[Plain abdominal radiograph - is there any additional clinical value based on the supine projection?]

BACKGROUND

To assess the diagnostic value of an additionally acquired plain abdominal radiograph in supine position.

MATERIALS AND METHODS

Two experienced radiologists evaluated retrospectively 2148 consecutive patients having plain abdominal radiographs acquired in a tertiary care center. There were 1385 patients having an erect view and 763 patients with a left lateral decubitus view. All patients had a second examination in supine position. First the radiographs in erect or decubitus view were evaluated regarding the presence and details of pathological changes. After 4 weeks all radiographs including the supine view were evaluated again. Next to pathological changes the additional value of the supine projection was assessed. The results were compared and the additional diagnostic value using the supine view was noted.

RESULTS

We evaluated 2148 patients having a plain abdominal radiograph (1325 men, 823 women, mean 58.9 years, range 15-96 years). The average age within the group acquired with left decubitus view was 61.1 years, while patients having an erect view had a mean age of 57.0 years. For the first evaluation we found pathological changes in 10.5% (decubitus view: 13.1%, erect view 9.5%; p = 0.01). The most frequent diagnosis was ileus (7.7%) followed by abdominal free air (2.4%). The results were confirmed during the second reading in 99.2%. In 3.5% (decubitus view 5.8%, erect view 2.2%) more anatomical structures were depicted considering the supine projection and the decubitus/erect projections. The anatomical information was in no case relevant for the diagnosis.

CONCLUSION

Having the information of an supine view additionally to an decubitus/erect view increases the depiction of anatomical structures up to 5.8%. Nevertheless there was no additional diagnostic relevant information based on the supine view.

Exome sequencing identifies mitochondrial alanyl-tRNA synthetase mutations in infantile mitochondrial cardiomyopathy

Infantile cardiomyopathies are devastating fatal disorders of the neonatal period or the first year of life. Mitochondrial dysfunction is a common cause of this group of diseases, but the underlying gene defects have been characterized in only a minority of cases, because tissue specificity of the manifestation hampers functional cloning and the heterogeneity of causative factors hinders collection of informative family materials. We sequenced the exome of a patient who died at the age of 10 months of hypertrophic mitochondrial cardiomyopathy with combined cardiac respiratory chain complex I and IV deficiency. Rigorous data analysis allowed us to identify a homozygous missense mutation in AARS2, which we showed to encode the mitochondrial alanyl-tRNA synthetase (mtAlaRS). Two siblings from another family, both of whom died perinatally of hypertrophic cardiomyopathy, had the same mutation, compound heterozygous with another missense mutation. Protein structure modeling of mtAlaRS suggested that one of the mutations affected a unique tRNA recognition site in the editing domain, leading to incorrect tRNA aminoacylation, whereas the second mutation severely disturbed the catalytic function, preventing tRNA aminoacylation. We show here that mutations in AARS2 cause perinatal or infantile cardiomyopathy with near-total combined mitochondrial respiratory chain deficiency in the heart. Our results indicate that exome sequencing is a powerful tool for identifying mutations in single patients and allows recognition of the genetic background in single-gene disorders of variable clinical manifestation and tissue-specific disease. Furthermore, we show that mitochondrial disorders extend to prenatal life and are an important cause of early infantile cardiac failure.

Do mitochondrial mutations cause recurrent miscarriage?

The cause of recurrent miscarriage (RM) can be identified in approximately 50% of cases, whereas in others, unknown genetic factors are actively being sought. As mitochondrial functions, and therefore also the mitochondrial genome [mitochondrial DNA (mtDNA)], have an important role in human development, through ATP production and participation in apoptosis, we aimed to study the role of mtDNA variations in RM. We screened 48 women with RM and 48 age-matched control women for heteroplasmic mitochondrial mutations using denaturing high performance liquid chromatography, a sensitive method that can detect approximately 5% heteroplasmy. As a result, we detected a heteroplasmic mtDNA variation in 13 RM women (27%) and in 9 control women (19%). Seven synonymous and five non-synonymous changes were detected within coding regions. In addition, seven heteroplasmic variations were detected within the non-coding control region. We were also able to show the presence of the variations in eight placental samples from three heteroplasmic women. In three of these cases, the proportion of variant mtDNA was higher in the placenta compared with that in the mother. We conclude that our sensitive methodology revealed a higher frequency of samples with heteroplasmic variations than expected in women with both RM and controls. However, no apparent increased frequency of heteroplasmic mtDNA variations or amounts of aberrant mtDNA was detected in the RM group. In addition, none of the detected variations were previously known to be pathogenic and therefore they are an unlikely cause of miscarriage.

