Core hypothermia in multiple sclerosis: case report with magnetic resonance imaging localization of a thalamic lesion.

Hypothermia is a rare condition in multiple sclerosis (MS). We report on a patient with a long-standing secondary progressive MS and six episodes of recurring hypothermia down to 29.9 degrees C with associated hypotension, bradycardia, coagulopathy and electrolyte dysequilibrium. Magnetic resonance imaging (MRI) demonstrated severe involvement of the corpus callosum with an associated lesion in the right posterior thalamus. These findings may link hypothermia in MS with callosal and associated thalamic pathology to Shapiro's syndrome, where agenesis of the corpus callosum and associated abnormalities are related to episodic spontaneous hypothermia. In MS, hypothermic episodes may be triggered by preceding infections, as shown in the present case.

Efficacy of flupirtine on cognitive function in patients with CJD: A double-blind study.

BACKGROUND: In cell culture experiments, flupirtine maleate (FLU), a triaminopyridine compound, was able to protect neuronal cells from apoptotic cell death induced by prion protein fragments and beta-amyloid peptides. As FLU is a clinically safe drug, the authors started a double-blind placebo-controlled study in patients with Creutzfeldt-Jakob disease (CJD). METHODS: Twenty-eight patients with CJD were randomized to an oral treatment with either FLU (n = 13) or matching placebo (PLA; n = 15). For inclusion and continuing the study, the patients had to achieve at least 50% in two of the subscales of the dementia tests employed. A battery of standardized questionnaires was employed to monitor the progression of the disease. The main outcome variable was the cognitive part of the Alzheimer's Disease Assessment Scale (ADAS-Cog); the difference between baseline and the best score under treatment was defined as the primary efficacy variable for hypothesis testing. RESULTS: CJD types were homogeneously distributed among the treatment groups. Patients treated with FLU showed significantly less deterioration in the dementia tests than patients treated with PLA. The mean change in ADAS-Cog (baseline to best) was +8.4 (+/-15.3) in the FLU group and +20.6 (+/-15.1) in the PLA group (p = 0.02, one-sided t-test). CONCLUSIONS: FLU has beneficial effects on cognitive function in patients with CJD. These positive results also may suggest a treatment potential of FLU in other neurodegenerative disorders. However, further studies are necessary.

[Veterinary medicine of the GDR in strained relations between technical instructions and political guidelines]. / Die Veterinärmedizin der DDR im Spannungsfeld von Fachauftrag und gesellschaftspolitischer Steuerung.

The development of Veterinary Medicine in the Soviet Occupation Zone in Germany and the former German Democratic Republic (GDR) is sketched in highlights. After the collectivization of agriculture (1960) a centralistically controlled national veterinary system was established. It was suited to the requirements of the industrially organized animal production. The successive classification of socialistic veterinary administration was associated with the following matters: the extension of veterinary subject matters, a vertical division of work with the aid of newly created technical veterinary professions, and a penetration of the profession with political guidelines. As the professional level of the veterinary system in the GDR was relatively high the reflection in retrospective needs to be evaluated in a differentiated way considering the textual and social conditions. In spite of centralism and indoctrination the veterinary system remained professionally autonomous with islands of political independence, which sustained the identity of this profession. The latter formed the base for self renewal of the East German veterinary system at the end of the socialistic area 1989/1990.

[Parasites of the common crane Grus grus (L.) in Europe]. / Parasiten des Grauen Kranichs Grus grus (L.) in Europa.

28 species of parasites (8 coccidia, 6 trematodes, 1 cestode, 6 nematodes, 1 tick, 6 mallophages) were found at the Common Crane. After presenting the interconnection of parasites with different carriers as vectors, intermediate and several final hosts in the biocoenosis of Common Cranes, the results of parasitological examination of 421 samples of cranes resulted in varying parasitization at different seasons and flyways. Further studies are needed to interprete these facts correctly. Changes of presented localities of diverted feedings and their parasitological and bacteriological control at resting places may avoid concentration of pathogens in soil, intermediate hosts and carriers.

Unaltered apoptotic behaviour of mononuclear cells from patients with sporadic Creutzfeldt-Jakob disease.

