[Diagnostics and conservative treatment of cervical and lumbar spinal stenosis]. / Diagnostik und konservative Therapie zervikaler und lumbaler Spinalkanalstenosen.

BACKGROUND: Degenerative stenotic spondylosis is not an uncommon cause of cervical spondylotic myelopathy (CSM) and cauda equina lesions in the aged population. Limited standardization exists with respect to diagnostic and therapeutic procedures. OBJECTIVE: Literature review with respect to diagnostic and therapeutic procedures for neurologically relevant cervical and lumbar spinals stenosis. MATERIAL AND METHODS: Comprehensive literature review. RESULTS AND CONCLUSION: Clinical neurological examination and diagnostic imaging are fundamental for the diagnosis of neurologically relevant cervical and lumbar spinal stenosis. Additional laboratory blood and cerebrospinal fluid testing might be required for a differential diagnosis. Neurophysiological testing is reserved for specific clinical problems. The clinical evidence for the efficacy of conservative therapeutic strategies is limited.

[Risk factors for the development of rotator cuff tears in individuals with paraplegia : A cross-sectional study]. / Risikofaktoren für Rotatorenmanschettenrupturen bei Paraplegikern : Eine Querschnittstudie.

QUESTION: Shoulder pain and rotator cuff tears are highly prevalent among wheelchair dependent individuals with paraplegia. The purpose of this study was to identify potential risk factors associated with the development of rotator cuff tears in this population. METHODS: A total of 217 wheelchair dependent individuals with paraplegia were included in this cross-sectional study (level of evidence III). The mean age of this population was 47.9 years and the mean duration of wheelchair dependence was 24.1 years. Each individual was asked to complete a questionnaire designed to identify risk factors for rotator cuff tears and underwent a standardized clinical examination with the documentation of the Constant-Murley shoulder outcome score and magnetic resonance imaging (MRI) of both shoulder joints. RESULTS: MRI analysis revealed at least one rotator cuff tear in 93 patients (43%). Multiple logistic regression analysis identified the following factors to be associated with the presence of rotator cuff tear: patient age, duration of spinal cord injury/wheelchair dependence, gender, and wheelchair athletic activity. Neither BMI nor the level of spinal cord injury was found to pose a risk factor in the population studied. With respect to patient age, the risk of developing a rotator cuff tear increased by 11% per annum. In terms of duration of spinal cord injury, the analysis revealed a 6% increased risk per year of wheelchair dependence (OR = 1.06). Females had a 2.6-fold higher risk of developing rotator cuff tears than males and wheelchair sport activity increased the risk 2.3-fold. DISCUSSION: There is a high prevalence of rotator cuff tears in wheel-chair dependent persons with paraplegia. Risk factors such as age, gender, duration of paraplegia, and wheel chair sport activity seem to play an important role in the development of rotator cuff tears.

Prevalence of upper extremity pain in a population of people with paraplegia.

STUDY DESIGN: Cross-sectional study. OBJECTIVES: To determine the prevalence, patterns, and predictors of musculoskeletal pain in the upper extremity joints among wheelchair-dependent individuals with post-traumatic paraplegia. Secondarily, to document most common reported causes of upper extremity pain. SETTING: Centre for Orthopaedics, Trauma Surgery and Spinal Cord Injury, Germany. METHODS: The study was done by means of a structured questionnaire, which was mailed to the individuals who had been treated between 1990 and 2007 for newly sustained or pre-existing, accident-related paraplegia (n = 670). The questionnaire was designed mainly to obtain the information regarding shoulder, elbow, and wrist pain. Additional data included participant demographics, mechanism, level and completeness of injury as well as wheelchair dependence and time since injury. The Frankel classification system was used to define the completeness of injury. RESULTS: Four hundred and fifty-one (67%) questionnaires were included. Pain was reported by approximately 81% of the participants. Of this sample, 61% had shoulder pain, 33% had elbow pain, and 43% had wrist pain, 19% had shoulder, elbow, and wrist pain, 27% had shoulder and elbow pain, 34% had shoulder and wrist pain, 21% had elbow and wrist pain. The main diagnoses were rotator cuff tears for individuals with shoulder pain, epicondylitis for those with elbow pain, and carpal tunnel syndrome for those with wrist pain. The development of shoulder/elbow and wrist pain correlated with age and time since injury. CONCLUSIONS: Age and the length of time since injury correlated with a higher rate of shoulder, elbow, and wrist pain. The completeness of injury, neurological level, and gender were correlated with shoulder, elbow, and wrist pain, respectively.

