Revealing x-ray and gamma ray temporal and spectral similarities in the GRB 190829A afterglow

Gamma-ray bursts (GRBs), which are bright flashes of gamma rays from extragalactic sources followed by fading afterglow emission, are associated with stellar core collapse events. We report the detection of very-high-energy (VHE) gamma rays from the afterglow of GRB 190829A, between 4 and 56 hours after the trigger, using the High Energy Stereoscopic System (H.E.S.S.). The low luminosity and redshift of GRB 190829A reduce both internal and external absorption, allowing determination of its intrinsic energy spectrum. Between energies of 0.18 and 3.3 tera-electron volts, this spectrum is described by a power law with photon index of 2.07 ± 0.09, similar to the x-ray spectrum. The x-ray and VHE gamma-ray light curves also show similar decay profiles. These similar characteristics in the x-ray and gamma-ray bands challenge GRB afterglow emission scenarios.

[Impact of psychiatric disorders on the outcome of acute geriatric inpatient treatment: an exploratory investigation]

BACKGROUND

Systematic study results of geriatric inpatient treatment assessing the impact of psychiatric disorders on treatment outcome are so far missing. This exploratory study investigated the impact of dementia, depression and delirium on treatment outcome in a geriatric department, compared to those individuals without psychiatric symptoms at the beginning of treatment.

METHOD

From January to June 2018 treatment data from geriatric inpatient records were retrospectively evaluated. Functional measurements (Barthel index, timed up and go test, Tinetti test and the De Morton mobility index) were assessed at the start of geriatric treatment and at discharge. A multivariate variance analysis (MANOVA) was used to calculate the possible impact of psychiatric disorders on functional improvement during treatment and to find out if there were significant differences between the four defined groups (dementia, depression, delirium and mentally sound).

RESULTS

A total of 280 geriatric inpatients with an average age of 84 years, were included in this study and showed a noticeable prevalence of psychiatric disorders: dementia 29%, depression 27%, and delirium 15%. As expected, the patients in the sample showed a high level of multimorbidity and polypharmacy. Functional improvement was present in each of the defined groups and significant differences between all groups were found. The results of MANOVA showed that none of the possible confounding variables, e.g. age, mini mental status examination (MMSE), degree of care, cognitive impairment, social status, gender and comorbid illness, had an important influence on the group results.

CONCLUSION

This study of an acute geriatric department demonstrated that psychiatric disorders in these multimorbid, aged patients did not prevent functional improvement by treatment, showed significant differences during the course of treatment and outcome and compared to inpatients without psychiatric symptoms.

Modular life cycle assessment of municipal solid waste management

Life cycle assessment (LCA) is commonly applied to examine the environmental performance of waste management systems. The system boundaries are, however, often limited to either one tonne of material or to specific waste treatments and are, therefore, lacking a systems perspective. Here, a framework is proposed to assess complete waste management systems based on actual waste flows, assessed with a detailed material flow analysis (MFA) in a modular MFA/LCA approach. The transformation of the MFA into a product-process-matrix facilitates a direct link between MFA and LCA, therefore allowing for the assessment of variations in flows. To allow for an up-to-date and geographically specific assessment, 190 LCA modules were set up based on primary industrial data and the ecoinvent database. The LCA modules show where there have been improvements in different recycling processes over the past years (e.g. for paper recycling) and highlight that, from an environmental perspective, closed-loop recycling is not always preferable to open-loop recycling. In a case study, the Swiss municipal solid waste management system, of which there is already a detailed MFA, was modeled using the new LCA modules and applying the modular MFA/LCA approach. Five different mass flow distribution scenarios for the Swiss municipal solid waste management system were assessed to show the environmental impact of political measures and to test the sensitivity of the results to key parameters. The results of the case study highlight the importance of the dominant fractions in the overall environmental impacts assessment; while the metal fraction has the highest impact on a per kilogram basis, paper, cardboard, glass and mixed municipal solid waste were found to dominate the environmental impacts of the Swiss waste management system due to their mass. The scenarios also highlight the importance of the energy efficiency of municipal solid waste incineration plants and the credits from material substitution as key variables. In countries with advanced waste management systems such as Switzerland, there is limited improvement potential with further increases in recycling rates. In these cases, the focus of political measures should be laid on (i) the utilization of secondary materials in applications where they replace high-impact primary production, and (ii) an increased recovery of energy in waste-to-energy plants.

