3-O sulfation of syndecan-1 mediated by the sulfotransferase HS3ST3a1 enhances myeloma aggressiveness

Multiple myeloma is a hematological neoplasm derived from plasma cells invariably developing in the bone marrow (BM). The persisting clinical challenge in MM resides in its high ability to resist drugs as shown by the frequent relapses observed in patients regardless of the treatment applied. In a mouse model of MM, we identified a subpopulation of cells harboring increased resistance to current MM drugs. These cells bound a proliferation inducing ligand (APRIL), a key MM promoting/survival factor. APRIL binding involved the heparan sulfate (HS) chain present on syndecan-1 (SDC-1), and correlated with reactivity to the anti-HS antibody 10e4. 10e4+cells had a high proliferation activity, and were able to form colonies in 3-D cultures. 10e4+ cells were the only cells able to develop in BM after intravenous injection. They also resisted drugs in vivo, since their number increased after treatment in BM. Notably, 10e4+ cells differentiated into 10e4- cells upon in vitro and in vivo expansion. Expression of one sulfotransferase, HS3ST3a1, allowed modification of syndecan-1 to confer reactivity to 10e4 and binding to APRIL. HS3ST3a1 deletion inhibited tumorigenesis in BM. Notably, the two populations coexisted at a variable frequency in the BM of MM patients at diagnosis. In total, our results indicate that 3-O-sulfation on SDC-1 carried out by HS3ST3a1 defines aggressive MM cells, and that targeting of this enzyme could possibly be used to better control drug resistance.

Bidirectional regulation of distinct memory domains by α5-subunit-containing GABAA receptors in CA1 pyramidal neurons

Reduction in the expression or function of α5-subunit-containing GABA_A receptors (α5GABA_ARs) leads to improvement in several hippocampus-dependent memory domains. However, studies thus far mostly lack anatomical specificity in terms of neuronal circuits and populations. We demonstrate that mice with a selective knockdown of α5GABA_ARs in CA1 pyramidal neurons (α5CA1KO mice) show improved spatial and trace fear-conditioning memory. Unexpectedly, α5CA1KO mice were comparable to controls in contextual fear-conditioning but showed an impairment in context discrimination, suggesting fine-tuning of activity in CA1 pyramidal cell dendrites through α5-mediated inhibition might be necessary for distinguishing highly similar contexts.

Analysis of historical negative control group data from the rat in vivo micronucleus assay

A database of micronuclei counts for historical negative control data from rat in vivo micronuclei tests performed in 10 different laboratories was established. Data were available from over 4000 negative control rats from 10 laboratories. The mean frequency of micronucleated cells (MN)/1000 cells ranged from 0.44 to 2.22, a 5-fold range. Overall there were no major sex or strain differences in frequency, although there were some small but statistically significant differences within laboratories. There was appreciable variability between experiments compared with variability within experiments in some laboratories. No specific factor was identified which could explain this variability although it was noted that many different vehicles were used in the experiments. It is hoped that these data will help laboratories beginning studies with the rat micronucleus assay and those involved in the assessment of micronucleus assay results.

Diagnostic value of digital clock drawing test in comparison with CERAD neuropsychological battery total score for discrimination of patients in the early course of Alzheimer's disease from healthy individuals

The early detection of cognitive impairment or dementia is in the focus of current research as the amount of cognitively impaired individuals will rise intensely in the next decades due to aging population worldwide. Currently available diagnostic tools to detect mild cognitive impairment (MCI) or dementia are time-consuming, invasive or expensive and not suitable for wide application as required by the high number of people at risk. Thus, a fast, simple and sensitive test is urgently needed to enable an accurate detection of people with cognitive dysfunction and dementia in the earlier stages to initiate specific diagnostic and therapeutic interventions. We examined digital Clock Drawing Test (dCDT) kinematics for their clinical utility in differentiating patients with amnestic MCI (aMCI) or mild Alzheimer’s dementia (mAD) from healthy controls (HCs) and compared it with the diagnostic value of the Consortium to Establish a Registry for Alzheimer’s Disease (CERAD) neuropsychological battery total score. Data of 381 participants (138 patients with aMCI, 106 patients with mAD and 137 HCs) was analyzed in the present study. All participants performed the clock drawing test (CDT) on a tablet computer and underwent the CERAD test battery and depression screening. CERAD total scores were calculated by subtest summation, excluding MMSE scores. All tablet variables (i.e. time in air, time on surface, total time, velocity, pressure, pressure/velocity relation, strokes per minute, time not painting, pen-up stroke length, pen-up/pen-down relation, and CDT score) during dCDT performance were entered in a forward stepwise logistic regression model to assess, which parameters best discriminated between aMCI or mAD and HC. Receiver operating characteristics (ROC) curves were constructed to visualize the specificity in relation to the sensitivity of dCDT variables against CERAD total scores in categorizing the diagnostic groups. dCDT variables provided a slightly better diagnostic accuracy of 81.5% for discrimination of aMCI from HCs than using CERAD total score (accuracy 77.5%). In aMCI patients with normal CDT scores, both dCDT (accuracy 78.0%) and CERAD total scores (accuracy 76.0%) were equally accurate in discriminating against HCs. Finally, in differentiating patients with mAD from healthy individuals, accuracy of both dCDT (93.0%) and CERAD total scores (92.3%) was excellent. Our findings suggest that dCDT is a suitable screening tool to identify early cognitive dysfunction. Its performance is comparable with the time-consuming established psychometric measure (CERAD test battery).

