P580Performance evaluation of dual vs. single lead automatic, real-world arrhythmic ECG recordings

Background

Detection of treatment-demanding paroxysmal arrhythmias can be difficult. Use of single lead ECG recordings for detection of Atrial Fibrillation (AF) has shown to lead to high false positive discovery rates, and requirements of additional manual clinical interpretation or 12-lead ECG to reach satisfactory diagnostic precision. Use of sequential, dual-lead ECG recordings for detection of AF has indicated significant clinical improvement in detection yield of AF and reduction of false positive discovery rates as compared to single lead-ECG.

Methods

The Coala Heart Monitor (Coala Life AB, Stockholm Sweden) system was evaluated by manual interpretation of 1,000 consecutive anonymous printouts of chest- and thumb-ECG waveforms, without any exclusion. The anonymized printouts contained three 10 s. strips of ECG at 25 mm/s, including mean heart rate, RR median and any user-provided annotation but with personal identification and algorithm analysis results blinded. The recordings were derived from actual Coala users with no training, control or influence, under a defined time period. The prevalence of cardiac conditions in the user population was unknown.

The blinded recordings were manually interpreted by a trained cardiologist. The interpretation was compared with the automatic analysis performed by an enhanced algorithm in the Coala Cloud to evaluate ECG signal performance and to calculate performance metrics of a combination of sequential dual chest- and thumb-ECG measurements as compared to the clinical performance metrics of singe lead ECG measurements only.

Results Metric Result using dual chest- and thumb-ECG and P-wave detection algorithm Result based on single lead thumb-ECG only Prevalence of AF in the recordings 14.4% (143 of 990 recordings) 14.4% (143 of 990 recordings) Percentage of recordings with ECG quality good enough to permit manual interpretation. 99,2% (8 of 998 non-readable) 98,7% (13 of 998 non-readable) Negative predictive value (NPV) for detecting AF 0.992 0.995 Positive predictive value (PPV) for detecting AF 0.872 0.647 False positive discovery rate 12.8% 35,3% Sensitivity for detecting AF 0.951 0.972 Specificity for detecting AF 0.976 0.909 Accuracy 0.973 0.919

Conclusion

Based on 1,000 real-world recordings the combination of dual chest- and thumb-ECG with P-wave detection yielded significantly higher Positive Predictive Values as compared to single lead ECG measurements. Dual chest- and thumb-ECG reduced false positive AF indications from 35,3% for single lead-ECG to 12,8% using combined chest- and thumb-ECG with P-wave detection.

P1456Evaluation of an enhanced, cloud-based AF-detection algorithm based on real-world arrhythmic recordings

Background

Cloud-based solutions offer the ability to centrally and continuously enhance detection algorithms for arrhythmias such as Atrial Fibrillation (AF) based on generated data.

Methods

The Coala Heart Monitor (Coala) system was evaluated by manual interpretation of 1,000 consecutive anonymous printouts of chest- and thumb-ECG waveforms, without any exclusion. The anonymized printouts were blinded from algorithm analysis, apart from gender and age within a 10-year span. The recordings were derived from actual Coala users in Sweden with no training, control or influence, under a defined time period. The prevalence of cardiac conditions in the user population was unknown. The blinded recordings were manually interpreted by a trained cardiologist.

The interpretation was compared with the automatic analysis performed by an algorithm in the Coala Cloud to evaluate ECG signal performance and calculate performance metrics.

An enhanced algorithm utilizing P-wave detection was then evaluated on the data set and compared with the performance metrics of the existing algorithm.

Results Metric Results with current algorithm Results with enhanced algorithm Prevalence of AF in the recordings 14.4% (143 of 990 recordings) 14.4% (143 of 990 recordings) Sensitivity for detecting AF 0.972 (95% CI = 0.930–0.992) 0.951 Specificity for detecting AF 0.946 (95% CI = 0.928–0.960) 0.976 Negative predictive value for detecting AF 0.995 (95% CI = 0.987–0.999) 0.992 Positive predictive value for detecting AF 0.751 (95% CI = 0.683–0.812) 0.872 Accuracy 0.950 0.973

Conclusion

The enhanced algorithm was found to improve the Positive Predictive Value for detecting AF as compared to the existing algorithm (0.872 vs 0.751). The reduced sensitivity for the enhanced algorithm was due to 3 consecutive recordings from a single individual who had misplaced the Coala with corresponding altered morphology of the ECG signal. The recordings were still reported as having an irregular rhythm by the algorithm.

The evolution demonstrates that cloud-based systems offer an ability to enhance detection accuracy by using reference data to train algorithms.

The CD44 ligand hyaluronic acid is elevated in the cerebrospinal fluid of suicide attempters and is associated with increased blood-brain barrier permeability

BACKGROUND

The glycosaminoglycan hyaluronic acid (HA) is an important component of the extracellular matrix (ECM) in the brain. CD44 is a cell adhesion molecule that binds to HA in the ECM and is present on astrocytes, microglia and certain neurons. Cell adhesion molecules have been reported to be involved in anxiety and mood disorders. CD44 levels are decreased in the cerebrospinal fluid (CSF) of depressed individuals, and the CD44 gene has been identified in brain GWAS studies as a possible risk gene for suicidal behavior.

