, the overwhelming majority of patients had been profoundly neutropenic for at least 14 days (n = 11 of 13) and were receiving systemic antifungal agents (n = 10 of 13). Clinical signs and symptoms were nonspecific but always included fever. All 11 patients who were diagnosed and treated during lifetime for a minimum of 10 days responded to either medical or combined medical and surgical treatment, and seven were cured (64%). Nevertheless, the overall long-term survival was merely 31% after a median follow-up of 5.68 years after diagnosis. Apart from refractory or recurrent cancer, the main obstacles to successful outcome were failure to diagnose IA during lifetime and bleeding complications in patients with established diagnosis. The frequency of invasive aspergillosis of greater than 15% in paediatric patients with acute myeloblastic leukaemia and recurrent leukaemias warrants the systematic investigation of preventive strategies in these highly vulnerable subgroups.