A Navigated Mechatronic System with Haptic Features to Assist in Surgical Interventions

OBJECTIVE

In orthopaedic surgery, the development of new computer-based technologies such as navigation systems and robotics will facilitate more precise, reproducible results in surgical interventions. There are already commercial systems available for clinical use, though these still have some limitations and drawbacks. This paper presents an alternative approach to a universal modular surgical assistant system for supporting less or minimally invasive surgery.

MATERIALS AND METHODS

The position of a mechatronic arm, which is part of the system, is controlled by a navigation system so that small patient movements are automatically detected and compensated for in real time. Thus, the optimal tool position can be constantly maintained without the need for rigid bone or patient fixation. Furthermore, a force control mode of the mechatronic assistant system, based on a force-torque sensor, not only increases safety during surgical interventions but also facilitates hand-driven direct positioning of the arm.

RESULTS

A prototype has been successfully tested in clinical applications at the Orthopadische Universitätsklinik Frankfurt. For the first time worldwide, implantation of the cup prosthesis in total hip replacement surgery has been carried out with the assistance of a mechatronic arm. According to measurements by the digitizing system, operating tool angle deviation remained below 0.5 degrees, relative to the preoperative planning.

CONCLUSION

The presented approach to a new kind of surgical mechatronic assistance system supports the surgeon as needed by optimal positioning of the surgical instruments. Due to its modular design, it is applicable to a wide range of tasks in surgical interventions, e.g., endoscope guidance, bone preparation, etc.

Different effects of the Cdx1 and Cdx2 homeobox genes in a murine model of intestinal inflammation

AIMS

The CDX1 and CDX2 homeoproteins are intestine-specific transcription factors regulating homeostasis. We investigated their relevance in experimentally-induced intestinal inflammation.

METHODS

The response to intestinal inflammation induced by dextran sodium sulfate (DSS) was compared in wild type, Cdx1(-/-) and Cdx2(+/-) mice. Intestinal permeability was determined in wild type and Cdx2(+/-) mice. Protein-protein interactions were investigated by co-immunoprecipitation and GST-pulldown, and their functional consequences were assessed using Luciferase reporter systems.

RESULTS

Heterozygous Cdx2(+/-) mice, but not Cdx1(-/-) mice, were hypersensitive to DSS-induced acute inflammation as all these mice showed blood in the stools at day 1 of DSS treatment. Hypersensitivity was associated to a 50% higher intestinal permeability. In Cdx2(+/-) mice, the colonic epithelium was repaired during the week after the end of DSS treatment, whereas two weeks were required for wild type animals. Subsequently, no colonic tumour was observed in Cdx2(+/-) mice subjected to 5 repeated cycles of DSS, in contrast to the 2.7 tumours found per wild type mouse. Based on the fact that Smad3(+/-) mice, like Cdx2(+/-) mice, better repair the damaged intestinal epithelium, we found that the CDX2 protein interacts with SMAD3, independently of SMAD4, resulting in a 5-fold stimulation of SMAD3 transcriptional activity. CDX1 also interacted with SMAD3 but it inhibited by 10-fold the SMAD3/SMAD4-dependent transcription.

CONCLUSION

The Cdx1 and Cdx2 homeobox genes have distinct effects on the outcome of a pro-inflammatory challenge. This is mirrored by different functional interactions of the CDX1 and CDX2 proteins with SMAD3, a major element of the TGFbeta signalling pathway.

Occupational risks for adenocarcinoma of the nasal cavity and paranasal sinuses in the German wood industry

OBJECTIVES

To examine the risk of wood dust and chemical exposures for adenocarcinoma of the nasal cavity and paranasal sinuses (ADCN) among German wood workers.

METHODS

An industry-based case-control study with 86 male ADCN cases and 204 controls was conducted in the German wood-working industries. Cumulative and average wood-dust exposure was quantified with a job-exposure matrix based on wood-dust measurements at recent and historical workplaces. Probabilities of exposure to wood preservatives, stains, varnishes, and formaldehyde were semi-quantitatively rated. Odds ratios and 95% confidence intervals were calculated with logistic regression analysis conditional on age and adjusted for smoking and other factors. For estimating the risks of either wood dust or chemical additives, the authors additionally adjusted for the corresponding co-exposure.

