Carbamazepine and oxcarbazepine in adult patients with Dravet syndrome: Friend or foe?

PURPOSE: In newly diagnosed patients with Dravet syndrome sodium channel blockers are usually avoided. However, in many adult patients the diagnosis was made long after the initiation of therapy. The purpose of our study was to acquire information concerning the potential risks and benefits of (ox)carba(ma)zepine withdrawal in adult patients with genetically confirmed Dravet syndrome. METHOD: We identified 16 adults with Dravet syndrome, living in a tertiary care facility for people with epilepsy and an intellectual disability. We reviewed clinical history, genetic findings, the type and duration of sodium channels blockers that were used, seizure types and frequency, and the effect of a change in these medications. RESULTS: The study population consisted of 9 men and 7 women. Median age was 35 years (range 20-61 years). An attempt to withdraw carbamazepine (CBZ) was made in 9 patients. In 3 of these patients an increase in tonic-clonic seizures was observed. An attempt to withdraw oxcarbazepine (OXC) was made in 3 patients, leading to a complete stop in 2 patients. 3 of the 4 deaths in the withdrawal-group were related to epilepsy. CONCLUSION: In adult patients with Dravet syndrome withdrawal of CBZ or OXC is not without risks. We suggest that (ox)carba(ma)zepine withdrawal should be considered in these patients but only if there is a good reason to do so and only if they are closely monitored.

Estudio de la variación de la permeabilidad de la dentina radicular usando isótopos 99mTc, después de la aplicación de láser de alta intensidad / Study of the dentin root permeability variation using99m Tc isotopes, after the application of high intensity laser

Objetivo: Este estudio tuvo como objetivo evaluar las variaciones de la permeabilidad dentinaria radicular de dientes humanos después del preparo químico-quirúrgico e irradiación con láser de Er: YAG, Nd: YAG, a través de la utilización del radioisótopo tecnecio-99m (99mTc) libre. Materiales y métodos: Canales de treinta raíces palatinas de primeros premolares superiores humanos fueron preparados y divididos, aleatoriamente, en 3 grupos experimentales: G1 (control), G2 (irradiación con láser de Er: YAG) y G3 (irradiación con láser de Nd: YAG). Las muestras recibieron en el interior del canal radicular, 99mTclibre en cantidad suficiente para el llenado y colocados en tubos de ensayo contiendo 1 ml de solución salina. Después de 1 hora, la cuenta del isótopo radioactivo (99mTc) fue realizada. Resultados: Después del análisis estadístico (ANOVA), fue verificado que los mejores resultados obtenidos en cuanto a la disminución de la permeabilidad se encontraron en el Grupo 3, seguido del Grupo 2 y del Grupo 1.Conclusión: Concluimos que irradiación con láser de Nd: YAG provocó una disminución significativa de la permeabilidad dentinaria del canal radicular. El láser de Er: YAG y el control en relación a la permeabilidad dela dentina de las paredes del canal radicular no presentaron diferencias estadísticamente significativas a nivel de 5% (AU)

Objective: The objective of this study was to evaluate changes in root dentin permeability of human teeth after chemical-surgical preparation, and laser irradiation with Er: YAG, Nd: YAG, through the use of the radioisotopetechnetium-99m (99mTc) free. Materials and methods: thirty Channels palatal roots of human maxillary first premolars were prepared and divided randomly into three experimental groups: G1 (control), G2 (laser irradiation with Er: YAG) and G3 (Ndlaser irradiation : YAG). in the samples were deposited 99mTc free inside the root canal, enough to fill and placed in test tubes containing 1 ml of saline. After 1 hour, the account of the radioactive isotope (99mTc) was performed. Results: After statistical analysis (ANOVA) found that the best results in terms of decreased permeability were found in Group 3, followed by Group 2 and Group 1.Conclusion: We conclude that irradiation with Nd: YAG caused a significant decrease in the permeability of root canal dentin. Laser Er: YAG and control in relation to the dentin permeability of root canal walls showed no statistically significant differences at 5% (AU)

High-density surface EMG study on the time course of central nervous and peripheral neuromuscular changes during 8 weeks of bed rest with or without resistive vibration exercise.

