ADHD medicine consumption in Europe after COVID-19: catch-up or trend change?

BACKGROUND

Although the COVID-19 pandemic and its implications have been associated with mental health services utilization and medication consumption, there is no longitudinal study on the long-term impact on ADHD medication use trends.

METHODS

This study examines the European ADHD medication consumption in 2020 to 2022 compared to the predicted consumption assuming the persistence of pre-pandemic trends. Predictions are calculated using Seasonal Autoregressive Integrated Moving Average (SARIMA) models.

RESULTS

While European ADHD medication sales recorded a drop in 2020, they returned to the predicted level in 2021, even slightly exceeding it. In 2022, we found a clear exceedance of the predicted level by 16.4% on average at country level. Furthermore, the increase in consumption growth in the post-pandemic period (2021-2022) compared to the pre-pandemic period (2014-2019) was significant in 26 of the 28 European countries under consideration.

CONCLUSION

There is strong evidence of a trend change in the ADHD medicine consumption growth throughout Europe after the COVID-19 pandemic.

The impact of the COVID-19 pandemic on ADHD medicine consumption in 47 countries and regions

The objective of this study is to quantify the impact of the COVID-19 pandemic on attention deficit hyperactivity disorder (ADHD) medication consumption globally and nationally using pharmaceutical sales data from 2014 to 2021 across 47 countries and regions. A seasonal autoregressive integrated moving average model (SARIMA) was applied to the time series until the end of 2019 at country level and used for the prediction of the ADHD medication consumption in 2020 and 2021. The deviations from the actual to the forecasted sales, which simulate the development without the emergence of COVID-19, yield estimates for the pandemic's impact. In 36 of the 47 countries and regions, the actual sales in 2020 were lower than predicted, with an average relative drop of 6.2% in defined daily doses (DDD) per 1000 inhabitants per day at country-level. In 2021, most countries recorded actually higher ADHD medication use than predicted at the end of 2019. On average, the consumption increased per country by 1.60%. The deviations strongly correlate with the stringency of anti-pandemic government policies. The findings suggest that the pandemic led to a substantially lower consumption of ADHD medication in 2020. However, in 2021 the pandemic had an accelerating effect as the increasing consumption trends are more pronounced than before the pandemic.

OctoPocus in VR: Using a Dynamic Guide for 3D Mid-Air Gestures in Virtual Reality

Bau and Mackays OctoPocus dynamic guide helps novices learn, execute, and remember 2D surface gestures. We adapt OctoPocus to 3D mid-air gestures in Virtual Reality (VR) using an optimization-based recognizer, and by introducing an optional exploration mode to help visualize the spatial complexity of guides in a 3D gesture set. A replication of the original experiment protocol is used to compare OctoPocus in VR with a VR implementation of a crib-sheet. Results show that despite requiring 0.9s more reaction time than crib-sheet, OctoPocus enables participants to execute gestures 1.8s faster with 13.8 percent more accuracy during training, while remembering a comparable number of gestures. Subjective ratings support these results, 75 percent of participants found OctoPocus easier to learn and 83 percent found it more accurate. We contribute an implementation and empirical evidence demonstrating that an adaptation of the OctoPocus guide to VR is feasible and beneficial.

Mimicry Attacks on Smartphone Keystroke Authentication

Keystroke behaviour-based authentication employs the unique typing behaviour of users to authenticate them. Recent such proposals for virtual keyboards on smartphones employ diverse temporal, contact, and spatial features to achieve over 95% accuracy. Consequently, they have been suggested as a second line of defense with text-based password authentication. We show that a state-of-the-art keystroke behaviour-based authentication scheme is highly vulnerable against mimicry attacks. While previous research used training interfaces to attack physical keyboards, we show that this approach has limited effectiveness against virtual keyboards. This is mainly due to the large number of diverse features that the attacker needs to mimic for virtual keyboards. We address this challenge by developing an augmented reality-based app that resides on the attacker’s smartphone and leverages computer vision and keystroke data to provide real-time guidance during password entry on the victim’s phone. In addition, we propose an audiovisual attack in which the attacker overlays transparent film printed with spatial pointers on the victim’s device and uses audio cues to match the temporal behaviour of the victim. Both attacks require neither tampering or installing software on the victim’s device nor specialized hardware. We conduct experiments with 30 users to mount over 400 mimicry attacks. We show that our methods enable an attacker to mimic keystroke behaviour on virtual keyboards with little effort. We also demonstrate the extensibility of our augmented reality-based technique by successfully mounting mimicry attacks on a swiping behaviour-based continuous authentication system.