Thymidine kinase 2 defects can cause multi-tissue mtDNA depletion syndrome

Mitochondrial DNA depletion syndrome (MDS) is a severe recessively inherited disease of childhood. It manifests most often in infancy, is rapidly progressive and leads to early death. MDS is caused by an increasing number of nuclear genes leading to multisystemic or tissue-specific decrease in mitochondrial DNA (mtDNA) copy number. Thymidine kinase 2 (TK2) has been reported to cause a myopathic form of MDS. We report here the clinical, autopsy and molecular genetic findings of rapidly progressive fatal infantile mitochondrial syndrome. All of our seven patients had rapidly progressive myopathy/encephalomyopathy, leading to respiratory failure within the first 3 years of life, with high creatine kinase values and dystrophic changes in the muscle with cytochrome c oxidase-negative fibres. In addition, two patients also had terminal-phase seizures, one had epilepsia partialis continua and one had cortical laminar necrosis. We identified two different homozygous or compound heterozygous mutations in the TK2 gene in all the patients: c.739 C s -> T and c.898 C -> T, leading to p.R172W and p.R225W changes at conserved protein sites. R172W mutation led to myopathy or encephalomyopathy with the onset during the first months of life, and was associated with severe mtDNA depletion in the muscle, brain and liver. Homozygosity for R225W mutation manifested during the second year of life as a myopathy, and showed muscle-specific mtDNA depletion. Both mutations originated from single ancient founders, with Finnish origin and enrichment for the new R172W mutation, and possibly Scandinavian ancestral origin for the R225W. We conclude that TK2 mutations may manifest as infantile-onset fatal myopathy with dystrophic features, but should be considered also in infantile progressive encephalomyopathy with wide-spread mtDNA depletion.

Global transcript profiles of fat in monozygotic twins discordant for BMI: pathways behind acquired obesity

BACKGROUND

The acquired component of complex traits is difficult to dissect in humans. Obesity represents such a trait, in which the metabolic and molecular consequences emerge from complex interactions of genes and environment. With the substantial morbidity associated with obesity, a deeper understanding of the concurrent metabolic changes is of considerable importance. The goal of this study was to investigate this important acquired component and expose obesity-induced changes in biological pathways in an identical genetic background.

METHODS AND FINDINGS

We used a special study design of "clonal controls," rare monozygotic twins discordant for obesity identified through a national registry of 2,453 young, healthy twin pairs. A total of 14 pairs were studied (eight male, six female; white), with a mean +/- standard deviation (SD) age 25.8 +/- 1.4 y and a body mass index (BMI) difference 5.2 +/- 1.8 kg/m(2). Sequence analyses of mitochondrial DNA (mtDNA) in subcutaneous fat and peripheral leukocytes revealed no aberrant heteroplasmy between the co-twins. However, mtDNA copy number was reduced by 47% in the obese co-twin's fat. In addition, novel pathway analyses of the adipose tissue transcription profiles exposed significant down-regulation of mitochondrial branched-chain amino acid (BCAA) catabolism (p < 0.0001). In line with this finding, serum levels of insulin secretion-enhancing BCAAs were increased in obese male co-twins (9% increase, p = 0.025). Lending clinical relevance to the findings, in both sexes the observed aberrations in mitochondrial amino acid metabolism pathways in fat correlated closely with liver fat accumulation, insulin resistance, and hyperinsulinemia, early aberrations of acquired obesity in these healthy young adults.

CONCLUSIONS

Our findings emphasize a substantial role of mitochondrial energy- and amino acid metabolism in obesity and development of insulin resistance.

Stigmatization experience, coping and sense of coherence in vitiligo patients

OBJECTIVE

This study examines the extent of stigmatization experienced by vitiligo patients considering the visibility of the lesions.

METHODS

363 vitiligo patients were assessed using the Experience with Skin Complaints (QES), Adjustment to Chronic Skin Disorders (ASC), and Sense of Coherence (SOC) questionnaires. Out of the total patients group two representative samples with 52 patients each were identified comparable for age, gender, and the duration of the skin disease, the first with visible and the second with invisible lesions.

RESULTS

Data indicate a significant negative correlation between the QES dimensions, except for 'Composure', and between coping scales with sense of coherence withstanding. The 'visible lesions' group scored higher compared to the 'invisible lesions' group on the two QES scales 'Self-Esteem' and 'Refusal', i.e., patients with visible lesions experienced a higher level of stigmatization.

