Complete remission of non-HIV collapsing glomerulopathy with deflazacort and lisinopril in an adult patient

Collapsing glomerulopathy is a form of focal segmental glomerulosclerosis that is usually associated with HIV-1 infection, and is characterized by its poor prognosis and almost inevitable progression to end-stage renal disease. Its pathological features include collapsed glomeruli, podocyte hypertrophy and hyperplasia, and pseudocrescents. This case report shows the evolution of a 58-year-old patient with non-HIV idiopathic collapsing glomerulopathy who presented with severe nephrotic syndrome and renal insufficiency and was treated with lisinopril and deflazacort, a synthetic corticosteroid that has shown fewer cosmetic effects and glucose and bone metabolism complications than prednisone. The patient responded with full recovery of renal function and normal range of protein excreted in urine after less than two years of treatment. The patient has not suffered a recurrence of his nephrotic syndrome after three years of steroid withdrawal. There is no proven therapy for collapsing glomerulopathy, and this case highlights an alternative for treating this disease with few secondary effects.     

Challenges and Facilitators to Adoption of a Point-of-Care Electronic Health Record in Home Care

Electronic health records (EHRs), intended to improve the clinical process, are understudied in home care. The researchers assessed clinician satisfaction, informed by workflow and patient outcomes, to identify EHR adoption challenges. The mixed methods study setting was a Philadelphia agency with 137 clinicians. Adoption challenges included: (a) hardware problems coupled with lack of field support; (b) inadequate training; and (c) mismatch of EHR usability/functionality and workflow resulting in decreased efficiency. Adoption facilitators were support for team communication and improved clinical data timeliness. Opportunities for improved adoption included sharing with front-line clinicians EHR data related to patient care and health outcomes.     

Transcranial Magnetic Stimulation for Migraine: A Safety Review

(Headache 2010;50:1153‐1163) Objective.— To review potential and theoretical safety concerns of transcranial magnetic stimulation (TMS), as obtained from studies of single‐pulse (sTMS) and repetitive TMS (rTMS) and to discuss safety concerns associated with sTMS in the context of its use as a migraine treatment. Methods.— The published literature was reviewed to identify adverse events that have been reported during the use of TMS; to assess its potential effects on brain tissue, the cardiovascular system, hormone levels, cognition and psychomotor tests, and hearing; to identify the risk of seizures associated with TMS; and to identify safety issues associated with its use in patients with attached or implanted electronic equipment or during pregnancy. Results.— Two decades of clinical experience with sTMS have shown it to be a low risk technique with promise in the diagnosis, monitoring, and treatment of neurological and psychiatric disease in adults. Tens of thousands of subjects have undergone TMS for diagnostic, investigative, and therapeutic intervention trial purposes with minimal adverse events or side effects. No discernable evidence exists to suggest that sTMS causes harm to humans. No changes in neurophysiological function have been reported with sTMS use. Conclusions.— The safety of sTMS in clinical practice, including as an acute migraine headache treatment, is supported by biological, empirical, and clinical trial evidence. Single‐pulse TMS may offer a safe nonpharmacologic, nonbehavioral therapeutic approach to the currently prescribed drugs for patients who suffer from migraine.     

Inhibitors of dipeptidyl peptidase IV and aminopeptidase N target major pathogenetic steps in acne initiation

Acne is a chronic disease hallmarked by sebaceous hyperplasia, follicular hyperkeratosis, and inflammation. Parallel targeting of these factors is required to treat acne effectively. Inhibitors of dipeptidyl peptidase IV (DP IV) and aminopeptidase N (APN) show strong anti-inflammatory effects on immune cells and therapeutic efficacy in autoimmune disorders. Our investigation focused on the expression and functional relevance of these ectopeptidases in three cell types which exhibit an altered phenotype in early acne lesions. We showed for the first time expression of DP IV and APN on human sebocytes. In the SZ95 sebocyte cell line, the DP IV inhibitors Lys[Z(NO2)]-thiazolidide and Lys[Z(NO2)]-pyrrolidide and the APN inhibitors actinonin and bestatin suppressed proliferation, enhanced terminal differentiation, and slightly decreased total neutral lipid production. The anti-inflammatory and differentiation-restoring cytokine IL-1 receptor antagonist was significantly upregulated in SZ95 sebocytes and the HaCaT keratinocyte cell line in the presence of inhibitors. Furthermore, the inhibitors suppressed proliferation and IL-2 production of Propionibacterium acnes-stimulated T cells ex vivo and enhanced the expression of the immunosuppressive cytokine transforming growth factor-beta1. Our data provide first evidence for a functional role of DP IV and APN in the sebaceous gland apparatus and for their inhibitors, used alone or in combination, as completely new substances possibly affecting acne pathogenesis in a therapeutic manner.     

