Underlying causes of cryptogenic stroke and TIA in the nordic atrial fibrillation and stroke (NOR-FIB) study - the importance of comprehensive clinical evaluation.

BACKGROUND: Cryptogenic stroke is a heterogeneous condition, with a wide spectrum of possible underlying causes for which the optimal secondary prevention may differ substantially. Attempting a correct etiological diagnosis to reduce the stroke recurrence should be the fundamental goal of modern stroke management. METHODS: Prospective observational international multicenter study of cryptogenic stroke and cryptogenic transient ischemic attack (TIA) patients clinically monitored for 12 months to assign the underlying etiology. For atrial fibrillation (AF) detection continuous cardiac rhythm monitoring with insertable cardiac monitor (Reveal LINQ, Medtronic) was performed. The 12-month follow-up data for 250 of 259 initially included NOR-FIB patients were available for analysis. RESULTS: After 12 months follow-up probable stroke causes were revealed in 43% patients, while 57% still remained cryptogenic. AF and atrial flutter was most prevalent (29%). In 14% patients other possible causes were revealed (small vessel disease, large-artery atherosclerosis, hypercoagulable states, other cardioembolism). Patients remaining cryptogenic were younger (p < 0.001), had lower CHA2DS2-VASc score (p < 0.001) on admission, and lower NIHSS score (p = 0.031) and mRS (p = 0.016) at discharge. Smoking was more prevalent in patients that were still cryptogenic (p = 0.014), while dyslipidaemia was less prevalent (p = 0.044). Stroke recurrence rate was higher in the cryptogenic group compared to the group where the etiology was revealed, 7.7% vs. 2.8%, (p = 0.091). CONCLUSION: Cryptogenic stroke often indicates the inability to identify the cause in the acute phase and should be considered as a working diagnosis until efforts of diagnostic work up succeed in identifying a specific underlying etiology. Timeframe of 6-12-month follow-up may be considered as optimal. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT02937077, EudraCT 2018-002298-23.

Improving IUI success by performing modified slow-release insemination and a patient-centred approach in an insemination programme with partner semen: a prospective cohort study.

BACKGROUND: Pregnancy rates after in vitro fertilisation (IVF) treatment continue to improve, while intrauterine insemination (IUI) programmes show no such trend. There is a need to improve success rates with IUI to retain it as a viable option for couples who prefer avoiding IVF as a first line treatment. OBJECTIVE: To investigate if a modified slow-release insemination (SRI) increases the clinical pregnancy rate (CPR) after intrauterine insemination (IUI) with partner semen. MATERIALS AND METHODS: This was a prospective cohort study in a Belgian tertiary fertility centre. Between July 2011 and December 2018, we studied data from an ongoing prospective cohort study including 989 women undergoing 2565 IUI procedures for unexplained or mild/moderate male infertility. These data were analysed in order to study the importance of different covariates influencing IUI success. Generalised estimating equations (GEEs) were used for statistical analysis. Results of two periods (2011-2015, period 1 and 2016-2018, period 2) were examined and compared. From January 2016 (period 2) onwards, a standardised SRI procedure instead of bolus injection of sperm was applied. The primary outcome parameter was the difference in clinical pregnancy rate (CPR) per cycle between period 1 (bolus IUI) and period 2 (modified SRI). Secondary outcome results included all other parameters significantly influencing CPR after IUI. RESULTS: Following the application of modified SRI the CPR increased significantly, from 9.03% (period 1) to 13.52% (period 2) (p = 0.0016). Other covariates significantly influencing CPR were partner's age, smoking/non-smoking partner, BMI patient, ovarian stimulation protocol and Inseminating Motile Count (after semen processing). CONCLUSIONS: Conclusions: The intentional application of modified slow-release of processed semen appears to significantly increase CPRs after IUI with homologous semen. Future studies should investigate whether SRI, patient-centred measures, or a combination of both, are responsible for this improvement.