METHOD

We measured the CSF levels of HA and the soluble CD44 (sCD44) in suicide attempters (n=94) and in healthy controls (n=45) using ELISA and electrochemiluminescence assays. We also investigated other proteins known to interact with CD44, such as osteopontin and the matrix metalloproteinases MMP1, MMP3 and MMP9.

RESULTS

The suicide attempters had higher CSF levels of HA (p=.003) and MMP9 (p=.004). The CSF levels of HA correlated with BBB-permeability (rho=0.410, p<.001) and MMP9 correlated with sCD44 levels (rho=0.260, p=.005).

LIMITATIONS

Other relevant biological contributors to suicidal behavior is not addressed in parallel to the specific role of CD44-HA signaling. The gender distribution of the patients from whom CSF was analyzed was uneven.

CONCLUSIONS

Increased BBB-permeability and HA levels might be a results of increased neuroinflammation and can play a role in the pathobiology of suicidal behavior. The CD44 signaling pathway might be considered a novel target for intervention in mood disorders.

Low IL-8 is associated with anxiety in suicidal patients: genetic variation and decreased protein levels

OBJECTIVE

Recent studies indicate that inflammation may play a role in the pathophysiology of suicidality. Interleukin-8 (IL-8) is a chemokine that in addition to its function in the immune system also exert neuroprotective properties. The involvement of this chemokine in neuropsychiatric conditions is incompletely known.

METHOD

We measured plasma and cerebrospinal fluid (CSF) IL-8, as well as the genotype frequency of a single nucleotide polymorphism (-251A/T, rs4073) in the promoter region of the IL8 gene, in suicide attempters (n=206) and healthy controls (n=578).

RESULTS

Plasma and CSF levels of IL-8 were significantly lower in suicide attempters with anxiety than in healthy controls. IL-8 in both plasma and CSF correlated negatively with symptoms of anxiety. Compared with the population-based cohort, the IL-8-251T allele was more prevalent among female suicide attempters. Furthermore, suicide attempters carrying this allele showed more severe anxiety. This correlative study warrants further mechanistic studies on the effects of IL-8 in the central nervous system.

CONCLUSION

We suggest that IL-8 might be involved in the biological mechanisms mediating resilience to anxiety. Thus, our findings highlight the chemokine IL-8 as a potential target for future development of anti-anxiety treatments and suicide prevention.

Glutathione in the blood and cerebrospinal fluid: a study in healthy male volunteers

Glutathione (GSH) is an important regulator of intracellular redox homeostasis. In the brain, glutathione is considered a major antioxidant, which is also found at high concentrations in the extracellular environment. Altered GSH balance in plasma, blood and cerebrospinal fluid (CSF) has been observed in several disorders suggesting that an impaired antioxidant function is part of the pathophysiology. The aim of the present study was to investigate a possible relationship between glutathione in plasma and CSF. Blood samples were collected from 26 healthy male volunteers at 8a.m., noon, 4p.m. and 8 p.m. At 8a.m. the following morning, blood was drawn and three 6-ml fractions of CSF were collected by lumbar puncture. In CSF, a disrupted gradient was found showing the highest glutathione concentration in the second compared to the first and third fraction (P<0.002). Moreover, correlation and regression analyses between glutathione in plasma and CSF revealed an association between the third fraction CSF and plasma glutathione 8 p.m. the day before lumbar puncture. Thus, if carefully standardised due to the disrupted gradient in CSF, it might be possible to estimate glutathione levels in CSF by analysing plasma in healthy males.

Stress and burnout in psychiatric professionals when starting to use dialectical behavioural therapy in the work with young self-harming women showing borderline personality symptoms

The aim of the study was to investigate how starting to use dialectical behavioural therapy (DBT) in the work with young self-harming women showing symptoms of borderline personality disorder affected the psychiatric professionals (n = 22) experience of occupational stress and levels of professional burnout. The study was carried out in relation to an 18-month clinical psychiatric development project, and used a mix of quantitative and qualitative research methods [a burnout inventory, the Maslach burnout inventory-General Survey (MBI-GS), free format questionnaires and group interviews]. The result confirms previous reports that psychiatric health professionals experience treatment of self-harming patients as very stressful. DBT was seen as stressful in terms of learning demands, but decreased the experience of stress in the actual treatment of the patients. The teamwork and supervision were felt to be supportive, as was one particular facet of DBT, namely mindfulness training which some therapists felt also improved their handling of other work stressors not related to DBT. The inventory for professional burnout, the MBI-GS, showed no significant changes over the 18-month period, although there was a tendency for increased burnout levels at the 6-month assessment, which had returned to baseline levels at 18 months.

A national stroke quality register: 12 years experience from a participating hospital

Registration of all hospitalized stroke patients is practiced in Sweden in order to assess care quality. Data in this register, Riks-Stroke (RS), may be biased due to incomplete registration. The purpose of this paper was to report changes in stroke outcome in relation to fluctuations in registration. Patients registered in RS at a hospital during the period 1994-2005 were analyzed. Case fatality at 28 days, living conditions, and activities of daily living (ADL) performance at 3 months were correlated to the number of patients registered and follow-up frequency. A total of 4994 stroke cases were registered during the period. A high annual registration rate was significantly correlated to a high case fatality ratio. A low annual follow-up rate was associated with a low proportion of patients living in their own home without any need of help. Quality parameters are sensible for selection bias, which make them difficult to compare over time and between hospitals. We suggest that by weighing outcome data against stroke severity, safer conclusions may be drawn. Additionally, hospitals considering setting up quality registers should make every effort to attain complete case ascertainment at all times, including patients managed outside the hospital, in order to avoid selection bias.