Electrochemistry in ultra-high vacuum: The fully transferrable ultra-high vacuum compatible electrochemical cell

A new experimental setup for in situ/operando investigations of redox reactions is introduced. This setup, in combination with ultra-high vacuum (UHV) methods from the field of surface science, provides completely new possibilities to investigate electrochemical redox reactions. Two types of cells are distinguished conceptionally: in the permeation configuration, the working electrode is electrochemically polarised on one side of a membrane (entry side), leading to atomic hydrogen uptake, and allowing proton and electron exchange between the entry and the other side (exit side) of the membrane. Here it is found that the applied potential on the entry side shows a 1:1 correlation with the measured potential on the exit side. The concept of the "window" cell requires ultra-thin, electron transparent "windows," such as single layer graphene, for X-ray photoelectron spectroscopy or X-ray transparent silicon nitride "windows" for X-ray absorption spectroscopy. In this case, the solid/liquid interface can be directly probed under applied potentials. In both configurations, the applied potential is measured with a palladium hydride reference electrode, with so far unseen precision and long-term stability. The cell design is constructed with regard to transferability within a UHV system, allowing sample preparation, and a modular construction, allowing a straightforward changeover between these two configurations. As a first application, an approach based on atomic hydrogen is presented. Further application concepts are discussed. The setup functionality is demonstrated by the example of in situ/operando investigation of the palladium oxide reduction.

Dimension of pain-related quality of life and self-reported mental health in men and women of the European Prospective Investigation into Cancer-Norfolk cohort: a population-based cross-sectional study

Both cognitive and behavioural factors are linked to the experience of pain as well as its interference with quality of life. Psychological distress has been shown to be associated to several emotional and social impairments. Although, the association between pain and mental health has been widely discussed, the understanding of life interference and outcome is not fully understood. This study examined the association of pain dimension and mental health domain in 16,051 participants of the EPIC-Norfolk cohort (mean age = 58.9 ± 9.1 years). Study outcomes were depressive or anxious behaviour and limitations due to emotional problems and impairments in social functioning (mental functional health components of the Short Form-36 (SF-36)). Logistic regression models were constructed controlling for the potentially confounding factors including socio-economic variables (occupational social class, deprivation, marital status, education), lifestyle behaviour (physical activity, smoking, alcohol, dietary) and previous medical history. Strong interference in quality of life due to pain (bottom 20% of pain dimension score of SF-36) was significantly associated with poor MH in men and women (odds ratios (ORs) (95% confidence intervals (CIs)): 1.35 (1.19, 1.54) and 1.39 (1.25, 1.55), respectively; p < 0.0001) in fully adjusted models. Moreover, strong interference due to pain was also significantly associated with poor overall MH including emotional and social functioning (ORs (95% CIs): 1.42 (1.25, 1.62) and 1.39 (1.25, 1.55) respectively; p < 0.0001) in fully adjusted models; subsidiary analysis using linear regression models demonstrated similar results for these domains. Although a strong association has been shown, further research is needed to provide information on the different site and/or causes of pain which would allow stratification. Moreover, assuming a bi-directional nature of both domains, systematic assessment and management of pain have a lot of potential to improve the MH-related quality of life in the general population and vice versa.

Evaluating authentication options for mobile health applications in younger and older adults

OBJECTIVE

Apps promoting patient self-management may improve health outcomes. However, methods to secure stored information on mobile devices may adversely affect usability. We tested the reliability and usability of common user authentication techniques in younger and older adults.

METHODOLOGY

Usability testing was conducted in two age groups, 18 to 30 years and 50 years and older. After completing a demographic questionnaire, each participant tested four authentication options in random order: four-digit personal identification number (PIN), graphical password (GRAPHICAL), Android pattern-lock (PATTERN), and a swipe-style Android fingerprint scanner (FINGERPRINT). Participants rated each option using the Systems Usability Scale (SUS).

