Thromboinflammatory challenges in stroke pathophysiology

Despite years of encouraging translational research, ischemic stroke still remains as one of the highest unmet medical needs nowadays, causing a tremendous burden to health care systems worldwide. Following an ischemic insult, a complex signaling pathway emerges leading to highly interconnected thrombotic as well as neuroinflammatory signatures, the so-called thromboinflammatory cascade. Here, we thoroughly review the cell-specific and time-dependent role of different immune cell types, i.e., neutrophils, macrophages, T and B cells, as key thromboinflammatory mediators modulating the neuroinflammatory response upon stroke. Similarly, the relevance of platelets and their tight crosstalk with a variety of immune cells highlights the relevance of this cell-cell interaction during microvascular dysfunction, neovascularization, and cellular adhesion. Ultimately, we provide an up-to-date overview of therapeutic approaches mechanistically targeting thromboinflammation currently under clinical translation, especially focusing on phase I to III clinical trials.

A-14 Propensity Scores in Neuropsychological Research: Four Aspects of Digital Clock Drawing Distinguish Individuals with Non-Dementia Idiopathic Parkinson’s Disease from Matched Controls

Objective

In situations in which randomized experiments are impossible or unethical, propensity score matching offers a method to reduce bias on causal effect estimates (Thoemmes & Kim, 2011). In this study, we examined differences on the digital clock drawing test (dCDT; Souillard-Mandar et al., 2016) between individuals with idiopathic non-dementia Parkinson’s disease (PD) and matched controls.

Method

This study involved a retrospective analysis of two federally funded investigations (NSF-13-543; R01-NS082386). The sample included 261 participants (110 PD, 151 non-PD). Participants were matched according to demographic covariates, as well as measures of mood, comorbidity, and premorbid functioning. The PD group and matched controls were compared using logistic regression in a Bayesian framework, with projection predictive variable selection implemented to obtain a parsimonious model (Piironen, Paasiniemi, & Vehtari, 2018). All effects were standardized.

Results

Of 261 participants, 212 were matched using nearest neighbor matching (Figure 1). The final, parsimonious model included four variables from the dCDT: total strokes (command condition), total time (command condition), and area (command and copy conditions). While all effects were retained, positive to strong evidence was found for dCDT total time (βMedian = 0.91, βSD = 0.25, 95% CI [0.44, 1.42], Bayes factor [BF] = 97.80) and dCDT area (copy condition; βMedian = −0.52, βSD = 0.19, 95% CI [−0.90, −0.17], BF = 4.78).

Conclusions

Propensity scores can be employed in causal comparative studies to match control participants and reduce bias from nuisance covariates. Four aspects of dCDT performance were optimal in distinguishing individuals with PD from matched controls.

Learning while multitasking: short and long-term benefits of brain stimulation

We employed a simulated production task that mimics the real-world skill acquisition required of operators working in control rooms of power plants to assess short and long-term effects of transcranial random noise stimulation (tRNS). tRNS has shown potential for enhancing learning and performance of cognitive skills. Forty subjects (24 female) learned how to execute the simulated production task during the training phase and were required to perform a secondary task during the skill acquisition phase while they received active (12 min) or sham tRNS on DLPFC. After 2 weeks they had to recall the task again without any stimulation. The results demonstrate that tRNS promoted better multitasking as reflected by better performance in a secondary task during and immediately after tRNS. However, 2 weeks later, beneficial effect of tRNS on retention was moderated by general mental ability. Particularly, tRNS benefited those with lower general mental ability. Practitioner summary: By using a simulated production task, we assessed the effects of tRNS on learning and skill retention. The study indicates that neurostimulation can enhance the learning of multiple complex tasks. Moreover, it shows that retention of those tasks can be supported by neurostimulation, especially for those with lower general mental ability.

