Intravenous Reelin rescues despair-like behavior, Reelin cells in the dentate sub-granular zone, and spleen atrophy in the cyclic corticosterone model of recurring depressive episodes.

Novel antidepressants are predominantly evaluated preclinically in rodent models of chronic stress in which animals experience a single prolonged exposure to chronic stress prior to treatment. Rodent models of a single episode of chronic stress translate poorly to human depressive disorders, which are commonly marked by recurring depressive episodes. Intravenous administration of Reelin has previously been shown to resolve immobility in the forced swim test of rats exposed to a single prolonged exposure to chronic stress. To determine whether Reelin has antidepressant-like properties in a model of recurring depressive episodes, Long-Evans rats (N = 57) were exposed to multiple cycles of chronic stress and stress-free periods before the administration of a single injection of Reelin during the final cycle of chronic stress. The animals then performed in the forced swim test and open field test before the post-mortem evaluation of Reelin cell counts in the sub-granular zone of the dentate gyrus to determine the impact of treatment on hippocampal Reelin levels and spleen white pulp to evaluate the role of Reelin treatment in peripheral inflammation. The results show a single Reelin injection reversed elevated levels of immobility in the forced swim test in both male and female subjects exposed to the cyclic chronic stress model of recurring depressive episodes. Treatment with Reelin also restored Reelin-positive cell counts in the dentate gyrus sub-granular zone and reversed atrophy of spleen white pulp. The results shown here indicate that treatment with Reelin could effectively resolve alterations in forced swim test behavior caused by the cyclic corticosterone model of recurring depressive episodes and that Reelin homeostasis is important for regulating stress-related inflammation. Future preclinical antidepressant research should incorporate models of multiple depressive episodes to improve the translation of preclinical rodent research to human depressive disorders.

The Clinical Outcome of Custom-Made Implants in Primary and Revision Hip Arthroplasty.

PURPOSE OF THE STUDY Facing the increasing number of priary and revision hip arthroplasties, the therapy of complex osseus defects becomes a crucial issue. Large acetabular defects cannot be treated with standard implant. Individual, customized implants based on 3D computed tomography (CT) scans are used for reconstruction. However, high complication and revision rates come along with final favorable outcomes. MATERIAL AND METHODS Eight patients underwent primary or revision total hip arthroplasty by an anterolateral surgical approach using patient matched implants based on 3D CT scans. Six patients with a Paprosky type IIIB acetabular defect, one patient with a nonunion acetabular and femoral neck fracture and one patient with a severe hip dysplasia were included. The clinical data and the Merle d'Aubigné score assessing the clinical outcome pre- and postoperatively were analyzed retrospectively. RESULTS Patient matched implants were used for eight patients (four male and four female). The mean Merle d'Aubigné score improved from 8.1 (range 2-11) pre-operatively to 13 (range 9-17) at the final follow-up (p < 0.01). Postoperative complications were recorded in 3 cases. CONCLUSIONS Customized implants of severe acetabular defects provide a solution with a favorable outcome. Nevertheless, dislocation presents a significant complication. A reduction of complications in order to achieve the optimal custome-made implant is desirable. Key words: revision arthroplasty, patient-matched implants, Paprosky IIIB defects, clinical outcome.

Repetitive transcranial magnetic stimulation in the treatment of resistant depression: changes of specific neurotransmitter precursor amino acids.

Repetitive transcranial magnetic stimulation (rTMS) for treatment-resistant major depression offers an alternative therapy, since more than every third patient is not responding to adequate antidepressive treatment. In this interventional study safety, symptom development and changes of serum concentrations of neurotransmitter precursor amino acids, of immune activation and inflammation markers, of brain-derived neurotrophic factor (BDNF), nitrite as well as of salivary amylase were measured before and after a frontal polar cortex stimulation using rTMS as add-on treatment in 38 patients with treatment-resistant depression. Out of these, 17 patients received sham stimulation as a control. Treatment was well tolerated: with the exception of one patient of the verum group, who described discomfort during the second treatment, no serious adverse effects were observed. Improvement of depression with a significant decrease in the HAMD-7 scale (p = 0.001) was found in patients treated with rTMS, but not in sham-treated patients. Furthermore, serum phenylalanine and tyrosine dropped significantly (p = 0.03 and p = 0.027, respectively) in rTMS-treated patients. The kynurenine to tryptophan ratio (Kyn/Trp) tended to decrease under rTMS (p = 0.07). In addition, associations between concentrations of BDNF and neopterin as well as serum nitrite levels were found in patients after rTMS treatment, which indicates an influence of immune regulatory circuits on BDNF levels. In the sham-treated patients, no changes of biomarker concentrations were observed. Results show that rTMS is effective in the treatment of resistant depression. rTMS appears to influence the enzyme phenylalanine hydroxylase, which plays a central role in the biosynthesis of neurotransmitter precursors tyrosine and dihydroxyphenylalanine (DOPA).