Multimessenger observations of a flaring blazar coincident with high-energy neutrino IceCube-170922A

Previous detections of individual astrophysical sources of neutrinos are limited to the Sun and the supernova 1987A, whereas the origins of the diffuse flux of high-energy cosmic neutrinos remain unidentified. On 22 September 2017, we detected a high-energy neutrino, IceCube-170922A, with an energy of ~290 tera–electron volts. Its arrival direction was consistent with the location of a known γ-ray blazar, TXS 0506+056, observed to be in a flaring state. An extensive multiwavelength campaign followed, ranging from radio frequencies to γ-rays. These observations characterize the variability and energetics of the blazar and include the detection of TXS 0506+056 in very-high-energy γ-rays. This observation of a neutrino in spatial coincidence with a γ-ray–emitting blazar during an active phase suggests that blazars may be a source of high-energy neutrinos.

Is there an environmentally optimal separate collection rate?

Material recycling often leads to environmental benefits when compared to thermal treatments or landfilling and is therefore positioned in the waste hierarchy as the third priority after waste prevention and reuse. To assess the environmental impacts of recycling and the related substitution of primary material, linear steady-state models of physical flows are typically used. In reality, the environmental burdens of collection and recycling are likely to be a non-linear function of the collection rate. This short communication aims at raising awareness of the non-linear effects in separate collection systems and presents the first non-linear quantitative model for PET bottle recycling. The influence of collection rates on the material quality and the transport network is analyzed based on the data collected from industrial partners. The results highlight that in the present Swiss recycling system a very high collection rate close to 100% yields optimum environmental benefits with respect to global warming. The empirical data, however, provided indications for a decrease in the marginal environmental benefit of recycling. This can be seen as an indication that tipping points may exist for other recycling systems, in which the environmental benefits from substituting primary materials are less pronounced than they are for PET.

Search for γ-Ray Line Signals from Dark Matter Annihilations in the Inner Galactic Halo from 10 Years of Observations with H.E.S.S

Spectral lines are among the most powerful signatures for dark matter (DM) annihilation searches in very-high-energy γ rays. The central region of the Milky Way halo is one of the most promising targets given its large amount of DM and proximity to Earth. We report on a search for a monoenergetic spectral line from self-annihilations of DM particles in the energy range from 300 GeV to 70 TeV using a two-dimensional maximum likelihood method taking advantage of both the spectral and spatial features of the signal versus background. The analysis makes use of Galactic center observations accumulated over ten years (2004-2014) with the H.E.S.S. array of ground-based Cherenkov telescopes. No significant γ-ray excess above the background is found. We derive upper limits on the annihilation cross section ⟨σv⟩ for monoenergetic DM lines at the level of 4×10^{-28}  cm^{3} s^{-1} at 1 TeV, assuming an Einasto DM profile for the Milky Way halo. For a DM mass of 1 TeV, they improve over the previous ones by a factor of 6. The present constraints are the strongest obtained so far for DM particles in the mass range 300 GeV-70 TeV. Ground-based γ-ray observations have reached sufficient sensitivity to explore relevant velocity-averaged cross sections for DM annihilation into two γ-ray photons at the level expected from the thermal relic density for TeV DM particles.

[Willingness to participate in group beneficial dementia research]

BACKGROUND

With the fourth Act on the amendment of pharmaceutical legal and other regulations it became law in Germany from the beginning of 2017 that under certain conditions, pharmaceutical research will be allowed with persons incapable of giving consent, even if this research may only be beneficial to other sufferers of the same disease, i. e. group beneficial research.

OBJECTIVE

We conducted a semistructured, non-representative survey among psychiatric patients and their relatives.

PARTICIPANTS AND METHODS

This survey was done for a period of 3 months until the end of September 2017 in the practice of M. H. with successively examined patients and their relatives. Patients incapable of giving consent related to dementia, depression and emergency cases, were excluded. Participants were asked about their attitudes related to evaluation of a) group beneficial research in principle, b) pharmaceutical withdrawal studies and c) research authorization. Sociodemographic and clinical variables were collected.