Outcome of men and women after atrial fibrillation and stroke.

OBJECTIVES: Atrial fibrillation (AF) is a well-known risk factor for ischaemic stroke. The aim was to examine long-term outcome of men and women after stroke related to AF. METHODS: Patients with AF and ischaemic stroke were followed up 1 year and 5 years after stroke. Level of dependence (Barthel Index), disability (modified Rankin Scale), risk factors, mortality and stroke prophylaxis before and after stroke were analysed. All parameters were compared between men and women. RESULTS: From a cohort of 597 stroke patients during a one-year period, 155 patients (94 women/61 men) with stroke related to AF were included. Women were older than men at stroke onset and more men had a history of smoking and diabetes, but there was no difference in stroke severity. Only 111 patients had been diagnosed with AF before stroke. After 1 year 78 patients (45 women/33 men) and after 5 years 35 patients (21 women/14 men) were followed up. There was no difference in mortality after 5 years with 76% women and 73% men deceased. Half of both genders were independent 1 year after stroke, and after 5 years, approximately a third among women, but half of the men, were independent. Women were less frequently treated with warfarin before stroke (11% vs 28%), but warfarin and NOAC treatment had increased among both women and men at hospital discharge. CONCLUSIONS: There were no gender differences in long-term mortality after stroke related to AF. Men were significantly more often prescribed anticoagulants before stroke, a finding that indicates the need for further studies.

Evaluation of recombinant Salmonella expressing CD154 for persistence and enhanced antibody response in commercial turkeys.

Foodborne illness due to Salmonella is a worldwide public health concern and epidemiological evidence has identified poultry and poultry products as a significant source of human Salmonella infection. To discover an effective vaccine that protects poultry against multiple Salmonella serotypes, several novel attenuated Salmonella Enteritidis strains (DeltaSE) were developed to express variations of a potential immune-enhancing CD154 peptide sequence on the outer membrane protein lamB in association with a M2e (marker) epitope. The 3 CD154 peptide sequences evaluated in this study correspond to those naturally occurring in turkeys, humans, and chickens. In 3 separate trials, poults were immunized with 10(7) to 10(8) cfu/poult of the appropriate recombinant Salmonella strains (DeltaSE-M2e, DeltaSE-M2e-T/CD154, DeltaSE-M2e-H/CD154, DeltaSE-M2e-C/CD154) via oral gavage on day of hatch and again on 21 d posthatch. Liver, spleen, and cecal tonsils were aseptically removed on d 7, 14, 21, 28, 35, and 42 posthatch for detection of Salmonella and blood samples were obtained at these same time points for determination of an M2e-specific antibody response. In all 3 trials, DeltaSE strains exhibited significantly less invasion of the liver and spleen at d 7 when compared with Salmonella Enteritidis phage type 13A (P < 0.05). In 2 of the 3 trials, the DeltaSE strains expressing a CD154 peptide sequence further decreased invasion of the liver and spleen. Similarly, colonization of the cecal tonsils was also decreased in the poults immunized with the DeltaSE strains. However, there were no differences in colonization or invasion due to the amino acid sequence of the CD154 insert in all 3 trials. By d 21, the DeltaSE strains exhibited a significantly higher M2e-specific antibody response when compared with the negative control and SE13A groups (P < 0.05). However, no significant differences in M2e-specific antibody responses were observed between any of the DeltaSE candidate vaccine strains expressing CD154 throughout the study. Overall, these data suggest that oral live attenuated Salmonella-vectored vaccines expressing a foreign peptide sequence are able to elicit a humoral immune response in commercial poults and may contribute to a reduction in Salmonella organ invasion and colonization.

Migraine and delayed ischaemic neurological deficit after subarachnoid haemorrhage in women: a case-control study.