Revealing the subfemtosecond dynamics of orbital angular momentum in nanoplasmonic vortices

The ability of light to carry and deliver orbital angular momentum (OAM) in the form of optical vortices has attracted much interest. The physical properties of light with a helical wavefront can be confined onto two-dimensional surfaces with subwavelength dimensions in the form of plasmonic vortices, opening avenues for thus far unknown light-matter interactions. Because of their extreme rotational velocity, the ultrafast dynamics of such vortices remained unexplored. Here we show the detailed spatiotemporal evolution of nanovortices using time-resolved two-photon photoemission electron microscopy. We observe both long- and short-range plasmonic vortices confined to deep subwavelength dimensions on the scale of 100 nanometers with nanometer spatial resolution and subfemtosecond time-step resolution. Finally, by measuring the angular velocity of the vortex, we directly extract the OAM magnitude of light.

Wilm’s tumor: Presentation and outcome at Kilimanjaro Christian Medical Center

Objective: The purpose of the present study was to identify the gaps in the management of Wilms’ tumor which resulted in an inferior outcome and to see if there is any improvement since the last study and to come up with recommendations to improve the outcome of Wilms’ tumor. Patients and Methods: This was a retrospective hospital based study at Urology Institute of Kilimanjaro Christian Medical Centre. Patients operated for Wilms’ tumor between January 2006 and December 2013 were identified and the medical records of the 46 patients eligible for the study retrieved. The relevant information was entered into the prepared data collection format. The data was cleaned, summarized and analysed using SPSS version 17. Results: Patients with Wilms’ tumor presented late to KCMC. There was no undue delay in reaching at diagnosis. From the 46 total number of patients in this study 20 (43.5%) of patients received neoadjuvant chemotherapy while 26 (56.5%) had an upfront nephrectomy. The one year recurrence free survival was 32.6% with a high rate of lost to follow up (41.3%), perioperative mortality of (10.8%), and recurrence rate of (26.8%). Conclusion: There was no improvement in the outcome of WT at KCMC compared to the last report 8 years back. Patients still present late to health institutions, there is high rate of lost to follow up and the prognosis of Wilm’s tumor in this part of Africa is still dismal.

Associations of chronic heart failure with outcome in acute ischaemic stroke patients who received systemic thrombolysis: analysis from VISTA

BACKGROUND AND PURPOSE

There are concerns that systemic thrombolysis might not achieve clinically important outcome amongst chronic heart failure (CHF) patients with acute ischaemic stroke. Our aim was to investigate the relevance of CHF on the outcome of acute stroke patients who received thrombolysis.

METHODS

A non-randomized cohort analysis was conducted using data obtained from the Virtual International Stroke Trials Archive. The association of outcome amongst CHF patients with thrombolysis treatment was described using the modified Rankin scale (mRS) distribution at day 90, stratified by the presence of atrial fibrillation. Dichotomized outcomes were considered as a secondary end-point.

RESULTS

5677 patients were identified, of whom 2366 (41.7%) received thombolysis. Five hundred and three (8.9%) patients had CHF, of whom 209 (41.6%) received thrombolysis. The presence of CHF was associated with a negative impact on overall stroke outcome [odds ratio (OR) 0.73 (95% confidence interval (CI) 0.62-0.87), P < 0.001]. However, thrombolysis treatment was associated with favourable functional outcome using ordinal mRS, irrespective of CHF status, after adjustment for age and baseline National Institutes of Health Stroke Scale [OR 1.44 (95% CI 1.04-2.01, P = 0.029) for CHF patients versus OR 1.50 (95% CI 1.36-1.66, P < 0.001) for non-CHF patients]. CHF patients had higher mortality at day 90 than non-CHF patients. There was no significant difference for recurrent stroke or symptomatic intracerebral haemorrhage within 7 days of the initial stroke between CHF and thrombolysis groups.

CONCLUSIONS

Chronic heart failure was associated with a worse outcome with or without thrombolysis. However, acute stroke patients who received thrombolysis had more favourable outcome regardless of CHF status, compared with their untreated peers. Our findings should reassure clinicians considering systemic thrombolysis treatment in hyperacute ischaemic stroke patients with CHF.

