抗原变异可使得多种致病微生物易于逃避宿主免疫应答。表达在感染红细胞表面的恶性疟原虫红细胞表面蛋白1（PfPMP1）与感染红细胞、内皮细胞、树突状细胞以及胎盘的单个或多个受体作用，在黏附及免疫逃避中起关键的作用。每个单倍体基因组var基因家族编码约60种成员，通过启动转录不同的var基因变异体为抗原变异提供了分子基础。

疟原虫var基因转换速率变化导致抗原变异[英]／Paul H, Robert P, Christodoulou Z, et al//Proc Natl Acad Sci U S A

2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC.

https://caltcm.memberclicks.net/assets/documents/acc_aha_chf_2013_guidelines.pdf

2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines

XI. STRATEGIES FOR IMPROVING DIABETES CARE D iabetes is a chronic illness that requires continuing medical care and patient self-management education to prevent acute complications and to reduce the risk of long-term complications. Diabetes care is complex and requires that many issues, beyond glycemic control, be addressed. A large body of evidence exists that supports a range of interventions to improve diabetes outcomes. These standards of care are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, treatment goals, and tools to evaluate the quality of care. While individual preferences, comorbidities, and other patient factors may require modification of goals, targets that are desirable for most patients with diabetes are provided. These standards are not intended to preclude more extensive evaluation and management of the patient by other specialists as needed. For more detailed information, refer to Bode (Ed.): Medical Management of Type 1 Diabetes (1), Burant (Ed): Medical Management of Type 2 Diabetes (2), and Klingensmith (Ed): Intensive Diabetes Management (3). The recommendations included are diagnostic and therapeutic actions that are known or believed to favorably affect health outcomes of patients with diabetes. A grading system (Table 1), developed by the American Diabetes Association (ADA) and modeled after existing methods, was utilized to clarify and codify the evidence that forms the basis for the recommendations. The level of evidence that supports each recommendation is listed after each recommendation using the letters A, B, C, or E.

Standards of Medical Care in Diabetes

Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group.

While respiratory, cardiac, nursing, nutritional, and rehabilitative management are critical in determining outcome in many patients with acute stroke, it is the emergence of several new direct treatment strategies for brain ischemia that has rekindled interest in the intensive management of acute stroke. Because there has been no proven treatment strategy available, a fatalistic or even nihilistic attitude towards acute stroke management has evolved in the medical and general communities. Patients are often admitted for “observation”, “supportive care”, or “physical therapy”. In the past, the major immediate treatment decision often revolved around acute anticoagulation with heparin, and anticoagulation frequently was not started until worsening had actually occurred in hospital. Therapeutic trials of new agents used patient entry times exceeding 24 h from onset, and several studies indicated that only a minority of patients present to their local emergency room within the first several hours after stroke onset. Upon arrival at the hospital there are frequent logistical delays, such as obtaining brain imaging, which impede prompt initiation of therapy. Since the therapeutic window in most patients with evolving brain infarction is probably less than 8 h, perhaps as brief as 2 h in some cases, such delays are not acceptable and must be overcome through aggressive educational programs. The NINDS thrombolytic trial in acute stroke has employed novel quality-management techniques to accelerate patient flow upon arrival at hospital.

Special Aspects in the Treatment of Severe Hemispheric Brain Infarction

Messung von Publikationsleistungen

INTRODUCTION: THE SYNDROME AND ITS PROGNOSIS Early death after acute ischaemic stroke is most frequently caused by space occupying ischaemic brain oedema. With complete middle cerebral artery (MCA) territory infarction, including the basal ganglia, and occasionally additional infarction of the anterior cerebral artery or the posterior cerebral artery territories, the large post ischaemic oedematous infarct may cause mass effect, raised intracranial pressure (ICP), and so herniation and brain death (Hacke et al. 1996; Frank 1995; Ropper 1984; Berrouschot et al. 1998). Clinically, the patients present with dense hemiplegia, head- and eye-deviation, progressive deterioration of consciousness over the first 24–48 h and reduced ventilatory drive. Herniation occurs between day 2 and day 5 after onset. Because older patients tend to have more brain atrophy, this condition is more frequently seen among patients under 60 years of age. Brain oedema formation depends on the size of infarct, location of vessel occlusion

https://pn.bmj.com/content/practneurol/2/3/144.full.pdf

Decompressive Surgery for Malignant Middle Cerebral Artery Territory Infarction

Stroke is a major cause of death and disability, and it consumes a large proportion of health resources. Numerous treatments have been suggested for acute ischemic stroke but so far none has been shown to be effective in large randomized controlled trials. Thrombolytic treatment, which is so effective in acute myocardial infarction, has been evaluated in numerous individual stroke patients and some small pilot studies. Its efficacy now needs to be tested in a large multicenter trial.

Thrombolytic and Antithrombotic Therapy in Acute Ischemic Stroke. Multicenter Acute Stroke Trial — Italy (MAST-I)

PURPOSE OF REVIEW The purpose is to review the results and impact of recent positive studies on endovascular stroke treatment in the context of previous negative trials. RECENT FINDINGS Since October 2014, the results of five randomized controlled multicenter trials on the endovascular stroke treatment as adjunct to conservative treatment (largely including intravenous tissue-type plasminogen activator) versus conservative treatment alone have been published. All of these trials largely used stent retrievers as endovascular device and included patients with proven large vessel occlusion (mostly distal internal carotid or proximal middle cerebral artery (M1), short time windows after stroke onset and mostly small infarctions on initial imaging. Over all there was an overwhelming beneficial effect on outcome measured as shift in the modified Rankin Scale score and independent survival, respectively. Moreover, the rate of adverse events, in particular hemorrhage rate, was not increased. These new findings contrast previous studies on endovascular stroke treatment using mostly first generation nonstent retriever devices, longer time windows and different imaging inclusion criteria, which were overall neutral for patient outcome. SUMMARY Endovascular stroke treatment with stent retrievers is the standard of care in large vessel occlusion. New randomized controlled trials should investigate safety and efficacy in extended indications as advanced time windows or more extensive signs of ischemia on initial imaging. The same applies for new devices apart from stent retrievers.

Werner Hacke

Papers

Special Aspects in the Treatment of Severe Hemispheric Brain Infarction

Messung von Publikationsleistungen

Decompressive Surgery for Malignant Middle Cerebral Artery Territory Infarction

Thrombolytic and Antithrombotic Therapy in Acute Ischemic Stroke. Multicenter Acute Stroke Trial — Italy (MAST-I)

Acute endovascular recanalization: lessons from randomized controlled trials.