[Periodic limb movements in sleep: polysomnographic and actigraphic methods for their detection]. / Periodické pohyby koncetinami ve spáinku a jejich vysetrování pomocí polygrafie a aktigrafie.

BACKGROUND: The aim of our study was to compare the results obtained by simultaneous polysomnographic and actigraphic recording and thus to estimate the specificity and sensitivity of actigraphic evaluation of periodic leg movements in sleep (PLMS). As a standard method, PLMS are detected by means of polysomnography, including superficial EMG of anterior tibial muscles. Since 1995, there have been efforts to detect PLMS by means of actigraphy, which is more convenient for both patient and investigator. METHODS AND RESULTS: Recordings were done during 44 nights in 42 patients (10 women, mean age 49.2, SD 13.1 years) in our sleep laboratory. The same criteria for periodic leg movements and the cut-off periodic leg movements index (PLMI > 5) were used in both methods. For the actigraphic way of PLMS detection, we found a specificity of 90%, sensitivity 60%, positive predictive value 88.2%, negative predictive value 64.3 % and total diagnostic accuracy of 73.3%. A close correlation (Spearman's coefficient rho > 0.64, p < 0.0001) between PLMI resulting from either method of recording was observed, though the PLMI actigraph proved to be significantly lower (Sign test--p < 0.01). CONCLUSIONS: Our study has proven good specificity a negative predictive value of the actigraphic recording. To improve its sensitivity, we suggest to reduce the threshold of significant presence PLMS, as expressed by PLMI, from 5 to 3. Actigraphy seems to be a suitable method from PLMS screening in the general population for both clinical and research purposes.

Wide-range transcriptional modulating effect of ntrR under microaerobiosis in Sinorhizobium meliloti.

A mutation in the second gene in the ntrPR operon results in increased expression of nodulation (nod) and nitrogen fixation (nif) genes in Sinorhizobium meliloti. Since this pleiotropic effect is particularly pronounced in the presence of external combined nitrogen, a nitrogen regulatory function has been suggested for NtrR. To identify the complete set of protein-coding genes influenced by loss of ntrR function, microarray hybridizations were carried out to compare transcript levels in the wild type and mutant strains grown under aerobic and microaerobic conditions. Of the 6207 genes examined, representing the entire genome of S. meliloti, 7% exhibited altered expression: 4.5% of the genes are affected under oxic, 2.5% under microoxic conditions. 0.4% of all the genes are affected under both oxygen concentrations. A microoxic environment is required for the induction of genes related to symbiotic functions but results in the down-regulation of other (e.g. metabolic) functions. When the alterations in transcription levels at low oxygen concentration in the mutant strain were compared to those of the wild type, a modulating effect of the ntrR mutation was observed. For example, symbiotic nif/fix genes were induced in both strains, but the level of induction was higher in the ntrR mutant. In contrast, genes related to transcription/translation functions were down-regulated in both strains, and the effect was greater in the wild-type strain than in the ntrR mutant. A relatively wide range of functions was affected by this modulating influence, suggesting that ntrR is not a nitrogen regulatory gene. Since genes encoding various unrelated functions were affected, we propose that NtrR may either interfere with general regulatory mechanisms, such as phosphorylation/dephosphorylation, or may influence RNA stability.

Surgical treatment of early-stage breast cancer in the Department of Defense Healthcare System.