CSF 5-HIAA, suicide intent and hopelessness in the prediction of early suicide in male high-risk suicide attempters

OBJECTIVE

To study the predictive value of the Beck Suicide Intent Scale (SIS), the Beck Hopelessness Scale (BHS) and of 5-hydroxyindoleacetic acid (5-HIAA) in the cerebrospinal fluid for future early suicide in a group of high-risk male suicide attempters.

METHOD

Fifteen consecutive male suicide attempters admitted to a psychiatric ward at the Karolinska Hospital, who were not receiving any treatment with antidepressants were diagnosed according to DSM-III, assessed with SIS and BHS and submitted to lumbar puncture. All patients were followed up for cause of death.

RESULTS

Five early suicides (within 2 years) were identified. Mean cerebrospinal fluid (CSF) 5-HIAA differed between suicides and survivors. Low CSF 5-HIAA was identified in those who committed early suicide. Neither the Suicide Intent Score nor the Hopelessness Score distinguished suicides from survivors.

CONCLUSION

In high suicide risk hospitalized male psychiatric patients CSF 5-HIAA may be a better predictor of early suicide after attempted suicide than SIS or BHS.

Induction of early light-inducible protein gene expression in Pisum sativum after exposure to low levels of UV-B irradiation and other environmental stresses

Plants are constantly subjected to environmental changes and have developed various defence mechanisms to facilitate their continued existence. Pisum sativum plants were exposed to low levels of UV-B radiation and ELIP (early light-inducible proteins) mRNA, with a probable protective function, was rapidly and strongly induced during this type of stress. To our knowledge, this is the only photosynthetic gene that is up-regulated following exposure to UV-B, and this result has to be compared with studies predominantly reporting down-regulation by UV-B of genes encoding proteins localised in the plastid. The expression pattern of ELIP mRNA in pea was also investigated during salt, wounding and ozone stress. The transcript levels of ELIP were induced after the salt and wounding treatments but not during ozone fumigation.

Elevated number of cells secreting transforming growth factor beta in Guillain-Barre syndrome

We used ELISPOT and cell ELISA to study secretion of IL-4, IFN-gamma, TGF-beta, IL-6, and TNF-alpha by circulating mononuclear cells during the course of Guillain-Barré syndrome (GBS). Compared to healthy controls, patients with GBS had higher numbers of TGF-beta-secreting cells and the number of individuals with myelin-peptide-induced IL-4 and TGF-beta secretion was higher in the GBS group. No significant differences were seen concerning the predominantly pro-inflammatory cytokines IFN-gamma, IL-6 or TNF-alpha. Our findings indicate a down-regulatory role for TGF-beta and IL-4 in GBS.

The host response to urinary tract infection

The authors use the UTI model to identify basic mechanisms of disease pathogenesis, host response induction, and defense. Their studies hold the promise to provide a molecular and genetic explanation for susceptibility to UTI, and to offer more precise tools for diagnosis and therapy of these infections. There are few infections where the host response is understood in such detail and where pathologic host responses can be linked to distinct disease states. The susceptibility to UTI varies greatly in the population. The studies suggest that distinct molecular defects can cause the clinical entity of acute pyelonephritis with renal scarring, and suggest that the susceptibility to UTI in certain patient groups may have a genetic basis. In addition, the distinct signal transduction pathways explain the development of symptoms, and propose that defects in those signaling mechanisms may occur in patients with ABU. In the future, it may be useful to include these host response parameters in the diagnostic arsenal, to help in early detection of patients susceptible to recurrent UTI and renal scarring. These patients may then be offered therapies that strengthen their defense, and be offered close surveillance for recurrences and other complications.

[Effect of P fimbriae on pyuria and bacterial colonization of the human urinary tract]

This study investigated the role of P fimbriae in colonization of Escherichia coli, host response, and bacterial persistence in humans. Human volunteers were inoculated intravesically with the nonadherent ABU isolate E. coli 83972 and with P fimbriated transformants of the same strain. During the following 24 h all urine samples, and thereafter daily samples, were collected for urine culture, analysis of neutrophil numbers, and cytokine concentrations (IL-6 and IL-8). The P fimbriated transformants showed enhanced bacterial colonization in comparison to E. coli 83972 and lowered the bacterial numbers needed for persistent bacteriuria. The P fimbriated transformants also lowered the bacterial numbers needed for a significant neutrophil and cytokine host response. We conclude that P fimbriae enhance bacterial colonization and trigger the host response in the human urinary tract.

