Broadening consent--and diluting ethics?

Biobank research is potentially fruitful. It is argued that broad consent is acceptable for future research on biological material because a) the benefit is high, b) it pays respect to people's autonomy, c) it is consistent with current practices and d) because the risk is low. Furthermore, broad consent should be allowed if information is handled safely, people can withdraw and expanded research should be approved by an ethics review board. However, these arguments are flawed and the criteria for broad consent are either too restrictive to allow any research or fail to address important challenges with biobank research. Broad consent for biobank research can hide substantial ethical challenges and threaten trust in research. This does not mean that biobank research should be abandoned or that people cannot authorise future research on donated biological material.

Interaction of vascular smooth muscle cells and monocytes by soluble factors synergistically enhances IL-6 and MCP-1 production

Inflammatory mechanisms contribute to atherogenesis. Monocyte chemoattractant protein (MCP)-1 and IL-6 are potent mediators of inflammation. Both contribute to early atherogenesis by luring monocytes and regulating cell functions in the vessel wall. MCP-1 and IL-6 production resulting from the interaction of invading monocytes with local vessel wall cells may accelerate atherosclerosis. We investigated the influence of the interaction of human vascular smooth muscle cells (SMCs) with human mononuclear cells (MNCs) or monocytes on IL-6 and MCP-1 production in a coculture model. Interaction synergistically enhanced IL-6 and MCP-1 production (up to 30- and 10-fold, respectively) compared with separately cultured cells. This enhancement was mediated by CD14-positive monocytes. It was dependent on the SMC-to-MNC/monocyte ratio, and as few as 0.2 monocytes/SMC induced the synergism. Synergistic IL-6 production was observed at the protein, mRNA, and functional level. It was mediated by soluble factors, and simultaneous inhibition of IL-1, TNF-alpha, and IL-6 completely blocked the synergism. IL-1, TNF-alpha, and IL-6 were present in the cultures. Blockade of the synergism by soluble glycoprotein 130Fc/soluble IL-6 receptor, as well as the induction of synergistic IL-6 production by costimulation of SMCs with IL-1, TNF-alpha, and hyper-IL-6, suggested the involvement of IL-6 trans-signaling. The contribution of IL-6 was consistent with enhanced STAT3 phosphorylation. The present data suggest that SMC/monocyte interactions may augment the proinflammatory status in the tissue, contributing to the acceleration of early atherogenesis.

Time-dependent observation of individual cellular binding events to field-effect transistors

Electrolyte-gate field-effect transistors (EG-FETs) gained continuously more importance in the field of bioelectronics. The reasons for this are the intrinsic properties of these FETs. Binding of analysts or changes in the electrolyte composition are leading to variations of the drain-source current. Furthermore, due to the signal amplification upon voltage-to-current conversion even small extracellular signals can be detected. Here we report about impedance spectroscopy with an FET array to characterize passive components of a cell attached to the transistor gate. We developed a 16-channel readout system, which provides a simultaneous, lock-in based readout. A test signal of known amplitude and phase was applied via the reference electrode. We monitored the electronic transfer function of the FETs with the attached cell. The resulting frequency spectrum was used to investigate the surface adhesion of individual HEK293 cells. We applied different chemical treatments with either the serinpeptidase trypsin or the ionophor amphotericin B (AmpB). Binding studies can be realized by a time-dependent readout of the lock-in amplifier at a constant frequency. We observed cell detachment upon trypsin activity as well as membrane decomposition induced by AmpB. The results were interpreted in terms of an equivalent electrical circuit model of the complete system. The presented method could in future be applied to monitor more relevant biomedical manipulations of individual cells. Due to the utilization of the silicon technology, our method could be easily up-scaled to many output channels for high throughput pharmacological screening.

Moral principles and medical practice: the role of patient autonomy in the extensive use of radiological services

There has been a significant increase in the use of radiological services in the past 30 years. There are many reasons for this, but one has received little attention: the increased role of patient autonomy in healthcare. Patients demand x rays, CT scans, MRI, and positron emission tomography scans. The key question in this article is how a moral principle, such as respect for patient autonomy, can influence the extension of radiological services. A literature review reveals how patient autonomy is acknowledged in radiology, and how it is used both to explain and to justify the increase in radiological examinations. Furthermore, it also shows how the premises favouring patients' exercise of their autonomy are not always present, which makes patient autonomy subject to adverse side effects and even abuse. Patient autonomy can be used to reduce the professionals' responsibility for radiological examinations (by avoiding complaints and lawsuits), to increase the popularity of the profession (by giving the people what they want), to increase the income of the professionals or their institutions, and to promote professional activity. Patient autonomy intended to reduce paternalism, to legitimise otherwise morally unjustifiable actions (such as exposure to radiation), and to protect patients, can easily be used as a moral means for opposite ends. These adverse effects are not peculiar to radiology. However, they emerge particularly clearly in explanations and justifications of the substantial increase in radiological services, as well as in debates on overuse of radiological services.

