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Background: Telemedicine improves access to specialized medical expertise, as required for paroxysmal disorders. The Epilepsy Network Hessen Evaluation (ENHE) is a pilot cross-sectoral teleconsultation network connecting primary neurologists and pediatricians with epilepsy centers in Hessen, a federal German state. Methods: We prospectively and longitudinally evaluated telehealthcare in the ENHE. Participating physicians rated each consultation for satisfaction and impact on further management. The survey was administered at each consultation and 3 months later. Results: We analyzed 129 consultations involving 114 adult and pediatric patients. Their mean age was 34 years (standard deviation: 26, range: 0.1-91 years), 48% were female, and 34% were children and adolescents. The most common consultation requests were co-evaluation of an electroencephalogram (electroencephalogram [EEG]; 76%) and therapeutic (33%) and differential diagnosis (24%) concerns. Physicians transmitted one paraclinical examination on average (range: 1-4), predominantly EEG (85%), followed by magnetic resonance imaging (17%) and written records (9%). Response rates were 72% for the initial and 67% for the follow-up survey. Across respondents, 99% ( n  = 92) were satisfied with the ENHE. Overall, 80% of the consultations contributed to the diagnosis, and 90% were considered helpful for treatment, influencing it in 71% of cases. Seizure frequency had decreased more often (96%) than increased (4%) at 3 months. The initial diagnosis was confirmed in 78% of patients. Discussion: In this pilot teleconsultation network for paroxysmal disorders, diagnostic and therapeutic advice was perceived as helpful. Clinical outcomes were largely positive, suggesting tele-epileptology is viable for paroxysmal (seizure) disorders.

Background and Purpose- Endovascular treatment for large vessel occlusion in ischemic stroke has proven to be effective in large clinical trials. We aimed to provide real-world estimates of endovascular treatment reperfusion rates and functional outcome on a countrywide scale. Methods- Two thousand seven hundred ninety-four patients with large vessel occlusion were included into an investigator-initiated, industry-independent, prospective registry in 25 sites in Germany between June 2015 and April 2018. The primary outcome was the score on the modified Rankin Scale ranging from zero (no symptoms) to 6 (death) at 3 months. Secondary analyses included the prediction of a good outcome (modified Rankin Scale, 0-2). Dichotomized analyses of predictors were performed using logistic regression adjusted for potential confounders. Results- Median age was 75 years (interquartile range, 64-82); median National Institutes of Health Stroke Scale score was 15 (interquartile range, 10-19). Vessel occlusion was in the anterior circulation in 2265 patients (88%) and in the posterior circulation in 303 patients (12%). Intravenous alteplase before endovascular treatment was given in 1457 patients (56%). Successful reperfusion was achieved in 2143 subjects (83%). At 3 months, 854 patients (37%) showed a good outcome; mortality was 29%. There was no difference between anterior and posterior circulation occlusions (P=0.27). Significant predictors for a good outcome were younger age (odds ratio [OR], 1.06; 95% CI, 1.05-1.07), no interhospital transfer (OR, 1.39; 95% CI, 1.03-1.88), lower stroke severity (OR, 1.10; 95% CI, 1.08-1.13), smaller infarct size (OR, 1.26; 95% CI, 1.15-1.39), alteplase use (OR, 1.49; 95% CI, 1.08-2.06), and reperfusion success (OR, 1.69; 95% CI, 1.45-1.96). Conclusions- High rates of favorable outcome can be achieved on a countrywide scale by endovascular treatment. Mortality appears to be greater in the daily routine than otherwise reported by authors of large randomized trials. There were no outcome differences between the anterior and posterior circulation. Clinical Trial Registration- URL: https://www.clinicaltrials.gov. Unique identifier: NCT03356392.

