Effects of state-wide implementation of the Los Angeles Motor Scale for triage of stroke patients in clinical practice.

BACKGROUND: The prehospital identification of stroke patients with large-vessel occlusion (LVO), that should be immediately transported to a thrombectomy capable centre is an unsolved problem. Our aim was to determine whether implementation of a state-wide standard operating procedure (SOP) using the Los Angeles Motor Scale (LAMS) is feasible and enables correct triage of stroke patients to hospitals offering (comprehensive stroke centres, CSCs) or not offering (primary stroke centres, PSCs) thrombectomy. METHODS: Prospective study involving all patients with suspected acute stroke treated in a 4-month period in a state-wide network of all stroke-treating hospitals (eight PSCs and two CSCs). Primary endpoint was accuracy of the triage SOP in correctly transferring patients to CSCs or PSCs. Additional endpoints included the number of secondary transfers, the accuracy of the LAMS for detection of LVO, apart from stroke management metrics. RESULTS: In 1123 patients, use of a triage SOP based on the LAMS allowed triage decisions according to LVO status with a sensitivity of 69.2% (95% confidence interval (95%-CI): 59.0-79.5%) and a specificity of 84.9% (95%-CI: 82.6-87.3%). This was more favourable than the conventional approach of transferring every patient to the nearest stroke-treating hospital, as determined by geocoding for each patient (sensitivity, 17.9% (95%-CI: 9.4-26.5%); specificity, 100% (95%-CI: 100-100%)). Secondary transfers were required for 14 of the 78 (17.9%) LVO patients. Regarding the score itself, LAMS detected LVO with a sensitivity of 67.5% (95%-CI: 57.1-78.0%) and a specificity of 83.5% (95%-CI: 81.0-86.0%). CONCLUSIONS: State-wide implementation of a triage SOP requesting use of the LAMS tool is feasible and improves triage decision-making in acute stroke regarding the most appropriate target hospital.

Adult-onset autosomal dominant centronuclear myopathy due to BIN1 mutations.

Centronuclear myopathies are congenital muscle disorders characterized by type I myofibre predominance and an increased number of muscle fibres with nuclear centralization. The severe neonatal X-linked form is due to mutations in MTM1, autosomal recessive centronuclear myopathy with neonatal or childhood onset results from mutations in BIN1 (amphiphysin 2), and dominant cases were previously associated to mutations in DNM2 (dynamin 2). Our aim was to determine the genetic basis and physiopathology of patients with mild dominant centronuclear myopathy without mutations in DNM2. We hence established and characterized a homogeneous cohort of nine patients from five families with a progressive adult-onset centronuclear myopathy without facial weakness, including three sporadic cases and two families with dominant disease inheritance. All patients had similar histological and ultrastructural features involving type I fibre predominance and hypotrophy, as well as prominent nuclear centralization and clustering. We identified heterozygous BIN1 mutations in all patients and the molecular diagnosis was complemented by functional analyses. Two mutations in the N-terminal amphipathic helix strongly decreased the membrane-deforming properties of amphiphysin 2 and three stop-loss mutations resulted in a stable protein containing 52 supernumerary amino acids. Immunolabelling experiments revealed abnormal central accumulation of dynamin 2, caveolin-3, and the autophagic marker p62, and general membrane alterations of the triad, the sarcolemma, and the basal lamina as potential pathological mechanisms. In conclusion, we identified BIN1 as the second gene for dominant centronuclear myopathy. Our data provide the evidence that specific BIN1 mutations can cause either recessive or dominant centronuclear myopathy and that both disorders involve different pathomechanisms.

Sudden unexpected death in epilepsy in children.

Sudden unexpected death in epilepsy (SUPEP) is the commonest cause of seizure-related mortality in people with intractable epilepsy. The incidence of SUDEP varies in different epilepsy populations, with lower rates in population-based studies, higher in referral populations and clinical trials of adjunct drugs for complex partial epilepsy, and highest rates for surgical series. Certain risk factors for SUDEP have been identified, with seizure activity being one of the strongest risk factor for SUDEP. Suspected underlying mechanisms include cardiac dysrhythmias, seizure-related apnoea and postictal respiratory arrest. Prevention of SUDEP has centred on seizure control, and SUDEP incidence has been reduced by epilepsy surgery in some studies. In this review, we present epidemiological data, and discuss risk factors and underlying pathophysiological mechanisms that are associated with SUDEP in children.

[Gamma-hydroxy butyric acid: neurotransmitter, sedative and party drug]. / Gamma-Hydroxybuttersäure: Neurotransmitter, Sedativum und Droge.

Gamma-hydroxybutyric acid (GHB) as a natural component of the mammalian brain was first introduced in clinical anaesthesic practice more than 40 years ago. The drug was nearly forced from clinical practice because of its prolonged and variable duration of action. The results of recent clinical studies indicate a re-evaluation of GHB in various clinical fields. In the intensive care unit, GHB may be a favourable alternative to established drugs. The results of various clinical studies also suggest that GHB is efficacious in the treatment of alcohol withdrawal syndrome, and narcolepsy. GHB has been used successfully for short-term sedation in children. In addition, GHB has emerged as a street drug ("liquid ecstasy"). Overdose may lead to respiratory depression, coma, and even death. Chronic abuse itself may lead to severe withdrawal syndrome. The purpose of this article is to outline the neurophysiological, pharmacodynamic and pharmacokinetic characteristics of GHB, and to summarize the potential fields of use and misuse of GHB in clinical medicine and toxicology.