The 'innate' host response protects and damages the infected urinary tract

Symptoms of infection and tissue pathology are caused by the host response; not by the microbe per se. The same response is also critical for the defence and is needed to clear infection. It is therefore essential to understand how the host response is activated and to identify the critical effector mechanisms of the defence. We have studied these issues in the urinary tract infection (UTI) model. The symptoms of UTI and the host defence both rely on the so-called 'innate' immune system, making this one of the best characterized human disease models of 'innate immunity. We discuss the critical molecular events that determine whether the host response will be activated by P-fimbriated uropathogenic Escherichia coli as well as factors determining whether the patient develops acute pyelonephritis or asymptomatic bacteriuria. We will describe the glycoconjugate receptors used by the P-fimbriated bacteria adhering to host tissues, the recruitment of TLR4 co-receptors and the signalling pathways that allow progression to symptomatic disease, and discuss how these mechanisms are altered in asymptomatic carriers, presenting the possible genetic basis for unresponsiveness. We have shown that neutrophils are the critical effectors of the host defence and that neutrophil dysfunctions lead to acute pyelonephritis and renal scarring. Here we discuss the mechanisms of neutrophil-mediated, chemokine receptor (CXCR1)-dependent clearance, and the defect in interleukin-8 receptor homolog knock-out (IL-8Rh KO) mice and describe the data linking low CXCR1 expression to recurrent pyelonephritis in man, as well as the information on the genetic basis for low CXCR1 expression in affected patients. Finally, the mechanisms of renal scarring in IL8Rh KO mice will be discussed in relation to human disease. Our studies hold the promise to provide a molecular and genetic explanation for disease susceptibility in some patients with UTI and to offer more precise tools for the diagnosis and therapy of these infections.

Management and prognostic features of intracerebral hemorrhage during anticoagulant therapy: a Swedish multicenter study

BACKGROUND AND PURPOSE

Patients treated with oral anticoagulants (ACs) have an increased risk of intracerebral hemorrhage (ICH), which is more often fatal than spontaneous ICH. Options to reverse the AC effect include intravenous administration of vitamin K, plasma, and coagulation factor concentrate. However, the optimal management of AC-related ICH has not been determined in any randomized trial. In this study, the present management of AC-related ICH was surveyed, and determinants of survival were assessed.

METHODS

We retrospectively reviewed the medical records of all AC-related ICHs at 10 Swedish hospitals during a 4-year period, 1993 to 1996. Survival status after the ICH was determined from the Swedish National population register.

RESULTS

We identified 151 patients with AC-related ICH. Death rates were 53.6% at 30 days, 63.6% at 6 months, and 77.5% at follow-up (mean 3.5 years). The case fatality ratio at 30 days was 96% among patients unconscious on admission (n=27), 80% among patients who became unconscious before active treatment was started (n=15), 55% among patients in whom no special action was taken except withdrawal of AC treatment (n=42), and 28% among patients given active anti-coumarin treatment while they were still conscious (n=64). The case fatality ratio at 30 days was 11% in the group treated with plasma (n=18), 30% in the group treated with vitamin K (n=23), and 39% in the group treated with coagulation factor concentrate (n=23). Within the first 24 to 48 hours after admission, 47% of the patients deteriorated. Choice of therapy to reverse the AC effect differed substantially between the hospitals (P<0.0001), as did the time interval from symptom onset to start of treatment. Multiple logistic regression analysis showed only 2 factors (intraventricular extension of bleeding and ICH volume) that were independently related to case fatality at both 30 days and 6 months. The results were similar when the analysis was restricted to patients who were conscious on admission.

CONCLUSIONS

In AC-related ICH, a progressive neurological deterioration during the first 24 to 48 hours after admission is frequent, and the mortality is high. Choice of therapy to reverse the AC effect differed considerably between the hospitals. There was no evidence that any treatment strategy was superior to the others. A randomized controlled trial is needed to determine the best choice of treatment.

Neutrophil recruitment, chemokine receptors, and resistance to mucosal infection

Neutrophil migration to infected mucosal sites involves a series of complex interactions with molecules in the lamina propria and at the epithelial barrier. Much attention has focussed on the vascular compartment and endothelial cells, but less is known about the molecular determinants of neutrophil behavior in the periphery. We have studied urinary tract infections (UTIs) to determine the events that initiate neutrophil recruitment and interactions of the recruited neutrophils with the mucosal barrier. Bacteria activate a chemokine response in uroepithelial cells, and the chemokine repertoire depends on the bacterial virulence factors and on the specific signaling pathways that they activate. In addition, epithelial chemokine receptor expression is enhanced. Interleukin (IL)-8 and CXCR1 direct neutrophil migration across the epithelial barrier into the lumen. Indeed, mIL-8Rh knockout mice showed impaired transepithelial neutrophil migration, with tissue accumulation of neutrophils, and these mice developed renal scarring. They had a defective antibacterial defense and developed acute pyelonephritis with bacteremia. Low CXCR1 expression was also detected in children with acute pyelonephritis. These results demonstrate that chemokines and chemokine receptors are essential to orchestrate a functional antimicrobial defense of the urinary tract mucosa. Mutational inactivation of the IL-8R caused both acute disease and chronic tissue damage.

A waste of life: fathers' experience of losing a child before birth

BACKGROUND

The prenatal loss of an expected child entails parental despair and grief. The grief after a stillborn child is sometimes described as a "forgotten form of grief" and the fathers as the "forgotten mourners." Our aim was to describe how fathers experienced losing a child as a result of intrauterine death.

METHOD

Eleven men were interviewed 5 to 27 months after the intrauterine death of their child during weeks 32 to 42 of pregnancy. The interviews were analyzed using a phenomenological methodology.