RESULTS

A total of 59 older and 43 younger participants completed the study. Overall, PATTERN was the fastest option (3.44s), and PIN had the fewest errors per attempt (0.02). Participants were able to login using PIN, PATTERN, and GRAPHICAL at least 98% of the time. FINGERPRINT was the slowest (26.97s), had an average of 1.46 errors per attempt, and had a successful login rate of 85%. Overall, PIN and PATTERN had higher SUS scores than FINGERPRINT and GRAPHICAL. Compared to younger participants, older participants were also less likely to find PATTERN to be tiring, annoying or time consuming and less likely to consider PIN to be time consuming. Younger participants were more likely to rate GRAPHICAL as annoying, time consuming and tiring than older participants.

CONCLUSIONS

On mobile devices, PIN and pattern-lock outperformed graphical passwords and swipe-style fingerprints. All participants took longer to authenticate using the swipe-style fingerprint compared to other options. Older participants also took two to three seconds longer to authenticate using the PIN, pattern and graphical passwords though this did not appear to affect perceived usability.

The Spatial Sign Covariance Matrix and Its Application for Robust Correlation Estimation

We summarize properties of the spatial sign covariance matrix and especially consider the relationship between its eigenvalues and those of the shape matrix of an elliptical distribution. The explicit relationship known in the bivariate case was used to construct the spatial sign correlation coefficient, which is a non-parametric and robust estimator for the correlation coefficient within the elliptical model. We consider a multivariate generalization, which we call the multivariate spatial sign correlation matrix. A small simulation study indicates that the new estimator is very efficient under various elliptical distributions if the dimension is large. We furthermore derive its influence function under certain conditions which indicates that the multivariate spatial sign correlation becomes more sensitive to outliers as the dimension increases.

Microfluidic Devices Made of Glass

Mikroglas is a young, innovative and highly-specialized enterprise, which has special know-how in the development of microstructured glass components. Due to its unique properties, glass plays an important role in the field of microtechnology. Most important for many of these new applications are:

• its optical transparency and good fluorescence properties, allowing the user to carry out in-situ-measurements, e.g., to detect products after a chemical reaction directly in the device • its stability at high temperatures so that reactions can be influenced by heating different zones of the device • its chemical resistivity, e.g., to handle aggressive substances • its high electrical resistivity, e.g., to transport liquids by electrophoresis or to carry out electrical measurements • its good biological compatibility which is necessary for medical and biological applications

The process of structuring FOTURAN will be described. With this technology different microfluidic devices have been manufactured. The channels have a width and depth of 50 μm up to 1 mm and a length of 20 mm up to 280 mm. Various parameters have been measured, e. g., the heat exchange and transfer coefficient for pure water as a function of the temperature. Also optical and thermal analysis techniques have been used to characterize the fluidic components. The results combined with advanced computational fluidic simulations lead to new solutions for different tasks.

Nuclear Trapping through Inhibition of Exosomal Export by Indomethacin Increases Cytostatic Efficacy of Doxorubicin and Pixantrone

PURPOSE

Although R-CHOP-based immunochemotherapy cures significant proportions of patients with aggressive B-cell lymphoma, tumor cell susceptibility to chemotherapy varies, with mostly fatal outcome in cases of resistant disease. We and others have shown before that export of cytostatic drugs contributes to drug resistance. Now we provide a novel approach to overcome exosome-mediated drug resistance in aggressive B-cell lymphomas.

EXPERIMENTAL DESIGN

We used well-established centrifugation protocols to purify exosomes from DLBCL cell lines and detected anthracyclines using FACS and HPLC. We used shRNA knockdown of ABCA3 to determine ABCA3 dependence of chemotherapy susceptibility and monitored ABCA3 expression after indomethacin treatment using qPCR. Finally, we established an in vivo assay using a chorioallantoic membrane (CAM) assay to determine the synergy of anthracycline and indomethacin treatment.

RESULTS

We show increased efficacy of the anthracycline doxorubicin and the anthracenedione pixantrone by suppression of exosomal drug resistance with indomethacin. B-cell lymphoma cells in vitro efficiently extruded doxorubicin and pixantrone, in part compacted in exosomes. Exosomal biogenesis was critically dependent on the expression of the ATP-transporter A3 (ABCA3). Genetic or chemical depletion of ABCA3 augmented intracellular retention of both drugs and shifted the subcellular drug accumulation to prolonged nuclear retention. Indomethacin increased the cytostatic efficacy of both drugs against DLBCL cell lines in vitro and in vivo in a CAM assay.