CONCLUSION

This study provides new information which supports the notion that the stigmatization experience of vitiligo patients is psychologically relevant.

A new approach to determining the content and 15N abundance of total dissolved nitrogen in aqueous samples: TOC analyser-QMS coupling

The standard method for determining the 15N abundance of total dissolved nitrogen (TDN) in aqueous samples (e.g., soil leachate, sewage, urine) is currently Kjeldahl digestion followed by steam distillation or diffusion to isolate the ammonium, and then 15N measurement using IRMS. However, this technique is both time-consuming and laborious. One way of overcoming these disadvantages could be to couple a TOC analyser to determine the TDN with a sufficient quadrupole MS to determine the 15N abundance. The high TOC analyser (Elementar Analysensysteme Hanau, Germany), which catalytically oxidises the sample's total nitrogen with a high, constant yield to nitrogen monoxide (NO), appeared particularly suitable. The quadrupole-MS ESD 100 (InProcess Instruments Bremen, Germany) proved to be a suitable mass spectrometer for the 15N determination of NO. This combination of instruments was found to provide a workable method in numerous measurements of standard and actual samples. The detection limit concerning the N amount required per analysis is 2 microg, corresponding to an N concentration of 0.7 mg/l in a maximum sample volume of 3ml. Depending on the N concentration, 15N abundances starting from 0.5 at.% can be measured with the required precision of better than 3% (simple standard deviation). For example, measuring the abundance of 0.5 at.% requires about 50 microg N, whereas for 1 at.% or more only about 5 microg N is needed per analysis.

[Only for limited indications. Biventricular pacemaker improves severe heart failure]

In patients with congestive heart disease in whom left ventricular dilatation is associated with severely disordered contraction due to delayed ventricular conduction, a new form of treatment not requiring drugs is currently becoming established--biventricular pacing. Via an implanted electrode, biventricular stimulation accelerates conduction in the left ventricle and resynchronizes its contraction. Patients being considered for such therapy must have stable stage III disease (NYHA classification) under optimal medication, and a left bundle branch block with a QRS of at least 150 ms. Definitive recommendations with regard to indications will be possible only when current randomized mortality studies have been concluded.

[Clinical symptoms, origin, and therapy of the "pusher syndrome"]

Stroke patients may exhibit the peculiar behavior of actively pushing away from the nonhemiparetic side, leading to lateral postural imbalance and a tendency to fall towards the paralyzed side. These patients use the nonparetic extremities to stem actively against attempts of passive correction towards upright orientation. This phenomenon has been called the "pusher syndrome". Recent findings disclose that the deficit leading to contraversive pushing is an altered perception of the body's orientation in relation to gravity. Pusher patients experience their body as upright when they are actually tilted to the nonhemiparetic side. In contrast, processing of visual and vestibular inputs for the determination of visual vertical was undisturbed. The results argue for a separate pathway in humans for sensing gravity apart from that for perception of the visual world. This second graviceptive system decisively contributes to our control of upright body posture. The present article describes this still largely unknown neurological disease. The clinical examination of contraversive pushing, its underlying disturbance, lesion location, and approaches for therapy are considered.

Exogenous isolation of antibiotic resistance plasmids from piggery manure slurries reveals a high prevalence and diversity of IncQ-like plasmids

Antibiotic resistance plasmids were exogenously isolated in biparental matings with piggery manure bacteria as plasmid donors in Escherichia coli CV601 and Pseudomonas putida UWC1 recipients. Surprisingly, IncQ-like plasmids were detected by dot blot hybridization with an IncQ oriV probe in several P. putida UWC1 transconjugants. The capture of IncQ-like plasmids in biparental matings indicates not only their high prevalence in manure slurries but also the presence of efficiently mobilizing plasmids. In order to elucidate unusual hybridization data (weak or no hybridization with IncQ repB or IncQ oriT probes) four IncQ-like plasmids (pIE1107, pIE1115, pIE1120, and pIE1130), each representing a different EcoRV restriction pattern, were selected for a more thorough plasmid characterization after transfer into E. coli K-12 strain DH5alpha by transformation. The characterization of the IncQ-like plasmids revealed an astonishingly high diversity with regard to phenotypic and genotypic properties. Four different multiple antibiotic resistance patterns were found to be conferred by the IncQ-like plasmids. The plasmids could be mobilized by the RP4 derivative pTH10 into Acinetobacter sp., Ralstonia eutropha, Agrobacterium tumefaciens, and P. putida, but they showed diverse patterns of stability under nonselective growth conditions in different host backgrounds. Incompatibility testing and PCR analysis clearly revealed at least two different types of IncQ-like plasmids. PCR amplification of total DNA extracted directly from different manure samples and other environments indicated the prevalence of both types of IncQ plasmids in manure, sewage, and farm soil. These findings suggest that IncQ plasmids play an important role in disseminating antibiotic resistance genes.