Wake-up stroke-Amendable for thrombolysis-like stroke with known onset time?

Patients suffering an acute ischemic stroke can be treated with intravenous thrombolysis in the absence of contraindications. A known onset time is a prerequisite as treatment, according to guidelines, has to be started within 4.5 hours. In patients awakening with a stroke, the last time they were seen without a neurological deficit is assumed to be the time of onset. Thus, despite of lack of contraindications on initial brain imaging, these patients are largely excluded from therapy. This review discusses the underlying pathophysiological, clinical, and radiological evidence surrounding wake-up stroke and its consequences for making treatment decisions.

Radiological imaging in acute ischaemic stroke.

Patients who suffer acute ischaemic stroke can be treated with thrombolysis if therapy is initiated early. Radiological evaluation of the intracranial tissue before such therapy can be given is mandatory. In this review current radiological diagnostic strategies are discussed for this patient group. Beyond non-enhanced computed tomography (CT), the standard imaging method for many years, more sophisticated CT stroke protocols including CT angiography and CT perfusion have been developed, and additionally an increasing number of patients are examined with magnetic resonance imaging as the first imaging method used. Advantages and challenges of the different methods are discussed.

Evaluation of the recombinant tissue plasminogen activator pretreatment in acute stroke patients with large vessel occlusions treated with the direct bridging approach. Is it worth the effort?

BACKGROUND AND PURPOSE: The direct bridging concept in acute stroke treatment combines intravenous thrombolysis (IVT) and endovascular treatment (EVT). The frequency and extent of reperfusion obtained already due to IVT were evaluated. Additionally undesired events and the clinical outcome were analysed. METHODS: Fifty-seven acute stroke patients treated with direct bridging were analysed for this study. The response to IVT was evaluated according to the modified Thrombolysis in Cerebral Infarction scale (m-TICI). IVT responders (m-TICI ≥2B in digital subtraction angiography) were compared with IVT non-responders (m-TICI <2B in digital subtraction angiography) with respect to clinical outcome and occurrence of undesired events. RESULTS: Fourteen patients (25%) got a change from TICI 0 to ≥2B due to IVT alone. There were otherwise no differences between the IVT responders and IVT non-responders. CONCLUSIONS: Intravenous thrombolysis pretreatment in the context of the bridging approach contributes substantially to revascularization.

Immunomodulatory effects in vitro of vitamin K antagonist acenocoumarol.

Neopterin production and tryptophan breakdown by indoleamine 2,3-dioxygenase (IDO) are induced within cell-mediated (=Th1-type) immune response, and in patients with coronary artery disease, serum neopterin and the kynurenine to tryptophan ratio (Kyn/Trp) are significantly predictive for cardiovascular and total mortality. To examine the potential impact of vitamin K-antagonist acenocoumarol (Sintrom) on the inflammatory response we investigated its effect on freshly isolated peripheral blood mononuclear cells (PBMC) from healthy donors, on myelomonocytic THP1-Blue and on intestinal Caco-2 cells in vitro. PBMC were incubated with increasing doses of acenocoumarol, and after 30 min either left unstimulated or stimulated with the mitogen phytohemagglutinin (PHA). Concentrations of neopterin, tryptophan, kynurenine, interferon-γ (IFN-γ) and tumor necrosis factor α (TNF-α) were measured in supernatants of PBMC after 48 h. Caco-2 cells were stimulated with IFN-γ and Kyn/Trp was used as readout. In THP1-Blue cells, the induction of NF-κB dependent reporter gene expression upon stimulation with lipopolysaccharide (LPS) was determined as an indicator of pro-inflammatory response. Upon stimulation, all measured immune response markers increased significantly compared to unstimulated cells. Acenocoumarol had no effect in unstimulated cells but in PHA-stimulated PBMC tryptophan breakdown and the formation of neopterin, as well as IFN-γ and TNF-α, were dose-dependently suppressed at concentrations as low as 10 µg/ml. Likewise, acenocoumarol dose-dependently inhibited tryptophan breakdown in IFN-γ stimulated Caco-2 cells. Interestingly, NF-κB expression was super-induced in the LPS treated cells. Data suggest that the immunomodulatory capacity of acenocoumarol contributes to its therapeutic efficacy.