RESULTS AND DISCUSSION

This study included 85 persons and all of them gave their informed consent to participation. The mean age was 70 years, 47% were male, 61% had a university degree and 46% an independent profession. Mild cognitive impairment was diagnosed in 26%. This survey revealed a relatively high basic approval of group beneficial dementia research as well as of pharmaceutical withdrawal studies. In addition, research authorization gained a substantially positive evaluation. Only a few participants were informed about the new law in force since 2017. The present results were drawn from an explorative study with an unrepresentative sample and, therefore, have to be interpreted with caution. They show, however, that in the general population more information and awareness about group beneficial research with persons incapable of giving informed consent should be achieved. The relatively high rate of approval in this study may reveal a widespread feeling of social responsibility; however, reported objections of the participants should also be seriously considered.

[Overcoming disease in systemic lupus erythematosus]

BACKGROUND

Systemic lupus erythematosus (SLE) is a chronic inflammatory autoimmune disease affecting a broad range of different organ systems and, hence, presenting with multiple symptomatic domains, which considerably reduces the quality of life of patients. Within the last decade the prognosis of the disease has been significantly improved by novel therapies and intensive monitoring; however, non-pharmaceutical strategies for symptom control, self-efficacy and coping abilities for those affected are still insufficiently established.

OBJECTIVE

This article describes the possibilities and limitations of non-pharmaceutical strategies and makes suggestions for future treatment and research.

RESULTS

Preliminary interventional studies using psychoeducational, psychosocial and behavioral psychotherapeutic approaches, have consistently shown that the needs and expectations of patients related to help and support by doctors and professional care can be adequately and sustainably met. In addition, coping abilities and the quality of life can be increased.

Structural virology. Near-atomic cryo-EM structure of the helical measles virus nucleocapsid

Measles is a highly contagious human disease. We used cryo-electron microscopy and single particle-based helical image analysis to determine the structure of the helical nucleocapsid formed by the folded domain of the measles virus nucleoprotein encapsidating an RNA at a resolution of 4.3 angstroms. The resulting pseudoatomic model of the measles virus nucleocapsid offers important insights into the mechanism of the helical polymerization of nucleocapsids of negative-strand RNA viruses, in particular via the exchange subdomains of the nucleoprotein. The structure reveals the mode of the nucleoprotein-RNA interaction and explains why each nucleoprotein of measles virus binds six nucleotides, whereas the respiratory syncytial virus nucleoprotein binds seven. It provides a rational basis for further analysis of measles virus replication and transcription, and reveals potential targets for drug design.

Binding site asymmetry in human transthyretin: insights from a joint neutron and X-ray crystallographic analysis using perdeuterated protein

Human transthyretin has an intrinsic tendency to form amyloid fibrils and is heavily implicated in senile systemic amyloidosis. Here, detailed neutron structural studies of perdeuterated transthyretin are described. The analyses, which fully exploit the enhanced visibility of isotopically replaced hydrogen atoms, yield new information on the stability of the protein and the possible mechanisms of amyloid formation. Residue Ser117 may play a pivotal role in that a single water molecule is closely associated with the γ-hydrogen atoms in one of the binding pockets, and could be important in determining which of the two sites is available to the substrate. The hydrogen-bond network at the monomer-monomer interface is more extensive than that at the dimer-dimer interface. Additionally, the edge strands of the primary dimer are seen to be favourable for continuation of the β-sheet and the formation of an extended cross-β structure through sequential dimer couplings. It is argued that the precursor to fibril formation is the dimeric form of the protein.

Design and development of an injection-molded demultiplexer for optical communication systems in the visible range

