Intravenöse Immunglobuline bei Multipler Sklerose Studien und Wirkmechanismen – ein Update

There is no doubt about the immunomodulatory capacity of intravenous immunoglobulins (IVIg). This also holds true for multiple sclerosis (MS), where clinical trials have shown a reduction in relapse rate and number of active lesions on MRI after IVIg treatment. Experimental data in the model of murine Theiler's virus encephalomyelitis (TMEV) gave rise to the hypothesis that IVIg may also promote remyelination. Unfortunately, recent trials were unable to demonstrate clinically relevant remyelination in MS patients treated with IVIg. A possible explanation could lie in the fact that IVIg do not influence the function of oligodendrogilial cells in vitro. In contrast, IVIg can protect oligodendrocytes against complement-mediated injury and thus provide more cells that could engage in remyelination. In addition, IVIg can modulate microglial functions in vitro, thus creating a microenvironment permissive for remyelination. Should such mechanisms also be operative in vivo, they would have escaped detection in the treatment protocols used to date. It would appear that IVIg need to be administered while the inflammatory process is still ongoing, whereas the published trials included only patients with a stable deficit when there is probably little or no active inflammation. Despite new studies on IVIg, its role in the management of MS remains elusive.     

Priming summation in the cerebral hemispheres: evidence from semantically convergent and semantically divergent primes

The ability to activate and to maintain a large and relatively undifferentiated semantic field has been thought to be an important component of lexical semantic processing by the right hemisphere (RH). An implication of this unique propensity of the RH was examined in the present study that included two divided visual field priming experiments with SOAs of 800 and 2500 ms. The experiments investigated the ability of the RH and the left hemisphere (LH) to summate activation from multiple primes followed by a laterally presented ambiguous target word. The priming words either converged onto the same semantic representation (i.e. all three words related to either the dominant or to the subordinate meaning of the target) or diverged onto distinct semantic representations (i.e. two words related to the dominant and one to the subordinate meaning of the target, or vice versa). Results indicated that for either an 800 or 2500 ms stimulus onset asynchrony (SOA) the LH benefited most from three semantically convergent primes that converged onto the dominant meaning of the ambiguous target word. There was no facilitation when three subordinate primes preceded the target. When the primes diverged onto different meanings, there was significant facilitation for the 800 ms SOA only. In contrast, with an 800 ms SOA, the RH benefited only from semantically divergent primes, that diverged onto alternate meanings of the ambiguous target word. With a 2500 ms SOA, the RH benefited from all combinations of primes. The discussion focuses on the implications for language processing of the differences between the two hemispheres in the scope and temporal pattern of the multiple prime effect.     

Dysphagia in multiple sclerosis

Objectives: (1) To determine the prevalence of swallowing problems in MS patients and its relation to the overall disability. (2) To define the most frequent symptoms suggestive of dysphagia. (3) To describe the abnormalities on manofluoroscopy (MFS). Methods: Three hundred and eight consecutive MS patients were asked whether they ever had swallowing problems. If so the questionnaire of the Johns Hopkins Swallowing Centre was applied to qualify the dysphagia. A MFS was performed in 30 patients with dysphagia covering the entire spectrum of MS. Overall disability was assessed using the Expanded Disability Status Scale (EDSS). Results: Seventy-three of our 309 patients had permanent dysphagia (24%). Another 5% had a history of transitory swallowing problems only. Permanent dysphagia started to be a problem in mildly impaired patients (EDSS 2–3). Prevalence increased together with rising disability to reach 65% in the most severely disabled subjects (EDSS 8–9). Two alarming symptoms of patients with swallowing problems, coughing or choking during the meal and a history of pneumonia were present in 59%, respectively, 12% of these patients. MFS showed deficiency of the oral phase in all patients, while only the patients with an EDSS higher than 7.5 showed abnormalities of the pharyngeal phase. Conclusions: Permanent dysphagia may already develop in mildly impaired MS patients but becomes a rather frequent finding in MS patients with moderate or severe disability. MFS is a sensitive and useful ancillary examination. Important qualitative changes of the pharyngeal phase on MFS are seen in patients with an EDSS higher than 7.5.     