The inference from a single case: moral versus scientific inferences in implementing new biotechnologies

Are there similarities between scientific and moral inference? This is the key question in this article. It takes as its point of departure an instance of one person's story in the media changing both Norwegian public opinion and a brand-new Norwegian law prohibiting the use of saviour siblings. The case appears to falsify existing norms and to establish new ones. The analysis of this case reveals similarities in the modes of inference in science and morals, inasmuch as (a) a single case functions as a counter-example to an existing rule; (b) there is a common presupposition of stability, similarity and order, which makes it possible to reason from a few cases to a general rule; and (c) this makes it possible to hold things together and retain order. In science, these modes of inference are referred to as falsification, induction and consistency. In morals, they have a variety of other names. Hence, even without abandoning the fact-value divide, there appear to be similarities between inference in science and inference in morals, which may encourage communication across the boundaries between "the two cultures" and which are relevant to medical humanities.

Potential biomarkers of ageing

Life span in individual humans is very heterogeneous.Thus, the ageing rate, measured as the decline of functional capacity and stress resistance, is different in every individual. There have been attempts made to analyse this individual age, the so-called biological age, in comparison to chronological age. Biomarkers of ageing should help to characterise this biological age and, as age is a major risk factor in many degenerative diseases,could be subsequently used to identify individuals at high risk of developing age-associated diseases or disabilities. Markers based on oxidative stress, protein glycation,inflammation, cellular senescence and hormonal deregulation are discussed.

Operative treatment of prolactinomas: indications and results in a current consecutive series of 212 patients

OBJECTIVE

Medical therapy with dopamine agonists (DA) is the primary treatment of choice in most patients with prolactinomas. 'Classical' surgical indications are intolerance or lack of efficiency of DA therapy. Focusing on a possible shift of recent indications, we retrospectively analyzed our results of surgical treatment in prolactinomas.

PATIENTS AND METHODS

Between 1990 and 2005, we have operated on 212 consecutive patients with prolactinomas. Surgical indications were divided into 'classical' indications and 'modern' indications defined as cystic prolactinomas or patients with microprolactinomas who individually decided on a primary surgical treatment.

RESULTS

Initial overall remission was accomplished in 53.2% including giant prolactinomas. However, in microadenomas, the remission rate was significantly higher with 91.3%. Overall remission at the latest follow-up was 42.7%, but 72.5% in intrasellar tumors, 80% in cystic prolactinomas, and 84.8% in microprolactinomas. The overall recurrence rate was 18.7%. Relapse of hyperprolactinemia in microprolactinomas was 7.1%. In our series, continually less patients were surgically treated for 'classical' indications. By contrast, the number of patients who individually decided on a primary surgical therapy has increased considerably.

CONCLUSION

Remission rates after surgical treatment of prolactinomas remain excellent, particularly in microadenoma and intrasellar macroadenomas, whereas morbidity of transsphenoidal surgery is low in the hands of experienced pituitary surgeons. Our remission rates not only confirm the already interdisciplinarily accepted surgical indications, but also emphasize the value of primary transsphenoidal surgery as a discussion-worthy alternative to dopaminergic therapy in young patients with microprolactinomas or cystic tumors.

Alveolar rhabdomyosarcoma of the clivus with intrasellar expansion: Case report

Rhabdomyosarcomas are common tumors of the head and neck region in children. However, a primarily intracranial localization of this tumor entity is rare. We report on a 3-year-old boy presenting with double vision due to left VI (th) nerve palsy. No other neurological deficits were recognized by clinical inspection. MRI scans visualized an enhancing mass lesion in the upper clivus compressing the cavernous sinus and the pituitary gland. Transsphenoidal biopsy was performed and histopathological examination as well as molecular diagnostics confirmed the diagnosis of an alveolar rhabdomyosarcoma (ARMS). Staging identified a metastatic lesion in the fourth thoracic vertebra resulting in the diagnosis of stage IV disease. Treatment modality included stereotactic radio- and chemotherapy.

[The endovenous laser therapy of varicose veins--substantial innovation or expensive playing?]

