Vagus nerve stimulation for conservative therapy-refractive epilepsy and depression. / Die Vagusnervstimulation bei konservativ therapierefraktärer Epilepsie und Depression.

Numerous studies confirm that the vagus nerve stimulation (VNS) is an efficient, indirect neuromodulatory therapy with electrically induced current for epilepsy that cannot be treated by epilepsy surgery and is therapy-refractory and for drug therapy-refractory depression. VNS is an established, evidence-based and in the long-term cost-effective therapy in an interdisciplinary overall concept.Long-term data on the safety and tolerance of the method are available despite the heterogeneity of the patient populations. Stimulation-related side effects like hoarseness, paresthesia, cough or dyspnea depend on the stimulation strength and often decrease with continuing therapy duration in the following years. Stimulation-related side effects of VNS can be well influenced by modifying the stimulation parameters. Overall, the invasive vagus nerve stimulation may be considered as a safe and well-tolerated therapy option.For invasive and transcutaneous vagus nerve stimulation, antiepileptic and antidepressant as well as positive cognitive effects could be proven. In contrast to drugs, VNS has no negative effect on cognition. In many cases, an improvement of the quality of life is possible.iVNS therapy has a low probability of complete seizure-freedom in cases of focal and genetically generalized epilepsy. It must be considered as palliative therapy, which means that it does not lead to healing and requires the continuation of specific medication. The functional principle is a general reduction of the neuronal excitability. This effect is achieved by a slow increase of the effectiveness sometimes over several years. Responders are those patients who experience a 50% reduction of the seizure incidence. Some studies even reveal seizure-freedom in 20% of the cases. Currently, it is not possible to differentiate between potential responders and non-responders before therapy/implantation.The current technical developments of the iVNS generators of the new generation like closed-loop system (cardiac-based seizure detection, CBSD) reduce also the risk for SUDEP (sudden unexpected death in epilepsy patients), a very rare, lethal complication of epilepsies, beside the seizure severity.iVNS may deteriorate an existing sleep apnea syndrome and therefore requires possible therapy interruption during nighttime (day-night programming or magnet use) beside the close cooperation with sleep physicians.The evaluation of the numerous iVNS trials of the past two decades showed multiple positive effects on other immunological, cardiological, and gastroenterological diseases so that additional therapy indications may be expected depending on future study results. Currently, the vagus nerve stimulation is in the focus of research in the disciplines of psychology, immunology, cardiology as well as pain and plasticity research with the desired potential of future medical application.Beside invasive vagus nerve stimulation with implantation of an IPG and an electrode, also devices for transdermal and thus non-invasive vagus nerve stimulation have been developed during the last years. According to the data that are currently available, they are less effective with regard to the reduction of the seizure severity and duration in cases of therapy-refractory epilepsy and slightly less effective regarding the improvement of depression symptoms. In this context, studies are missing that confirm high evidence of effectiveness. The same is true for the other indications that have been mentioned like tinnitus, cephalgia, gastrointestinal complaints etc. Another disadvantage of transcutaneous vagus nerve stimulation is that the stimulators have to be applied actively by the patients and are not permanently active, in contrast to implanted iVNS therapy systems. So they are only intermittently active; furthermore, the therapy adherence is uncertain.

[Orbital complications]. / Orbitale Komplikationen.

A disease or symptom of disease spreading from the vicinity of the orbit to the internal structures of the orbit is referred to as an orbital complication. Orbital complications can have a traumatic, inflammatory, allergic, or autoimmunologic cause. They are more frequent in children than adults. The present review aims to provide a description of orbital complications, their etiology, pathogenesis, and treatment. Recent literature in the field is acknowledged and discussed, and results from the authors' own patient groups are analyzed. Particular attention is paid to orbital complications due to acute sinusitis and those caused by acute hemorrhage. The term "orbital phlegmon" frequently used for orbital complications with inflammatory causes is confusing and should be replaced by differentiated grading. Diagnosis and treatment of orbital complications requires interdisciplinary collaboration, whereby inclusion of ophthalmologists is particularly important. Treatment of orbital complications depends on their cause. In inflammatory cases affecting only the preseptal tissues and compartment, conservative therapy is indicated. If clinical findings worsen within 24 h of conservative therapy, or if the patient presents with a high-grade orbital complication with loss of visual acuity or impairment of globe mobility, surgery is required. In cases of acute hemorrhage into the orbit, a procedure for decreasing intra-orbital pressure is mandatory (i. e., canthotomy, cantholysis, orbital decompression).

