Prolonged asystole provoked by head-up tilt testing

We describe a patient with a history of neurocardiogenic syncopes who had a positive headup tilt test that resulted in an lasting asystole lasting 34 seconds. However, the previously carried out Schellong test with a 30-min phase of standing showed a normal result. The patient showed typical orthostatic symptoms while tilted at the angle of 75 degrees. Shortly before asystole occurred, heart rate variability showed high frequency bands, indicating vagal stimulation. The pathophysiology of neurocardiogenic syncope (NCS) in context with heart rate variability is discussed. This patient was successfully treated with propranolol. This case shows the utility of a provocative head-up tilt test in establishing the diagnosis of NCS. If the Schellong test is normal, still further examination by tilt-table test is indispensable.

Status of oral healthcare in long-term care facilities

Oral health is a fundamental component in the overall well-being and quality of life for elders living in long-term care facilities. Effective oral care interventions must not only involve recognising the importance of oral health in this population, but giving oral hygiene the same priority as other care practices in long-term care settings.

Pharmacology and clinical trial results of saruplase (scuPA) in acute myocardial infarction

Saruplase is the non-glycosylated form of single chain urokinase-type plasminogen activator; it is produced by recombinant technique in Escherichia coli. Saruplase has plasminogen activating properties; it can also be cleaved to the potent plasminogen activator, double chain urokinase, resulting in the generation of plasmin. By means of a positive feedback mechanism, plasmin itself is able to cleave saruplase. At present, a bolus of 20 mg followed by an infusion of 60 mg over 1 h and preceded by a heparin bolus of 5000 U, represents the standard saruplase regimen. The PRIMI trial showed that this standard saruplase regimen achieves higher early patency rates than streptokinase. In the COMPASS trial, saruplase has been shown to be at least as effective as streptokinase, in terms of 30 day mortality. A comparative trial with urokinase (SUTAMI) resulted in similar late coronary patency. Saruplase has been tested against alteplase (100 mg over 180 min) in the SESAM trial. The early coronary patency and safety of both regimens were comparable. In a recent study, three bolus applications of saruplase have been investigated. A double bolus of 40 mg each given 30 min apart, is suggested to be more effective than standard saruplase, but concerns about safety remain. Further studies are required to assess safety of the double bolus regimen, and to compare saruplase with the gold-standard of frontloaded alteplase, or the equivalent double bolus reteplase regimen.

Risk of cancer after low doses of ionising radiation: retrospective cohort study in 15 countries

OBJECTIVES

To provide direct estimates of risk of cancer after protracted low doses of ionising radiation and to strengthen the scientific basis of radiation protection standards for environmental, occupational, and medical diagnostic exposures.

DESIGN

Multinational retrospective cohort study of cancer mortality.

SETTING

Cohorts of workers in the nuclear industry in 15 countries.

PARTICIPANTS

407 391 workers individually monitored for external radiation with a total follow-up of 5.2 million person years.

MAIN OUTCOME MEASUREMENTS

Estimates of excess relative risks per sievert (Sv) of radiation dose for mortality from cancers other than leukaemia and from leukaemia excluding chronic lymphocytic leukaemia, the main causes of death considered by radiation protection authorities.

RESULTS

The excess relative risk for cancers other than leukaemia was 0.97 per Sv, 95% confidence interval 0.14 to 1.97. Analyses of causes of death related or unrelated to smoking indicate that, although confounding by smoking may be present, it is unlikely to explain all of this increased risk. The excess relative risk for leukaemia excluding chronic lymphocytic leukaemia was 1.93 per Sv (< 0 to 8.47). On the basis of these estimates, 1-2% of deaths from cancer among workers in this cohort may be attributable to radiation.

CONCLUSIONS

These estimates, from the largest study of nuclear workers ever conducted, are higher than, but statistically compatible with, the risk estimates used for current radiation protection standards. The results suggest that there is a small excess risk of cancer, even at the low doses and dose rates typically received by nuclear workers in this study.

