[Changes in therapy aims and palliative treatment for severe stroke]. / Therapiezieländerung und Palliativmedizin beim schweren Schlaganfall.

Recent years have seen considerable advances in acute stroke treatment. Patients who survive the acute phase following major stroke often retain severe limitations of motor, cognitive, and communicative functions. In such patients whose death is imminent, curative therapies should be avoided. Instead, the goal of any therapy should shift to palliative treatment and concentrate on reducing causes of suffering. Palliative methodologies and concepts are already well established in neurology, e.g. for amytrophic lateral sclerosis. Particularly those stroke patients who remain stable for a long period with massive neurological deficits require interdisciplinary palliative care that goes beyond mere reduction of symptoms and seeks a response to possible complications and the question of maintaining life-preserving measures. Not only medical indications but also the expressed or presumed will of the patient must be included in such considerations. This article describes and elucidates basic questions of palliative medicine and symptomatic palliative treatment concepts for stroke patients.

Variable galactocerebroside expression by human Schwann cells in dissociated and peripheral nerve explant cultures.

It has been well established that rat Schwann cells down regulate their cell-surface expression of galactocerebroside (GalC) in vitro under normal cell culture conditions. To determine whether human Schwann cells exhibit a similar down-regulation of GalC in vitro we examined GalC expression in dissociated human Schwann cell cultures derived from normal adult peripheral nerve. Twenty-four hours post-dissociation up to 63% of human Schwann cells were found to express detectable levels of GalC on their surface whereas less than 8% of the Schwann cells expressed detectable levels of GalC at 14 days post-dissociation. In contrast, after nearly 3 months of peripheral nerve explant culture, greater than 30% of human Schwann cells still retained their GalC expression. A similar pattern was also observed when analyzing Schwann cell purity with dissociated cultures exhibiting a rapid decrease in Schwann cell purity under normal culturing conditions although Schwann cell purity was found to be largely unaffected during the period of peripheral nerve explant culture. In summary, we found there was less variation in both GalC expression and Schwann cell purity with time in peripheral nerve explant cultures than dissociated cultures.

High-titre IgM anti-sulfatide antibodies in individuals with IgM paraproteinaemia and associated peripheral neuropathy.

The common association between monoclonal gammopathy and peripheral neuropathy was studied in seven patients with demyelinating polyneuropathy and IgM paraproteinaemia. Plasma samples from these individuals were thoroughly tested for antiperipheral nerve myelin (PNM) antibodies and then screened for glycoprotein and glycolipid reactivity by western immunoblotting and thin-layer chromatography (TLC) immunostaining. Three of the seven samples showed strong IgM anti-PNM and antisulfatide (GalS) antibody reactivity. Two of these three plasma samples showed extraordinarily high antisulfatide IgM antibody titres, ranging from 1 x 104 to 1 x 106 arbitrary units/L. These same samples also showed intense myelin staining of sciatic nerve sections (paraffin and cryostat) and teased nerve fibres. No axonal immunoreactivity was observed. These results suggest that high titre IgM antisulfatide antibodies may play a pathogenetic role in the immune demyelination associated with IgM paraproteinaemia.

High titre anti-sulphatide antibodies in HIV-infected individuals.

Plasma samples from 35 individuals with human immunodeficiency virus (HIV) infection but without peripheral neuropathy were screened by enzyme linked immunosorbent assay (ELISA) for IgM and IgG antibodies against sulphatide (GalS). Five of these were shown to contain raised anti-GalS IgM antibody titres, while six had raised IgG titres. All plasma samples screened were compared to an internal neurological disease control which contained raised anti-GalS IgM antibody titres. Anti-GalS IgM antibody titres in the HIV cohort ranged between 200 and 2000 arbitrary units/litre (AU/l), whereas, IgG titres were between 200 and 10,000 AU/l. Two of four plasma samples from HIV-infected individuals with neuropathy (HIV+PN) also showed IgM reactivity with GalS; one also binding to the gangliosides GM1, GD1a, GD1b and GT1b. The other two samples showed IgG reactivity against GalS. These data indicate that antibodies against GalS occur more frequently in HIV infection than in HIV-seronegative individuals with and without neurological disease and may participate in the pathogenesis of neuropathies associated with HIV infection.