Creutzfeldt-Jakob disease (CJD) belongs to the group of transmissible spongiform encephalopathies. It is suspected that a pathologically altered form of the prion protein (PrPSc) is the decisive trigger of the disease. Data from animal experiments suggest an involvement of the lymphatic system in the intracorporal transport of PrPSc. However, it has not so far been possible to detect PrPSc on mononuclear cells (MNCs) either in the sporadic form of CJD or in the new variant of CJD (vCJD). In order to determine a possible alteration of MNCs in CJD, we investigated the natural and induced apoptotic behaviour of these cells. MNCs from 19 patients with sporadic CJD and from 20 patients with other neurological disorders were used. The cells were analysed by fluorescence cytometry with and without apoptosis induction by xanthine oxidase and hypoxanthine. The apoptosis rate was quantified using the stain 7-amino-actinomycin D (7-AAD). In the morphological investigation of the cells before apoptosis induction, there were no significant differences between the groups with regard to cell size and granularity of the MNCs. After apoptosis induction, the typical significant decrease in cell size and increase in granularity of the cells occurred in both groups. Significant differences between the patient populations were not found. For the first time, our investigation has demonstrated that a functional impairment of MNCs with regard to their apoptotic behaviour does not occur in sporadic CJD. It remains open to question whether this mechanism plays an important role in forms of transmissible encephalopathy other than sporadic CJD, especially after oral transmission.

Physiological consequences of oxygen-dependent chloride binding to hemoglobin.

The PO(2)-dependent binding of chloride to Hb decreases the Cl(-) concentration of the red blood cell (RBC) intracellular fluid in venous blood to approximately 1-3 mmol/l less than that in arterial blood. This change is physiologically important because 1) Cl(-) is a negative heterotropic allosteric effector of Hb that competes for binding sites with 2,3-bisphosphoglycerate and CO(2) and decreases oxyhemoglobin affinity in several species; 2) it may help reconcile several longstanding problems with measured values of the Donnan ratios for Cl(-), HCO, and H(+) across the RBC membrane that are used to calculate total CO(2) carriage, ion flux rates, and membrane potentials; 3) it is a factor in the change in the dissociation constant for the combined nonvolatile weak acids of Hb associated with the Haldane effect; and 4) it diminishes the decrease in strong ion difference in the RBC intracellular fluid that would otherwise occur from the chloride shift and prevent the known increase of HCO concentration in that compartment.

[Peracute mortality in common cranes (Grus grus)]. / Perakute Todesfälle bei Grauen Kranichen (Grus grus).

Out of a nonbreeding group of cranes, 10 birds died peracutely at the end of April 1998. The pathological investigation showed changes in the intestine, liver and kidneys caused probably by an intoxication; but corresponding analyses did not result in a specified poison. The proof of E. coli, Cl. perfringens and Campylobacter jejuni is to be interpreted as a subordinate result. 7 of 8 cranes had a low to high infestation with endoparasites (Porrocaeum spp., Eimeria pusilla, Echinostoma spp.). 5 of 8 birds showed leaness, possibly as a result of the migration exertion. Further on, the analysis results of a 9th crane found at another place are included in this paper.

Entry of tromethamine into the cerebrospinal fluid of humans after cerebrovascular events.

OBJECTIVE: The intravenous administration of tromethamine (INN, trometamol) lowers the intracranial pressure in patients with brain edema. One postulated mechanism of action is the increase of the pH of the cerebrospinal fluid. METHODS: To study tromethamine kinetics in serum and cerebrospinal fluid, nine patients with external ventriculostomies and normal serum creatinine values received 60 mmol intravenous tromethamine (Tris 36.34%, pH 11) over 30 minutes. Serum and cerebrospinal fluid were drawn repeatedly, and concentrations were determined by HPLC. RESULTS: Maximum serum concentrations (Cmax) ranged from 211 to 426 mg/L (median, 302 mg/L). The volume of distribution was 0.34 to 0.86 L/kg body weight (median, 0.53 L/kg), and the elimination half-life in serum (t1/2beta) 3.22 to 8.44 hours (median, 4.53 hours). Cerebrospinal fluid Cmax values ranging from 0.68 to 34.14 mg/L (median, 3.88 mg/L) were observed 1 to 12 hours after the end of the tromethamine infusion (median, 2 hours). AUC(CSF)/AUC(S) as a measure of overall cerebrospinal fluid penetration was 0.015 to 0.46 (median, 0.068). Cerebrospinal fluid Cmax and AUC(CSF)/AUC(S) depended on the function of the blood-cerebrospinal fluid barrier. Cerebrospinal fluid t1/2 (8.52 to 14.2 hours; median, 11.2 hours) was substantially longer than the t1/2beta in serum. In vitro, cerebrospinal fluid concentrations < or =30 mg/L did not influence cerebrospinal fluid pH. CONCLUSION: Tromethamine cerebrospinal fluid concentrations will be high enough to increase the pH of the cerebrospinal fluid only at large doses and in patients with a pronounced disruption of the blood-cerebrospinal fluid barrier.