BACKGROUND: The choice between breast-conserving surgery and modified radical mastectomy in the treatment of women with early stage breast cancer in the Department of Defense Healthcare System may be influenced by demographic factors. STUDY DESIGN: The Department of Defense Automated Central Tumor Registry (ACTUR) was queried for women diagnosed with American Joint Committee on Cancer Stage I or II invasive breast carcinoma from January 1, 1986, to December 31, 1996. Univariate analysis and multivariate analysis were applied to the study variables. Year of diagnosis, age at diagnosis, tumor size, type of hospital, geographic region, and local availability of radiation therapy were evaluated with respect to the type of surgical treatment performed. Surgical treatment was either breast conservation therapy (BCT) or modified radical mastectomy. RESULTS: After excluding women for whom the data were incomplete (n = 308), 7,815 women were identified who met study criteria. There was a progressive increase in the use of BCT to treat tumors of all sizes from 16% to 47% over the 11 years of the study (p < 0.0001). BCT was more frequently used for smaller tumors (< 2cm), with an odds ratio of 2.46 (2.20-2.76, 95% CI). In 1996, 54% of women with T1 (< 2 cm) tumors were treated with BCT. Women treated with BCT were nearly the same age as those undergoing modified radical mastectomy (55.5 years versus 56.8 years, p < 0.0001). BCT was used at a slightly greater rate in medical centers than in community hospitals (31% versus 28%, p < 0.0001). Use of BCT varied among geographic regions from a low of 24% in the southwestern USA to a peak of 36% in the Northeast and 40% in hospitals outside of the continental United States (p < 0.0001). Local availability of radiation therapy did not influence choice of treatment. CONCLUSIONS: The use of BCT to treat early stage invasive breast carcinoma in the Department of Defense Healthcare System is increasing. But BCT is used less often to treat larger tumors. Regional differences in the use of BCT persist, even after controlling for other factors. Patient age and type of hospital (community versus academic center) appear to exert little influence on the choice of treatment. Local availability of radiation therapy did not seem to influence the choice of treatment. Our data suggest that efforts to promote the use of BCT should target the central and southwestern USA. Use of BCT should also be emphasized for women with larger tumors (> 2 cm).

Minimally invasive approaches to mediastinal neoplasms.

The goal of minimal-access surgery is to cause the least trauma necessary to gain exposure for an operative procedure. Application of this principle to mediastinal neoplasms involves the use of small incisions with both mediastinoscopy and video-assisted thoracoscopic surgery (VATS). The mediastinum is divided into anterior, middle, and posterior compartments, and this anatomy provides a framework for discussion of diagnostic and therapeutic procedures. Neoplasms occur with a characteristic frequency that varies with age and location. Neurogenic tumors and thymic neoplasms account for one third of all masses. Knowledge of the potential cause of a neoplasm and the surrounding anatomy provides the context for determining the surgical approach. The operative indications and goals of a procedure should not be significantly affected by the operative approach. Conversion from a minimal-access approach to a more traditional incision should be an anticipated possibility that is often undertaken as the next logical step rather than an expression of exasperation.

[Reliability and validity studies with the triflexometer, a new method for assessing form and flexibility of the spine]. / Reliabilitäts- und Validitätsstudien mit dem Triflexometer, einer neuen Methode zur Bestimmung von Form und Beweglichkeit der Wirbelsäule.

Developed by Orthotronic Medizintechnik GmbH, the so-called Triflexometer, version 3.22 was tested for its reliability and validity in measuring spinal posture and mobility. Reliability studies on 20 healthy subjects have shown this measurement method to be reliable, yet intra- and inter-rater reliability analyses also revealed that even for this healthy population discrepancies in the various measures may occur, both due to differences in compliance as well as fatigue and learning effects, and due to difficulties in stabilization of the normal posture, to a lesser extent due to certain specifics of the measurement technique (placing the markers, guiding the sensor). In total spinal immobility (ankylosing spondylitis), practically identical measurements are found, as is the case in dummy studies. The validity study on 20 healthy subjects found good correlations between the measurements obtaining using the triflexometer and those for double inclinometer, respectively, and that only minor mean value differences occur for the two methods. Also, triflexometer measurements for total anteflexion were found to correlate with those determined with the fingertip-to-floor method, no correlation was present however between the Triflexometer values and the Schober test. Triflexometer measurements performed on 114 healthy subjects of various ages served to prove that the range of spinal movement in the directions measured (sagittal and frontal) will reduce with age. To a lesser extent, this also applies to hip movement. Overall, our findings prove the triflexometer an easy-to-handle system which possesses high reliability and is suitable for valid and objective noninvasive assessment of global and segmental spinal mobility. Triflexometer examinations are highly uncomplicated to implement, and print-outs of the results obtained permit lasting documentation of the present status.

Spinal factors in the generation of fibromyalgia syndrome.

In fibromyalgia as well as in low back pain we frequently find disturbances of the posture of vertebral column clinically and radiologically. Also, reduction in the mobility of whole spine and localized movement impairments in both conditions was present. It is likely that the disturbances are responsible for the first manifestations of fibromyalgia in a single localization, especially in lumbar and cervical regions.

Determination of sulphur and total sulphur dioxide in wines by an ICP-AES method.

