Predictors of Stroke in the Elderly

Abstract. Hypertension, diabetes mellitus, coronary heart disease and cigarette smoking have repeatedly been identified as risk factors for stroke in young and middle-aged individuals. In order to find predicting factors for stroke in the elderly we assessed health characteristics in 55 stroke victims in the age range 65–75 years (mean 70.7±2.7) allocated to our stroke unit at Östra University Hospital in Gothenburg. For comparison we used data from 2009 individuals participating in the ongoing longitudinal population study “70-year-old people in Gothenburg, Sweden”. Among the stroke victims we found a higher prevalence of hypertension (63.5% vs. 27.8%, p<0.001), diabetes mellitus (21.8% vs. 6.2%, p<0.001) and a history of previous myocardial infarction (12.7% vs. 4.8%, p<0.01), thus confirming previous findings. There was no difference with regard to smoking habits (32.7% vs. 27.5%, NS), which is at variance with findings in the young and middle-aged.     

Acute Myocarditis

ABSTRACT In a prospective study, 57 patients with a preliminary diagnosis of myocarditis were investigated. Twenty-four patients were considered to have an acute myocarditis, 14 had a suspected myocarditis, while in 19 patients myocarditis was excluded. Episodes of frequent supraventricular and/or ventricular extrasystoles during hospital stay were seen in 8/24 cases (33%) with myocarditis and in 1/19 cases (5%) without myocarditis. On follow-up 1 month later, no supraventricular extrasystoles were observed in either group. Echocardiographic signs consistent with left ventricular insufficiency were noted in 7/24 cases (29%) with myocarditis, in 1/14 cases (7%) with suspected myocarditis and in no case without myocarditis. With a “routine” serologic test battery covering influenza viruses A and B, adenovirus, Coxsackie virus group B, ECHO viruses, Chlamydia psittaci, Mycoplasma pneumoniae and hemolytic streptococci group A, a possible etiology could be documented in 9/24 cases (38%) with myocarditis and in 4/19 cases (21%) without myocarditis. Enterovirus-specific IgM was detected with solid-phase reverse immunosorbent test (SPRIST) in 12/23 (48%) cases with myocarditis and in 3/16 cases (19%) without myocarditis. In SPRIST-IgM-positive cases, IgM antibodies were detected in 15/20 (75%) of the sera taken on admission. The overall serological results indicated a recent infection in 16/24 cases (67%) with myocarditis and in 5/19 cases (26%) without myocarditis (p < 0.05).     

Acute epiglottitis in children: experiences with tracheotomy and intubation

Acute epiglottitis is one of the most serious and potentially fatal conditions dealt with in paediatric laryngology. The infectious agent is mostly Haemophilus influenzae. An active and planned treatment to secure the airway is necessary to reduce the morbidity and mortality. The ‘watch and wait’ attitude should be abandoned. Tracheotomy or intubation should be performed. Mostly literature today is in favour of intubation. However, both tracheotomy and intubation can be used, and if properly managed the complication rate with both methods is low. This series comprised 102 children of whom 79 were tracheotomized and 23 were intubated. No differences could be found between intubation or tracheotomy time (2.3 and 2.9 days respectively) or in hospital stay (6.7 and 6 days). The complication rate was low in both groups except for subcutaneous and mediastinal emphysema in the tracheotomy group but these did not cause any serious problems.     

