Grading of a positive sputum smear and the risk of Mycobacterium tuberculosis transmission.

SETTING: After the diagnosis of a case of tuberculosis (TB), contact tracing is directed by the risk of transmission, for which sputum acid-fast bacilli (AFB) staining results are highly relevant. Limited data are available on the effect of the degree of acid-fast positivity, of a polymerase chain reaction (PCR) result or of bronchoalveolar lavage (BAL) fluid results on the risk of transmission. OBJECTIVES: To investigate factors associated with TB transmission, focusing on quantitative sputum smear results. DESIGN: Retrospective study of contact investigations performed over a period of 5 years in a Dutch Municipal Health Service among all index patients with TB, and the tuberculin skin test and chest radiography results in contacts. Three definitions of transmission were used: ≥ 1 or ≥ 5 contacts with positive TST or active TB in contacts. RESULTS: The highest (+4/+5) sputum AFB grades were associated with the highest relative risk (≥ 8) of extensive transmission or active TB among contacts. Novel risk factors observed were employment or school attendance, positive PCR of sputum and positive AFB staining of BAL fluid. Pulmonary symptoms, infiltrate or cavity and positive AFB sputum stain were also associated with transmission, confirming previous studies. CONCLUSION: The risk factors observed in this study may aid in the extension of contact investigations.

Genetic bases and phenotypes of autosomal recessive Parkinson disease in a Turkish population.

BACKGROUND AND PURPOSE: To evaluate the phenotype and the frequencies of mutations in PRKN, DJ1 and PINK1 genes in patients with Parkinson disease (PD) in Turkey. METHODS: Eighty-six patients from 77 PD families participated in the study. Seventy-four families were originating from Turkey, two families from Greece and one family from Bulgaria. All patients underwent detailed neurological examination. PRKN, PINK1 and DJ1 genes were sequenced, and dosage analysis was performed by multiplex ligation-dependent probe amplification. RESULTS: Sixteen patients with PD were found to carry homozygous (n = 14) or compound heterozygous (n = 2) PRKN mutations. We identified exon rearrangements, three point mutations and one new point mutation in exon 2 (p.K27del). In two families, two new PINK1 point mutations (L31X and P416L) were identified. No pathogenic mutations were found in DJ1 gene. Clinical phenotypes of PRKN patients were comparable to previously described features, but only in four of 13 families, the pedigree structure was clearly consistent with an autosomal recessive (AR) mode of inheritance in comparison with nine families where also different pattern of transmission could have been possible. CONCLUSIONS: Our data suggest that the PRKN gene mutation is the most frequent form of ARPD in Turkey. The proportion of mutations with regard to the age of onset in our population is in the range of those previously described, but our pedigrees are characterized by high rate of consanguinity, which might explain the high proportion of families with homozygous mutations and of patients in more than one generation. Pathogenic DJ1 mutations do not seem to play a major role in Turkey.

Molecular analyses of the LRRK2 gene in European and North African autosomal dominant Parkinson's disease.

BACKGROUND: Mutations in the leucine-rich-repeat kinase 2 (LRRK2) gene have been identified in families with autosomal dominant Parkinson's disease (ADPD), the most common of which is the p.G2019S substitution that has been found at varying frequencies worldwide. Because of the size of the LRRK2 gene, few studies have analysed the entire gene in large series of ADPD families. METHODS: We performed extensive mutation analyses of all 51 coding exons of the LRRK2 gene in index cases from 226 Parkinson's disease families compatible with autosomal dominant inheritance, mostly from France (n = 182) and North Africa (n = 14). RESULTS: We found 79 sequence variants, 29 of which were novel. Eight potentially or proven pathogenic mutations were found in 22 probands (9.7%). There were four novel amino acid substitutions that are potentially pathogenic (p.S52F, p.N363S, p.I810V, p.R1325Q) and two novel variants, p.H1216R and p.T1410M, that are probably not causative. The common p.G2019S mutation was identified in 13 probands (5.8%) including six from North Africa (43%). The known heterozygous p.R1441H and p.I1371V mutations were found in two probands each, and the p.E334K variant was identified in one single patient. Most potentially or proven pathogenic mutations were located in the functional domains of the Lrrk2 protein. CONCLUSION: This study leads us to conclude that LRRK2 mutations are a common cause of autosomal dominant Parkinson's disease in Europe and North Africa.