CONCLUSIONS

We propose pretreatment with indomethacin toward enhanced antitumor efficacy of anthracyclines and anthracenediones.

Spatially coupled catalytic ignition of CO oxidation on Pt: mesoscopic versus nano-scale

Spatial coupling during catalytic ignition of CO oxidation on μm-sized Pt(hkl) domains of a polycrystalline Pt foil has been studied in situ by PEEM (photoemission electron microscopy) in the 10(-5) mbar pressure range. The same reaction has been examined under similar conditions by FIM (field ion microscopy) on nm-sized Pt(hkl) facets of a Pt nanotip. Proper orthogonal decomposition (POD) of the digitized FIM images has been employed to analyze spatiotemporal dynamics of catalytic ignition. The results show the essential role of the sample size and of the morphology of the domain (facet) boundary in the spatial coupling in CO oxidation.

Echocardiographic screening for pulmonary arterial hypertension in HIV-positive patients

Human immunodeficiency virus (HIV) infection is associated with an increased risk for pulmonary arterial hypertension (PAH). Upon the screening of 220 asymptomatic HIV-positive individuals by echocardiography, we detected and confirmed HIV-associated PAH in 0.45 % of cases. Mild elevations of systolic pulmonary arterial pressure most probably owing to left ventricular diastolic dysfunction were found in 7.7 % of cases, without progress after 2 years. We suggest that the screening of asymptomatic HIV-positive patients for PAH should not be performed.

A novel laboratory set-up for investigating surface and interface reactions during short term annealing cycles at high temperatures

High temperature oxidation is an important research discipline that covers many topics in steel manufacture and modern energy research. To account for the need of adjusting accurate processing conditions, recent developments of the high temperature laboratory setup at the Max-Planck-Institut für Eisenforschung GmbH will be presented. The experimental assembly has been optimized to investigate surface and interface reactions at elevated temperatures in low oxygen activity gases, covering a large field of experimental possibilities. Many efforts have been taken to enable an accurate control and in situ monitoring of process conditions such as gas flow, gas composition, impurity content, and mass change of the sample.

The Role of Defects in the Local Reaction Kinetics of CO Oxidation on Low-Index Pd Surfaces

The role of artificially created defects and steps in the local reaction kinetics of CO oxidation on the individual domains of a polycrystalline Pd foil was studied by photoemission electron microscopy (PEEM), mass spectroscopy (MS), and scanning tunneling microscopy (STM). The defects and steps were created by STM-controlled Ar+ sputtering and the novel PEEM-based approach allowed the simultaneous determination of local kinetic phase transitions on differently oriented μm-sized grains of a polycrystalline sample. The independent (single-crystal-like) reaction behavior of the individual Pd(hkl) domains in the 10-5 mbar pressure range changes upon Ar+ sputtering to a correlated reaction behavior, and the reaction fronts propagate unhindered across the grain boundaries. The defect-rich surface shows also a significantly higher CO tolerance as reflected by the shift of both the global (MS-measured) and the local (PEEM-measured) kinetic diagrams toward higher CO pressure.

Silicon Oxide Surface Segregation in CO Oxidation on Pd: An in situ PEEM, MS and XPS Study

ABSTRACT

The effect of silicon oxide surface segregation on the locally-resolved kinetics of the CO oxidation reaction on individual grains of a polycrystalline Pd foil was studied in situ by PEEM, MS and XPS. The silicon oxide formation induced by Si-impurity segregation at oxidizing conditions, was monitored by XPS and its impact on the global and local (spatially resolved) kinetics of the CO oxidation was determined by MS and PEEM. The results reveal a drastic inhibiting effect of silicon oxide on the Pd reactivity towards CO oxidation, manifested both in the collapse of the global CO2 formation rate and in the modified local reactive properties of individual Pd micrograins. The presence of adsorbed oxygen on the Pd surface effectively enhances the silicon segregation to the Pd surface.