[New aspects of stroke medicine]

Systemic thrombolysis with recombinant tissue-type plasminogen activator (rt-PA) remains the only effective and approved medical treatment of acute ischemic stroke. Several studies have demonstrated the importance of rapid recanalization. The efficacy of thrombectomy has so far not been sufficiently shown in randomized clinical trials; therefore, inclusion of suitable patients in one of the currently ongoing randomized trials is of great importance. The early treatment with magnesium after acute ischemic stroke during the pre-hospital phase did not prove to be neuroprotective. Intermittent pneumatic compression of the lower extremities in immobilized stroke patients effectively prevents deep venous thrombosis and pulmonary embolism. In patients with lacunar stroke the combination of aspirin and clopidogrel is not superior to aspirin alone and causes more bleeding complications. The novel oral anticoagulants are superior to warfarin in secondary prevention and carry a lower risk of intracranial and systemic bleeding complications. New studies will investigate whether dabigatran or rivaroxaban are superior to aspirin in secondary prevention after cryptogenic stroke.

Interdependence of stroke outcome scales: reliable estimates from the Virtual International Stroke Trials Archive (VISTA)

BACKGROUND AND PURPOSE

Clinical deficits from stroke are diverse, prompting measurement in trials by a range of outcome scales. Statistical and clinical advantage can be gained by combining scales into a global outcome provided combinations are chosen with limited correlations. We aimed to clarify the interdependence of outcome scales by systematic review of published data and by novel analysis of data from completed acute trials.

SUMMARY OF REVIEW

We systematically searched ScienceDirect and PubMed to summarize published data on correlations between stroke outcome scales. We generated new data on correlations among salient scales at 90 days poststroke in patients from the Virtual International Stroke Trials Archive (VISTA). We calculated Pearson and Spearman-Rank correlation coefficients for continuous and ordinal measures, respectively. We also assessed partial correlations, adjusted for baseline National Institute of Health Stroke Scale (NIHSS), and age. Published estimates of interdependence were limited to small single-trial cohorts and gave divergent results. From the more extensive VISTA dataset, we found that the modified Rankin Scale at 90 days poststroke explained 80.8% of the National Institute of Health Stroke Scale at 90 days poststroke and 86.5% of the European Stroke Scale. National Institute of Health Stroke Scale explained 75.9% of the Barthel Index and 81.2% of the Scandinavian Stroke Scale. After adjustment, modified Rankin Scale explained 56.6% of National Institute of Health Stroke Scale, 75.2% of Barthel Index. National Institute of Health Stroke Scale explained 60.2% of Barthel Index.

CONCLUSION

Correlations and partial correlations among stroke outcome scales in trial datasets are higher than previously reported. The new estimates are more reliable for trial planning due to the sample size and diversity.

Use of paracetamol in ischaemic stroke patients: evidence from VISTA

OBJECTIVES

Paracetamol is frequently prescribed for pain and fever control in acute stroke patients, but its effect on stroke outcome is unclear. The aim was to investigate the safety and benefit of paracetamol administration in the acute phase of ischaemic stroke.

METHODS

We analysed the impact of paracetamol exposure on functional outcome at 90 days among ischaemic stroke patients registered in a clinical trials archive. We used an adjusted Cochran-Mantel-Haenszel test to test for significance (P) followed by proportional odds logistic regression analysis to estimate the odds ratios (OR) for more favourable modified Rankin Scale score.

RESULTS

Data were available for 6015 patients, of whom 2435 had received paracetamol. No association of paracetamol-use with overall stroke outcome could be detected among those patients who experienced pain and/or fever (OR 1.03, 95% CI 0.86-1.20, P = 0.931). In patients without recorded pain and/or fever events and a baseline temperature below 37°C, in whom paracetamol was started within 3 days of stroke, paracetamol was associated with worse outcome (OR 0.58, 95% CI 0.47-0.72, P = <0.001).

CONCLUSION

This retrospective analysis is discouraging for prophylactic use of paracetamol in acute stroke patients, but underlines the need for a sufficiently powered randomized controlled trial.

