Opportunities and challenges of self-binding directives: A comparison of empirical research with stakeholders in three European countries

BACKGROUND

Self-binding directives (SBDs) are psychiatric advance directives that include a clause in which mental health service users consent in advance to involuntary hospital admission and treatment under specified conditions. Medical ethicists and legal scholars identified various potential benefits of SBDs but have also raised ethical concerns. Until recently, little was known about the views of stakeholders on the opportunities and challenges of SBDs.

AIMS

This article aims to foster an international exchange on SBDs by comparing recent empirical findings on stakeholders' views on the opportunities and challenges of SBDs from Germany, the Netherlands, and the United Kingdom.

METHOD

Comparisons between the empirical findings were drawn using a structured expert consensus process.

RESULTS

Findings converged on many points. Perceived opportunities of SBDs include promotion of autonomy, avoidance of personally defined harms, early intervention, reduction of admission duration, improvement of the therapeutic relationship, involvement of persons of trust, avoidance of involuntary hospital admission, addressing trauma, destigmatization of involuntary treatment, increase of professionals' confidence, and relief for proxy decision-makers. Perceived challenges include lack of awareness and knowledge, lack of support, undue influence, inaccessibility during crisis, lack of cross-agency coordination, problems of interpretation, difficulties in capacity assessment, restricted therapeutic flexibility, scarce resources, disappointment due to noncompliance, and outdated content. Stakeholders tended to focus on practical challenges and did not often raise fundamental ethical concerns.

CONCLUSIONS

Stakeholders tend to see the implementation of SBDs as ethically desirable, provided that the associated challenges are addressed.

Ultrahigh resolution whole body photon counting computed tomography as a novel versatile tool for translational research from mouse to man

X-ray computed tomography (CT) is a cardinal tool in clinical practice. It provides cross-sectional images within seconds. The recent introduction of clinical photon-counting CT allowed for an increase in spatial resolution by more than a factor of two resulting in a pixel size in the center of rotation of about 150 µm. This level of spatial resolution is in the order of dedicated preclinical micro-CT systems. However so far, the need for different dedicated clinical and preclinical systems often hinders the rapid translation of early research results to applications in men. This drawback might be overcome by ultra-high resolution (UHR) clinical photon-counting CT unifying preclinical and clinical research capabilities in a single machine. Herein, the prototype of a clinical UHR PCD CT (SOMATOM CounT, Siemens Healthineers, Forchheim, Germany) was used. The system comprises a conventional energy-integrating detector (EID) and a novel photon-counting detector (PCD). While the EID provides a pixel size of 0.6 mm in the centre of rotation, the PCD provides a pixel size of 0.25 mm. Additionally, it provides a quantification of photon energies by sorting them into up to four distinct energy bins. This acquisition of multi-energy data allows for a multitude of applications, e.g. pseudo-monochromatic imaging. In particular, we examine the relation between spatial resolution, image noise and administered radiation dose for a multitude of use-cases. These cases include ultra-high resolution and multi-energy acquisitions of mice administered with a prototype bismuth-based contrast agent (nanoPET Pharma, Berlin, Germany) as well as larger animals and actual patients. The clinical EID provides a spatial resolution of about 9 lp/cm (modulation transfer function at 10%, MTF_10%) while UHR allows for the acquisition of images with up to 16 lp/cm allowing for the visualization of all relevant anatomical structures in preclinical and clinical specimen. The spectral capabilities of the system enable a variety of applications previously not available in preclinical research such as pseudo-monochromatic images. Clinical ultra-high resolution photon-counting CT has the potential to unify preclinical and clinical research on a single system enabling versatile imaging of specimens and individuals ranging from mice to man.

Aktuelle Ist-Analyse zur Situation des nichttraumatologischen Schockraummanagements in Deutschland

Einleitung

In Notaufnahmen kommen bundesweit nichttraumatologische kritisch kranke Patienten zur Aufnahme. Zur Struktur, Organisation und Ausstattung des nichttraumatologischen Schockraummanagements ist bisher wenig bekannt. Mittels einer Umfrage sollte daher der Ist-Zustand analysiert werden.

Methodik

Durch die Arbeitsgruppe „Schockraum“ der Deutschen Gesellschaft Interdisziplinäre Notfall- und Akutmedizin (DGINA) wurde mittels E‑Mail den 420 ärztlichen Leiter*Innen des DGINA-Mitgliederregisters eine Onlineumfrage zugesendet. Zwei Wochen nach initialem Anschreiben erfolgte eine Erinnerung. Die Ergebnisse wurden in einer anonymisierten Datenbank extrahiert und ausgewertet.