Sulphur contents of the original sample and the sample free from sulphur dioxide were determined by ICP-AES following nitric acid digestion under high pressure (using PAAR HPA equipment), and the total sulphur content was calculated from the difference between the results obtained. With the aim of preparing a sample free from sulphur dioxide, bound sulphur dioxide was released by sodium hydroxide, then after acidifying by phosphoric acid, boiling was carried out. Relative standard deviations of the results obtained for total sulphur, the sulphur without S(IV) and total sulphur dioxide were lower than 2.5, 3.5 and 5% respectively. Various amounts of sulphur (in the form of Na(2)SO(4)), added to wine samples, were successfully recovered between 95.5 and 104.9%. Based on comparative analyses performed by a widely accepted classic method, the indirect method developed was found to be adequate for the determination of total sulphur dioxide. The procedure is suitable for serial tests.

Evaluation of diagnostic peritoneal lavage in stable patients with gunshot wounds to the abdomen.

BACKGROUND: Diagnostic peritoneal lavage (DPL) is used to diagnose intra-abdominal injury in patients with stab wounds and blunt trauma. Because exploratory celiotomy is routinely performed on patients with gunshot wounds to the abdomen, DPL is rarely employed. However, several studies have questioned routine exploration and have drawn attention to the associated morbidity of negative celiotomy. Diagnostic peritoneal lavage is an easily performed and inexpensive test that may be useful in this situation. OBJECTIVE: To evaluate the performance of DPL in the diagnosis of intra-abdominal injury in hemodynamically stable patients with gunshot wounds to the abdomen. DESIGN: A prospective clinical trial. SETTING: Two urban trauma centers. PATIENTS: Patients with gunshot wounds to the abdomen and a systolic blood pressure of at least 90 mm Hg. INTERVENTIONS: Clinical predication of intra-abdominal injury in the emergency department and DPL performed in the operating room before the initiation of celiotomy. Injuries found during the celiotomy were recorded. MAIN OUTCOME MEASURES: The results of the clinical evaluation and DPL were compared with the findings of the celiotomy. RESULTS: Forty-four patients were enrolled into the study. Intra-abdominal injury was present in 32 (73%) of these patients. The senior surgery resident correctly predicted the presence of intra-abdominal injury in 36 (82%) of the patients (sensitivity = 90.0%, specificity = 58.3%, positive predictive value = 85.3%, negative predictive value = 63.6%, phi = 0.52, P < .01) in the emergency department before DPL and celiotomy were performed. Diagnostic peritoneal lavage correctly identified the presence or absence of intra-abdominal injury in 40 (91%) of the patients (positive predictive value = 96.7%, negative predictive value = 78.6%, phi = 0.79, P < .01). CONCLUSIONS: Clinical judgment is highly accurate in separating patients with tangential gunshot wounds to the abdomen from those with intra-abdominal injury but may miss patients with intra-abdominal hemorrhage. Diagnostic peritoneal lavage is highly predictive of the presence of intra-abdominal injury. The return of gross blood on aspiration or a lavage red blood cell count greater than 10 x 10(9)/L should prompt an urgent celiotomy. Missed injuries are rare and most likely to be bowel perforations. Diagnostic peritoneal lavage is an objective test that may augment clinical judgment in selecting hemodynamically stable patients with potential tangential gunshot wounds for observation and is especially useful in identifying intra-abdominal hemorrhage.

[The diagnostic value of IgG galactosylation in rheumatoid arthritis]. / Az IgG galaktoziláció diagnosztikai jelentösége rheumatoid arthritisben.

Glycosylation is the main posttranslational modification of protein molecules. Human immunoglobulin G (IgG) is unique among serum glycoproteins because it is associated with at least 30 different biantennary oligosaccharide moieties. Elevated ratio of circulating IgG molecules lacking galactose from the oligosaccharides on the CH2 domain correlates with severity of the disease in a number of different autoimmune illnesses. Moreover, it may be helpful in differential diagnosis of rheumatoid arthritis (RA). By that we may try to predict outcome of RA. Its seems that agalactosyl IgG is distinctively connected with rheumatoid arthritis and may be involved in its immunopathogenesis.

[Systemic mastocytosis]. / Systemás mastocytosis.

The systemic mastocytosis is a rare disorder, however, the authors recently diagnosed two cases causing diagnostic problems. The diagnosis was proved by bone marrow biopsy in both patients. The authors review the diagnostic pathway considering the pitfalls. According to their conclusion, the most important factor in the diagnosis of systemic mastocytosis is to think of the possibility of systemic mastocytosis.