Growing Region Segmentation Software (GRES) for quantitative magnetic resonance imaging of multiple sclerosis: intra- and inter-observer agreement variability: a comparison with manual contouring method

Lesion area measurement in multiple sclerosis (MS) is one of the key points in evaluating the natural history and in monitoring the efficacy of treatments. This study was performed to check the intra- and inter-observer agreement variability of a locally developed Growing Region Segmentation Software (GRES), comparing them to those obtained using manual contouring (MC). From routine 1.5-T MRI study of clinically definite multiple sclerosis patients, 36 lesions seen on proton-density-weighted images (PDWI) and 36 enhancing lesion on Gd-DTPA-BMA-enhanced T1-weighted images (Gd-T1WI) were randomly chosen and were evaluated by three observers. The mean range of lesion size was 9.9-536.0 mm(2) on PDWI and 3.6-57.2 mm(2) on Gd-T1WI. The median intra- and inter-observer agreement were, respectively, 97.1 and 90.0% using GRES on PDWI, 81.0 and 70.0% using MC on PDWI, 88.8 and 80.0% using GRES on Gd-T1WI, and 85.8 and 70.0% using MC on Gd-T1WI. The intra- and inter-observer agreements were significantly greater for GRES compared with MC ( P<0.0001 and P=0.0023, respectively) for PDWI, while no difference was found between GRES an MC for Gd-T1WI. The intra-observer variability for GRES was significantly lower on both PDWI ( P=0.0001) and Gd-T1WI ( P=0.0067), whereas for MC the same result was found only for PDWI ( P=0.0147). These data indicate that GRES reduces both the intra- and the inter-observer variability in assessing the area of MS lesions on PDWI and may prove useful in multicentre studies.     

Whole-body computed tomography in polytrauma: techniques and management

An interdisciplinary team should be involved in the diagnosis and management of severely injured patients. The adoption of criteria for starting treatment for multiple trauma avoids underestimation of seriousness of injury. These criteria are established by the circumstances of the accident, the patterns of trauma, and the vital findings. Basic diagnosis comprises a limited number of plain films in the trauma room, including supine chest, lateral cervical spine, and pelvis, and ultrasound of abdomen, pleura, and pericardium. Organ diagnosis using CT is complementary and depends on the clinical findings and findings from the basic investigations. We recommend spiral CT (skull base 2/2/4 mm, cerebrum 8/8/8 mm native) and after intravenous contrast medium thoracic (5/7.5/5 mm) and abdominal CT (8/12/8 mm). Image reconstruction of bony structures can be added. The CT and the trauma center should be in close proximity; time-consuming transfers must be avoided. If this is not possible, a CT can be integrated in the trauma room. Our hospital trauma registry contains over 2200 entries. A quality committee has been established and external quality control is implemented.     

Evaluation of Gd-enhancement in brain MR of multiple sclerosis: image subtraction with and without magnetization transfer

The aim of our study was to test the possibility of using image subtraction in detecting enhancing lesions in brain MR scans with and without magnetization transfer (MT) in multiple sclerosis (MS). Ten MS patients underwent 1.5-T MR imaging of the brain with spin-echo T1-weighted sequences with and without MT, repeated after 0.1 mmol/kg of an usual two-compartment paramagnetic contrast agent (Gadoteridol, Gd-HP-DO3A). Precontrast images were subtracted from postcontrast. Enhancing lesions were counted on the postcontrast images only (post-Gd), comparing pre- and postcontrast images by direct visual control (pre/post-Gd), and on the subtracted images (SI) only. Without MT, 36 enhancing lesions were counted on post-Gd, 36 on pre/post-Gd, and 59 on SI; using MT, 69, 52, and 50, respectively. Significant differences were found for pre/post-Gd without MT vs SI without MT ( p=0.028) and vs pre/post-Gd with MT ( p=0.012) as well as for pre/post-Gd with MT vs post-Gd with MT ( p=0.028). With pre/post-Gd, MT allowed the detection of 1.6 enhancing lesions per patient more than without MT. Whereas the SI without MT allow the detection of an increased number of enhancing lesions, SI with MT do not. An off-site final assessment allowed calculation of sensitivity and positive predictive value as follows: without MT were 63 and 94% (post-Gd), 67 and 100% (pre/post-Gd), 96 and 88% (SI); and with MT were 93 and 73% (post-Gd), 96 and 100% (pre/post-Gd), 91 and 98% (SI), respectively. Thus, SI seem to increase the sensitivity without MT; moreover, they could be used to correct the pseudoenhancement that impair post-Gd images with MT.     