Optical simulation software based on the ray-tracing method offers easy and fast results in imaging optics. This method can also be applied in other fields of light propagation. For short distance communications, polymer optical fibers (POFs) are gradually gaining importance. This kind of fiber offers a larger core diameter, e.g., the step index POF features a core diameter of 980 μm. Consequently, POFs have a large number of modes (>3 million modes) in the visible range, and ray tracing could be used to simulate the propagation of light. This simulation method is applicable not only for the fiber itself but also for the key components of a complete POF network, e.g., couplers or other key elements of the transmission line. In this paper a demultiplexer designed and developed by means of ray tracing is presented. Compared to the classical optical design, requirements for optimal design differ particularly with regard to minimizing the insertion loss (IL). The basis of the presented key element is a WDM device using a Rowland spectrometer setup. In this approach the input fiber carries multiple wavelengths, which will be divided into multiple output fibers that transmit only one wavelength. To adapt the basic setup to POF, the guidance of light in this element has to be changed fundamentally. Here, a monolithic approach is presented with a blazed grating using an aspheric mirror to minimize most of the aberrations. In the simulations the POF is represented by an area light source, while the grating is analyzed for different orders and the highest possible efficiency. In general, the element should be designed in a way that it can be produced with a mass production technology like injection molding in order to offer a reasonable price. However, designing the elements with regard to injection molding leads to some inherent challenges. The microstructure of an optical grating and the thick-walled 3D molded parts both result in high demands on the injection molding process. This also requires complex machining of the molding tool. Therefore, different experiments are done to optimize the process parameter, find the best molding material, and find a suitable machining method for the molding tool. The paper will describe the development of the demultiplexer by means of ray-tracing simulations step by step. Also, the process steps and the realized solutions for the injection molding are described.

Lipid-based intravesical drug delivery systems with controlled release of trospium chloride for the urinary bladder

The overactive bladder (OAB) is a common disease with an overactivity of the detrusor muscle in the bladder wall. Besides peroral administration of anticholinergic drugs and bladder irrigations, there is a need for a sustained release formulation in the urinary bladder. In order to realise a local long-term treatment of the overactive urinary bladder, lipidic drug delivery systems were prepared. Requirements for an intravesical application are a long-term controlled release of trospium chloride, a high drug loading and small sized drug carriers to permit an insertion through the urethra into the urinary bladder. The drug delivery systems were manufactured by using compression (mini-tablets), solid lipid extrusion (extrudates) and a melting and casting technique (mini-moulds) with different amounts of trospium chloride and glyceryl tristearate as matrix former. Drug release depended on the drug loading and the preparation method. Mini-tablets and lipidic extrudates showed a drug release over five days, whereas that from mini-moulds was negligibly small. The appearance of polymorphic transformations during processing and storage was investigated by using differential scanning calorimetry and X-ray diffraction. In contrast to mini-tablets and mini-moulds, lipidic extrudates showed no polymorphic transformations. In summary, lipids are suitable matrix formers for a highly water-soluble drug, like trospium chloride. Despite a drug loading of up to 30%, it was feasible to achieve a drug release ranging from several days up to weeks. In addition, small dosage forms with a size of only a few millimetres were realised. Therefore, an insertion and excretion through the urethra is possible and the requirements for an intravesical application are fulfilled.

Preliminary neutron crystallographic study of human transthyretin

Preliminary studies of perdeuterated crystals of human transthyretin (TTR) have been carried out using the LADI-III and D19 diffractometers at the Institut Laue-Langevin in Grenoble. The results demonstrate the feasibility of a full crystallographic analysis to a resolution of 2.0 Å using Laue diffraction and also illustrate the potential of using monochromatic instruments such as D19 for higher resolution studies where larger crystals having smaller unit cells are available. This study will yield important information on hydrogen bonding, amino-acid protonation states and hydration in the protein. Such information will be of general interest for an understanding of the factors that stabilize/destabilize TTR and for the design of ligands that may be used to counter TTR amyloid fibrillogenesis.

Formation and photocatalytic decomposition of a pellicle on anatase surfaces

The acquired dental pellicle plays a critical role in the adhesion and detachment of dental plaque bacteria. It has been reported that titanium dioxide biomaterials decompose single-protein films by photocatalysis. However, it is not known whether this can also be achieved with complex structured pellicle films. This in vitro study investigated in real-time the formation and photocatalytic decomposition of human pellicle at anatase-saliva interfaces. Nanostructured polycrystalline anatase layers were deposited on titanium-coated quartz crystals by magnetron-sputtering, serving as a model for titanium implant surfaces. The quartz crystals were used as acoustic sensors in a quartz-crystal microbalance (QCM) system with dissipation. In situ UV irradiation of pellicle-covered anatase caused a statistically significant decrease of the adsorbed salivary mass. In contrast, photocatalytic decomposition of pellicle could not be observed on reference titanium surfaces. Wettability characterization revealed superhydrophilicity of anatase upon UV irradiation, whereas titanium was unaffected. XPS measurements provide further information concerning the decomposition of the salivary films. The results suggest that the photocatalytic activity of polycrystalline anatase-modified biomaterial surfaces is able to decompose complex structured macromolecular pellicle films. Therefore, this study opens the way to surface modifications supporting therapeutic approaches of biofilm removal.