Time scales of autonomic information flow in near-term fetal sheep

Autonomic information flow (AIF) characterizes fetal heart rate (FHR) variability (fHRV) in the time scale dependent complexity domain and discriminates sleep states [high voltage/low frequency (HV/LF) and low voltage/high frequency (LV/HF) electrocortical activity (ECoG)]. However, the physiologic relationship of AIF time scales to the underlying sympathetic and vagal rhythms is not known. Understanding this relationship will enhance the benefits derived from using fHRV to monitor fetal health non-invasively. We analyzed AIF measured as Kullback–Leibler entropy (KLE) in fetal sheep in late gestation as function of vagal and sympathetic modulation of fHRV, using atropine and propranolol, respectively (n = 6), and also analyzed changes in fHRV during sleep states (n = 12). Atropine blockade resulted in complexity decrease at 2.5 Hz compared to baseline HV/LF and LV/HF states and at 1.6 Hz compared to LV/HF. Propranolol blockade resulted in complexity increase in the 0.8–1 Hz range compared to LV/HF and in no changes when compared to HV/LF. During LV/HF state activity, fHRV complexity was lower at 2.5 Hz and higher at 0.15–0.19 Hz than during HV/LF. Our findings show that in mature fetuses near term vagal activity contributes to fHRV complexity on a wider range of time scales than sympathetic activity. Related to sleep, during LV/HF we found lower complexity at short-term time scale where complexity is also decreased due to vagal blockade. We conclude that vagal and sympathetic modulations of fHRV show sleep state-dependent and time scale-dependent complexity patterns captured by AIF analysis of fHRV. Specifically, we observed a vagally mediated and sleep state-dependent change in these patterns at a time scale around 2.5 Hz (0.2 s). A paradigm of state-dependent non-linear sympathovagal modulation of fHRV is discussed.

“Being prepared for the infrequent”: A comparative study of two refresher training approaches and their effects on temporal and adaptive transfer in a process control task

Operators working with highly automated technical systems face the challenge of skill retention due to few opportunities to apply the skills they acquired during initial training. Therefore, the use of refresher training is common in many high-risk environments. However, so far, the design and effectiveness of refresher training has not been focused on in training and human factors related research. We compared two refresher training approaches–practice and symbolic rehearsal–to a control group without refresher training. Fifty-nine engineering students were trained for one hour on a simulated process control task. A week later, the practice group completed four trials with the simulated task and the symbolic rehearsal group underwent four trials in written form. The final testing session took place two weeks after initial training. Refresher training was effective for temporal transfer, with the practice refresher group performing significantly better than the symbolic rehearsal group.

Was gibt es Neues beim Schlaganfall?

Anhand von selektierten Publikationen aus den vergangenen 12 Monaten werden aktuelle Entwicklungen und Neuheiten in der Prävention und Behandlung des Schlaganfalls dargestellt. Der orale direkte Thrombininhibitor Dabigatran zeigt weniger intrakranielle Blutungskomplikationen bei überlegener Wirksamkeit gegenüber Warfarin und ist seit August 2011 für die Behandlung von Patienten mit Vorhofflimmern zugelassen. Andere Antikoagulantien der neuen Generation wie Rivaroxaban und Apixaban sind gegenüber Warfarin ebenfalls überlegen, jedoch in Europa bislang noch nicht zur Behandlung von Patienten mit Vorhofflimmern zugelassen. Bei Patienten mit Vorhofflimmern wird das Risiko kardio- oder zerebrovaskulärer Ereignisse durch Angiotensin-Rezeptorblocker nicht reduziert. Eine aggressive Therapie des Diabetes mellitus senkt das Risiko für mikrovaskuläre, nicht jedoch für zerebro- und kardiovaskuläre Ereignisse oder die Sterblichkeit. Das Absetzen von Thrombozytenfunktionshemmern erhöht das Schlaganfall-Rezidivrisiko um 40%. Die Ausweitung des Zeitfensters für eine systemische Thrombolyse von 3 auf 4,5 Stunden hat weder die Blutungsrate oder Mortalität noch die mediane Latenzzeit von Aufnahme bis Lysebeginn erhöht. Ein Alter über 80 Jahre allein sollte kein Grund sein Patienten von der Lysetherapie auszuschließen. Angiotensin-Rezeptorblocker führen weder zur Verbesserung des Behandlungsergebnisses noch zur Reduktion kognitiver Störungen nach Schlaganfall. Zur Behandlung symptomatischer Carotisstenosen ist die Thrombendarteriektomie dem Stenting vorzuziehen. Das Stenting intrakranieller Stenosen und asymptomatischer extrakranieller Stenosen wird eher nicht empfohlen. Die zeitnahe Gabe von niedermolekularen Heparinen zur Thromboseprophylaxe und die Wiederaufnahme der oralen Antikoagulation 10–30 Wochen nach intrazerebraler Blutung sind wahrscheinlich sicher. Durch moderne CT-Diagnostik können Subarachnoidalblutungen und intrakranielle Aneurysmen ausreichend zuverlässig diagnostiziert werden. Endothelin-Rezeptor-Antagonisten sind zur Behandlung von Vasospasmen nach Subarachnoidalblutung unwirksam.

