Endovascular stroke treatment does not preclude high thrombolysis rates.

BACKGROUND AND PURPOSE: In 1995 intravenous recombinant tissue plasminogen activator (IVRTPA) was the first reperfusion therapy to be approved in patients with acute ischaemic stroke (AIS). The significance and impact of IVRTPA in times of modern endovascular stroke treatment (EST) were analysed in a German academic stroke centre. METHODS: A retrospective observational cohort analysis of 1034 patients with suspected AIS presenting at the emergency department in 2014 was performed. Patients were evaluated for baseline characteristics, reperfusion procedures, IVRTPA eligibility, clinical outcome, symptomatic intracranial haemorrhage (sICH) and mortality. Data acquisition was part of an investigator-initiated, prospective and blinded end-point registry. RESULTS: In 718 (69%) patients the diagnosis of symptomatic AIS was confirmed. 419 (58%) patients presented within 4.5 h of symptom onset and of those 260 (62%) received reperfusion therapy (IVRTPA alone, n = 183; combination or bridging therapy, n = 60; EST alone, n = 17). Subtracting cases with absolute contraindications for IVRTPA resulted in an effective thrombolysis rate of 82%. sICH occurred in two patients treated with IVRTPA alone (1.1%). The median door-to-needle interval was 30 min. Fifty (17%) non-EST eligible AIS patients presenting within 4.5 h without absolute contraindications did not receive IVRTPA mainly due to mild or regressive symptoms. Most of these untreated IVRTPA eligible patients (82%) were discharged with a good clinical outcome (modified Rankin Scale ≤ 2). CONCLUSIONS: Intravenous recombinant tissue plasminogen activator remains the most frequently applied reperfusion therapy in AIS patients presenting within 4.5 h of onset in a tertiary stroke centre. An effective thrombolysis rate of over 80% can be achieved without increased rates of sICH.

Prospective assessment of perioperative course in 2648 patients after surgical treatment of benign prostatic obstruction.

PURPOSE: TUR-prostate (TUR-P) is considered the reference method for surgical treatment of benign prostatic obstruction (BPO); Greenlight laser photoselective vaporization (PVP) and thulium laser vapoenucleation (ThuVEP) have also been established as treatments of BPO. Objective of this prospective observation was to compare a large numbers of patients treated in everyday routine. METHODS: This prospective multicentre data collection assesses morbidity and perioperative course of consecutive men treated with BPO-related transurethral surgery between 2011 and 2014 in a German metropolis area with TUR-P, PVP or ThuVEP. RESULTS: Two thousand six hundred and forty-eight patients have been treated in the time period. All treatment options achieved immediate improvement of voiding parameters. Multivariate analyses proved shorter hospital stay after laser treatments as compared to resection (p < 0.001). In terms of hospital stay, the advantage of ThuVEP compared to TUR-P increased with prostate volume (p < 0.001). Patients with ongoing anticoagulation or bridging had prolonged hospital stay (p < 0.001). Overall adverse events were least frequent in PVP (p 0.016), as were Clavien 3b events (p < 0.001). CONCLUSIONS: Surgical treatment of BPO is effective and safe independent of the surgical procedure. Volume reduction is most effective in ThuVEP; PVP has the lowest rate of severe complications. Laser treatment is associated with shorter hospital stay. Surgery under ongoing anticoagulation prolonged the post-operative hospital stay.

HIV encephalopathy: glial activation and hippocampal neuronal apoptosis, but limited neural repair.

OBJECTIVES: HIV infection affects the central nervous system (CNS), frequently causing cognitive impairment. Hippocampal injury impedes the ability to transfer information into memory. Therefore, we aimed to examine neuronal injury and repair in the hippocampal formation in HIV encephalopathy. METHODS: We compared neuropathological findings in 14 autopsy cases after death from systemic complications of HIV infection and in 15 age-matched HIV-negative control cases after sudden death from nonneurological causes using immunohistochemistry. RESULTS: The density of apoptotic granule cells in the dentate gyrus was higher in HIV-infected than in control cases (P = 0.048). Proliferation of neural progenitor cells in the dentate gyrus was increased in HIV infection (P = 0.028), whereas the density of recently generated TUC-4 [TOAD (turned on after division)/Ulip/CRMP family 4]-expressing neurons in this region was not significantly elevated in HIV-infected cases (P = 0.13). HIV infection caused microglial activation and astrocytosis in the neocortex and hippocampal formation. Conversely, we were unable to detect more pronounced axonal injury in HIV-infected than in control cases. CONCLUSIONS: As in other infections involving the CNS, apoptosis of hippocampal neurons accompanied by microglial activation and astrocytosis is a prominent feature of HIV encephalopathy. The regenerative potential, assessed using the density of young neurons in the hippocampal dentate gyrus, in HIV infection appears to be lower than in acute bacterial meningitis and septic encephalitis.