RESULTS

After being informed of the infant's death, most fathers first wanted their partners to have a cesarean section, but all later thought that it would be right for the child to be delivered vaginally. A strong feeling of frustration and helplessness came over them during and after the delivery. Several men found meaning and relief in their grief by supporting their partner. Tokens of remembrance from the child were invaluable, and fathers appreciated that the staff collected these items, even if the parents declined them. The perceived prerequisite for resuming their everyday lives consisted of the support they received from the hospital staff and precious memories of the child. The most important comfort in their grief was a good relationship with their partner. Some fathers missed having a man to talk to both at the time of the stillbirth and subsequently.

CONCLUSION

The fathers' general trust in life and the natural order was suddenly and unexpectedly severely tested by the death of their child, which they perceived as a terrible waste of life. They sought understanding as grieving men and fathers from both the hospital personnel and their partners, as well as from relatives. Being able to protect their partner and to grieve in their own way was important to the fathers.

Improving the interface between primary and secondary care: a statement from the European Working Party on Quality in Family Practice (EQuiP)

A group from the European Working Party on Quality in Family Practice (EQuiP), working with over 20 European colleges of primary care, has assessed what, in their view, is needed to improve the quality of care at the interface between general practice and specialists. Experiences and ideas from a wide range of people were gathered through focused group discussions. From these it was clear that, for real improvement at the interface of care, changes are needed in the system of care and in the ways that doctors view their roles and their performance. All providers of care need to be able to see the care system from the patients' perspective if they are to help their patients make sense of and benefit from an increasingly complex system. This paper outlines the EQuiP recommendations on how cooperation between general practitioners and specialists might be improved. This includes strategic perspectives and both targets for improvement and methods for teaching, training and development that are all independent of country and health care system. The 10 targets for development identified by the group are: leadership, initial shared care approaches, task division, mutual guidelines, patient perspective, informatics, education, team building, quality monitoring systems, and cost effectiveness. Working towards these targets could provide an effective approach to improving the cooperation between the interfaces of care. Getting effective leadership is a necessary first step as implementation of such a strategy will involve significant change. Responsibility lies primarily with the medical profession.

Psychiatric care as seen by the attempted suicide patient

Psychiatric care as seen by the attempted suicide patient This study highlights the experiences of patients during in-patient psychiatric care in Sweden following a suicide attempt. Eighteen patients were interviewed as close to being discharged as possible. Each respondent was asked to narrate his/her experiences of the care received. An interview guide concerned the following areas: admission to the hospital, feelings and reactions, and positive as well as negative experiences during the hospital stay. The interviews were transcribed verbatim and a qualitative content analysis concerning the meanings, intuitions, consequences and the context of the data was performed. Three central categories were identified: being a psychiatric patient, patients' perceptions of the caregivers and the care provided, as well as important aspects of the psychiatric care received. The importance of being well cared for and receiving understanding and confirmation was emphasized. Lack of confirmation may have contributed in some cases to a feeling of being burdensome, demands for discharge or even another suicide attempt. Verbal contacts with the staff were seen as essential for the process of healing and for the desire to go on living.

Nurses' attitudes to attempted suicide patients

The purpose of this study was to investigate the attitudes towards attempted suicide patients among registered nurses involved in the somatic care of such patients, and to compare them with those of psychiatric nurses. The attitudes were measured on a newly constructed scale, the Understanding of Suicide Attempt Patients Scale (USP-Scale), and three brief clinical vignettes with the answer format of a visual analogue scale (VAS). The nurses working within the psychiatric services were more understanding and more willing to nurse suicide attempt patients than nurses in somatic disciplines. Among all the nurses, older personnel were more favourably disposed than the younger, and more frequent contact with suicide-prone patients was related to more positive attitudes. The perceived need for further training in suicidology was significantly stronger among the nurses in the general hospitals. This suggests that their 'negative attitudes' may to some extent be a result of lack of knowledge and uncertainty rather than a hostile attitude. The nurse has a responsibility to create a positive climate in the patient's encounter with the health services. Knowledge and understanding are needed to enable the nurse to provide professional care for a difficult and challenging patient group.

Sensorimotor stroke; clinical features, MRI findings, and cardiac and vascular concomitants in 32 patients

BACKGROUND AND PURPOSE

Sensorimotor stroke (SMS) is often included among the lacunar syndromes, although the underlying cause of this stroke-subtype is less well documented. To this end we analysed 32 patients presenting with a sensorimotor syndrome.

METHODS

The study protocol included vascular risk factors, echocardiography, Doppler sonography of carotid arteries, CT scan and MRI of the brain.

RESULTS

There were 23 men and 9 women, mean age 65.7 years. Hypertension was present in 28% and diabetes in 19%. In all, 63% had sensorimotor deficit of faciobrachiocrural areas and 37% had faciobrachial or brachiocrural deficits. MRI disclosed a presumably relevant infarct in 26 patients (81%); 20 patients (62%) localized to the territory of small perforating arteries, 3 patients (9.5%) in the internal borderzone, and 3 patients (9.5%) in cortical territories. Eight of 20 deep infarcts were larger than 15 mm. No hemorrhage or non-vascular lesion was found. A potential cardioembolic source was present in 5 patients (16%), whereas 2 patients (6%) had an ipsilateral carotid stenosis >50%.