Macrophage migration inhibitory factor (MIF) expression in human malignant gliomas contributes to immune escape and tumour progression

Macrophage migration inhibitory factor (MIF), which inhibits apoptosis and promotes angiogenesis, is expressed in cancers suppressing immune surveillance. Its biological role in human glioblastoma is, however, only poorly understood. We examined in-vivo expression of MIF in 166 gliomas and 23 normal control brains by immunohistochemistry. MIF immunoreactivity was enhanced in neoplastic astrocytes in WHO grade II glioma and increased significantly in higher tumour grades (III-IV). MIF expression was further assessed in 12 glioma cell lines in vitro. Quantitative RT-PCR showed that MIF mRNA expression was elevated up to 800-fold in malignant glioma cells compared with normal brain. This translated into high protein levels as assessed by immunoblotting of total cell lysates and by ELISA-based measurement of secreted MIF. Wild-type p53-retaining glioma cell lines expressed higher levels of MIF, which may be connected with the previously described role of MIF as a negative regulator of wild-type p53 signalling in tumour cells. Stable knockdown of MIF by shRNA in glioma cells significantly increased tumour cell susceptibility towards NK cell-mediated cytotoxicity. Furthermore, supernatant from mock-transfected cells, but not from MIF knockdown cells, induced downregulation of the activating immune receptor NKG2D on NK and CD8+ T cells. We thus propose that human glioma cell-derived MIF contributes to the immune escape of malignant gliomas by counteracting NK and cytotoxic T-cell-mediated tumour immune surveillance. Considering its further cell-intrinsic and extrinsic tumour-promoting effects and the availability of small molecule inhibitors, MIF seems to be a promising candidate for future glioma therapy.

Association of genetic polymorphisms in ESR2, HSD17B1, ABCB1, and SHBG genes with colorectal cancer risk

The incidence rates and relative risks for colorectal cancer (CRC) are higher in men than in women. Sex steroids may play a role in this gender-associated difference in CRC risk. This study was conducted to explore the relationship of single nucleotide polymorphisms (SNPs) in steroid hormone signaling (ESR1, ESR2, PGR, NR1I2, and SHBG), phase I- and II-metabolizing enzyme (COMT, HSD17B1, CYP1A1, CYP17A1, CYP1A2, CYP1B1, CYP2C9, CYP3A4, CYP2C19, and GSTP1), and hormone transporter (ABCB1) genes with the risk of CRC in German women and men, separately. From the population-based DACHS study (South Germany), 47 putatively functional SNPs were genotyped in 1798 CRC cases (746 women and 1052 men) and 1810 controls (732 women and 1078 men). Significant allele dose-response associations were observed with ESR2_rs1255998, ESR2_rs928554, HSD17B1_rs605059, and ABCB1_rs2229109 in women (P trend=0.004, 0.05, 0.03, and 0.05 respectively) and with ABCB1_rs1045642, ABCB1_rs9282564, and SHBG_rs6259 in men (P trend=0.01, 0.03, and 0.02 respectively). The ESR2_rs1255998_G allele showed the most significant association with risk for CRC in women, with a per-allele odds ratio (OR) of 0.68 (95% confidence interval (CI) 0.52-0.88). This finding was replicated in an independent study from North Germany including 1076 female CRC cases and 1151 controls (OR=0.84, 95% CI 0.71-1.04), yielding a per-allele OR of 0.80 (95% CI 0.69-0.93, P trend=0.003) in the pooled sample. These findings implicate a role of ESR2 in the risk for developing CRC in women and suggest that HSD17B1, ABCB1, and SHBG genes may contribute to sex steroid-mediated effects on CRC development.