Design and Objectives of the Evaluation of Oral Xemilofiban in Controlling Thrombotic Events (EXCITE) Study

Clinical trials have demonstrated the efficacy of glycoprotein (GP) IIb/IIIa antagonists in preventing the thrombotic end points of death, myocardial infarction, and urgent revascularization when they are administered at the time of percutaneous coronary revascularization (PTCR). It has been postulated that prolongation of receptor blockade beyond acute intervention would extend the clinical benefit of these agents. The Evaluation of Oral Xemilofiban in Controlling Thrombotic Events (EXCITE) study was a multicenter, international, randomized placebo-controlled trial of the oral GP IIb/IIIa antagonist Xemilofiban administered prior to and after PTCR. The study was designed to assess the efficacy and safety of continuing oral xemilofiban for 6 months to prevent these primary thrombotic end points. More than 7,200 patients were randomized in 29 countries to receive placebo or one of two doses of xemilofiban. Stenting was performed at the discretion of the operator. All patients received aspirin and periprocedural heparin; all stented patients received continuous xemilofiban, or ticlopidine for 2–4 weeks followed by xemilofiban-placebo. Most patients were also evaluated 1 month after conclusion of the study drug treatment. Clinical data from up to 6 months of drug treatment and 1 month posttreatment were used to evaluate the acute and long-term efficacy and safety of xemilofiban. Secondary end points included the need for any revascularization, repeat hospitalization for unstable angina, and nonhemorrhagic stroke. The cumulative incidence of bleeding events and effects of xemilofiban in stented and nonstented patients were evaluated. The efficacy of continuing xemilofiban and aspirin therapy as the sole antithrombotic medications following stent deployment was assessed against a ticlopidine and aspirin control group. The incremental clinical benefit of long-term receptor blockade over acute receptor antagonism was evaluated.     

Economic consequences of occupational disorders in women with repetitive industrial work

Background: In a previous study, we found a three to four timesincrease in sick listing and disability pensioning among 269women in industrial repetitive work, as compared to 290 referentwomen in varied work. Methods: Here, by using an economic model,we estimated the costs for society of the work-environment dysfunctionsin the industrial group. Results: The costs for disability pensionsin the exposed group were 38.8 kSEK per person year at riskand for sick-leave 27.2 kSEK per person year, while the directcosts for health care were 2.2 kSEK per person year. Among referents,the sums were much lower: 5.6 kSEK per person year for disabilitypensions and 7.9 kSEK per person year for sick-leave and costsfor health care were 0.9 kSEK per person year. The costs (lossesin production) per person year of employment were 4.7 timeshigher for the exposed women than for the referents. The differencewas 53, 800 SEK (1 ECU = 8.74 SEK), of which disability pensioningwas 62%, sick-leave 35% and healthcare 3%. The actual transfersin the social insurance system corresponded to 45.1 MSEK amongthe exposed workers, as compared to 9.1 MSEK for the referents.Conclusions: Repetitive industrial work results in huge costs.Hence, preventive and other measures are needed.     

Immune hierarchy among HIV‐1 CD8+ T cell epitopes delivered by dendritic cells depends on MHC‐I binding irrespective of mode of loading and immunization in HLA‐A*0201 mice

Recent human immunodeficiency virus type 1 (HIV‐1) vaccination strategies aim at targeting a broad range of cytotoxic T lymphocyte (CTL) epitopes from different HIV‐1 proteins by immunization with multiple CTL epitopes simultaneously. However, this may establish an immune hierarchical response, where the immune system responds to only a small number of the epitopes administered. To evaluate the feasibility of such vaccine strategies, we used the human leukocyte antigen (HLA)‐A*0201 transgenic (tg) HHD murine in vivo model and immunized with dendritic cells pulsed with seven HIV‐1‐derived HLA‐A*0201 binding CTL epitopes. The seven peptides were simultaneously presented on the same dendritic cell (DC) or on separate DCs before immunization to one or different lymphoid compartments. Data from this study showed that the T‐cell response, as measured by cytolytic activity and γ‐interferon (IFN‐γ)‐producing CD8⁺ T cells, mainly focused on two of seven administered epitopes. The magnitude of individual T‐cell responses induced by immunization with multiple peptides correlated with their individual immunogenicity that depended on major histocompatibility class I binding and was not influenced by mode of loading or mode of immunization. These findings may have implications for the design of vaccines based on DCs when using multiple epitopes simultaneously.     