[Traumatic optic nerve neuropathy. Longterm results following microsurgical optic nerve decompression]. / Traumatische Optikusneuropathie. Langzeitergebnisse nach endonasaler mikrochirurgischer Dekompression des N. opticus.

BACKGROUND: Traumatic optic nerve neuropathy (TON) is defined as injury to the optic nerve with subsequent vision loss due to head or craniocerebral trauma. The treatment of this disease is the subject of controversial discussions. The purpose of the present study was to investigate pre- and immediate postoperative visual acuity in patients with unilateral TON and to compare the results with the time interval between trauma and surgical intervention. PATIENTS AND METHODS: A total of 20 patients with unilateral TON and considerable vision loss were examined. All were treated with high dose corticoids and underwent microsurgical optic nerve decompression. Visual acuity was determined pre- and postoperatively. In long-term follow-up visual acuity was determined 3 months postoperatively. RESULTS: Postoperatively, nine patients (45%) achieved an improvement in visual acuity of more than 0.4, and another three patients (15%) an improvement of ≥0.2. At 3 months postoperatively another four patients achieved a further improvement of their visual acuity of >0.2. A decrease in visual acuity was not observed in any case, nor were major surgical complications. CONCLUSIONS: Factors which predict good prognosis for vision recovery include a short time interval between trauma and intervention, edema, and/or hematoma of the optic nerve sheath. Factors which predict a worse prognosis are a fracture line directly through the nerve canal, a time period between trauma and intervention of more than 24 h, and initial complete amaurosis.

Effects of memantine on behavioural symptoms in Alzheimer's disease patients: an analysis of the Neuropsychiatric Inventory (NPI) data of two randomised, controlled studies.

INTRODUCTION: Behavioural symptoms are common in moderate to severe Alzheimer's disease (AD). We have analysed the databases of two randomised studies with regard to the effects of memantine treatment on behavioural symptoms, measured using the 12-item version of the Neuropsychiatric Inventory (NPI). SUBJECTS: The monotherapy study (memantine only) reported by Reisberg et al. (2003) involved 252 patients with baseline MMSE total score of between 3 and 14, whereas the combination study (memantine and donepezil) reported by Tariot et al. (2004) comprised 404 patients with MMSE scores of between 5 and 14. In both studies, patients received 10 mg memantine b.i.d. or matching placebo, and lived in the community. METHODS: For both studies NPI total and individual domains scores were analysed in the ITT population. For the monotherapy study a dichotomised analysis was performed separately for patients who had behavioural symptoms at baseline and for those without pre-existing symptoms. Furthermore, a factor analysis was used to identify any behavioural clusters within the patient population. RESULTS: In both studies, the change in NPI total scores at endpoint was consistently in favour of memantine treatment, reaching statistical significance in the combination study (p = 0.002). Memantine treatment showed a significant beneficial effect in comparison to placebo treatment in the NPI agitation/aggression domain in both studies (p = 0.008; p = 0.001). The dichotomised analysis of the monotherapy study showed that there was significantly less agitation/aggression emerging in the memantine-treated group compared to placebo (p = 0.003). Factor analysis showed that hyperactivity accounted for 27% of the data variance. CONCLUSIONS: Memantine has a beneficial effect on the behavioural symptoms of patients with moderate to severe AD, with the most pronounced effect on agitation/aggression.

Specific functional effects of memantine treatment in patients with moderate to severe Alzheimer's disease.

Treatment of Alzheimer's disease (AD) that combats progressive functional deterioration can improve the patient's quality of life and reduce caregiver burden. Memantine, a moderate affinity N-methyl-D-aspartate receptor antagonist, reduces global deterioration in AD patients and provides cognitive and functional benefits relative to placebo. Two previous studies reported statistically significant benefits of memantine for overall functional ability on the Alzheimer Disease Cooperative Study Activities of Daily Living Inventory modified for severe dementia (ADCS-ADL(19)), Functional Assessment Staging, and G2 scale. The present study reports a single-item analysis of the ADL scales from the two trials and shows that patients treated with memantine demonstrated a numerical advantage over placebo on all items assessed. These results help to translate the positive effects of memantine into specific aspects of functional ability, information that is relevant to AD patients and their families as well as to researchers interested in the assessment of functional ability in AD clinical trials.

