Systematic quantitative assessment of motor function in clinically isolated REM sleep behaviour disorder: A diagnostic window into early alpha-synucleinopathies.

Mild motor abnormalities can herald the beginning of Parkinson´s disease but their diagnostic value is limited by multifactorial ageing-related influences on motor function. We characterized mild motor abnormalities in different motor domains by conducting a systematic motor assessment in 20 patients with clinically isolated REM sleep behaviour disorder (iRBD) without parkinsonian motor signs and 20 healthy controls. We addressed the influence of lifestyle factors and age on motor function, which needs to be distinguished from neurodegenerative motor features, and assessed the diagnostic value of innovative and established quantitative motor tests in iRBD. Patients with iRBD showed abnormalities in perceptual motor speed (falling stick test), trunk movement coordination (bend, twist and touch test) and dynamic balance (line walk test) without alterations in simple motor speed (alternate tap test), dexterity (grooved pegboard), static balance (force plate) and gait (timed up and go test). The falling stick test showed the highest diagnostic accuracy in identifying subjects with RBD (ROC-AUC 0.85, p ≤ 0.001). Multivariate analysis revealed physical activity and age as additional determinants of motor test performance. iRBD comprises a wide spectrum of mild motor abnormalities which cannot be verified by established tests for motor speed, gait and balance. The falling stick test, an innovative screening test for perceptual motor speed, provides high diagnostic potential in identifying subjects with subclinical neurodegenerative symptoms before parkinsonian motor signs become apparent. Normative data for physical activity and age need to be obtained to ensure correct interpretation of motor test results in prodromal Parkinson-related disease.

Value of the eazyplex® CSF direct assay in rapid diagnosis of invasive meningococcal disease - Case report.

There is a need for easy-to-use molecular assays for diagnosis of invasive meningococcal disease. Here, we report the rapid identification of Neisseria meningitidis in a cerebrospinal fluid sample from a patient with purulent meningitis using a commercially available loop-mediated isothermal amplification assay, resulting in a prompt de-escalation of the initial empiric antibiotic therapy.

What you get from what you see: Parametric assessment of visual processing capacity in multiple sclerosis and its relation to cognitive fatigue.

Multiple sclerosis (MS(1)) is a diffusely disseminated inflammatory disease affecting widespread cerebral networks. Major cognitive impairments are a reduction of processing capacity and mental fatigue, i.e., an "abnormal sense of tiredness or lack of energy". Here, the present study provides the first assessment of the distinct components of visual processing capacity based on a 'theory of visual attention' (TVA(2)) in MS patients and relates it to measures of subjective as well as (more) objective fatigue. The performance of 36 relapsing-remitting MS patients in a whole report task of brief letter arrays was compared to healthy control subjects matched for gender, age and education. Additionally, the sustained attention test PASAT-3(3) served as a measure of objective fatigue, and the self-report questionnaire MFIS(4) as a measure of subjective fatigue. Results indicate generally diminished processing speed as well as iconic memory buffers, and increased perceptual thresholds in MS patients compared to healthy controls. Block-wise analysis of attentional parameters shows that the processing speed performance of MS patients declines in the second half of the TVA-based test compared to healthy controls and in particular for patients with high versus low objective fatigue. These findings describe which aspects of processing capacity are impaired in MS, and show that fatigue mainly affects speed of processing. Thus, TVA-based assessment provides a novel approach in the determination of cognitive impairments and fatigue in MS. However, further research is required to elucidate the complex relations of processing capacity and cognitive functions in MS.

Assessment of pulmonary function in amyotrophic lateral sclerosis: when can polygraphy help evaluate the need for non-invasive ventilation?