The aim of the present case-control study was to investigate the role of migraine as a potential risk factor for a delayed ischaemic neurological deficit (DIND) after subarachnoid haemorrhage (SAH). A telephone interview was performed in patients or their relatives to determine the prevalence of migraine. Thirty-six women aged <60 years had SAH with Hunt & Hess grade I-III and DIND (group A). This group was compared with an age-matched group of 36 female SAH patients, Hunt & Hess grade I-III without DIND (group B). The two populations were also characterized regarding hypertension, smoking, diabetes mellitus and alcohol use. A significant difference was only found for the prevalence of migraine with 47% in group A and 25% in group B (P < 0.05; odds ratio: 2.68, confidence interval: 0.99-7.29). Migraineurs revealed similar prevalences of risk factors independently of the presence of DINDs. This retrospective study suggests that women with migraine have a higher risk to develop a DIND than women without migraine.

The carbonic anhydrase I locus contains a c-Myb target promoter and modulates differentiation of murine erythroleukemia cells.

The Myb proto-oncogene encodes a transcription factor (c-Myb) that is essential for normal hematopoiesis and is thought to regulate hematopoietic cell proliferation and differentiation by regulating expression of specific target genes. We identify the mouse erythroid-specific carbonic anhydrase I promoter (CAIe) as a target of c-Myb activity and demonstrate that Myb activity is critical for carbonic anhydrase I (CAI) expression in C19 MEL cells. CAI expression is downregulated when MEL cells differentiate in response to MEnT or treatment with N, N-hexamethylene bisacetamide (HMBA). Coexpression of GATA-1 with c-Myb results in synergistic activation of transcription from the CAIe promoter and both transcription factors interact with the CAIe promoter in vivo. We identify a novel 20 bp sequence in the CAIe promoter that is sufficient to mediate synergistic activation of the CAIe promoter by c-Myb and GATA-1. c-Myb and GATA-1 interact with this DNA sequence suggesting that c-Myb and GATA-1 may be contained in a complex that interacts with this region of the CAIe promoter. Forced expression of CAI delayed HMBA-induced differentiation of MEL cells and maintained them in a proliferating state. These data strongly suggest that CAI is a c-Myb target and is involved in regulating MEL cell proliferation and differentiation.

[Subsequent treatment of surgically managed, fresh, anterior cruciate ligament ruptures--a randomized, prospective study]. / Die Nachbehandlung operativ versorgter frischer vorderer Kreuzbandrupturen--eine randomisierte prospektive Studie.

The prospective study examined two different postoperative treatments on 46 patients with acute and isolated disruption of the anterior cruciate ligament (acl), who were treated with reconstruction and augmentation using the semitendinosus-tendon. The patients were randomised and divided into two groups either to use a postoperative brace (Donjoy Ind.) set at full extension (group A) or to use the same brace set at a flexion of 20 degrees (group B) on the first 3 days after surgery. All patients undertook a standard "accelerated" rehabilitation protocol and were evaluated after 3, 6 and 12 months after surgery. The results were as follow: the patients of group A reached the full extension faster than group B without any loss of knee stability. Postoperative extension even led to an earlier return to work and sport activities. The muscle strength side-to-side difference (Cybex-measurement) was lower in group A. The severity and intensity of postoperative pain, swelling and giving-way was reduced in group A as was the risk of arthrofibrosis. Evaluated with the scoring scales of the "Orthopädische Arbeitsgruppe Knie" (OAK), the "International Knee Documentation Committee" (IKDC), the Tegner activity score and the Lysholm score, the clinical outcome and activity-level were higher in group A than in group B. This prospective study shows, that immediate postoperative extension, compared to the postoperative flexion of 20 degrees, reduces the term of rehabilitation and optimizes the operative results after acl-reconstruction.

Microembolic signal counts increase during hyperbaric exposure in patients with prosthetic heart valves.