Etomidate Impairs Long-Term Potentiation In Vitro by Targeting α5-Subunit Containing GABAA Receptors on Nonpyramidal Cells

Previous experiments using genetic and pharmacological manipulations have provided strong evidence that etomidate impairs synaptic plasticity and memory by modulating α5-subunit containing GABAA receptors (α5-GABAARs). Because α5-GABAARs mediate tonic inhibition (TI) in hippocampal CA1 pyramidal cells and etomidate enhances TI, etomidate enhancement of TI in pyramidal cells has been proposed as the underlying mechanism (Martin et al., 2009). Here we tested this hypothesis by selectively removing α5-GABAARs from pyramidal neurons (CA1-pyr-α5-KO) and comparing the ability of etomidate to enhance TI and block LTP in fl-α5 (WT), global-α5-KO (gl-α5-KO), and CA1-pyr-α5-KO mice. Etomidate suppressed LTP in slices from WT and CA1-pyr-α5-KO but not gl-α5-KO mice. There was a trend toward reduced TI in both gl-α5-KO and CA1-pyr-α5-KO mice, but etomidate enhanced TI to similar levels in all genotypes. The dissociation between effects of etomidate on TI and LTP in gl-α5-KO mice indicates that increased TI in pyramidal neurons is not the mechanism by which etomidate impairs LTP and memory. Rather, the ability of etomidate to block LTP in WT and CA1-pyr-α5-KO mice, but not in gl-α5-KO mice, points toward α5-GABAARs on nonpyramidal cells as the essential effectors controlling plasticity in this in vitro model of learning and memory.

The effect of aggression management training programmes for nursing staff and students working in an acute hospital setting. A narrative review of current literature

BACKGROUND

Patient aggression is a longstanding problem in general hospital nursing. Staff training is recommended to tackle workplace aggression originating from patients or visitors, yet evidence on training effects is scarce.

AIMS

To review and collate current research evidence on the effect of aggression management training for nurses and nursing students working in general hospitals, and to derive recommendations for further research.

DESIGN

Systematic, narrative review.

DATA SOURCES

Embase, MEDLINE, the Cochrane library, CINAHL, PsycINFO, pubmed, psycArticles, Psychology and Behavioural Sciences Collection were searched for articles evaluating training programs for staff and students in acute hospital adult nursing in a 'before/after' design. Studies published between January 2000 and September 2011 in English, French or German were eligible of inclusion.

REVIEW METHODS

The methodological quality of included studies was assessed with the 'Quality Assessment Tool for Quantitative Studies'. Main outcomes i.e. attitudes, confidence, skills and knowledge were collated.

RESULTS

Nine studies were included. Two had a weak, six a moderate, and one a strong study design. All studies reported increased confidence, improved attitude, skills, and knowledge about risk factors post training. There was no significant change in incidence of patient aggression.

CONCLUSION

Our findings corroborate findings of reviews on training in mental health care, which point to a lack of high quality research. Training does not reduce the incidence of aggressive acts. Aggression needs to be tackled at an organizational level.