Stepwise comparative status analysis (STEP) - A clinical method for identifying regional brain syndromes in patients with dementia

This paper presents the Swedish translation of stepwise comparative status analysis (STEP), which is a clinical method for identifying regional brain syndromes in dementia, developed by Wallin and colleagues. Added are guidelines with regard to the order in which the items can be assessed and a checklist including those items that require information from relatives or nursing staff to be correctly assessed (such as items connected with the patient's premorbid personality). The analysis is made in three steps, including evaluation of primary, compound, and complex status variables. The primary variables represent single symptoms and signs (for example, memory disturbance, apraxia, and mental slowness). The compound variables represent symptom constellations that suggest damage to certain brain regions (for example, instrumental difficulties). Scores on the presence and intensity of the primary and compound variables form the basis of the evaluation of the complex variables. These represent regional brain syndromes (global, frontal, subcortical, parietal, frontosubcortical, and frontoparietal), among which the one that dominates is identified by means of elimination. STEP can be used in the diagnostic evaluation of suspected dementia. It might also be useful in identifying predementia states.     

Increased p53 immunoreactivity in proliferative inflammatory atrophy of prostate is related to focal acute inflammation

Proliferative inflammatory atrophy (PIA) of prostate has been proposed as a precursor lesion of prostate cancer. The aim of the current study was to evaluate the expression of p53 protein in PIA lesions and to investigate the relationship between p53 staining and Ki‐67, glutathione S‐transferase‐π (GSTP1) and cyclooxygenase‐2 (COX‐2) immunohistochemical expression. The results revealed that p53 nuclear immunostaining appeared in PIA lesions in 2.1±3.4% (mean±SD) of the basal and 0.9±2.3% of the luminal epithelial cells. Both these values were significantly higher than those in normal‐appearing acini (p<0.0001). Increased p53 expression in luminal cells was related to focal infiltration of polymorphonuclear leucocytes. A positive correlation between p53 expression and Ki‐67 was found in COX‐2‐positive PIA lesions (r=0.610, p<0.0001). Half of the p53‐positive epithelial cells expressed diffuse GSTP1 immunostaining in the same lesions. The present study demonstrates an increased p53 expression in PIA lesions, and inflammation, especially acute inflammation, may play a role in the induction of p53 over‐expression, particularly as cells in PIA lesions are known to have a reduced defence against DNA damage.     

L-Ala-substituted rat galanin analogs distinguish between hypothalamic and jejunal galanin receptor subtypes

In order to explore which amino acids or which blocks of amino acids in the 29 amino acid neuropeptide galanin are important for recognition of the endogenous ligand by galanin receptor subtypes present in the jejunum and in the hypothalamus, respectively, we have carried out L-Ala substitutions of individual amino acids or of blocks of amino acids in the rat galanin sequence and examined the binding of the obtained analogs to the rat hypothalamic and jejunal galanin receptor subtypes. This study reveals that the galanin sequence YLLGPH^9–14 is essential for recognition of galanin by both the rat hypothalamic and jejunal galanin receptor subtypes. Substitution of the N-terminal amino acids, GWTL^1–4, leads to total loss of affinity of galanin for both hypothalamic and jejunal galanin receptors. The α-helical C-terminal amino acid (25–29) part of galanin has no greater influence on the affinity of galanin to the hypothalamic galanin receptor subtype. L-Ala substitution of the C-terminal amino acids of galanin KHGLT^25–29 shows, however, that this C-terminal motif is essential for the recognition by the jejunal galanin receptor subtype, whereas amino acids in the middle portion of galanin NSAG^5–8 are of importance for binding to the hypothalamic but not to the jejunal receptor. [Ala^5–8] Galanin thus has a more than 100-fold higher affinity to jejunal receptor than to the hypothalamic receptor, while [Ala^25–29] galanin has a more than 100-fold higher affinity for the hypothalamic than for jejunal galanin receptor subtypes. pH dependence of the galanin binding to these receptor subtypes is also different. © Munksgaard 1997.