Bacterial load of conditioned pressure ulcers is not a predictor for early flap failure in spinal cord injury.

OBJECTIVES: Pressure ulcers impose a major lifetime medical problem to patients with high-grade spinal cord injury (SCI). For patients with stages 3-4 pressure ulcers, plastic surgery is often the only remaining treatment option. Despite considerable flap failure rates of around 30%, only sparse knowledge exists on predictors for flap failure. Hence, identification of predictors for flap failures is needed. METHODS: We prospectively enrolled 38 SCI patients with stages 3-4 pressure ulcers scheduled for plastic surgery. Preoperative wound swabs, intraoperative tissue samples and postoperative drainage liquids were microbiologically analyzed. In multivariable logistic regression analyses, bacterial loads of deep tissue cultures of intraoperative samples as well as other clinical variables were analyzed with respect to the prediction of flap failures. RESULTS: The flap failure rate was 27.5%. Bacterial loads of deep tissue cultures were not predictive for flap failure, neither was the colonization with a specific bacterial strain. We observed a considerable fluctuation of microbiological environment from initial swab cultures, intraoperative samples and postoperative drainage fluids. Antibioprophylaxis was sufficient in only 75% of deep tissue cultures and 69% of drainage fluids. Insufficient antibioprophylaxis was associated with a higher flap failure rates (odds ratio 6.3, confidence interval 1.2-41.0). CONCLUSION: After inpatient wound conditioning, bacterial load analysis of intraoperative wound tissue cultures is ineffective in order to predict flap failure rates in SCI patients with stages 3-4 pressure ulcers after flap surgery. Instead, insufficient antibioprophylaxis might be a factor contributing to flap failure.

Spinal cord injury: association with axonal peripheral neuropathy in severely paralysed limbs.

BACKGROUND AND PURPOSE: Pressure sores are a major health problem in spinal cord injury (SCI). In this population pressure damage to peripheral nerves was not thoroughly investigated so far. However, intact peripheral nerves and innervated muscles are a prerequisite for the effectiveness of supportive therapies like functional electrical stimulation (FES). METHODS: We assessed electroneurographic (ENG) data of lower limbs in SCI individuals admitted to our hospital due to severe pressure sores. Our centers prospectively acquired ENG data of the European Multicenter study about SCI (EMSCI) patients served as early control. RESULTS: In the pressure sore cohort (n = 15) all patients were sensory-motor complete (American Spinal Cord Injury Association Impairment Scale A). Most patients (10/15) suffered from a severe axonal sensory-motor polyneuropathy in paralysed legs with absent compound muscle action potentials (CMAPs) of tibial/peroneal nerves as well as absent sensory nerve action potentials of sural nerves. The onset of this polyneuropathy dates within the first year after incident SCI and was mainly associated with increasing sensory-motor completeness as demonstrated by a significant CMAP drop of our centers EMSCI-ENG data on serial tibial nerve recordings in 275 patients. CONCLUSIONS: Severe SCI is associated with an early-onset axonal polyneuropathy in paralysed limbs to which pressure damage might contribute. Because intact peripheral nerves are required for: (i) maintenance of motor function in centrally impaired muscles; and (ii) effectiveness of supportive therapies like FES, ENG-monitoring could serve as a low invasive screening method for peripheral nerve integrity in patients with SCI to initiate pressure relief procedures early enough.

Does the STAF score help detect paroxysmal atrial fibrillation in acute stroke patients?

BACKGROUND AND PURPOSE: Detecting paroxysmal atrial fibrillation (pAF) soon after acute cerebral ischaemia has a major impact on secondary stroke prevention. Recently, the STAF score, a composite of clinical and instrumental findings, was introduced to identify stroke patients at risk of pAF. We aimed to validate this score in an independent study population. METHODS: Consecutive patients admitted to our stroke unit with acute ischaemic stroke were prospectively enrolled. The diagnostic work-up included neuroimaging, neuroultrasound, baseline 12-channel electrocardiogram (ECG), 24-h Holter ECG, continuous ECG monitoring, and echocardiography. Presence of AF was documented according to the medical history of each patient and after review of 12-lead ECG, 24-h Holter ECG, or continuous ECG monitoring performed during the stay on the ward. Additionally, a telephone follow-up visit was conducted for each patient after 3 months to inquire about newly diagnosed AF. Items for each patient-age, baseline NIHSS, left atrial dilatation, and stroke etiology according to the TOAST criteria - were assessed to calculate the STAF score. RESULTS: Overall, 584 patients were enrolled in our analysis. AF was documented in 183 (31.3%) patients. In multivariable analysis, age, NIHSS, left atrial dilatation, and absence of vascular etiology were independent predictors for AF. The logistic AF-prediction model of the STAF score revealed fair classification accuracy in receiver operating characteristic curve analysis with an area under the curve of 0.84. STAF scores of ≥5 had a sensitivity of 79% and a specificity of 74% for predicting AF. CONCLUSION: The value of the STAF score for predicting the risk of pAF in stroke patients is limited.