The aim of the present study was to assess the time course and the origin of adaptations in neuromuscular function as a consequence of prolonged bed rest with or without countermeasure. Twenty healthy males volunteered to participate in the present study and were randomly assigned to either an inactive control group (Ctrl) or to a resistive vibration exercise (RVE) group. Prior to, and seven times during bed rest, we recorded high-density surface electromyogram (sEMG) signals from the vastus lateralis muscle during isometric knee extension exercise at a range of contraction intensities (5-100% of maximal voluntary isometric torque). The high-density sEMG signals were analyzed for amplitude (root mean square, RMS), frequency content (median frequency, F(med)) and muscle fiber conduction velocity (MFCV) in an attempt to describe bed rest-induced changes in neural activation properties at the levels of the motor control and muscle fibers. Without countermeasures, bed rest resulted in a significant progressive decline in maximal isometric knee extension strength, whereas RMS remained unaltered throughout the bed rest period. In line with observed muscle atrophy, both F(med) and MFCV declined during bed rest. RVE training during bed rest resulted in maintained maximal isometric knee extension strength, and a strong increase ( approximately 30%) in maximal EMG amplitude, from 10 days of bed rest on. Exclusion of other factors led to the conclusion that the RVE training increased motor unit firing rates as a consequence of an increased excitability of motor neurons. An increased firing rate might have been essential under training sessions, but it did not affect isometric voluntary torque capacity.

Comparison of phenotypic methods for penicillinase detection in Staphylococcus aureus.

Penicillinase testing is required for Staphylococcus aureus isolates with a penicillin MIC of

Aspirin non-responder status in patients with recurrent cerebral ischemic attacks.

BACKGROUND: Antiplatelet agents such as acetylsalicylic acid (aspirin) reduce the relative risk for cerebrovascular events in patients with cardiovascular or cerebrovascular disorders by approximately 23 %. Recent observations raise the possibility that aspirin resistance may contribute to the failure of aspirin treatment in a significant proportion of patients (aspirin non-responders). To evaluate the clinical relevance of aspirin non-responder status, we analysed platelet functions in symptomatic and asymptomatic patients treated with aspirin for secondary prevention of cardiovascular and cerebrovascular events. METHODS: A total of 53 patients on 100 mg aspirin daily for secondary prevention (mean treatment duration > 60 months) were included. Patients were categorized as asymptomatic if they were free of cerebrovascular incidents for at least 24 months (n = 18). Symptomatic patients had suffered ischemic strokes or transient ischemic attacks within the previous 3 days (n = 35). Platelet function was assessed using the PFA-100 system that allows for quantitative assessment of platelet function, reporting platelet aggregatability as the time required to close a small aperture in a biologically active membrane. RESULTS: Collagen/epinephrine closure times were significantly shorter in symptomatic patients than in asymptomatic patients (p < 0.01). Individual closing times were normal in 12 of 35 symptomatic patients (34 % non-responders) whereas all asymptomatic patients had prolonged closure times. CONCLUSIONS: Aspirin non-responder status may contribute to failure of aspirin therapy in the secondary prevention of cerebrovascular incidents in as much as 30-40 % of patients. Quantitative assessment of platelet functions may provide a means to predict aspirin treatment failure in individual patients and to re-direct therapeutic strategies.

Influence of motoneuron firing synchronization on SEMG characteristics in dependence of electrode position.

