Understanding caregiver descriptions of initial signs and symptoms to improve diagnosis of metachromatic leukodystrophy

BACKGROUND

Metachromatic leukodystrophy (MLD), a relentlessly progressive and ultimately fatal condition, is a rare autosomal recessive lysosomal storage disorder caused by a deficiency of the enzyme arylsulfatase A (ARSA). Historically management has been palliative or supportive care. Hematopoietic stem cell transplantation is poorly effective in early-onset MLD and benefit in late-onset MLD remains controversial. Hematopoietic stem cell gene therapy, Libmeldy (atidarsagene autotemcel), was recently approved by the European Medicines Agency for early-onset MLD. Treatment benefit is mainly observed at an early disease stage, indicating the need for early diagnosis and intervention. This study contributes insights into the caregiver language used to describe initial MLD symptomatology, and thereby aims to improve communication between clinicians and families impacted by this condition and promote a faster path to diagnosis.

RESULTS

Data was collected through a moderator-assisted online 60-min survey and 30-min semi-structured follow-up telephone interview with 31 MLD caregivers in the United States (n = 10), France (n = 10), the United Kingdom (n = 5), and Germany (n = 6). All respondents were primary caregivers of a person with late infantile (n = 20), juvenile (n = 11) or borderline late infantile/juvenile (n = 1) MLD (one caregiver reported for 2 children leading to a sample of 32 individuals with MLD). Caregivers were asked questions related to their child's initial signs and symptoms, time to diagnosis and interactions with healthcare providers. These results highlight the caregiver language used to describe the most common initial symptoms of MLD and provide added context to help elevate the index of suspicion of disease. Distinctions between caregiver descriptions of late infantile and juvenile MLD in symptom onset and disease course were also identified.

CONCLUSIONS

This study captures the caregiver description of the physical, behavioral, and cognitive signs of MLD prior to diagnosis. The understanding of the caregiver language at symptom onset sheds light on a critical window of often missed opportunity for earlier diagnosis and therapeutic intervention in MLD.

Synthesis, Crystal Structure, and Optical Characterization of the Sulfide Chloride Oxide CsBa6V4S12ClO4 with a Near-Infrared Fluorescence

When CsCl, BaS, BaO, V, and S are reacted in a solid-state reaction under inert conditions, pure powders and single crystals of senary CsBa₆V₄S₁₂ClO₄ can be obtained. Its unique crystal structure has the symmetry R3̅H (no. 148) and unit cell parameters a = 9.0575(2) and c = 28.339(1) Å. The crystal structure contains polar units [VS₃O]^3- and a complex BaS₇ClO₂ coordination. The compound gets its deep-red color from a low-energy charge transfer, which can be explained by an electron transfer from S^2- to V⁵⁺. In the near-infrared range, down-converted fluorescence occurs at 1.06 and 0.90 eV, and both emissions appear <450 ps after excitation at about 1.27 eV.

Influence of the average molar mass of poly(N-vinylpyrrolidone) on the dimensions and conductivity of silver nanowires

Improving the performance of Ag nanowire electrodes by adjusting the reaction conditions and the molar mass of PVP.

Cold Flow as Versatile Approach for Stable and Highly Luminescent Quantum Dot-Salt Composites

Since the beginning of the 1980s, colloidally synthesized quantum dots (QDs) have been in the focus of interest due to their possible implementation for color conversion, luminescent light concentrators, and lasing. For all these applications, the QDs benefit from being embedded into a host matrix to ensure stability and usability. Many different host materials used for this purpose still have their individual shortcomings. Here, we present a universal, fast, and flexible approach for the direct incorporation of a wide range of QDs into inorganic ionic crystals using cold flow. The QD solution is mixed with a finely milled salt, followed by the removal of the solvent under vacuum. Under high pressure (GPa), the salt powder loaded with QDs transforms into transparent pellets. This effect is well-known for many inorganic salts (e.g., KCl, KBr, KI, NaCl, CsI, AgCl) from, e.g., sample preparation for IR spectroscopy. With this approach, we are able to obtain strongly luminescent QD-salt composites, have precise control over the loading, and provide a chemically robust matrix ensuring long-term stability of the embedded QDs. Furthermore, we show the photo-, chemical, and thermal stability of the composite materials and their use as color conversion layers for a white light-emitting diode (w-LED). The method presented can potentially be used for all kinds of nanoparticles synthesized in organic as well as in aqueous media.