BACKGROUND: Patients with prosthetic heart valves have an increased risk of thromboembolic events, and transcranial Doppler sonography reveals microembolic signals. Whereas microembolic signals were initially assumed to be of particulate matter, recent studies suggest that they are partially gaseous in origin. If this is true, alteration of environmental pressure should change microembolic signal counts. We undertook this study to evaluate the influence of hyperbaric exposure on microembolic signal counts in persons with prosthetic heart valves. METHODS AND RESULTS: Microembolic signal counts were monitored by transcranial Doppler sonography of both middle cerebral arteries under normobaria (normobaria 1), 2 subsequent periods of hyperbaria (2.5 and 1.75 bar), and a second period of normobaria (normobaria 2) in 15 patients with prosthetic heart valves. Each monitoring period lasted 30 minutes. Compression and decompression rates were 0.1 bar/min. Microembolic signal counts increased from 20 (12-78) at normobaria 1 to 79 (30-165) at 2.5 bar (P <.01 vs normobaria 1 and 2), decreased to 44 (18-128) at 1.75 bar (P <.01 vs normobaria 1 and 2.5 bar; P <.001 vs normobaria 2), and returned to 20 (8-96) at normobaria 2 (values are medians and 95% confidence intervals). CONCLUSIONS: Our results strongly suggest that gaseous bubbles are underlying material for part of the microembolic signals detected in patients with prosthetic heart valves.

In vitro studies of cryoablation of the endometrium.

OBJECTIVE: The aims of this study were to quantify the tissue damage in vitro of a series of freezing protocols with the Endocryo (Spembley Medical Ltd, Andover, United Kingdom) cryoprobe for ablation of the endometrium and to determine the relative importance of the freezing parameters contributing to the cryolesion. STUDY DESIGN: The efficacy and safety of the Endocryo cryoprobe were assessed in vitro with 84 different experiments on freshly excised uterine specimens. Tissue necrosis was quantified by means of a histochemical technique after incubation of the uterine specimens under nearly physiologic conditions. RESULTS: A typical lesion was made up of a superficial area of tissue necrosis and a deeper area of sublethal damage. Tissue necrosis was >3 mm when the probe was in direct contact with the endometrium. Consistent tissue necrosis was only observed with tissue temperatures below -30 degrees C. Safe tissue damage was only consistently seen after < or =2 minutes of freezing. When the gap between the probe and the endometrium was filled with distention medium and was >2 mm, tissue damage was insufficient for clinical purposes irrespective of the medium used. CONCLUSION: The Endocryo cryoprobe provided a successful means of achieving endometrial ablation in vitro. The use of a uterine distention medium appeared to be of little value in improving the efficacy of the probe in vitro.

Patient satisfaction with outpatient hysteroscopy versus day case hysteroscopy: randomised controlled trial.

OBJECTIVE: To compare outpatient hysteroscopy with day case hysteroscopy in terms of patient satisfaction and acceptability. SETTING: Gynaecology clinic of a teaching hospital. PARTICIPANTS: 100 women. DESIGN AND INTERVENTIONS: Patients were randomly allocated to outpatient hysteroscopy or day case hysteroscopy provided they had no preference for either procedure. MAIN OUTCOME MEASURES: Satisfaction rate, requirements for postoperative analgesia, speed of recovery, time away from home, and time off work. RESULTS: The outpatient group recovered preoperative fitness more quickly than the day case group (2 days (range 1-2.7) versus 3 days (2-4), P<0.05). After the procedure, the outpatient group were also fully mobile more quickly than the day case group (0 minutes (0-5) versus 105 minutes (80-120), P<0.001). Requirements for postoperative analgesia were similar in both groups. Overall, 78% of patients considered that the pain from outpatient hysteroscopy was less than that usually experienced during menstruation. Patient satisfaction was similar in both groups (83.6% in the outpatient group versus 77.0% in the day case group). CONCLUSIONS: Outpatient hysteroscopy and day case hysteroscopy were equally acceptable to patients. Patients recovered significantly more quickly from outpatient hysteroscopy than from day case hysteroscopy.