A multidisciplinary study of patients with early-onset PD with and without parkin mutations.

OBJECTIVE: To establish phenotype-genotype correlations in early-onset Parkinson disease (EOPD), we performed neurologic, neuropsychological, and psychiatric evaluations in a series of patients with and without parkin mutations. BACKGROUND: Parkin (PARK2) gene mutations are the major cause of autosomal recessive parkinsonism. The usual clinical features are early-onset typical PD with a slow clinical course, an excellent response to low doses of levodopa, frequent treatment-induced dyskinesias, and the absence of dementia. METHODS: A total of 44 patients with EOPD (21 with and 23 without parkin mutations) and 9 unaffected single heterozygous carriers of parkin mutations underwent extensive clinical, neuropsychological, and psychiatric examinations. RESULTS: The neurologic, neuropsychological, and psychiatric features were similar in all patients, except for significantly lower daily doses of dopaminergic treatment and greater delay in the development of levodopa-related fluctuations (p < 0.05) in parkin mutation carriers compared to noncarriers. There was no major difference between the two groups in terms of general cognitive efficiency. Psychiatric manifestations (depression) were more frequent in patients than in healthy single heterozygous parkin carriers but did not differ between the two groups of patients. CONCLUSION: Carriers of parkin mutations are clinically indistinguishable from other patients with young-onset Parkinson disease (PD) on an individual basis. Severe generalized loss of dopaminergic neurons in the substantia nigra pars compacta in these patients is associated with an excellent response to low doses of dopa-equivalent and delayed fluctuations, but cognitive impairment and special behavioral or psychiatric symptoms were not more severe than in other patients with early-onset PD.

Rare heterozygous parkin variants in French early-onset Parkinson disease patients and controls.

BACKGROUND: Mutations in the parkin gene cause autosomal recessive early-onset parkinsonism. The effect of single heterozygous mutations in parkin is still unclear. The aim of this study was to evaluate the frequency of exonic parkin variants in a case-control study. METHODS: The parkin gene was screened for both point mutations and exon rearrangements in 172 French patients with Parkinson disease (PD) and 170 controls from the same population. Patients with single parkin variants were also screened for PINK1, DJ-1 and LRRK2 exon 41 mutations. RESULTS: 10 exonic sequence variations were identified, including 3 known polymorphisms and 7 rare heterozygous variants, 2 of which were novel. There were significantly more rare heterozygous variants in patients (n = 10) with early-onset PD than in controls (n = 2). Screening of PINK1, DJ-1 and LRRK2 exon 41 in the 10 patients heterozygous for parkin failed to identify a second causative mutation. CONCLUSION: These results suggest that single parkin mutations increase the risk of early-onset PD, but the possibility of a second parkin mutation cannot be excluded.

Causal relation between alpha-synuclein gene duplication and familial Parkinson's disease.

The alpha-synuclein gene (SNCA) has been implicated in autosomal dominant forms of Parkinson's disease. We screened 119 individuals from families with this rare form of the disease for SNCA duplications by semiquantitative multiplex PCR. Two patients had duplications, which were confirmed by analysis of intragenic and flanking microsatellite markers. The phenotype in both patients was indistinguishable from idiopathic Parkinson's disease and no atypical features were present, by contrast with reports of families with triplication of the same gene. These results indicate that SNCA is more frequently associated with familial Parkinson's disease than previously thought, and that there is a clear dosage effect according to the number of supernumerary copies of this gene.

Screening for DJ-1 mutations in early onset autosomal recessive parkinsonism.

The DJ-1 gene was identified as responsible for early onset autosomal recessive parkinsonism in two families (PARK7). In this study, after excluding mutations in the parkin gene, the authors screened a large series of early onset autosomal recessive parkinsonism families and consanguineous isolated patients of diverse geographic origins for DJ-1 mutations. No mutations were found. This indicates that PARK7 is not a common locus for early onset autosomal recessive parkinsonism, and that one or more new loci remains to be identified.