Beeinflussung der Wuchsformen des Lactobacillus bifidus

In der vorstehenden Arbeit wird gezeigt, daß der L. bifidus, der im Stuhl des an der Brust ernährten Säuglings praktisch ausschließlich als Stäbchen wächst, in vitro nur dann Verzweigungen verschiedenen Grades bildet, wenn die Nährböden bestimmte Hemmstoffe enthalten, bzw. die Nährböden nicht optimale Verhältnisse schaffen. Als ein solcher Stoff wurde der Bakterienhemmstoff aus dem sterilen Kulturfiltrat der Hefe Candida pseudotropicalis Basgal erkannt. Weiter wird nachgewiesen, daß auch Sulfathiazol und Sublimat in geringem Grade Verzweigungen bewirken. Kurz dauernde Einwirkung von Formaldehyd verursacht bei manchen Bifidus-Stämmen stärkste Verzweigungen. Alle Verzweigungen verschwinden wieder im Laufe einiger Passagen. Sterile Kulturfiltrate eines Stammes von E. coli und St. lactis verhinderten das Angehen von Bifidus-Kulturen, hemmten aber wachsende Kulturen nicht und bewirkten auch keine Verzweigungen. Zuletzt wird darauf hingewiesen, wie unwahrscheinlich es ist, daß Stämme von L. bifidus mit einer so großen Mutationsrate behaftet sind, daß sie nahezu konstant zu L. acidophilus mutieren, wie dies die erwähnten amerikanischen Autoren behaupten.

Die normale Wuchsform des L. bifidus ist die Stäbchenform.

FOXP3 expression in cancer cells and anthracyclines efficacy in patients with primary breast cancer treated with adjuvant chemotherapy in the phase III UNICANCER-PACS 01 trial

BACKGROUND

Predictive markers of response to chemotherapy are lacking in breast cancer patients. Forkhead Box Protein 3 (FOXP3) is an anti-oncogene whose absence in cancer cells could confer resistance to DNA damaging agent. So we made the hypothesis that FOXP3 expression predicts the response to anthracyclines in breast cancer patients and that adjuvant chemotherapy adding taxanes to anthracyclines confers an overall survival (OS) benefit over anthracyclines alone, in patients with FOXP3-negative tumors.

PATIENTS AND METHODS

Expression of FOXP3 in cancer cells was evaluated by immunohistochemistry in tumor samples from 1097 patients who participated in the PACS01 randomized trial that evaluated in adjuvant setting the adjunction of docetaxel (Taxotere) to anthracyclines in patients with localized breast cancer. Kaplan-Meier analysis and Cox regression model were used to assess OS according to the presence or absence of FOXP3 expression in tumor cells.

RESULTS

Four hundred and five tumors were found to express FOXP3 (37%). FOXP3 expression in breast cancer cells was associated with better OS (P = 0.003). Uni- and multivariate survival analyses according to treatment arm revealed that FOXP3 expression in breast cancer cells is independently associated with improved OS in patients treated with anthracycline-based adjuvant chemotherapy, but not in patients treated with sequential anthracycline-taxane. Moreover, in vitro experiments showed that FOXP3 induction in breast cancer cell lines using histone deacetylase inhibitor enhances anthracyclines efficacy.

CONCLUSION

FOXP3 expression in tumor cells may be an accurate predictive biomarker of anthracycline efficacy in breast cancer.

Metachromatic leukodystrophy: a scoring system for brain MR imaging observations

BACKGROUND AND PURPOSE

Metachromatic leukodystrophy (MLD) is a devastating demyelinating disease for which novel therapies are being tested. We hypothesized that MR imaging of brain lesion involvement in MLD could be quantified along a scale.

