Mena/VASP and αII-Spectrin complexes regulate cytoplasmic actin networks in cardiomyocytes and protect from conduction abnormalities and dilated cardiomyopathy

Background

In the heart, cytoplasmic actin networks are thought to have important roles in mechanical support, myofibrillogenesis, and ion channel function. However, subcellular localization of cytoplasmic actin isoforms and proteins involved in the modulation of the cytoplasmic actin networks are elusive. Mena and VASP are important regulators of actin dynamics. Due to the lethal phenotype of mice with combined deficiency in Mena and VASP, however, distinct cardiac roles of the proteins remain speculative. In the present study, we analyzed the physiological functions of Mena and VASP in the heart and also investigated the role of the proteins in the organization of cytoplasmic actin networks.

Results

We generated a mouse model, which simultaneously lacks Mena and VASP in the heart. Mena/VASP double-deficiency induced dilated cardiomyopathy and conduction abnormalities. In wild-type mice, Mena and VASP specifically interacted with a distinct αII-Spectrin splice variant (SH3i), which is in cardiomyocytes exclusively localized at Z- and intercalated discs. At Z- and intercalated discs, Mena and β-actin localized to the edges of the sarcomeres, where the thin filaments are anchored. In Mena/VASP double-deficient mice, β-actin networks were disrupted and the integrity of Z- and intercalated discs was markedly impaired.

Conclusions

Together, our data suggest that Mena, VASP, and αII-Spectrin assemble cardiac multi-protein complexes, which regulate cytoplasmic actin networks. Conversely, Mena/VASP deficiency results in disrupted β-actin assembly, Z- and intercalated disc malformation, and induces dilated cardiomyopathy and conduction abnormalities.

A Visual Analytics Approach to Multiscale Exploration of Environmental Time Series

We present a Visual Analytics approach that addresses the detection of interesting patterns in numerical time series, specifically from environmental sciences. Crucial for the detection of interesting temporal patterns are the time scale and the starting points one is looking at. Our approach makes no assumption about time scale and starting position of temporal patterns and consists of three main steps: an algorithm to compute statistical values for all possible time scales and starting positions of intervals, visual identification of potentially interesting patterns in a matrix visualization, and interactive exploration of detected patterns. We demonstrate the utility of this approach in two scientific scenarios and explain how it allowed scientists to gain new insight into the dynamics of environmental systems.

A Visual Analysis Concept for the Validation of Geoscientific Simulation Models

Geoscientific modeling and simulation helps to improve our understanding of the complex Earth system. During the modeling process, validation of the geoscientific model is an essential step. In validation, it is determined whether the model output shows sufficient agreement with observation data. Measures for this agreement are called goodness of fit. In the geosciences, analyzing the goodness of fit is challenging due to its manifold dependencies: 1) The goodness of fit depends on the model parameterization, whose precise values are not known. 2) The goodness of fit varies in space and time due to the spatio-temporal dimension of geoscientific models. 3) The significance of the goodness of fit is affected by resolution and preciseness of available observational data. 4) The correlation between goodness of fit and underlying modeled and observed values is ambiguous. In this paper, we introduce a visual analysis concept that targets these challenges in the validation of geoscientific models - specifically focusing on applications where observation data is sparse, unevenly distributed in space and time, and imprecise, which hinders a rigorous analytical approach. Our concept, developed in close cooperation with Earth system modelers, addresses the four challenges by four tailored visualization components. The tight linking of these components supports a twofold interactive drill-down in model parameter space and in the set of data samples, which facilitates the exploration of the numerous dependencies of the goodness of fit. We exemplify our visualization concept for geoscientific modeling of glacial isostatic adjustments in the last 100,000 years, validated against sea levels indicators - a prominent example for sparse and imprecise observation data. An initial use case and feedback from Earth system modelers indicate that our visualization concept is a valuable complement to the range of validation methods.

Early functional results after hemiarthroplasty for femoral neck fracture: a randomized comparison between a minimal invasive and a conventional approach

BACKGROUND

A minimal invasive approach for elective hip surgery has been implemented in our institution in the past. It is widely hypothesized that implanting artificial hips in a minimal invasive fashion decreases surgical trauma and is helpful in the rehabilitation process in elective hip surgery. Thereby geriatric patients requiring emergency hip surgery also could theoretically benefit from a procedure that involves less tissue trauma.

METHODS

Sixty patients who sustained a fractured neck of femur were randomly assigned into two groups. In the minimal invasive arm, the so called "direct anterior approach" (DAA) was chosen, in the conventional arm the Watson-Jones-Approach was used for implantation of a bipolar hemi-arthroplasty.Primary outcome parameter was the mobility as measured by the four-item-Barthel index. Secondary outcome parameters included pain, haemoglobin-levels, complications, duration of surgery, administration of blood transfusion and external length of incision. Radiographs were evaluated.

RESULTS

A statistically significant difference (p = 0,009) regarding the mobility as measured with the four-item Barthel index was found at the 5th postoperative day, favouring the DAA. Evaluation of the intensity of pain with a visual analogue scale (VAS) showed a statistically significant difference (p = 0,035) at day 16. No difference was evident in the comparison of radiographic results.

CONCLUSIONS

Comparing two different approaches to the hip joint for the implantation of a bipolar hemi-arthroplasty after fractured neck of femur, it can be stated that mobilization status is improved for the DAA compared to the WJA when measured by the four-item Barthel index, there is less pain as measured using the VAS. There is no radiographic evidence that a minimal invasive technique leads to inferior implant position.

LEVEL OF EVIDENCE

Level II therapeutic study.

Peripartum pain management in opioid dependent women

Increased pain sensitivity and the development of opioid tolerance complicate the treatment of pain experiencedby opioid maintained pregnantwomenduring delivery and the perinatal period. Theaim of the present study was to investigate differences in pain management of opioid maintained compared to nondependent pregnant women during delivery and the postpartum period. 40 deliveries of 37 opioid dependent women enrolled in a double-blind, double-dummy randomized controlled trial (RCT) examining the safety and efficacy of methadone (mean dose at the time of delivery = 63.89 mg) and buprenorphine (mean dose at the time of delivery = 14.05 mg) during pregnancy were analyzed and participants were matched to a non-dependent comparison group of 80 pregnant women. Differences in pain management (opioid and non-opioid analgesic medication) during delivery and perinatal period were analyzed. Following cesarean delivery opioid maintained women received significantly less opioid analgesics (day of delivery p = 0.038; day 1: p = 0.02), NSAIDs were administered more frequently to opioid dependent patients than to the comparison group during cesarean section and on the third day postpartum. Significantly higher nicotine consumption in the group of opioid dependentwomenhad a strong influence onthe retrieved results, and might be considered as an independent factor of altered pain experience. Differences in pain treatment became evident when comparing opioid maintained women to healthy controls. These differences might be based on psychosocial consequences of opioid addiction along with the lack of an interdisciplinary consensus on pain treatment protocols for opioid dependent patients.