慢性萎缩性胃炎癌前病变病理演变与中医证型的相关性*

【目的】探讨慢性萎缩性胃炎癌前病变的病理演变与中医证型的相关性。【方法】将内镜和病理检查确诊为慢性萎缩性胃炎（CAG）伴异型增生（Dys）和／或肠上皮化生（IM）的106例患者，辨证分型为3组，观察各中医证型中度以上的萎缩、肠化及异型增生情况。【结果】阴虚有热型和气阴两虚型组中度以上CAG及伴有中度和熏度IM与Dys者，较血瘀热毒型组明显增多，有显著性差异。重度CAG及伴有重度IM与Dys者中，气阴两虚型较血瘀热毒型和阴虚有热型明显增多，有非常显著性差异。【结论】其发病早期多属于血瘀热毒；发病中期多属于阴虚有热；发病后期则属于气阴两虚：其病理演变与中医证型存在一定的关系。     

多发伤伴休克预后高危因素分析

目的探讨影响多发伤伴休克患者预后的某些高危因素。方法回顾性分析我院中心ICU收治的40例多发伤伴休克病人临床资料,根据患者的预后分为死亡组与存活组,观察早期血糖、APACHEⅡ评分、休克持续时间等3个因素对多发伤伴休克患者预后的影响。结果死亡组早期血糖、APACHEⅡ评分、休克持续时间高于存活组(P<0.01),颅脑损伤合并多发伤患者病死率高。结论早期血糖、APACHEⅡ评分、休克持续时间均可作为判断多发伤伴休克患者预后有价值的临床指标。     

多发性脑膜瘤的临床和组织学研究

目的：研究多发性脑膜瘤的临床和组织学特点.方法：对39例多发性脑膜瘤的临床资料进行回顾性分析,免疫组化检测孕激素受体（PR）、p53和细胞周期蛋白抗体MIB-1在多发性脑膜瘤中的表达,并与单发性脑膜瘤进行比较.结果：多发性脑膜瘤女性多见,肿瘤的分布较为广泛,大脑半球凸面为好发部位.免疫组化结果显示：PR的表达在多发性脑膜瘤比单发性脑膜瘤强,p53和MIB-1的表达则两者无显著性差异.结论：多发性脑膜瘤的诊断主要依靠影像学资料,其发生学可能与孕激素及其受体有关,单克隆起源的可能性较大.     

影响学校细菌性肠道传染病暴发疫情流行时间的多因素分析

目的了解影响学校内细菌性肠遗传染病暴发疫情流行时间的因素，提出针对性控制对策。方法收集各级疾病预防控制机构对2001—2004年广西发生于学校的55起暴发疫情的调查处理报告和资料并建立数据库，对资料进行流行病学描述并以流行时间为应变量，以病种、学校等级等8个因素为自变量进行多因素逐步回归分析。结果55起暴发疫情中伤末副伤寒31起、细菌性痢疾13起、感染性腹泻11起，流行时间分别为23d、14d和11d，罹惠率在0.25％-34，7％之间；多数发生于城乡结合部和乡镇学校当中（占87.27％），阻高中和初中为主（占81.25％）；水型传播多见（占67．27％）；发现X6（首例与疫情报告时间间隔）、X8（重视程度）、X2（学校等级）、X1（病种）、X7（病例隔离措施）和X5（传播途径）等6个因素进入方程。由此提出了针对性措施。结论及时报告疫情、加强各级领导和部门对疫情的重视程度、及早采取和落实病例的隔离措施是迅速有效控制疫情的关键措施；等级较高的学校发生水型传播引起的伤寒副伤寒暴发疫情时尤要注意加强各项控制措施。