Cytokine concentration in serum of lupus erythematosus patients: the effect on acute phase response.

In order to get a better insight into cytokine network regulation in systemic lupus erythematosus (SLE), we analyzed levels of interleukin-10 (IL-10), interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-alpha), and interferon-gamma (IFN-gamma) in the sera from 36 SLE patients. Moreover, C-reactive protein (CRP), alpha-1-acid-glycoprotein (AGP), and alpha-1-antichymotripsin (ACT) serum levels were evaluated. Serum levels of IL-10 and IL-6 were significantly increased when compared with healthy controls. TNF-alpha and IFN-gamma did not differ from normal values. We established the relationship between IL-10 and IL-6 as well as between IL-10 and TNF-alpha. None of the analyzed cytokines correlated with the acute phase protein levels. Based on the obtained data, we conclude that IL-10 may play the superior regulating role in SLE. A lack of correlation between the cytokines and acute phase proteins suggests their independence from cytokine regulation.

Eco-grammar systems: a grammatical framework for studying lifelike interactions.

A formal framework for studying systems made up of a community of agents and their environment is proposed. The suggested model, technically based on the theory of formal grammars and called an eco-grammar system, captures some common features of ecological, economic, social, and collective robotic systems. The article contains an informal presentation as well as the formal definition of the model, presents some properties of variants of eco-grammar systems, and discusses the emergence of important lifelike features such as birth and death. Emphasis is put on results with relevance for artificial life. Some recent developments are also briefly reported.

Effect of ambient temperature on metabolic rate after thermal injury.

OBJECTIVE: The authors describe the effect of ambient temperature on metabolic rate after thermal injury. SUMMARY BACKGROUND DATA: Thermal injury induces a hypermetabolic state, which is reported to increase with the extent of burn. The magnitude of this response is further influenced by ambient temperature. METHODS: The resting energy expenditure was measured by indirect calorimetry at ambient temperatures of 22, 28, 32, and 35 C. It was indexed to a calculated basal metabolic rate in normal volunteers and adult patients with burns involving at least 20% of the total body surface area who had no evidence of systemic infection. These measurements were performed between postburn days 6 and 21. RESULTS: The effect of ambient temperature on metabolic rate was measured in 44 burn patients and 8 normal volunteers. Burn size ranged from 20 to 97% total body surface area with a mean of 44 +/- 18.5% total body surface area. Metabolic rate did not change significantly in control subjects as ambient temperature was varied (p<0.05). Regression analysis showed that burn size and ambient temperature were significant determinants (p<0.01) of metabolic rate in the patients and that together these factors accounted for 55% of the variation observed (df adj. r(2)=0.55) across the range of ambient temperatures studied. Metabolic rate was independent of burn size at ambient temperatures of 32 and 35 C (p<0.02) and increased by a factor of 1.5 X basal metabolic rate. A further increase in metabolic rate, which was positively correlated with burn size, resulted from nonshivering thermogenesis at ambient temperatures 28 and 22 C. The magnitude of this response was greatest at 22 C. CONCLUSIONS: These findings suggest that the hypermetabolic response to thermal injury is maximal in burns as small as 20% total body surface area and that an additional burn size-dependent increase in metabolic rate results from heat loss at ambient temperatures below thermoneutrality.

[The place of micro- and modern mini-laparotomy in the management of biliary calculi]. / Micro- és modern mini-laparotomia helye az epekövesség mütéti kezelésében.

The authors treated 537 patients biliary stone disease between 1-st january 1991. and 1-st june 1994. With the conventional method of 20 cm of the subcostal incision, they operated 250 patients, among them 17 (6.8%) also had the common bile duct stone. There was no case of mortality and common bile duct injury. The postoperative morbidity was 12.8%. The average days of treatment was 9. With micro- and modern mini-laparotomy 287 cases were operated, 16 (5.5%) of them had common bile duct stones which were extracted during the process of cholecystectomy. In one case transduodenal sphincterectomy was performed. There was no case of mortality and injury of common bile duct. The postoperative morbidity was 10.4%. There was 6 cases of conversion (2.09%). The average period of treatment was 5 days. The treatment of biliary stone disease by micro- or modern minilaparotomy does not cause more danger to the patients than the conventional subcostal method. This approach is suitable for the surgical treatment of all kinds of biliary stone disease. This method is also suitable to extract a stone (stones) from the common bile duct discovered during cholecystectomy. This method has a pleasant cosmetical results.

