Plasma Levels of Bevacizumab and Vascular Endothelial Growth Factor After Low-Dose Bevacizumab Treatment for Retinopathy of Prematurity in Infants

Importance

Intravitreal bevacizumab effectively treats severe retinopathy of prematurity (ROP), but it enters the bloodstream and may reduce serum vascular endothelial growth factor (VEGF), potentially causing detrimental effects on developing organs in the premature infant.

Objective

To evaluate the association of intravitreal bevacizumab with plasma bevacizumab and VEGF concentrations at 2 and 4 weeks after predefined, de-escalating doses of intravitreal bevacizumab were administered to infants with severe ROP.

Design, Setting, and Participants

This phase 1 dose de-escalation case series study was conducted at 10 US hospitals of ophthalmology institutions from May 21, 2015, to May 7, 2019. Blood samples were collected 2 and 4 weeks after intravitreal bevacizumab injection. Participants included 83 premature infants with type 1 ROP in 1 or both eyes and no previous ROP treatment. Data were analyzed from April 2017 to August 2021.

Interventions

Study eyes received a single bevacizumab injection of 0.250 mg, 0.125 mg, 0.063 mg, 0.031 mg, 0.016 mg, 0.008 mg, 0.004 mg, or 0.002 mg. When the fellow eye required treatment, one dose higher was administered. Total dose administered at baseline was defined as the sum of doses given to each eye within 3 days of initial study-eye injection.

Main Outcomes and Measures

Plasma bevacizumab concentration at 2 and 4 weeks after injection and the percentage change in plasma VEGF concentrations from pretreatment levels.

Results

A total of 83 infants (mean [SD] age, 25 [2] weeks; 48 boys [58%]) were included in this study. Higher doses of bevacizumab administered at baseline were associated with higher plasma bevacizumab concentrations at 2 weeks (ρ, 0.53; 95% CI, 0.31-0.70) and 4 weeks (ρ, 0.44; 95% CI, 0.18-0.64). Plasma VEGF concentrations decreased by 50% or more from pretreatment levels in 40 of 66 infants (61%) at 2 weeks and 31 of 61 infants (51%) at 4 weeks, but no association was observed between the total dose of bevacizumab administered at baseline and percentage change in plasma VEGF concentrations 2 weeks (ρ, -0.04; 95% CI, -0.28 to 0.20) or 4 weeks (ρ, -0.17; 95% CI, -0.41 to 0.08) after injection.

Conclusions and Relevance

Results of this phase 1 dose de-escalation case series study revealed that bevacizumab doses as low as 0.002 mg were associated with reduced plasma VEGF levels for most infants at 2 and 4 weeks after intravitreal administration; however, no association was observed between total bevacizumab dose administered and reductions in plasma VEGF levels from preinjection to 2 weeks or 4 weeks. Additional studies are needed to evaluate the long-term effects of low-dose bevacizumab on neurodevelopment and retinal structure.

Conspiracy beliefs and distrust of science predicts reluctance of vaccine uptake of politically right-wing citizens

It is not uncommon for conspiracy theories to have a political agenda, some conspiracies are more endorsed by the political left-wing than the political right-wing and vice-versa. Conspiracy theories quickly flourished as the COVID-19 pandemic emerged and this may have been an underlying factor in a reluctance by some in following public health policies such as the wearing of face masks. In the present study, we surveyed a community sample of 1358 adults just prior to the COVID-19 vaccine rollout in Aotearoa New Zealand. Our first aim was to determine whether one’s political orientation, whether they are politically left- or right-wing, would be predictive of an individual’s belief in conspiracy theories and determine whether this relationship can be exacerbated by a distrust in science. The second aim was to determine how such a relationship could explain an individual’s vaccine hesitancy. Our results supported that indeed those that identify as right-wing tended to have higher hesitancy associated with taking the COVID-19 vaccine. However, we demonstrated that this association, in part, can be explained by a corresponding belief in COVID-19 related conspiracies. Interestingly, such a relationship only emerged in the presence of a general distrust in science. In other words, if a right-wing individual has at least a moderate trust in science, they demonstrated similarly low endorsement of COVID-19 conspiracies as their left-wing counterparts. Mitigating the right-wing endorsement of COVID-19 conspiracies then aligned with a reduction in vaccine hesitancy. Our findings indicated that public interventions seeking to increase trust in science may mitigate right-wing endorsement of conspiracy theories and thus lead to a more unified and positive response to public health behaviours such as vaccination.

s-VCAM-1 is an independent predictor of all-cause mortality in patients with dilated cardiomyopathy and hypokinetic non-dilated cardiomyopathy

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): University Medicine Munich University Medicine Greifswald

Introduction

The vascular cell adhesion molecule-1 (VCAM-1) is overexpressed in a number of different inflammatory processes on activated endothelium. This could be shown in both a mouse model for autoimmune myocarditis and in human heart tissue from patients with lymphocytic myocarditis.

In addition to the tissue-bound one, a soluble isoform of VCAM-1 (s-VCAM-1) can also be detected in the blood. Higher levels have been associated with worse clinical outcome in chronic heart failure patients of different etiology and other patient groups.

Purpose

Since both inflammation and fibrosis are key processes involved in the pathogenesis of dilated cardiomyopathy (DCM) and hypokinetic non-dilated cardiomyopathy (HNDC), we aimed to investigate the prognostic value of s-VCAM-1 plasma levels for survival in a large cohort of DCM and HNDC patients.

Methods

The cohort comprised of patients with a primary diagnosis of DCM, defined as reduced left ventricular ejection fraction (LVEF <45%), increased left ventricular enddiastolic diameter according to HENRY score (LVEDD >117%) at time of diagnosis as well as HNDC, defined as a reduced left ventricular ejection fraction (LVEF <45%) but no increased LVEDD according to HENRY score (LVEDD < =117%). Exclusion criteria were primary valvular diseases (≥ second degree), acute myocarditis, cancer, chronic alcoholism, coronary artery disease with epicardial stenosis >50%, peripheral artery occlusive disease, known auto-immune disease and heart failure of other origins. Levels of s-VCAM-1 were measured in human plasma using an enzyme-linked immunosorbent assay (R&D Systems, USA). A Cox proportional hazard model for the association between s-VCAM-1 and all-cause mortality was adjusted for age, sex, time since symptom-onset, LVEF, kidney function (eGFR-CKDEPI), CRP and NT-proBNP.

Results

A total of 334 DCM patients were included in this single-center cohort (78.4 % males) with a mean age of 54.0 years [interquartile range [IQR] 47.0, 63.2). On average time since symptom onset was 1.5 years (IQR 0.1, 1.1), LVEF 30.7 % (IQR 25, 37), LVEDD 67.1 mm (IQR 62, 72). During a median follow-up of 12.4 years (IQR 10.1, 13.9), a total of 118 (35.3 %) patients died. Multivariable-adjusted cox regression model revealed a significantly increased all-cause mortality risk with increasing levels of s-VCAM-1 (p for trend =0.039), (hazard ratio [HR] 1.00045 (Conf. Interval 1.00002, 1.00087) for VCAM increase of 1 ng/mL, for increase of 100 ng/ml HR 1.046 (Conf- interval 1.002, 1.091), for increase of 1000ng/ml HR 1.57 (Conf_interval 1.02-2.41) (Kaplan Meier survival estimates see Figure 1, median s-VCAM-1 = 664 ng/ml, IQR 515,874).