MATERIALS AND METHODS

Thirty-four brain MR images in 28 patients with proved biochemical and genetic defects for MLD were reviewed: 10 patients with late infantile, 16 patients with juvenile, and 2 patients with adult MLD. All MR images were reviewed by experienced neuroradiologists and neurologists (2 readers in Germany, 2 readers in the United States) for global disease burden, as seen on the T2 and fluid-attenuated inversion recovery images. A visual scoring method was based on a point system (range, 0-34) derived from the location of white matter involvement and the presence of global atrophy, analogous to the scoring system developed for adrenoleukodystrophy. The readers were blinded to the neurologic findings.

RESULTS

Thirty-three of 34 MR images showed confluent T2 hyperintensities of white matter. The inter-rater reliability coefficient was 0.988. Scores between readers were within 2 points of each other. Serial MR imaging studies in 6 patients showed significant progressive disease in 3 patients (initial score average, 4; mean follow-up, 24.3) and no change or 1 point progression in 3 patients (initial score average, 12; mean follow-up, 12.66). Projection fibers and the cerebellum tended to be involved only in advanced stages of disease.

CONCLUSIONS

The MLD MR severity scoring method can be used to provide a measure of brain MR imaging involvement in MLD patients.

Spinalan�sthesie bei der Arthroskopie des Kniegelenks

BACKGROUND AND OBJECTIVE

Intrathecal morphine provides effective postoperative analgesia but is associated with the risk of respiratory depression. A dose of only 0.1 mg has been shown to be optimal for effective and safe pain relief after abdominal surgery. This study was designed to determine whether the addition of 0.1 mg of morphine to the local anesthetic for spinal anesthesia produces adequate analgesia following arthroscopic knee joint surgery.

METHODS

A prospective, randomized, placebo-controlled, double-blind clinical trial was performed. Forty ASA I/II patients undergoing knee arthroscopy under spinal anesthesia were randomized to receive either mepivacaine 4% with 0.1 mg of morphine or mepivacaine 4% with saline (placebo) intrathecally. Postoperative analgesia consisted of intravenous morphine delivered by patient-controlled analgesia (bolus: 2 mg, lockout time: 5 min). During the study period of 24 h, pain intensity at rest and on movement (visual analogue scale, 0: no pain, 100: maximum pain), vigilance, and vital parameters were recorded every hour.

RESULTS

There were no statistically significant differences between the two groups in postoperative pain scores, morphine requirements, vigilance, blood pressure, heart rate, and breathing frequency. The patients of the morphine group required 12.3+/-10.2 mg (mean+/-SD) and those of the placebo group 11.6+/-8.4 mg of intravenous morphine from patient-controlled analgesia. The pain scores at rest and on movement were 10.0+/-8.1 and 16.0+/-12.6 in the morphine group and 8.2+/-7.9 and 11.7+/-11.3 in the placebo group. We did not observe severe side effects in any of the patients.

CONCLUSION

Intrathecal administration of 0.1 mg of morphine does not contribute to postoperative analgesia after arthroscopic knee joint surgery.

Position dependent changes of cerebral blood flow velocities in premature infants

The supine or prone positioning of infants has been a cause of much controversy. Recently it has been postulated that the position dependent hypoperfusion of the brainstem represents a possible cause of sudden infant death. To demonstrate position dependency and maturational changes of cerebral perfusion in premature newborn infants we investigated cerebral blood flow velocities (CBFV) in the main supratentorial and brainstem cerebral arteries. Measurements of CBFV were done with transfontanellar colour-coded Doppler sonography in the internal carotid artery (ICA), basilar artery (BA), and vertebral artery (VA) in the prone (head centered-baseline) and supine positions (maximal rotation to both sides) in 23 premature infants aged between 3-5 days of life. We performed follow-up measurements in 17 infants 7-10 days later and in 16 infants at the corrected age of 1 month. There was no difference in mean CBFVs between the prone and supine position at the first investigation. At the third investigation, CBFVs were significantly higher in the supine compared to the prone position. The CBFVs of the ICA were higher than in the BA and VA. This difference was not influenced by the body position but increased with post-natal age more in the VA (159%) than in the BA (129%) and ICA (128%). Position dependency was not seen in the ICA perfusion. In the prone position, five infants showed an incomplete steal effect in the contralateral VA. There was no significant side difference in the CBFVs of the ICA and VA, but in the resistance indices in the VA (left > right).