Burn center care for patients with toxic epidermal necrolysis.

BACKGROUND: Toxic epidermal necrolysis (TEN) is a life threatening exfoliative disorder that is most commonly precipitated by the administration of a medication. Efforts to reduce morbidity and improve survival have brought into question the use of corticosteroids and recommend the transfer of patients to a burn center to facilitate wound care. STUDY DESIGN: This study evaluated the correlation of measures of disease severity and impact of treatment strategies on morbidity and mortality in patients with TEN. The records of all patients with TEN admitted to the United States Army Institute of Surgical Research during a 12 year period were reviewed. Patient characteristics, etiologic agents, time to referral of patients to the burn center, corticosteroid therapy, and other demographic features were studied. Univariate and multivariate analyses were used to determine the significance of these factors with respect to outcome. RESULTS: The sulfonamides and phenytoin were the most frequently identified etiologic agents. Patients at the extremes of age had a higher mortality rate. The period of hospitalization was longer in patients transferred to the burn center more than seven days after skin slough. Percent of epidermalysis, white blood cell count nadir, and corticosteroid administration for more than 48 hours were independently associated with mortality. CONCLUSIONS: These data indicate that the sulfonamides and phenytoin are the most common etiologic agents, expeditious transfer to a burn center reduces morbidity, and corticosteroid administration dramatically increases mortality.

Association of relative nocturnal hypertension and autonomic neuropathy in insulin-dependent diabetic children.

Twenty-four hour BP and heart rate measurements were carried out in fourteen newly diagnosed-, and in twenty-eight diabetics with 5-13 years of duration; and in eight healthy control children. Mean arterial BP rose at night in five-, fell slightly (less than 10%) in five- and fall markedly (more than 10%) in eighteen diabetics with longer duration of the disease. The diurnal-nocturnal difference of mean arterial pressure was significantly lower in the groups with nocturnal BP rise and slight nocturnal BP fall, compared to the control group (< 0.001; p < 0.01, respectively). The diurnal-nocturnal differences of heart rates were significantly lower in diabetics with relative "nocturnal hypertension" compared to the control group (p < 0.05). The presence of subclinical signs of diabetic autonomic neuropathy was significantly higher in patients with nocturnal BP rise and slight nocturnal BP fall compared to patients with marked nocturnal BP fall and newly diagnosed diabetics (chi squared p = 0.02 and p = 0.01, respectively). In conclusion, the prevalence of autonomic symptoms in diabetic children could be related to change in diurnal/nocturnal arterial BP, however longitudinal studies of ABPM are needed to define, whether patients with abnormal BP profiles are candidates for the development of diabetic vascular disease.

[Selenium supplementation with bread]. / Szelénpótlás kenyérrel.

Bread produced with selenium-enriched yeast was given to ten volunteers. The daily dose contained approximately 100 micrograms of selenium. The subjects' mean baseline whole blood selenium concentration (52.2 +/- 16.7 micrograms/l) was indicative of a suboptimal selenium status. After two weeks of supplementation, the subjects' mean whole blood selenium level increased significantly (to 66.1 +/- 11.9 micrograms/l). Supplementation of selenium-enriched bread seems to be an easily implementable and promptly acting method of selenium status improvement.

Relative nocturnal hypertension in children with insulin-dependent diabetes mellitus.

Twenty-four-hour blood pressure and heart rate measurements were carried out in 14 newly diagnosed diabetics and in 28 diabetics with 5-13 years' duration of the disease; 8 healthy children were used as controls. Mean arterial blood pressure increased at night in 5, decreased slightly (less than 10%) in 5 and decreased markedly (more than 10%) in 18 diabetics with longer duration of the disease. The diurnal-nocturnal differences in heart rates were significantly lower in diabetics with relative "nocturnal hypertension" compared to the control group (p < 0.05). A significant negative correlation was found between maximal arterial blood pressure during physical exercise and the diurnal-nocturnal differences in mean arterial blood pressure in diabetics (r = -0.58; p < 0.02). In conclusion, we found elevated nocturnal blood pressure in a subgroup of children with longer duration of diabetes and without increased albumin excretion. However, longitudinal studies of blood pressure profiles are needed to identify the candidates for diabetic vasculopathy among diabetic children.