GRAPHICAL ABSTRACT

Structure and Volta potential of lipid multilayers: effect of X-ray irradiation

The effect of hard X-ray radiation on the structure and electrostatics of solid-supported lipid multilayer membranes is investigated using a scanning Kelvin probe (SKP) integrated with a high-energy synchrotron beamline to enable in situ measurements of the membranes' local Volta potential (V(p)) during X-ray structural characterization. The undulator radiation employed does not induce any detectable structural damage, but the V(p) of both bare and lipid-modified substrates is found to undergo strong radiation-induced shifts, almost immediately after X-ray exposure. Sample regions that are macroscopically distant (~cm) from the irradiated region experience an exponential V(p) growth with a characteristic time constant of several minutes. The V(p) variations occurring upon periodic on/off X-ray beam switching are fully or partially reversible depending on the location and time-scale of the SKP measurement. The general relevance of these findings for synchrotron-based characterization of biomolecular thin films is critically reviewed.

[What vision loss might bring to light]

We report a case of a 36-year old patient who suffered from a unilateral painless loss of vision. Ophthalmological examination in the context of a highly reactive syphilis serology revealed an acute syphilitic posterior placoide chorioretinitis (ASPPC). Additional clinical findings were a mucosal lesion on the upper lip, consistent with a plaque opaline and an alopecia specifica as manifestation of secondary syphilis. Treatment consisted in 6 x 4 Mio. IE* Penicillin G for 14 days and 50 mg Prednisone for five days to prevent a Jarisch Herxheimer reaction. The diagnostic measures, therapy and follow up of syphilis, focusing on ocular involvement, are described.

[Primary treatment of complicated flexor tendon injuries of the hand]

Complicated flexor tendon injuries are classified into lacerations, avulsions, ruptures, and defects. They are often a challenge for hand surgeons and frequently they present unsatisfactory functional results postoperatively. Lacerations and avulsions are usually treated by pull-out sutures and suture anchors. In ruptures, the causality should be sought. Tendon-linking, transposition and tenodesis/arthrodesis are the domain of rheumatoid arthritis. The primary transplantation of tendons is rarely indicated, ideally in non-contaminated flexor tendon defects in zones III-V with an uninjured surrounding soft tissue situation. Postoperative rehabilitation programs are very the same as in normal flexor tendon injuries.

Mapping the local reaction kinetics by PEEM: CO oxidation on individual (100)-type grains of Pt foil

The locally-resolved reaction kinetics of CO oxidation on individual (100)-type grains of a polycrystalline Pt foil was monitored in situ using photoemission electron microscopy (PEEM). Reaction-induced surface morphology changes were studied by optical differential interference contrast microscopy and atomic force microscopy (AFM). Regions of high catalytic activity, low activity and bistability in a (p,T)-parameter space were determined, allowing to establish a local kinetic phase diagram for CO oxidation on (100) facets of Pt foil. PEEM observations of the reaction front propagation on Pt(100) domains reveal a high degree of propagation anisotropy both for oxygen and CO fronts on the apparently isotropic Pt(100) surface. The anisotropy vanishes for oxygen fronts at temperatures above 465 K, but is maintained for CO fronts at all temperatures studied, i.e. in the range of 417 to 513 K. A change in the front propagation mechanism is proposed to explain the observed effects.

Eukaryotic DNA polymerases require an iron-sulfur cluster for the formation of active complexes

The eukaryotic replicative DNA polymerases (Pol α, δ and ɛ) and the major DNA mutagenesis enzyme Pol ζ contain two conserved cysteine-rich metal-binding motifs (CysA and CysB) in the C-terminal domain (CTD) of their catalytic subunits. Here we demonstrate by in vivo and in vitro approaches the presence of an essential [4Fe-4S] cluster in the CysB motif of all four yeast B-family DNA polymerases. Loss of the [4Fe-4S] cofactor by cysteine ligand mutagenesis in Pol3 destabilized the CTD and abrogated interaction with the Pol31 and Pol32 subunits. Reciprocally, overexpression of accessory subunits increased the amount of the CTD-bound Fe-S cluster. This implies an important physiological role of the Fe-S cluster in polymerase complex stabilization. Further, we demonstrate that the Zn-binding CysA motif is required for PCNA-mediated Pol δ processivity. Together, our findings show that the function of eukaryotic replicative DNA polymerases crucially depends on different metallocenters for accessory subunit recruitment and replisome stability.

