Therapeutic response to glucocorticoids, anticoagulation and plasma exchange in a patient with primary antiphospholipid syndrome presenting with purpura fulminans.

We report the case of a 25-year-old female patient who presented with purpura fulminans as a manifestation of primary antiphospholipid syndrome. Purpura fulminans is considered a rare cutaneous manifestation of antiphospholipid syndrome. Most frequently, it occurs in the context of catastrophic antiphospholipid syndrome and is associated with significant morbidity and mortality, either due to loss of affected extremities or thromboembolic damage to internal organs. After insufficient efficacy of parenteral anticoagulation and oral glucocorticosteroid treatment, we escalated treatment to high-dose intravenous glucocorticosteroid and five consecutive sessions of plasma exchange with good and sustained clinical response. At follow-up six months after admission, skin manifestations had healed with scarring, and no additional thrombotic events had occurred. Plasma exchange may hold promise as a therapeutic option in refractory or severe cases of antiphospholipid syndrome-related purpura fulminans with extensive cutaneous necrosis, although evidence is limited.

Dialysis vintage time has the strongest correlation to psychosocial pattern of oral health-related quality of life - a multicentre cross-sectional study.

BACKGROUND: Aim of this cross-sectional, multicentre study was to investigate associations of dialysis vintage time in haemodialysis (CKD5D) patients with oral health-related quality of life (OHRQoL) and dental and periodontal treatment need. MATERIAL AND METHODS: CKD5D patients were divided into subgroups according to dialysis vintage time in different dialysis centres in Germany. OHRQoL was assessed with oral health impact profile (OHIP-G14). Dental treatment need was classified as presence of carious lesions. Periodontal treatment need was defined as periodontal screening index score (PSI) 3-4. RESULTS: In total, 190 participants were divided into the subgroups according to the time on CKD5D: 0 - 2 (n = 29), 3 - 5 (n = 35), 6 - 8 (n = 34), 9 - 12 (n = 29), 13 - 20 (n = 34) and >20 years (n = 29). The overall treatment need in the total cohort was 92% (dental 56%, periodontal 88%) with a total OHIP-G14 sum score of 4.17 [2; 0-5] without a significant correlation. Time on CKD5D was inversely correlated with the OHIP G14 score (p<0.01, R = -0.201). The pattern psychosocial impact was significantly associated with the dialysis duration (p<0.01) and showed a negative correlation to the OHIP-G14 (R = -0.283, Spearman's rho test p<0.01). For oral function also a negative correlation with OHIP-G14 was detected (Spearman's rho: -0.183). CONCLUSIONS: Patients with a prolonged dialysis vintage time show an improved OHRQoL, which might be mainly caused by the positive development of psychosocial pattern of OHRQoL. The oral health situation of HD patients seems unsatisfying, independently of dialysis vintage time and OHRQoL. Accordingly, an improvement in oral health situation of CKD5D patients is mandatory necessary. Thereby, consideration of psychosocial aspects especially at the beginning of CKD5D therapy and a sensitization regarding oral health issues with increasing vintage time might be recommendable.

Oral health-related quality of life in patients on chronic haemodialysis and after kidney transplantation.

OBJECTIVES: The objective of the study was to evaluate oral health-related quality of life (OHRQoL) depending on dental and periodontal situation in patients on haemodialysis (HD) and after kidney transplantation (KTx) compared to healthy controls (HC). SUBJECTS AND METHODS: OHRQoL was assessed using the German short form of Oral Health Impact Profile (OHIP G14). Dental health was estimated using the decayed, missing and filled teeth index (DMF-T). Periodontal health was classified as healthy/mild or moderate/severe periodontitis. STATISTICAL ANALYSIS: Mann-Whitney U-test, Kruskal-Wallis test, chi-square test and Fisher's test. RESULTS: Eighty-seven HD patients, 39 KTx patients and 91 HC were included. Significant differences in DMF-T, D-T, M-T and F-T scores were identified between groups (P < 0.001). The prevalence of moderate/severe periodontitis was significantly higher in the HD and KTx group compared to HC (P = 0.002). Differences in OHIP G14 between groups were neither clinical relevant nor statistically significant (P = 0.199). A significant effect of DMF-T (P = 0.012), M-T (P < 0.001) and periodontitis (P = 0.023) on the OHIP G14 scores was identified only in HC. CONCLUSIONS: Improvement in dental care of HD and KTx patients is required. OHIP G14 values provide a subjectively considered low importance of oral health in HD and KTx patients, leading to need of motivation and sensitisation of these patients.