Background: Up to every fourth woman with multiple sclerosis (MS) or neuromyelitis optica spectrum disorder (NMOSD) suffers a clinically relevant relapse during pregnancy. High doses of steroids bear some serious risks, especially within the first trimester of pregnancy. Immunoadsorption (IA) is an effective and more selective treatment option in disabling MS relapse than plasma exchange. Data on the use of IA during pregnancy and breastfeeding are scarce., Methods: In this retrospective multicenter study, we analyzed the safety and efficacy of IA treatment in acute relapses during pregnancy or breastfeeding. The primary outcome parameter - change of acute relapse-related disability after IA - was assessed using Expanded Disability Status Scale (EDSS) and visual acuity (VA) measurements for patients with optic neuritis (ON)., Results: A total of 24 patients were analyzed, 23 with relapsing-remitting MS, and 1 with NMOSD. Twenty patients were treated with IA during pregnancy. Four patients received IA postnatally during the breastfeeding period. Treatment was started at a mean 22.5 [standard deviation (SD) 13.9] days after onset of relapse. Patients were treated with a series of 5.8 (mean, SD 0.7) IA treatments within 7-10 days. Sixteen patients received IA because of steroid-refractory relapse, eight were treated without preceding steroid pulse therapy. EDSS improved clinically relevant from 3.5 [median, interquartile range (IQR) 2] before IA to 2.5 (median, IQR 1.1) after IA, p < 0.001. In patients with ON, VA improved in four out of five patients. Altogether, in 83% of patients, a rapid and marked improvement of relapse-related symptoms was observed after IA with either a decrease of ⩾1 EDSS grade or improvement in VA ⩾20%. No clinically relevant side effect was reported in 138 IA treatments., Conclusions: Tryptophan-IA was found to be effective and well tolerated in MS/NMOSD relapses, both as an escalation option after insufficient response to steroid pulse therapy and as first-line relapse treatment during pregnancy and breastfeeding., Competing Interests: Conflict of interest statement: F Hoffmann has received speaker honoraria and grant support from Bayer Vital, Biogen, DIAMED Medizintechnik, Merz, Genzyme, Grifols, Ipsen, Novartis and Teva. A Kraft has received grant support from Bayer Vital, Boehringer, Ipsen, Novartis and Pfizer. R Klingel and C Fassbender received research grants from Asahi Kasei Medical and DIAMED Medizintechnik. F Heigl received lecture fees from B Braun, Melsungen, DIAMED Medizintechnik and Fresenius Medical Care. J Koehler has reported a professional or personal relationship to Almirall, Bayer, Biogen Idec, Fresenius, Genzyme, Merck Serono, Novartis Pharma, Roche Pharma, Sanofi-Aventis and Teva. L Harms received grant support from Bayer Vital, Biogen, DIAMED Medizintechnik, Genzyme, Merz, Novartis, Roche and Teva. T Kümpfel has received travel expenses and speaker honoraria from Bayer Healthcare, Teva Pharma, Merck, Novartis Pharma, Sanofi-Aventis/Genzyme, CLB Behring, Roche Pharma and Biogen, as well as grant support from Bayer-Schering AG, Novartis and Chugai Pharma. W. Köhler has received speaker honoraria and grant support from Bayer Vital, Biogen, DIAMED Medizintechnik, Merck Serono, Genzyme, Grifols, Ipsen, Novartis, Roche and Teva. A Bayas received personal compensation from Merck, Biogen, Bayer Vital, Novartis, Teva, Roche and Sanofi/Genzyme, and grants for congress trips and participation from Biogen, Teva, Novartis, Sanofi/Genzyme and Merck. G Ellrichmann has received grant support from Biogen, Novartis and Teva. T Slowinski received speaker fees and research grants from DIAMED Medizintechnik. K-H Henn received speaker honoraria from Genzyme, Merck Serono, Beratung Genzyme, Merck Serono, Novartis, Teva, and grant support from Teva, Biogen, Bayer, Merck Serono and Boehringer Ingelheim. S Schimrigk has received grant support and speaker honoraria from Bayer Vital, Bionorica research GmbH, Biogen, DIAMED Medizintechnik, Genzyme, Novartis, Pfizer and Teva. The following authors declare that there is no conflict of interest: J Weinmann-Menke, I Ayzenberg, E Mauch, H Weihprecht, S Ehrlich, C Beuker, H Fritz, M Brand, T Stiegler and J Galle.

The concentrations of sialic acid in the serum of patients with benign and malignant diseases were determined and the criteria of diagnostic validity (sensitivity, specificity, efficiency, likelihood ratio, predictive values) were calculated. The concentrations of sialic acid in sera of patients with benign diseases (median 0.826 g/l, 5. percentile 0.62 g/l, 95. percentile 1.27 g/l, p less than 0.001) and malignant diseases (median 0.90 g/l, 5. percentile 0.67 g/l, 95. percentile 1.48 g/l, p less than 0.001) were significantly higher than those in a population of healthy persons (median 0.62 g/l, 5. percentile 0.52 g/l, 95. percentile 0.78 g/l). In malignant diseases, the serum sialic acid concentrations are significantly higher (p less than 0.005) than those in benign diseases. In the group of benign diseases marked increases were seen in patients with rheumatoid arthritis and collagenoses (median 1.03 g/l) and infectious-inflammatory diseases (median 0.97 g/l). In the group of malignant diseases increases were seen in cases of gastrointestinal carcinomas (median 1.1 g/l), bladder tumours (n = 2, 1.12 g/l, 1.08 g/l) and carcinoma of the uterus (median 1.0 g/l). The sensitivity at a decision limit of 0.78 g/l for benign diseases is 0.68, for malignant diseases 0.83 and for both categories 0.71. The specificity for benign diseases is 0.94, for malignant diseases 0.32, for both categories 0.94. For benign diseases, the positive predictive values at a decision limit of 0.78 g/l are 0.55 and 0.72 (given prevalences 0.1 and 0.2, respectively); for malignant diseases, 0.11 and 0.23 (prevalences 0.1 and 0.2); for both categories 0.77 and 0.88 (prevalences of 0.1 and 0.2).(ABSTRACT TRUNCATED AT 250 WORDS)

The enzymatic determination of sialic acid, commercially introduced recently as an end point method, has been considerably improved by the development of initial rate and peak rate modifications of the kinetic method, respectively, and adapted to a centrifugal analyser (Cobas Bio). The assay is completed within 3 min, takes 3 microliter sample volume and is reduced to a total reaction volume of 153 microliter. The costs per test thereby are lowered to about 10% of the original procedure. Within-run and day-to-day imprecisions (means = 0.81 g/l) are 2% and 3.9%, respectively; inaccuracy is between +1% and -2%. The detection limit is 0.012 g/l, i.e. about 3 times higher than that of the thiobarbituric acid method (0.0037 g/l) for sialic acid determination. The enzymatic-kinetic assay correlates well with the latter method (r = 0.973). There was no measurable interference by EDTA (less than 3 mg/l), bilirubin (less than 160 mumol/l), haemolysis (haemoglobin less than 5.25 g/l), or triglycerides (less than 3.50 g/l). The reference range (2.5th to 97.5th percentile) for sialic acid in sera of adults is 0.51 to 0.84 g/l (median 0.63 g/l) with no significant sex-related differences. The reference range for sialic acid in spontaneous urine samples is 0.01-0.13 g/l.