Flexible outpatient hysteroscopy without anaesthesia: a safe, successful and well tolerated procedure.

The objective of this study was to assess the feasibility and tolerance of diagnostic outpatient flexible hysteroscopy without anaesthesia. Records from 554 consecutive patients were analysed retrospectively. Success rate, reasons for failure, adverse reactions and level of pain were the main outcome measures. Hysteroscopy was successful in 90.5% of patients and well tolerated in 93.3%; 5.4% experienced moderate to severe pain. Inability to negotiate the cervical canal accounted for 47% of failed procedures and poor view for 42%. These results suggest that flexible outpatient hysteroscopy without anaesthesia is a successful and well tolerated procedure.

Up-regulation of flk-1/vascular endothelial growth factor receptor 2 by its ligand in a cerebral slice culture system.

Vascular endothelial growth factor (VEGF) and its tyrosine kinase receptors VEGFR-1 (flt-1) and VEGFR-2 (flk-1/KDR) are key mediators of physiological and pathological angiogenesis. They are expressed in most tissues during embryonic development but are down-regulated in the adult, when angiogenesis ceases. Up-regulation of VEGFR-2 and of VEGF are observed in many pathological conditions under which angiogenesis is reinduced. A major regulator of VEGF expression is hypoxia. Although the temporal expression pattern of VEGFR-2 parallels VEGF expression to a high extent, little is known about its regulation. Here, we show that VEGFR-2 is highly expressed in early postnatal mouse brain but is down-regulated commencing at postnatal day 15 (P15) of mouse brain development and is hardly detectable in P30 mouse brain. Using P30 mouse brain slices, we observed that hypoxia up-regulates VEGFR-2 in the slices but not in human umbilical vein endothelial cells, suggesting the presence of a hypoxia-inducible factor in the murine neuroectoderm that up-regulates VEGFR-2. To identify the factors involved, normoxic P30 cerebral slices were cultured with growth factors that are either hypoxia-inducible (e.g., PDGF-BB, erythropoietin, and VEGF) and/or are known to act on endothelial cells (e.g., PDGF-BB, VEGF, and PIGF). Exogenously added recombinant VEGF led to an up-regulation of VEGFR-2 expression, which could be inhibited by preincubation with a neutralizing anti-VEGF antibody. Addition of PDGF-BB, PIGF, and erythropoietin had no effect on VEGFR-2 expression. Our results suggest a differential but synergistic regulation by hypoxia of VEGF and VEGFR-2: a direct induction of VEGF that subsequently up-regulates VEGFR-2 in endothelial cells. This autoenhancing system may represent an important mechanism of tumor angiogenesis.

Labelling, control and radiopharmacological evaluation of 99mTc-adenosine 5'-diphosphate (99mTc-ADP) as tumour seeking agent.

A study of 99mTc-adenosine-5'-diphosphate (99mTc-ADP) as a radiopharmaceutical for tumour diagnosis is presented. Two different labelling methods, using SnCl2 in alkaline solution and Zn as reducing agents, were developed. Reduction with Sn(II) alkaline solution was the selected method because a lower concentration of ADP (0.5 mg/mL) could be used and a higher radiochemical yield was achieved. A labelled molecule with a radiochemical purity higher than 95%, in vitro stability of at least 6 hours and an over all negative charge was obtained Biodistribution studies carried out in normal mice and rats revealed rapid urinary excretion and no specific accumulation of activity in any other particular organ. This behaviour was similar to that reported for 99mTc-adenosine-5'-triphosphate (99mTc-ATP). Rapid blood clearance, that could be fitted to a bicompartimental model, was also verified. No evidence of in vivo instability was observed. Studies in mice and rats bearing spontaneous mammary adenocarcinomas were performed and the results were compared to those from the 99mTc-ATP studies. Although the tumour models used were not the same, the incorporation of both labelled compounds was very similar. Radioactivity uptake in the tumour and the tumour-to-blood ratio were not notably high. However, a significant increment was observed in the tumour-to-muscle ratio (1.0 +/- 0.2 at 30 minutes to 2.7 +/- 0.4 at 240 minutes). Whole-body autoradiography enabled tumour visualization. Further investigations, including scintigraphic imaging, must be carried to complete the clinical evaluation of 99mTc-ADP as a tumour seeking agent.