Enhanced blood coagulation and fibrinolysis in mice lacking histidine-rich glycoprotein (HRG)

Histidine-rich glycoprotein (HRG) is a serum protein belonging to the cystatin superfamily. HRG may play a regulatory role in hemostasis and innate immunity. However, this role is uncertain because of a lack of rigorous testing in an animal model. We generated mice lacking the translation start point of exon 1 of the Hrg gene, effectively resulting in a null mutation (Hrg-/-). The mice were viable and fertile but had no HRG in their blood. Antithrombin activity in the plasma of Hrg-/- mice was higher than in the plasma of heterozygous Hrg+/- or wild-type Hrg+/+ mice. The prothrombin time was shorter in Hrg-/- mice than in Hrg+/- and Hrg+/+ mice. Bleeding time after tail tip amputation in Hrg-/- mice was shorter than in Hrg+/+ mice. The spontaneous fibrinolytic activity in clotted blood of Hrg-/- mice was higher than in Hrg+/+ mice. These findings suggest that HRG plays a role as both an anticoagulant and an antifibrinolytic modifier, and may regulate platelet function in vivo.

Differential capacity of CD8+ alpha or CD8- alpha dendritic cell subsets to prime for eosinophilic airway inflammation in the T-helper type 2-prone milieu of the lung

BACKGROUND

Different subsets of dendritic cells (DCs), identified in mouse spleen by their differential expression of CD8 alpha, can induce different T-helper (Th) responses after systemic administration. CD8 alpha(-) DCs have been shown to preferentially induce Th type 2 (Th2) responses whereas CD8 alpha(+) DCs induce Th1 responses.

OBJECTIVE

To study if these DC subsets can still induce different Th responses in the Th2-prone milieu of the lung and differentially prime for eosinophilic airway inflammation, typical of asthma.

METHODS

Donor mice first received daily Flt3L injections to expand DC numbers. Purified CD8 alpha(+) or CD8 alpha(-) splenic DCs were pulsed with ovalbumin (OVA) or phosphate-buffered saline and injected intratracheally into recipient mice in which carboxyfluorescein diacetate succinimidyl ester-labelled OVA-specific T cell receptor transgenic T cells had been injected intravenously 2 days earlier. T cell proliferation and cytokine production of Ag-specific T cells were evaluated in the mediastinal lymph nodes (MLNs) 4 days later. The capacity of both subsets of DCs, to prime for eosinophilic airway inflammation was determined by challenging the mice with OVA aerosol 10 days later.

RESULTS

CD8 alpha(-) DCs migrated to the MLN and induced a vigorous proliferative T cell response accompanied by high-level production of IL-4, IL-5, IL-10 and also IFN-gamma during the primary response and during challenge with aerosol, leading to eosinophilic airway inflammation. In the absence of migration to the MLN, CD8 alpha(+) DCs still induced a proliferative response with identical levels of IFN-gamma but reduced Th2 cytokines compared with CD8 alpha(-) DCs, which led to weak eosinophilic airway inflammation upon OVA aerosol challenge. Unpulsed DCs did not induce proliferation or cytokine production in Ag-specific T cells.

CONCLUSION

CD8 alpha(-) DCs are superior compared with CD8 alpha(+) DCs in inducing Th2 responses and eosinophilic airway inflammation in the Th2-prone environment of the lung.

Possible applications of a non-contact 1.48 μm wavelength diode laser in assisted reproduction technologies

Recently, one laser system has been introduced in IVF fulfilling all safety requirements, while achieving a high standard of reproducibility in terms of ablation diameter. This 1.48 microm wavelength indium-gallium-arsenic-phosphorus (InGaAsP) semiconductor laser offers a variety of laser applications to the embryologist. On the one hand, zona pellucida of oocytes or embryos can be manipulated in order to facilitate ICSI or biopsy and assist hatching, and on the other, spermatozoa may be paralysed or immobilized prior to usage. To conclude, the 1.48 microm diode laser provides a promising tool for the microdissection of subcellular targets. The diode laser stands out due to the rapidity, the simplicity and the safety of the procedure which is supported by healthy offspring after laser application.

New options for prenatal diagnosis in autosomal recessive polycystic kidney disease by mutation analysis of the PKHD1 gene

Due to the poor prognosis of severe autosomal recessive polycystic kidney disease (ARPKD), there is a strong demand for prenatal diagnosis (PD). Reliable PD testing is possible by molecular genetic analysis only. Although haplotype-based analysis is feasible in most cases, it is associated with a risk of misdiagnosis in families without pathoanatomically proven diagnosis. Linkage analysis is impossible in families where DNA of the index patient is not available. Direct mutation analysis of the recently identified polycystic kidney and hepatic disease 1 gene opens new options in families to whom a reliable PD cannot be offered on the basis of linkage analysis. We for the first time report two cases with PD based on mutation detection, illustrating the new options for PD in ARPKD.