BACKGROUND: Non-invasive positive-pressure ventilation (NPPV) is an established, effective, long-term treatment for patients with amyotrophic lateral sclerosis (ALS), but the correct indicators for the establishment of NPPV have not been defined. METHODS: In this retrospective study, records (spirometry, nocturnal polygraphy, nocturnal blood gases) of 131 patients with ALS were reviewed in order to evaluate the role of polygraphy for prediction of respiratory failure in ALS. RESULTS: The patient group reporting with versus without dyspnoea had significantly lower values on the revised ALS-Functional Rating Scale (ALSFRS-R), vital capacity (VC), forced VC (FVC), arterial oxygen saturation and arterial oxygen tension readings, including a higher apnoea-hypopnoea index. 23 patients, who did not report about dyspnoea, had an FVC of <75%. Nocturnal hypoventilation was observed in 67% of the patients with ALS independent of their ALSFRS-R. The patient group with nocturnal hypoventilation was characterised by a significantly lower VC, FVC and maximal static inspiratory pressure compared with the group without nocturnal hypoventilation. However, also in the absence of nocturnal hypoventilation, 8 patients had a VC <50% as predicted. DISCUSSION: Our study shows that in patients not reporting dyspnoea and having an FVC of >75%, nocturnal hypoventilation was observed in nearly every second patient. Therefore, for the question of whether NPPV should be initiated, polygraphy does not provide useful additional information if the FVC is already <75% as predicted. However, in patients with more or less normal lung function parameters or where lung spirometry cannot perform adequately (eg, bulbar ALS), it can provide sufficient evidence for the need of NPPV.

[Anamnesis, Pathological Assessment, Therapeutic Features and Course of Disease: Retrospective Study on Clinical-Based Factors for Prediction of Cancer-Specific Survival of 378 Patients with Stage pT1 Urothelial Bladder Carcinoma]. / Anamnese, pathologische Originalbefunde, Therapie bezogene Parameter und Krankheitsverlauf: retrospektive Analyse von klinisch basierten Faktoren für die Prognose des tumorspezifischen Überlebens von 378 Patienten mit pT1-Harnblasenkarzinom.

BACKGROUND: Urothelial carcinoma of the bladder (UBC) at stage pT1 is a heterogenous disease. Established criteria for prognosis prediction are not suitable for every patient. Choosing the right therapeutic strategy for the individual patient thus remains a challenge. The aim of the present study was to identify clinical parameters regarding cancer-specific survival (CSS) in patients with pT1 UBC. MATERIALS AND METHODS: A retrospective analysis of clinical parameters of all patients with a pT1 UBC between 1989 and 2012 from a single centre was performed. Treatment consisted of transurethral resection, second resection followed by initially bladder sparing treatment. Anamnestic data, histopathological reports and clinical course were assessed with CSS being defined as primary endpoint. Kaplan-Meier analysis, uni- and multivariate analysis were performed using SPSS (Version 22, IBM). RESULTS: 378 patients (78% male, median age 72 years) were included, median follow-up was 35 months. Pathological stage pT1G3 (66 vs. 91%, p<0.001), lack of instillation therapy (66 vs. 83%, p<0.001), presence of a second malignoma (41 vs. 77%, p=0,004), diagnosis after 2000 (75 vs. 76%, p=0,018) and tumour progress (42 vs. 85%, p<0.001) were associated with a worse CSS in univariate and Kaplan-Meier analysis. Multivariate analysis revealed the presence of a second malignoma (HR 2.267; CI 95% 1.143-4.497, p=0.019), pathological stage pT1G3 at initial diagnosis (HR 4.567; CI 95% 2.040-10.22, p<0.001) and tumour progress (HR 3.742; CI 95% 1.544-9.069, p=0.003) as independent negative predictors of CSS. Instillation therapy was a prognostic factor for improved CSS (HR 0.368; CI 95% 0.212-0.638, p<0.001). CONCLUSION: The present study identified the presence of a second malignoma, pathological stage pT1G3 and tumour progress as negative predictive factors for CSS. Maintenance instillation therapy after reresection was associated with an improved CSS.

Muscle ultrasound for early assessment of critical illness neuromyopathy in severe sepsis.

INTRODUCTION: Muscle ultrasound is emerging as a promising tool in the diagnosis of neuromuscular diseases. The current observational study evaluates the usefulness of muscle ultrasound in patients with severe sepsis for assessment of critical illness polyneuropathy and myopathy (CINM) in the intensive care unit. METHODS: 28 patients with either septic shock or severe sepsis underwent clinical neurological examinations, muscle ultrasound, and nerve conduction studies on days 4 and 14 after onset of sepsis. 26 healthy controls of comparable age underwent clinical neurological evaluation and muscle ultrasound only. RESULTS: 26 of the 28 patients exhibited classic electrophysiological characteristics of CINM, and all showed typical clinical signs. Ultrasonic echogenicity of muscles was graded semiquantitatively and fasciculations were evaluated in muscles of proximal and distal arms and legs. 75% of patients showed a mean echotexture greater than 1.5, which was the maximal value found in the control group. A significant difference in mean muscle echotexture between patients and controls was found at day 4 and day 14 (both p < 0.001). In addition, from day 4 to day 14, the mean grades of muscle echotexture increased in the patient group, although the values did not reach significance levels (p = 0.085). Controls revealed the lowest number of fasciculations. In the patients group, fasciculations were detected in more muscular regions (lower and upper arm and leg) in comparison to controls (p = 0.08 at day 4 and p = 0.002 at day 14). CONCLUSIONS: Muscle ultrasound represents an easily applicable, non-invasive diagnostic tool which adds to neurophysiological testing information regarding morphological changes of muscles early in the course of sepsis. Muscle ultrasound could be useful for screening purposes prior to subjecting patients to more invasive techniques such as electromyography and/or muscle biopsy. TRIAL REGISTRATION: German Clinical Trials Register, DRKS-ID: DRKS00000642.