Neurothrombectomy in acute ischaemic stroke: a prospective single-centre study and comparison with randomized controlled trials.

BACKGROUND AND PURPOSE: In the last few months five multicentre, randomized controlled trials (RCTs) unequivocally showed the superiority of mechanical thrombectomy in large vessel occlusion acute ischaemic stroke compared to systemic thrombolysis. Despite varying inclusion criteria and time intervals from onset to revascularization overall increases of good functional outcome between 55% and 81% were reported. However, only a minority of screened patients (approximately 1%) were eligible for intra-arterial (IA) therapy. METHODS: An investigator-initiated, single-centre, prospective and blinded end-point analysis was performed of 3123 consecutive patients with acute ischaemic stroke presenting between February 2010 and December 2014. RESULTS: One hundred and fifty-four patients [4.9%, age (years) mean (SD), median (interquartile range) 71.2 (±14), 74.7 (65.9-81.4)] met the inclusion criteria of sparse early ischaemic signs on initial standard cranial computed tomography (CT) (ASPECT score ≥7), large vessel occlusion in the anterior circulation on CT angiography and start of treatment within 6 h of onset of symptoms. After consensual interdisciplinary treatment decisions 130 patients (4.2%) received IA treatment - in the majority stent-assisted thrombectomy in combination with intravenous (IV) recombinant tissue plasminogen activator - and 24 patients (0.7%) standard IV thrombolysis. On 3 months' follow-up an overall significant improvement of disability (P = 0.05) as measured by the modified Rankin Scale was shown in favour of the IA treatment group. Good functional outcome was achieved in about twice as many patients (IA vs. IV, 41.2% vs. 21.2%; P = 0.078). CONCLUSION: By choosing pragmatic inclusion criteria state-of-the-art IA therapy of a specialized tertiary stroke centre can be safely applied under real-world conditions to a higher percentage of patients with similar success to the recently published RCTs.

[Posttraumatic complications on children's elbows]. / Posttraumatische Komplikationen am kindlichen Ellenbogen.

Most fractures during growth affect the upper extremities. Severe fractures with an increased number of complications are mainly localized beyond the elbow joint. Displaced fractures of the elbow joint have limited potential for spontaneous correction as the bones near the elbow joint account for only 20% of growth in length and the possibility of spontaneous correction is already exhausted at the age of 7. The consequences of inadequately reduced elbow fractures, therefore, may adversely affect a patient for his lifetime. Cubitus varus and valgus are the most common deformities following insufficiently treated supracondylar humerus fractures, fractures of the radial or dislocations of the radial head. Posttraumatic deformities of the elbow are usually the result of an insufficient primary therapy and rarely the result of growth disturbances. For the attending surgeon, posttraumatic deformities on a child's elbow are challenging.

Is there a gender gap in clinical neurosciences? A cross-sectional analysis of female participation in academic neurology, neurosurgery, and psychiatry.

Gender equality or the lack thereof is a constantly recurring theme. Here, we sought to provide an overview of the status with respect to the participation and leadership of female doctors in clinical neuroscience analyzing different disciplines (neurosurgery, neurology and psychiatry). A total of 1910 articles published in six representative journals (07-12/2020) were reviewed. Of these, 1327 were original research papers, 145 invited publications and 303 letters/comments. Out of a total of 15,080 authors, 4365 (29%) were women. The percentage of female authors was found to differ significantly between the different specialties (19% in neurosurgery, 39% in neurology and 45% in psychiatry). Women were last authors in 9.5% of the papers in neurosurgery, 29% in neurology and 39% in psychiatry Based on these findings, it can be concluded that gender disparity in academic neuroscience is quite conspicuous. Our review seeks to address the reasons behind this phenomenon in the context of new publications as well as various cultural and historical underpinnings.