Viral hepatitis and the surgeon

BACKGROUND

Viral hepatitis is an infection of the liver caused by one or more of six known (HAV-HGV) hepatotropic viruses. It is a common problem among health care workers and their patients. Surgeons are at particular risk of both acquiring and transmitting some of these viruses from and to their patients. Unfortunately, specific immunoprophylaxis for viral hepatitis is presently limited to protecting against the spread of hepatitis A and B viral infections, leaving a high degree of vigilance and careful surgical technique as the only means available to prevent the transmission of other viruses relative to the surgeon. The purpose of this paper is to review the various forms of viral hepatitis including the nature of the virus, serologic testing, clinical features, epidemiology (with specific reference to those issues that arise in surgical practice), treatment and prevention.

Typical metabolic traits of two Oenococcus oeni strains isolated from Valpolicella wines

AIMS

Physiological comparison of two indigenous Oenococcus oeni strains, U1 and F3 isolated in the same area (Valpolicella, Italy) in order to select a performant starter for MLF in wine.

METHODS AND RESULTS

Growth rate, sugar and malate metabolism in FT80 media at pH 5.3 and 3.5 were analysed. The amount of total protein synthesized and the level of expression of the small Hsp Lo18 were evaluated by radiolabelling and immunodetection experiments after heat (42 degrees C), acid (pH 3.5) and ethanol (12% v/v) stresses. Strain U1 showed significantly lower specific growth rate and growth yield in acid conditions than strain F3. However, strain U1 had a higher malate consumption capacity at pH 3.5 than strain F3, in relation with an higher malolactic activity determined on whole cells. Strain U1 exhibited about half the total protein synthesis level than strain F3, but both strains expressed Lo18 similarly. Evaluation of malolactic fermentation (MLF) performance by microvinification trials was carried out. Strain U1 was able to complete MLF, whereas strain F3 degraded malic acid partially when inoculated in Amarone wine.

CONCLUSIONS

Considering its performances in microvinifications experiments, strain U1 could be a good candidate for malolactic starter as an alternative to deficient commercial starters.

Characterization and expression pattern of the novel MIA homolog TANGO

A novel human gene, TANGO, encoding a MIA ('melanoma inhibitory activity') homologous protein was identified by a gene bank search. TANGO, together with the homologous genes MIA, OTOR (FPD, MIAL) and MIA2 define a novel gene family sharing important structural features, significant homology at both the nucleotide and protein level, and similar genomic organization. The four members share 34-45% amino acid identity and 47-59% cDNA sequence identity. TANGO encodes a mature protein of 103 amino acids in addition to a hydrophobic secretory signal sequence. Sequence homology confirms the highly conserved SH3 structure present also in MIA, OTOR and MIA2. Thus, it appears that there are a number of extracellular proteins with SH3-fold like structures. Interestingly, in situ hybridization, RT-PCR and Northern Blots revealed very broad TANGO expression patterns in contrast to the highly restricted expression patterns previously determined for the other members of the MIA gene family. The only cells lacking TANGO expression are cells belonging to the hematopoetic system. High levels of TANGO expression were observed both during embryogenesis and in adult tissues.

Complete oocyte activation failure after ICSI can be overcome by a modified injection technique

BACKGROUND

Complete fertilization failure after ICSI is a rare event, and it may happen repeatedly even in cases of normal sperm parameters and good ovarian response. In these cycles, alternative ICSI techniques may prove useful.

METHODS

Our modified ICSI (mICSI) is characterized by aspiration close to the opposite membrane (the region of the mitochondria with a high inner mitochondrial membrane potential) which is followed by central deposition of the sperm. The method was applied prospectively to ICSI cycles of patients with a history of complete fertilization failure in previous ICSI cycles. In parallel, mICSI was compared with conventional ICSI in terms of further preimplantation development and treatment outcome.