RESULTS

ADCN occurred relatively more frequently among wood workers that had ever worked as cabinet makers or joiners (OR 2.96, 95% CI 1.46 to 6.01) than as saw millers (OR 0.15, 95% CI 0.03 to 0.68). Average exposure to inhalable wood dust >/=5 mg/m(3) was associated with a high risk (OR 48.47, 95% CI 13.30 to 176.63) compared to levels below 3.5 mg/m(3). Assuming 40 years of exposure under these concentrations, the corresponding OR was 4.20 (95% CI 1.69 to 10.43). Exposure between 3.5 and 5 mg/m(3) was also found to pose a risk (OR 10.54, 95% CI 3.34 to 33.27). Exposure to pigment stains before 1970 was associated with an increased risk (OR 3.03; 95% CI 1.11 to 8.26). No significant associations were estimated for wood preservatives, varnishes, and formaldehyde.

CONCLUSIONS

The authors found an elevated ADCN risk for exposure to inhalable wood dust above 3.5 mg/m(3). The rareness of the disease does not allow the exclusion of risk below that concentration. For pigment stains, there is evidence for an association of historical exposure with the development of ADCN in German wood workers.

Multiple neurotoxic stresses converge on MDMX proteolysis to cause neuronal apoptosis

MDMX has been shown to modulate p53 in dividing cells after DNA damage. In this study, we investigated the role of MDMX in primary cultures of neurons undergoing cell death. We found that DNA damage, but also membrane-initiated apoptotic stresses (glutamate receptor; Amyloid beta precursor) or survival factor deprivation downregulated MDMX protein levels. Forced downregulation of murine double minute X (MDMX) by shRNA induced apoptosis suggesting that MDMX is required for survival in neurons. Protease inhibitors prevented the loss of MDMX after neurotoxic treatments, indicating a regulation of protein stability. Some, but not all, neurotoxic stresses induced phosphorylation of MDMX at serine 367, further supporting regulation at the protein level. Interestingly, we found that depending on the stimulus either p53 or E2F1 was induced, but overexpression of MDMX inhibited the transcriptional activity of both proapoptotic factors, and maintained neuronal viability upon neurotoxic stresses. Taken together, our data show that MDMX is an antiapoptotic factor in neurons, whose degradation is induced by various stresses and allows activation of p53 and E2F-1 during neuronal apoptosis.

Sprouty2 inhibits BDNF-induced signaling and modulates neuronal differentiation and survival

Sprouty (Spry) proteins are ligand-inducible inhibitors of receptor tyrosine kinases-dependent signaling pathways, which control various biological processes, including proliferation, differentiation and survival. Here, we investigated the regulation and the role of Spry2 in cells of the central nervous system (CNS). In primary cultures of immature neurons, the neurotrophic factor BDNF (brain-derived neurotrophic factor) regulates spry2 expression. We identified the transcription factors CREB and SP1 as important regulators of the BDNF activation of the spry2 promoter. In immature neurons, we show that overexpression of wild-type Spry2 blocks neurite formation and neurofilament light chain expression, whereas inhibition of Spry2 by a dominant-negative mutant or small interfering RNA favors sprouting of multiple neurites. In mature neurons that exhibit an extensive neurite network, spry2 expression is sustained by BDNF and is downregulated during neuronal apoptosis. Interestingly, in these differentiated neurons, overexpression of Spry2 induces neuronal cell death, whereas its inhibition favors neuronal survival. Together, our results imply that Spry2 is involved in the development of the CNS by inhibiting both neuronal differentiation and survival through a negative-feedback loop that downregulates neurotrophic factors-driven signaling pathways.