[Prevalence and symptoms of vitamin D deficiency in general practices]

In 776 primary care patients serum vitamin D level was measured in month of september showing deficiency (<50 nmol/l) in 45,1%, severe deficiency (<30 nmol/l) in 9,8% and serum levels below the recommended target level of 75 nmol/l in 88,9% of cases. Three possible symptoms of vitamin D deficiency were assessed by a visual analogue scale (0-10): fatigue, muscle weakness, and muscle and joint pain. A significant correlation between muscle weakness and degree of vitamin D deficiency was shown (p=0,04), whereas there was no correlation in the two other symptoms. However, patients with vitamin D deficiency more frequently reported fatigue (p=0,02) and muscle weakness (p=0,009) than patients without deficiency did, and no difference was seen concerning muscle and joint pain.

[Characteristics of consultations by general practitioners in Switzerland - time, topics and verbal behaviour]

To conduct consultations is the main task of general practitioners. This study concerns itself with consultations, what they are about, how they are structured and how their achievements can be described. In total, 127 recorded consultations were analysed. The 12 recorded general practitioners were themselves involved in the data analysis. The analysis confirms that in comparison to the European average, the Swiss consultation is rather long with a consultation length of 12.5 minutes. 80% of the consultation time is taken up by mere conversation. Per average, three medical topics are discussed within that time. Thus, about three minutes are at disposal per topic. In every consultation we can also find one non-medical topic. The structure of a consultation is complex and changes continually depending on the performed tasks.

[Smoking behaviour and willingness to stop smoking in patients admitted in an internal medicine ward]

Smoking is one of the leading preventable risk factors for the development of lung-, cardio-vascular diseases and cancer. We report results of a prospective survey regarding smoking behaviour and willingness to stop smoking in patients of an internal medicine clinic. Twenty percent of participants admitted smoking cigarettes in the previous 7 days. Smokers were more often males and were younger than non- or ex-smokers. Every second smoker reported being told to stop smoking by a physician before but only about a third was offered active support in doing so. About half of the smoking participants were interested to quit smoking and to participate in a hospital-based smoking cessation program. In patients admitted to the hospital, smoking behaviour and willingness to quit smoking should be recorded and help in quitting smoking should be offered actively. Beside recording smoking behaviour and willingness to quit, patients who are admitted in the hospital should be offered help to quit smoking or to join a proactive structured smoking cessation program.

[Fatigue and anemia]

We herein report on an 80-year old male patient with a history of muscle weakness, fatigue and weight loss since several months. Because of a pathologic synacthen test in combination with decreased levels of ACTH, we diagnosed a secondary chronic adrenal insufficiency. Because of a normochromic, normocytic, and hypo-proliferative anemia, bone marrow puncture was performed, showing an anemia of chronic disease. We initiated hydrocortisone and anemia and patients' symptoms were fully reconstituted.

Design, construction, and first commissioning results of superconducting source for ions at NSCL/MSU

A new electron cyclotron resonance ion source (ECRIS) was constructed at the NSCL/MSU to replace the existing SC-ECRIS. This ECRIS operates at 18+14.5 GHz microwave frequencies with a planned upgrade to 24-28 GHz in the second phase of commissioning. A superconducting hexapole coil system produce the radial magnetic field; the axial trapping is produced with six superconducting solenoid coils enclosed in an iron yoke to allow the optimization of the distance between the plasma electrode and the resonant zone in the plasma. We report the details of the design, construction, and initial commissioning results of this new ECRIS.

Cortical glutamatergic neurons mediate the motor sedative action of diazepam

The neuronal circuits mediating the sedative action of diazepam are unknown. Although the motor-depressant action of diazepam is suppressed in alpha1(H101R) homozygous knockin mice expressing diazepam-insensitive alpha1-GABA(A) receptors, global alpha1-knockout mice show greater motor sedation with diazepam. To clarify this paradox, attributed to compensatory up-regulation of the alpha2 and alpha3 subunits, and to further identify the neuronal circuits supporting diazepam-induced sedation, we generated Emx1-cre-recombinase-mediated conditional mutant mice, selectively lacking the alpha1 subunit (forebrain-specific alpha1(-/-)) or expressing either a single wild-type (H) or a single point-mutated (R) alpha1 allele (forebrain-specific alpha1(-/H) and alpha1(-/R) mice, respectively) in forebrain glutamatergic neurons. In the rest of the brain, alpha1(-/R) mutants are heterozygous alpha1(H101R) mice. Forebrain-specific alpha1(-/-) mice showed enhanced diazepam-induced motor depression and increased expression of the alpha2 and alpha3 subunits in the neocortex and hippocampus, in comparison with their pseudo-wild-type littermates. Forebrain-specific alpha1(-/R) mice were less sensitive than alpha1(-/H) mice to the motor-depressing action of diazepam, but each of these conditional mutants had a similar behavioral response as their corresponding control littermates. Unexpectedly, expression of the alpha1 subunit was reduced in forebrain, notably in alpha1(-/R) mice, and the alpha3 subunit was up-regulated in neocortex, indicating that proper alpha1 subunit expression requires both alleles. In conclusion, conditional manipulation of GABA(A) receptor alpha1 subunit expression can induce compensatory changes in the affected areas. Specifically, alterations in GABA(A) receptor expression restricted to forebrain glutamatergic neurons reproduce the behavioral effects seen after a global alteration, thereby implicating these neurons in the motor-sedative effect of diazepam.