RESULTS

In patients with previous ICSI failures using conventional ICSI (no 2Pn zygotes out of 70 oocytes that had been injected) application of mICSI led to adequate fertilization (53.6%) and pregnancy rates (33.3%) (P < 0.001; P < 0.01). In patients without previous failed fertilization, no improvement in the rates of fertilization, blastocyst formation, implantation or clinical pregnancy could be seen.

CONCLUSIONS

Our data indicate that the present version of ICSI is a reliable alternative to conventional ICSI. However, although it overcomes oocyte-dependent activation failure, routine application does not improve the overall results.

The fate of dendritic cells in a mouse model of liver ischemia/reperfusion injury

Ischemia/reperfusion during liver transplantation triggers a complex cascade of inflammatory events that may lead to organ dysfunction. Herein, we investigated the consequences of hepatic ischemia/reperfusion on liver dendritic cells. Liver damage was documented by increased levels of serum alanine aminotransferase and by histopathology showing large areas of hepatocyte cytolysis. MHC class II+ CD45-B220 F4/80 dendritic cells were detected in necrotic areas 20 hours after reperfusion. Dendritic cells freshly isolated from reperfused livers displayed a mature phenotype characterized by upregulated expression of B7 costimulatory molecules; MHC-class II, and CD1d molecules. As shown by real-time PCR, IL-10, and TGF-beta mRNA accumulated in liver dendritic cells isolated after reperfusion, whereas IL-12p40 mRNA levels were decreased and IFN-gamma mRNA levels were unchanged. These results suggest that hepatic ischemia/reperfusion results in maturation of dendritic cells, which preferentially produce inhibitory cytokines.

Peyronie's disease fibroblasts demonstrate tumorigenicity in the severe combined immunodeficient (SCID) mouse model

Peyronie's disease is a localized connective tissue disorder, caused by trauma to the erect penis, which results in cellular proliferation and excess extracellular matrix production within the tunica albuginea of the penis. We have previously demonstrated that cells derived from Peyronie's disease plaque tissue demonstrate increased cell growth, increased S-phase on flow cytometry, stabilization and inactivation of p53, and consistent morphologic transformation, all suggesting that these cells are biologically transformed. Severe combined immunodeficient (SCID) mice have been used extensively to study the pathobiology of malignant and benign tissue and cells. This study was undertaken to determine if Peyronie's derived fibroblasts had the potential to demonstrate tumorigenicity in the SCID mouse model, thus confirming their biologically transformed nature. Cultured fibroblasts were derived from three sources, namely, plaque tissue excised from men with Peyronie's disease, tunical tissue excised from young men with congenital penile curvature and neonatal foreskins. BALB/C SCID mice were divided into three groups and each group was inoculated with cultured fibroblasts from each of the three different sources. All animals were evaluated regularly and maintained in isolation for a period of 3 months following inoculation. All SCID mice inoculated with cells derived from Peyronie's disease plaque tissue (n=10) developed subcutaneous nodules at a mean time period of 2.5+/-0.5 months following injection. The mean maximum dimension and weight of the nodules at the time of killing the animal was 1.1+/-0.2 cms and 0.6+/-0.2 g, respectively. Histologically, the nodules were composed of large pleomorphic epithelioid cells with a high mitotic activity, which were negative for cytokeratin but positive for vimentin. None of the SCID mice inoculated with cells cultured from either normal tunica (n=5) or foreskin (n=5) developed subcutaneous nodules. In conclusion, the tumorigenic nature of Peyronie's disease plaque-derived fibroblasts sheds further light on the pathobiologic characteristics of these cells. Specifically, these data confirm that cells cultured from Peyronie's disease plaque are biologically transformed. Future refinement and study of this animal model may permit a more complete understanding of the pathophysiology of Peyronie's disease and fibromatoses in general. Furthermore, such an animal model may, in the future, allow a more ready evaluation of the therapeutic interventions for Peyronie's disease.

Laser-assisted zona pellucida thinning prior to routine ICSI

BACKGROUND

In MII oocytes showing difficult oolemma breakage, ICSI can cause an increase in the degeneration rate. This may be overcome by laser-assisted ICSI using a 5-10 micro m opening in the zona pellucida for injection. However, such a small opening might impair the hatching process, especially if assisted hatching is applied in addition. In order to prevent this, the present study used routine injection through an area of zona pellucida in which laser zona thinning had been applied, providing for both a reduced mechanical stress to the oocyte and assisted hatching.