Septic metastatic encephalitis: coexistence of brain damage and repair.

AIMS: Septic metastatic encephalitis (SME) arises from systemic bacterial infections and is a severe complication of sepsis with a high mortality. In this study, we examined the neuropathological findings in humans suffering from SME including white matter pathology and proliferation of neural precursor cells in the hippocampal dentate gyrus. METHODS: The brains of 10 autopsy cases with SME and 10 control cases after sudden death from non-neurological causes were studied by means of immunohistochemistry. RESULTS: We found diffuse axonal injury and demyelination in the frontal cortex (P = 0.01) as well as increased numbers of recently generated TUC-4 expressing neurones in the hippocampal dentate gyrus in SME cases (P = 0.01). The median density of apoptotic granule cells in the dentate gyrus also was higher in SME cases, the difference, however, failed to reach statistical significance (P = 0.25). CONCLUSION: The coexistence of degenerative processes predominantly in the neocortex and regenerative activity in the hippocampal formation known from bacterial meningitis also characterizes the pathology of SME.

[Fluorescence cytology. Improvement of urinary cytology]. / Die Fluoreszenzzytologie. Eine Weiterentwicklung der Urinzytologie.

Urothelial cancer of the bladder is a frequent disease, and urinary cytology often is used as a routine diagnostic tool. But this technique has an impaired sensitivity in low-grade tumours, and as a subjective method it is highly dependent on the experience of the cytologist. Here we present the technique of fluorescence cytology as an improvement of conventional cytology. This method is potentially able to compensate for the disadvantages of urinary cytology as it is an automated process that uses the principles of 5-Ala-induced photodynamic diagnosis (PDD).

Clinical Impact of Ventilation Duration in Patients with Stroke Undergoing Interventional Treatment under General Anesthesia: The Shorter the Better?

BACKGROUND AND PURPOSE: Whether general anesthesia for neurothrombectomy in patients with ischemic stroke has a negative impact on clinical outcome is currently under discussion. We investigated the impact of early extubation and ventilation duration in a cohort that underwent thrombectomy under general anesthesia. MATERIALS AND METHODS: We analyzed 103 consecutive patients from a prospective stroke registry. They met the following criteria: CTA-proved large-vessel occlusion in the anterior circulation, ASPECTS above 6 on presenting cranial CT, revascularization by thrombectomy with the patient under general anesthesia within 6 hours after onset of symptoms, and available functional outcome (mRS) 90 days after onset. RESULTS: The mean ventilation time was 128.07 ± 265.51 hours (median, 18.5 hours; range, 1-1244.7 hours). Prolonged ventilation was associated with pneumonia during hospitalization and unfavorable functional outcome (mRS ≥3) and death at follow-up (Mann-Whitney U test; P ≤ .001). According to receiver operating characteristic analysis, a cutoff after 24 hours predicted unfavorable functional outcome with a sensitivity and specificity of 60% and 78%, respectively. Our results imply that delayed extubation was not associated with a less favorable clinical outcome compared with immediate extubation after the procedure. CONCLUSIONS: Short ventilation times are associated with a lower pneumonia rate and more favorable clinical outcome. Cautious interpretation of our data implies that whether patients are extubated immediately after the procedure is irrelevant for clinical outcome as long as ventilation does not exceed 24 hours.

Basic fibroblast growth factor in serum and urine of patients with head and neck cancer.

Between 1996 and 1997 serum and urine levels of basic fibroblast growth factor (b-FGF) in patients with head and neck cancer were measured to answer the following questions: i) Are increased levels of b-FGF in serum and urine detectable in patients with malignant head and neck tumors? ii) Do these parameters correlate with tumor stage and differentiation of tumors? iii) Is there an association between growth behaviour (local or metastatic growth) and b-FGF levels in serum and/or urine? Eighty-nine patients with head and neck cancer as well as 45 patients with diseases unrelated to cancer were investigated. Detectable levels of b-FGF were found in the serum and urine of patients with malignant head and neck tumors. In addition, there was a significant correlation between tumor size and b-FGF levels in either serum or urine. No association of b-FGF concentrations with degree of histologic differentiation and tumor growth behaviour was observed. The results of this study demonstrate that b-FGF levels are elevated in serum and urine of patients with head and neck cancer. These findings suggest an involvement of b-FGF in the formation of solid tumors.