CONCLUSIONS

Small vessel disease was the most likely cause in 69% of our patients with SMS, whereas 31% had a potential cardioembolic source, large artery disease or infarcts not compatible with perforating artery disease.

T helper type 2 like cytokine responses to peptides from P0 and P2 myelin proteins during the recovery phase of Guillain-Barré syndrome

T-lymphocytes are probably involved in the pathogenesis of Guillain-Barré syndrome (GBS). T-helper-1 (Th1) cytokines activate macrophages and induce a delayed type hypersensitivity (DTH) inflammatory response, consistent with the morphology of the demyelination in GBS. Th2 cytokines encourage antibody production and downregulate Th1 responses. To study the Th1/Th2 cytokines in relation to the clinical course of GBS an ELISPOT method for determination of single cells secreting interferon-gamma, IFN-gamma (Th1) or interleukin-4, IL-4 (Th2) was used. We serially investigated antigen-induced cytokine secretion from circulating T-cells stimulated with human peptides from the P0 and P2 proteins in seven patients and compared to results from seven serially investigated healthy controls. Most patients (five of seven) showed IL-4 responses during the plateau- or recovery-phase as compared to controls. One patient with a prolonged disease course, on the other hand, had an IFN-gamma dominated reactivity. We suggest that the IL-4 responses are beneficial in GBS, and may have a role in terminating the disease process in this self-limiting inflammatory disease.

Suicidal feelings and work environment in psychiatric nursing personnel

Suicidal feelings, attempted suicide and aspects of work environment and well-being in Swedish psychiatric nursing personnel were studied using a questionnaire. The questionnaire, containing 190 questions, was mailed to all 242 nurses and attendants working in psychiatric care at the department of psychiatry at Karolinska Hospital. Eighty-one percent (n = 197) returned the questionnaire. Suicidal feelings "last year" were lower than in the general population, but suicidal feeling and attempted suicide "earlier than last year" were much more common, and 13% reported that they had attempted suicide earlier in life. In order to study the possible association between work environment and suicide, a factor analysis was performed. Four factors were extracted and labelled: suicidality, quality of work, negative work environment and burn out/depression. The correlation between the factors suggests that negative work environment is associated with burn out/depression, which in turn is related to suicidality. No direct link was demonstrated between suicidality and work environment, and completed suicide was not investigated. The study provides some indirect evidence that a negative work environment may increase suicidal feelings.

Malignant and benign tumors in patients with neurofibromatosis type 1 in a defined Swedish population

BACKGROUND

The development of malignant and benign tumors in patient with neurofibromatosis type 1 (NF1) was investigated in a long term follow-up study of 70 adult NF1 patients living in Göteborg, Sweden, on January 1, 1978. Their mean age at that time was 44 years (range, 20-81 years). The 70 NF1 patients had previously been investigated in a population-based study.

METHODS

The first part of this study involved a cancer registry study. The authors compared the number of tumors in the 70 NF1 patients reported to the Swedish Cancer Registry during the period 1978-1989 with the number of tumors expected in the general population by matching the incidence rates of the two populations specific to age, time of follow-up, and gender. The 95% confidence interval for the risk quotient between the risk to the patients and the risk to the general population was estimated. The second part of the study was a clinical pathologic follow-up study. All living patients were offered a clinical reexamination in 1990. All hospital records for all the NF1 patients were reviewed, and death certificates were also reviewed when available.

RESULTS

Malignant tumors were reported to the Cancer Registry four times as often in the NF1 patient group as in the general population (95% confidence interval, 2.1-7.6) during the follow-up period 1978-1989. Before 1978, 5 of 70 patients (7%) had 6 malignant tumors; these patients were not included in the Cancer Registry study. Using all available clinical data on the 70 NF1 patients from their birth up to 1990, the authors found that 17 of 70 patients (24%) had developed a total of 19 malignant tumors, namely, 5 sarcomas (in 7% of patients), 13 carcinomas (in 16%), and 1 malignant melanoma (in 1%). Four pheochromocytomas (in 6% of patients), 2 adenomas, and 1 C-cell hyperplasia were diagnosed. Five gastrointestinal stromal tumors (in 7% of patients) were also diagnosed.

CONCLUSIONS

Malignant tumors were reported to the Swedish Cancer Registry significantly more often in the NF1 patients than was expected in the general population matched for age, gender, and time of follow-up. The development of tumors is part of the NF1 disease process, and this deserves attention both in the clinical setting and in family counseling dealing with complications of NF1 in adulthood.

Attitudes of psychiatric nursing personnel towards patients who have attempted suicide

The aim of this study was to examine the attitudes towards suicidal patients of a group of psychiatric nursing personnel (n = 197) and to establish a baseline of attitudinal measures against which the effects of a subsequent educational programme can be assessed. A scale, known as the Understanding of Suicide Attempt Patient Scale (USP Scale) was developed for this purpose. The reliability of the scale was satisfactory, and its correlation with visual analogue scale (VAS) scores based on clinical vignettes suggests that it has validity. Women tended to be more sympathetic than men, and older personnel were more favourably disposed than the younger nurses. Differences between personnel working in different settings were found, which might be explained by differences in the frequency of contact with suicide-prone patients, more frequent exposure being associated with more positive attitudes.