Bioequivalence study of low-dose diclofenac potassium tablet formulations.

BACKGROUND AND AIM: Diclofenac is a nonsteroidal antiinflammatory drug with potent analgesic and anti-inflammatory properties. An immediate-release formulation containing a low dose of 12.5 mg diclofenac-potassium (-K) is marketed as over the counter (OTC) medication in most European countries. An immediate-release formulation containing 25 mg diclofenac-K has now also been approved for OTC use. This study assessed the bioequivalence of two immediate-release diclofenac formulations when administered at the same dose. SUBJECTS AND METHODS: A randomized, crossover, open-label study was conducted in 29 healthy volunteers to assess the bioequivalence of single 25 mg dose of diclofenac-K in two formulations: 2 x 12.5 mg as film-coated tablets and 1 x 25 mg as sugar-coated tablet. Blood samples for pharmacokinetic analyses were obtained over 10 hours post administration. RESULTS: Plasma time courses of diclofenac were similar for the tested formulations. Mean AUC yen was 798 +/- 281 ng x h/ml (mean +/- SD) for the film-coated and 776 +/- 249 ng x h/ml for the sugar-coated formulation, respectively. The 2-sided 90% confidence interval for the mean test/reference ratio of AUCinfinity (95.5 - 107.5) fell within the predetermined equivalence range of 80 - 125%. Both formulations were rapidly absorbed; median time to maximal plasma concentration was 35 min in each group. Adverse events (peripheral erythema on the hand, headache, hypoesthesia) reported during the study were of mild severity and were considered as unlikely to be drug-related. CONCLUSION: The two diclofenac-K immediate release formulations were pharmacokinetically similar. It can be concluded that the new sugar-coated tablet formulation is equivalent to the available film-coated tablet formulation with respect to the extent of diclofenac absorption.

Fulminant onset of cerebral immunocomplex vasculitis as first manifestation of neuropsychiatric systemic lupus erythematosus (NPSLE).

Fulminant onset of neuropsychiatric symptoms as first manifestation of neuropsychiatric systemic lupus erythematosus (NPSLE) is rare and diagnosis is difficult if only one organ is involved. Here, we report the case of a previously healthy woman who presented with a clinical syndrome most compatible with acute onset of NPSLE. However, American College of Rheumatology (ACR) criteria were not sufficiently met. Brain biopsy showed an autoimmune complex vasculitis consistent with central nervous system (CNS) lupus. Because the prognosis of SLE-related CNS involvement is poor, aggressive immunosuppressive treatment was initiated using methylprednisolone in combination with cyclophosphamide.

[Ten years' experience at a major stroke center]. / Systemische Thrombolysetherapie des akuten Hirninfarkts. Zehn Jahre Erfahrungen aus einem überregionalen Schlaganfallzentrum.

BACKGROUND: About 1,300 stroke patients from a primarily rural area are treated each year at the Department of Neurology of the University Hospital of Heidelberg, Germany. Demographic and treatment data of all stroke patients there were prospectively collected. In a retrospective study we report on the changes in this patient population from 1996 to 2006, with special consideration of those suitable for intravenous thrombolysis. METHODS: For all stroke patients the basic data were collected--age, sex, type of stroke (transient ischemic attack, stroke, or intracerebral hemorrhage), NIH Stroke Scale, duration between symptom onset and hospital arrival, delay between arrival and first doctor's contact, patient's further whereabouts, and for patients treated by iv thrombolysis, start of treatment and dosage. RESULTS: There were no changes in the total number of stroke patients and median stroke severity, according to the NIH Stroke Scale, from 1996 to 2006. The proportion of stroke patients admitted within the first 3 h after symptom onset increased from 12.1% (1996) to 21.9% (2006). Thus we managed to treat 10.1% of all our ischemic stroke patients with iv thrombolysis, which means 39% of those patients with cerebral infarction arriving within 3 h. DISCUSSION: During the study period there were no significant changes in the patients' sociodemographic data. By consistent reduction of prehospital delay, the number of stroke patients that could be treated acutely by intravenous thrombolysis was increased.