Detection of membrane-bound tumor necrosis factor (TNF): an analysis of TNF-specific reagents

Tumor necrosis factor (TNF) exists in two bioactive forms, the membrane integrated form and the proteolytically derived soluble cytokine. Both forms of TNF are involved in a variety of different physiological and pathophysiological situations. Here we analyzed different human and mouse TNF-specific reagents for their ability to determine the expression of membrane-expressed TNF. The data prove some antibodies to be very useful for the analysis of transmembrane TNF expression because these antibodies distinguish between the transmembrane form of TNF and soluble TNF bound to cellular TNF receptors. In addition, we found that recombinant human TNF receptor fusion proteins are advantageous tools to analyze both human and mouse transmembrane TNF expression.

The tyrosine kinase inhibitor CGP 57148 (ST1 571) induces apoptosis in BCR-ABL-positive cells by down-regulating BCL-X

CGP 57148 is a potent inhibitor of the ABL protein tyrosine kinase and a promising new compound for the treatment of a variety of BCR-ABL-positive leukemias. We used this enzyme inhibitor to characterize the biological effects of BCR-ABL in primary cells and two growth factor-dependent BCR-ABL-transfected cell lines. The effect of CGP 57148 on primary cells is dependent on the stage of differentiation. The growth of maturing chronic myeloid leukemia cells is independent of BCR-ABL in the presence of growth factors. However, the proliferation of leukemic immature cobblestone-forming area cells is almost completely blocked after the inhibition of the BCR-ABL kinase. In the BCR-ABL-transfected cell lines, M07/ p210 and Ba/F3/p185, CGP 57148 induces apoptosis by releasing cytochrome c, activating caspase 3, and cleavage of PARP. No alteration of the expression level of the apoptosis regulator BCL-2 was observed. In contrast, BCL-X was down-regulated after exposure to CGP 57148. Inhibitors of signal transduction proteins such as PI-3 kinase, mitogen-activated protein/extracellular signal-regulated kinase kinase, and Janus-activated kinase 2 pathways were not capable of a comparable down-regulation of BCL-X. The Fas/Fas ligand system was not involved either in the induction of apoptosis by CGP 57148. We conclude that the inhibition of the BCR-ABL kinase by CGP 57148 (a) preferentially inhibits the growth of immature leukemic precursor cells, (b) efficiently reverts the antiapoptotic effects of BCR-ABL by down-regulation of BCL-X, and (c) is more effective than the inhibition of the downstream signal transduction pathways of PI-3 kinase, mitogen-activated protein/extracellular signal-regulated kinase kinase, and Janus-activated kinase 2.

Transport of lipids from golgi to plasma membrane is defective in tangier disease patients and Abc1-deficient mice

Mutations in the gene encoding ATP-binding cassette transporter 1 ( ABC1) have been reported in Tangier disease (TD), an autosomal recessive disorder that is characterized by almost complete absence of plasma high-density lipoprotein (HDL), deposition of cholesteryl esters in the reticulo-endothelial system (RES) and aberrant cellular lipid trafficking. We demonstrate here that mice with a targeted inactivation of Abc1 display morphologic abnormalities and perturbations in their lipoprotein metabolism concordant with TD. ABC1 is expressed on the plasma membrane and the Golgi complex, mediates apo-AI associated export of cholesterol and phospholipids from the cell, and is regulated by cholesterol flux. Structural and functional abnormalities in caveolar processing and the trans-Golgi secretory pathway of cells lacking functional ABC1 indicate that lipid export processes involving vesicular budding between the Golgi and the plasma membrane are severely disturbed.

Surgical versus medical care for postoperative cardiac surgical patients at the general ward

OBJECTIVES

To shorten hospital stay after cardiac surgery, several risk factors have been defined to identify patients who can be discharged early. These risk factors are dependant on the patient; no studies exist on the influence of the treating physician himself on postoperative patient stay.