Functional outcome in patients with lacunar infarction

BACKGROUND AND PURPOSE

Little is known about the prognosis and the predictive factors for functional outcome after lacunar infarction. Our aim was to analyze this issue in more detail and with a longer follow-up than in previous reports.

METHODS

Functional outcome was assessed in 81 consecutive patients with a first-ever stroke and clinical and MRI findings compatible with lacunar infarction. We measured impairment (motor, sensory, and cognitive function), disability (Katz's Index of Activities of Daily Living [ADL] and four instrumental activities), and handicap (Oxford Handicap Scale). The patients were followed up for 3 years.

RESULTS

During follow-up, 6% of the patients died and 21% had recurrent strokes, mostly new lacunar infarcts. A fast initial recovery was found in most patients. At 1 year, 12% were dependent in personal ADL, which after 3 years had increased to 24%, mostly as a result of the effects of recurrent strokes. In a logistic multivariate regression model, moderate or severe hemiparesis 1 month after stroke onset was the strongest predictor of physical dependence or death at 3 years (P < .001), followed by white matter hyperintensities on MRI (P < .01). Age, vascular risk factors, and recurrent stroke were not statistically significant independent predictors of functional outcome.

CONCLUSIONS

Functional outcome regarding physical independence was favorable in most patients. Motor impairment and white matter disease were the strongest predictors of a poor functional outcome. Recurrent stroke increased disability and handicap but was not a statistically significant independent risk factor. Measurements of personal ADL alone were insensitive in detecting the consequences of stroke in many patients with preserved self-care ability, who still experienced disability and handicap.

Survival analysis of suicide risk after attempted suicide

Survival analysis of suicide risk by sex and age after attempted suicide was studied in a cohort of 1573 suicide attempters referred to the psychiatric emergency room at the Karolinska Hospital from 1981 to 1988. The time course of suicide risk and the overall prognosis after attempted suicide and, in particular, the possible usefulness of sex and age as risk factors for the prediction of suicide risk after attempted suicide was analyzed. Nearly two thirds of the sample were women and most of the suicide attempters were young (in their twenties and thirties), and the median age was 35 years. The overall mortality after a 5-year mean observation period after attempted suicide was 11%, and the suicide mortality was 6%. The suicide risk after attempted suicide among men (8.3%) was nearly twice the female suicide risk (4.3%). Age as a possible suicide risk factor was analyzed for each sex separately by median split subgrouping. It was concluded that both older and younger male suicide attempters are at high risk of suicide (7% and 10% respectively), and older women are at higher risk than younger (6% vs 2%). The suicide risk is particularly high during the first year after the suicide attempt. The high suicide risk group of young adult male suicide attempters is one of the main feasible targets of psychiatric intervention research programs on suicidal behavior. Suicide among young men is a major cause of years of life lost.

Sensory symptoms and signs and results of quantitative sensory thermal testing in patients with lacunar infarct syndromes

BACKGROUND AND PURPOSE

Quantitative data on sensory impairment in stroke patients are limited. We measured the perception thresholds for temperature and thermal pain in patients with different lacunar syndromes, correlated the results with clinical and magnetic resonance imaging (MRI) findings, and studied the long-term prognosis of sensory dysfunction.

METHODS

Quantitative thermal testing was performed by means of the Marstock method in 39 patients with lacunar syndromes (pure motor, sensorimotor, or pure sensory stroke) and MRI findings compatible with occlusion of a single perforating artery. Thresholds for cold, warmth, and heat pain were obtained bilaterally from the cheek, hand, and leg. The unaffected side was used as control. Follow-up included clinical assessments and repeated quantitative thermal testing (in 17 patients) up to 1 year after stroke onset.

RESULTS

Patients with pure sensory stroke and sensorimotor stroke (n = 22) had a significant thermal hypoesthesia on the affected side for all modalities and test locations. Patients with pure motor stroke (n = 17) exhibited thermal hypoesthesia for cold and heat pain in the hand and for cold perception in the leg. On MRI, infarcts causing pure motor and sensorimotor stroke were predominantly lenticulocapsular, while a thalamic site of infarction was found in pure sensory stroke. The prognosis of sensory impairment was favorable, except for poststroke pain syndromes in three patients.

CONCLUSIONS

Quantitative thermal testing confirmed an involvement of spinothalamic pathways in lacunar infarcts causing pure sensory and sensorimotor stroke and revealed a subclinical sensory impairment in patients with pure motor stroke. Infarction sites were similar in patients with pure motor and sensorimotor stroke.

CSF 5-HIAA predicts suicide risk after attempted suicide

Suicide risk after attempted suicide, as predicted by cerebrospinal fluid (CSF) monoamine metabolite concentrations, was studied in a sample of 92 psychiatric mood disorder inpatients admitted shortly after attempting suicide. The potential of the serotonin metabolite 5-hydroxyindoleacetic acid (5-HIAA) in the CSF to predict suicide risk within the first year after attempted suicide was studied by means of survival analysis after after median split subgrouping. Eleven patients (12%) committed suicide within 1 year after attempted suicide. Eight of these belonged to the below-the-median (< 87 nM) CSF 5-HIAA subgroup, that is, the suicide risk was 17% as compared with 7% among those with above-the-median CSF 5-HIAA. The cumulative number of survived patient-months during the first year after attempted suicide was significantly lower in the low CSF 5-HIAA subgroup. It was concluded that low CSF 5-HIAA predicts short-range suicide risk after attempted suicide in mood disorder psychiatric inpatients. These findings lend further support to the serotonin hypothesis of suicide risk.