Peripheral nerve binding patterns of anti-sulphatide antibodies in HIV-infected individuals.

HIV-positive plasma samples from patients with and without neuropathy and with high titre anti-GalS antibodies showed strong binding to the myelin membrane of both fixed and unfixed human sciatic nerve specimens. This staining pattern was also seen with a plasma sample from a patient with IgM paraproteinaemic inflammatory demyelinating neuropathy with anti-GalS IgM antibody. Teased nerve fibres incubated with these anti-GalS antibodies from both HIV and non-HIV plasma samples showed immunofluorescence at the paranodal regions and Schmidt-Lanterman incisures. These data support a potential role for these antibodies in the aetiology of HIV-associated immune mediated neuropathies.

Destructiveness, atrocities and healing: epistemological and clinical reflections.

In this paper, destructiveness is approached as a multi-dimensional phenomenon where the mental health perspective addresses only one of these dimensions. An attempt is made to locate this phenomenon in the context of epistemological and societal considerations. Critical of mono-dimensional explanations based on causal-reductive epistemology, the paper instead proposes the idea of an 'ecology of destructiveness', according to which mental health professionals cannot possibly continue to assume the role of detached observers. The ordinariness and archetypal fascination of destructiveness are discussed as preventing the psychologizing and pathologizing of it. In addition, it is suggested that 'destructiveness may be a tragic facet of the human condition', without this implying any justification of it. Based on my work with a group of Bosnian ex-camp prisoners, some basic principles of how one can work with survivors of atrocities are derived and discussed. A central feature of this work is the attempt to create an appropriate therapeutic context within which a 'therapeutic presence' and 'therapeutic witnessing' can be developed. Finally, the relevance of Jungian insights to this kind of work is reviewed and the emergence of new types of defences of the self is identified.

Antibodies against peripheral myelin glycolipids in people with HIV infection.

Plasma samples from 35 individuals with HIV infection but without clinical peripheral neuropathy were screened by ELISA for IgM and IgG antibodies against peripheral myelin. Eighteen of the 35 samples (51%) showed IgM reactivity and 11 (31%) showed IgG reactivity. By comparison, none of 48 samples from healthy blood donors showed IgM or IgG reactivity. Epitopes reacting with these antibodies were identified by TLC immunostaining as sulphatide (GalS) and the gangliosides GM1, GD1a and GD1b. Plasma samples from four people with HIV infection and neuropathy (HIV+PN), six HIV-seronegative individuals with IgM paraproteinaemic demyelinating neuropathy (IgMPDN) and 12 HIV-seronegative individuals with a variety of other neurological disorders (HIV-OND) were also investigated. Two of the four HIV+PN samples showed IgM reactivity with GalS; and two showed IgG reactivity against GalS. Of the six IgMPDN samples, three showed IgM reactivity with GalS. These data indicate that antibodies against peripheral myelin glycolipids, in particular GalS, occur more frequently in HIV infection than in HIV-seronegative individuals with and without neurological disease, and may contribute to subclinical neuropathy in HIV infection.

The amyloid protein precursor of Alzheimer's disease is a mediator of the effects of nerve growth factor on neurite outgrowth.

The beta A4 protein, the major component of the amyloid deposition characterizing Alzheimer's disease, derives from the amyloid protein precursor (APP), an integral membrane protein with soluble derivatives. The function of APP is unknown. Both soluble and membrane-associated human brain APP (10(-10) M) significantly increased (P less than 0.025) neurite length and branching in pheochromocytoma PC12 cells, but did not affect the number of neurites per cell. At higher concentrations, APP was cytotoxic, with a half-maximal concentration of 5 x 10(-9) M. Nerve growth factor (NGF) is known to affect APP expression in vivo and in vitro. Antibodies to APP specifically diminished the effects of NGF on neurite length and branching. Thus APP may act to mediate neurite outgrowth promotion by NGF.