The KdpC subunit of the Escherichia coli K+-transporting KdpB P-type ATPase acts as a catalytic chaperone

In Bacteria and Archaea, high-affinity potassium uptake is mediated by the ATP-driven KdpFABC complex. On the basis of the biochemical properties of the ATP-hydrolyzing subunit KdpB, the transport complex is classified as type IA P-type ATPase. However, the KdpA subunit, which promotes K(+) transport, clearly resembles a potassium channel, such that the KdpFABC complex represents a chimera of ion pumps and ion channels. In the present study, we demonstrate that the blending of these two groups of transporters in KdpFABC also entails a nucleotide-binding mechanism in which the KdpC subunit acts as a catalytic chaperone. This mechanism is found neither in P-type ATPases nor in ion channels, although parallels are found in ABC transporters. In the latter, the ATP nucleotide is coordinated by the LSGGQ signature motif via double hydrogen bonds at a conserved glutamine residue, which is also present in KdpC. High-affinity nucleotide binding to the KdpFABC complex was dependent on the presence of this conserved glutamine residue in KdpC. In addition, both ATP binding to KdpC and ATP hydrolysis activity of KdpFABC were sensitive to the accessibility, presence or absence of the hydroxyl groups at the ribose moiety of the nucleotide. Furthermore, the KdpC subunit was shown to interact with the nucleotide-binding loop of KdpB in an ATP-dependent manner around the ATP-binding pocket, thereby increasing the ATP-binding affinity by the formation of a transient KdpB/KdpC/ATP ternary complex.

Multifunctional nature of UV-irradiated nanocrystalline anatase thin films for biomedical applications

Anatase is known to decompose organic material by photocatalysis and to enhance surface wettability once irradiated by ultraviolet (UV) light. In this study, pulse magnetron-sputtered anatase thin films were investigated for their suitability with respect to specific biomedical applications, namely superhydrophilic and biofilm degrading implant surfaces. UV-induced hydrophilicity was quantified by static and dynamic contact angle analysis. Photocatalytic protein decomposition was analyzed by quartz crystal microbalance with dissipation. The surfaces were characterized by X-ray diffraction, atomic force microscopy, scanning electron microscopy and X-ray photoelectron spectroscopy. The radical formation on anatase, responsible for photocatalytic effects, was analyzed by electron spin resonance spectroscopy. Results have shown that the nanocrystalline anatase films, in contrast to reference titanium surfaces, were sensitive to UV irradiation and showed rapid switching towards superhydrophilicity. The observed decrease in carbon adsorbents and the increase in the fraction of surface hydroxyl groups upon UV irradiation might contribute to this hydrophilic behavior. UV irradiation of anatase pre-conditioned with albumin protein layers induces the photocatalytic decomposition of these model biofilms. The observed degradation is mainly caused by hydroxyl radicals. It is concluded that nanocrystalline anatase films offer different functions at implant interfaces, e.g. bedside hydrophilization of anatase-coated implants for improved osseointegration or the in situ decomposition of conditioning films forming the basal layer of biofilms in the oral cavity.

Structure of the τ60/Δτ91 Subcomplex of Yeast Transcription Factor IIIC: Insights into Preinitiation Complex Assembly

Yeast RNA polymerase III is recruited upon binding of subcomplexes tauA and tauB of transcription factor IIIC (TFIIIC) to the A and B blocks of tRNA gene promoters. The tauB subcomplex consists of subunits tau60, tau91, and tau138. We determined the 3.2 A crystal structure of tau60 bound to a large C-terminal fragment of tau91 (Deltatau91). Deltatau91 protein contains a seven-bladed propeller preceded by an N-terminal extension, whereas tau60 contains a structurally homologous propeller followed by a C-terminal domain with a novel alpha/beta fold. The two propeller domains do not have any detectable DNA binding activity and mediate heterodimer formation that may serve as scaffold for tau138 assembly. We show that the C-terminal tau60 domain interacts with the TATA binding protein (TBP). Recombinant tauB recruits TBP and stimulates TFIIIB-directed transcription on a TATA box containing tRNA gene, implying a combined contribution of tauA and tauB to preinitiation complex formation.