The frequency content of the surface electromyography (SEMG) signal, expressed as median frequency (MF), is often assumed to reflect the decline of muscle fiber conduction velocity in fatigue. MF also decreases when motor unit firings synchronize, and we hypothesized that this effect can explain the electrode-dependent pattern in our previous recordings from the trapezius muscle. An existing motoneuron (MN) model describes the afterhyperpolarization following a spike as an exponential function on which membrane noise is superimposed. Splitting the noise into a common and an individual component extended the model to a MN pool with a tunable level of firing synchrony. An analytical volume conduction model was used to generate motor unit action potentials to simulate SEMG. A realistic level of synchrony decreased the MF of the simulated bipolar SEMG by approximately 30% midway between endplate position and tendon but not above the endplate. This is in accordance with experimental data from the biceps brachii muscle. It was concluded that the pattern of decrease of MF during sustained contractions indeed reflects MN synchronization.

Impaired motor cortical inhibition in Parkinson's disease: motor unit responses to transcranial magnetic stimulation.

Transcranial magnetic stimulation (TMS)-induced corticospinal volleys can be investigated in detail by analysing the firing pattern modulation of active motor units (MUs) at close to threshold stimulation strengths. In amyotropic lateral sclerosis (ALS) these volleys are dispersed and prolonged, attributed to altered motor cortical excitability. Impaired intracortical inhibition, as found in ALS, is not unique to this disease, but is also a well-established finding in Parkinson's disease (PD). The present study explored whether reduced inhibition in the motor cortex in PD is accompanied by similar changes in motor unit firing modulation by TMS as are found in ALS. TMS was applied to the contralateral motor cortex during a low-force voluntary elbow flexion while 126-channel surface electromyography (SEMG) was recorded from the brachial biceps muscle. A recently developed method for SEMG decomposition was used to extract the firing pattern of up to five simultaneously active MUs. Sixteen MUs in 7 PD patients and 17 MUs in 5 healthy control subjects were analysed and peristimulus time histograms (PSTHs) and interspike interval change functions (IICFs) were calculated. The IICF provides an estimate of the modulation of the postsynaptic membrane potential at the spinal motoneuron, evoked by the stimulus. In PD the duration of the PSTH peak was significantly increased and the synchrony was decreased. The excitatory phase at 20-50 ms of the IICF was broader in PD, reflecting a longer duration of the TMS-evoked excitatory postsynaptic potential. It is proposed that these results are due to prolonged corticospinal volleys resulting from impaired intracortical inhibition.

Expression of galanin in human placenta.

The neuropeptide galanin was originally implicated in the regulation of feeding behaviour. Today, galanin is implicated in several physiological functions including reproduction and feeding. Many hypothalamic neurohormones of the hypothalamo--pituitary axis (HPA) are also expressed in the placenta where the specialized topological compartments of the HPA are missing and where paracrine and autocrine regulatory mechanisms consequently prevail. Since galanin influences gonadotrophin-releasing hormone secretion in the HPA, we argued that a similar regulatory role for galanin might exist in human placenta. Since the presence of galanin in human placenta had not been previously reported, we analysed galanin expression in the human placenta by immunohistochemistry and quantitative polymerase chain reaction (PCR) throughout gestation. We found that the peptide hormone localizes to the syncytio- and cytotrophoblast layers; its RNA could be detected. By quantitative PCR we observed that throughout gestation, there is a loss of galanin mRNA which parallels the fall in signal intensity from immunohistochemical detection of the galanin oligopeptide. Furthermore, we detected secretion of galanin from isolated trophoblastic cells. We conclude that galanin may be an important and novel regulator of placental function.

Endogenous regulation of the GnRH receptor by GnRH in the human placenta.