[Therapy-refractory arterial hypertension in a young patient]

We report on a 41-year-old patient admitted for refractory arterial hypertension that had developed after a curative chemotherapy regimen due to seminoma stadium IIb four years ago. After exclusion of secondary forms of arterial hypertension (actually unsuccessfully treated with 5 different antihypertensive drugs) we performed a controlled medication intake-trial in our outpatient clinic. 90 minutes after taking the pills the patient complained of dizziness and perspiration while hypotension and bradycardia were measured simultaneously. Due to the difficult psychosocial situation (conflicts with the insurance and in the family, financial problems) and the suspected narcisstic personality disorder the issue of the proven malcompliance was not openly discussed in order to preserve the patient-doctor alliance. The antihypertensive regimen was then reduced to a double regimen. In the second part of the article the most common reasons for refractory arterial hypertension, especially the problem of treatment malcompliance, are summarized.

[Orthostatic hypotension and hypertension lying down: a clinical dilemma. 56-year-old patient with multiple system atrophy]

A 56-year-old patient with multisystem atrophy of Parkinson type presents himself with severe, symptomatic and orthostatic hypotension and concomitant arterial hypertension while in a recumbent position. Etiology and pathophysiology of orthostatic hypotension and concomitant hypertension in recumbent position is discussed as it relates to this specific patient. Specific indications for antihypertensive therapies and other potential therapeutic options are also discussed.

Mapping the contribution of beta3-containing GABAA receptors to volatile and intravenous general anesthetic actions

Background

Agents belonging to diverse chemical classes are used clinically as general anesthetics. The molecular targets mediating their actions are however still only poorly defined. Both chemical diversity and substantial differences in the clinical actions of general anesthetics suggest that general anesthetic agents may have distinct pharmacological targets. It was demonstrated previously that the immobilizing action of etomidate and propofol is completely, and the immobilizing action of isoflurane partly mediated, by β3-containing GABA_A receptors. This was determined by using the β3(N265M) mice, which carry a point mutation known to decrease the actions of general anesthetics at recombinant GABA_A receptors. In this communication, we analyzed the contribution of β3-containing GABA_A receptors to the pharmacological actions of isoflurane, etomidate and propofol by means of β3(N265M) mice.

Results

Isoflurane decreased core body temperature and heart rate to a smaller degree in β3(N265M) mice than in wild type mice, indicating a minor but significant role of β3-containing GABA_A receptors in these actions. Prolonged time intervals in the ECG and increased heart rate variability were indistinguishable between genotypes, suggesting no involvement of β3-containing GABA_A receptors. The anterograde amnesic action of propofol was indistinguishable in β3(N265M) and wild type mice, suggesting that it is independent of β3-containing GABA_A receptors. The increase of heart rate variability and prolongation of ECG intervals by etomidate and propofol were also less pronounced in β3(N265M) mice than in wild type mice, pointing to a limited involvement of β3-containing GABA_A receptors in these actions. The lack of etomidate- and propofol-induced immobilization in β3(N265M) mice was also observed in congenic 129X1/SvJ and C57BL/6J backgrounds, indicating that this phenotype is stable across different backgrounds.

Conclusion

Our results provide evidence for a defined role of β3-containing GABA_A receptors in mediating some, but not all, of the actions of general anesthetics, and confirm the multisite model of general anesthetic action. This pharmacological separation of anesthetic endpoints also suggests that subtype-selective substances with an improved side-effect profile may be developed.