Lesion development in Marburg's type of acute multiple sclerosis: from inflammation to demyelination.

We report a patient who suffered from acute inflammatory CNS demyelination and underwent two consecutive diagnostic stereotactic brain biopsies during the early disease course. The first lesion was drawn 33 days after the onset of disseminated neurological symptoms. Macrophages and T lymphocytes diffusely infiltrated small vessel walls and the white matter. mRNA for tumor necrosis factor alpha (TNFalpha) and inducible nitric oxide synthase (iNOS) was abundantly expressed. Myelin sheaths were entirely preserved. The second biopsy 76 days later showed confluent demyelinating lesions with a diffuse infiltration of macrophages that were positive for myelin debris, activation markers and TNFalpha and iNOS mRNA. IgG and C9neo deposits were found along myelin sheaths. The patient had received intravenous immunoglobulins (IVIG) prior to biopsy. Findings from this single patient affirm that demyelination follows the migration of inflammatory cells from the circulation into the white matter with subsequent inflammation and demyelination. Inflammation alone may be sufficient to cause significant clinical deficits without demyelination. Inflammatory mediators such as TNFalpha and NO are involved at very early stages in the pathogenetic process. IVIG treatment may lead to the deposition of immunoglobulins and to the activation of the complement cascade, but the clinical relevance of this particular finding remains uncertain.

Serum markers of treatment success in leprosy.

UNLABELLED: Intercellular adhesion molecule-1 (ICAM-1) and E-selectin and other variables were evaluated as possible markers of the success of multidrug therapy (MDT) in leprosy. Multibacillary (MB, N = 45) and paucibacillary (PB, N = 29) leprosy patients were examined during MDT, which typically lasted 12 months for MB and 6 months for PB patients. Serum values for total protein, albumin, immunoglobulin gamma (IgG), ICAM-1, and E-selectin (selectin) were recorded, as were lesion type, number, and distribution. Response at the end of therapy was assessed as good, fair, or poor. The bacterial index (BI) of lesions was measured at the beginning and end of therapy. The earlier reported findings of this investigation are herein re-examined. RESULTS: age and lowered serum albumin correlated with the poorer condition of the patients, as did elevated selectin. Albumin was inversely correlated with the BI (p = 0.008) in MB patients, and IgG was positively correlated (p = 0.009). ICAM and E-selectin alone were not useful markers of individual patient condition. A regression combining serum albumin under 41 g/l, age and E-selectin was able to identify 85% of the patients in poorer condition. CONCLUSION: serum albumin was a useful nonspecific marker of both patient condition and infection. Age is an important negative factor in patient response. Albumin and IgG correlate with the BI and with each other (p = 0.011) in MB patients, but not in PB patients.

Pharmacokinetic optimisation of the treatment of bacterial central nervous system infections.

Central nervous system (CNS) infections caused by bacteria with reduced sensitivity to antibacterials are an increasing worldwide challenge. In successfully treating these infections the following conditions should be considered: (i) Antibacterials do not distribute homogeneously in the central nervous compartments [cerebrospinal fluid (CSF), extracellular space of the nervous tissue, intracellular space of the neurons, glial cells and leucocytes]. Even within the CSF, after intravenous administration, a ventriculo-lumbar concentration gradient is often observed. (ii) Valid parameters of drug entry into the CSF are the CSF: serum concentration ratio in steady state and the CSF: serum ratio of the area under the concentration-time curves (AUCCSF/AUCS). Frequently, the elimination half-life (t1/2 beta) in CSF is longer than t1/2 beta in serum. (iii) For most antibacterials, lipophilicity, molecular weight and serum protein binding determine the drug entry into the CSF and brain tissue. With an intact blood-CSF and blood-brain barrier, the entry of hydrophilic antibacterials (beta-lactam antibacterials, glycopeptides) into the CNS compartments is poor and increases during meningeal inflammation. More lipophilic compounds [metronidazole, quinolones, rifampicin (rifampin) and chloramphenicol] are less dependent on the function of the blood-CSF and blood-brain barrier. (iv) Determination of the minimal inhibitory concentrations (MIC) of the causative organism is necessary for optimisation of treatment. (v) For rapid sterilisation of CSF, drug concentrations of at least 10 times MIC are required. The minimum CSF concentration: MIC ratio ensuring successful therapy is unknown. Strategies to achieve optimum antibacterial concentrations in the presence of minor disturbances of the blood-CSF and blood-brain barrier include, the increased use of low toxicity antibacterials (e.g., beta-lactam antibiotics), the use of moderately lipophilic compounds, and the combination of intravenous and intraventricular administration. Antibacterials which do not interfere with bacterial cell wall synthesis delay and/or decrease the liberation of proinflammatory bacterial products, delay or inhibit tumour necrosis factor release, and may reduce brain oedema in experimental meningitis. Conclusive evidence of the reduction of neuronal damage by this approach, however, is lacking.