New parkin mutations and atypical phenotypes in families with autosomal recessive parkinsonism.

The frequency of parkin mutations was evaluated in 30 families of highly diverse geographic origin with early-onset autosomal recessive parkinsonism. Twelve different mutations, six of which were new, were found in 10 families from Europe and Brazil. Patients with parkin mutations had significantly longer disease duration than patients without the mutation but with similar severity of disease, suggesting a slower disease course. Two patients with parkin mutations had atypical clinical presentation at onset, with predominant tremor when standing.

Implications of the introduction of fixed reimbursement rates in Germany.

The introduction of fixed reimbursement rates in Germany for cardiac surgery of adults, mainly coronary artery bypass grafting (CABG) and valve surgery, has shifted the financial risk from insurers to providers of medical care, namely hospitals. Costs in turn are closely related to the preoperative condition of a patient, implicating that surgery in high-risk patients may result in financial losses for the operating institution. Furthermore, reports from the Society of Thoracic Surgeons national database indicate a trend over time towards a higher proportion of patients with adverse risk factors for the United States. To determine whether these trends are holding true for Germany, we conducted an analysis of the data from two institutions with the following questions: 1. Is there a trend over time towards unfavourable risk factors, and 2. Is there a relation between preoperative risk factors and postoperative length of stay? From 1987 to 1995, 3872 patients underwent CABG at the Departments of Cardiovascular Surgery of Justus-Liebig University Giessen and German Heart Center Munich. Medical history, preoperative condition, intra-, and postoperative course were recorded for these patients according to the protocol of the German quality assurance program. Preoperative condition of the patient was summarized with an additive risk score. The correlation between postoperative length of stay in the intensive care unit (ICU) and preoperative risk was investigated. For a subgroup of 30 patients, detailed cost analysis was performed and the relationship to preoperative risk examined. For all risk factors examined, a significant increase in prevalence between 1987 and 1995 was observed. A close correlation between preoperative risk and postoperative length of stay in the ICU was found. A similar correlation existed between preoperative risk and actual costs of treatment. In addition, high-risk patients had a significantly higher likelihood of being discharged directly from our ICU to the ICU of other hospitals. Postoperatively, high-risk patients suffer more often from morbidity with subsequent prolonged intensive care and are, therefore, a financial burden for the operating institution in a reimbursement system with fixed rates. This is aggravated by the fact that a trend towards adverse risk profiles among patients undergoing cardiac surgery can be observed. Both factors combined may result in a scenario where those who would benefit most are denied surgical treatment.

Sequence of the new Drosophila melanogaster small heat-shock-related gene, lethal(2) essential for life [l(2)efl], at locus 59F4,5.

In this study, we report the molecular cloning of a novel Drosophila melanogaster small heat-shock (HS)-homologous gene, l(2)efl, identified on the right arm of the second chromosome at locus 59F4,5. We describe the temporal expression of l(2)efl in the wild-type and present its structure. The deduced amino-acid sequence of the Efl protein shows significant homology to all known small HS proteins identified in Drosophila and vertebrates, and to mammalian alpha-crystallin.

Ecogenetic and pharmacogenetic studies in Hungary.

12 population groups of Hungary, 1514 individuals altogether, have been studied for polymorphisms of alpha 1antitrypsin, serum cholinesterase, paraoxonase and delta-aminolevulinic acid dehydrase, N-acetyltransferase variation and aldehyde dehydrogenase deficiency. A possible relationship between their allele frequencies and environmental factors in the context of ecogenetic and pharmacogenetic phenomena in Hungary is discussed.

Factors determining ventricular fibrillation after induced cardiac arrest.

