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.

Die intraventrikulare Fibrinolyse ist eine experimentelle Therapie intraventrikularer Hamatome zur schnelleren Clearance intraventrikularen Blutes. Wesentliche Komplikationen wurden bisher nicht beobachtet. Wir berichten uber 9 Patienten (7 Manner, 2 Frauen, mittleres Alter 64 J.) mit intrazerebralen Hamatomen mit Ventrikeleinbruch, die wir mit intraventrikularer Infusion mit rt-PA (2–32 mg, mittlere Dosis 17 mg) behandelten. Bei 2 Patienten kam es zu einer mit der Fibrinolyse assoziierten klinisch signifikanten Zunahme des intraventrikularen Blutes; bei einer Patientin wurde die Fibrinolyse deswegen abgebrochen. Andere Komplikationen wurden nicht beobachtet. Bei 8 der 9 Patienten kam es wahrend der Fibrinolyse zu einer raschen und weitgehenden Reduktion des intraventrikularen Blutvolumens. Ein permanenter Shunt wurde bei 2 Patienten notwendig. Wir schliesen, das die intraventrikulare Lyse wahrscheinlich zu einer schnelleren Clearance des intraventrikularen Blutes fuhrt. Eine Shuntanlage wird nicht in jedem Fall verhindert. Die intraventrikulare Fibrinolyse ist eine potentiell gefahrliche Therapie mit dem Risiko von Infektionen und Blutungen.

Fibrinolyse intraventrikulärer Hämatome mit rt-PA

Acute stroke trials are becoming increasingly multinational. Working toward a shared ethical standard for acute stroke research necessitates evaluating the degree of consensus among international researchers. We surveyed all 275 coinvestigators and coordinators who participated in the AbESTT II study (evaluating abciximab vs placebo) about their experience with their local institutional review board (IRB) or equivalent, as well as, about their personal beliefs regarding the ethical aspects of acute stroke trials. A total of 90 coinvestigators from 15 different countries responded to our survey. Among the IRBs represented by the responding coinvestigators, only 18% allowed surrogate consent to be obtained over the phone. Although 52% allowed the participation of subjects with aphasia, only 5% allowed the participation of subjects with neglect/hemi-inattention. The National Institutes of Health Stroke Scale score was deemed adequate to establish decisional capacity based on language by 62% of the coinvestigators and 36% of the IRBs. A belief that IRB regulations cause unnecessary delays and fear in relatives/patients was reported by 67% of coinvestigators, and the belief that granting an exemption from informed consent under specific circumstances is appropriate was reported by 41%. There appears to be considerable international diversity in the ethical priorities and informed consent standards among different IRBs and investigators in stroke research. The stroke community should make an attempt to standardize the consent process used in research. Given the critical nature of the time to treatment in stroke care, these standards should be integrated into current frameworks of clinical care and research. The absence of an ethical consensus can become a barrier to advancing stroke treatment internationally.

Lack of international consensus on ethical aspects of acute stroke trials.

Although at times an incidental finding in asymptomatic patients [1–3], occlusion of the basilar artery (BA) with progressive brainstem symptoms has a poor prognosis: mortality is between 60% and 100% [4–6]. The first successful and angiographically proved recanalization of the BA with urokinase (u-PA) in a young female patient after 4 days of severe brainstem symptoms and consecutive excellent clinical outcome [7] has encouraged others to develop the technique of intraarterial (IA) fibrinolytic therapy in patients with acute vertebrobasilar occlusion [8]. On the basis of anecdotal reports and small uncontrolled studies, the experience with thrombolysis in vertebrobasilar stroke has established two convictions: (1) administration of fibrinolytics such as streptokinase, u-PA, and recombinant tissue plasminogen activator (rt-PA) can recanalize occluded intracranial arteries, and (2) recanalization of the basilar artery is safe, clinically beneficial, and lifesaving in selected cases.

Thrombolytic Therapy of Basilar Artery Occlusion: Preconditions for Recanalization and Good Clinical Outcome

/pdf/the-european-stroke-initiative-eusi-20sh2w4mxs.pdf

The European Stroke Initiative (EUSI)

Let’s admit it, as the principal investigators of two early endovascular stroke therapy cohorts and trials (Basilar artery thrombosis, Hacke et al. (1) and PROACT II, Furlan et al. (2)) we are both biased in favor of endovascular therapy (indeed we are certain it works in some patients). Unfortunately, we are concerned that a promising and powerful treatment approach could be abandoned prematurely because of flaws in recent trial design coupled with reimbursement policies for devices. How is it that we have thus far failed to definitively prove efficacy for such a promising treatment approach? The reasons are complex and include methodological, economic and psychological aspects.

Werner Hacke

Papers

Fibrinolyse intraventrikulärer Hämatome mit rt-PA

Lack of international consensus on ethical aspects of acute stroke trials.

Thrombolytic Therapy of Basilar Artery Occlusion: Preconditions for Recanalization and Good Clinical Outcome

The European Stroke Initiative (EUSI)

(Here comes that) Razors Edge Endovascular stroke therapy: the end, or only the beginning?†