The intestine-specific homeobox gene Cdx2 decreases mobility and antagonizes dissemination of colon cancer cells

The gravity of colorectal cancer is mainly due to the capacity of tumor cells to migrate out of the tumor mass to invade the stroma and disseminate as metastases. The acquisition of a migratory phenotype also occurs during wound healing. Here, we show that several features characterizing invasive colon tumor cells are shared by migrating cells during wound repair in vitro. In particular, the expression of the intestine-specific transcription factor Cdx2, a key gene for intestinal identity downregulated in invasive cancer cells, is reduced during wound healing in vitro. Transcription factors involved in epithelial-mesenchymal transition such as Snail and Slug are upregulated during wound healing and are able to repress Cdx2 transcription. In vitro, forced expression of Cdx2 in human colon cancer cell lines retarded wound repair and reduced migration, whereas inhibition of Cdx2 expression by RNA interference enhanced migration. In vivo, forced expression of Cdx2 opposed tumor cells spreading in nude mice xenografted at three different sites. These data provide evidence that Cdx2 antagonizes the process of tumor cell dissemination, and they suggest that this homeobox gene might represent a new therapeutic target against metastatic spreading of colon cancer.

Inhaled nitric oxide for the postoperative management of pulmonary hypertension in infants and children with congenital heart disease

BACKGROUND

Nitric oxide (NO) is a prevalent molecule in the human body responsible for many physiologic activities including pulmonary vasodilation. An exogenous, inhaled form (iNO) exists that mimics this action without directly affecting systemic blood pressure. This therapy has been implemented in the treatment of pulmonary hypertension. This review examines the efficacy of iNO in the postoperative management of infants and children with congenital heart disease.

OBJECTIVES

To compare the effects of postoperative iNO versus placebo and/or conventional management on infants and children with congenital heart disease. The primary outcome was mortality, while secondary outcomes included length of hospital stay, assessment of neurodevelopmental disability, number of pulmonary hypertensive crises (PHTC), changes in haemodynamics including mean pulmonary arterial pressure (MPAP), mean arterial pressure (MAP), and heart rate (HR), changes in oxygenation measured as the ratio PaO2:FiO2, and measurement of maximum methaemoglobin level as a marker of toxicity.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 3, 2004), MEDLINE (1966 to 2004), and EMBASE (1980 to 2004). We included abstracts and all languages.

SELECTION CRITERIA

We included randomized and quasi-randomized controlled trials comparing iNO with placebo and conventional management, or both. Trials included only children with congenital heart disease requiring surgery and complicated by pulmonary hypertension.

DATA COLLECTION AND ANALYSIS

Data were collected on mortality, number of PHTC, changes in MPAP, MAP, HR, and PaO2:FiO2, and maximum methaemoglobin level, while data on long-term mortality, neurodevelopmental disability, and length of hospital stay were unavailable. We performed subgroup analysis by age and method of control. We performed sensitivity analysis using studies of highest methodologic quality.

MAIN RESULTS

We included four randomized trials. We observed no differences between groups with respect to mortality (P = 0.50), PHTC (P = 0.79), change in MPAP (P = 0.16), MAP (P = 0.40), HR (P = 1.00), or PaO2:FiO2 (P = 0.46). There was a significant reduction in MPAP in the subgroup of patients from birth to three months (P = 0.005), although this finding was based on a small number of patients (N = 23).

AUTHORS' CONCLUSIONS

We observed no differences with the use of iNO as compared with control in the majority of outcomes reviewed. No data were available for analysis with respect to several clinical outcomes including long-term mortality and neurodevelopmental outcome. We found it difficult to draw valid conclusions because of concerns regarding methodologic quality, bias, sample size, and heterogeneity.

Mammalian sprouty proteins inhibit cell growth and differentiation by preventing ras activation

Sprouty was genetically identified as an antagonist of fibroblast growth factor signaling during tracheal branching in Drosophila. In this study, we provide a functional characterization of mammalian Sprouty1 and Sprouty2. Sprouty1 and Sprouty2 inhibited events downstream of multiple receptor tyrosine kinases and regulated both cell proliferation and differentiation. Using NIH3T3 cell lines conditionally expressing Sprouty1 or Sprouty2, we found that these proteins specifically inhibit the Ras/Raf/MAP kinase pathway by preventing Ras activation. In contrast, activation of the phosphatidylinositol 3-kinase pathway was not affected by Sprouty1 or Sprouty2. We further showed that Sprouty1 and Sprouty2 do no prevent the formation of a SNT.Grb2.Sos complex upon fibroblast growth factor stimulation, yet block Ras activation. Taken together, these results establish mammalian Sprouty proteins as important negative regulators of growth factor signaling and suggest that Sprouty proteins act downstream of the Grb2.Sos complex to selectively uncouple growth factor signals from Ras activation and the MAP Kinase pathway.