Identification of a Molecular Target Mediating the General Anesthetic Actions of Pentobarbital

Barbiturates were introduced into medical practice in 1934. They are widely used today as general anesthetics. Although in vitro studies revealed that the activity of a variety of ligand-gated channels is modulated by barbiturates, the target(s) mediating the anesthetic actions of barbiturates in vivo are unknown. Studying pentobarbital action in beta3(N265M) mice harboring beta3-containing GABAA receptors insensitive to a variety of general anesthetic agents, we found that the immobilizing action of pentobarbital is mediated fully, and the hypnotic action is mediated in part by this receptor subtype. It was surprising that the respiratory depressant action of pentobarbital is indistinguishable between beta3(N265M) and wild-type mice and thus is mediated by other as-yet-unidentified targets. Whereas the target for the immobilizing and hypnotic actions of pentobarbital seems to be the same as for etomidate and propofol, these latter agents' respiratory depressant actions are mediated by beta3-containing GABAA receptors. Thus, in contrast to etomidate and propofol, pentobarbital can elicit respiratory depression by a beta3-independent pathway. Pentobarbital reduced heart rate and body temperature to a slightly smaller extent in beta3(N265M) mice compared with wild-type mice, indicating that these actions are largely mediated by other targets. Pentobarbital-induced increase of heart rate variability and prolongation of ECG intervals are seen in both beta3(N265M) mice and wild-type mice, suggesting that they are not dependent on beta3-containing GABAA receptors. In summary, we show a clear pharmacological dissociation of the immobilizing/hypnotic and respiratory/cardiovascular actions of pentobarbital.

Regulation of the Dha Operon of Lactococcus lactis

Dihydroxyacetone (Dha) kinases are a novel family of kinases with signaling and metabolic functions. Here we report the x-ray structures of the transcriptional activator DhaS and the coactivator DhaQ and characterize their function. DhaQ is a paralog of the Dha binding Dha kinase subunit; DhaS belongs to the family of TetR repressors although, unlike all known members of this family, it is a transcriptional activator. DhaQ and DhaS form a stable complex that in the presence of Dha activates transcription of the Lactococcus lactis dha operon. Dha covalently binds to DhaQ through a hemiaminal bond with a histidine and thereby induces a conformational change, which is propagated to the surface via a cantilever-like structure. DhaS binding protects an inverted repeat whose sequence is GGACACATN6ATTTGTCC and renders two GC base pairs of the operator DNA hypersensitive to DNase I cleavage. The proximal half-site of the inverted repeat partially overlaps with the predicted -35 consensus sequence of the dha promoter.

C-reactive protein and echocardiography have little impact on risk stratification in never-treated hypertensive patients

The aim of this study was to assess the contribution of increased concentrations of high-sensitivity C-reactive protein (hsCRP) and echocardiography to risk stratification according to the 2003 European guidelines for the management of arterial hypertension in patients with untreated hypertension. A total of 207 consecutive medical outpatients with untreated hypertension were included. History and clinical examination, electrocardiography, laboratory analyses including the measurement of hsCRP and echocardiography were performed in all patients. Patients were classified into four risk groups with and without using echocardiography and hsCRP concentrations of at least 10 mg/l according to the 2003 guidelines for the management of hypertension. The majority of the 207 patients (81%) were at moderate or high cardiovascular risk before adding echocardiography and/or hsCRP to the risk stratification process. When echocardiography was included, only three patients were reclassified from the moderate added risk to the high added risk group. Adding hsCRP concentrations of at least 10 mg/l had no impact on risk stratification. Using an hsCRP cutoff level of 3 mg/l, one patient was at moderate instead of low added risk, eight patients were at high instead of moderate added risk and one patient was at very high instead of high added risk. We conclude that hsCRP at the proposed cutoff level of 10 mg/l has no impact on risk stratification in outpatients with untreated hypertension. An hsCRP cutoff level of 3 mg/l may be more suitable for risk stratification. Finally, our data suggest that depending on the population studied, there is minimal impact of echocardiography on risk stratification.

[Foot drop paralysis after intoxicated state]

Bei einem 20-jährigen Mann kommt es nach einem Rauschzustand zu einer peripheren Peronaeusparese, ausgelöst durch langes Verharren in einer Hockstellung. Das typische klinische Bild der Peronaeusparese ist der Steppergang. Druckparesen sind die häufigsten Ursachen der peripheren N. peronaeus-Läsionen. Die Therapie ist konservativ. Eine Anpassung eines Heidelberger-Winkels (Kunststoffschiene) wird empfohlen. Generell scheint die Prognose bei druckbedingten Läsionen gut zu sein. Die Peronaeusparese sollte vom Tibialis anterior-Syndrom differenziert werden.