Computer-assisted pre- and postoperative evaluation of surgically assisted rapid maxillary expansion

OBJECTIVE

Computer-assisted methods were used to evaluate different variants of surgically assisted rapid maxillary expansion (SARME) in terms of bone repositioning, new bone formation in the osteotomy gap, and bone quality before and after surgery.

MATERIALS AND METHODS

Twenty-nine patients (18 male, 11 female) with a mean age of 29 years (16 to 44 years) were included in the study. Surgically assisted rapid maxillary expansion with Le Fort I osteotomy was performed in all patients studied. High-resolution computed tomography (CT) was carried out directly before and 6 to 8 weeks after surgery. After registration of the preoperative CT data on the postoperative data, 3D models were constructed and superimposed. New bone formation in the osteotomy gap was visualized by means of a visualization procedure developed specifically for this purpose. Bone quality was analyzed by dividing the models into different anatomical segments. A qualitative comparison of the data was accomplished using a direct volume rendering procedure with a special transfer function. A quantitative comparison was carried out based on the pre- and postoperative histograms of each region.

RESULTS

Maxillary widening was confirmed in all patients by computer-assisted analysis. Four patients exhibited significant maxillary asymmetry after surgery. New bone formation within the osteotomy gap was irregular along the osteotomy lines but often symmetrical on both sides. The more symmetrical the osteotomy, the more symmetrical the new bone formation proved to be. In all but two cases, the postoperative qualitative and quantitative analyses showed a significant decrease in Hounsfield units, particularly in the vestibular bone.

CONCLUSION

The differences in new bone formation in the osteotomy gap suggest that the type of surgical technique and distractor used influence the outcome. Our results indicate that SAME results in a decrease in bone quality, particularly in the vestibular bone. Computer-assisted analysis clearly results in an information gain.

[Antithrombotic and anticoagulation therapy after stroke and transient ischemic attacks]

Patients with a transient ischemic attack (TIA) or ischemic stroke are at high risk for a recurrent stroke. Platelet inhibitors can reduce this risk in patients with non-cardioembolic stroke or TIA. Aspirin is used for secondary prevention in patients with a low risk of recurrent stroke while the combination of aspirin and dipyridamole or clopidogrel is recommended in patients with a higher risk. Patients with atrial fibrillation have a five-fold increased risk of stroke. In comparison to placebo oral anticoagulation reduces the risk of stroke by 60-70% in primary and secondary stroke prevention. Aspirin can still reduce the relative stroke risk by 22% in patients with atrial fibrillation who have contraindications against anticoagulation. Given the limitations of oral anticoagulation with vitamin K antagonists a new generation of anticoagulants is currently being investigated which include factor Xa inhibitors and direct thrombin antagonists. Dabigatran has been shown to be as efficacious as warfarin given at a lower dose and significantly more efficacious when administered at a higher dosage. Both cerebral and intracranial hemorrhages were reduced by 60-80% in patients treated with dabigatran when compared to warfarin.

Prognosis and prognostic factors in ADL-dependent stroke patients during their first in-patient rehabilitation – a prospective multicentre study

PURPOSE

This prospective longitudinal study aimed at a description of ADL-functioning and at an analysis, which clinical instruments predict independency 6 months after discharge from in-patient rehabilitation following disabling first stroke.

METHOD

A total of 147 patients with disabling first stroke were recruited from three neurological rehabilitation centres. They were assessed during their first in-patient rehabilitation with the NIH Stroke Scale, Hemispheric Stroke Scale (HSS), Activity Index, Barthel Index, Neurobehavioural Rating Scale, Cornell Depression Scale, and the prognostic prediction of the rehabilitation neurologist. The 6 months outcome was established with the Nottingham Extended ADL Scale (NEADL) and by the legal dependency status.

RESULTS

The best prediction of 6 months outcome as measured by the NEADL was obtained by the HSS and a multivariate model that also included the physician's prognostic prediction, both early in rehabilitation and at discharge. The dependency status was best predicted by the HSS and patient's sex.