Is there a role for antenatal TRH therapy for the prevention of neonatal lung disease?

Unfortunately, surfactant therapy is not routinely available to infants in some parts of the world because of its cost. It is the hypothesis of this article that in situations where surfactant is not available, there may be a role for antenatal thyrotropin-releasing hormone (TRH) plus glucocorticoid therapy. Data from randomized clinical trials, which compared therapy with antenatal glucocorticoid plus TRH to that with glucocorticoid alone were extracted and subjected to meta-analysis. The trials that incorporated surfactant therapy were analyzed separately from those in which surfactant was not used. In addition, because surfactant therapy was only available to some patients in the Australian ACTOBAT trial, each group analysis was performed with and without the ACTOBAT data. A characteristic of the earlier presurfactant trials is that few were designed for "intention to treat" analysis. In most of these studies, it was decided a priori to include babies who delivered within a specified time period after hormone therapy. The addition of TRH did not decrease respiratory distress syndrome in those trials in which surfactant therapy was used. In the presurfactant trials, respiratory distress syndrome was significantly decreased when "intention to treat" data were examined, as well as in those infants who delivered between 1 and 10 days after maternal therapy. There was also a significant decrease in oxygen dependency at 28 days after birth, and in oxygen dependency or death at this time, in those infants who delivered 1 to 10 days after treatment. Antenatal TRH had no significant effect of on neonatal complications such as air leak, intraventricular hemmorhage, patent ductus arteriosus, retinopathy of prematurity, or necrotizing enterocolitis. However, TRH did produce transient suppression of the pituitary thyroid axis. There were also a variety of transient complications in the mothers, including nausea, vomiting or flushing, light-headed feeling, and increased blood pressure. The authors conclude that the implementation of appropriate antenatal glucocorticoid treatment is the first priority. Once this has been established, the data presented here suggest that addition of antenatal TRH should be considered in those situations where surfactant is not available.

Organization of immature human immunodeficiency virus type 1

Immature retrovirus particles contain radially arranged Gag polyproteins in which the N termini lie at the membrane and the C termini extend toward the particle's center. We related image features to the polyprotein domain structure by combining mutagenesis with cryoelectron microscopy and image analysis. The matrix (MA) domain appears as a thin layer tightly associated with the inner face of the viral membrane, separated from the capsid (CA) layer by a low-density region corresponding to its C terminus. Deletion of the entire p6 domain has no effect on the width or spacing of the density layers, suggesting that p6 is not ordered in immature human immunodeficiency virus type 1 (HIV-1). In vitro assembly of a recombinant Gag polyprotein containing only capsid (CA) and nucleocapsid (NC) domains results in the formation of nonenveloped spherical particles which display two layers with density matching that of the CA-NC portion of immature HIV-1 Gag particles. Authentic, immature HIV-1 displays additional surface features and an increased density between the lipid bilayers which reflect the presence of gp41. The other internal features match those of virus-like particles.

Recent advances in respiratory care of the term neonate

Persistent pulmonary hypertension is a major cause of morbidity and mortality in the term and near-term infant. Management of this condition, which is characterized by respiratory distress and cyanosis, has been greatly enhanced by inhaled nitric oxide (NO) therapy. The following treatment regime is suggested: Conventional ventilation should be used initially, and hyperventilation should be avoided. Surfactant should be administered early, preferably within 6 hours of diagnosis. If conventional ventilation fails, the next step is high-frequency ventilation or inhaled NO. Some infants who do not respond to inhaled NO when administered by conventional ventilation will respond to NO delivery via a high-frequency ventilator. If all of these therapies fail, extracorporeal membrane oxygenation (ECMO) should be considered. By the use of this approach, the mortality from PPH has been considerably reduced, and concerns today relate primarily to morbidity, particularly long-term neurologic outcome and chronic lung disease resulting from ventilation and barotrauma.