METHODS

This prospective study involved 100 cycles with 1016 MII oocytes. Conventional ICSI (control group) was compared with a modified laser-assisted ICSI (study group) in sibling oocytes. In the latter group oocytes were injected through an extended area of zona thinning.

RESULTS

Degeneration rate was significantly lower in the study group (P < 0.004). There were no differences in fertilization, or formation and quality of blastocysts. In the study group embryo quality on day 2 was significantly better (P = 0.004) and herniation of day 5 blastocysts was increased (P = 0.005). Rates of implantation and pregnancy were not affected. However, on day 3 laser-assisted ICSI proved beneficial (P = 0.038) in terms of clinical pregnancy rate.

CONCLUSIONS

The new method combines a less invasive ICSI technique with assisted hatching. Our preliminary data indicate that in addition to an improved oocyte survival, this new approach increases the hatching rate in vitro, which may explain the increase in pregnancy rate, at least in day 3 transfers.

Presence, but not type or degree of extension, of a cytoplasmic halo has a significant influence on preimplantation development and implantation behaviour

BACKGROUND

Since there is considerable disagreement in grading cytoplasmic haloes, this prospective study was set up to evaluate if certain subtypes of haloes are related to further development.

METHODS

Out of a total of 152 patients, 713 zygotes could be checked for the formation of a halo. Where present, haloes were subdivided into concentric (symmetric) and polar (asymmetric) types. In addition, each halo was measured accurately to see if the extension of the halo might influence further development. In parallel, pronuclear patterns were checked.

RESULTS

Halo-positive zygotes did not differ from halo-negative ones in terms of embryo quality and blastocyst formation rate. However, quality of blastocysts (assessed by their inner cell mass consistency) was significantly increased (P < 0.001) if a halo appeared at zygote stage. This phenomenon was not related to type of halo or degree of halo. In terms of pronuclear pattern, pattern 0 (0A, 0B) led to significantly more blastocysts (P < 0.001) of better quality (P = 0.002) compared with patterns 1-5. A stepwise logistic regression showed no relationship between different halo types and pronuclear pattern 0.

CONCLUSIONS

The present study indicates that any halo has a positive prognostic value on blastocyst quality, irrespective of the fact that it is light or extreme, polar or concentric. In addition, the developmental advantage of pattern 0 is confirmed.

Signal recognition particle-dependent protein targeting, universal to all kingdoms of life

The signal recognition particle (SRP) and its membrane-bound receptor represent a ubiquitous protein-targeting device utilized by organisms as different as bacteria and humans, archaea and plants. The unifying concept of SRP-dependent protein targeting is that SRP binds to signal sequences of newly synthesized proteins as they emerge from the ribosome. In eukaryotes this interaction arrests or retards translation elongation until SRP targets the ribosome-nascent chain complexes via the SRP receptor to the translocation channel. Such channels are present in the endoplasmic reticulum of eukaryotic cells, the thylakoids of chloroplasts, or the plasma membrane of prokaryotes. The minimal functional unit of SRP consists of a signal sequence-recognizing protein and a small RNA. The as yet most complex version is the mammalian SRP whose RNA, together with six proteinaceous subunits, undergo an intricate assembly process. The preferential substrates of SRP possess especially hydrophobic signal sequences. Interactions between SRP and its receptor, the ribosome, the signal sequence, and the target membrane are regulated by GTP hydrolysis. SRP-dependent protein targeting in bacteria and chloroplasts slightly deviate from the canonical mechanism found in eukaryotes. Pro- and eukaryotic cells harbour regulatory mechanisms to prevent a malfunction of the SRP pathway.

Developmental competence of oocytes showing increased cytoplasmic viscosity

BACKGROUND

The objective of the study was to investigate the developmental fate of oocytes with increased cytoplasmic viscosity as assessed by the persistence of the injection funnel after withdrawal of the ICSI pipette.

METHODS

For this purpose, 1008 oocytes showing a characteristic injection funnel during ICSI were subdivided into two groups according to the oocyte's ability to restore its spherical shape within 2-3 min after ICSI. Fertilization and further development was evaluated in both groups. In addition, implantation and pregnancy rates were analysed.