Smyd2 controls cytoplasmic lysine methylation of Hsp90 and myofilament organization

Protein lysine methylation is one of the most widespread post-translational modifications in the nuclei of eukaryotic cells. Methylated lysines on histones and nonhistone proteins promote the formation of protein complexes that control gene expression and DNA replication and repair. In the cytoplasm, however, the role of lysine methylation in protein complex formation is not well established. Here we report that the cytoplasmic protein chaperone Hsp90 is methylated by the lysine methyltransferase Smyd2 in various cell types. In muscle, Hsp90 methylation contributes to the formation of a protein complex containing Smyd2, Hsp90, and the sarcomeric protein titin. Deficiency in Smyd2 results in the loss of Hsp90 methylation, impaired titin stability, and altered muscle function. Collectively, our data reveal a cytoplasmic protein network that employs lysine methylation for the maintenance and function of skeletal muscle.

Needs of fathers and mothers of schizophrenia patients

Introduction

Most studies investigating the problems and needs of schizophrenia patients’ carers include only one care-giving relative - mostly the patients’ mothers.

Purpose

The compare needs of mothers and fathers of patients with schizophrenia.

Methods

101 sets of parents of patients suffering from schizophrenia were included in this study. They were assessed by means of the “Carers’ Needs Assessment for Schizophrenia”.

Results

Compared to fathers, mothers reported significantly more often problems concerning stress due to earlier life events and burn-out. Mothers required some interventions such as individual psychoeducation or family counselling more than twice as often than fathers. Overall, mothers reported more problems and needs than fathers. The number of mothers’ problems was predicted by not living with a partner and a shorter duration of the patients’ illness (DUPI). The number of mothers’ needs was predicted by patients’ psychiatric symptoms, not living with a partner and a shorter DUPI. Among fathers we could not identify any predictors, neither for problems nor for needs.

Conclusions

Parents of schizophrenic patients have various problems handling their child's illness and therefore need professional support. Overall, mothers reported more problems and needs for interventions than fathers. The differences between mothers’ and fathers’ problems and needs indicate the importance of considering the carer's gender in clinical work.

Native GABA(B) receptors are heteromultimers with a family of auxiliary subunits

GABA(B) receptors are the G-protein-coupled receptors for gamma-aminobutyric acid (GABA), the main inhibitory neurotransmitter in the brain. They are expressed in almost all neurons of the brain, where they regulate synaptic transmission and signal propagation by controlling the activity of voltage-gated calcium (Ca(v)) and inward-rectifier potassium (K(ir)) channels. Molecular cloning revealed that functional GABA(B) receptors are formed by the heteromeric assembly of GABA(B1) with GABA(B2) subunits. However, cloned GABA(B(1,2)) receptors failed to reproduce the functional diversity observed with native GABA(B) receptors. Here we show by functional proteomics that GABA(B) receptors in the brain are high-molecular-mass complexes of GABA(B1), GABA(B2) and members of a subfamily of the KCTD (potassium channel tetramerization domain-containing) proteins. KCTD proteins 8, 12, 12b and 16 show distinct expression profiles in the brain and associate tightly with the carboxy terminus of GABA(B2) as tetramers. This co-assembly changes the properties of the GABA(B(1,2)) core receptor: the KCTD proteins increase agonist potency and markedly alter the G-protein signalling of the receptors by accelerating onset and promoting desensitization in a KCTD-subtype-specific manner. Taken together, our results establish the KCTD proteins as auxiliary subunits of GABA(B) receptors that determine the pharmacology and kinetics of the receptor response.

Hook plate for medial clavicle fracture

Medial clavicle fractures are the least common type of clavicular fractures. Although rare, such injuries deserve rapid diagnosis and effective treatment to avoid future complications. An optimal, standardized operative treatment has not been yet established. We report a case of medial clavicle fracture, where primary operative treatment was indicated due to gross dislocation. An open reduction and osteosynthesis with a modified hook plate was performed, leading to an excellent postoperative outcome after a sixteen-month follow-up. The hook plate seems to be a promising approach for the operative treatment of medial clavicle fractures.

Deltoid muscular flap transfer for the treatment of irreparable rotator cuff tears

The purpose of this study was to evaluate the outcome of deltoid muscle flap transfer for the treatment of irreparable rotator cuff tears. In a retrospective study 20 consecutive patients were evaluated. The index procedure took place between 2000 and 2003. Fifteen patients were male, mean age was 62 years. Inclusion criterion was a rotator cuff defect Bateman grade IV. Exclusion criteria were smaller defects, shoulder instability and fractures of the injured shoulder. An open reconstruction with acromioplasty and a pedicled delta flap was performed. Follow up period was mean 42 months. Follow-up included clinical examination, Magnetic Resonance Imaging (MRI) and the Constant and Simple (CS) shoulder tests. According to the Constant shoulder test the results were good in 13 patients, fair in 5 and unsatisfactory in 2. The pre-operative Constant Score improved from mean 25.7 points (±5.3) to 72.3 (±7.8) at follow-up. The mean values for the subcategories of CS increased significantly from 3.9 to 14.4 points for pain and from 4.2 to 15.9 points for activities daily routine (p<0.05). The change in range of motion and strength were not significant (p>0.05). Results of the Simple Shoulder Test showed a significant increase of the mean values from pre-operative 4.3 to 14.7 points post-operatively. MRI showed a subacromial covering of the defect in all cases, all flaps where intact on MRI but always the flap showed marked fatty degeneration. In conclusion, the delta flap is a simple method for the repair of large defects of the rotator cuff leading to satisfying medium results.