Gonadotrophin releasing hormone (GnRH) plays an important regulatory role in the function and growth of human placenta, but its placental expression sites and co-localization with GnRH receptor (GnRH-R) are not well known. GnRH and GnRH-R expression has been found in both placenta and cultured trophoblasts; however, cultured trophoblastic cells very quickly lose GnRH-R message and subsequently receptor protein. Speculating that endogenously released GnRH induced this down-regulation, we determined GnRH-R in cultures of trophoblastic cells in the presence of a neutralizing anti-GnRH antibody. Cells incubated with this antibody showed a strong signal for the GnRH-R, while those cultured without did not (as analysed by immunofluorescence, reverse transcription-polymerase chain reaction, protein 'dot blot' and Western blotting). Furthermore, addition of the GnRH agonist buserelin led to a reduction of the receptor protein. We have therefore shown that GnRH released from trophoblastic cells down-regulates GnRH-R in these trophoblastic cells. Having previously shown that trophoblast layers were synchronously positive for GnRH and GnRH-R, these new findings support the hypothesis of an ultrashort feedback regulation of trophoblasts by GnRH involving autocrine regulation of GnRH-R.

Magnetic stimulation-induced modulations of motor unit firings extracted from multi-channel surface EMG.

The noninvasive assessment of motor unit (MU) firing patterns on the basis of topographical information from 128-channel high-density surface electromyography (SEMG) is reported. First, multi-channel MU action potential (MUAP) templates are obtained by clustering detected firing events according to the surface topography of the MUAP. Second, a template-matching algorithm is used to find all firings of a MU, including the superimpositions of MUAPs. From a single recording, the firing pattern of up to five MUs could be derived. The modulation of MU firing by transcranial magnetic stimulation was analyzed in peri-stimulus time histograms. The results are similar to previous results of transcranial magnetic stimulation (TMS) obtained by needle electromyographic (EMG) recordings. The method can be used to investigate MU firing patterns in patients with central motor disorders. An additional advantage of the technique, apart from its noninvasiveness, is the structural and functional information that it provides on the MUs, which is not obtained by needle EMG.

Analysis of ultrashort feedback regulation in human placenta: synthesis and secretion of GnRH by human trophoblastic cells.

BACKGROUND: Gonadotropin-releasing hormone (GnRH) presumably controls placental growth and functions by autocrine/paracrine mechanisms, and is therefore an important part of the neuroendocrine network in human placenta. AIM: Our earlier work had indicated that GnRH was expressed in human placenta; in extension to these findings, we wanted to analyse synthesis and release of GnRH by trophoblastic cells. GnRH-associated peptide, co-linearly synthesised with GnRH, was used as indicator of actual peptide synthesis. METHOD: First, we immunised rabbits with lipopeptides containing partial sequences of GnRH-associated peptide (GAP) and developed antibodies for immunohistochemical staining. Second, we set up a competitive enzyme immunoassay to measure GnRH: Non-biotinylated GnRH, GnRH analogues or trophoblastic cell culture supernatants were used to inhibit binding of biotinylated des-pGlu1-GnRH to a monoclonal anti-GnRH antibody. RESULTS: a) Placental sections stained positive for GAP in the layers of trophoblastic cells. b) GnRH could be detect by a competitive EIA in supernatants of placental cultures in concentrations between 200 and 5 nM. CONCLUSIONS: GnRH is synthesised and released by trophoblastic cells.

Surface EMG mapping of the human trapezius muscle: the topography of monopolar and bipolar surface EMG amplitude and spectrum parameters at varied forces and in fatigue.

OBJECTIVES: To investigate the factors affecting the topography of trapezius muscle EMG, multichannel recordings were made at different forces of isometric shoulder elevation and during fatiguing exercise. METHODS: Twenty-eight channels of monopolar EMG were recorded from an array of 4 x 7 electrodes placed on the upper trapezius muscle. From the monopolar EMG and the bipolar derivations the root mean square (RMS(monopolar), RMS(bipolar)) and power spectrum median frequency (MF(monopolar), MF(bipolar)) were calculated. RESULTS: The maximum RMS(monopolar) was located above the middle part of the trapezius muscle, where a minimum was found for RMS(bipolar). The cranial-caudal RMS distribution shifted upwards when the force was increased from 50 to 100% MVC and during fatigue. MF(bipolar) showed a peak above the endplate region, where the MF(monopolar) was low. During fatigue the normalized MF slope was independent of the cranial-caudal electrode position, but MF(monopolar) decreased most strongly at positions above the endplate region, where MF(bipolar) decreased less. CONCLUSIONS: While the changes in MF reflected metabolic properties and volume conduction phenomena in the muscle, changes in RMS reflected a compensation for the fatigue processes within the muscle. The RMS changes in fatigue can be explained by the direction of the fibres involved in shoulder elevation.