A double-blind, placebo-controlled multicentre study of memantine in mild to moderate vascular dementia (MMM500).

The aim of the reported trial was to investigate the safety and efficacy of memantine in mild to moderate vascular dementia (VaD). This was a 28-week, double-blind, parallel, randomized controlled trial of memantine 20 mg daily versus placebo which was conducted in 54 centres in the UK. Memantine is a uncompetitive, moderate affinity N-methyl-D-aspartate receptor antagonist. Patients with a diagnosis of probable VaD and Mini Mental State Examination total scores between 10 and 22 were eligible for inclusion. Primary efficacy parameters were the Alzheimer's Disease Assessment Scale-Cognitive Subscale (ADAS-cog) and the Clinical Global Impression of Change (CGI-C). A total of 579 patients were randomized and 548 patients with at least one post-baseline efficacy assessment qualified for the intent-to-treat analysis. At endpoint, memantine was shown to improve cognition relative to placebo in VaD: the change of ADAS-cog from baseline differed by a mean of -1.75 points (95% confidence intervals -3.023 to -0.49) and a median of 2 points between the two groups, while CGI-C ratings showed no significant differences between treatment groups. A total of 77% of all memantine-treated patients experienced adverse event, versus 75% of the placebo-treated patients, dizziness being the most frequent adverse event (11% versus 8%, respectively). Memantine was well tolerated and safe.

Measuring cognition in advanced Alzheimer's disease for clinical trials.

Measurement of cognitive dysfunction and treatment response in the early stages of Alzheimer's disease (AD) has used such scales as the Mini-Mental State Examination (MMSE) and the AD Assessment Scale (ADAS). With the exception of clinical rating scales, however, there are only a few objective measures of cognition for tracking progression in advanced AD. Given renewed interest in potential therapies for advanced AD, objective measures of cognition are important for the adequate evaluation of change due to AD progression or therapy. Several cognitive measures for advanced AD are reviewed. One measure, the Severe Impairment Battery (SIB) is reviewed in detail. Preliminary analyses from a trial of memantine show significant change on the SIB in memory (p < 0.001) and visuospatial functions (p < 0.02) over six-months with a trend for language and praxis. Data from a donepezil trial also highlight the importance of accurate assessment in advanced AD.

Glutamate receptors as a target for Alzheimer's disease--are clinical results supporting the hope?

Several years after the introduction of cholinergic drugs in Alzheimer's disease therapy, other approaches for symptomatic and also disease-modifying pharmacotherapy are progressing in their development. Among these, the NMDA antagonist memantine represents the most advanced and promising agent, gifted with many years of clinical experience in Germany. This paper provides an overview of both, the novel pharmacological background and recent clinical evidence in dementia. Memantine was recently recommended for central European approval.

New approaches to clinical trials in vascular dementia: memantine in small vessel disease.

Although criteria for the diagnosis of vascular dementia (VaD) are established, the diagnostic concept is still controversial and there is no regulatory guidance for clinical drug development. Clinical trials in VaD present a number of pitfalls and challenges and, so far, no compound has received regulatory approval for this indication. The methodological issues of clinical VaD trials are discussed using the development of memantine for this indication as an example. In a pooled analysis of two placebo-controlled trials with the NMDA-antagonist memantine in VaD, the cognitive benefit by memantine treatment was more pronounced for patients with 'small vessel disease' than for those with other neuroradiological findings at baseline. In a subgroup of patients with 'large vessel disease' or macrolesions, there was less cognitive decline among the placebo patients. It may therefore be helpful to use predefined diagnostic subcategories in clinical studies in this indication. The findings further suggest that stroke or multiple infarctions may not be the primary reason for cognitive decline in VaD patients.

Neuroprotective and symptomatological action of memantine relevant for Alzheimer's disease--a unified glutamatergic hypothesis on the mechanism of action.