Sensitivity of crescent-shaped metal nanoparticles to attachment of dielectric colloids

The response of the plasmonic resonances of crescent-shaped nanoparticles to the attachment of a dielectric colloidal particle was investigated. The colloid serves as a model analyte which is easy to handle and allows for benchmarking of the sensing capabilities of plasmonic resonators. A clear red shift of the resonances is observed in agreement with the prediction from numerical simulations. From the response for different colloid positions, we obtain information on the nanoscale near field distribution. A field localization to length scales of 20 nm is proven directly. All resonators under study show a comparable response which is important for possible sensing application. We estimate that a further increase of the sensitivity by a factor of 8 would allow for label-free single biomolecule detection.

Fathers and Mothers of Patients with Schizophrenia

Aims:

To investigate caregiving and its consequences among fathers and mothers of the same patients suffering from schizophrenia.

Methods:

101 patients as well as both parents were investigated using the “Carers' Needs Assessment for Schizophrenia”, the “Beck Depression Inventory”, the “Involvement Evaluation Questionnaire” and the “Family Problem Questionnaire”.

Results:

The mean number of days fathers lived together with the patients was not significant from that of the mothers, but the average duration (hours per week) of contact with the patient was significantly higher for mothers than for fathers. Among 40% of the sample, fathers and mothers spend an equal amount of time caring for the patient. Mothers reported significantly more often problems than fathers concerning stress due to earlier life events and burn-out. Mothers needed some interventions such as individual psychoeducation or family counselling more than twice as often as fathers. Mothers reported overall higher numbers of problems and needs for intervention than fathers. The overall score of caregivers' involvement did not differ significantly between fathers and mothers. The mothers' objective burden was significantly higher than the fathers' objective burden, but parents did not show differences concerning subjective burden. Using the “Beck Depression Inventory”, mothers were more often depressed than fathers.

Conclusions:

This study shows that often fathers and mothers spend an equal amount of time caring for the patient. The differences found between mothers and fathers should be considered when planning services for family caregivers.

Disability in Schizophrenic Disorders

Aims:

The purpose of this study was to investigate disability among patients suffering from schizophrenia and to identify predictors of disability.

Methods:

101 patients from different types of psychiatric services in Vienna and diagnosed with schizophrenia according to ICD-10 were included. They were investigates by means of 36-Item self-administered version of the WHO Disability Assessment Schedule II (WHO-DAS-II) and the PANSS-scale. Patients’ mothers and fathers were asked to fill in the Family Problem Questionnaire.

Results:

The mean total score of the WHO-DAS-II was 74.1 (SD 21.9). When using weighted sub-scores the highest disability scores were found for social contacts, participation in society and household (means 2.58, 2.57 and 2.51 respectively). Using logistic regression, overall disability was positively associated with patient's age, overall severity of symptoms (PANSS) and number of previous hospital admissions. Overall disability was not associated with duration of illness and or patient's gender. The subjective burden experienced by patients’ fathers and mothers were increased by reduced social contacts and impaired participation in society, while we could not find an association with other domains of patient's disability (understanding, mobility, self-care, household).

Conclusions:

This study shows that schizophrenia results in disability in several domains. Family caregivers’ burden was predominantly increased by social consequences of schizophrenia.

Pharmacophilia and pharmacophobia: determinants of patients' attitudes towards antipsychotic medication

OBJECTIVE

To identify factors that influence attitudes towards psychopharmacological treatment in patients suffering from schizophrenia and schizoaffective psychoses.

METHODS

Ninety-two participants in an outpatient psychoeducational program, classed as "pharmacophobic" or "pharmacophilic" according to the Drug Attitude Inventory scale, were compared with regard to sociodemographic variables, clinical characteristics, subjective deficit syndrome, illness concepts, knowledge, locus of control, and quality of life.

RESULTS

The 59 pharmacophilic and the 33 pharmacophobic patients did not differ significantly with regard to most sociodemographic variables, symptoms, or classic personality traits such as locus of control, self-concept, and quality of life. The only differences concerned hospitalization history ( P < 0.05) and statements on the actual, subjective experience of desired and undesired effects of medication ( P < 0.01).

CONCLUSIONS

The impact of subjective experiences with drug treatment on attitudes towards medication and compliance needs to be a main focus of interventions targeting attitudes towards pharmacological treatment.

DaVinci robotic-assisted laparoscopic bariatric surgery: is it justified in a routine setting?

BACKGROUND

Laparoscopic silicone adjustable gastric banding (SAGB) has gained popularity for the surgical treatment of morbid obesity. The implantable gastric stimulator (IGS) system represents a novel surgical alternative. We aimed to assess the feasibility of robotic-assisted laparoscopic bariatric operations and to critically elucidate the technical and financial advantages and patient outcome.

METHODS

Robotic-assisted laparoscopic bariatric procedures were performed on 10 consecutive patients using the daVinci robot system (4 SAGB, 4 IGS, 2 SAGB revisions). 10 conventional laparoscopic-operated patients (4 SAGB, 4 IGS, 2 SAGB revisions) during the learning curve served as controls. Equipment, operative technique and procedural time were evaluated. A cost analysis was calculated.

RESULTS

The personnel equipment, numbers of trocars and operation technique were comparable in both groups. The mean operative time was 137 min (range 110-175) and 97 min (60-140) in robotic-assisted and conventional laparoscopy, respectively (P =0.04). Establishment of the pneumoperitoneum and placement of trocars and robotic arms took a mean of 30 min (15-45) in the robotic-assisted group, compared with 5 min in the control group (P <0.001). In 1 patient, intraoperative gastric injury was suspected and led to band removal in the robotic-assisted group. There was no postoperative complication. Average procedural costs were significantly higher in the robotic-assisted group.

CONCLUSION

Primary and revisional robotic-assisted bariatric surgery is technically simple, with the benefit of precise instrument handling. However, it is still expensive, the set-up of the system is time-consuming, and a limited variety of instruments are available presently.

High-dose tamoxifen and sulindac as first-line treatment for desmoid tumors

BACKGROUND

Desmoid tumors are mesenchymal nonmetastasizing neoplasms. Although rare in the general population, they are a common extracolonic manifestation of familial adenomatous polyposis (FAP). Because of high tumor recurrence rates, surgery has been less than satisfactory in the treatment of desmoid tumors. In the current study, high doses of tamoxifen in combination with sulindac were used to treat severe desmoid tumors to avoid surgery.