A longitudinal prospective study of soluble adhesion molecules in acute stroke.

BACKGROUND AND PURPOSE: Activation of endothelial cells is a consequence of cerebral ischemia and leads to the expression of adhesion molecules such as intercellular adhesion molecule 1 (ICAM-1), vascular cell adhesion molecule 1 (VCAM-1), and E-selectin, which can be released into the blood. This study aimed to define the kinetics of soluble adhesion molecule serum levels after cerebral ischemia and their correlation with the extent of neurological deficits, clinical outcome, and infarct volume as measured on CT scans. Methods-Plasma levels of soluble (s) ICAM-1, sVCAM-1, and sE-selectin were repeatedly determined by ELISA in 38 patients during a period of 14 days after acute cerebral ischemia. RESULTS: Soluble adhesion molecule levels demonstrated considerable variability. Overall, concentrations revealed characteristic and significant changes after completed strokes but not after transient ischemic attacks. In patients with completed stroke (n=26) but not in patients with transient ischemic attacks (n=12), sICAM-1 peaked within 24 hours (P=0.04), sVCAM-1 reached a maximum after 5 days (P=0.02), and sE-selectin levels decreased after 5 days (P=0.002). There was no clear-cut correlation of soluble adhesion molecule levels with infarct volume or clinical disability. The initial increase of sE-selectin levels was higher in more disabled patients (P=0.02). sICAM-1 levels were higher in patients with signs of infection (n=9; P=0.03). CONCLUSIONS: As a result of large interindividual variability influenced by ischemia-independent factors, soluble adhesion molecules are not reliable candidates as surrogate markers in acute cerebral ischemia. The characteristic profile of individual soluble adhesion molecules after completed stroke supports prior hypotheses of their involvement in the pathogenesis of acute cerebral ischemia, but this needs to be clarified in detail.

Disposition and elimination of meropenem in cerebrospinal fluid of hydrocephalic patients with external ventriculostomy.

The broad antibacterial spectrum and the low incidence of seizures in meropenem-treated patients qualifies meropenem for therapy of bacterial meningitis. The present study evaluates concentrations in ventricular cerebrospinal fluid (CSF) in the absence of pronounced meningeal inflammation. Patients with occlusive hydrocephalus caused by cerebrovascular diseases, who had undergone external ventriculostomy (n = 10, age range 48 to 75 years), received 2 g of meropenem intravenously over 30 min. Serum and CSF were drawn repeatedly and analyzed by liquid chromatography-mass spectroscopy. Pharmacokinetics were determined by noncompartmental analysis. Maximum concentrations in serum were 84.7 +/- 23.7 microg/ml. A CSF maximum (CmaxCSF) of 0.63 +/- 0.50 microg/ml (mean +/- standard deviation) was observed 4.1 +/- 2.6 h after the end of the infusion. CmaxCSF and the area under the curve for CSF (AUCCSF) depended on the AUC for serum (AUCS), the CSF-to-serum albumin ratio, and the CSF leukocyte count. Elimination from CSF was considerably slower than from serum (half-life at beta phase [t1/2beta] of 7.36 +/- 2.89 h in CSF versus t1/2beta of 1.69 +/- 0.60 h in serum). The AUCCSF/AUCS ratio for meropenem, as a measure of overall CSF penetration, was 0.047 +/- 0.022. The AUCCSF/AUCS ratio for meropenem was similar to that for other beta-lactam antibiotics with a low binding to serum proteins. The concentration maxima of meropenem in ventricular CSF observed in this study are high enough to kill fully susceptible pathogens. They may not be sufficient to kill bacteria with a reduced sensitivity to carbapenems, although clinical success has been reported for patients with meningitis caused by penicillin-resistant pneumococci and Pseudomonas aeruginosa.