Conclusions

s-VCAM-1 predicts long-term survival in DCM patients independent of NT-pro-BNP and other risk determinants. Further research needs to evaluate whether this biomarker proves useful in monitoring and planning management of DCM and HNDC patients (e.g. more intensive management in high-risk patients).

Abstract Figure. Kaplan-Meier survival estimates

Efficacy of Retreatment After Failed Direct-acting Antiviral Therapy in Patients With HCV Genotype 1-3 Infections

Hepatitis C virus infection is causing chronic liver disease, cirrhosis, and hepatocellular carcinoma. By combining direct-acting antivirals (DAAs), high sustained virologic response rates (SVRs) can be achieved. Resistance-associated substitutions (RASs) are commonly observed after DAA failure, and especially nonstructural protein 5A (NS5A) RASs may impact retreatment options.^1-3 Data on retreatment of DAA failure patients using first-generation DAAs are limited.^4-7 Recently, a second-generation protease- and NS5A-inhibitor plus sofosbuvir (voxilaprevir/velpatasvir/sofosbuvir [VOX/VEL/SOF]) was approved for retreatment after DAA failure.⁸ However, this and other second-generation regimens are not available in many resource-limited countries or are not reimbursed by regular insurance, and recommendations regarding the selection of retreatment regimens using first-generation DAAs are very important. This study aimed to analyze patients who were re-treated with first-generation DAAs after failure of a DAA combination therapy.

Save the children by treating their mothers (PriVileG-M-study) - study protocol: a sequentially randomized controlled trial of individualized psychotherapy and telemedicine to reduce mental stress in pregnant women and young mothers and to improve Child's health

BACKGROUND

As early as pregnancy, maternal mental stress impinges on the child's development and health. Thus, this may cause enhanced risk for premature birth, lowered fetal growth, and lower fetal birth weight as well as enhanced levels of the stress hormone cortisol and lowered levels of the bonding hormone oxytocin. Maternal stress further reduces maternal sensitivity for the child's needs which impairs the mother-child-interaction and bonding. Therefore, prevention and intervention studies on mental stress are necessary, beginning prenatally and applying rigorous research methodology, such as randomized controlled trials, to ensure high validity.

METHODS

A randomized controlled trial is used to assess the impact of psychotherapy and telemedicine on maternal mental stress and the child's mental and physical health. Mentally stressed pregnant women are randomized to an intervention (IG) and a not intervened control group. The IG receives an individualized psychotherapy starting prenatal and lasting for 10 months. Afterwards, a second randomization is used to investigate whether the use of telemedicine can stabilize the therapeutic effects. Using ecological momentary assessments and video recordings, the transfer into daily life, maternal sensitivity and mother-child-bonding are assessed. Psycho-biologically, the synchronicity of cortisol and oxytocin levels between mother and child are assessed as well as the peptidome of the colostrum and breast milk, which are assumed to be essential for the adaptation to the extra-uterine environment. All assessments are compared to an additional control group of healthy women. Finally, the results of the study will lead to the development of a qualification measure for health professionals to detect mental stress, to treat it with low-level interventions and to refer those women with high stress levels to mental health professionals.

DISCUSSION

The study aims to prevent the transgenerational transfer of psychiatric and somatic disorders from the mother to her child. The effects of the psychotherapy will be stabilized through telemedicine and long-term impacts on the child's and mothers' mental health are enhanced. The combination of psychotherapy, telemedicine and methodologies of ecological momentary assessment, video recording and bio banking are new in content-related and methodological manner.

TRIAL REGISTRATION

German Clinical Trials Register: DRKS00017065. Registered 02 May 2019. World Health Organization, Universal Trial Number: U1111-1230-9826. Registered 01 April 2019.

Scalp simulation - A novel approach to site-specific biomechanical modeling of the skin

OBJECTIVES

This study aimed to determine the hardness of the human scalp in vivo in order to identify an appropriate scalp simulant, from a range of commercially available silicone materials, for force impact assessment. Site-dependent variation in scalp hardness, and the applicability of contemporary skin simulants to the scalp were also considered.

MATERIALS AND METHODS

A Shore A-type durometer was used to collected hardness data from the scalps of 30 human participants (five males and five females in each of the three age categories: 18-30, 31-40, 41-50) and four commercially available silicones (light, medium, and heavy-bodied PVS, and duplication silicone). One-sample t-tests were used to compare the mean hardness of simulants to that of the scalp. Site-dependent variation in the hardness of the scalp was assessed using a mixed-model repeated measures ANOVA.

RESULTS

Mean human scalp hardness derived from participants was 20.6 Durometer Units (DU; SD = 3.4). Analysis revealed only the medium-bodied PVS to be an acceptable scalp simulant when compared to the mean hardness of the human scalp (p = 0.869). Scalp hardness varied significantly anteroposteriorly (with an observable linear trend, p < 0.001), but not mediolaterally (p = 0.271). Comparisons of simulants to site-specific variation in scalp hardness anteroposteriorly found the medium-bodied PVS to be only suitable in the central region of the scalp (p = 0.391). In contrast, the duplication silicone (p = 0.074) and light-bodied PVS (p = 0.147) were only comparable to the posterior region.

CONCLUSIONS

Contemporary skin simulants fail to accurately represent the scalp in terms of hardness. There is strong support for the use of medium-bodied PVS as a scalp simulant. Human scalp hardness varies significantly anteroposteriorly, but not mediolaterally, corresponding to regional anatomical variation within the scalp. A number of materials were identified as potential simulants for different regions of the scalp when more site-specific simulant research is required.

Analysis of the three common mutations in the CARD15 gene (R702W, G908R and 1007fs) in South African colored patients with inflammatory bowel disease

The caspase recruitment domain-containing protein 15 gene (CARD15) was recently identified as an important susceptibility gene for Crohn's disease (CD). The purpose of this study was to assess the likelihood that the three most common CARD15 mutations, R702W, G908R and 1007fs, contribute to inflammatory bowel disease (IBD) susceptibility in the South African colored population. The study cohort included 76 IBD patients, 41 with CD and 35 with ulcerative colitis (UC), and 100 population-matched controls. Mutations R702W, G908R and 1007fs were present at relatively low frequencies (<20%) in our study population. No statistically significant differences were furthermore, observed for these mutations between UC and CD patients or when compared with normal control individuals. Two additional mutations were identified, one novel (A661P) and one previously described (A725G), with the latter being identified in 4 of 35 (11%) UC patients. Statistically significant differences were obtained between UC and control individuals when comparing both allele (p<0.004, chi2 with Yates' correction=8.01) and genotype frequencies (p<0.004, chi2 with Yates' correction=8.14) for the A725G mutation, suggesting a possible role for this variant in disease expression.