METHODS

Since 1992, 25 patients at Heinrich Heine University (Dusseldorf, Germany) were treated with a combination of tamoxifen and sulindac. In the current study, 17 patients with FAP-associated and 8 patients with sporadic desmoid tumors received 120 mg of tamoxifen and 300 mg of sulindac daily. Every 6 months, the protracted course of desmoid growth was measured by computed tomography and/or magnetic resonance imaging scans. Tumor responses were characterized as progressive disease, stable disease (SD), partial regression (PR), and complete regression (CR).

RESULTS

Of the group of patients who received tamoxifen and sulindac as a primary treatment, all three patients with sporadic desmoid tumors demonstrated cessation of growth, and 10 of the 13 patients with FAP-associated tumors achieved either a PR or CR. In the sporadic desmoid tumor group, eight of nine patients developed tumor recurrences after undergoing surgery at other institutions. Of these, two patients had SD and two patients had a PR to CR.

CONCLUSIONS

The patients with desmoid tumors who were managed conservatively with high-dose tamoxifen and sulindac had the best outcome. Desmoid tumor recurrence after surgery was high and in the FAP-associated tumor group, therapy with tamoxifen and sulindac was found to be less successful. Based on this experience, the authors recommended high-dose tamoxifen and sulindac as the primary treatment for patients with FAP-associated desmoid tumors. However, to our knowledge, the best approach after surgical intervention for patients with sporadic desmoid tumors remains to be determined.

[Psychooncological aspects in the care of females in HNPCC families]

HNPCC families are characterized by a genetic predisposition for colorectal and other cancers. In Düsseldorf we pursue an interdisciplinary counselling approach (geneticists, psychologists and surgeons). Apart from the genetic counselling itself, special emphasis is placed on the benefits of surveillance and screening recommendations. In this pilot study we were interested in investigating if the counselled women had understood the increased risk of gynecological cancers and correspondingly underwent the intensified screening modalities. We selected the approach of a telefone interview and encountered broad acceptance for contacting persons this way. Affected women are better compliant to screening recommendations than women at risk. Both groups consider colonoscopy more strainful than gynecological surveillance. A regular transvaginal ultrasound is not performed in some 40 % of at risk women although 2/3 of them see their gynecologist in regular intervals. Given the support of gynecologists a higher rate of transvaginal ultrasound in women at risk should be achievable.

Identification and quantification of phosphatidylethanolamine-derived glucosylamines and aminoketoses from human erythrocytes--influence of glycation products on lipid peroxidation

While the Maillard reaction of amino acids and proteins as well as its consequences in vivo has been thoroughly investigated, little attention has so far been paid to the glycation of aminophospholipids such as phosphatidylethanolamine (PE) or phosphatidylserine (PS), which are essential for structure and functionality of biological membranes. PE-derived glucosylamines (Schiff-PEs) and aminoketoses (Amadori-PEs) have now for the first time been simultaneously identified and quantified in erythrocytes from diabetics and healthy individuals by liquid chromatography-electrospray mass spectrometry (LC-(ESI)MS). The amounts of glycated PE (gPE) were significantly higher in diabetics (0.18-34.2 mol% Schiff-PE and 0.047-0.375 mol% Amadori-PE) than in controls (0.12-3.99 mol% Schiff-PE and 0.018-0.055 mol% Amadori-PE). A positive correlation between fructosylated hemoglobin (HbA(1c)) and the gPE levels was established. No advanced glycation endproducts (AGEs) like 5-hydroxymethylpyrrole-2-carbaldehyde (pyrrole-PE), carboxymethyl (CM-PE), or carboxyethyl (CE-PE) derivatives were detected. To investigate the influence of gPE on lipid peroxidation of biological membranes, liposomes consisting of soy-PE and synthetically prepared Amadori-PE (16:0-16:0) were incubated for several days and the formation of oxidation products was monitored. It could be shown that Amadori-PE extensively promotes lipid peroxidation even in the absence of transition metal ions like Cu(2+) and Fe(3+). Oxidative damage to membrane lipids therefore is supposed to be at least partially caused by the glycation of aminophospholipids.

Neopterin: a prognostic variable in operations for lung cancer

BACKGROUND

We studied the prognostic value of preoperatively measured neopterin to predict survival of lung cancer patients. Neopterin is produced and secreted by interferon-gamma-stimulated monocytic cells. High urinary neopterin concentrations are found in patients with viral infections, allograft rejection episodes, and some malignant diseases. In various tumor types high urinary neopterin concentrations are associated with a worse prognosis.

METHODS

Preoperative neopterin levels of 110 patients (29 women, 81 men) with lung cancer including 7 patients with small cell lung cancer were measured and related to the time of survival after operation. Patients with clinically suspected stage IIIB lung cancer were not operated and therefore not enrolled in this study. Infectious diseases were not apparent at the time of preoperative urine sampling. Median postoperative follow-up period was 17.4 months.

RESULTS

In a univariate analysis, patients with a preoperative neopterin concentration of more than 212 micromol/mol creatinine (4th quartile) were determined to have a significantly lower survival probability. In a multivariate analysis, a neopterin concentration of more than 212 micromol/mol creatinine (p < 0.01) and T-stage status (p < 0.005) were determined to be significantly predictive variables for worse survival prognosis.

CONCLUSIONS

Preoperative neopterin proved to be a reliable prognostic factor for survival. Immunology may provide an accurate assessment of tumor aggression and its clinical behavior. In this sense, neopterin can serve as an immunologically based estimation of malignant outgrowth. In patients who are operable by clinical tumor stage but have a high risk for operation, elevated preoperative neopterin may help in the decision for a nonoperative treatment.

[Paraffinoma--a rare complication following endonasal surgery]

BACKGROUND

Paraffin is a mineral oil which was discovered by Reichenbach in 1830. Injection of paraffin into tissue causes a foreign body reaction that results in the formation of a paraffinoma.

METHODS

We are reporting on two cases of paranasal paraffinomas, in a 30-year-old male three months after a septorhinoplasty in which paraffin nasal packing was used and in a 56-year-old female patient two months after sinus surgery.

