[Errors in treatment of soft tissue phlegmon : expert assessment and forensic evaluation]

In ten cases of soft part phlegmons resulting in death (8) and amputation (2) respectively, various types of medical malpractice were evident. The diagnosis was missed, or the disease was correctly diagnosed but underestimated. Typical therapeutic mistakes were the omission of bacteriological investigations and of the proper antibiotical therapy, a delayed hospital admission, or a delayed or insufficient surgical intervention. These errors however could never be proved to have caused the unfavorable outcome in view of the doubtful prognosis of soft part phlegmons even under proper treatment. Thus, evident malpractice never resulted in a condemnation for bodily injury or involuntary manslaughter.

Residual 201Tl activity in irreversible defects as a marker of myocardial viability. Clinicopathological study

BACKGROUND

The objective of the present study was to characterize the relation between the residual 201Tl activity in irreversible perfusion defects and the extent of irreversible myocardial damage indicated by the volume fraction of myocardial interstitial fibrosis in patients with chronic coronary artery disease.

METHODS AND RESULTS

Stress planar 201Tl scintigraphy with tracer reinjection at rest was performed in 37 patients with > or = 75% stenosis of the left anterior descending coronary artery, and anteroseptal 201Tl activity was quantified by computer-assisted placement of regions of interest from the serial myocardial images. During coronary artery bypass grafting (performed within 6 +/- 3 weeks after scintigraphy), two transmural biopsy specimens were taken from the anterior wall of the left ventricle and the amount of interstitial fibrosis was assessed by use of light microscopic morphometry. A wide spectrum of interstitial fibrosis was obtained, ranging from 15 vol% to 60 vol%. Interstitial fibrosis was similar in patients with reversible (n = 11) or irreversible (n = 15) tracer defects in conventional stress-redistribution images. However, interstitial fibrosis was significantly lower in patients who had enhanced regional 201Tl activity after tracer reinjection compared with those who did not have enhancement of tracer activity after reinjection (28 +/- 8 vol%, n = 7, versus 41 +/- 12 vol%, n = 8; P = .031). The correlation between relative poststenotic 201Tl activity and interstitial fibrosis after tracer reinjection was significantly improved compared with conventional redistribution images (r = -.622 versus r = -.851, n = 15; P < .01).

CONCLUSIONS

The present data demonstrate that the level of regional 201Tl activity in redistribution and, in particular, reinjection images is significantly related to the mass of preserved viable myocytes in poststenotic left ventricular myocardium. Therefore, the residual 201Tl activity provides information about viability within irreversible perfusion defects and may itself serve as marker of myocardial viability.

The influence of age on injury severity of restrained front seat occupants in head-on collisions

This excerpt is part of a large-scale retrospective study on the interrelationship between accident severity and injury severity. A multivariate analysis of 319 cases of restrained front seat occupants involved in car-to-car head-on collisions showed the significant influence of the energy equivalent speed (EES) and age of the occupants on the number of rib fractures and sternum fractures. Three hundred occupants sustained no rib fractures, nine occupants one to 16 rib fractures, and ten occupants 17 to 32 rib fractures. In these three groups the EES increased from 35 km/h (no rib fractures) to 55 km/h (one to 16 rib fractures) and to then to 67 km/h (17 to 32 rib fractures). The average age in these groups was 34, 55 and 57 years respectively. Twenty-four occupants sustained sternum fractures. The average values of the EES and the average age were: in the group with sternum fractures: 56 km/h; 50 years old; in the group without sternum fractures: 35 km/h; 34 years old. The probability of sustaining fatal injuries in a head-on collision depended on the EES as well as the age of the occupant. At an EES of 60 km/h the probability of fatal injuries was 0.05% in the group < 30 years and 35% in the group > 59 years. Fifty-eight per cent of the occupants with sternal fractures had rib fractures as well; 46% of the occupants with rib fractures also had sternal fractures. The results were compared to the results of 185 post-mortem simulations of head-on collisions from the year 1973 to 1978. In post-mortem simulations the number of rib fractures and sternum fractures was influenced by vehicle decelerations and the age of the test subjects. The number of rib fractures increased at higher collision speeds, higher decelerations and increased age; the number of sternum fractures increased at higher deceleration and increased age of the test subjects. Seventy-two per cent of the test subjects with sternal fractures had rib fractures; 91% of the subjects with rib fractures had sternal fractures.