Impairment–oriented training and adaptive motor cortex reorganisation after stroke: a fTMS study

In a sample of 28 subacute anterior circulation ischemic stroke patients with severe arm paresis, reduced motor cortex excitability (increased motor thresholds, reduced MEP amplitudes, reduced number of active points) and a reduced conduction velocity in the corticospinal system were found in the affected hemisphere. At the same time motor cortex topology for the abductor pollicis brevis (APB) representation was comparable for the affected and non-affected hemisphere. Considerable arm motor recovery (Fugl-Meyer test) was observed when assessed four weeks later after a period of rehabilitation intervention. Motor cortex excitability and conduction velocity in the corticospinal system improved in the affected hemisphere. In addition, APB representation showed a medial shift in patients with such a representation at pre test (n=14). Multiple stepwise regression indicated that of all transcranial magnetic stimulation (TMS) parameters only the medial shift of the motor cortex map predicted motor recovery. Assessing the effect of training time (non-intensified vs. intensified therapy) and type of arm training (Bobath approach vs. Arm BASIS training) with a randomised controlled design revealed that the impairment-oriented Arm BASIS training improved motor control more than the control conditions. In addition, patients of the group receiving the Arm BASIS training with an APB representation at pre test showed a medial shift of the motor cortex map and improved conduction times. In conclusion, changes in motor cortex topology were likely to be relevant for motor recovery and might have been induced by the impairment-oriented training.

Fallbericht einer „HERDA-ähnlichen” equinen kutanen Bindegewebserkrankung zweier American Quarter Horses

Gegenstand: Die „HERDA” (hereditäre equine regionale dermale Asthenie) amerikanischer Quarter Horses stellt eine hereditäre Erkrankung des kollagenen Bindegewebes der Haut dar, die in vergleichbarer Weise auch bei anderen Tierarten und beim Menschen (Ehlers-Danlos-Syndrom) beschrieben worden ist. Material und Methode: Bei zwei American Quarter Horses der selben väterlichen Abstammung wurde aufgrund einer klinisch manifesten dermalen Hyperelastizität, vor allem im Bereich der Sattellage, die klinische Diagnose einer „HERDA-ähnlichen” Erkrankung gestellt. Die Therapie erfolgte mittels Lasertechnik und anschließender konservativer Chirurgie. Haut und Unterhautproben wurden (immun)histologisch und elektronenmikroskopisch untersucht. Ergebnisse: Die Behandlung war erfolgreich. (Immun)histologische sowie elektronenmikroskopische Untersuchungen entnommener Hautareale ergaben keine Hinweise auf einen kutanen Kollagenfaserdefekt. Schlussfolgerung und klinische Relevanz: Die Befunde beider Quarter Horses sprechen für eine hinsichtlich der Klinik „HERDA-ähnliche” Erkrankung. Die beiden Fälle zeigen, dass derartige klinisch manifeste kutane Bindegewebserkrankungen beim Pferd, im Unterschied zu den in der Literatur bereits dokumentierten Fällen, auch ohne ein histomorphologisches Korrelat auftreten können.

Associations of health related behaviour, social relationships, and health status with persistent physical activity and inactivity: a study of Finnish adolescent twins

OBJECTIVE

To examine the association between leisure time physical activity over a three year period and health related behaviour, social relationships, and health status in late adolescence as part of a nationwide longitudinal study.

METHODS

Five birth cohorts of adolescent twins aged 16 at baseline (n = 5028; 2311 boys and 2717 girls) participated in the study. Questionnaires on leisure time physical activity, other health related behaviour, social relationships, and health status were sent to the twins on their 16th and 17th birthdays and six months after their 18th birthday. The combined response rate to the three questionnaires was 75.8% for boys and 81.7% for girls. Those who answered in all three questionnaires that their frequency of physical activity was 4-5 times a week or more were defined as persistent exercisers, and those who exercised at most twice a month in all three were defined as persistently inactive. Logistic regression analyses were used to identify baseline variables associated with outcome measures.

RESULTS

Overall, 20.4% of boys and 13.0% of girls were persistent exercisers and 6.5% of boys and 5.3% of girls were persistently inactive. In both sexes, smoking, irregular breakfast eating, attending vocational school, and poor self perceived current health were significantly associated with persistent inactivity.

CONCLUSIONS

Persistent physical inactivity in adolescents is associated with a less healthy lifestyle, worse educational progression, and poor self perceived health. Tailoring methods to promote physical activity may prove useful for influencing other health habits. Such programmes are indicated for vocational schools in particular.

Stability of leisure-time physical activity during adolescence--a longitudinal study among 16-, 17- and 18-year-old Finnish youth

Participation in physical activity during childhood and adolescence is frequently mentioned as one factor likely to promote a more active lifestyle in adulthood with its health benefits. We studied the changes in leisure-time physical activity pattern and self-reported fitness during a three-year period in adolescence and investigated whether the type of sports has an effect on stability of physical activity at leisure. A questionnaire with identical physical activity items was sent to Finnish twins on their 16th and 17th birthdays and 6 months after the 18th birthday. A total of 1338 boys and 1596 girls responded to all three questionnaires, with response rates of 73.6% and 86.5%. The proportions of very active adolescents and adolescents with very good self-reported fitness seem to be alike at each age. Among girls, 23.7% to 27.7% reported being very active (4-5 times a week) and 13.7% to 15.1% considered their physical fitness to be very good at the ages of 16, 17 and 18. Among boys, the comparable percentages were 31.5% to 35.5% and 30.6% to 34.4%. However, the longitudinal three-year follow up showed substantial changes over time among individuals from one physical activity group to another. Only 19.1% of boys and 11.2% of girls were persistent exercisers (i.e., very active on all three years) and 15.6% of boys and 5.1% of girls were persistently fit (i.e., very good self-reported fitness on all three years). Stability of leisure-time physical activity was highest among those who participated in several different types of sports. Among boys the proportion of persistent exercisers was highest for those who participated in cross-country skiing, jogging and body-building (22.0-41.5%) and among girls for those who participated in ball games (11.9-28.6%). Those who participated in organised sports were more often persistent exercisers than those who did not (odds ratio = 13.2 for boys (CI 9.4-18.7) and 8.9 for girls (CI 6.4-12.5)). Also, those who participated in organised sports were more often persistently fit (odds ratio = 7.3 for boys (CI 5.2-10.2) and 10.4 for girls (CI 6.4-16.9). Adolescents are recommended to participate in and try different types of sports, and especially for girls ball games would appear to favour long-term maintenance of leisure-time physical activity.

Perinatal risk factors for hay fever--a study among 2550 Finnish twin families

Previous studies have suggested that perinatal factors influence the risk for asthma but population studies on perinatal factors and risk for hay fever are few. We studied the effect of perinatal factors on the risk for hay fever among adolescent twins by a questionnaire study involving five consecutive nation-wide birth cohorts of 16-year-old twins and their parents. The risk for parent-reported, doctor-diagnosed hay fever in the adolescents associated with several perinatal characteristics was assessed with logistic regression analysis among individuals and by a discordant pair analysis. In the univariate analysis of the birth factors, the risk for hay fever increased with increasing birth weight (p for trend = 0.048, OR for those > or = 3000 g 1.35, 95% CI 0.91-2.02 compared to those < 2000 g) and gestational age (p for trend = 0.04, OR for those born after 40 weeks of gestation 2.24, 95% CI 1.03-4.86, compared to those born before 33 weeks of gestation) and was lower in those subjects hospitalised in the neonatal period (OR 0.74, 95% CI 0.58-0.93). Because of significant interactions between parental hay fever status and birth factors (ponderal index, p = 0.03 and maternal age p = 0.04), stratified analysis were performed. The positive association between birth weight and hay fever was most obvious among adolescents with no parental history of hay fever (p for trend = 0.03). Similar, though not significant, trends were found with other birth factors among these families, whereas no such trend was found among adolescents with parental hay fever, suggesting that gestational maturity increases the risk for hay fever in the absence of genetic predisposition. However, of the perinatal factors only neonatal hospitalisation (OR 0.75, 95% CI 0.59-0.96) remained a significant risk factor for the development of hay fever, when adjusted for non-perinatal factors.