RESULTS

A paraffinoma is probably caused by penetration of paraffin through a mucous membrane defect into the adjacent soft tissue. Paraffinomas are usually treated by excision. Although recurrences are frequent, a complete removal should be attempted because of the potential carcinogenicity of paraffin.

CONCLUSION

Paraffinomas must be considered in the differential diagnosis of periorbital or paranasal swellings that occur months after endonasal procedures where paraffin packing was used.

Reflux-induced apoptosis of the esophageal mucosa is inhibited in Barrett's epithelium

BACKGROUND

Apoptosis maintains cell homeostasis. Altered apoptosis is involved in carcinogenesis. It was our aim to investigate whether reflux esophagitis may alter apoptosis in the esophageal mucosa and whether antireflux surgery may restore normal apoptosis.

METHODS

Apoptosis was studied preoperatively and postoperatively in esophageal biopsies of 39 patients with various grades of reflux esophagitis and in Barrett's mucosa using the TUNEL method. Biopsies were also taken from lesions of the squamous epithelium adjacent to the Barrett's mucosa.

RESULTS

Apoptosis increased with the severity of esophagitis. Apoptosis was low in Barrett's epithelium. Squamous epithelium adjacent to Barrett's mucosa showed increased apoptosis. After surgery apoptosis decreased in squamous epithelium, and it remained low in Barrett's epithelium.

CONCLUSIONS

Apoptosis in reflux esophagitis may be protective against increased proliferation. Low apoptosis following antireflux surgery indicates that surgery is effective to prevent reflux-induced cell proliferation. Inhibition of apoptosis in Barrett's may promote carcinogenesis. This may not change following surgery.

Ileal carbohydrates inhibit cholinergically stimulated exocrine pancreatic secretion in humans

CONCLUSION

Ileal inhibitory effects on pancreatic enzyme output are also demonstrable during exogenous, cholinergic stimulation of exocrine pancreatic secretion. These findings support the hypothesis that direct inhibition of cholinergic systems may be involved in the ileal inhibitory effects on pancreatic enzyme secretion. Furthermore, glucagon-like peptide-1 (GLP-1) may play a role in the mediation of the ileum-induced effects.

BACKGROUND

Ileal carbohydrate perfusion inhibits endogenously stimulated exocrine pancreatic secretion in humans. Our aim was to investigate if ileal perfusion of carbohydrates exerts similar effects on exogenously stimulated pancreatic enzyme output, i.e., if the inhibitory mechanisms are reproducible during direct, cholinergic stimulation of the exocrine pancreas. Furthermore, we sought to clarify the role of the potential humoral mediators (GLP-1) and peptide YY (PYY).

METHODS

Eight healthy fasting volunteers were intubated with an oroileal multilumen tube system for aspiration of duodenal juice and perfusion of test solutions. Exocrine pancreatic secretion was stimulated by a continuous i.v. infusion of the cholinergic agonist carbachol. Additionally, the ileum was perfused for 15-min intervals with either carbohydrates (total load: 18 g) or saline as control. Blood samples for determination of GLP-1 and PYY were taken before the beginning of exogenous stimulation and before and after ileal perfusion.

RESULTS

Exogenously stimulated pancreatic enzyme secretion was significantly inhibited by additional ileal carbohydrate perfusion (p < 0.05), whereas ileal saline had no effect. Moreover, plasma levels of GLP-1 increased significantly (p = 0.004) after ileal perfusion of carbohydrates, but not after saline. PYY plasma concentrations remained unchanged after both ileal perfusates.

Enolases are highly conserved fungal allergens

BACKGROUND

Lack of knowledge of the identity of fungal allergens still is a major obstacle for improvement of diagnosis and therapy of allergies to moulds. We have therefore further analyzed the allergens of the two moulds, Alternaria alternata and Cladosporium herbarum and found that enolases (EC 4.2.1.11) are major allergens, at least of the two fungal species just mentioned.

METHODS

The enolases of Alternaria and Cladosporium were cloned from cDNA libraries constructed from vegetative cells of the two moulds by immunological screening with sera from selected patients allergic to the moulds. The two enolases were expressed as recombinant nonfusion proteins and used for determination of the incidence of allergy to enolase among a cohort of patients.

RESULTS

Sequencing of the two enolases showed very close relationships with other known fungal enolase sequences. Competition experiments using immunoblots of the recombinant nonfusion proteins showed nearly complete identity of the epitopes on both enolases. Serum from a patient reactive to Cladosporium enolase reacted equally well with the enolases of Alternaria, Saccharomyces and Candida. About 50% each of the sera from patients reactive to Cladosporium and Alternaria were strongly reactive to the recombinant enolases.

CONCLUSIONS

Enolases are therefore considered to be highly conserved major fungal allergens.

Pain treatment after thoracotomy: is it a special problem?

BACKGROUND

Although it is frequently stated in the literature that thoracotomy is one of the most painful operative incisions, few data supporting this view are available.

METHODS

Patients' postoperative pain experience can be assessed on the basis of their usage of patient-controlled analgesia. In a prospective trial the daily self-administered doses of analgesics in 55 patients within the first 4 days after posterolateral thoractomy were compared with those in 30 patients for the same number of days after median laparotomy. The visual analog scale was used as a second measure to evaluate postoperative pain.

RESULTS

On the basis of patient-controlled analgesia usage on the first postoperative day and the visual analog scale score for the first 2 days, a small but significant difference between the two patient groups was found which showed that thoracotomy is less painful than median laparotomy.

CONCLUSIONS

The common belief that posterolateral thoracotomy is a very painful operative access is not true. Therefore it is not necessary to use special techniques for postthoracotomy pain relief in these patients. Patient-controlled analgesia is sufficient for pain relief after major thoracic or abdominal incisions.