Nalbuphine by PCA-pump for analgesia following hysterectomy: bolus application versus continuous infusion with bolus application.

The analgesic properties of the partial agonist-antagonist nalbuphine in the postoperative period are well known. When used for patient-controlled analgesia (PCA) the effectiveness of this substance is comparable to that of morphine or tramadol. However, the optimal programme for administration of nalbuphine in PCA-pumps has not been investigated. In particular, the combination of bolus administration vs bolus administration plus continuous basal administration is disputable.We hypothesized that the administration of an extra basal rate of nalbuphine in addition to the patient- triggered bolus administration and supplemental doses of diclofenac when required, would lead to a significant improvement in analgesia, without affecting the differences in vital signs and side effects.After approvement by the institutional ethics committee, 50 female patients (ASA I or II) scheduled for elective hysterectomy were included in a prospective, single-blinded study and randomized either into bolus-continuous (BC-)group (3 mg base rate/h, 1 mg bolus, 20 min lock out) or bolus (B-)group (no base rate, 1 mg bolus, 10 min lock out). During the observation period (up to 24 h postoperative) vital parameters, extent of analgesia (10-step VAS), and vigilance (5-step scale) were registered. Groups were compared by using unpaired Student t-test. A p<0.05 was considered to be significant.No differences were found in demographic data or vital parameters (MAP, PaO2, PaCO2, respiratory rate, heart rate, peripheral SaO2) during the observation period. Vital parameters showed no pathological changes in any group. With an identical rate of requirement for diclofenac (32 and 36%), analgesia in BC-group showed a decrease in VAS from 4.28+/-2.11 to 2.04+/-1.21 and from 3.64+/-2.20 to 2.08+/-0.96 in B-group. Vigilance was only marginally diminished in both groups. No serious side effects were found in either group. The consumption of nalbuphine (mg) was significantly higher in BC-group (70.28+/-13.85 vs. 47.44+/-22.99;p =0.0002) when compared to B-group. Subjective rating of effectiveness by the patients was similar in both groups.The two administration settings of nalbuphine by PCA pump have shown to be equally effective in the treatment of postoperative pain following hysterectomy. However, as the total amount of nalbuphine was significantly lower in B-group, the use of this administration schedule should be encouraged.     

Genetic Heterogeneity in Saliva from Patients with Oral Squamous Carcinomas: Implications in Molecular Diagnosis and Screening

We performed microsatellite analysis at chromosomal regions frequently altered in head and neck squamous carcinoma on matched saliva and tumor samples from 37 patients who had oral squamous carcinoma. The results were correlated with the cytologic findings and traditional clinicopathologic factors to assess the diagnostic and biological potential of these markers. Our data showed that 18 (49%) of the saliva samples and 32 (86%) of the tumors had loss of heterozygosity (LOH) in at least one of the 25 markers studied. In saliva, the combination of markers D3S1234, D9S156, and D17S799 identified 13 (72.2%) of the 18 patients with LOH in saliva (P < 0.001). For tumors, markers D3S1234, D8S254, and D9S171 together identified 27 (84.3%) of the 32 tumors with LOH at any of the loci tested (P < 0.001). Eleven (55%) of the 20 saliva samples with cytologic atypia and seven (35%) of the 17 specimens without atypia had LOH. Significant correlation between LOH in tumor at certain markers and smoking and alcohol use was found. Our results indicate that: 1) epithelial cells in saliva from patients with head and neck squamous tumorigenesis provide suitable material for genetic analysis; 2) combined application of certain markers improves the detection of genetic alteration in these patients; 3) clonal heterogeneity between saliva and matching tumor supports genetic instability of the mucosal field in some of these patients; and 4) LOH at certain chromosomal loci appears to be associated with smoking and alcohol consumption.     

Zur Frage des „Zerfalls” und „Alterns” der Liquorzellen

Ohne ZusammenfassungD 19.