[Urinary calculi in small and other animals--a retrospective study of the years 1980-1989]. / Harnsteine bei Kleintieren und anderen Tierarten--eine retrospektive Studie aus den Jahren 1980-1989.

More than 500 uroliths from dogs, cats, minks, rabbits and 9 further animal species originating from various regions of former East Germany were analysed. The observations were made between 1980 and 1989 using X-ray diffraction and infrared spectroscopy. The urinary stones consisted of struvite, whewellite, weddellite, cystine, ammonium urate, brushite, whitlockite, hydroxyapatite or carbonate-apatite, calcium carbonate, silicon dioxide and organic matrix stones. In dogs, the most frequent types were struvite and apatite concrements, followed by calcium oxalate and cystine uroliths. Among the diseased animals poodles, dachshunds and terriers ranked first. In the analysed material from cats apatite and struvite predominated. With few exceptions, minks formed struvite uroliths only. The analysed calculi from rabbits consisted principally of calcium phosphate or calcium carbonate concrements. The present analysis has been compared with results of former studies, differences are discussed.

Beta-trace protein concentration in cerebrospinal fluid is decreased in patients with bacterial meningitis.

Although meninges represent a major site of biosynthesis, beta-trace protein (beta-trace) has not been studied in the cerebrospinal fluid (CSF) of meningitis patients. We measured beta-trace in lumbar CSF of normal controls (n = 27) and in patients with various neurological diseases (n = 92) by an immunonephelometric assay. The mean concentration of beta-trace in CSF of control patients was 16.6+/-3.6 mg/l. In bacterial meningitis (n = 41), CSF beta-trace was significantly decreased (8.7+/-3.9 mg/l; P< 0.001), whereas in spinal canal stenosis it was elevated (29.2+/-10.3 mg/l; P= 0.002). In viral meningoencephalitis (n = 12), beta-trace CSF concentrations were normal. Beta-trace concentrations remained below the normal range even after curing of bacterial meningitis, and normalisation of CSF leucocytes and blood-CSF barrier function. Beta-trace may be a useful tool for studying the pathophysiology of bacterial meningitis.

CO2 and heat have different effects on directed ventilation behavior of grasshoppers Melanoplus differentialis.

We tested the hypothesis that CO2 and heat have different effects on the ventilatory pattern of grasshoppers Melanoplus differentialis. Eight grasshoppers were sealed between rostral (inspiratory) and caudal (expiratory) spiracles in separated, airtight, chambers and pressure changes were measured. Normal breathing patterns decreased pressure in the rostral chamber and increased pressure in the caudal chamber (i.e. unidirectional pumping rostral to caudal). Insects exposed to ventilatory stimulation by CO2 or heat significantly increased pumping frequency from 26+/-2 (+/-S.E.M.) at 0% CO2 to 54+/-6 breaths/min at 8% CO2 (at 30 degrees C), and from 27+/-3 at 30 degrees C to 44+/-4 breaths/min at 45 degrees C. Unidirectional pumping failed to change with increased CO2 concentration and increased significantly with heat exposure. Thus, while CO2 only increased pumping frequency, heat increased pumping frequency and unidirectional pumping.

[Treatment of patients with thromboses of the basilar artery and locked-in syndrome. An ethical dilemma]. / Die Behandlung von Patienten mit Thrombosen der Arteria basilaris und Locked-in-Syndrom. Ein ethisches Dilemma.

Decisions regarding the extent of treatment of severely ill patients can be an ethical dilemma when life-prolonging intensive care contradicts the goal of avoiding unnecessary suffering on the part of the patient. Here we present the results of a written survey of physicians on neurological intensive care units in Germany regarding the treatment of patients with basilar artery thrombosis and locked-in syndrome. 52% of the 93 physicians who replied advocated not treating severe infections with antibiotics, 38% were in favor of stopping intensive care. In contrast, 55% recommended intubating the patient in the presence of swallowing disturbances and imminent aspiration. 58% were in favor of discussing these problems in detail with the patient, and 87% advocated discussing them with relatives. Nearly all physicians (97%) recommended using adequate amounts of opiates and benzodiazepines. In very rare cases, 99% would agree to the use of passive euthanasia and 19% to active euthanasia. These findings illustrate the current disagreement on some of the important treatment decisions among physicians on neurological intensive care units. An open exchange of views on these questions could facilitate the appropriate consideration of ethical matters in the treatment of these patients.