Acute ischemic stroke--from symptom recognition to thrombolysis.

OBJECTIVES: The understanding of stroke has changed in the recent years from rehabilitation to an emergency approach. We review existing data from symptom recognition to thrombolysis and identify challenges in the different phases of patient treatment. RESULTS: Implementation of treatment in dedicated stroke units with a multidisciplinary team exclusively treating stroke patients has led to significant reduction of stroke morbidity and mortality. Yet, first the introduction of treatment with intravenous rtPA (IVT) has led to the 'time is brain' concept where stroke is conceived as an emergency. As neuronal death in stroke is time dependent, all effort should be laid on immediate symptom recognition, rapid transport to the nearest hospital with a stroke treatment facility and diagnosis and treatment as soon as possible. The main cause of prehospital delay is that patients do not recognize that they suffered a stroke or out of other reasons do not call the Emergency Medical Services immediately. Educational stroke awareness campaigns may have an impact in increasing the number of patients eligible for rtPA treatment and can decrease the prehospital times if they are directed both to the public and to the medical divisions treating stroke. Stroke transport times can be shortened by the use of helicopter and a stroke mobile--an ambulance equipped with a CT scanner--may be helpful to decrease time from onset to treatment start in the future. Yet, IVT has several limitations such as a narrow time window and a weak effect in ischemic strokes caused by large vessel occlusions. In these cases, interventional procedures and the concept of bridging therapy, a combined approach of IVT and intraarterial thrombolysis or mechanical thrombectomy, might improve recanalization rates and patient outcome. CONCLUSIONS: As neuronal death in stroke patients occurs in a time-dependent fashion, all effort should be made to decrease time from symptom onset to treatment start with rtPA: major challenges are stroke recognition in the public, transport times to hospital and an efficient stroke triage in the hospital.

Specific immunotherapy normalizes tryptophan concentrations in patients with allergic rhinitis.

BACKGROUND/AIMS: An immune shift towards Th2-type immunity seems to be critical in the pathogenesis of allergic asthma and rhinitis. In a previous study, we found higher serum tryptophan concentrations in patients with seasonal tree or grass pollen rhinoconjunctivitis who underwent specific immunotherapy (SCIT) than in controls, and those with the highest levels at baseline responded less well to SCIT. In the present study, we examined whether 'booster immunotherapy' after cessation of SCIT had any influence on tryptophan metabolism during follow-up. METHODS: Serum concentrations of tryptophan, kynurenine and neopterin were assayed in 19 patients (mean age: 26.2 years; 6 females) allergic to grass and/or tree pollen before and after they had received a booster immunotherapy with 4 injections of an allergoid vaccine (Pollinex Quattro; Bencard Vienna, Austria) over 8 ± 3 months outside the pollen season. RESULTS: Serum tryptophan and kynurenine concentrations decreased after booster immunotherapy (mean ± SD, before immunotherapy: 81.1 ± 14.2 µmol/l, after immunotherapy: 61.4 ± 20.9 µmol/l and before immunotherapy: 2.25 ± 0.44, after immunotherapy: 1.69 ± 0.70 µmol/l, respectively; both p < 0.01); this was especially true in those responders who also tended to have lower baseline kynurenine concentrations as compared with nonresponders (p = 0.05). Finally, a correlation between changes in tryptophan metabolism and neopterin concentrations was observed after immunotherapy. CONCLUSIONS: The decrease in tryptophan and kynurenine concentrations following booster immunotherapy in hay fever patients strengthens the hypothesis that tryptophan metabolism might be involved in the course of allergic responses. However, it is still unclear whether the abnormal tryptophan metabolism in pollinosis patients is related to indoleamine 2,3-dioxygenase and/or to a specific cytokine background.

Altered immune responses during septicaemia in patients suffering from haematological malignancies.