INTRODUCTION

The aim of the study was to evaluate the efficiency of the endovenous use of laser for treatment of varicose veins. In particular the influence of laser energy on the perivenous temperature, the postoperative clinical and duplex ultrasound course was taken into account.

METHOD

The patients were divided into two groups. In 33 cases the laser therapy was used without perivenous liquid protection. In 30 cases a 0.9 % NaCl solution has been injected around the vein. The laser used was a 980 nm diode laser (Ceralas D 980, Biolitec AG, Bonn). The pulse-mode procedure has been applied for triggering the laser impulse (1.5 s pulse length, 1.5 s pause with a 3 mm withdrawal of the laser fibre. The laser energy was 15 watt. 20 cm distal to the saphenofemoral or saphenopopliteal junction a thermo unit measured continuously the perivenous temperature. Clinical and duplex ultrasound checks were carried out before and on the day of the operation. Further checks followed on the first and tenth day after the operation and 8 weeks and 6 months afterwards.

RESULTS

The perivenous temperature prior to ELT was 31.3 degrees C, then dropping after the injection of the NaCl solution by 3.4 degrees C. During the ELT the temperature rose by 10.0 degrees C without and by 5.5 degrees C with infiltration. The rise in temperature happened only 3 cm before the tip of the laser fibre arrived at the thermo unit and fell quite rapidly. 98 % of the veins showed within the time period of 2 to 14 months an effective occlusion controlled by duplex ultrasound without refluxing segments. All operations were out-patient treatments. The patients were able to take up work after 1 to 7 days.

CONCLUSION

The endovenous laser treatment is an innovative method for the treatment of varicose veins. Considering the mid-term subjective and objective outcomes this method can not only compete with the conventional surgery but has proved to be superior as regards the recurrence rate and patient's comfort. The study presented here, did not find a risk of damage to surrounding non-target tissue.

Analysis and cryopreservation of hematopoietic stem and progenitor cells from umbilical cord blood

BACKGROUND

Umbilical cord blood (UCB) is an important source of hematopoietic stem and progenitor cells (HSC/HPC) for the reconstitution of the hematopoietic system after clinical transplantation. Cryopreservation of these cells is critical for UCB banking and transplantation as well as for research applications by providing readily available specimens. The objective of this study was to optimize cryopreservation conditions for CD34+ HSC/HPC from UCB.

METHODS

Cryopreservation of CD34+ HSC/HPC from UCB after mononuclear cell (MNC) preparation was tested in a research-scale setup. Experimental variations were concentration of the cryoprotectant, the protein additive and cell concentration. In addition, protocols involving slow, serial addition and removal of DMSO were compared with standard protocols (fast addition and removal of DMSO) in order to avoid osmotic stress for the cryopreserved cells. Viability and recoveries of MNC, CD34+ cells and total colony-forming units (CFU) were calculated as read-outs. In addition, sterility testing of the collected UCB units before further processing was performed.

RESULTS

The optimal conditions for cryopreservation of CD34+ HPC in MNC preparations were 10% DMSO and 2% human albumin at high cell concentrations (5 x 10(7) MNC/mL) with fast addition and removal of DMSO. After cryopreservation using a computer-controlled freezer, high viabilities (89%) and recoveries for CD34+ cells (89%) as well as for CFU (88%) were observed. Microbial contamination of the collected UCB samples was reduced to a rate of 6.4%.

DISCUSSION

Optimized cryopreservation conditions were developed for UCB MNC in respect of the composition of the cryosolution. In addition, our results showed that fast addition of DMSO is essential for improved cryopreservation and post-thaw quality assessment results, whereas the speed of DMSO removal after thawing has little influence on the recoveries of CD34+ cells and CFU.

Filter Buffy Coats (FBC): a source of peripheral blood leukocytes recovered from leukocyte depletion filters