CONCLUSION

in premature newborns, position dependent changes of cerebral blood flow velocity develop with maturation and are most pronounced in the vertebrobasilar system. These changes are possibly due to compression of the vertebral artery by neck movement and suggest an individual risk of brainstem perfusion deficits that may be aggravated with age and head rotation in a prone position.

[Evaluation of the cardiorespiratory monitor SpiroGuard C for infants. Improved registration of respiratory events by new sensors and intelligent alarm management system]

OBJECTIVES

The SpiroGuard C is a commercially available cardiorespiratory monitor working with field plethysmography, wireless signal transmission and a novel alarm management system. In order to determine the recognition rates for central, mixed and obstructive apneas, a prospective clinical trial was performed comparing frequency and kind of signals from the monitor with those simultaneously registered by polysomnographic studies.

DESIGN

Normal respiratory and alarm signals of the monitor under investigation were integrated into a polysomnographic setting. All central, mixed and obstructive apneas lasting more than 10 seconds as well as all alarms obtained from the monitor were evaluated.

RESULTS

47 series of monitor recordings could be evaluated in parallel to polysomnographic studies: the detection rate for central apneas was 298/328 (90.85%), for mixed apneas 9/41 (21.95%) and for obstructive apneas 0/36 (0%). Out of the total of 708 registered alarms 359 (50.71%) were false alarms, 307 (43.36%) were apnea-related and 42/708 (5.93%) were alarms due to technical problems. 177 of the 359 false alarms (49.30%) occurred during apneas that were shorter than 10 seconds, 119 (33.15%) were related to bad signal quality, and 55 (15.32%) were caused by movement artifacts.

CONCLUSION

The recognition rate for central apneas was high (> 90%), while sensitivity for mixed and obstructive apneas was not satisfactory. Approximately half of the alarms were false alarms. These could be reduced by setting the apnea detection time to > 15 seconds, by tighter fastening of the respiration belt (improving the signal transmission), and by turning off the instrument when the child is awake and physically active. The wireless system renders the SpiroGuard C an attractive alternative for home monitoring.

Cerebral Doppler sonography of the neonate. A résumé after 20 years and future aspects

Up until recently the evaluation of CVR (analysis of pulsatility) had been a priority in Doppler sonography. In preterm and term infants with open fontanels and sutures this information is restricted despite its value in extreme situations. Continuous Doppler sonography allows a new approach to monitoring pathophysiologic processes. In connection with improved data recording and processing as well as progress in monitoring blood pressure and central venous pressure, new noninvasive methods of surveillance become possible. Thanks to these methods experimental and clinical research has increasingly gained insight on the autonomic nervous system over the last few years (e.g., m- and r-wave analysis during continuous measurement of arterial blood pressure and heart rate). Already well-known and newly developed functional tests (e.g., tilting test, CO2-reactivity, phase shift, and so forth) will further improve our understanding of physiologic processes and help us develop individual therapy concepts for the newborn.

Cerebral blood flow velocities in an infant with moyamoya disease

Moyamoya disease is a progressive cerebrovascular disorder with bilateral occlusion of the basal circulation and development of collateral blood supply. In a 6-month-old female with multifocal ischemic infarctions, transcranial pulsed Doppler sonography revealed extremely high and low cerebral blood flow velocities, dampened waveforms, reversed flow, and musical murmurs. Magnetic resonance angiography revealed different degrees of vascular stenosis and an abnormal collateral network. Moyamoya disease was confirmed by conventional angiography at the age of 10.5 months. Pulsed-wave transcranial Doppler sonography is a noninvasive screening method in infants at risk of moyamoya disease.

Paclitaxel-anthracycline combination chemotherapy in relapsing advanced ovarian cancer after platinum-based chemotherapy: a pilot study

Despite high response rates with platinum-based front-line chemotherapy, the prognosis for advanced ovarian carcinoma (AOC) is poor. Salvage chemotherapy for recurrent AOC was of little benefit before paclitaxel as single-agent therapy showed appreciable efficacy. Anthracyclines are effective, but are not often part of first-line therapy. In this pilot study, we investigated the feasibility of an anthracycline plus paclitaxel combination therapy for recurrent AOC. Twenty-four patients received 150 mg/m2 paclitaxel on day 1, with either 50 mg/m2 doxorubicin on day 1 or 75 mg/m2 epirubicin on day 1 every 3 weeks. A 27% overall response rate was obtained. Myelosuppression was the major toxicity, but was manageable. No myocardiac toxicity was observed. We conclude that paclitaxel-anthracyclines is a promising salvage combination therapy in AOC that should be investigated further.