[Endophthalmitis, liver abscess, and cerebral and pulmonary emboli in a 48-year-old Vietnamese man]. / Endophthalmitis, Leberabszess sowie zerebrale und pulmonale Embolien bei einem 48-jährigen Vietnamesen.

We present the case of a 48-year-old Vietnamese man with endophthalmitis, liver abscess, and pulmonary and cerebral septic emboli. Klebsiella pneumoniae was isolated as the causative organism; there were no laboratory findings suggestive of invasive fungal infection. Klebsiella pneumoniae invasive syndrome is a rare disease in Germany. This case report exemplifies the necessity of a dedicated diagnostic approach that takes into consideration factors such as ethnic origin and accompanying diseases of the patient.

The CX(3)C-chemokine fractalkine in kidney diseases.

The chemokine CX(3)C-L/FKN is expressed in both soluble and transmembrane/mucin hybrid forms, thus combining chemoattractant functions together with receptor/adhesion molecule properties. In contrast to other chemokine receptors, CX(3)C-R is expressed not only on lymphoid cell populations, but also on several intrinsic cells including tubular epithelial cells and renal fibroblasts where it regulates various aspects of cell viability, matrix synthesis and degradation, migration, inflammation as well as oxidative stress. In the kidney, the chemokines/receptor pair has been shown to play a role in nephrogenesis as well as in the pathogenesis primary and secondary nephropathies. In several animal models and human specimens with acute and chronic renal failure including allograft nephropathy, CX(3)C-L/CX(3)C-R has been shown to exert immune and non-immune mediated renal damages. A blockade of this chemokine system ameliorated acute and chronic renal damages, though the latter to a more robust extent. There seems to a role of the CX(3)C-L/CX(3)C-R pair in mediating acute renal inflammation as well as in progressive chronic renal failure. However, functional studies are lacking for many aspects and further studies are necessary to better define the functional properties of CX(3)C-L/FKN and its receptor.

Delta sleep deficits in schizophrenia: evidence from automated analyses of sleep data.

BACKGROUND: Several, though not all, polysomnographic studies that use conventional visual scoring techniques show delta sleep deficits in schizophrenia. Delta sleep (in particular, > or = 1- to 2-Hz frequency range), mediated by thalamocortical circuits, is postulated to be abnormal in schizophrenia. We investigated whether deficits in delta sleep occur in schizophrenia and whether these are primarily related to the illness or are epiphenomena of previous medication use or illness chronicity. METHODS: We compared 30 unmedicated schizophrenic patients and 30 age- and sex-matched controls for sleep data evaluated by visual scoring as well as automated period amplitude analyses and power spectral analyses. RESULTS: Schizophrenic patients had reduced visually scored delta sleep. Period amplitude analyses showed significant reductions in delta wave counts but not rapid eye movement counts; power spectral analyses showed reductions in delta as well as theta power. Delta spectral power was also reduced in the subset of 19 neuroleptic-naive, first-episode schizophrenic patients compared with matched controls. Delta deficits were more pronounced in the greater than 1- to 2-Hz frequency range. CONCLUSIONS: Delta sleep deficits that occur in schizophrenia may be related to the primary pathophysiological characteristics of the illness and may not be secondary to previous neuroleptic use. Automated sleep quantification by means of period amplitude and power spectral analyses can complement the use of conventional visual scoring for understanding electrophysiological abnormalities in psychiatric disorders.

Intrathecal NSAIDS attenuate inflammation-induced neuropeptide release from rat spinal cord slices.

Inflammation enhances release of neuropeptides from sensory nerve terminals in the spinal cord, and this may contribute to the development of hyperalgesia. In a similar manner, proinflammatory prostaglandins also augment peptide release from sensory neurons. To ascertain whether the inflammation-induced increase in peptide release from spinal cord slices is mediated by production of these eicosanoids, we examined whether intrathecal administration of nonsteroidal antiinflammatory drugs (NSAIDS) could attenuate the effects of inflammation. Unilateral injection of 150 microl of complete Freund's adjuvant (CFA) into the hindpaw of adult Sprague-Dawley rats resulted in a lower threshold for paw withdrawal (hyperalgesia) on 1, 4, and 5 days after injection. Five days after the induction of inflammation, capsaicin-evoked release of immunoreactive substance P (iSP) and immunoreactive calcitonin gene-related peptide (iCGRP) was increased approximately 2-fold in slices of cord tissue from the side ipsilateral to CFA injection, compared to spinal cord slices from the non-inflamed side. Intrathecal administration of 1 microl/h of 10 nmol/microl solution of the NSAID, ketorolac, for 1 day prior to and throughout the inflammation significantly attenuated the inflammation-induced increase in capsaicin-evoked release of both peptides without altering release in cord tissue from the non-inflamed side. Systemic administration of the same amount of ketorolac did not attenuate the effect of inflammation on peptide release. Intrathecal administration of 16 nmol/h (S)-ibuprofen, before and throughout the inflammation, also significantly attenuated the increase in evoked neuropeptide release associated with inflammation, whereas (R)-ibuprofen was ineffective. These results suggest that inhibition of cyclooxygenase at the level of the spinal cord attenuates the augmentation of neuropeptide release induced by peripheral inflammation, and provide further evidence for an action of prostaglandins at central terminals of sensory neurons during inflammation.