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.

Reperfusion injury in skeletal muscle: controlled limb reperfusion reduces local and systemic complications after prolonged ischaemia

Previous studies in isolated limbs using crystalloid perfusion solutions have shown that control of the initial reperfusion reduces postischaemic complications. However, no experimental study has been undertaken to evaluate the concept of controlled limb reperfusion experimentally in an in vivo blood-perfused model and to assess the local as well as systemic effects of normal blood reperfusion and controlled limb reperfusion. Of 20 pigs undergoing preparation of the infrarenal aorta and iliac arteries, six were observed for 7.5 h and served as controls; 14 others underwent 6 h of complete infrarenal occlusion. Thereafter, embolectomy was simulated in eight pigs by removing the aortic clamp and establishing normal blood reperfusion at systemic pressure. In six other pigs, the composition of the reperfusate and the conditions of reperfusion were controlled during the first 30 min, followed by normal blood reperfusion. Some 6 h of infrarenal aortic occlusion leads to a severe decrease in high-energy phosphates and muscle temperature, together with a slight increase in creatine kinase and potassium in the systemic circulation. Normal blood reperfusion resulted in severe reperfusion injury: massive oedema developed, the tissue showed a marked decrease in oxygen consumption, glucose consumption, tissue ATP, total adenine nucleotides, muscle pH and total calcium in the femoral vein. Furthermore, a massive increase was seen in plasma creatine kinase concentration and potassium, together with the development of muscle rigidity. In sharp contrast, initial treatment of the ischaemic skeletal muscle by controlled limb reperfusion resulted in normal water content, oxygen consumption, glucose consumption, flow and muscle rigidity. Furthermore, controlled limb reperfusion resulted in higher total adenine nucleotides content, less tissue acidosis, markedly reduced creatine kinase release, and potassium release as compared with that of normal blood reperfusion. This study shows that 6 h of acute infrarenal aortic occlusion will result in severe reperfusion injury (postischaemic syndrome) if normal blood at systemic pressure is given in the initial reperfusion phase. In contrast, initial treatment of the ischaemic skeletal muscle by controlled limb reperfusion reduces the metabolic, functional and biochemical alterations.

[Life threatening complications in alternative medicine--problems in patient education]

The risk of treatment offered by nonmedical practitioners are demonstrated with six casuistic expertise reports. In four cases the treatment had a lethal outcome, because the underlying illnesses had been underestimated or had not been diagnosed. To the authors opinion a patient's consent in a treatment by nonmedical practitioners is inoperative, because a nonmedical practitioner is on principle unable to inform a patient regularly because of his lack of medical knowledge.

Penetration of spin-labeled dihydrolipoate into the skin of hairless mice. Modification of epidermal and dermal polarity

Electron paramagnetic resonance (EPR) imaging with the modulated field gradient technique is a novel method to investigate skin biophysical and biochemical properties employing specific nitroxide spin probes. Using this method, a distinct increase in polarity from epidermis towards lower dermis is observed with the spin label dit-butylnitroxide (DTBN). With proxylmaleimide a considerable increase in mobility is found, when epidermis is compared with dermal compartments. The effect of the natural antioxidant dihydrolipoate on skin membrane polarity was studied. Skin penetration of spin labeled dihydrolipoate was investigated by EPR imaging. The results indicate that dihydrolipoate also increases membrane polarity. The biophysical and biochemical changes in the epidermis and dermis as revealed by spatial imaging, provide indirect evidence for skin penetration of dihydrolipoate. This conclusion was supported by the finding that spin labeled derivatives of dihydrolipoate and lipoate were detected inside epidermis and dermis by EPR imaging. This study demonstrates the feasibility of EPR imaging to investigate pharmacodynamic and pharmacokinetic properties of spin labeled drugs in skin.

[Capacity to act after stab and cutting injury]

Among 31 cases of death by stab or cut from the years 1989 to 1991 a common injury pattern cases was brought out and related to surviving-time and the capacity to act. The results revealed a short surviving-time if a great blood loss can occur in a short time. There was no correlation between the volume of blood loss and the capacity to act or the lungs weight. From these cases, three cases are reported. First, a single throatcut with cut of the trachea and a surviving-time of 30 minutes. Second, one case of a single heart stab in which the victim could run about 100 meters, and third, one case of an isolated cut of the A. pericardiaca and an estimated surviving-time of 4-12 hours.