CONCLUSION

Clinical scales performed during rehabilitation such as the HSS are valid for prediction of ADL-dependency 6 months after discharge.

Physicians' estimates of rehabilitation requirements after stroke and traumatic brain injury - a questionnaire survey in East Germany

PURPOSE

The provision of rehabilitation services is organized differently in Germany than most other countries, with large indication-specific in-patient centres. This study is aimed at the rehabilitative knowledge of physicians who initiate and conduct rehabilitation in Germany.

METHODS

Medical specialists routinely involved in the treatment and rehabilitation of patients with stroke and traumatic brain injury (TBI) from acute hospitals, rehabilitation centres, and the Medical Services of the Workers' Pension Funds of Sachsen-Anhalt and Mecklenburg-Vorpommern were included in a systematic questionnaire survey aiming at the rehabilitation requirements of patients under their care or evaluation. These specialists are crucial for decision-making in rehabilitation ressource allocation.

RESULTS

According to these experts, rehabilitation requirements for stroke and TBI patients are dominated by deficits in motor functions and daily-living. They are aware that TBI rehabilitation includes a greater focus on memory functions, problem-solving and attention, and in stroke on language functions. According to the surveyed specialists, the present system of medical rehabilitation in Germany covers the requirements of stroke and TBI patients only partially. Deficits are identified in out-patient and day clinic rehabilitation.

CONCLUSIONS

Although the knowledge of rehabilitation requirements is adequate in general, its large ranges reflect the necessity for further analysis. The opinions of the surveyed specialists reflect their respective professional setting. Advantages and disadvantages of the German system require further investigation.

Pregabalin in the treatment of neuropathic pain associated with diabetic peripheral neuropathy

Neuropathic pain associated with diabetic peripheral neuropathy (DPN) is a common debilitating complication of diabetes mellitus with unmet therapeutic needs. Pregabalin is a recently introduced α2-δ subunit ligand at the voltage- sensitive calcium channel that has shown good efficacy with a tolerable side-effect profile in the treatment of PDN. According to the Australian datasheet, 1438 patients have been studied receiving either placebo (460) or pregabalin (978). The dose ranged from 75 to 600 mg daily. The number needed to treat averaged from the published data is 3.8 patients for the two higher doses. Pregabalin has a linearly increased plasma concentration with dose escalation and achieves analgesia as early as 1 day after initiating therapy. As its mechanism of action is different from other anticonvulsants and antidepressants, and interactions with other drugs are unlikely from the pharmacokinetic profile, combining pregabalin with other agents that are effective in DPN is a clinically safe option and should result in improved pain control.

Enzastaurin-induced apoptosis in glioma cells is caspase-dependent and inhibited by BCL-XL

The novel protein kinase C-beta inhibitor enzastaurin (ENZA) induced apoptosis in LNT-229 and T98G cells whereas A172 cells were resistant. Further, ENZA reduced proliferation in glioblastoma-initiating cells T 269 and T 323 but did not induce apoptosis. ENZA-induced apoptosis involved cleavage of caspases 3, 8, and 9 and led to mitochondrial cytochrome c release and was strongly suppressed by the broad spectrum caspase inhibitor zVAD-fmk but only slightly by the expression of the viral caspase 1/8 inhibitor cytokine response modifier-A. ENZA did not reduce the phosphorylation of protein kinase B (Akt), but of p70 S6 kinase and of its substrate S6 protein in T98G cells. Inhibition of the phosphatidylinositol 3 kinase signaling pathway did not restore sensitivity of A172 cells towards ENZA, and constitutively active Akt did not protect LNT-229 and T98G cells from ENZA-induced apoptosis. Dephosphorylation of glycogen synthase kinase 3beta, a biomarker of ENZA action, and cell death induction by ENZA were separately regulated. Inhibition or activation of Akt only weakly modulated ENZA-induced dephosphorylation of glycogen synthase kinase 3beta. In ENZA-resistant A172 cells, apoptosis ligand 2 (Apo2L.0)-induced cleavage of caspases 3, 8, and 9 was increased by ENZA, resulting in synergistic activity of ENZA and Apo2L.0.