[Anesthesia for cesarean section in Germany. A survey]

AIM OF STUDY

Goal of this survey is to give an overview of anaesthesia for caesarean section in Germany.

METHOD

In 1994 and 1995, we sent a questionnaire to the chief-anaesthetists of all German hospitals with departments of gynaecology/obstetrics to find out the routine anaesthetic procedures for caesarean section.

RESULTS

We obtained data from 409 hospitals (response rate 46.4%) with 321,816 births--50,123 of which were sections (mean caesarean section rate 16.6%). The mean general anaesthesia rate for elective caesarean sections was 66.5%, for non-elective sections 90.8%. The mean epidural anaesthesia rate for caesarean section was 22.6% and the mean spinal anaesthesia rate was 9.8%. For general anaesthesia most hospitals used antacids and/or histamine2-receptor antagonists (64.6% of responding hospitals). Anaesthesia was induced with intravenous barbiturates (82%), succinylcholine for intubation (98.2%) and no opioids before clamping of the cord (94.8%). For regional anaesthesia bupivacaine was the most common local anaesthetic (spinal 84.0%, epidural 96.8%). Opioids were added to local anaesthetics for epidural anaesthesia at 21.4% of the hospitals.

CONCLUSIONS

General anaesthesia is the commonest practice for caesarean sections at German hospitals. Nowadays regional anaesthesia gains more importance compared to previous German surveys and in agreement with foreign data.

[Neuroectodermal differentiation of embryonal carcinoma of the testis]

We report here a rare differentiation of an embryonal carcinoma of the testis to a peripheral neurectodermal tumor (PNET) with lymph nodes and lung metastases. In the present case a complete remission was obtained by a PNET oriented chemotherapy combination followed by 2 courses of classical BEP.

Bacteremia due to Gordona sputi in an immunocompromised patient

We report a case of bacteremia due to a strain identified as Gordona sputi in a patient with metastatic melanoma. The origin of infection remains unknown, but extensive cutaneous lesions due to interleukin-2 treatment may have been the portal of entry. The isolate was related to G. sputi on the basis of its biochemical and genomic properties but exhibited some differences from the type strain.

[Survival results after 10 years of 39 patients with inflammatory breast cancer treated by two different neoadjuvant chemotherapy protocols]

The aim of this study was to compare the survival results at ten years of two groups of respectively 19 and 20 females who had an inflammatory breast cancer, treated with two different neoadjuvant chemotherapy protocols of six days for the first one, and of one day for the second one. Among these 39 patients, 16 are alive, 15 without any symptoms of disease since the end of the treatment. There is no statistically significant difference between the two groups for the disease free survival interval and for the survival population.

Effects of non-specific immunostimulants (echinacin, isoprinosine and thymus factors) on the infection and antigen expression in herpesvirus-6 exposed human lymphoid cells

Non-specific immunostimulants such as plant extracts and natural and synthetic thymic preparations are widely used for enhancing the reactivity of the human defence system in chronic infections, immunodeficiency, autoimmunity and neoplastic diseases. Considering the high prevalence of latent infections by Lymphotropic herpesviruses and their frequent spontaneous reactivation, one wonders whether the stimulation of lymphoid cells by such immunostimulants may further support virus reactivation. We have performed tissue culture experiments using the well defined infectious system of human herpesvirus-6 (HHV-6) and the immature T cell HSB2 to test the effects of echinacin, isoprinosine and thymus factors on the frequency and extent of virus antigen expression in infected cells. The results show that various viral antigens related to virus replication and to the synthesis of structural components appear earlier in cells stimulated with such substances as echinacin, timunox and TP-1, but not following the stimulation with isoprinosine. Similarly, virus genome containing cells as determined by in situ hybridization techniques increased after stimulation with thymic preparations (thymostimulin and thymopentin), but not with echinacin and isoprinosine. The data suggest that the synthesis of proteins or DNA of lymphotropic viruses may be transiently enhanced when lymphoid cells are stimulated by certain non-specific immunostimulants. There was no evidence, however, of increased virus replication. Since the data presented here are rather preliminary results from tissue culture studies, the use of such substances in patients should include a critical monitoring of the activity of lymphotropic viruses to exclude untoward effects through persistent viral activity and/or autoimmune dysregulations (e.g. secondary to selective expression of viral antigens). More detailed studies are needed to this effect including long-term controls in patients treated by these substances.