Modification of sialic acids by 9-O-acetylation is detected in human leucocytes using the lectin property of influenza C virus

Influenza C virus spike glycoprotein HEF specifically recognizes glycoconjugates containing 9-O-acetyl-N-acetylneuraminic acid. The same protein also contains an esterase activity. Taking advantage of these two properties, influenza C virus was used as a very sensitive probe for the detection of traces of 9-O-acetyl-N-acetylneuraminic acid in human leucocytes. The binding of influenza C virus to leucocyte glycoproteins and gangliosides separated by sodium dodecyl sulphate-polyacrylamide gel electrophoresis and thin-layer chromatography, respectively, was assayed using a chromogenic esterase substrate. In this way, glycoproteins of B-lymphocytes and T-lymphocytes were found to contain 9-O-acetylated sialic acids. Of the various 9-O-acetylated gangliosides detected, one had the characteristics of 9-O-acetylated GD3. The identification of 9-O-acetylated sialic acids on distinct glycoproteins and glycolipids should be helpful in assigning a physiological role to this sugar.

Purification of ATP synthase from beef heart mitochondria (F0F1) and co-reconstitution with monomeric bacteriorhodopsin into liposomes capable of light-driven ATP synthesis

ATP synthase was isolated from beef heart mitochondria by extraction with N,N-bis-(3-D-gluconamidopropyl)deoxycholamide or by traditional cholate extraction. The enzyme was purified subsequently by ion-exchange and gel-permeation chromatographies in the presence of glycerol and the protease inhibitor diisopropylfluorophosphate. The ATP synthase consisted of 12-14 subunits and contained three tightly bound nucleotides. The co-reconstitution of crude or purified ATP synthase with monomeric bacteriorhodopsin by the method of detergent incubation of liposomes yielded proteoliposomes capable of light-driven ATP synthesis, as detected with a luciferase system for at least 30 min. The reaction was suppressed by the inhibitors oligomycin (> 90%) and dicyclohexylcarbodiimide (85%) and by the uncoupler carbonylcyanide-p-trifluormethoxyphenylhydrazone (> 95%). The purified ATP synthase was apparently free of cytochrome impurities and of adenylate kinase activity, i.e. the enzyme exhibited light-driven ATP synthesis without the dark reaction. For the first time, this is demonstrated with purified ATP synthase from beef heart mitochondria.

Cardiac recovery during post-ischemic reperfusion is improved by combination of vitamin E with dihydrolipoic acid

Effects of dietary vitamin E supplementation in rats were studied to determine whether or not they have a higher tolerance against cardiac ischemia-reperfusion injury using the working or Langendorff heart systems. Also, dihydrolipoic acid, recently reported to have potent antioxidant properties and accelerate vitamin E recycling of membrane in vitro, was perfused into the heart model systems to investigate its in vivo relationship with vitamin E. Tissue vitamin E content was increased by vitamin E feeding, but heart preparations did not show any improved functional recovery. Control hearts perfused with dihydrolipoic acid also did not show any improvement. However, a synergistic response is observed with the combination of dihydrolipoic acid perfusion and high dietary vitamin E using both perfusion systems in improvement of cardiac recovery. These results indicate that a high concentration of myocardial vitamin E does not increase tolerance to ischemia-reperfusion injury by itself, but, the combination of exogenous dihydrolipoic acid and high endogenous vitamin E can produce synergistic protective effects on recovery from ischemia during reperfusion.

Nitroxide radical biostability in skin

Nitroxide radicals are important chemical tools in dermatologic research (e.g., for studying biophysical properties of skin lipids and epidermal membranes with the method of electron paramagnetic resonance, EPR, spectroscopy). However, nitroxides may loose their paramagnetic properties in biological tissues, which could limit their usefulness in biomedical applications. We analyzed the biostability of various chemical types of nitroxide radicals in keratinocytes, epidermis homogenate, and intact skin. EPR signal loss of imidazoline, pyrrolidine, piperidine, and oxazolidine nitroxides is attributed to their reduction to the corresponding hydroxylamine. The rate of nitroxide reduction in skin varies considerably with nitroxide ring structure and substitution. The order of nitroxide stability in isolated human keratinocytes, mouse epidermis homogenate, and intact mouse and human skin is imidazoline > pyrrolidine > di-t-butylnitroxide (DTBN) > piperidine > oxazolidine. Cationic nitroxides are reduced much faster than neutral or anionic probes, presumably due to transmembrane electron shuttle or internalization. The results indicate that imidazoline- and pyrrolidine-type nitroxides should be used when high biostability of nitroxides is needed. Piperidine-type nitroxides are versatile probes for studying one-electron transfer reactions in skin.