Surface EMG of shoulder and back muscles and posture analysis in secretaries typing at visual display units.

OBJECTIVE: A study was carried out to investigate temporal changes of activation of shoulder and back muscles in workers at visual display units by means of surface EMG. Moreover, postural parameters were recorded to distinguish fatigue-related from posture-related changes of the myoelectrical activity. METHODS: Nine healthy female office workers typed texts spoken from tape during three 1-h-long sessions. After the first and again after the second hour there was a break of 15 min. Sixteen-channel surface EMG was bipolarly recorded from the erector spinae, trapezius, deltoid and sternocleidomastoid muscles. Root mean square (RMS) and power spectrum median frequency of the EMG were calculated. Sitting posture was assessed using an eight-channel movement analysis system with ultrasound markers. The position of the seventh cervical spinous process and the left and the right acromion were analysed synchronously with the EMG characteristics using regression analysis. RESULTS: The normalised RMS of the left and right trapezius muscle increased, while the median frequency did not change. The increase of the normalised RMS was significantly lower when the linear influence of posture was excluded. On average, the distance between C7 and the left and right acromion decreased within each working an hour. C7 became lower on average by 5.5 mm within an hour, whereas the acromions became lower by only 1.7 mm (left) and 3.3 mm (right). CONCLUSION: The increase in trapezius muscle activity was partly related to a lifting of the shoulders to compensate a slight slumping of the back. Another part of the EMG activity increase has to be attributed to fatigue, to attention-related activity or to the combination of both. Therefore, training of the back muscles and a varied organisation of work might have a preventive effect with respect to musculoskeletal complaints in VDU workers.

Expression and functional analysis of endothelial nitric oxide synthase (eNOS) in human placenta.

We have investigated the expression and localization of endothelium-derived nitric oxide synthase (eNOS) and the effect of eNOS on placental human chorionic gonadotrophin (HCG) release. eNOS mRNA was found to be expressed in all tissues, with its expression significantly (P<0.05) increased across gestation. Compared to normal term gestation, placentae from term pregnancies with fetal retardation, or maternal diabetes, but not with maternal hypertension, displayed significantly more (P<0.05) eNOS mRNA. By immunocytochemistry, we found staining for eNOS in both the cyto- and syncytiotrophoblasts of first trimester and a loss of cytotrophoblast eNOS staining in term placentae, while syncytiotrophoblasts at term were strongly eNOS positive. Additional staining was found in endothelium surrounding the vascular tree. HCG was found to colocalize with eNOS in trophoblasts, but not in endothelia. When placental explants were perifused, exposure to the NOS substrate, the NO donor, I-arginine and trinitroglycerol evoked a prompt, albeit transient, increase of HCG release. The NOS inhibitor delayed, but did not block arginine-induced HCG release. Thus, eNOS is expressed in the human placenta at increasing levels during gestation with further increases during some pathological conditions. A role for NO in the acute endocrine modulation of the placenta is suggested by the colocalization of eNOS with HCG in human trophoblasts and the prompt secretion of HCG in response to agents which increase NO concentrations.

Magnetic stimulation of the dorsal premotor cortex modulates the Simon effect.

In choice reaction tasks, subjects typically respond faster when the relative spatial positions of stimulus and response match than when they do not match. A prominent explanation attributes this 'Simon effect' to automatic response activation elicited by spatial correspondence, which facilitates or competes with the controlled selection of the response demanded by the stimulus. To test this account, we applied repetitive transcranial magnetic stimulation (rTMS) on the dorsal premotor cortex (PMd), as this area may subserve the inhibitory control of automatic response activation. Temporary interference with PMd was predicted to release the automatic activation from inhibition and thereby enhance the Simon effect. The results confirmed a modulation for trials following an incompatible trial, providing new evidence for competition between automatic and controlled response activation as a mechanism underlying the Simon effect.