E-cadherin is a WT1 target gene

The WT1 tumor suppressor gene encodes a transcription factor that can activate and repress gene expression. Transcriptional targets relevant for the growth suppression functions of WT1 are poorly understood. We found that mesenchymal NIH 3T3 fibroblasts stably expressing WT1 exhibit growth suppression and features of epithelial differentiation including up-regulation of E-cadherin mRNA. Acute expression of WT1 in NIH 3T3 fibroblasts after retroviral infection induced murine E-cadherin expression. In transient transfection experiments, the human and murine E-cadherin promoters were activated by co-expression of WT1. E-cadherin promoter activity was increased in cells overexpressing WT1 and was blocked by a dominant negative form of WT1. WT1 activated the murine E-cadherin promoter through a conserved GC-rich sequence similar to an EGR-1 binding site as well as through a CAAT box sequence. WT1 produced in vitro or derived from nuclear extracts bound to the WT1-response element within the murine E-cadherin promoter, but not the CAAT box. E-cadherin, a gene important in epithelial differentiation and neoplastic transformation, represents a downstream target gene that links the roles of the WT1 in differentiation and growth control.

Indoor determinants of Der p 1 and Der f 1 concentrations in house dust are different

BACKGROUND

Exposure to mite allergens is a major risk factor for sensitization and the development of asthma. Der p 1 and Der f 1 content in homes and probably the proportion of both antigens is highly variable even in the same geographical area.

OBJECTIVE

We investigated specific indoor determinants of Der p 1 and Der f 1 concentrations in house dust of two German cities, Erfurt and Hamburg (n = 405 homes).

METHODS

Mite allergen levels were determined using monoclonal antibodies against Der p 1 and Der f 1 by the ELISA method. Indoor relative humidity and temperature were monitored continuously in the homes over 1 week. The characteristics of homes and occupants were assessed by questionnaire to obtain information on factors which may have an impact on the mite antigen concentration in house dust. These determinants were studied by multivariate regression analysis.

RESULTS

The correlation between concentrations of Der p 1 and Der f 1 inside the homes was weak (r = 0.29-0.35), indicating that different determinants are relevant. Concentrations of the allergens were significantly higher on lower floors (ratios 2-8 times, Der p 1, Der f 1), on old mattresses (ratios 3-13 times, Der p 1, Der f 1), in post-war buildings (ratio 6 times, Der p 1), for non-central heating (ratio 2 times, Der p 1), for old carpets (ratio 3 times, Der p 1) and for the presence of a dog in the house (ratio 3 times, Der f 1). Furthermore, mite concentration increases with raising relative humidity (ratio 1.03 per 1%, Der p 1) and with decreasing temperature (ratio 0.86 per 1 degrees C, Der p 1) indoors.

CONCLUSION

Both Der p 1 and Der f 1 concentrations should be measured in house dust, since they are only weakly correlated and have different determinants.

A conformational switch controlling HIV-1 morphogenesis

Assembly of infectious human immunodeficiency virus type 1 (HIV-1) proceeds in two steps. Initially, an immature virus with a spherical capsid shell consisting of uncleaved Gag polyproteins is formed. Extracellular proteolytic maturation causes rearrangement of the inner virion structure, leading to the conical capsid of the infectious virus. Using an in vitro assembly system, we show that the same HIV-1 Gag-derived protein can form spherical particles, virtually indistinguishable from immature HIV-1 capsids, as well as tubular or conical particles, resembling the mature core. The assembly phenotype could be correlated with differential binding of the protein to monoclonal antibodies recognizing epitopes in the HIV-1 capsid protein (CA), suggesting distinct conformations of this domain. Only tubular and conical particles were observed when the protein lacked spacer peptide SP1 at the C-terminus of CA, indicating that SP1 may act as a molecular switch, whose presence determines spherical capsid formation, while its cleavage leads to maturation.