Salz, Hypertonie und kardiovaskuläres Risiko

Eine große Zahl von Studien fand eine signifikante direkte Beziehung zwischen täglichem Kochsalzkonsum und Blutdruck. Der blutdrucksenkende Effekt einer Kochsalzrestriktion von 100 mmol pro Tag wird auf 3–5 mmHg systolisch und 1–2 mmHg diastolisch geschätzt. Das Ausmaß der Blutdruckreduktion hängt stark von der Salzsensitivität ab. Die momentane Datenlage unterstützt die Empfehlung, den täglichen Kochsalzkonsum auf Mengen unter 100 mmol zu senken (= 2.3 g Natrium oder 5.8 g Natriumchlorid). In westlichen Ländern liegt der tägliche Kochsalzkonsum bei etwa 150 mmol. Die Reduktion des Kochsalzkonsums dürfte sich vor allem positiv bei Diabetikern, Schwarzen, älteren und adipösen Personen auswirken. Hingegen ist es fraglich, ob eine generelle Einschränkung des Kochsalzkonsums bei Personen ohne arterielle Hypertonie sinnvoll ist, da der Effekt auf den Blutdruck in dieser Population bescheiden ist. Ob eine generelle Einschränkung des Kochsalzkonsums schlussendlich die kardiovaskuläre Morbidität und Mortalität in der Bevölkerung beeinflusst, ist unklar.

Distinct molecular targets for the central respiratory and cardiac actions of the general anesthetics etomidate and propofol

General anesthetics are among the most widely used and important therapeutic agents. The molecular targets mediating different endpoints of the anesthetic state in vivo are currently largely unknown. The analysis of mice carrying point mutations in neurotransmitter receptor subunits is a powerful tool to assess the contribution of the respective receptor subtype to the pharmacological actions of clinically used general anesthetics. We examined the involvement of beta3-containing GABA(A) receptors in the respiratory, cardiovascular, hypothermic, and sedative actions of etomidate and propofol using beta3(N265M) knock-in mice carrying etomidate- and propofol-insensitive beta3-containing GABA(A) receptors. Although the respiratory depressant action of etomidate and propofol, as determined by blood gas analysis, was almost absent in beta3(N265M) mice, the cardiac depressant and hypothermic effects, as determined by radiotelemetry, and the sedative effect, as determined by decrease of motor activity, were still present. Taken together with previous findings, our results show that both immobilization and respiratory depression are mediated by beta3-containing GABA(A) receptors, hypnosis by both beta3- and beta2-containing GABA(A) receptors, while the hypothermic, cardiac depressant, and sedative actions are largely independent of beta3-containing GABA(A) receptors.

[A small virus among the large]

Eine Parvovirus B19-Infektion kann sich im Erwachsenenalter mit arthritischen Beschwerdem, Arthralgien mit oder ohne grippale Symptome manifestieren. Die Beschwerden heilen meistens innerhalb von zwei bis drei Wochen spontan aus. Eine symptomatische Behandlung mit nichtsteroidalen Antirheumatika wirkt beschwerdelindernd. Ob eine akute oder chronische Parvovirus B19-Infektion prädisponierend auf die Entwicklung einer Kollagenose oder einer Rheumatoide Arthritis wirkt, ist in der Literatur bisher nicht bewiesen worden.

[Angiotensin II receptor blockers--evidence along the cardiovascular continuum]

The introduction of Angiotensin II receptor blockers (ARB) in 1995 was another milestone in the pharmacological management of hypertension. Due to the manifold effects on several target organs Angiotensin II is one of the most important mediator in the pathogenesis of hypertension. The blockade of the Angiotensin II receptor type 1 is a crucial cornerstone in interrupting the pathophysiological pathways in hypertension. Furthermore ARB have an excellent tolerability comparable with placebo. In the last decade large placebo-controlled trials could prove the efficiency of ARB in terms of morbidity and mortality. Patients after acute myocardial infarction and patients with chronic heart failure benefit from treatment with ARB equally compared to treatment with ACE inhibitors. Combining ARB and ACE inhibitors in patient after myocardial infarction increases the rate of adverse events without improving survival. Increase of microalbuminuria and worsening of diabetic nephropathy is reduced by ARB in patients with diabetes type 2, but an advantage over ACE inhibitors could not be documented. Hypertensive patients with electrocardiographically left ventricular hypertrophy treated with ARB seem to have an additional benefit in terms of morbidity and mortality compared to treatment with beta-blockers. In the early treatment of stroke patients treated with ARB have a lower 12-mounth mortality than patients receiving placebo. In conclusion, Angiotensin II receptor blockers are due to their well proved efficiency, the cardio- and renoprotective qualities and the excellent tolerability profile a useful therapeutic option in the management of patients with hypertension.