Detection of gonadotrophin releasing hormone and its receptor mRNA in human placental trophoblasts using in-situ reverse transcription-polymerase chain reaction.

Neuropeptides such as gonadotrophin releasing hormone (GnRH) are presumed to play an important role in the regulation of the function and growth of human placenta. Knowledge about the placental site of GnRH expression and the eventual co-localization of its peptide with the GnRH receptor (GnRH-R) is crucial for a better understanding of possible autocrine/paracrine mechanisms. We therefore investigated these questions by use of in-situ reverse transcription-polymerase chain reaction (RT-PCR) alone or in combination with immunocytochemistry in human first and third trimester placentae. Paraffin-embedded placental sections (7 microm thick), or single trophoblasts in monolayer cultures for up to 3 days, were treated with proteinase K. Following RT with GnRH or GnRH-R specific oligoprimers, PCR was performed employing primers with exon-exon overlaps to exclude non-specific DNA amplification. Detection of the amplicons was accomplished by nested PCR which was performed with digoxigenin-labelled dUTP and nitroblue tetrazolium/5-bromo-4-chloro-3-indoyl-phosphate (NBT/BCIP) for substrate visualization. The GnRH peptide was detected using a sandwich-antibody assay. GnRH and GnRH-R gene expression was found in all first and third trimester placentae, with abundant signals for the GnRH and GnRH-R message both in the cyto- and syncytiotrophoblasts. Single trophoblasts of different gestational ages in culture also displayed GnRH expression in individual cytotrophoblasts and in syncytiotrophoblast-like fusionates. Additional immunostaining revealed GnRH peptide to be co-localized with GnRH-R message in trophoblast layers. Since messages for GnRH and GnRH-R were found in virtually all trophoblasts, we infer that GnRH and GnRH-R are co-expressed in identical cells. These data strongly suggest that the trophoblasts are the source of GnRH, and that there is autocrine/ paracrine regulation by GnRH in human placenta.

Bacterial stimulators of macrophages.

Our current understanding of the interaction between bacteria and macrophages, cells of the immune system that play a major role in the defense against infection, is summarized. Cell-surface structures of Gram-negative and Gram-positive bacteria that account for these interactions are described in detail. Besides surface structures, soluble bacterial molecules, toxins that are derived from pathogenic bacteria, are also shown to modulate macrophage functions. In order to affect macrophage functions, bacterial surface structures have to be recognized by the macrophage and toxins have to be taken up. Subsequently, signal transduction mechanisms are initiated that enable the macrophage to respond to the invading bacteria. To destroy bacteria, macrophages employ many strategies, among which antigen processing and presentation to T cells, phagocytosis, chemotaxis, and different bactericidal mechanisms are considered to be the main weapons.

Lipopeptide-polyoxyethylene conjugates as mitogens and adjuvants.

Two lipopeptide analogues of the Escherichia coli lipoprotein rendered water-soluble by polyoxyethylene were tested for mitogenicity in vitro in murine and human B lymphocytes and for adjuvant activity in vivo in mice. These highly amphiphilic lipopeptides retained the biological activity other lipopeptides usually exerted which supports the hypothesis of specific interactions of lipopeptides with membranes of reactive cells. The activation of human B lymphocytes by these lipopeptides was much less pronounced compared to that of murine cells. However, given in combination with anti-CD40 antibodies plus interleukin-4, human B lymphocytes could synergistically be stimulated to proliferate. As an adjuvant, the polyoxyethylene linked lipopeptides were almost as potent as Freund's adjuvants and other basic lipopeptides. Being water-soluble, these novel analogues are easy to apply and they are suitable for field studies as adjuvants when sonication can not usually be provided.