Arm ability training for stroke and traumatic brain injury patients with mild arm paresis: a single-blind, randomized, controlled trial

OBJECTIVE

To test the efficacy of the arm ability training (AAT) on a sample of patients with central arm paresis after traumatic brain injury (TBI) or stroke.

DESIGN

Single-blind, randomized, controlled trial.

SETTING

Inpatient rehabilitation center.

PATIENTS

Consecutive sample of 74 patients of whom 60 (45 with stroke, 15 with TBI) completed the study; 37 patients received a 1-year follow-up.

INTERVENTION

Daily AAT with (n = 20) or without (n = 20) knowledge of results, or no AAT (n = 20) during a 3-week intervention period.

MAIN OUTCOME MEASURES

Summary time scores of the Test Evaluant les Membres superieurs des Personnes Agees (TEMPA)-a test of upper extremity function with daily function-like activities (focal disability)-and kinematic analysis of aimed movements.

RESULTS

Patients with AAT realized superior improvement as compared with controls. Mean improvement in the time needed to perform (1) all TEMPA tasks was 41.4 versus 12.8 seconds (p =.0012); (2) unilateral TEMPA tasks, 16.5 versus 4.2 seconds (p =.0036); and (3) the ballistic component of aimed movements, 96 versus 20ms (p =.0115). Knowledge of result did not substantially modify these effects. A functional benefit existed at 1-year follow-up.

CONCLUSION

The AAT reduces focal disability among stroke and TBI patients with mild central arm paresis.

Tracking of body size from birth to late adolescence: contributions of birth length, birth weight, duration of gestation, parents' body size, and twinship

Birth weight has correlated positively with adult body mass index (BMI), but rarely have birth length, duration of gestation, or parents' body size been taken into account. The authors examined tracking of birth length and weight, adjusted for gestational age, to late adolescence, with special reference to parents' height and BMI. Longitudinal information from a nationally representative sample of Finnish twin adolescents (birth cohorts 1975-1979) and their parents was collected via questionnaires mailed when the twins were aged 16 years (n = 4,376; 2,062 males, 2,314 females) and 18 years (n = 3,917; 1,742 males, 2,175 females). The twins showed significant tracking of body size from birth to late adolescence, which was greatly influenced by their parents' body size. Height in adolescence was predicted by length and weight at birth and by parents' height, whereas BMI was predicted by birth weight and parents' BMI. An especially high risk for overweight was found for subjects of average length but a high weight at birth. These findings suggest that the intrauterine period has enduring effects on later body size but leave unresolved whether these effects are genetic or environmental.

Switch from systemic steroids to budesonide in steroid dependent patients with inactive Crohn's disease

BACKGROUND

Steroid dependent patients with Crohn's disease are at high risk of developing glucocorticosteroid induced side effects.

AIMS

We evaluated the possibility of switching from systemic steroids to budesonide (Entocort) in prednisolone/prednisone dependent patients with inactive Crohn's disease affecting the ileum and/or ascending colon.

PATIENTS

Steroid dependent patients with a Crohn's disease activity index </=200 were included.

METHODS

In a double blind multicentre trial, 120 patients were randomly assigned to receive budesonide 6 mg once daily or placebo. Prednisolone was tapered to zero during the first 4-10 weeks and budesonide or placebo was given concomitantly and for a further 12 weeks. Relapse was defined as an index >200 and an increase of 60 points from baseline or withdrawal due to disease deterioration.

RESULTS

After one and 13 weeks without prednisolone, relapse rates were 17% and 32%, respectively, in the budesonide group, and 41% and 65% in the placebo group (95% confidence intervals for the difference in percentages -41%, -8% and -51%, -16%; p=0.004 and p<0.001, respectively). The number of glucocorticosteroid side effects was reduced by 50% by switching from prednisolone and was similar in the budesonide and placebo groups. Basal plasma cortisol increased in both groups.

CONCLUSIONS

The majority of patients with steroid dependent ileocaecal Crohn's disease may be switched to budesonide controlled ileal release capsules 6 mg without relapse, resulting in a sharp decrease in glucocorticosteroid side effects similar to placebo, and with an increase in plasma cortisol levels.

Multimodal EEG analysis in man suggests impairment-specific changes in movement-related electric brain activity after stroke

Movement-related slow cortical potentials and event-related desynchronization of alpha (alpha-ERD) and beta (beta-ERD) activity after self-paced voluntary triangular finger movements were studied in 13 ischaemic supratentorial stroke patients and 10 age-matched control subjects during movement preparation and actual performance. The stroke patients suffered from central arm paresis (n = 8), somatosensory deficits (n = 3) or ideomotor apraxia (n = 2). The multimodal EEG analysis suggested impairment-specific changes in the movement-related electrical activity of the brain. The readiness potential of paretic subjects was centred more anteriorly and laterally; during movement, they showed increased beta-ERD at left lateral frontal recording sites. Patients with somatosensory deficits showed reduced alpha-ERD and beta-ERD during both movement preparation and actual performance. Patients with ideomotor apraxia showed more lateralized frontal movement-related slow cortical potentials during both movement preparation and performance, and reduced left parietal beta-ERD during movement preparation. We conclude that (i) disturbed motor efference is associated with an increased need for excitatory drive of pyramidal cells in motor and premotor areas or an attempt to drive movements through projections from these areas to brainstem motor systems during movement preparation; (ii) an undisturbed somatosensory afference might contribute to the release of relevant cortical areas from their 'idling' state when movements are prepared and performed; and (iii) apraxic patients have a relative lack of activity of the mesial frontal motor system and the left parietal cortex, which is believed to be part of a network subserving ideomotor praxis.

Quality assurance in hip arthroplasty

Documentation is key to quality assurance (QA): Data must be complete, plausible, and comparable, and then analyzed to implement corrective measures. Important factors are: qualification of care-providing staff, equipment and implants available (structural quality), effective scheduling of operations and therapy management (process quality), and patient status monitoring (outcome quality). The primary aim is to reveal deficits in process quality and develop and implement improvements in care. QA does not aim at exposing individual mistakes or flawed techniques; rather it is designed to analyze processes and treatments and implement specific solutions. An evaluation profile with the key quality indicators and a QA guideline is presented. A survey conducted in Germany, Austria, and Switzerland revealed: (1) up to 12-month waiting period for surgery in 6%, (2) only 40% written instructions, (3) data mostly written by hand, (4) differences in surgery planning and use of prosthesis passport, (6) inconsistent data analysis, (7) corrective measures rarely implemented.

Prostate blood flow characteristics in the chronic prostatitis/pelvic pain syndrome

PURPOSE

We determine whether the chronic prostatitis/pelvic pain syndrome is associated with abnormal prostate blood flow.

MATERIALS AND METHODS

We used color Doppler ultrasonography to examine 53 patients with inflammation, 80 men without inflammation and 22 healthy controls. Images were recorded and scored using standardized criteria to characterize the degree and distribution of prostatic vascularity.