Prokaryotic Kdp-ATPase: recent insights into the structure and function of KdpB

P-type ATPases are amongst the most abundant enzymes that are responsible for active transport of ions across biological membranes. Within the last 5 years a detailed picture of the structure and function of these transport ATPases has emerged. Here, we report on the recent progress in elucidating the molecular mechanism of a unique, prokaryotic member of P-type ATPases, the Kdp-ATPase. The review focuses on the catalytic parts of the central subunit, KdpB. The structure of the nucleotide-binding domain was solved by NMR spectroscopy at high resolution and a model of the nucleotide-binding mode was presented. The nucleotide turned out to be 'clipped' into the binding pocket by a pi-pi interaction to F377 on one side and a cation-pi interaction to K395 on the other. The 395KGXXD/E motif and thus the nucleotide-binding mode seems to be conserved in all P-type ATPases, except the heavy metal-transporting (class IB) ATPases. Hence, it can be concluded that KdpB is currently misgrouped as class IA. Mutational studies on two highly conserved residues (D583 and K586) in the transmembrane helix 5 of KdpB revealed that they are indispensable in coupling ATP hydrolysis to ion translocation. Based on these results, two possible pathways for the reaction cycle are discussed.

[Combined medical treatment and psychotherapy in early-stage Alzheimer's over a period of 30 months]

The present case delineates the results of a 30-month combined pharmacological and psychotherapeutic treatment in a mildly to moderately depressed patient with early Alzheimer's dementia. At onset and during following visits, clinical examination and standardized test procedures for measuring cognitive and emotional changes were completed. Treatment results reveal a consistent benefit to cognitive levels and emotional distress over time. The present example of a mildly demented, depressed Alzheimer's patient shows a therapeutic outcome which is markedly superior to usual expectations in Alzheimer's treatment and encourages combination of therapeutic strategies in early stages of the disease.

The holo-form of the nucleotide binding domain of the KdpFABC complex from Escherichia coli reveals a new binding mode

P-type ATPases are ubiquitously abundant enzymes involved in active transport of charged residues across biological membranes. The KdpB subunit of the prokaryotic Kdp-ATPase (KdpFABC complex) shares characteristic regions of homology with class II-IV P-type ATPases and has been shown previously to be misgrouped as a class IA P-type ATPase. Here, we present the NMR structure of the AMP-PNP-bound nucleotide binding domain KdpBN of the Escherichia coli Kdp-ATPase at high resolution. The aromatic moiety of the nucleotide is clipped into the binding pocket by Phe(377) and Lys(395) via a pi-pi stacking and a cation-pi interaction, respectively. Charged residues at the outer rim of the binding pocket (Arg(317), Arg(382), Asp(399), and Glu(348)) stabilize and direct the triphosphate group via electrostatic attraction and repulsion toward the phosphorylation domain. The nucleotide binding mode was corroborated by the replacement of critical residues. The conservative mutation F377Y produced a high residual nucleotide binding capacity, whereas replacement by alanine resulted in low nucleotide binding capacities and a considerable loss of ATPase activity. Similarly, mutation K395A resulted in loss of ATPase activity and nucleotide binding affinity, even though the protein was properly folded. We present a schematic model of the nucleotide binding mode that allows for both high selectivity and a low nucleotide binding constant, necessary for the fast and effective turnover rate realized in the reaction cycle of the Kdp-ATPase.

Improvement of coping abilities in patients with systemic lupus erythematosus: a prospective study

OBJECTIVE

To evaluate a novel specific psychological intervention aimed at improving coping in patients with systemic lupus erythematosus (SLE).

METHODS

34 community living SLE patients were recruited for the study. Intervention was undertaken in groups of up to eight patients and in two blocks over six months each. Eight patients were enrolled as a waiting list group. The 18 group sessions focused on information about the disease and specific problems of SLE patients, combining psychoeducative and psychotherapeutic elements. Psychological and medical evaluations were conducted at baseline and after three, six, and 12 months, using validated instruments.