Ventricular fibrillation following release of the aortic cross clamp is not uncommon. In 38 patients undergoing aortic valve replacement we investigated if this disturbance of rhythm is due to perioperative myocardial ischemia or due to deterioration of myocardial function prior to surgery. In all cases hypothermic cardioplegic arrest (Bretschneider) was used. The mean duration of ischemia was 49.39 +/- 10.46 minutes. After release of the aortic cross clamp in 17 of 38 patients ventricular fibrillation occurred. To find out which factors are responsible for the occurrence of ventricular fibrillation we performed a statistical analysis. Thereby we found out that the occurrence of ventricular fibrillation did not correlate with ischemia, the maximal level of myocardium-bound creatine kinase, the NYHA stage, or the left ventricular end diastolic pressure. The left-ventricular concentration of noradrenaline determined just before release of the aortic cross clamp showed a significant negative correlation with the occurrence of ventricular fibrillation. From our results we conclude that ischemic injury was not the determining factor for the occurrence of ventricular fibrillation in our study. We suggest that the significant correlation with reduced myocardial noradrenaline content demonstrates that myocardial deterioration prior to surgery is the determining factor for the occurrence of ventricular fibrillation.

[Pharmacokinetic parameters as criteria for clinical use of hydroxyethyl starch preparations]. / Pharmakokinetische Merkmale als Kriterien für den klinischen Einsatz von Hydroxyethylstärke.

Pharmacokinetic Parameters as Criteria for Clinical Use of Hydroxyethyl Starch Preparations In a study with volunteers (n = 2 x 6) pharmacokinetic data of two only marginally differing starch preparations were investigated. We were able to demonstrate that there exist significant differences in raw materials used which determined the pharmacokinetic data in humans. Newly implemented analyzing methods (LALLS) were used. In addition to the degree of substitution, further differences concerning the position of hydroxyethylization at the anhydroglucose molecule could be documented. The C2/C6 positions of hydroxyethylization at the molecule seem to be most essential. To classify and to differentiate starch preparations we propose to include these data in general informations for clinicians because these differences might determine clinical usage and efficacy.

Beneficial effects of prostacyclin in a rabbit endotoxin shock model.

Thirty rabbits received an infusion of lipopolysaccharide B (75 micrograms/kg.h) over 4 hours (groups E, EI, EA; n = 10 each). Saline was given to a control group (C; n = 8). In group EI, prostacyclin (PGI2; 500 ng/kg.min) was given simultaneously to endotoxin. Into group EA animals, aspirin (20 mg/kg) was injected before the endotoxin infusion was started. PGI2 and aspirin both improved survival of animals (6/10 each vs. 2/10 in group E). The drop of platelet counts was significantly reduced by PGI2, while leukocyte depletion was similar in all endotoxin groups. PGI2 preserved the functional capacity of platelets as indicated by collagen stimulated aggregation and thromboxane formation. PGI2 but not aspirin significantly reduced renal fibrin deposition.

[Effect of particle size and emulsifier on pharmacokinetic values of a parenterally administered fat emulsion]. / Uber den Einfluss von Teilchengrösse und Emulgator auf pharmakokinetische Kenndaten einer parenteral applizierten Fettemulsion.

To evaluate pharmacokinetic data during parenteral application of a fat emulsion a controlled study in healthy volunteers was performed. Another aim of the study was to investigate whether these kinetics could be changed by modification of the emulsion. For this purpose, 10 male medical students--free of any metabolic disorders--received modified batches of one fat emulsion (Lipovenös), differing with respect to particle size or emulsifier. The emulsions were applied using a pump-controlled continuous infusion technique. The dosage was calculated according to body weight: 0.1 g/kg B.W./h. There was a 7-10 day interval between one application and the following study period, again using the same volunteers. Thus every volunteer served as his own control. Routine laboratory parameters as well as parameters relating to fat metabolism were measured. While routine laboratory parameters were not statistically different between the groups, pharmacokinetic data showed differences according to the batches used. Highest triglyceride and free fatty acid levels i.s. were present after application of the emulsion with low medium particle size, while lowest levels were found after increasing the particle size to 380 nm. In addition, it could be documented that an increase in medium particle size resulted in higher elimination rate, transfer and pool size. The modified emulsifier led to an additional increase of these effects, thus inducing beneficial metabolic profiles. The results of the present investigation might perhaps enable us to adjust the profile of future fat emulsions, with the aim of optimizing or restoring metabolic hemostasis.