RESULTS

Flow was observed to the entire prostatic capsule in 77% of patients but only 18% of controls (p<0.0001). Parenchymal flow was evaluated using several criteria. On a 2-point scale flow was classified as grade 2 in 74% of patients compared to 27% of controls (p<0.0001). Similar findings were noted on a Doppler spot scale, with flow classified as grade 2 in 47% of patients compared to 14% of controls (p<0.004). Patients also had more parenchymal Doppler spots than controls (p<0.01). Diffuse blood flow throughout the prostatic parenchyma was observed in 63% of patients compared to 36% of controls (p<0.03). There was no significant difference in the amount or distribution of blood flow in patients with and without inflammation.

CONCLUSIONS

The chronic prostatitis/pelvic pain syndrome was associated with increased blood flow to the prostatic capsule and diffuse flow throughout the prostatic parenchyma. Despite technical limitations, color Doppler ultrasonography may provide objective documentation of prostate blood flow abnormalities in patients with this syndrome.

Perinatal risk factors for asthma in Finnish adolescent twins

BACKGROUND

Previous studies have suggested that, in addition to genetic liability and environment in early childhood, intrauterine life also influences the risk for asthma beyond childhood. Low birth weight, prematurity, young maternal age, and maternal smoking have all shown an association with asthma. The effect of perinatal factors on the risk for asthma in relation to familial and social risk factors was studied in a nationwide population-based sample of adolescent twins. In addition to a distribution of birth characteristics among twins which differs from that of singletons, data on twins enable a distinction to be made between genetic and environmental sources of variation.

METHODS

Questionnaires were sent to five consecutive birth cohorts of Finnish 16 year old twins born in 1975-9 and to their parents (3065 families). The outcome measure was life time prevalence of doctor-diagnosed asthma in these adolescents. The association between asthma and potential risk factors was assessed by multiple logistic regression and discordant twin pair analysis.

RESULTS

Risk for asthma increased with increasing ponderal index (p for trend <0.01) and decreasing maternal age (p for trend <0.05). Among the 25% of twins with the highest ponderal index, the odds ratio for asthma was 1.82 (95% confidence interval 1.18 to 2.79) compared with those in the lowest 25%. Neither birth weight, gestational age, nor Apgar score was associated with asthma. When perinatal risk factors were combined with familial and social risk factors, ponderal index, maternal smoking, parental asthma, and sibship size were all significant independent determinants of asthma in these adolescents.

CONCLUSIONS

The risk for asthma in adolescent twins increases with increasing ponderal index when adjusted for familial and social factors.

Sonographic detection of acute parenchymal injury in an experimental porcine model of renal hemorrhage: gray-scale imaging using a sonographic contrast agent

OBJECTIVE

The purpose of this study was to determine the usefulness of contrast-enhanced sonography in the detection of acute parenchymal injury.

SUBJECTS AND METHODS

In a model of acute renal injury in pigs, four separate renal parenchymal bleeds were created by puncturing an interlobar artery of the upper and lower poles of the kidneys. B-mode gray-scale scans of the kidneys before and after injury, and after the administration of i.v. and intraarterial (i.a.) contrast agents were recorded on videotape for 5 min for each condition (baseline, after injury, after i.v. contrast administration, and after i.a. contrast administration). For each condition and injury, selected frames were analyzed with regions of interest of the normal renal parenchyma, the area of injury, and the perinephric space. Randomized videotape clips from each of the experimental conditions were rated by three sonologists as to the presence or absence of increased intrarenal parenchymal echogenicity, perinephric echogenicity, and confidence as to whether renal injury was present.

RESULTS

Areas of renal injury were isoechoic with normal parenchyma on unenhanced scans. After both i.v. and i.a. contrast material injection, areas of injury were visible as areas of increased echogenicity. Contrast increased from 0.2 on unenhanced images to 4.0 and 4.5, respectively, after i.v. and i.a. administration of the new contrast agent. The three observers' ability to diagnose renal injury increased from 0.61, 0.64, and 0.54 to 0.71, 0.70, and 0.74 after i.v. injection and to 0.93, 0.92, and 0.97 after i.a. injection as indicated by the area under the curve in the receiver operating characteristic analysis.

CONCLUSION

Transabdominal contrast-enhanced gray-scale sonography can reveal the area of acute renal hemorrhage. This procedure may be applicable in patients when sonographic contrast agents, imaging procedures, and modes of contrast administration are optimized for clinical use in trauma.

Individual differences in adolescent religiosity in Finland: familial effects are modified by sex and region of residence

Data from 16-year-old Finnish twin pairs were used to estimate familial effects on religiosity and the modification of those effects by sex and residential region. The sample of 2265 twin boys and 2521 twin girls formed 779 monozygotic and 1614 dizygotic pairs, 785 of the same sex and 829 of opposite sex. We compared religiosity scores of twins living in more rural and traditional northern Finland with those living in the more urban and secular southern region. Girls had higher religiosity scores than did boys, and twins living in northern Finland had higher religiosity scores than those resident in southern Finland. Correlations for monozygotic twins were slightly higher than those for dizygotic twins, and covariance modeling found modest heritability of religiosity [11% (95% CI 0-24) for girls; 22% (95% CI 6-38) for boys], and substantial shared environmental effects [60% (95% CI 49-69) and 45% (95% CI 31-57)] among girls and boys, respectively. The correlation between shared environmental effects in boys and girls was estimated to be 0.84 (95% CI 0.73-0.99). In analyses distinguishing region of residence, girls living in southern Finland were found to have significantly higher unshared environmental effects than girls in northern Finland, while boys living in the urban south appeared to have lower shared environmental effects, and higher additive genetic effects, than boys living in the rural north.

[Nomenclature and classification in orthopedics]

In the following report we give a definition of the terms nomenclature and classification. We find out, that the two terms are very similar. They include the keys for diagnosis and therapy. We propose a method to construct new coding-systems. Furthermore we report about the existing coding-systems in Orthopaedics and Traumatology. We cite a list of national and international coding-systems. Because of the actuality we finally give a definition of the term "Indikationsspezifische Komplikation", which is of importance since the "5. Anderungsverordnung" of the "BPFLV-95" within the classification of the "Fallpauschalen". "Fallpauschalen" are a system like the American DRG's (Diagnosis related groups), but not exactly the same.

Familial and socioregional environmental effects on abstinence from alcohol at age sixteen

OBJECTIVE

This study identifies, in genetically informative data, familial and socioregional environmental influences on abstinence from alcohol at age 16.

METHOD

Data are from FinnTwin 16, a population-based study of five consecutive birth cohorts of Finnish twins (N = 5,747 twin individuals), yielding 2,711 pairs of known zygosity. Measures of alcohol use, embedded into a health-habits questionnaire, were taken from earlier epidemiological research with nontwin Finnish adolescents. The questionnaire was administered sequentially to all twins as they reached age 16. Separate questionnaires, including measures of alcohol use and screening questions for alcohol problems, were received from 5,243 of the twins' parents.

RESULTS

Abstinence from alcohol to age 16 exhibits very significant familial aggregation, largely due to nongenetic influences. Abstinence rates are influenced by socioregional variation, sibling interaction effects and parental drinking patterns. Sibling and parental influences are greater in some regional environments than in others: the relative likelihood that a twin abstains, given that the co-twin does, or that both parents do, is shown to be modulated by socioregional variation.