3,3'-Dimethyl-1,1'-methylenediimidazolium tetrachlorocobaltate(II)

The title compound, (C9H14N4)[CoCl4], a methylene-bridged bis-imidazolium salt containing a tetrachlorocobaltate anion, is one of the first examples where an alkyl-bridged bis-imidazolium compound could be structurally characterized. Short C-H...Cl contacts between the imidazolium C-H bonds and the Cl atoms of the counter-anion build up a three-dimensional network and indicate that the C-H bonds are strongly polarized.

Diagnostic significance of transferrinuria and albumin-specific dipstick testing in primary care patients with elevated office blood pressure

This study assesses the diagnostic accuracy of transferrinuria and an albumin-specific dipstick assay for detection of renal target organ damage (microalbuminuria) in hypertensive patients in a general practice setting. A spot urine sample of 130 nondiabetic patients with elevated office blood pressure readings (>140 and/or 90 mmHg) was investigated by measuring albumin to creatinine ratio (ACR) and transferrin to creatinine ratio (TCR) and by using an albumin-specific dipstick test (Micral). ACR was considered as comparative gold standard. TCR was elevated (>0.19 mg/mmol) in 26 urine samples (20.0% of the test samples). ACR was raised in 29 samples (22.3% of the test samples). Elevated TCR had a sensitivity of 97% and specificity of 91% for detection of microalbuminuria. Positive predicting value for microalbuminuria was 65%; negative predicting value was 99%. Correlation between ACR and TCR was strong (r=0.96). Dipstick testing for albumin was positive in 23 urine samples (17.7% of the test samples), 27 (20.8%) tests were false positive and six (4.6%) false negative. When dipstick was positive, the sensitivity of detecting microalbuminuria was 79%, and specificity 73%. In conclusion, detection of urinary transferrin in nondiabetic patients with hypertension is strongly associated with urinary albumin excretion. However, assessment of TCR does not identify additional patients with microalbuminuria compared to measurement of ACR alone. The semiquantitative Micral test offers a simple and valuable method to screen hypertensive patients for microalbuminuria in a primary care setting.

[Father of a family with pruritic papules below the belt line]

Die Herbstmilbe befällt häuptsächlich im August/September den Menschen als Fehlwirt. Bevorzugt werden Körperstellen mit eng anliegenden Kleidern (z.B. Gummizug, Gürtel) befallen. Die Milben lösen mit ihrem Speichel das Gewebe punktuell auf und lösen so eine ausgeprägte Immunreaktion aus. Es entsteht eine Papel und starker Juckreiz. Die Milben werden meistens durch Kratzen zerstört, lindernd wirken lokale Kortikosteroide. Die Hautreaktion besteht für etwa zehn Tage. Als Prophylaxe wird empfohlen, Füsse und Beine gut bedeckt zu halten, Mückenschutzpräparate zu verwenden und nachmittags keine Gartenarbeiten durchzuführen.

[Idiopathic gingival hyperplasia]

Anhand einer Fallbeschreibung werden die Differentialdiagnosen bei Gingivahyperplasie besprochen. Schwerpunktmässig wird im Kommentar anhand des beschriebenen Falles auf die Sarkoidose im Allgemeinen und speziell bei Beteiligung der Gingiva eingegangen.

[A 63-old patient with right-sided hypogastric pain at 6 months after appendectomy]

Anhand einer Fallbeschreibung werden die Differentialdiagnosen bei rechtsseitigem Unterbauchschmerz mit den entsprechenden weiterführenden Abklärungen besprochen. Schwerpunktmässig wird im Kommentar anhand des beschriebenen Falles auf die Bildgebung von Dünndarmprozessen und im speziellen auf das diffuse, grosszellige B-Zell-Lymphom (Schwerpunkt Therapie, Prognose) eingegangen.

Drug Hypersensitivity Syndrome to Carbamazepine and Human Herpes Virus 6 Infection: Case Report and Literature Review

We describe a patient with a drug-induced hypersensitivity syndrome to carbamazepine and a concomitant active infection with human herpes virus 6 (HHV-6). The potential role of HHV-6 regarding the drug-induced hypersensitivity syndrome is discussed and the main clinical features of this potentially fatal adverse drug reaction are highlighted.