Stoichiometry of potassium channel opener action

Potassium channel openers (KCOs; e.g., P1075, pinacidil) exert their effects on excitable cells by opening ATP-sensitive potassium channels. These channels are heteromultimers composed with a 4:4 stoichiometry of an inwardly rectifying K(+) channel subunit plus a regulatory subunit comprising the receptor sites for hypoglycemic sulfonylureas and KCOs (a sulfonylurea receptor). To elucidate stoichiometry of KCO action, we analyzed P1075 sensitivity of channels coassembled from sulfonylurea receptor isoforms with high or low P1075 affinity. Concentration activation curves for cDNA ratios of 1:1 or 1:10 resembled those for channel opening resulting from interaction with a single site, whereas models for activation requiring occupation of two, three, or four sites were incongruous. We conclude KCO-induced channel activation to be mediated by interaction with a single binding site per tetradimeric complex.

Allergens in house-dust samples in Germany: results of an East-West German comparison

The background of this study is the finding of several studies that the frequency of respiratory allergies was significantly higher in the former West Germany than the former East Germany. The present study investigated the levels of allergens of house-dust mite (Der p 1 and Der f 1), cat (Fel d 1), and cockroach (Bla g 2) in the household dust of 201 homes in Hamburg (West Germany) and 204 homes in Erfurt (East Germany), and examined the factors that affect these levels. The characteristics of homes were assessed by a questionnaire. The allergen levels were studied in dust from living rooms (LR), bedrooms (BR), and mattresses (MA). We detected in samples from Hamburg significantly higher allergen concentrations than in Erfurt: three times higher Der p 1, five times higher Der f 1, and three times higher Fel d 1. For Bla g 2, no comparison was possible because the concentrations were below the detection limit in 93% of the samples. Most of the differences could be explained by differences in housing and living characteristics between both cities. The mean ratio of Der p 1 levels in mattress dust between Hamburg and Erfurt decreased from 4.1 to 1.54 (NS) after adjustment for season, building material, age of the house, story of the dwelling, type of heating, age of carpet/mattress, presence of dogs, and indoor climate (temperature, humidity). The mean ratio of Der f 1 levels decreased from 6.9 to 2.78 (P<0.05) after adjustment for these factors. The mean ratio for Fel d 1 in mattress dust decreased fom 4.03 to 1.65 (P<0.05) after adjustment for season, building material, story of dwelling, size of dwelling, ventilation, cleaning routines, and pets. A similar reduction was seen for floor dust (LR plus BR). Our results indicate that the differences between the concentrations of mite and cat allergens found in Hamburg and Erfurt are explicable mainly, but not completely, by different building characteristics (age of houses, building material, story, and size of the dwelling) which affected the indoor climate, as well as by differences in other individual living habits (keeping of pets, age of carpets or mattresses, and cleaning routines).

Identification of the Potassium Channel Opener Site on Sulfonylurea Receptors

Diversity of sulfonylurea receptor (SUR) subunits underlies tissue specific pharmacology of K(ATP) channels, which represent critical regulators of electrical activity in numerous cells. Notably, the neuronal/pancreatic beta-cell receptor, SUR1, imparts high sensitivity to hypoglycemic sulfonylureas (SUs; e.g. glibenclamide) and low to potassium channel openers (KCOs; e.g. P1075), whereas the opposite drug sensitivities are conferred by cardiovascular receptors, SUR2A and SUR2B. By exchanging domains between SUR1 and SUR2B, we identify two regions (KCO I: Thr(1059)-Leu(1087) and KCO II: Arg(1218)-Asn(1320); rat SUR2 numbering) within the second set of transmembrane domains (TMDII) as critical for KCO binding. Swapping both regions reconstitutes KCO affinities and sensitivities of the donor SUR isoform. High glibenclamide affinity of SUR1 is not reduced by transfer of KCO I plus II from SUR2B, demonstrating that high SU and KCO affinity can coexist in the same SUR molecule. Consistently, high SU affinity was imparted on SUR2B by substituting the region separating KCO I and II (Ile(1088)-Val(1217)) with the corresponding domain of SUR1. We infer the receptor sites for KCOs and SUs to be closely associated within a regulatory domain (Thr(1059)-Asn(1320)) in TMDII of SURs.