[Persistent neutropenia]

We report the case of a 72-old patient with persistent neutropenia diagnosed during investigation of sialadenitis. Further examination led to the diagnosis of immune neutropenia and systemic lupus erythematosus. Anamnesis and the clinical course made initial diagnosis of drug-induced lupus erythematosus implausible. Steroid trial was done, followed by maintenance therapy, with good control of symptoms.

Emissions of inorganic and organic arsenic compounds via the leachate pathway from pretreated municipal waste materials: a landfill reactor study

The emission of arsenic (As) with leachate from mechanically biologically pretreated municipal solid waste (MBP-MSW) was quantified over one year using landfill simulation reactors. Arsenic mobilization and transformation processes were studied by simulating different environmental conditions (anoxic conditions with underlying soil or oxic/anoxic conditions). Amounts of mono-, di-, and trimethylated As in MBP-MSW prior to simulation were < 48 microg As kg(-1) and were magnified to 300-390 microg As kg(-1) under anoxic conditions, whereas methylated As was undetectable in the oxic setup. The highest leachate concentrations (up to 84 microg L(-1)) occurred during the first four weeks of manipulation. The annual Astotal release with leachates averaged 19.6, 7.6, and 4.5 microg kg(-1) under an anoxic environment with underlying soil, oxic conditions, and anoxic conditions, respectively, with 15-50% occurring as organic As. The annually released As represented 0.2-0.8% of the Astotal pool, suggesting that As mobilization from waste is a slow process. The anoxia diminished As release rates, whereas anoxic conditions with underlying soil material elevated the As mobilization, probably due to reductive dissolution of soil-derived Fe and Mn (hydr)oxides. The mass balance of methylated As in MBP-MSW and leachates before and after the treatments highlights As methylation under anoxic conditions and demethylation under oxic landfill conditions.

A double-blind, placebo-controlled pilot study of quetiapine for depressed adolescents with bipolar disorder

OBJECTIVE

To conduct a pilot study comparing the effects of quetiapine and placebo for the treatment of depressive episodes in adolescents with bipolar I disorder.

METHOD

Thirty-two adolescents (ages 12-18 years) with a depressive episode associated with bipolar I disorder were randomized to eight weeks of double-blind treatment with quetiapine, 300-600 mg/day, or placebo. This two-site study was conducted from March 2006 through August 2007. The primary efficacy measure was change in Children's Depression Rating Scale-Revised Version (CDRS-R) scores from baseline to endpoint. Secondary efficacy measures included change in CDRS-R scores over the eight-week study period (PROC MIXED), changes from baseline to endpoint in Hamilton Anxiety Rating Scale (HAM-A), Young Mania Rating Scale (YMRS), and Clinical Global Impression-Bipolar Version Severity (CGI-BP-S) scores, as well as response and remission rates. Safety and tolerability were assessed weekly.

RESULTS

There was no statistically significant treatment group difference in change in CDRS-R scores from baseline to endpoint (p = 0.89, effect size =-0.05, 95% confidence interval: -0.77-0.68), nor in the average rate of change over the eight weeks of the study (p = 0.95). Additionally, there were no statistically significant differences in response (placebo =67% versus quetiapine = 71%) or remission (placebo = 40% versus quetiapine = 35%) rates, or change in HAM-A, YMRS, or CGI-BP-S scores (all p > 0.7) between treatment groups. Dizziness was more commonly reported in the quetiapine (41%) than in the placebo (7%) group (Fisher's exact test, p = 0.04).

CONCLUSIONS

The results suggest that quetiapine monotherapy is no more effective than placebo for the treatment of depression in adolescents with bipolar disorder. However, limitations of the study, including the high placebo response rate, may have contributed to our findings and should be considered in the design of future investigations of pharmacological interventions for this population.

[Effects of a structured medication review by geriatrician and clinical pharmacologist on appropriateness of pharmacotherapy in frail elderly inpatients]

OBJECTIVE

To study the results of a structured medication review of geriatric inpatients by both geriatrician and hospital pharmacist/clinical pharmacologist.

METHODS

Patients who were present at the geriatric ward were eligible for a review of their medication and medical problems using a screening form. Recommendations and questions following these forms were subsequently discussed in the gerontopharmacologic meeting ('GFO') held every two weeks.