[Placebo: an unappreciated factor in medicine]

Placebo is a provoking factor in medicine that is discussed controversially and not fully understood so far. From the scientific point of view and according to evidence-based medicine a proved indication to prescribe a placebo does not exist. Therapy of pain may be an exclusion. In our daily work we consciously use the placebo-effect, but on the other hand we are committed to the placebo-phenomenon. This article gives an overview of various aspects of placebo. The currently supported theory about the placebo response, conditioning and expectancy, are discussed. Further, the side effects (nocebo-phenomenon) and the utility of placebo in randomised clinical trials is highlighted.

[Patient questions on Barrett esophagus]

Anhand eines Fallbeispieles wird die Prognose, die Therapieoptionen und ein mögliches endoskopisches Nachkontroll-Schema bei Barrett-Ösophagus besprochen. Grundlage für die Diskussion bilden Fragen, welche von einem betroffenen Patienten anlässlich einer Erstkonsultation gestellt wurden.

[Scleral icterus in a 22-year-old housewife]

Anhand einer Fallbeschreibung wird die Differentialdiagnose der isolierten Hyperbilirubinämie besprochen. Im Kommentar wird schwerpunktmässig die klinische Beudeutung der chronischen, unkonjugierten Hyperbilirubinämie (Gilbert's Syndrom) diskutiert.

[Hypertensive emergency]

Hypertensive emergencies are acute, life-threatening events, characterised by high blood pressure and concomitant acute hypertensive target organ damage. These patients need immediate lowering of blood pressure mostly with parenteral drugs in the range of the autoregulative capacity of organ circulation and in-hospital monitoring of the vital functions. Hypertensive urgencies are not necessarily life-threatening, but persistence of high blood pressure may lead to acute target organ damage. Blood pressure should be lowered within 24 to 48 hours. Oral therapy is normally sufficient and hospitalisation is rarely necessary, but maintenance of antihypertensive therapy outside the hospital has to be ascertained.

[The Basel Medical University Polyclinic on the brink of the 21st century: retrospective and prospective view]

At the occasion of its 125th anniversary the outpatient department of internal medicine is being analysed with regard to its history, development and future. Originally it was founded to improve practical patient-oriented teaching of students and to serve the poor population of Basel. While today the Swiss Health Insurance system warrants proper care for every citizen and thus renders the latter purpose unnecessary, new marginal patient groups have evolved that need proper attention such as HIV patients, asylum-seekers, geriatric patients and others. Teaching obligations have even increased, especially with regard to primary care and family medicine. Thus the reasons for running a medical outpatient department have changed considerably, but still include teaching, research and provision of care to special patient groups. Outpatient departments have to be flexible and to adapt to modern trends in health care.

Prevalence and clinical outcome of hepatitis C infection in children who underwent cardiac surgery before the implementation of blood-donor screening

BACKGROUND AND METHODS

There are few data on the prevalence and clinical outcome of hepatitis C infection in children. We studied 458 children who underwent cardiac surgery in Munich, Germany, before 1991, when blood-donor screening for hepatitis C was introduced in Germany. Their mean age at first operation was 2.8 years; none of the children had received blood transfusions before or 'after cardiac surgery, and none of their mothers had antibodies to the hepatitis C virus (anti-HCV). We compared these patients with 458 control subjects matched for age and sex.

RESULTS

Sixty-seven (14.6 percent) of the 458 patients who had undergone cardiac surgery had anti-HCV, as compared with 3 (0.7 percent) of the control subjects (P<0.001). At a mean interval of 19.8 years after the first operation, 37 (55 percent) of the 67 patients who were positive for anti-HCV had detectable HCV RNA in their blood. The infection had cleared in the other 30 patients, as evidenced by negative results on three polymerase-chain-reaction analyses performed at six-month intervals. Only 1 of the 37 patients who were positive for HCV RNA had elevated levels of liver enzymes; that patient had severe right-sided congestive heart failure. Of the 17 patients who underwent liver biopsies, only 3 had histologic signs of progressive liver damage. These three patients had additional risk factors: two had congestive heart failure, and the third had also been infected with hepatitis B virus.

CONCLUSIONS

Children who had undergone cardiac surgery in Germany before the implementation of blood-donor screening for hepatitis C had a substantial risk of acquiring the infection. However, after about 20 years, the virus had spontaneously cleared in many patients. The clinical course in those still infected seems more benign than would be expected in people infected as adults.