Comparison of hand-held, suction, and automated trephines on experimental corneal wound size.

Three trephines were tested to determine their uniformity in creating a circular opening during penetrating keratoplasty. Twenty-one globes (seven per instrument) were trephined with a hand-held, suction or automated trephine. The mean astigmatism was greatest with the hand-held device (mean 0.73 cm) and least with the automated trephine (mean 0.50 cm). The automated and the suction trephines (mean astigmatism 0.51 cm) may result in reduced corneal astigmatism during penetrating keratoplasty.

BTA-TRAK--a useful diagnostic tool in urinary bladder cancer?

During recent years the BTA-TRAK-assay (Bard Diagnostics, Redmont, USA) has been described in several investigations to be of clinical utility for patients suffering from bladder cancer. In a prospective study we investigated over four months the voided urine samples of all consecutive patients undergoing cystoscopy independent of their clinical background (n = 244) with the BTA-TRAK-assay. With a specificity of 95% for benign urological diseases (cut off: 1300 U/mL) we found a sensitivity of 13% for active bladder tumours. Using healthy individuals as a reference group (cut off: 40 U/mL) we found a sensitivity of 56% (specificity 67%). Using the cut off value recommended by the manufacturer (14 U/mL) a specificity of 54% and a sensitivity of 62% was found. For patients without relapse (NED) versus patients with active bladder tumours we got a specificity of 55% and a sensitivity of 62%. Due to an insufficient specificity and sensitivity the BTA-TRAK-test is not able to replace cystoscopy nor to improve existing diagnostic strategies in bladder cancer.

Descemetocele formation in a patient with a postoperative corneal dellen.

Dellen formation generally follows localized evaporation and dehydration of the cornea. The condition follows a disruption in the ocular tear film and usually can be managed conservatively with lubricants. We recently treated a patient with a postoperative dellen that progressed to a descemetocele and required a patch graft to prevent perforation. Recognition of this potential complication emphasizes the need to begin treatment immediately after the onset of dellen.

[Fluorescence cytology of the urinary bladder]. / Fluoreszenzzytologie der Harnblase.

5-aminolevulinic acid induced fluorescence cystoscopy is invaluable for diagnosing urinary bladder carcinoma and its precursors. Because neoplastic cells of the urinary bladder possess striking fluorescent properties due to protoporphyrin IX, we initiated a study to evaluate the use of fluorescence microscopy in urinary sediments. In 27 patients suspected of having bladder carcinomas, we instilled 5-aminolevulinic acid into their urinary bladders before transurethral therapy and compared thereafter our studies of standard cytological sediments with those made under fluorescence microscopy. The results of fluorescence cystoscopy and those using urinary sediments for neoplastic cells under fluorescence microscopy correlated extremely well. In this pilot study using fluorescence microscopy, we found that we could diagnose with precision urinary neoplasms of different grades of differentiation. Accordingly, we regard fluorescence microscopy as a valuable complement for standard urinary cytology, especially since with fluorescence microscopy we can readily recognize fluorescing cells of highly differentiated urinary tumors and flat premalignant dysplasias.

[Respiratory manifestations of reflux disease. Gastric acidity--poison for larynx, teeth and respiratory tract]. / Respiratorische Manifestationen der Refluxkrankheit. Der saure Magensaft--Gift für Kehlkopf, Zähne und Atemwege.

Gastroesophageal reflux is now a generally accepted risk factor for the development of adenocarcinoma of the esophagus. Less well known is the relationship of reflux disease (GERD) and respiratory disorders. Among the extra-esophageal manifestations of reflux disease is reflux laryngitis, which affects up to 78 patients with chronic hoarseness, Reinke's edema, laryngeal stricture, postnasal drip, asthma and non-cardiac chest pain. Despite popular opinion, changes in lifestyle (for example, cessation of smoking and drinking, avoidance of fatty foods) do not result in an improvement in symptoms. The treatment of choice for GERD is the use of proton pump inhibitors (PPI) in the form of stepdown therapy; in individual cases as symptom-orientated on-demand therapy.