CONCLUSION

Environmental contexts affect the likelihood of maintaining abstinence from alcohol to midadolescence, and socioregional variation modulates influences of siblings and parents. The results illustrate how genetically informative data can inform prevention research by identifying target variables for intervention efforts.

Nomenclature and classification in orthopaedics

In the following report we give a definition of the terms nomenclature and classification. We find out, that the two terms are very similar. They include the keys for diagnosis and therapy. We propose a method to construct new coding-systems. Furthermore we report about the existing coding-systems in Orthopaedics and Traumatology. We cite a list of national and international coding-systems. Because of the actuality we finally give a definition of the term "Indikationsspezifische Komplikation", which is of importance since the "5. Änderungsverordnung" of the "BPFLV-95" within the classification of the "Fallpauschalen". "Fallpauschalen" are a system like the American DRG's (Diagnosis related groups), but not exacly the same.

Distribution and heritability of BMI in Finnish adolescents aged 16y and 17y: a study of 4884 twins and 2509 singletons

OBJECTIVE

1) To estimate the heritability of body mass index (BMI) in twins aged 16y and 17y, with a special emphasis on gender-specific genetic effects and 2) to compare heights, weights, BMIs, and prevalences of 'overweight' (BMI > or = 25 kg/m2) in these twins and in singletons aged 16.5y.

DESIGN

Cross-sectional and longitudinal epidemiological questionnaire study of twins at ages 16y and 17 y, and cross-sectional study of singletons at age 16.5y.

MEASUREMENTS

BMI (kg/m2) was calculated from self-reported heights (m) and weights (kg).

SUBJECTS

4884 twins (2299 boys, 2585 girls) at baseline (age 16 y), 4401 twins (2002 boys, 2399 girls) at age 17 y, and 2509 singletons (1147 boys, 1362 girls) at age 16.5 y. Both twin and singleton samples are nationally representative.

RESULTS

At the ages of 16y and 17y, genetic effects accounted for over 80% of the interindividual variation of BMI. The correlations for male-female pairs were smaller than for either male-male or female-female dizygotic pairs. The singletons, especially the boys, had a higher BMI than the twins. Nine percent of singleton boys, but only 4-6% of twin boys and twin and singleton girls were 'overweight' (BMI > or = 25 kg/m2).

CONCLUSIONS

Among adolescents, genetic factors play a significant role in the causes of variation in BMI. The genetic modelling suggested that the sets of genes explaining the variation of BMI may differ in males and females. At this age, the twin boys, but not girls, seem to be leaner than singletons. Further follow-up will indicate whether these small differences disappear, and if not, what implications it might have to the generalizability of twin studies.

Effect of chronic duodenal ulceration and its treatment with lanzoprazole or sucralfate on gastroduodenal mucosal protein turnover and TGF-alpha, bFGF, and EGF receptor expression in humans

In order to investigate whether chronic duodenal ulcer disease is a consequence of disturbed mucosal turnover and growth factor expression, we studied 16 patients with duodenal ulcers before, during, and after endoscopic healing with lansoprazole or sucralfate. Before treatment, gastric fundal and antral mucosal protein turnover rates were higher in patients than controls, without parallel increases in growth factors. Both forms of therapy produced similar changes, with overall increases in duodenal mucosal turnover and transforming growth factor-alpha (TGF-alpha) and epidermal growth factor receptor (EGF-r) levels. Measurements after healing showed persistent elevations of mucosal turnover in the antrum and duodenum and depressions of basic fibroblast growth factor (bFGF) in gastric fundal and duodenal mucosa. We conclude that mucosal turnover is abnormally high in patients with chronic duodenal ulcer disease and is not easily explained by growth factor changes. The failure of lansoprazole and sucralfate to normalize rates, despite endoscopic healing, may explain the high ulcer relapse rates in non-HP-eradicated patients.

The influence of intravenous infusions of glucose and amino acids of pancreatic enzyme and mucosal protein synthesis in human subjects

BACKGROUND

Animal studies have shown that the synthesis and secretion of pancreatic enzymes and the turnover of mucosal proteins is strongly influenced by diet.

METHODS

To determine whether the absorbed products of digestion are responsible for these changes, we investigated in groups of five healthy volunteers, the effects of i.v. infusions of amino acids (0.08 g/kg/h) and glucose (0.3 g/kg/h) on pancreatic enzyme and mucosal protein synthesis. Proteins were labeled in vivo by a 4-hours i.v. infusion of 14C-leucine and the enteric infusion of 3H-leucine tracer, during simultaneous cholecystokinin stimulation and duodenal collection of secreted pancreatic enzymes. Labeling of mucosal proteins was measured by endoscopic biopsy.

RESULTS

The amino acid infusions elevated plasma amino acid levels, and the glucose infusions increased both glucose and insulin concentrations. The rates for amylase and trypsin secretion were significantly lower during the first 2 hours of glucose infusion and the rate of synthesis of trypsin was delayed by i.v. amino acid infusions from 52.1 +/- 4.1 to 77.6 +/- 8.5 minutes. Mucosal protein turnover rates were unaffected. 3H-labeling via the enteral route showed similar enzyme synthesis rates but variable mucosal incorporation rates.

CONCLUSIONS

I.v. nutrients do not appear to stimulate the synthesis of pancreatic and mucosal proteins in human subjects.

A comparison of budesonide and mesalamine for active Crohn's disease. International Budesonide-Mesalamine Study Group

BACKGROUND

Crohn's disease is often treated with glucocorticoids or mesalamine. We compared the efficacy and safety of controlled-ileal-release budesonide capsules and slow-release mesalamine tablets in patients with active Crohn's disease affecting the ileum, the ascending colon, or both.

METHODS

In a double-blind, multicenter trial, we enrolled 182 patients with scores of 200 to 400 on the Crohn's Disease Activity Index (with higher scores indicating greater disease activity) and randomly assigned 93 to receive 9 mg of budesonide once daily and 89 to receive 2 g of mesalamine twice daily for 16 weeks. The primary efficacy variable was clinical remission, defined as a score of 150 or less on the Crohn's Disease Activity Index.

RESULTS

In the analysis of all patients who received at least one dose of study drug, the rates of remission after 8 weeks of treatment were 69 percent in the budesonide group and 45 percent in the mesalamine group (P=0.001); the respective rates after 16 weeks of treatment were 62 percent and 36 percent (P<0.001). Seventy-seven patients in the budesonide group completed the 16 weeks of treatment, as compared with 50 patients in the mesalamine group (P<0.001). The numbers of patients with adverse events were similar in the two groups, but those assigned to budesonide had fewer severe adverse events. Among patients who completed 16 weeks of treatment, the morning plasma cortisol value was normal in 67 percent of budesonide-treated patients and 83 percent of mesalamine-treated patients (P=0.06); 90 percent and 100 percent, respectively, had normal increases in cortisol in response to cosyntropin (P=0.02).

CONCLUSIONS

In patients with active Crohn's disease affecting the ileum, the ascending colon, or both, a controlled-ileal-release formulation of budesonide was more effective in inducing remission than a slow-release formulation of mesalamine.

