Peter Költringer

Lipoprotein(a) in ischemic cerebrovascular disease A new approach to the assessment of risk for stroke

We estimated the serum levels of lipoprotein(a) [Lp(a)] of 87 patients suffering from ischemic cerebrovascular disease (ICVD) (50 men, 37 women; mean age, 66.7 f 10.9 years; median, 66) and of 66 healthy controls (33 men, 33 women; mean age, 62.2 k 11.1; median, 63). The Lp(a) serum levels of the ICVD group (mean, 20.5 k 23 mg/dl; median, 9.5) were significantly elevated compared with those of controls (mean, 14.2 k 23.1 mg/dl; median, 5). In a smaller submouu, limiting the age range to 30 to 60 vears. I. the difference in the Lp(a) serum levels between the ICVD patients and the controls was even highly significant (p < 0.001).We estimated the serum levels of lipoprotein(a) [Lp(a)] of 87 patients suffering from ischemic cerebrovascular disease (ICVD) (50 men, 37 women; mean age, 66.7 +/- 10.9 years; median, 66) and of 66 healthy controls (33 men, 33 women; mean age, 62.2 +/- 11.1; median, 63). The Lp(a) serum levels of the ICVD group (mean, 20.5 +/- 23 mg/dl; median, 9.5) were significantly elevated compared with those of controls (mean, 14.2 +/- 23.1 mg/dl; median, 5). In a smaller subgroup, limiting the age range to 30 to 60 years, the difference in the Lp(a) serum levels between the ICVD patients and the controls was even highly significant (p less than 0.001).

Prevalence of autoimmune thyroiditis and non-immune thyroid disease in multiple sclerosis.

Abstract. Since multiple sclerosis (MS) and autoimmune thyroiditis (AIT) are presumed to be of autoimmune origin the correlation of these two diseases is of special interest. The aim of this study was to determine whether there are differences in the prevalence of thyroid disease with special emphasis on AIT compared with MS and normal subjects and whether the presence of thyroid disease correlates with disability, disease course, age, and disease duration. 353 consecutive patients with clinically definite MS, without interferon-beta treatment and 308 patients with low back pain or headache were extensively examined for the presence of non-immune or autoimmune thyroid disease. We found a significantly higher prevalence of AIT in male MS patients (9.4 %) than in male controls (1.9 %; p = 0.03). The prevalence of AIT in female MS patients (8.7 %) did not differ from female controls (9.2 %). Hypothyroidism, caused by AIT in almost all cases, showed a tendency to be more severe and more often present in patients with MS. There was no association between relapsing-remitting and secondary progressive disease course of MS and the prevalence of AIT. MS patients with AIT were significantly older but did not differ in disease duration and expanded disability status scale (EDSS). Further studies are warranted, to see if there is a difference in sex-hormone levels between MS patients with and without AIT and healthy controls. Longitudinal studies comparing MS patients with or without AIT could show whether there is an influence of AIT on the disease course or progression.

High-dose olanzapine in Huntington's disease.

The few reports available on olanzapine in Huntingtons disease (HD) are insufficiently documented and/or insufficiently dosed. We describe a 30-year-old woman with genetically confirmed HD who presented with severe chorea. She was not able to eat or dress without help and did not respond to haloperidol; the motor scale of the Unified HD Rating Scale (UHDRS-I) revealed 65 of a possible 124 points. After admission, we treated the patient with a high dose of olanzapine (30 mg daily). The chorea almost ceased in the next 2 days, she was able to eat and walk without assistance (UHDRS-I of 21 points), and fine motor tasks improved, as well as gait and eye movements. This effect lasted for 5 months. We conclude that high-dose olanzapine appears to be useful in grave choreatic attacks.

The impact of geographical, clinical, dietary and radiation-induced features in epidemiology of thyroid cancer

Cancer of the thyroid accounts for less than 1% of all cancers recognised each year, but the incidence is rising. Much of the early work of the epidemiology and aetiology of thyroid cancer was based on the assumption that thyroid cancer can be treated as an entity. The recognition that two distinct types of endocrine cell occur within the thyroid has made it clear that any discussion of the aetiology and epidemiology of thyroid malignancies must take into account the histological classification of these tumours. Moreover, there are difficult problems to be considered when comparing thyroid cancer incidence across tumour registries, because of a lack of standardisation or morbidity data collection, difficulties in histological diagnosis, varying rates of diagnosis of occult papillary carcinoma, and prevalence and techniques of autopsies. So far only a relatively small proportion of thyroid cancer cases can be explained with adequate certainty as regards epidemiology and aetiology. As in cancer in general, the aetiology and epidemiology of thyroid cancer in detail remains unknown in the majority of cases.

Pramipexole ameliorates neurologic and psychiatric symptoms in a Westphal variant of Huntington's disease.

Levodopa is recommended as a therapeutic approach for patients with the hypokinetic-rigid, Westphal variant of Huntingtons disease, but no guidelines are available for the case of nonrespondence to levodopa. In this study, however, we report a 34-year-old woman with this rare variant who showed a clear-cut improvement in motor function and depressive symptoms after treatment with pramipexole, a new dopamine agonist.