Noninvasive assessment of cerebral perfusion and oxygenation in acute ischemic stroke by near-infrared spectroscopy.

BACKGROUND: In acute stroke patients, there is a need for noninvasive measurement to monitor blood flow-based therapies. We investigated the utility of near-infrared spectroscopy (NIRS) to determine cerebral perfusion in these patients. METHODS: Eleven patients were investigated within 1.4 +/- 2.2 days after onset of an ischemic middle cerebral artery infarction by monitoring the kinetics of an intravenous bolus of indocyanine green (ICG). For ICG kinetics, bolus peak time, time to peak (TTP = time between 0 and 100% ICG maximum), maximum ICG concentration, rise time (time between 10 and 90% ICG maximum), slope (maximum ICG/TTP), and blood flow index (BFI = maximum ICG/rise time) were obtained. Perfusion-weighted MRI (PWI) and NIRS measurements were performed within 24 h, and the interhemispherical differences of TTP values were compared. RESULTS: Stroke patients showed an increased bolus peak time (p < 0.02), TTP (p < 0.01), and rise time (p < 0.01), whereas slope (p < 0.01) and BFI (p < 0.01) were diminished at the site of infarction as compared to the unaffected hemisphere. The interhemispherical differences of TTP as measured by PWI and NIRS were closely correlated (r = 0.86). CONCLUSIONS: Noninvasive measurements of cerebral ICG kinetics by NIRS provide a useful means of detecting cerebral perfusion deficits in patients with acute stroke, which correlate well with those obtained by PWI.

Ecumenical in spite of ourselves: a Protestant assessment of Roman Catholic, Eastern Orthodox, and Anglican Catholic approaches to bioethics.

A Christian approach to the issues that constitute bioethics is inevitable for us who cherish the truth of historic, creedal, trinitarian Christianity. Scripture teaches and the Greek and Latin Church Fathers as well as the Reformers aver that man, created in the image of God, has an inherent, if vestigial, sense of right and wrong and a conscience however marred by the fall and by rebellion. We must believe that we share this most basic ecumenism with all humanity, not because of rational observation and analysis of nature, but because Scripture reveals it. We who are convinced of the truth of historic, creedal, trinitarian Christianity have a high view of Scripture and hold it to be infallible and utterly trustworthy irrespective of the importance we assign to our specific post-biblical traditional distinctives. This is a narrower but much more vital ecumenism than the first. Faithful adherence to Scripture inevitably manifests itself in remarkably similar priorities and values, often, lamentably, not because of, but in spite of, ourselves.

[Clinical assessment of the activity and results of therapy in joint diseases through cytologic examination of puncture fluids (author's transl)]. / Zytologische Aktivitäts- und Therapieerfolgsbeurteilung an Gelenkpunktaten aus klinischer Sicht.

Activity and results of therapy of joint diseases can be evaluated by means of cytological examinations of the synovia which is at the same time a prerequisite for differential diagnosis using the puncture fluid. Our cytological examinations of more than 700 puncture fluids stemming from different joint diseases were carried out immediately after the puncture on the fresh material, in order to prevent misinterpretation. This may occur through flaking out in stored material, which results in decrease in the cell count and a non-representative differential cell picture in the supernatant, as well as through degeneration of cells. In two thirds of our patients the local process activity, measured in terms of the cytological phase of activity, became evident in the total clinical activity. The synovia analysis furthermore permits objective assessment of the result of intra-articular injection treatment. Intractable activity, substantiated through synovia examination indicates synovectomy.