[Quality assurance in endoprosthetics]

BACKGROUND

To evaluate the level of documentation as an instrument of ongoing quality management in arthroplasty, a questionnaire was created on this subject, which concentrated on structural and process indicators.

METHODS

A total of 908 questionnaires was sent to orthopedic and trauma departments in Austria, Germany and Switzerland and were evaluated anonymously.

RESULTS

The quota of return was 54% in Switzerland, 47% in Austria and 25% in Germany. The waiting period for an arthroplasty is much less in Switzerland and in Germany than in Austria. Only 40% of patients receive forms for informed consent. Documentation is seldomly standardized thus making comparison virtually impossible. Surgical planning is usually done with templates in Germany and Austria, in Switzerland with drawings. Prosthesis passports are predominately used by orthopedic departments. The data regarding complication rates and infections are not analyzed at regular intervals (max. 30%) and corrective measures are rarely implemented.

CONCLUSION

Documentation is the basic instrument of quality management and requires completeness (totality) and plausibility of the datas. It is of great importance that evaluated data are analyzed and consequences are taken. The primary aim of quality assurance is to identify problems that adversely affect quality in order to develop and implement process sequences for the improvement of patient care and management.

Central mechanisms in human enhanced physiological tremor

The sites of the central nervous structures involved in enhanced physiological tremor (EPT) are still unclear. The syndrome of persistent mirror movements (PMM) is characterized by abnormal bilateral corticospinal projections. If a supraspinal mechanism is involved in EPT, the activity of EPT should be coherent between both sides in subjects with this abnormality. We investigated three PMM subjects and three normal controls. Focal transcranial magnetic stimulation (TMS) resulted in contralateral hand muscle responses in the controls. The PMM subjects, in contrast, had bilateral responses. Similarly, long-latency reflexes (LLR) in PMM could be recorded bilaterally, while the control subjects showed responses only on the stimulated side. EPT was evoked by intravenous salbutamol. EMG time series were recorded bilaterally from the wrist extensor muscles and cross spectra were calculated. If there was a significant right-left-coherence, phase analysis was performed. No control subject showed a significant right-left-coherence of tremor activity. In contrast, a significant coherence was found in PMM between 8 and 12 Hz. When the mechanical tremor frequency of one hand was reduced by loading, coherences and phase spectra of the EMGs remained unchanged. By comparing the results from TMS, LLR and cross spectral analysis we come to the conclusion, that the 8 to 12 Hz component of EPT is transmitted transcortically, most likely originating from two separate generators for both sides.

Familial aggregation of leisure-time physical activity -- a three generation study

Studies of parental influence on children's physical activity have had different results. Parental effect on physical activity during adolescence is less studied, and three generation studies have not been carried out. The purpose of our study was to examine intra- and intergenerational associations of leisure time physical activity among family members in three generations. Due to the major changes in society during this time, we also took into consideration the socioeconomic status of the adult subjects. The material consisted of 3254 twins at the age of 16, their parents and grandparents. Twins and their parents received a questionnaire in 1991-1993, which included questions about the health and lifestyle, socioeconomic status and leisure time physical activity. The parents' questionnaire also included questions about their own parents' leisure time physical activity and socioeconomic status. Based on these questions adolescents, parents and grandparents were classified into physical activity classes. The socioeconomic classification of parents and grandparents was based on their occupation. Intragenerational physical activity patterns were significantly associated with each other. Among adolescents the strongest correlation were between monozygotic boys (0.720) and monozygotic girls (0.638). Physical activity patterns were not associated between generations, but there was a significant difference between very active and inactive mothers concerning their daughters' physical activity. Farmers had the lowest proportion of very active subjects only among the parental generation. Because physical activity patterns do not appear to be transmitted from one generation to the next, it is probable that by constant training and education we can obtain the benefits of physical activity.

[Neurofibroma with contralateral linear hyperpigmentation along Blaschko lines]

We describe a patient with plexiform neurofibroma and contralateral circumscribed hyperpigmentation along the lines of Blaschko. Such findings represent a form of segmental neurofibromatosis. The origin and classification of segmental neurofibromatosis and its relationship to NFI (von Recklinghausen disease) are discussed.

[Sonography as a tool in the diagnosis of displacement of the abomasum]

43 Holstein-Friesian cows were investigated by sonography for the occurrence of a displacement of the abomasum. 26 animals suffered from a displacement of the abomasum. The results of sonography of these diseased and of healthy animals are described. After sonography all animals were subjected to an exploratory laparotomy in order to check the validity of the sonographic diagnosis. The results and the diagnosis obtained by laparotomy were compared to the sonographic findings.

Common genetic influences on BMI and age at menarche

Genetic influences on variability of body weight and onset of menarche are well known. To investigate the genetic and environmental contributions to the association of body weight with onset of menarche, we studied Finnish twins from consecutive birth cohorts (the FinnTwin16 study) ascertained from the national population registry, which identifies nearly 100% of all living twins. Baseline questionnaires were mailed to the twins within 60 days of their sixteenth birthday and later to older sibs of the twins. Pairwise response rates (approximately 85% across gender and zygosity) and 30 months of data collection yielded results from 1283 twin pairs. The questionnaires included a survey of health habits and attitudes, a symptom checklist, MMPI personality scales, and a survey of relationships with parents, peers, and the co-twin. Age at menarche was reported by 468 monozygotic (MZ) girls, 378 girls from like-sex dizygotic (FDZ) pairs, 434 girls from opposite-sex (OSDZ) pairs, and 141 older female sibs of the twins. The one-month test-retest reliability of age at menarche in an independent sample (N = 136) of 16-year-olds from a national survey was 0.96. Girls from OSDZ pairs had a significantly higher mean age at menarche (13.33 yr) than FDZ girls (13.13 yr) (difference, 0.20 yr; 95% confidence interval, 0.05-0.35). The MZ correlation for age at menarche was 0.75, the DZ correlation was 0.31, and the sib-twin correlation was 0.32. A bivariate twin analysis of age at menarche and body mass index (wt/ht2) indicated that 37% of the variance in age at menarche can be attributed to additive genetic effects, 37% to dominance effects, and 26% to unique environmental effects. The correlation between additive genetic effects on age at menarche and body mass index was 0.57, indicating a substantial proportion of genetic effects in common.

[Calciphylaxis]

HISTORY AND CLINICAL FINDINGS

Acute, zigzag-shaped livid skin markings developed on both thighs of a 55-year-old woman who had been on dialysis for 6 years. Within 7 days these areas increased in size to about 10 cm in diameter and contained central dry and painful necroses. On legs, lower arms and hands hard subcutaneous nodules were palpable with a diameter up to 3 mm. For many years the phosphate and parathormone levels, as well as alkaline phosphatase activity had been raised. The patient had often failed to follow treatment recommendations.

TESTS

There were increased serum concentrations of calcium (2.8 mmol/l) and phosphate (1.78 mmol/l). The calcium phosphate ion product was 4.98 (mmol/l)2. Furthermore, there were raised levels of alkaline phosphatase (315 U/l) and parathormone (1076 ng/l, normal: 10-65). X-ray film of the hands showed soft tissue and arterial calcifications, while histological examination of a deep skin biopsy revealed calcium phosphate emboli of the main vessels.