Hypoxia-dependent changes of enzyme activities in different fibre types of rat soleus and extensor digitorum longus muscles. A cytophotometrical study

Using cytophotometry activity changes of succinate dehydrogenase, glycerol-3-phosphate dehydrogenase and myofibrillar adenosine triphosphatase were measured in 3 fibre types of soleus and extensor digitorum longus muscles under normal and experimental conditions. Fibres were typed by means of cytophotometrical data into slow-oxidative, fast-oxidative glycolytic and fast-glycolytic ones. After experimental hypoxia of 20 min duration a significant increase of enzyme activities was observed especially in slow-oxidative and fast-oxidative glycolytic fibres of both muscles, e.g. succinate dehydrogenase activity increased by 21% in these fibres of soleus muscle and by 23-26% in these fibres of extensor digitorum longus muscle. Moreover, an increase of glycerol-3-phosphate dehydrogenase activity by 10% in slow-oxidative fibres and by 28% in fast-oxidative glycolytic fibres and a 10-12% increased ATPase activity in all fibres of extensor digitorum longus muscle were measured. Treatment with Ginkgo biloba extract for 3 months before exposure to hypoxia resulted in increased adenosine triphosphatase activity in all fibres of both muscles and in decreased succinate dehydrogenase activity of slow-oxidative and fast-oxidative glycolytic fibres of extensor digitorum longus muscle. These results could be interpreted as a protective effect of Ginkgo biloba extract.

A novel application of a competitive binding model in dioxin risk assessment

The EPA-recommended toxicity equivalence factor (TEF) approach to estimating the lifetime incremental cancer risks for dioxins does not address (a) differences in the severity of toxicity according to the composition of chemical mixture and (b) potentials for modification of tissue-level doses of congeners in mixtures and consequently the cancer risk estimates. Our earlier efforts to model the binding of congeners to the Ah receptor in the low-dose range and to develop quantitative estimates for the formation of fractions of Ah receptor-congener complexes resulted in the definition of a unique parameter, defined as competitive binding ratio (CBR), to adjust tissue-level doses for mixture exposure. We made an effort to incorporate CBR values in the dose-response analysis and risk characterization of congeners in two distinct exposure scenarios. The modified approach to estimating tissue-level doses of congeners in mixtures by the use of a competitive binding model indicated that (a) the Ah receptor affinity is an important criterion in the determination of tissue-level dose of congeners, (b) the TEF doses calculated by using the model algorithms modified the tissue-level doses for congeners in mixture exposures, and (c) the combined lifetime incremental cancer risks for all congeners were generally lower when model algorithms were used in the dose-response analysis. However, the percentage contribution of toxic congeners was significantly higher when model algorithms were used. The percentage contribution of higher congeners with low toxicity was considerably reduced when model algorithms were used.(ABSTRACT TRUNCATED AT 250 WORDS)

Molecular cloning of major and minor allergens of Alternaria alternata and Cladosporium herbarum

The two moulds, Alternaria alternata and Cladosporium herbarum, are recognized as major causes of fungal allergies. Cloning, sequencing and heterologous expression of the allergens of the two moulds is a necessary step in understanding fungal allergy and in the development of new and improved methods of diagnosis and therapy. The seven new mould allergens presented here represent four new allergen proteins: aldehyde dehydrogenase (ALDH), enolase, YCP4 (previously found as a Saccharomyces cerevisiae protein of unknown function), and the acidic ribosomal protein, P2. Three of them (ALDH, YCP4 and P2) were found to be allergens in both fungi, Alternaria and Cladosporium. All allergens found so far are cytoplasmic proteins and are rather well conserved in evolution even when comparing distant species. Most of the allergens have "household" functions (ALDH, enolase). One allergen (P2) is a homolog of a very highly conserved human lupus erythematodes (LE) antigen. None of the fungal allergens is clearly related to other known non-fungal allergens.

Reperfusion injury in skeletal muscle: interaction of osmotic and colloid-osmotic pressure in the initial reperfusate for oedema prevention

Previous studies from the authors' laboratory have shown that controlled limb perfusion after prolonged, acute ischaemia minimizes reperfusion injury. The present study was performed to investigate the role of osmotic and colloid-osmotic pressure in the initial reperfusate in order to reduce postischaemic limb oedema and subsequent reperfusion injury. A total of 96 isolated rat hindlimbs were used: 18 were perfused immediately after amputation (no ischaemia; untreated) and 78 limbs were subjected to 4 h of warm ischaemia in a moist chamber. Thereafter eight limbs were used to investigate the effects of the addition of mannitol to the initial reperfusate. The remaining 70 limbs received controlled reperfusion (modified reperfusate with various osmotic (315-580 mosmol/l) and colloid-osmotic pressure (0-50 mmHg. perfusion pressure 50 mmHg) during the first 30 min after ischaemia. Controlled reperfusion was always followed by uncontrolled reperfusion (30 min. perfusion pressure 100 mmHg) to simulate the clinical condition where normal blood perfusion at systemic pressure will follow controlled reperfusion. Functional recovery, limb weight, water content of the soleus muscle, limb flow and tissue high-energy phosphates were assessed at the end of the experiment. Results show that a reperfusate without colloid-osmotic pressure (i.e. without macromolecules) produces severe limb oedema (84.6(2.0)% water content) and allows no functional recovery after prolonged warm ischaemia. Addition of mannitol to the initial reperfusate does not prevent severe reperfusion injury. In contrast, a hyperosmotic reperfusate with a colloid-osmotic pressure of 26 mmHg effectively prevents limb oedema (78.6(0.9)% water content, 110.8(2.4)% of control weight). Physiological osmotic pressure (315 mosmol/l), however, will not reduce oedema formation (82.7(0.4)% water content). Furthermore, colloid-osmotic pressure > 26 mmHg increases the viscosity of the reperfusate (flow decreases to < 50% of control) and does not allow an optimal functional recovery. Macromolecules used to create the colloid-osmotic pressure should be of similar molecular weight to albumin (69,000 Da); those with a smaller molecular weight (e.g. hydroxyethyl starch40,000/0.5) produce excessive limb oedema (184.9(13.5)% control weight; 85.7(1.4)% water content) without functional recovery (0% control contractions). The present data suggest that after prolonged limb ischaemia: (1) addition of mannitol to a crystalloid solution does not prevent oedema; (2) hyperosmotic reperfusates (380-480 mosmol/l) with a colloid-osmotic pressure of 26 mmHg are most effective in preventing limb oedema; and (3) macromolecules used to achieve colloid-osmotic pressure should have a molecular weight similar to albumin.

[Accelerated hyperfractionated radiotherapy combined with simultaneous chemotherapy in locally advanced pharyngeal and oral carcinomas]

PURPOSE

To evaluate the feasibility and effectiveness of a concurrent radio-chemotherapy regimen for locally advanced carcinomas of the pharynx and floor of the mouth.