Autonomic nervous function assessment using thermal reactivity of microcirculation

There are only a few reliable objective methods of diagnosing peripheral neuronal damage suitable for routine use; the most important is based on measurement of nerve conduction velocity, which only shows changes when severe disturbances are already present. However, it is precisely at this stage that the possibilities of therapy are no longer satisfactory. As small fibres are affected earlier in the course of most forms of PNP than the large ones, assessment of afferent as well as efferent C-fibre function gains importance in the management of this widespread disease. In assessment of autonomic dysfunction, variability of the heartbeat with deep breathing or the Valsalva manoeuvre is a good and generally accepted test, although not strongly associated with other PNP test abnormalities. However, axonal degeneration starts in the most distal parts of the axon due to impaired axonal transport. Therefore, the longest C-fibres, i.e. in the lower extremities, are affected first, and incipient changes are most prominent there. For this reason HLDF, a reflex response of the skin blood flow stimulated by heat, has advantages in assessment of early C-fibre dysfunction. Considering the fact that the afferent and efferent sympathetic C-fibres are involved in regulation of microcirculation, the skin blood flow regulation is investigated by means of laser Doppler flowmetry. The microcirculation is stimulated by heat and the reaction of microcirculation is assessed as a value for the function of afferent and efferent (sympathetic) C-fibres. The results of this method are in close correlation with electrophysiologic tests, which is not achieved with sudomotor function.

Zolpidem in progressive supranuclear palsy

often well tolerated, whereas high doses are rarely helpful and may impair motor function, such as swallowing, and cognitive function (Calabrese, 1973; Login et al., 1982). No enduring therapeutic benefit has been reported so far, but recently anectotical reports on the atypical neuroleptic olanzapine give reason to hope in HDassociated psychosis and slight choreatic conditions (Dipple, 1999; Grove et al., 2000). In our view, it also seems to be useful in grave chorea. Moreover, we suggest to add a neuroprotection as is performed in other neurodegenerative disorders like Alzheimer’s disease or Parkinson’s disease. Riluzole is a neuroprotective agent (Urbani & Belluzzi, 2000), which seems to have a proper ameliorative effect on activities of daily living and total functional capacity in HD for some months (Rosas et al., 1999; Seppi et al., 2001). We present two patients: the first, a 59-year-old woman with genetically confirmed HD of 12 years duration was hospitalized because of continuous worsening of her motor abilities. She was not able to walk or eat without help, she could not dress or undress without help. The motor scale of the Unified HD rating scale (UHDRSm) (Huntington Study Group, 1996) revealed 78 of 124 points. The patient was treated with olanzapine (20 mg daily) and her motor function improved significantly, especially the subscores of the fine motor tasks and the chorea (UHDRSm 41 points). After 2 weeks of treatment with olanzapine, riluzole (50 mg/twice a day) was added for neuroprotection and a further slight improvement was seen in the next 2 weeks without additional side-effects (UHDRSm 34 points). The second patient, a 28-year-old man with genetically confirmed HD of 3 years duration presented with an UHDRSm of 43/124 points (mainly oculomotoric function, fine motor tasks, chorea). We treated with 5 mg olanzapine daily and the patient showed a clear improvement (UHDRSm 23 points). After 2 weeks of treatment with olanzapine, riluzole (50 mg/twice a day) was added and a further slight improvement (especially in the fine motor tasks) was seen in the next 2 weeks without additional side-effects (19 points). The patient did not complain of any adverse effects. In summary, severe chorea in HD may be treated effectively and without significant side-effects with a combination of high dose olanzapine and riluzole. In the future, minocycline may be an alternative option for neuroprotection (Chen et al., 2000).

THE EFFECT OF D‐ VERSUS L‐ PROPRANOLOL IN THE TREATMENT OF HYPERTHYROIDISM

The purpose of this study is to determine whether there is a difference in treatment of hyperthyroidism using either the D‐ or L‐isomer of propranolol. Two groups of 20 patients with overt hyperthyroidism received either 120 mg L‐or D‐propranolol each for a period of 5 days. In the D‐propranolol administered group there was a significant decrease in TT3 and f T3 plasma levels and in the ratio of TT3 to TT4; however, a significant increase occurred in rT3 values up to day 5. On the other hand, L‐propranolol treatment resulted in a less pronounced decrease in TT4 and TT3 values, while all other thyroid hormone levels remained unchanged as, above all, did the T3/T4 ratio. The well known effect of D,L‐propranolol upon peripheral conversion of T4 to T3 is thus not due to the beta‐blocking action of L‐propranolol but is mainly conditioned by the D‐isomer which has no beta‐blocking action itself.

Misinterpretation of iodine uptake in papillary thyroid carcinoma and primary lung adenocarcinoma

SummaryThis is the first case report of an iodine-storing metastasising carcinoma of extrathyroidal origin and the simultaneous presence of a papillary thyroid carcinoma. In the course of the disease, an increase in pathological iodine uptake was observed after repeated iodine-131 ablation, so that the original tentative diagnosis of a metastasising, differentiated thyroid carcinoma appeared to be confirmed; moreover, the histological work-up of a femur metastasis — without adequate immunohistochemical assessment — was misinterpreted. What is also remarkable about this case report is a pathological iodine-131 uptake both in the extrathyroidal primary tumor and the metastases.

Cerebrovascular disease and Lp(a): its role in atherosclerotic plaque formation and vessel wall elasticity of the carotid arteries

Lp(a) was found to represent an independent risk factor of extracranial carotid atherosclerosis (CA). Here we report on an investigation with 808 subjects randomly selected from stroke patients as well as from asymptomatic subjects. Serum levels of Lp(a), total cholesterol (TC), HDL-C and the ratios of TC/HDL-C and LDL-C/HDL-C correlated highly significantly with the carotid score using a univariate test. Performing a discriminant analysis, the following ranking was obtained: Lp(a), HDL-C, LDL-C/HDL-C. Evaluation of the vessel wall elasticity in 746 subjects revealed Lp(a) to be the only highly significant parameter. Thus, Lp(a) has to be taken into consideration when establishing a risk profile of CA.