Power spectral analysis of EEG in a multiple-bedroom, multiple-polygraph sleep laboratory.

OBJECTIVES: We describe the methods for power spectral analysis (PSA) of sleep electroencephalogram (EEG) data at a large clinical and research sleep laboratory. The multiple-bedroom, multiple-polygraph design of the sleep laboratory poses unique challenges for the quantitative analysis of the data. This paper focuses on the steps taken to ensure that our PSA results are not biased by the particular bedroom or polygraph from which the data were acquired. METHODS: After describing the data acquisition system hardware, we present our signal amplitude calibration procedure and our methods for performing PSA. We validate the amplitude calibration procedure in several experiments using PSA to establish tolerances for data acquisition from multiple bedrooms and polygraphs. RESULTS: Since it is not possible to acquire identical digitized versions of an EEG signal using different sets of equipment, the best that can be achieved is data acquisition that is polygraph-independent within a known tolerance. We are able to demonstrate a tolerance in signal amplitude of +/- 0.25% when digitizing data from different bedrooms. When different data acquisition hardware is used, the power tolerance is approximately +/- 3% for frequencies from 1 to 35 Hz. The power tolerance is between +/- 3 and +/- 7% for frequencies below 1 Hz and frequencies between 35 and 50 Hz. Additional data demonstrate that variability due to the hardware system is small relative to the inherent variability of the sleep EEG. CONCLUSION: The PSA results obtained in one location can be replicated elsewhere (subject to known tolerances) only if the data acquisition system and PSA method are adequately specified.

[Microalbuminuria and albuminuria: differential diagnosis and consequences for treatment]. / Mikroalbuminurie und Albuminurie: Differenzialdiagnose und therapeutische Konsequenzen.

The occurrence of microalbuminuria or albuminuria indicates a disturbance of the barrier function of endothelial cells, basement membrane or of a structural-renal disease (including diseased podocytes). The prevalence of microalbuminuria in the general population is about 8 %, however, in high risk groups, prevalence rates of 50 % and more have been observed. Its incidence is strongly associated with increased cardiovascular morbidity and mortality. Blood pressure control and the blockade of the renin-angiotensin-aldosteron-system (RAAS), respectively, is the central mechanism to reduce cardio-vascular-renal end points as well as mortality.

Muscle artifacts in the sleep EEG: automated detection and effect on all-night EEG power spectra.

Owing to the use of scalp electrodes in human sleep recordings, cortical EEG signals are inevitably intermingled with the electrical activity of the muscle tissue on the skull. Muscle artifacts are characterized by surges in high frequency activity and are readily identified because of their outlying high values relative to the local background activity. To detect bursts of myogenic activity a simple algorithm is introduced that compares high frequency activity (26.25-32.0 Hz) in each 4-s epoch with the activity level in a local 3-min window. A 4-s value was considered artifactual if it exceeded the local background activity by a certain factor. Sensitivity and specificity of the artifact detection algorithm were empirically adjusted by applying different factors as artifact thresholds. In an analysis of sleep EEG signals recorded from 25 healthy young adults 2.3% (SEM: 0.16) of all 4-s epochs during sleep were identified as artifacts when a threshold factor of four was applied. Contamination of the EEG by muscle activity was more frequent towards the end of non-REM sleep episodes when EEG slow wave activity declined. Within and across REM sleep episodes muscle artifacts were evenly distributed. When the EEG signal was cleared of muscle artifacts, the all-night EEG power spectrum showed significant reductions in power density for all frequencies from 0.25-32.0 Hz. Between 15 and 32 Hz, muscle artifacts made up a substantial part (20-70%) of all-night EEG power density. It is concluded that elimination of short-lasting muscle artifacts reduces the confound between cortical and myogenic activity and is important in interpreting quantitative EEG data. Quantitative approaches in defining and detecting transient events in the EEG signal may help to determine which EEG phenomena constitute clinically significant arousals.