Septicaemia is a frequent complication in patients with haematological malignancies. In this study we analysed markers of inflammation/immune activation (C- reactive protein, interleukin-6, neopterin), tryptophan metabolites and mannose binding lectin (MBL) levels consecutively in 36 septic patients with haematological malignancies (HM) and non-haematological diseases [intensive care unit (ICU) patients]. During septicaemia different chronological sequences for inflammation markers CRP, IL-6 and neopterin were seen in HM and ICU patients. Septic ICU-patients presented with significantly increased tryptophan degradation and higher neopterin and CRP levels at baseline, while MBL levels were lower in this group compared to subjects with HM. Concentrations of inflammation markers were linked to each other and associated with enhanced tryptophan degradation. Patients who died during follow-up of 28 days tended to have lower baseline MBL concentrations than survivors. Septic patients with HM showed an impaired pro-inflammatory immune response compared to patients with non-haematological diseases.

Ischemic stroke--novel therapeutic strategies.

OBJECTIVES: Treatment of acute, ischemic stroke has changed markedly during the last two decades. We review existing data for optimizing modern stroke care. RESULTS: Implementation of stroke units, giving systematic treatment and observation to stroke patients, has lead to a significant reduction in death and dependency. Introduction of intravenous rt-PA (IVT) within 3 h for selected stroke patients and recent extension of the time window to 4.5 h improved the outcome even further. Still, one must consider that IVT has several limitations, such as a narrow time window and several contraindications, and the effect is modest, particularly in strokes with a large vessel occlusion. Recanalization of the occluded vessel is a major predictor for good outcome and should be set as a goal. Intra-arterial rt-PA (IAT) and the concept of bridging therapy (IVT prior to IAT or thrombectomy with a mechanical device) may improve recanalization rates and outcome. Randomized controlled trials (RCT) are available for IAT, but not for thrombectomy with devices, and we mostly have retrospective non-controlled data. The Merci- and Penumbra system are the most studied devices, for which recent studies report acceptable safety and efficacy. CONCLUSIONS: Sufficiently powered RCTs to evaluate the effect of thrombectomy with mechanical devices are warranted, but as the natural course of a large vessel stroke carries a devastating prognosis, a proactive recanalization approach is justified based on today's knowledge.

Isolated cerebral manifestation of Epstein-Barr virus-associated post-transplant lymphoproliferative disorder after allogeneic hematopoietic stem cell transplantation: a case of clinical and diagnostic challenges.

We present the case of a 49-year-old male patient with Epstein-Barr virus (EBV)-associated post-transplant lymphoproliferative disorder (PTLD) limited to the brain that occurred 6 months after allogeneic hematopoietic stem cell transplantation (HSCT). Clinical symptoms included mental confusion, ataxia, and diplopia. Magnetic resonance imaging (MRI) revealed cerebellar and periventricular lesions consistent with an inflammatory process. Cerebrospinal fluid (CSF) analysis, but not peripheral blood, was positive for EBV-DNA, but no malignant cells were found. Brain biopsy was not feasible because of low platelet counts. As we considered a diagnosis of either EBV-associated encephalitis or PTLD, the patient was treated with rituximab combined with antiviral therapy. However, the cerebral lesions progressed and follow-up CSF testing revealed immunoglobulin H clonality as evidence of a malignant process. Subsequent treatment attempts included 2 donor lymphocyte infusions (DLI). Despite treatment, the patient died from autopsy-proven PTLD within 8 weeks of the onset of symptoms. This case demonstrates the clinical and diagnostic challenges of primary cerebral PTLD in a patient following allogeneic HSCT.

In vitro testing for anti-inflammatory properties of compounds employing peripheral blood mononuclear cells freshly isolated from healthy donors.

INTRODUCTION: Inflammation is crucially involved in a variety of diseases like autoimmune syndromes, cardiovascular and neurodegenerative disorders, cancer, sepsis and allograft rejection. METHODS: Freshly isolated human peripheral blood mononuclear cells (PBMCs) are used as a screening assay for anti-inflammatory properties of compounds. Determinations of neopterin production by ELISA and of tryptophan degradation by HPLC are used as read-outs. Results are compared with further markers of immune response and oxidative stress. RESULTS: Phytohaemagglutinin induced significant tryptophan degradation and neopterin formation in PBMC, which correlated with IFN-γ, TNF-α, soluble cytokine receptors and isoprostane-8. Addition of vitamin C and E suppressed the responses dose-dependently. DISCUSSION: The determination of tryptophan degradation and neopterin production in PBMC reflects various pro- and anti-inflammatory cascades that are of relevance also in patients. It constitutes a robust and reliable approach to screen anti-inflammatory or immunosuppressive drugs and may improve throughput, speed and cost-effectiveness in drug discovery.