The involvement of glutamate mediated neurotoxicity in the pathogenesis of Alzheimer's disease is finding increasingly more acceptance in the scientific community. Central to this hypothesis is the assumption that in particular glutamate receptors of the N-methyl-D-aspartate (NMDA) type are overactivated in a tonic rather than a phasic manner. Such continuous mild activation leads under chronic conditions to neuronal damage. Moreover, one should consider that impairment of plasticity (learning) may result not only from neuronal damage per se but also from continuous activation of NMDA receptors. To investigate this possibility we tested whether overactivation of NMDA receptors using either non-toxic doses/concentrations of a direct NMDA agonist or through an indirect approach--decrease in magnesium concentration--produces deficits in plasticity. In fact NMDA both in vivo (passive avoidance test) and in vitro (LTP in CA1 region) impaired learning and synaptic plasticity. Under these conditions memantine which is an uncompetitive NMDA receptor antagonist with features of "improved magnesium" (voltage dependence, affinity) attenuated the deficit. The more direct proof that memantine can act as a surrogate for magnesium was obtained in LTP experiments under low magnesium conditions. In this case as well, impaired LTP was restored in the presence of therapeutically relevant concentrations of memantine (1 microM). In vivo, doses leading to similar brain/serum levels produce neuroprotection in animal models relevant for neurodegeneration in Alzheimer's disease such as neurotoxicity produced by inflammation in the NBM or beta-amyloid injection to the hippocampus. Hence, we postulate that if in Alzheimer's disease overactivation of NMDA receptors occurs indeed, memantine would be expected to improve both symptoms (cognition) and slow down disease progression because it takes over the physiological function of magnesium.

Pharmacologic rationale for memantine in chronic cerebral hypoperfusion, especially vascular dementia.

Memantine is a moderate-affinity, voltage-dependent, uncompetitive antagonist of N-methyl-D-aspartate (NMDA) receptors. In contrast to competitive NMDA antagonists, Memantine is well tolerated in humans and is being developed for the treatment of dementia. The pathogenesis of vascular dementia (VaD) is largely unknown, and is likely multifactorial, but it involves the impairment of blood circulation as a common denominator. There is broad evidence for the efficacy of Memantine in several animal models of ischemia. Memantine also acts on several secondary, potentially contributing factors in VaD such as neuronal depolarization, removal of magnesium block of NMDA receptors, chronic overstimulation of these receptors, and, possibly, mitochondrial dysfunction. Among others, it also has additional positive effects on long-term potentiation and cognition in standard animal models of impaired synaptic plasticity. Recently, clinical efficacy of Memantine has been shown in an etiologically mixed population of severely demented patients, including those with VaD. Given the difficulties of diagnosing VaD in clinical practice, an optimal antidementive drug should be beneficial in both Alzheimer disease and VaD. Preclinical data presented in this paper indicate that such benefits can be achieved with Memantine. In addition, phase II clinical data in dementia are summarized, and two ongoing pivotal trials in VaD are described. Suggestions for VaD guideline development are made regarding clinical instruments, and etiologies and severity stages are considered.

[Simultaneous occurrence of a cystadenolymphoma (Warthin tumor) in the parotid gland and larynx]. / Simultanes Auftreten eines Zystadenolymphoms (Warthin-Tumor) in Parotis und Larynx.

Warthin's tumour of the larynx is an unusual finding. In present literature only four cases have been reported. Only one case of a woman suffering from Warthin's tumour of the parotid gland and the ipsilateral site of the larynx has been published. A case of a 74-year-old woman with an Warthin's tumour of the right parotid gland and the left false cord is presented. The theories about the development of Warthin's tumours are discussed.

Solid state systems for the potentiometric determination of CO(2).

In a survey of solid state systems for the potentiometric determination of CO(2) their different fundamentals, possibilities and problems are demonstrated. Experimental results are given, obtained from sensors in which Na(2)CO(3) reacts electrochemically with an oxide forming the sodium salt thermodynamically stable in contact with it. Sensors with Na(2)YZr(PO(4)) as solid electrolyte and MoO(3) or SiO(2) did not yield long-term stable signals, probably mainly because of chemical reactions between the oxides and the solid electrolyte. Satisfactory results were obtained with galvanic cells represented by the symbol. Their standard cell tensions U* (= -emf*) determined with different test gases are in relatively good agreement with values thermodynamically calculated.

The GABAB receptor antagonist CGP 36,742 and the nootropic oxiracetam facilitate the formation of long-term memory.

The memory-enhancing effects of a single treatment with the GABAB antagonist CGP 36,742 (10 mg/kg) or the nootropic agent oxiracetam (100 mg/kg) given immediately after a learning experience ('post-trial') remain detectable for at least 4 months thereafter. This indicates that in all probability these substances facilitate the formation of the long-term memory trace.

Pharmacokinetics of CGP 36,742, an orally active GABAB antagonist, in humans.