RESULTS

In a 30 month-period 44 GFO's were held during which 184 patients were discussed. A total of 206 recommendations were made and 115 questions were asked. Of the recommended interventions,134 (65%) were accepted by the geriatrician. To stop a medication (64/206), to change the dosage of a medication (60/206) and to switch to another medication (44/206) were the types of interventions most accounted for.

CONCLUSION

Structured medication review led to a substantial number of medication changes in geriatric inpatients. Nearly two-thirds of the recommended interventions were accepted by the geriatricians. Seventy-two recommendations (35%) were not implemented due to logistic or patient-related reasons.

[Hypokalemic thyrotoxic periodic paralysis following rice consumption]

HISTORY AND ADMISSION FINDINGS

A 38-year-old previously healthy Swiss presented with acute onset of progressive weakness in his legs in the morning hours after a carbohydrate-rich meal the preceding evening. Examination on admission revealed symmetrical paresis affecting the upper and lower limbs without involvement of the respiratory muscles. Hyperthyroidism was suspected. Similar symptoms three weeks before admission had earlier resolved spontaneously.

INVESTIGATIONS

Laboratory tests revealed severe hypokalemia of 1.4 mmol/l. Hyperthyroidism, caused by Grave's disease, was confirmed and a diagnosis of hypokalemic thyrotoxic periodic paralysis (TPP) was made. TREATMENT AND FOLLOW-UP: After initiating potassium replacement paresis was observed to disappear within three hours. Symptomatic treatment with propranolol and thyrostatic treatment with carbimazole prevented further episodes of paresis.

CONCLUSION

Hypokalemic thyrotoxic periodic paresis is a rare but increasingly common medical condition among people living in Western Europe. Diagnostically one's attention should turn to TPP at the presentation of acute paresis in combination with hypokalemia, especially in young men. Serious cardio-pulmonary complications can be avoided with early diagnosis and treatment.

Glucagon-like peptide-1 is involved in sodium and water homeostasis in humans

In previous studies with glucagon-like peptide-1 (GLP-1) we have observed that this peptide modulates fluid intake and increases renal sodium excretion in healthy volunteers and in patients with diabetes mellitus type 2. The effect of GLP-1 on thirst, water intake and on osmoregulation has, however, not been examined in detail in humans.

METHODS

Seventeen healthy male subjects were enrolled in two double-blind, placebo-controlled studies. In study part A, 8 volunteers participated in a protocol with an intravenous salt load of 26.7 +/- 0.9 g comparing the effect of an infusion of GLP-1 (1.5 pmol/kg x min) to isotonic saline (placebo). Sodium excretion and water intake were measured. In part B, 9 volunteers were challenged with an oral salt load of 27.7 +/- 0.5 g; sodium excretion and water intake were determined comparing an infusion of GLP-1 (1.5 pmol/kg x min) to isotonic saline (placebo). In part C, intestinal biopsies along the gastrointestinal tract were obtained from 14 healthy subjects. Expression of human GLP-1 receptor mRNA was measured by real-time polymerase chain reaction.

RESULTS

In study part A, an increase in renal sodium excretion was demonstrated: FeNa rose from 1.6 +/- 0.3 (placebo) to 2.7 +/- 0.2% (GLP-1; p = 0.0005). There was no difference in water consumption between the two treatments: 1,291 +/- 69 (saline) vs. 1,228 +/- 74 ml (GLP-1; p = 0.49). In part B, an oral salt challenge of 27.7 +/- 0.5 g led to an increased renal excretion of sodium during GLP-1: FeNa increased from 1.6 +/- 0.2% (placebo) to 2.0 +/- 0.2% (GLP-1; p = 0.012). In contrast to part A, oral water intake was reduced by 36% under GLP-1 treatment: 1,848 +/- 331 ml (placebo) vs. 1,181 +/- 177 ml (GLP-1; p = 0.0414). Three subjects in part B did not finish treatment with GLP-1 because of diarrhea. Human GLP-1 receptor mRNA expression was highest in the proximal human small intestine compared to terminal ileum and colon (p < 0.02).

CONCLUSIONS

GLP-1 acts on renal tissue reducing sodium absorption, probably via similar sodium transporters, which also may be localized in the gastrointestinal tract. This hypothesis needs to be confirmed by further studies.