Accuracy of bedside antigen tests in the diagnosis of new influenza A/H1N1v infection.

To evaluate the clinical reliability of two rapid influenza detection tests (RIDTs), we analyzed 107 specimens from patients with clinically suspected pandemic influenza A/H1N1v by these tests as well as by real-time PCR as a standard. Both RIDTs had a moderate sensitivity (28-32%), a high specificity (93-99%) and a negative predictive value of 80%. These results will impact on the clinical management and isolation precautions in patients with suspected infection. Although a positive RITD is mostly confirmatory, a negative result in the presence of high clinical likelihood of infection should be interpreted with caution and be re-evaluated by PCR.

Plasma concentrations of the cardiovascular risk factor asymmetric dimethylarginine (ADMA) are increased in patients with HIV-1 infection and correlate with immune activation markers.

OBJECTIVE: Higher concentrations of inflammation and immune activation markers as well as the endogenous nitric oxide synthase inhibitor asymmetric dimethylarginine (ADMA) are associated with an increased cardiovascular risk. In vitro, parallel formation of ADMA and macrophage marker neopterin was found in stimulated human peripheral blood mononuclear cells. METHODS: In 112 HIV-1 infected patients, concentrations of ADMA, SDMA and arginine were compared to C-reactive protein and neopterin concentrations before they were referred to antiretroviral therapy. Disease activity was determined by viral load (qPCR), CD4(+) cell counts (FACS) and neopterin concentrations in plasma and urine (HPLC and ELISA). Additionally, concentrations of lipids were determined. RESULTS: HIV-1 infected patients presented with increased neopterin, ADMA and SDMA concentrations, whereas CD4(+) counts and arginine and plasma lipid concentrations were low. ADMA and SDMA concentrations significantly correlated with markers of immune activation, but not with plasma lipids. CONCLUSIONS: Results of this study indicate that increased ADMA and SDMA production may be related to an increased activity of immune activation pathways.

Serum hepcidin concentration in chronic haemodialysis patients: associations and effects of dialysis, iron and erythropoietin therapy.

BACKGROUND: Hepcidin, a liver-derived peptide induced by iron overload and inflammation, is a major regulator of iron homeostasis. As hepcidin decreases gastrointestinal iron absorption and recirculation from monocytes, over-expression is associated with the development of anaemia. METHODS: We studied the associations between circulating hepcidin levels and various laboratory parameters related to anaemia and/or inflammation in 20 patients on chronic haemodialysis. Furthermore, we determined the impact of dialysis and iron and/or erythropoietin (rhEpo) supplementation therapy on hepcidin serum concentrations. The patients were withheld from iron and rhEpo for 2 weeks before study entry. Hepcidin was measured by liquid chromatography-mass spectrometry (LC-MS/MS); serum iron and haematological parameters, cytokines and pro-hepcidin by commercially available enzyme-linked immunosorbent assays (ELISA) or standard automated methods. RESULTS: While hepcidin levels at baseline were not correlated to pro-hepcidin, interleukin-6 or transforming growth factor-beta concentrations, we found significant associations with reticulocyte count (r = -0.55; P = 0.015), serum iron (r = 0.7; P = 0.004) and ferritin levels (r = 0.63; P = 0.004) and transferrin saturation (r = 0.69, P = 0.001). Dialysis using either a high or a low flux biocompatible dialyser resulted in a significant decrease of hepcidin concentrations, which returned to pre-dialysis values before the next dialysis session. When studying the effects of anaemia treatment, we observed a significant reduction of hepcidin levels following administration of rhEpo but not iron. CONCLUSIONS: Hepcidin levels in stable haemodialysis patients appear to reflect systemic iron load, but not inflammation. Due to the negative association between reticulocyte counts and hepcidin, the reduction of circulating hepcidin concentrations by dialysis and/or rhEpo treatment may positively affect erythropoiesis.