[Morbidity, mortality, and overall survival after radical cystectomy: comparison of single-center results with the literature and a nomogram]. / Morbidität, Mortalität und Gesamtüberleben nach radikaler Zystektomie: Abgleich eigener Daten mit der Literatur und einem Nomogramm.

BACKGROUND: Overall survival (OS) after radical cystectomy is determined. It is investigated retrospectively whether prediction is possible using a nomogram. A comparison with published data from "high-volume" centers is performed. PATIENTS AND METHODS: Data of 100 consecutive radical cystectomies performed between 2006 and 2012 were collected. Age, ASA score, tumor stage, urinary diversion, and Clavien score were recorded. The OS after 2 and 5 years was recorded (Kaplan-Meier analysis) and the nomogram-based predictive accuracy was calculated. RESULTS: Median age was 70.8 years. A T≤2, T3, T4, N+ stage was present in 40, 37, 23, and 43%, respectively. Urinary diversion: neobladder, conduit, and ureterostomy were performed in 35, 53, and 12%. The 30-day mortality was 1%. At follow-up, there were 95 patients with a median observation time of 19.8 months. The 2- and 5-year OS were 0.68 and 0.45 (Kaplan-Meier analysis) and 0.65 and 0.39, respectively (nomogram). A significant correlation was observed (rs=0.79; rs=0.80). Compared to published "high-volume" series, no relevant differences concerning morbidity, mortality, and OS were observed. However, there are significant differences concerning the characteristics of "high-volume centers". CONCLUSION: In this series, the OS can be predicted by a multivariate nomogram. The results are comparable with published data. There is no clear definition of a "high-volume center".

Murine adult neural progenitor cells alter their proliferative behavior and gene expression after the activation of Toll-like-receptor 3.

Viral infections during pregnancy significantly increase the risk for psychological pathologies like schizophrenia in the offspring. One of the main morphological hallmarks of schizophrenia is a reduced size of the hippocampus. Since new neurons are produced in this particular brain compartment throughout life, it might be possible that low neurogenesis levels triggered by a maternal viral infection contribute to developmental deficits of the hippocampus. We injected polyinosinic:polycytidylic acid (Poly I:C) in pregnant C57Bl/6 mice to stimulate an anti-viral response through TLR3 and examined gene expressions in the neuronal progenitor cells (NPCs) of the offspring at different ages. Additionally, we treated adult NPC lines with Poly I:C to investigate its direct effect. We could show for the first time that TLR3 and its downstream effector molecule IRF3 are expressed in adult NPCs. Poly I:C treatment in vitro and in vivo led to the regulation of proliferation and genes involved in antiviral response, migration, and survival. These findings indicate that NPCs of the fetus are able to react towards an in utero immune response, and thus, changes in the neuronal stem cell pool can contribute to the development of neurological diseases like schizophrenia.

[Expression of the tumormarker p16INK4a in cytology specimens of the urinary bladder. A new means for early recognition and surveillance of urothelial cancer]. / Vorkommen einer p16INK4a-Expression in Zytologien der Harnblase. Ein neuer Weg zur Früherkennung und Verlaufskontrolle beim Urothelkarzinom.

BACKGROUND: This study was carried out to learn whether cytological specimens from urinary bladder lavages express the tumor suppressor gene p16INK4a, whether an abnormally increased expression indicates a cancerous state and whether cytological measurements are comparable regarding sensitivity and specificity with measurements made in histological sections of biopsies. PATIENTS AND METHODS: A total of 82 urine specimens of patients suspected of having a bladder tumor were examined for the presence of p16INK4a. RESULTS: Out of 46 patients with urothelial carcinoma 29 expressed p16INK4a in the cells in the urine specimens. Out of 36 patients free of cancer 30 expressed no p16INK4a in cytological specimens. The sensitivity of the expression proved to be 63% and the specificity 83%. Well-differentiated carcinomas seldomly expressed an increased p16INK4a (sensitivity 27%), whereas moderately differentiated carcinomas showed a sensitivity of 69% and poorly differentiated carcinomas a sensitivity of 77%. CONCLUSION: Compared to other minimally invasive tumor markers, such as NMP22, the expression of p16INK4a in cytology specimens of urine appears to be a sensitive marker for urothelial carcinoma, especially for the detection of poorly differentiated carcinomas. Its high specificity makes it ideal for use in tumor screening.