Effects of timolol on terbutaline- and VIP-stimulated aqueous humor flow in the cynomolgus monkey

The effects of timolol on terbutaline- and VIP-stimulated aqueous humor flow were investigated in cynomolgus monkeys, with a labeled albumin dilution method. The maximal increase in aqueous humor flow caused by intracameral (100 micrograms/ml) or intravenous (0.4 micrograms/kg/min) administration of terbutaline was about 100%. The effect of intravenously infused terbutaline was completely abolished by intracameral administration of timolol, 0.1 mg/ml. The same dose of timolol also abolished the effect of intravenously infused VIP, 50 ng/kg/min. Intravenous administration of timolol, 0.2 mg/kg, had no effect on VIP-stimulated aqueous humor flow, when VIP (90 micrograms) was given intracamerally, but abolished completely the effect of intracameral terbutaline, 100 micrograms/ml. The results suggest that the effect of intravenously infused VIP on aqueous humor flow is secondary to activation of the sympathetic nervous system, while the effect of intracameral administration of VIP is a direct effect on the ciliary epithelium. The maximal aqueous humor flow achieved with terbutaline is comparable to that in conscious cynomolgus monkeys.

Myopathy with respiratory failure and typical myofibrillar lesions

16 patients representing 7 different pedigrees exhibited an unusual, adult onset limb-girdle myopathy with typical clinical hallmarks. In a majority of cases there was evidence of an autosomal dominant inheritance. A prominent early finding in all cases was respiratory muscle weakness, and in many of these an acute respiratory incapacity was the reason for the first neurological examination. Neck flexor and sometimes foot extensor weakness were other early symptoms. The clinical picture seems to be at variance with that of the more well known hereditary myopathies. Electrophysiological analysis confirmed a myopathy and serum muscle enzyme concentrations were normal or slightly elevated. Muscle biopsy findings revealed myofibrillar changes which, at the light microscopy level, included plaques that stained strongly with rhodamine-conjugated phalloidin, a specific marker for F-actin. At the ultrastructural level, these plaques were observed to be composed of moderately dense, thin filaments and were related to splitting of Z-discs or formed extensions from Z-discs. We believe that the muscle biopsy changes revealed by cytochemical and ultrastructural observations indicate defective myofibrillogenesis, and the possibility of defective actin polymerization is discussed. A conclusive answer requires further immunocytochemical and immunoelectrophoretic studies and possibly the application of molecular genetics.

Increased uveoscleral outflow as a possible mechanism of ocular hypotension caused by prostaglandin F2 alpha-1-isopropylester in the cynomolgus monkey

The effects of topical application of a single dose of prostaglandin F2 alpha, administered as the isopropylester, on the intraocular pressure (IOP), aqueous humor flow (AHF), conventional, and uveoscleral outflow were studied in cynomolgus monkeys under pentobarbital anesthesia. 1 microgram PGF2 alpha decreased the IOP by 2.9 +/- 0.6 mmHg (3 hr after the application) as compared with the vehicle-treated control eye. The mean AHF during the whole experiment was slightly higher in the experimental than in the control eye, 1.34 +/- 0.11 microliters min-1 compared with 1.16 +/- 0.09 microliters min-1. The uveoscleral outflow was significantly increased in the PGF2 alpha-treated eye, 0.98 +/- 0.12 microliters min-1 compared with 0.61 +/- 0.10 microliters min-1 for the control eye. The conventional outflow was lower in the experimental eye throughout the experiment. Topical application of 10 micrograms pilocarpine at the time when the fall in IOP was expected prevented the drop in the IOP. Simultaneously the increase in the uveoscleral outflow was abolished. After systemic pretreatment with atropine, 1 mg (kg body weight)-1 i.v., there was no significant difference in IOP, AHF, conventional or uveoscleral outflow between the PGF2 alpha-treated, and the control eye. The results of the present investigation suggest that PGF2 alpha decreases the intraocular pressure by increasing the uveoscleral outflow. The mechanism behind the increase in the uveoscleral outflow remains to be established. Relaxation of the ciliary muscle as well as enlarged intramuscular spaces and loss of extracellular material may contribute to the effect.

Metoprolol and propranolol in migraine prophylaxis: a double-blind multicentre study

In a double-blind, cross-over multicentre trial, the prophylactic antimigraine effect of the beta 1-selective beta-blocker metoprolol was evaluated and compared with that of the non-selective beta-blocker propranolol. Metoprolol was used in a dosage of 50 mg b.i.d. and propranolol in 40 mg b.i.d. 56 patients with classical or common migraine were included in the double-blind part of the investigation. 3 patients withdrew, but none because of side-effects. The data suggest that metoprolol is clinically equivalent in effectiveness to propranolol in migraine prophylaxis regarding parameters such as attack frequency, improvement in sum of severity score and subjective evaluation. Both drugs were generally well tolerated and the number of reported side-effects was similar to those reported during the run-in period (placebo).