[Determination of sub-populations of circulating T lymphocytes in alcoholic cirrhosis using monoclonal antibodies OKT3, 4, 5, Leu 2 and Leu 15. Effect of hepatitis B virus infection]

Peripheral T lymphocyte subpopulations were quantified in 24 alcoholic cirrhotic patients, 11 of them having anti-HBs and/or anti-HBc antibodies, and were compared with 35 healthy control subjects, 10 of them having anti-HBs and/or anti-HBc antibodies. The monoclonal antibodies utilized (OKT3, OKT4, OKT8 in simple staining, Leu 2 and Leu 15 in double staining) are considered as markers of mature (CD3), helper (CD4), cytotoxic/suppressor (CD8, Leu 2), suppressor (Leu [2+ 15+), and cytotoxic (Leu 2+ 15-) T cells. In cirrhotics, when compared to controls, the number of CD3 cells was reduced (p less than 0.01); the proportion of CD4 cells was within normal range, and that of CD8 cells diminished (p less than 0.001), contrasting with an increased proportion of Leu 2+ cells (p less than 0.01), related to an increased proportion of Leu 2+ 15+ cells. Leu 2+ 15- lymphocytes were within normal range. In control subjects, a decreased proportion of Leu 2+ 15+ cells was found (p less than 0.05) when Ac HBs and/or Ac HBc were present. In cirrhotics having at least one serologic marker of hepatitis B virus infection, when compared with negative ones, increased proportions of Leu 2+ (p less than 0.05) and Leu 2+ 15+ (p less than 0.05) cells were found. These results show that data concerning T lymphocyte subpopulations are conflicting when various types of antibodies are used. However, they suggest abnormalities of immune regulation, possibly a defect of T suppressor cell function. Hepatitis B virus infection probably modifies immune regulation in alcoholic cirrhosis, and perhaps in normal subjects.

Genetic and regulatory aspects of methionine biosynthesis in Saccharomyces cerevisiae

Methionine biosynthesis and regulation of four enzymatic steps involved in this pathway were studied in Saccharomyces cerevisiae, in relation to genes concerned with resistance to ethionine (eth(1) and eth(2)). Data presented in this paper and others favor a scheme which excludes cystathionine as an obligatory intermediate. Kinetic data are presented for homocysteine synthetase [K(m)(O-acetyl-l-homoserine) = 7 x 10(-3)m; K(i) (l-methionine) = 1.9 x 10(-3)m]. Enzymes catalyzing steps 3, 4, 5, and 9 were repressible by methionine. Enzyme 4 (homoserine-O-transacetylase) and enzyme 9 (homocysteine synthetase) were simultaneously derepressed in strains carrying the mutant allele eth(2) (r). Studies on diploid strains confirmed the dominance of the eth(2) (s) allele over eth(2) (r). Regulation of enzyme 3 (homoserine dehydrogenase) and enzyme 5 (adenosine triphosphate sulfurylase) is not modified by the allele eth(2) (r). The other gene eth(1) did not appear to participate in regulation of these four steps. Gene enzyme relationship was determined for three of the four steps studied (steps 3, 4, and 9). The structural genes concerned with the steps which are under the control of eth(2) (met(8): enzyme 9 and met(a): enzyme 4) segregate independently, and are unlinked to eth(2). These results are compatible with the idea that the gene eth(2) is responsible for the synthesis of a pleiotropic methionine repressor and suggest the existence of at least two different methionine repressors in S. cerevisiae. Implications of these findings in general regulatory mechanisms have been discussed.