Surface glycoprotein of influenza C virus: inactivation and restoration of the acetylesterase activity on nitrocellulose

The influenza C glycoprotein HEF was analyzed for acetylesterase activity after SDS-polyacrylamide gel electrophoresis and transfer to nitrocellulose membranes. Using a histological esterase assay, the glycoprotein was detected as a colored band indicating that it is enzymatically active. The enzyme activity was not affected by low pH, but was abolished after denaturation by SDS as well as after breaking the disulfide bonds by reducing agents. Glycoprotein inactivated by SDS regained its enzyme activity if the ionic detergent was displaced by either bovine serum albumin or a nonionic detergent. The stability of the enzyme combined with the color assay provides a convenient tool to study the acetylesterase activity of the influenza C virus glycoprotein.

Cellular changes in HeLa cells and cervix cells after treatment with cyclic nucleotides

Determination of tumor cell maturity and induction of cell differentiation are significant issues in oncology. We studied here in vitro the effects of cyclic AMP and cyclic GMP on human cervix carcinoma cells (HeLa cells), using normal human cervix cells as controls. Relative plasma membrane fluidity (which corresponds with the adhesive power of the cell, membrane permeability, and the ability to maintain the ionic milieu), cell cycle characteristics, and protein kinase C activity (a regulator of the cell cycle) were determined. In the untreated HeLa cells, membrane fluidity and protein kinase C activity were increased versus the controls. Administration of dbcAMP decreased the membrane fluidity and the protein kinase C activity, prolonged the G0/G1 phase of the cell cycle and shortened the S + G2 + M phase; with dbcGMP, the opposite changes were recorded (all findings, p < 0.05). Findings from HeLa cells treated with dbcAMP approached those from the normal controls. Each of the parameter studied reflected the differentiation of the HeLa cells during dbcAMP treatment. They may be of potential use for the determination of tumor cell maturity in clinical oncology.

Molecular aspects of membrane stabilization by ursodeoxycholate [see comment]

BACKGROUND

Ursodeoxycholate, used for therapy in biliary liver diseases, prevents bile salt damage in animal experiments. Using isolated red blood cell and both canalicular and basolateral hepatocyte membranes, the present study examined this protective effect.

METHODS

Membranes were incubated with chenodeoxycholate, with chenodeoxycholate and ursodeoxycholate simultaneously, and first with ursodeoxycholate followed by chenodeoxycholate. Changes in membrane structure were investigated by electron paramagnetic resonance spectroscopy, using different spin labels. Data were confirmed by analysis of membrane lipids and studies with 14C-labeled bile acids.

RESULTS

The increase of polarity in the apolar domain of the membrane caused by chenodeoxycholate corresponded to the amount of solubilized lipids. After preincubation with ursodeoxycholate or its conjugates, membrane damage by subsequent chenodeoxycholate incubation was prevented. This effect was caused by binding of ursodeoxycholate in the apolar domain, of its conjugates in the interface of the membrane.

CONCLUSIONS

Chenodeoxycholate solubilizes membrane lipids and permits water to permeate into plasma membranes. The steroid nucleus of ursodeoxycholate is bound to the apolar domain and that of the conjugates to the interface of the membrane, thus stabilizing membrane structure.

Dihydrolipoic acid prevents hypoxic/reoxygenation and peroxidative damage in rat heart mitochondria

Fluorescence anisotropy (r) was determined in hypoxic/reoxygenating rat heart mitochondria by means of 1,6-diphenyl-1,3,5-hexatriene. During hypoxia, values for r increased, indicating a rigidified membrane. Membrane fluidity was increased when 20 pmol to 2 nmol/mg protein of dihydrolipoic acid (DHL) was present during hypoxia. Dithiothreitol (DTT) or 2-mercaptopropionylglycin (MPG) at similar concentration did not result in membrane fluidization under these conditions. Peroxidative damage was induced in mitochondria by H2O2. In the presence of 2 nmol/mg protein of DHL, malondialdehyde production was decreased by 50%. DTT or MPG brought about only a 25% decrease. These results were corroborated by spin label studies with 4-maleimido-TEMPO and 5-proxylnonane (5-P-9); H2O2 induced a decrease in fluidity in the region of labeled thiol groups and an increase in polarity sensed by 5-P-9. DHL proved efficient in reducing such fluidity and polarity changes.