Miniature endplate potentials as a tool in neurotoxicology.

The toxic effect of thallium added to the bath solution was studied with intra- and extracellular recordings from mammalian nerve-muscle preparations. To elucidate the target region, 3 different functional parameters were studied: (1) Post-synaptic endplate potentials (EPPs) resulting from evoked transmitter release; (2) Post-synaptic miniature endplate potentials (MEPPSs) resulting from spontaneous transmitter release; and (3) Presynaptic ion currents at the nerve terminal. At a concentration of 0.5 mM/l thallium acetate, EPP amplitudes were irreversibly decreased while MEPP amplitudes remained unaffected. MEPP frequencies were reversibly increased, indicating a presynaptic rather than a post-synaptic target site of thallium toxicity. The subpopulation of small MEPPs (sub-MEPPs) behaved like the MEPP population, except that upon addition of 4-AP, the sub-MEPP population was augmented at the cost of the MEPP population. In view of the slow time course of the toxic effects (30 min for a 10-fold increase of MEPP frequency, 100-180 min for a 50% reduction of EPP amplitudes), it is concluded that thallium needs to be transported across the cell membrane before it finally interferes with release mechanisms. It is hypothesised that thallium reduces the number of active sites recruited by one action potential (reduced EPP amplitude), while at the same time the probability of transmitter liberation is enhanced (increased MEPP frequency). The rather indirect mode of action of thallium was also found when presynaptic ion currents were recorded using extracellular electrodes. In proportion to the decrease of the EPP amplitudes, a reduction of all inward and outward currents was observed. This effect was also irreversible. It is concluded that in spite of some similarities, thallium behaves quite differently from bivalent heavy metals like cobalt and cadmium, which act as competitive calcium antagonists at the presynaptic nerve terminal. In these toxic substances, the time course of intoxication is much faster, the required concentration is much lower, and the inhibition of the slow calcium current is reversible.

Detection of sub-miniature endplate potentials by harmonic analysis.

In phrenic nerve-diaphragm preparations from young rats and mice, long-term recordings of miniature endplate potentials (MEPPs) from single synapses were performed. Amplitude histograms obtained from these experiments were analysed with respect to the presence of multiple peaks which are believed to reflect quantal transmitter release. This was accomplished by subjecting MEPP amplitude histograms as well as matched random number histograms to Fourier analysis; harmonics in the MEPP amplitude distribution were considered valid only if they exceeded those of the random number distribution. In 9 out of 11 experiments, substantial evidence for the existence of preferred amplitudes was obtained; in two cases, however, it was completely missing. Applying our method to a series of promising MEPP amplitude histograms selected from the literature, we found a similar relationship between positive and negative results. We also noted a fairly constant relationship between the size of the elementary sub-MEPPs and the mean amplitude of the bell-MEPPs, named so according to the Gaussian shape of their amplitude distribution.

The action of thallium acetate on spontaneous transmitter release in the rat neuromuscular junction.

Frequencies and amplitudes of miniature endplate potentials (MEPP's) were recorded from neuromuscular junctions of the rat phrenic nerve-diaphragm preparation in vitro. Superfusion of the preparations with Ringer solution containing thallium acetate (Tlac) gradually increased the frequency of MEPP's by a factor of 10 within 30 min (1 X 10(-3) mol/l Tlac) and 180 min (5 X 10(-4) mol/l Tlac), whereas the amplitude of MEPP's remained unchanged. Frequency of MEPP's fitted a Poisson-distribution which persisted during superfusion with Tl+-Ringer. Sub-MEPP amplitudes remained unaffected by the action of thallium. It is concluded that thallium interferes presynaptically with spontaneous transmitter release.