PATIENTS AND METHODS

Since January 1990, 97 patients with locally advanced carcinomas of the naso-, oro-, hypopharynx and the oral cavity in UICC stages III and IV were treated according to an accelerated hyperfractionated radiotherapy schedule with concurrent chemotherapy. The primary tumor and positive lymph nodes received a total dose of 72 Gy in 6 weeks. In the first 3 weeks, large fields were irradiated 5 times per week with 2 Gy per fraction. Thereafter, treatment was accelerated, giving 2 daily fractions of 1.4 Gy with minimal intervals of 6 hours. Target volumes were reduced after 49.6 and 59.4 Gy, excluding clinically uninvolved lymph node regions of low and high risk. On day 1, 350 mg/m2 5-FU and 50 mg/m2 folinic acid were given as intravenous bolus followed by continuous infusion of 350 mg/m2 5-FU and 100 mg/m2 folinic acid, days 1 to 5. 10 mg/m2 mitomycin C was given on day 5 and 36 of the treatment. Salvage surgery was offered for residual disease 5 to 6 weeks after the end of radiotherapy.

PATIENT CHARACTERISTICS

70 male, 27 female; age: 27 to 81 years; T2/T3/T4: 7/30/60; N0/N1/N2/N3: 20/18/53/6; nasopharynx/oropharynx/hypopharynx/oral cavity: 16/33/36/12. Median follow-up is 26 months.

RESULTS

Overall survival and recurrence-free survival at 2 years were

RESULTS

Overall survival and recurrence-free survival at 2 years were 68 +/- 5% and 74 +/- 5%. Multivariate analysis revealed a significant influence of the geometric mean neck node diameter or the N-stage on loco-regional control and survival. T-stage, tumor volume, or tumor localisation did not become significant. Acute toxicity of this schedule was acceptable but required optimised supportive care. Treatment related grade 4+ late toxicity of mucosa, soft tissue and bone were observed with a cumulative frequency of 13% at 2 years. Two patients died during a phase of severe leuko- or thrombocytopenia.

CONCLUSION

This phase I to II trial shows favourable results using an intensified treatment radio-chemotherapy protocol. A phase III study is now planned, comparing this regime with an accelerated hyperfractionated radio-therapy alone to an increased total dose of 77.6 Gy.

E-cadherin as a functional marker of the differentiation and invasiveness of squamous cell carcinoma of the head and neck

The cell-cell-adhesion molecule E-cadherin is necessary for the maintenance of the epithelial cellular structure. We were able to show a correlation between decreasing E-cadherin expression, dedifferentiation and increased invasiveness in a cell line model. We studied 73 squamous cell carcinomas from the upper aerodigestive tract using the immunofluorescent method to demonstrate expression of E-cadherin. Decreased E-cadherin expression correlated with a decreased grade of differentiation and an increased lymph node metastatic rate. This confirms the significance of E-cadherin as a marker for differentiation and invasiveness of squamous cell carcinoma of the pharynx and larynx.

Improving the delivery of clinic care

There has been an increasingly widespread movement toward the delivery of health care in outpatient settings. Hospitals must start to prepare for the shift from inpatient to outpatient services. Reductions in reimbursement and increasing costs will force hospitals to collect and obtain more data on outpatient services. Projecting future demands and assessing current utilization rates are two of the key factors in maintaining stability. This article is a case study of a major urban medical center's outpatient clinic. It includes a summary of observations on the clinic's daily operations and several recommendations for improvement. While the original analysis was highly specific to the actual facility observed, this article has been structured so that it may be applied to other institutions.

CAD-design, stress analysis and in vitro evaluation of three leaflet blood-pump valves

The computer-supported development of valves for cardiac-assist devices or artificial hearts is shown in relation to plastic technology. A CAD-system is used for the design development, whereas the dimensioning of the critical and highly stressed membranes is examined by FEM-analyses. Economic manufacture is permitted by the combined thermoforming-dip moulding technique; the blood-side components are made from biocompatible polyurethane to minimize blood damage. The first long-term results in the test set-up are compared to the FEM results.

E-cadherin expression in squamous cell carcinomas of head and neck: inverse correlation with tumor dedifferentiation and lymph node metastasis

Tissue sections of 32 squamous cell carcinomas (SCCs) of the head and neck were investigated for the expression of the epithelium-specific cell adhesion molecule E-cadherin. We found that E-cadherin expression is inversely correlated both with the loss of differentiation of the tumor and with lymph node metastasis. The well-differentiated SCCs expressed E-cadherin, often as strongly as the normal stratified epithelium (12 cases were tested); the moderately differentiated SCCs expressed intermediate amounts of E-cadherin or were heterogeneous (15 cases were analyzed); whereas the poorly differentiated SCCs were all E-cadherin-negative (five cases were investigated). Furthermore, seven of eight infiltrated lymph nodes of SCCs were E-cadherin-negative. These data indicate that the loss of the cell adhesion molecule E-cadherin in fact plays an important role in the progression of human squamous cell carcinomas, i.e., that down-regulation of expression is associated with dedifferentiation and metastasis of the tumor cells in vivo.

Early and late results following coronary bypass surgery beyond the age of 75 years

The indication for coronary bypass surgery in the elderly has been dramatically expanded in recent years. The results, however, are often contradictory. 1,538 consecutive patients undergoing cardiac surgery were divided into two groups by their age at the time of operation: younger than 75 years (n = 1,480) and 75 years and older (n = 58). These groups were compared with regard to influencing factors of early and late mortality, morbidity, and quality of life. Preoperatively, the clinical condition of the group greater than or equal to 75 years was significantly worse than the condition of the group less than 75 years (NYHA IV: greater than or equal to 75 years: 63.8%; less than 75 years: 31.9%). Cerebrovascular diseases occurred more often in the patients greater than or equal to 75 years (stroke or transient ischemic attack: greater than or equal to 75 years: 8.6%; less than 75 years: 2.3%). The necessity of carotid reconstruction prior to coronary surgery was significantly higher in the patients greater than or equal to 75 years: (greater than or equal to 75 years: 5.2%; less than 75 years: 1.5%). Diabetes mellitus could be observed in 19.0% of the patients greater than or equal to 75 years and in 10.1% of the patients less than 75 years. The preoperative ejection fraction was similar in both groups. Cardiopulmonary bypass time and crossclamping time of the aorta did not differ significantly. Both groups received approximately the same number of distal coronary anastomoses. Rethoracotomy due to hemorrhage had been observed more often in the older group (greater than or equal to 75 years: 8.6%; less than 75 years: 4.5%).(ABSTRACT TRUNCATED AT 250 WORDS)