Excimer laser pumped by an intense, high-energy heavy-ion beam.

High-energy heavy ions are an ideal tool to generate homogeneously excited, extended volumes of nonthermal plasmas. Here, the high-energy loss (dE/dx) and absolute power deposition of heavy ions interacting with matter has been used to pump an ultraviolet laser. A pulsed 70 MeV/u 238U beam with up to 2.5 x 10(9) particles in approximately 100 ns beam bunches was stopped in a 1.2 m long laser cell filled with a 1.6 bar Ar-Kr-F2 mixture (typically 50%:49.9%:0.1%). Laser effect on the 248 nm KrF* excimer transition is clearly demonstrated.

Subarachnoid hemorrhage due to Borrelia burgdorferi-associated vasculitis.

We report the case history of a patient who suffered a subarachnoid hemorrhage (SAH) in association with early Lyme neuroborreliosis. After a tick bite, this patient developed erythema chronicum migrans and complained of stinging radicular pain in both legs. A computed tomography (CT) scan was performed because of acute headache and nuchal rigidity, which revealed an occipital SAH. Cerebrospinal fluid analysis provided further evidence of acute neuroborreliosis. Digital substraction angiography showed irregularities in the right posterior cerebral artery, which might be due to vasculitis, but no aneurysms.

[Intracerebral hemorrhage related to anticoagulant therapy]. / Antikoagulanzienassoziierte Hirnblutungen.

Intracerebral hemorrhage (ICH) is the most serious complication of oral anticoagulant therapy (OAT). The growing use of OAT has resulted in an increase of fatal ICH. The mortality rate is about 65%, and most of the surviving patients remain disabled. While improvements in the treatment of spontaneous ICH have recently been described, there are no internationally accepted guidelines for managing patients with OAT-ICH. Therefore, identifying effective treatments is essential for improving clinical outcome. This article reviews the epidemiology of OAT-ICH, its pathophysiology, and current treatment options and discusses open questions with particular respect to more recent pharmacological therapies.

[Superficial siderosis of the CNS. 2 cases and a review of the literature]. / Superfizielle Siderose des ZNS. 2 Kasuistiken und eine Ubersicht über die Literatur.

Superficial siderosis of the CNS is a rare disease. The superficial deposition of haemosiderin in the cerebrum, cerebellum and spinal cord is due to chronic and recurrent subarachnoidal haemorrhage (SAH). Known sources of bleeding are vascular CNS-tumours, CSF-cavity lesions, vascular malformations, nerve root lesions and neurosurgical interventions. Detection of the source of bleeding is successful in only about 50% of cases. The clinical syndrome is characterized by sensorineural deafness, cerebellar ataxia and pyramidal signs. CSF-investigation might be indicative for SAH, while ferritin and ionic iron can be elevated in the CSF. CT is unspecific and insensitive but MR imaging of the brain and spinal cord is very sensitive and specific. The elimination of the source of bleeding alone might prevent the progression of the disease, therefore, an early and extensive search for this source is highly recommended.

[Spontaneous intracerebral hemorrhages]. / Spontane intrazerebrale Blutungen.

Spontaneous intracerebral hemorrhage (ICH) accounts for 8-15% of all cases of stroke and among patients receiving oral anticoagulants this number increases up to 40%. Mortality and morbidity are considerably higher in patients with ICH compared to patients with ischemic stroke. Large randomized controlled trials provide only little evidence for therapeutic strategies in patients with spontaneous ICH. In this review we summarize the available data and give recommendations on the management of spontaneous ICH.

[Leptomeningeal tumor cell infiltrations as a first manifestation of an immunocytoma (Waldenstrom's macroglobulinemia)]. / Leptomeningeale Tumorzellinfiltration als Erstmanifestation eines Immunozytoms (M. Waldenström).

Immunocytoma (Waldenstrom's macroglobulinemia) is a rare chronic lymphoproliferative disorder of B-cell origin. It is characterized by the presence of large amounts of circulating monoclonal immunoglobulin M (IgM) and lymphoplasmocytoid bone marrow infiltration. Affection of the peripheral nervous system is common and causes polyneuropathy (5-10%). An isolated leptomeningeal infiltration by neoplastic cells is very rare and has been reported in few cases only. The diagnosis is difficult, in particular if cerebrospinal fluid (CSF) cytology is inconclusive. We present the case of a patient who developed a personality disorder and cognitive impairment. Initial CSF findings were compatible with chronic lymphocytic (aseptic) meningitis. The serologic detection of IgM paraproteinemia and bone marrow cytology suggested immunocytoma. The selective analysis of B-cell clonality in both whole CSF cell lysates and individual CSF cells using polymerase chain reaction (PCR) based amplification of the rearranged CDR3 region of the IgH gene revealed the presence of a monoclonal B-cell population and was diagnostic for leptomeningeal tumor cell infiltration by immunocytoma.