In compliance with federal regulations, blood banks routinely use leukocyte depletion filters to eliminate contaminating leukocytes from blood products such as red blood cell and platelet concentrates. We developed and optimized conditions to elute leukocytes adsorbed to these filters; resulting in leukocyte suspensions which we termed Filter Buffy Coats (FBCs). These Filter Buffy Coats can replace standard buffy coats for various research applications. After optimizing both the filter elution medium as well as elution protocols, we compared commonly used leukocyte depletion filters from four different manufacturers. Relative fractions as well as total recoveries of leukocyte subsets, such as lymphocytes, monocytes and granulocytes, found in Filter Buffy Coats were identified and compared among the filters as well as to standard buffy coats and whole blood. Flow cytometric analysis of Filter Buffy Coats confirmed the presence of T- and B-lymphocytes, NK cells and monocytes. Furthermore, a significant quantity of CD34(+) hematopoietic stem or progenitor cells (HSC/HPC) was detected in Filter Buffy Coats prepared from different filters, thus making FBCs a valuable source for research on HSC/HPC. Colony assays revealed that most of these CD34(+) cells are functional. Using immunomagnetic cell sorting (MACS), we isolated a variety of leukocyte populations from FBC mononuclear cells (Filter-PBMCs) including T lymphocytes (CD4(+), CD8(+), CD3(+)), B lymphocytes (CD19(+)), NK cells (CD56(+)), HSC/HPC (CD34(+), CD133(+)) or dendritic cells (BDCA-4(+)). Functional properties of Filter-PBMCs, as well as of some of these isolated leukocyte populations, were confirmed using standard assays. In summary, Filter Buffy Coats are a valuable and convenient source of different peripheral leukocyte populations and can replace standard buffy coat preparations for research applications.

Characterisation of operation conditions and online monitoring of physiological culture parameters in shaken 24-well microtiter plates

A new online monitoring technique to measure the physiological parameters, dissolved oxygen (DO) and pH of microbial cultures in continuously shaken 24-well microtiter plates (MTP) is introduced. The new technology is based on immobilised fluorophores at the bottom of standard 24-well MTPs. The sensor MTP is installed in a sensor dish reader, which can be fixed on an orbital shaker. This approach allows real online measurements of physiological parameters during continuous shaking of cultures without interrupting mixing and mass transfer like currently available technologies do. The oxygen transfer conditions at one constant shaking frequency (250 1/min) and diameter (25 mm) was examined with the chemical sulphite oxidation method. Varied filling volumes (600-1,200 microL) of Escherichia coli cultures demonstrated the importance of sufficient oxygen transfer to the culture. Cultures with higher filling volumes were subjected to an oxygen limitation, which influenced the cell metabolism and prolongated the cultivation time. The effects could be clearly monitored by online DO and pH measurements. A further study of different media in an E. coli fermentation elucidated the different growth behaviour in response to the medium composition. The MTP fermentations correlated very well with parallel fermentations in shake flasks. The new technique gives valuable new insights into biological processes at a very small scale, thus enabling parallel experimentation and shorter development times in bioprocessing.

Ethics of palliative surgery in patients with cancer

BACKGROUND

Surgery is an important palliative method for patients with advanced malignant disease. In addition to concerns related to clinical decision making, various moral challenges are encountered in palliative surgery. Some of these relate to the patients and their illness, others to the surgeons, their attitudes, skills and knowledge base.

METHOD AND RESULTS

Pertinent moral challenges are addressed and analysed with respect to prevailing perspectives in normative ethics. The vulnerability of patients with non-curable cancer calls for moral awareness. Demands regarding sensibility and precaution in this clinical setting represent substantial challenges with regard to the 'duty to help', benevolence, respect of autonomy and proper patient information. Moreover, variations in definition of palliative surgery as well as limited scientific evidence with respect to efficacy, effectiveness and efficiency pose methodological and moral problems. Therefore, a definition of palliative surgery that addresses these issues is provided.

CONCLUSION

Both surgical skill and much moral sensibility are required to improve palliative care in surgical oncology. This should be taken into account not only in clinical practice but also in education and research.

Bilateral subdural haematomata and lumbar pseudomeningocele due to a chronic leakage of liquor cerebrospinalis after a lumbar discectomy with the application of ADCON-L gel

The anti-adhesion gel ADCON-L has been available since the end of the 1990s. During disc surgery it can be applied to the spinal nerve roots and the dura mater spinalis in order to inhibit fibroblast migration and thus avoid postoperative adhesions or excessive keloids, respectively. Due to the way ADCON-L works, inadvertent, intraoperational dural lesions may stay open much longer than usual because ADCON-L inhibits the natural healing process. Possible consequences are a chronic leakage of cerebrospinal fluid in combination with intracranial hypotension syndrome. We report on a patient who underwent lumbar disc surgery with application of ADCON-L gel. Postoperatively he suffered from acute headache, nausea, and vomiting. A lumbar pseudomeningocele was demonstrated on magnetic resonance imaging (MRI). Furthermore, cranial MRI revealed bilateral, chronic subdural haematomata which indicated intracranial hypotension syndrome or continuous leakage of cerebrospinal fluid at the lumbar site. With conservative treatment the problems were gradually reduced and eventually the subdural haematomata were no longer detected. The pseudomeningocele persisted over a 4 month period of observation. Because of the complications we found, the local application of ADCON-L during lumbar disc surgery should be critically evaluated.