METHODS

In a university affiliated cardiac surgical clinic we investigated patients who were postoperatively treated either on medical wards with no cardiac surgeon's presence or on a cardiac surgical ward; at both types of wards physicians had several years experience with cardiac surgical patients. Taking several risk factors for postoperative morbidity into account, postoperative length of stay and incidence of wound healing complications have been compared.

RESULTS

Within a 3-month period, 84 patients were treated at the cardiac surgical ward, 102 patients at the medical wards. Risk factors for postoperative morbidity were present in 87% of patients, statistically independent of postoperative wards. Although demographic data and median ICU-stay of both patient groups was comparable, the median post-ICU stay was 9 days at the surgical and 13 days at the medical wards (P < 0.0001). Incidence of wound healing complication was higher (19.6%) at the medical wards than at the surgical ward (10.7%), without reaching statistical significance.

CONCLUSION

As patients at the respective wards were statistically not different, the difference in post-ICU stay, infection and costs must depend on the treating physicians. As a consequence, postoperative care for cardiac surgical patients in all cases should include direct cardiac surgical participation.

[Porokeratosis Mibelli gigantea: case report and literature review]

Porokeratos of Mibelli is a rare inherited disorder of epidermal keratinization, whose pathogenesis is not fully understood. The common clinical feature is a erythematous plaque surrounded by a hyperkeratotic border. The histopathologic hallmark is a parakeratotic cornoid lamella. An unusual case of porokeratosis gigantea, a morphological variant of classical porokeratosis of Mibelli, is reported. The pathogenesis, taking in account especially the clonal hypothesis and premalignant nature of porokeratosis, is discussed.

Detection and characterization of broad-host-range plasmids in environmental bacteria by PCR

Primer systems for PCR amplification of different replicon-specific DNA regions were designed on the basis of published sequences for plasmids belonging to the incompatibility (Inc) groups IncP, IncN, IncW, and IncQ. The specificities of these primer systems for the respective Inc groups were tested with a collection of reference plasmids belonging to 21 different Inc groups. Almost all primer systems were found to be highly specific for the reference plasmid for which they were designed. In addition, the primers were tested with plasmids which had previously been grouped by traditional incompatibility testing to the IncN, IncW, IncP, or IncQ group. All IncQ plasmids gave PCR products with the IncQ primer systems tested. However, PCR products were obtained for only some of the IncN, IncP, and IncW group plasmids. Dot blot and Southern blot analyses of the plasmids revealed that PCR-negative plasmids also failed to hybridize with probes derived from the reference plasmids. The results indicated that plasmids assigned to the same Inc group by traditional methods might be partially or completely different from their respective reference plasmids at the DNA level. With a few exceptions, all plasmids related to the reference plasmid at the DNA level also reacted with the primer systems tested. PCR amplification of total DNA extracted directly from different soil and manure slurry samples revealed the prevalence of IncQ- and IncP-specific sequences in several of these samples. In contrast, IncN- and IncW-specific sequences were detected mainly in DNA obtained from manure slurries.

Characteristic but unfamiliar--the cowpox infection, transmitted by a domestic cat

An 11-year-old girl had been suffering from 2 recently developed reddish ulcerated nodules on the right side of her neck and, concomitantly, from a very hard swelling as well as from painless lymphadenopathy. Subsequently, thick black eschars appeared on the surface of the ulcers. Using the negative staining technique, an orthopox virus infection could be identified by electron microscopy. The patient's characteristic history as well as her close contact with a cat frequently hunting nice indicated the diagnosis of a cowpox infection, which was unequivocally confirmed by identification of both the viral culture and specific antibodies in the serum of the patient.

The IRMM--International Measurement Evaluation Program (IMEP). IMEP-3--trace elements in synthetic and natural water

The aim of the IRMM--International Measurement Evaluation Program (IMEP) is to test out a possible realization of international measurement comparability for field laboratories through traceability of their measurements to the SI Unit for amount of substance: the mole. In IMEP-3, 10 different trace elements, B, Ca, Cd, Cu, Fe, K, Li, Pb, Rb, and Zn, were determined in a synthetic and a natural water by participating laboratories using their routine methods and graphically compared (in coded form) to certified values, established by IRMM and NIST using an isotope-specific method (Isotope Dilution Mass Spectrometry, Neutron Activation Analysis). The number of participants was 70; 64 laboratories have reported results. The results show a spread of more than 50% asymmetrically around the certified value. The Youden graphs allow evaluation of the overall performance of the laboratories in the IMEP-3 round.