RESULTS

In the funnel positive cohort (group 1) significantly fewer oocytes degenerated after injection (P < 0.01) compared with oocytes without persistent funnel (group 2). However, at zygote stage, presence of a halo (P < 0.05) and a optimal pronuclear pattern 0 (P < 0.01) was increased in group 2. In addition, significantly fewer poor quality embryos were found in this group (P < 0.01). The number of good quality blastocysts but not blastocyst formation was increased in group 2 (P < 0.05). This resulted in an increased clinical pregnancy rate if embryos which derived exclusively from funnel negative oocytes were transferred (P < 0.05).

CONCLUSIONS

Our data suggest that cytoplasm of higher viscosity delays development up to cleavage stage and impairs optimal development. Injection funnel persistence was found to be a negative prognostic marker of preimplantation development.

Selection based on morphological assessment of oocytes and embryos at different stages of preimplantation development: a review

In contrast to IVF, in ICSI the surrounding cumulus and corona cells must be removed completely, as only denuded oocytes can be successfully manipulated by the holding pipette. This ancillary effect of ICSI allows us to focus on the morphology of preimplantation development from the earliest stages. Early prognosis regarding the developmental fate of oocytes would help to limit a negative impact of culture conditions. However, little evidence is available that non-invasive selection at the oocyte stage (first polar body, granular cytoplasm) may be of prognostic value. Recently, certain patterns of pronuclei (number and the distribution of nucleoli) at the zygote stage were found to correlate with treatment outcome in IVF and ICSI cycles, offering an additional prognostic tool prior to cleavage. As there is evidence that embryo selection on day 2 or 3 based on morphological criteria (fragmentation, number of blastomeres, multinucleation, uneven cleavage) may be imprecise, patients might benefit from extended embryo culture to day 5. However, not all major chromosomal aberrations are incompatible with blastocyst formation, and prolonged culture in vitro does not exclusively select embryos with a normal chromosomal complement. Consequently, special care should be taken to minimize the presence of aneuploid concepti in culture. In addition, multiple selection at different stages of development will be required to filter out the correct 'candidate' embryo which will result in a healthy newborn.

[Otorhinolaryngologic diseases and flying]

Physiological and pathological aspects of pressure changes, noise, acceleration, variation of temperature, low humidity, stress and time differences in flight passengers and aircrew are discussed. Typical ear, nose, and throat clinic (ENT)-cases such as tubal function disturbances, barotrauma, hypacusis, sudden hearing loss, tinnitus, acute and chronic middle ear diseases, post ear surgery conditions, hearing aids, vertigo and motion sickness are described. The influence on flying of acute and chronic affections of the paranasal sinuses, nasal septal deviation and allergy are listed. The problem of transport of ENT-incapacitated passengers in commercial aircrafts and ambulance jets are dealt with.

First polar body morphology and blastocyst formation rate in ICSI patients

BACKGROUND

It may be beneficial to identify, at a very early stage of development, concepti that will result in viable blastocysts by using a non-invasive technique.

METHODS

Homogeneous groups in terms of first polar body (PB) morphology were analysed with regard to fertilization, embryo quality and blastocyst formation. The strategy was to transfer a maximum of two blastocysts with an adequate inner cell mass deriving from oocytes with identical first PBs in order to obtain information about the actual implantation potential.

RESULTS

A significant relationship between first PB morphology and embryo quality was found. Fragmentation after 2 days was increased in embryos derived from oocytes with fragmented first PBs (P < 0.05) in comparison with those derived from oocytes with intact PBs. No similar correlation could be demonstrated for fertilization rate. Embryos in the intact first PB group showed an increased rate of blastocyst formation as compared with the fragmented first PB group (P < 0.05). In addition, a significant difference in implantation rate (48.6 versus 22.0%; P < 0.025) and ongoing pregnancy rate (68.4 versus 34.8%; P < 0.05) was observed for the intact versus fragmented groups respectively.

CONCLUSION

In conclusion, the current study provides further evidence that preselection at a very early stage may be helpful in identifying a subgroup of preimplantation embryos with a good prognosis to form blastocysts and, consequently, to implant.