RESULTS

The 34 SLE patients (91% female, mean age 42 years) improved significantly over a six month period on most of the psychological measuring instruments applied, such as depression, anxiety, and overall mental burden. The waiting list group showed no significant changes.

CONCLUSIONS

Conceptualised psychoeducational support may produce a significant and sustained improvement in coping skills of SLE patients and hence in their quality of life.

[Treatment of Alzheimer's disease utilising the best available evidence-based medicine -- utopia?]

STUDY OBJECTIVES

To practice evidence-based medicine is considered to improve health care, particularly of chronically ill patients. Taking Alzheimer's as an example the objective of this study is to explore as to how far ambulatory Alzheimer's patients receive the medical treatment with the best evidence available.

METHOD

In 2000 and 2002 the health care situation of Alzheimer's disease patients was assessed by conducting telephone interviews with one hundred randomly selected general practitioners and specialists listed in the panel of the Institut fur Medizinische Statistik (IMS -- Institute for Medical Statistics). By means of a standardised questionnaire the interviewees' prescriptions were assessed as well as their knowledge of the medical therapy for Alzheimer's and the use of non-medical therapeutic measures. Besides, the interviewees' prescriptions were checked on the basis of quantitative data taken from the IMS panel. Cholinesterase inhibitors (ChE-I), which are accorded the best evidence presently available in the medical treatment of Alzheimer's, were seen as a marker for the improvement of health care in the course of the study.

RESULTS AND CONCLUSIONS

The interviewed physicians considered the evidence of medical Alzheimer's disease therapy with cholinesterase inhibitors high. 67 % of the interviewees would use ChE-I as the drug of first choice if a near relative fell ill with Alzheimer's. However, the ChE-I prescriptions were limited to 13 % in the base year 2000 and to 24 % in the base year 2002. Obviously, the implementation of this medical therapy is hampered by budgetary regulations. The interviewees find it particularly disadvantageous that the prescription of ChE-I may overstrain the budgets allocated to their practices. As a consequence, the effort to improve the quality of health care by implementing evidence-based medicine is thwarted by the increasing pressure on German physicians to prescribe drugs according to economic viability.

Inter-domain motions of the N-domain of the KdpFABC complex, a P-type ATPase, are not driven by ATP-induced conformational changes

P-type ATPases are involved in the active transport of ions across biological membranes. The KdpFABC complex (P-type ATPase) of Escherichia coli is a high-affinity K+ uptake system that operates only when the cell experiences osmotic stress or K+ limitation. Here, we present the solution structure of the nucleotide binding domain of KdpB (backbone RMSD 0.17 A) and a model of the AMP-PNP binding mode based on intermolecular distance restraints. The calculated AMP-PNP binding mode shows the purine ring of the nucleotide to be "clipped" into the binding pocket via a pi-pi-interaction to F377 on one side and a cation-pi-interaction to K395 on the other. This binding mechanism seems to be conserved in all P-type ATPases, except the heavy metal transporting ATPases (type IB). Thus, we conclude that the Kdp-ATPase (currently type IA) is misgrouped and has more similarities to type III ATPases. The KdpB N-domain is the smallest and simplest known for a P-type ATPase, and represents a minimal example of this functional unit. No evidence of significant conformational changes was observed within the N-domain upon nucleotide binding, thus ruling out a role for ATP-induced conformational changes in the reaction cycle.

[Outpatient treatment of patients suffering from Alzheimer dementia. Two exploratory studies on the characteristics of therapy in medical practice]

In two exploratory studies on the outpatient treatment of patients suffering from Alzheimer dementia research was done into the characteristics of therapy in medical practice on the basis of exemplary interviews of 100 doctors in 2000 and 2002. The interviewers discern the burden of the disease for the patients and their relatives. However, medical treatment is still too scarce and inappropriate as the prescribing of antidementia drugs shows, among which especially acetylcholinesterase inhibitors as drugs of first choice. The spectrum of non-pharmacological interventions is applied but psychosocial measures are under-represented. To maintain the Alzheimer patient's functional level and to thus relieve the caring relatives a multimodal therapy should be intensified preferably by comprehensive co-operations.