Response of multicellular tumor spheroids to liposomes containing TNF-alpha.

This publication describes a new model to investigate the influence of tumor necrosis factor-alpha (TNF-alpha) on a three-dimensional glial cell aggregate under defined, standardized, reproducible conditions using the glioma cell line A 172. The cells are initially grown as normal monolayer culture until they reach a cell density of up to 1 x 10(6). Subsequently they are grown as spheroids by the liquid overlay technique. Spheroids grown in this way were divided into ten groups of more than 50 cell aggregates. Three groups were coincubated with free TNF-alpha in increasing dosages (100 ng/ml, 200 ng/ml and 1000 ng/ml); three groups were incubated with empty liposomes (0.2 mg/ml, 0.4 mg/ml and 2 mg/ml); three groups received liposomes which had been loaded with TNF-alpha, and one group, which received no treatment, served as control. The diameter of the spheroids ranged from 80 microns to 350 microns. There was no significant difference in growth between the 3 groups treated with 'free' TNF-alpha. Comparing spheroids treated with TNF-alpha with those which had been coincubated with empty liposomes, there was a significant difference (p < 0.001) in growth, which correlated with the amount of liposomes. Similarly, free TNF-alpha had a significantly (P < 0.001) stronger growth-inhibiting effect as compared to liposomes loaded with TNF-alpha. Comparing the groups treated with liposomes only to those treated with liposomes loaded with TNF-alpha, the latter exhibited a more marked (although not significantly) growth-inhibiting effect. The preliminary conclusion is that the major growth-inhibiting effect seems to be mediated by the liposomes.(ABSTRACT TRUNCATED AT 250 WORDS)

Integrated optical density and entropiefluss (current of entropy) in bronchial carcinoma.

Histological sections of formalin-fixed, paraffin-embedded bronchial carcinomas comprising 241 surgical specimens (lobes and lungs) were Feulgen stained. The integrated optical density of the nuclei (IOD) and the minimum distance between their centers of gravity (DG) was measured with an automated image analyzing system consisting of a TV camera connected to a personal computer via a frame grapper. Intratumorous lymphocytes served as DNA standard (2C peak), and 300 nuclei were measured at minimum. The entropy of the IOD, the percentage of S-phases (PS) of tumor cells with an IOD > 3C and > 5C, and the 2CV mean standard deviation were measured. According the theory of thermodynamically open systems, the entropiefluss (current of entropy) was defined by the gradient IOD/time through the surface of the tumors which can be approximated by the formula IOD*PS*DG/tumor volume. The following results were obtained: a) IOD of bronchial carcinoma is not associated with tumor size or lymph node infiltration (pT and pN stage). b) The minimum distance between tumor cells decreases with increasing tumor stage and increasing lymph node stage (pT, pN stage). c) The entropiefluss is low in limited and advanced tumor stages, and highest in tumors at moderately progressive tumor stages (pT2, pT3, pN1, pN2). Thus, in accordance with the theory of thermodynamically open systems, the entropiefluss reflects the "biological activity" of bronchial carcinoma.

Usher syndrome type I associated with bronchiectasis and immotile nasal cilia in two brothers.

Usher syndrome type I is an autosomal recessive disease characterised by congenital sensorineural deafness, involvement of the vestibular system, and progressive visual loss owing to retinitis pigmentosa. Here we report the association of this disease with bronchiectasis, chronic sinusitis, and reduced nasal mucociliary clearance in two sibs and we suggest Usher syndrome type I could be a primary ciliary disorder.