Studies of reperfusion injury in skeletal muscle: preserved cellular viability after extended periods of warm ischemia

Four hours of complete normothermic ischemia in the rat hindlimb has been thought to produce extensive and irreversible damage and no possibility of salvage by reperfusion. This study tests the hypothesis that, in contrast to conventional wisdom, the cellular integrity is preserved after 4 hours of complete warm ischemia and control of the initial reperfusion can restore immediate contractility in these limbs. Ninety-two rat hindlimbs were isolated and 26 of the 92 did not undergo ischemia or reperfusion and served as controls. Sixty-six limbs were subjected to 4 hours of complete warm ischemia; of those 34 were assessed after the ischemic period without reperfusion and 32 were reperfused after the ischemic period. Nineteen hindlimbs were reperfused with Krebs-Henseleit buffer at a pressure of 100 mmHg to simulate embolectomy (uncontrolled reperfusion). In 13 legs a modified reperfusate at a pressure of 60 mmHg was used during the initial 30 minutes followed by an additional 30 minutes of reperfusion with 100 mmHg using Krebs-Henseleit buffer (controlled reperfusion). At the end of each experimental protocol, limbs were assessed by the following methods: muscle contraction, water content, volume, high energy phosphate content, muscle pH, effluent pH, mitochondrial function, ultrastructure, flow, and creatinkinase activity in the effluent. Data are expressed as mean +/- SEM. Significant differences were defined as probabilities for each test of p less than 0.05. Four hours of complete warm ischemia resulted in a severe reduction of adenosine triphosphate (4.0 +/- 0.8 vs 27.1 +/- 6.7 mumol/gm protein, p less than 0.001) and no contractions could be stimulated (0.0 +/- 0.0% CC). Muscle pH fell to 6.3 +/- 0.1 (p less than 0.001), and ultrastructural damage occurred (score 3.3 +/- 0.4 vs 0.8 +/- 0.1, p less than 0.002). However, there was only a slight increase in water content of the soleus muscle (78.7 +/- 0.2% vs 74.8 +/- 1.1%, p less than 0.05) without increase in limb volume (103.6 +/- 0.6% CV). In addition mitochondrial function was preserved well: mitochondrial oxidative phosphorylation capacity remained at 94% of control levels, ST3 at 93%, and ADP/O at 100% of control. Most importantly, controlled reperfusion restored immediate contractility in all limbs and was superior in all parameters investigated compared to uncontrolled reperfusion. These data support our inference that necrosis of skeletal muscle does not invariably occur after four hours of complete warm ischemia and suggest that muscle salvage by controlled reperfusion is possible after at least 4 hours of warm ischemia.

Neuromyelitis optica (Devic's syndrome) and pulmonary tuberculosis

Neuromyelitis optica and acute necrotic myelopathy occur in association with pulmonary tuberculosis. We studied 8 patients with either neuromyelitis optica (6), acute myelopathy (1), or acute optic neuropathy (1) in close temporal association with pulmonary tuberculosis, but with no evidence for CNS tuberculosis. Neurologic symptoms preceded the use of antituberculosis medication in 5 patients. Different patients showed similar clinical features, suggesting a consistent disease pattern. Autopsy examination (1 patient) revealed extensive spinal cord and optic nerve demyelination. We identified only 5 additional patients seen over the same period with idiopathic neuromyelitis optica, thus suggesting that the close temporal relationship to pulmonary tuberculosis is not coincidental. The syndrome is most likely due to an immune reaction to tuberculosis rather than the use of antituberculosis medication.

Data for long-term care planning. Application of a synthetic estimation technique

To provide state-level estimates for long-term care planning, synthetic estimation techniques were used to generate estimates of dependency in activities of daily living (ADL) and mobility among each state's population. Dependency is regressed on demographic predictor variables in a data set created by combining the 1977 National Health Interview Survey and 1977 National Nursing Home Survey. Coefficients were then applied to 1980 U.S. Bureau of the Census state prevalence estimates for these predictors. The results are state estimates that vary from 7.2% of the aged population ADL dependent in Alaska to 10.4% in Iowa and Nebraska. An alternative model regresses dependency on state mortality rates and produces similar but generally lower estimates.

The production of pregnancy associated alpha glycoprotein (PAG) from human peripheral blood mononuclear cells

A sensitive enzyme-linked immuno-assay has been developed which can measure the amounts of pregnancy-associated alpha 2 glycoprotein (PAG) produced by human peripheral blood mononuclear cells (MNC) in culture. Ethinyl oestradiol, indomethacin and pokeweed mitogen (PWM) stimulated PAG production directly while indomethacin produced an additional increase in PAG production by PWM-stimulated MNC probably by inhibiting the production of prostaglandins with down-regulatory effects on the MNC. Oestrogen stimulation of MNC produced significant increases in PAG levels only by the MNC of women on oral contraceptives but not from the cells of males or of females of reproductive age not on oral contraceptives. Since PAG has immunosuppressive properties these observations may be of relevance in understanding the mechanisms involved in the significant decrease in the incidence of rheumatoid arthritis in women taking oral contraceptives.

Nutritional practices and outcome of extremely premature infants

We analyzed the records of 182 newborns with birth weights under 1000 g, who survived longer than seven days, to determine risk factors for subacute mortality and morbidity. Statistical analysis using logarithm-linear modeling was used to identify complex interactions and to minimize confounding. Nosocomial infection, necrotizing enterocolitis, male gender, and chronic lung disease (CLD) were identified as independent risk factors for subacute mortality. Male gender and CLD were associated with increased mortality only among patients who received parenteral nutrition (PN). Moreover, PN, rather than enteral nutrition (EN), was a risk factor for delayed growth, nosocomial infection, and CLD. Delayed initiation of EN was associated with decreased necrotizing enterocolitis risk only among male infants with birth weights under 775 g. Our results do not support elective withholding of EN in other groups of extremely low-birth-weight infants. We conclude that indications for PN and for withholding initiation of EN in very-very-low-birth-weight infants need to be established by prospective studies.