TREATMENT AND COURSE

Excision of the cutaneous necroses was followed by parathyroidectomy at which only three parathyroid glands were identified and removed. The parathormone level fell postoperatively, but rose again after 4 weeks. The fourth parathyroid gland was then found and removed, after which the parathormone level fell below measurable levels. The skin ulcers healed completely 4 weeks after the second operation.

Persistent mirror movements: force and timing of "mirroring" are task-dependent

A simple isometric motor task was used to quantify intended and unintended finger movements in two subjects (father and son) with persistent mirror movements. One hand voluntarily changed grip force between thumb and index finger at different amplitudes and frequencies, while the other hand was to maintain a constant force. During all experimental conditions the "steady" hand showed insuppressible, highly cross-correlated contractions, compatible with bilateral distribution of a single motor command to the spinal cord. However, these associated movements were not strictly mirror images, nor did they show a fixed relationship to the voluntary movements across experimental conditions. The ratio of mirror to voluntary movement ranged from 1.4 to 19.1% and from 3.4 to 78.4% in the two subjects and was directly related to voluntary strength and speed. At maximum speed, mirror activity tended to precede voluntary activity, while it was delayed in slow force changes. Comparable time lags were not found in control subjects instructed to simulate mirror movements. We conclude that neuronal mechanisms in addition to bilateral corticomotoneuronal connections are at work in persistent mirror movements.

[Unreported cases--obstacle to exact research in clinical orthopedics and traumatology]

In number 2 1991 of the "Orthopädie Mitteilungen" we referred to problems in obtaining valid data in orthopaedics and orthopaedic traumatology. There we mentioned several unknown cases in the epicrisis related to anamnestic facts. Now we continue the report with the support of our completely quality checked basis documentation. The comparison of the operation-report and the epicrisis shows us that data in three out of four cases are identical. We get nearly the same result, if we compare the operation-site (left or right are in four out of five cases identical). Furthermore we discuss a critical research of aneurysmatic bone cysts out of 24,000 epicrisis. Research into benign tumors or tumorlike lesions is very difficult, because the patients normally leave the hospital before the exact diagnosis was made. Therefore we must take into account uncertain results of our investigations. As far as possible our results take into account rare bibliographic data. Therefore we can show that our modified documentation of all epicrisis should be preferred to documentation of specific forms. Furthermore the investigation demonstrates, that our "frame coding system" is superior to a "precise coding system" for the precise system does not regard the background of the inquiries. But considering the background, we are able to discover most of the unknown cases and make them part of our conclusions.

Migraine and concomitant symptoms among 8167 adult twin pairs

We studied the inheritance of migraine and concomitant symptoms among 2690 monozygotic (1524 female and 1166 male) pairs and 5497 dizygotic (2951 female and 2546 male) twin pairs. Our material consists of a population-based questionnaire study among Finnish twins in 1981. The definition of migraine is based on a questionnaire method. Concordance was assessed using probandwise concordance rates and tetrachoric correlations for monozygotic (MZ) and dizygotic (DZ) twin pairs. For estimating the contribution of genetic factors to the susceptibility of migraine, a polygenic multifactorial model was used. Structural equation models were applied for estimating variance components and to compare different genetic models. Nearly one-half (40% to 50%) of the liability to migraine is attributable to genetic factors. In all structural analyses, the model with both additive genetic and unshared environmental component had the best goodness-of-fit value. The genetic component varied between 34% to 51% in different migraine types. There were no remarkable differences between sexes except in the effects due to dominance, where the proportion was 26% for men and 14% for women. Concomitant symptoms among subjects within pairs concordant for headache had genetic effects varying from 56% (subjects with unilaterality) and 56% (subjects with visual symptoms) to 45% (persons with nausea and vomiting). The two threshold model of headache points to the continuum model of headache, and the thresholds represent different levels of severity of the pain. Our results emphasize a multifactorial and higher than previously reported genetic pattern in the etiology of migraine. Also unshared environmental factors play an important role.

Magnetic resonance imaging signal changes in denervated muscles after peripheral nerve injury

The evaluation of peripheral nerve disorders has traditionally relied on a clinical history, physical examination, and electrodiagnostic studies. Recent studies have used magnetic resonance imaging (MRI) to evaluate a variety of both nerve and muscle disorders. In this article, we describe the use of MRI, using short-tau inversion recovery (STIR) sequences, to evaluate muscle signal characteristics in a variety of peripheral nerve disorders. A total of 32 patients were studied, and 12 representative cases are discussed in detail. Increased STIR signal in muscle was seen in cases of severe axonotmetic injuries involving the transection of axons producing severe denervation changes on electromyography. The increased STIR signal in denervated muscles was seen as early as 4 days after the onset of clinical symptoms, which is significantly earlier than changes detected on electromyography. The MRI signal changes were reversible when the recovery of motor function occurred as a result of further muscle innervation. In cases of neurapraxic nerve injuries, characterized by conduction block without axonal loss, the STIR signal in muscle was normal. These findings show that MRI using STIR sequences provides a panoramic visual representation of denervated muscles useful in localizing and grading the severity of peripheral nerve injury secondary to either disease or trauma. MRI using STIR sequences may therefore play an important role in the prediction of clinical outcome and the formulation of appropriate therapy early after peripheral nerve injury.

Coexistence of cholinergic and somatostatin receptors on astrocytes of rat CNS

Electrophysiological studies have shown that somatostatin (SOM; 10(-8) and 10(-7) M) causes a hyperpolarization of the majority of astrocytes in explant cultures of rat spinal cord and cortex. When SOM and the cholinergic agonists muscarine and nicotine (10(-6) M) were tested on the same cell, all three compounds produced hyperpolarizations, suggesting a colocalization of functional cholinergic and SOM receptors on the glial membrane. Combined immunohistochemical and autoradiographic binding studies demonstrating that almost all astrocytes which were immunostained by the monoclonal muscarinic or nicotinic antibodies were also intensely labelled by 125I-SOM, provide further evidence for the coexistence of cholinergic and SOM receptors on astrocytes.

Development of an innovative nursing care delivery system

In the reform of healthcare lies its renaissance, and in its challenges lie its opportunities. Faced with the changing needs of consumers, the evolving roles of care givers, technologic advances, and economic pressures, institutions are redesigning their physical facilities and systems of care delivery in preparation for a new era in healthcare. Innovative care delivery systems, developed to complement creative facility designs, will provide an approach to health-care that promotes administrative efficiency, patient/care giver satisfaction, and cost-effective use of resources. This article chronicles the development of a care delivery system for obstetric nursing, a blueprint for future healthcare at one institution.

Electrophysiological evidence for the presence of receptors for cholecystokinin and bombesin on cultured astrocytes of rat central nervous system

The action of cholecystokinin (CCK) and bombesin (Bom) was studied on the membrane potential of astrocytes in explant cultures of rat cortex, cerebellum, brain stem and spinal cord. Both peptides (10(-8) and 10(-7) M) caused a hyperpolarization of most astrocytes studied. The hyperpolarization by CCK was markedly reduced or blocked by the CCKB-antagonist L-365,260 whereas addition of the Bom-antagonist [D-Phe12,Leu14]-Bom antagonized the effects of Bom, suggesting a specific action of these peptides. When CCK and Bom were tested on the same cell, both peptides were effective, indicating a colocalization of receptors for CCK and Bom on the glial membrane. Our electrophysiological investigations provide strong evidence for the existence of functional CCK and Bom receptors on astrocytes.