A study was conducted to evaluate the pharmacokinetics of CGP 36 742 (3-aminopropyl-n-butyl-phosphinic acid), an orally active gamma-aminobutyric acid B (GABAB) antagonist, in humans. Pharmacokinetic results after a single oral (600 mg) dose included maximum observed concentration (Cmax), 27 mumol/L (95% CI 22.9, 30.8); time to Cmax (tmax), 3 hours (median); half-life (t1/2), 3.6 hours (95% CI 3.24, 3.9); renal clearance (ClR), 125 mL/min (95% CI 114, 136); and absolute bioavailability (Fabs), 0.44 (95% CI 0.33, 0.47). Administration with food decreased the oral systemic availability (Frel) by 30%. The volume of distribution (285 L/kg) was in the order of magnitude of extracellular body water. The absorbed fraction of the compound was excreted completely and unchanged via the kidney, thus renal function would be the limiting factor for excretion. The rate of absorption and amount absorbed did not differ significantly between elderly and young healthy male volunteers, both after single and multiple doses. There was no gender-related difference in pharmacokinetics in healthy elderly volunteers. CGP 36 742 showed an excellent safety profile: there were no clinically relevant changes in cardiovascular variables, body temperature, or blood chemistry. In the placebo-controlled trial, adverse experiences were rare and evenly distributed among participants receiving placebo and the study drug. In addition, a newly developed high-performance liquid chromatography (HPLC) method for measurement of CGP 36 742 concentrations in plasma and urine using fluorescence detection is described.

Determination of rat brain and plasma levels of the orally active GABAB antagonist 3-amino-propyl-n-butyl-phosphinic acid (CGP 36742) by a new GC/MS method.

An involvement of GABAergic neurons has been suggested in the process of memory consolidation based on anatomical evidence and increasing physiological and biochemical data. With the advent of orally active GABAB antagonists, such as CGP 36742, the question of their therapeutic value, for example in Alzheimer's disease, becomes relevant. Therefore, a new GC/MS method was developed to determine the concentration of CGP 36742 (3-amino-propyl-n-butyl phosphinic acid) in various intra- and extracerebral tissues after different routes of application. The compound was chemically derivatised in a two-step process (acylation of the amino group and esterification of the phosphinic acid). The limit of detection of the method was 0.01 microgram/g tissue and 0.0005 microgram/mL plasma. The time-course after i.p. treatment showed peak levels of CGP 36742 between 30 min and 1 hr after injection. After a dose of 100 mg/kg, the concentration in the brain ranged from 1 to 1.4 microgram/g or 6 to 8 microM, assuming that 1 mg tissue equals 1 microL (i.e., below the IC50 of the interaction with GABAB receptors as measured by [3-3H]-aminopropyl-phosphinic acid binding [35 microM]). These results are discussed in light of the psychopharmacological effects (improvement of cognitive performance of rats) of CGP 36742 observed at very low oral doses.

[Assessment of hemodynamics in the cerebral cortex in newborn infants]. / Die Erfassung der Hämodynamik im Bereich der Hirnrinde bei Neugeborenen.

Determinations of blood velocity in vessels of cerebral cortex have been done using a 20 MHz impulse Doppler unit. In comparison we registered the blood flow pulsation curves at the anterior cerebral artery with aid of a 5 MHz-cw-Doppler system. The peripheral resistance index was calculated and it could be proved a strong correlation between the results of the anterior cerebral artery and the vessels of cerebral cortex. Another study showed that the results of the method could be reproduced. The problem of the impulse Doppler examinations of cerebral cortical vessels is the fact, that the exact topography of the vessels examined cannot be defined exactly.

[Modification of cerebral hemodynamics by invasive routine diagnostic procedures]. / Die Beeinflussung der zerebralen Hämodynamik durch invasive diagnostische Routinemassnahmen.

By means of cw-Doppler-ultrasonics pulsation curves of anterior cerebral arteries were recorded before, during and after a necessary capillary blood sampling in 12 premature newborns. Patients were stable and needed no oxygenation. Blood pressure and transcutaneous oxygen saturation have been recorded simultaneously. The most important hemorheological parameters were within normal range. Immediately following irritation pulsatility indices increased, partly diastolic reflux phenomena could be observed. Finishing irritation values went back to starting position very fast. It is supposed such strong changes of cerebral vascular resistance could be the reason of cerebrovascular damages in non sedated premature newborn babies.