Cathepsin D as a vitality marker in human skin wounds

This paper shows the results obtained by studying the lysosomal enzyme Cathepsin D as a potential marker for the vitality of wounds in human specimens. We have analyzed 53 samples using enzymological and histological techniques. Our results show the ability of Cathepsin D to establish the vital origin of wounds inflicted 5 minutes or less before death, where the specific activity of cathepsin D reached 0.055 units at the wound edge and 0.01 units in their respective controls (P < 0.001). As previously demonstrated in an experimental series, Cathepsin D seems to be a very useful marker of high forensic interest in especially difficult cases. Further studies are in progress to check the influence of different factors such as drugs intake and clinical conditions on Cathepsin D activity.

Cardioprotective efficiency of dihydrolipoic acid in working rat hearts during hypoxia and reoxygenation. 31P nuclear magnetic resonance investigations

The working rat heart model was used for 31P nuclear magnetic resonance (NMR) studies during normoxia, hypoxia and reoxygenation. Aortic flows of about 35 ml/min could be achieved which equals 65% of the values obtained outside the NMR magnet. Addition of dihydrolipoic acid (DHL) at a concentration of 0.3 mumol/l during hypoxia accelerated the recovery of aortic flow and stabilized it during reoxygenation. During hypoxia, inorganic phosphate contents (Pi) were significantly higher in controls. The phosphate shift indicated a pH decrease in control to 6.98, in DHL treated hearts the calculated pH was 7.15. During both hypoxia and reoxygenation, the phosphocreatinine (PCr) contents were higher in the DHL treated hearts than in controls. In the controls, saturation transfer measurements revealed a decrease of the flux PCr-->ATP during initial reoxygenation, whereas after addition of 0.3 mumol/l of DHL during hypoxia creatine kinase flux remained constant or increased. In isolated rat heart mitochondria, creatine kinase activities were measured under saturating and non-saturating concentrations of PCr. An increase in activity was observed under low PCr (non-saturating) conditions in the presence of 0.7 nmol DHL per mg of protein. At higher concentrations of DHL, creatine kinase activity was increased under all conditions. An increase in ATP synthesis in the working rat heart under influence of DHL is corroborated by NMR spectroscopy.

Intracellular changes of HeLa cells after single or repeated treatment with cytostatics

HeLa cells were treated once or repeatedly using the cytostatics doxorubicin (adriamycin, Ad, CAS 23214-92-8), cisplatin (Pt, CAS 15663-27-1) and fluorouracil (FU, CAS 51-21-8). Intracellular GSH (reduced glutathione) contents, activities of protein kinase C, cytotoxicity and membrane fluidity were investigated. During single treatment protein kinase C activities as well as membrane fluidity increased, whereas intracellular GSH decreased. With repeated treatments protein kinase C activities increased further. Membrane fluidity as well as intracellular GSH contents increased. The investigated parameters may be correlated with sensitivity of cells against cytostatics.

Generation of free radicals in Langendorff and working hearts during normoxia, hypoxia, and reoxygenation

The release of .OH and alkyl free radicals into the coronary flow were compared in Langendorff perfused and working rat hearts during normoxia (30 min), hypoxia (30 min) and reoxygenation (60 min) by means of spin-trapping techniques using 5,5-dimethyl-1-pyrroline-1-oxide (DMPO). In Langendorff hearts, there was a small but steady increase in the radical concentration during the course of hypoxia and reoxygenation. At the start of reoxygenation, only small initial peaks of hydroxyl and alkyl radicals occurred. After a general decrease of free radical production during hypoxia, working hearts produced nearly double the amount of free radicals during reoxygenation as Langendorff hearts. After an initial large increase during early reoxygenation, the amount of free radicals produced fluctuated on a high level during the remaining reoxygenation period. Heart work is thus correlated with an increased production of free radicals, possibly due to an increase in oxygen consumption by the heart.