[Acute meningitis after transrectal prostate biopsy]. / Akute Meningitis nach transrektaler Prostatapunktion.

Acute meningitis caused by Escherichia coli is a rare disease in adulthood. Medical procedures, e.g. surgical interventions, have been described as a cause. Infection by blood transmission of fecal E. coli is also known. We report a case of acute meningitis after transrectal prostate biopsy. E. coli could be identified both in the cerebrospinal fluid and in the blood culture. A broad initial antibiotic therapy was administered. After cultural isolation of E. coli the therapy was switched to cefotaxime. The initially comatose patient recovered swiftly.

Regulation of mouse podocyte process dynamics by protein tyrosine phosphatases rapid communication.

BACKGROUND: Effacement of podocyte foot processes occurs early in many glomerular diseases associated with proteinuria and is accompanied by a reorganization of the actin cytoskeleton. The molecular mechanisms regulating these structural changes are poorly understood. METHODS: To address these questions, we analyzed the effect of the polycation, protamine sulfate (PS), and puromycin aminonucleoside (PA) on the morphology, cytoskeleton, and tyrosine phosphorylation of differentiated process-bearing cultured podocytes. RESULTS: PS and PA induced similar profound morphological alterations, including retraction and detachment of podocyte processes from the extracellular matrix (ECM). The effects of PS occurred within six hours, whereas PA showed its most severe effects after 72 hours. Structural changes included reorganization of the actin cytoskeleton and focal contacts and were accompanied by an increase in tyrosine phosphorylation. The same effects were induced by application of vanadate, an inhibitor of protein tyrosine phosphatases (PTPs), suggesting that PTPs regulate podocyte process structure. Since disruption of the actin cytoskeleton with cytochalasin B protected the cells from PS-induced effacement and detachment, cytoplasmic PTPs were implicated in these events. Using reverse transcription-polymerase chain reaction (RT-PCR), we demonstrated the expression of four cytoplasmic PTPs in podocytes: SHP-2, PTP-PEST, PTP-1B, and PTP-36. CONCLUSIONS: These studies indicate an important role for cytoplasmic PTPs as regulators of podocyte process dynamics. Future studies will aim at restoring the normal foot process architecture of podocytes in glomerular diseases associated with proteinuria by modulating the activity of cytoplasmic PTPs.

Criminal behavior in males with affective disorders.

Prevalence of criminal behavior in a population of 261 male inpatients with affective disorders was studied. The patients were divided into 3 RDC subgroups and compared with the same number of matched subjects drawn from the general population. The full account of conviction records in the criminal register was used as a measure of criminal behavior. Altogether, 42% of patients and 31% of non-patients had a criminal record. A higher criminality rate was found in bipolar patients and in patients suffering from unipolar minor or intermittent depression, whereas no increased criminality rate was found in patients with unipolar major depression.

Yeast retrotransposon Ty4: the majority of the rare transcripts lack a U3-R sequence.

The retrotransposon Ty4 is found in different yeast strains at only one to three copies per haploid genome. In the present study, we aimed at relating the apparent low transpositional activity of Ty4 to transcriptional features of this element. RT-PCR revealed that Ty4 is transcribed at a very low level, being comparable with that of GAL4. Contrary to other Ty elements, the transcriptional rate of Ty4 is not affected in a sin4 background nor by treatment of cells with alpha factor. From experiments measuring the expression levels in 1acZ fusion constructs, we conclude that Ty4 transcription is repressed by a negative regulating element residing within the LTR, whereas positive cis-acting elements, like those that have been found to mediate expression of Ty1/2 and Ty3, are absent from Ty4. Analysing Ty4 transcript termini by the RACE-PCR method, we found several distinct transcriptional initiation sites. But surprisingly, the majority of the polyadenylated Ty4 transcripts terminate shortly upstream from the 3' LTR boundary, so that these transcripts do not contain a U3-R sequence, which is normally required for obligate strand transfer during DNA synthesis. Thus, the extremely low transcription rate of Ty4 and imperfect Ty4 transcripts are the reason for the low transpositional activity of this element.