Psychische St�rungen bei rheumatischen Erkrankungen am Beispiel des Systemischen Lupus Erythematodes (SLE)

Among the rheumatic diseases, systemic lupus erythematosus (SLE) reveals the highest frequency of central nervous symptoms. Psychiatric abnormalities are present in over 90% of the patients, if very mild cognitive impairment is included. The psychiatric syndromes listed by the American College of Rheumatologists encompass cognitive syndromes, including the acute confusional state, anxiety disorders, depressive symptomatology and psychosis. Associations between cognitive impairment and demographic and disease variables, i. e. disease severity, have not been clearly identified so far. The same holds true for the evolution of depressive symptoms. Reactive depression in coping with a chronic disease is, however, a psychologically plausible factor in addition to specific cerebral lesions. Therapeutic interventions in SLE should consist of a combined pharmacological and nonpharmacological treatment. Corticosteroid drugs, however, may be effective in alleviating mild psychiatric symptoms as well.

[Early diagnosis and treatment of Alzheimer's disease. Implementation in the doctor's office]

The efficacy of antidemential agents proven in comprehensive studies and by clinical experience, now justifies an active and positive approach by the general physician to the diagnosis and treatment of patients with dementia. The proposals on how to implement diagnostic and therapeutic measures in the doctor's office comply both with medical quality criteria and the requirements for appropriateness of treatment and considerations of economy stipulated by German law. They therefore provide the basis for a modern diagnostic work-up and treatment strategy, which will also meet economical demands.

Infantile Alexander disease: a GFAP mutation in monozygotic twins and novel mutations in two other patients

Alexander disease (AD) is a rare disorder of cerebral white matter due to a dysfunction of astrocytes. The most common infantile form presents as a megalencephalic leukodystrophy. Recently, heterozygous de novo mutations in the glial fibrillary acidic protein gene (GFAP) have been demonstrated to be associated with AD. We report heterozygous mutations in GFAP in 5 patients, including a pair of monozygotic twins, with clinical and neuroradiological features of infantile AD. Novel mutations were detected affecting nucleotides 304 T --> C (L97 P) and 730 G --> C (R239 P) in two other patients. None of the parents of our patients carried the mutations stressing dominant de novo mutations as the cause of AD. The presence of an identical mutation 250 G --> A (R79 H) in both monozygotic twins with infantile AD points to the origin of these GFAP mutations in germ cells or very early postzygotic stages.

[Is it Alzheimer disease? Recognizing the first signs of dementia syndrome]

Today, early diagnosis of different forms of dementia is possible with a relatively easy-to-apply set of diagnostic tools. The quality of the medical history, including the information supplied by relatives and friends, together with the psychological and physical findings, determine the diagnostic hit rate. Laboratory investigations and imaging techniques are indispensable for detecting the underlying cause of existing dementia. Standardized rapid screening procedures for the identification of mild cognitive deficits have speeded up the reliable selection of suspicious cases needing referral to a specialist. Identification of individual day-to-day problems and non-cognitive disorders round off the diagnosis of dementia, and establish the conditions for planning a suitable treatment strategy.

Improvement of agitation and anxiety in demented patients after psychoeducative group intervention with their caregivers

OBJECTIVES

It has been convincingly demonstrated that in dementia, psychoeducative group intervention with caregivers positively impacts on motivation for care and satisfaction of the caregivers. It has, however, been neglected to examine the effect of psychoeducative group intervention on the behavioural and psychological symptoms of the demented patients.

METHODS

In a 3-month, expert-based and conceptualized group intervention with caregiving relatives of demented patients we investigated whether behavioural and psychological symptoms may improve and which of a set of independent variables may predict improvement.

RESULTS

The 3-month group intervention yielded a significant improvement in agitation and anxiety of the demented patients. The presence of an additional somatic disease in the patients and male gender predicted a less positive outcome of the intervention related to the presence of agitation.

CONCLUSIONS

This study demonstrated that psychoeducative group intervention with the caregivers of demented patients is helpful for the demented patients themselves. This evidence of a positive mediator effect of the group intervention on the behavioural and psychological symptoms of the patients underscores the importance of nonpharmacological strategies in the treatment of dementia.