Ergebnisse

Insgesamt lag die Rücklaufquote mit 131 verwertbaren Antworten bei 31 %. Die Umfrage erfasste Krankenhäuser der Basis- (24 %), erweiterten (39 %) und umfassenden Notfallversorgung (37 %). Korrespondierend zur Versorgungsstufe stiegen die jährlichen Patientenkontakte (21.000 vs. 31.000 vs. 39.000), die Monitorplätze in den Notaufnahmen (9 ± 4 vs. 13 ± 6 vs. 18 ± 10), die Betten der assoziierten Notaufnahmestationen (4 ± 5 vs. 10 ± 17 vs. 13 ± 12), die verfügbaren Schockräume (1 ± 1 vs. 2 ± 1 vs. 3 ± 1) und deren Größe (31 ± 16 vs. 35 ± 9 vs. 38 ± 14 m2) an. Hinsichtlich verschiedener Ausstattungsmerkmale (z. B. Röntgenlafette: 58 vs. 65 vs. 78 %, Computertomographie im Schockraum: 6 vs. 12 vs. 27 %) zeigten sich deutliche Unterschiede in Abhängigkeit von der Versorgungsstufe. Während Kühlungssysteme in 30 % in allen Versorgungsstufen vorgehalten wurden, fanden sich andere Ausstattungsmerkmale (z. B. Videolaryngoskopie: 65 vs. 80 vs. 86 %, Bronchoskopie: 29 vs. 22 vs. 45 %) und spezielle Notfallprozeduren (z. B. REBOA [„resuscitative endovascular balloon occlusion of the aorta“]: 3 vs. 5 vs. 12 %, ACCD [„automated chest compression device“]: 26 vs. 57 vs. 61 %) häufiger in höheren Versorgungsstufen.

Schlussfolgerung

Die vorliegenden Ergebnisse zeigen erstmals den Ist-Zustand der nichttraumatologischen Schockraumversorgung in verschiedenen Versorgungsstufen in Deutschland. Empfehlungen zu Ausstattungsmerkmalen für das nichttraumatologische Schockraummanagement müssen zukünftig formuliert werden.

Opportunities and risks of self-binding directives: A qualitative study involving stakeholders and researchers in Germany

PURPOSE

Self-binding directives (SBDs) are a special type of psychiatric advance directive in which mental health service users can consent in advance to involuntary hospital admission and involuntary treatment during future mental health crises. This study presents opportunities and risks of SBDs reported by users with bipolar disorder, family members of people with bipolar disorder, professionals working with people with bipolar disorder and researchers with expertise in mental health ethics and law.

METHODS

Seventeen semi-structured interviews with users, family members and professionals, and one focus group with five researchers were conducted. The data was analyzed using qualitative content analysis.

RESULTS

Six opportunities and five risks of SBDs were identified. The opportunities were promotion of autonomy and self-efficacy of users, relief of responsibility for family members, early intervention, reduction of (perceived) coercion, positive impact on the therapeutic relationship and enhancement of professionals' confidence in decision-making. The risks were problems in the assessment of mental capacity, inaccurate information or misinterpretation, increase of coercion through misuse, negative impact on the therapeutic relationship due to noncompliance with SBDs, and restricted therapeutic flexibility and less reflection on medical decision-making. Stakeholders tended to think that the opportunities of SBDs outweigh their risks, provided that appropriate control and monitoring mechanisms are in place, support is provided during the drafting process and the respective mental healthcare setting is sufficiently prepared to implement SBDs in practice.

CONCLUSIONS

The fact that stakeholders consider SBDs as an opportunity to improve personalized crisis care for people with bipolar disorder indicates that a debate about the legal and clinical implementation of SBDs in Germany and beyond is necessary.

[Isolation precautions, diagnostics and organization in German emergency departments during the 2020 COVID-19 pandemic]

BACKGROUND

Since the beginning of the coronavirus disease 19 (COVID-19) pandemic, German emergency departments (ED) have been working in the area of conflict between high case load and demanding hygienic and organizational challenges. The aim of this study was to gain an overview of the current status of isolation measures, diagnostics and patient allocation of suspected COVID-19 cases.

METHODS

Supported by the German Society for Interdisciplinary Emergency and Acute Medicine (DGINA) we invited leading ED physicians to answer an anonymous online survey regarding isolation measures, diagnostics and organization in emergency rooms during the COVID-19 pandemic.

RESULTS

A total of 139 responders from all federal states and all levels of care took part in the survey. Standard operating procedures on COVID-19 exist in almost all participating EDs, although concrete measures to end isolation are often missing. Most EDs screen patients for the "classic" COVID-19 symptoms such as fever, respiratory symptoms or contact to positive subjects in a standardized fashion, although the threshold for prophylactic isolation varies greatly. The individual swab-testing and allocation strategies vary relatively strongly. Less than half of all EDs have a separate procedure for uninterrogatable patients (e.g. major trauma). In about 8% of suspected cases, COVID-19-specific thoracic computed tomography is performed in the ED.

CONCLUSION

The current survey shows that the German EDs are well positioned for the moment, even though the isolation threshold is too high at some locations. In view of a possible increase in the number of cases during the winter season, a more precise differentiation of the previous recommendations of the Robert Koch Institute, especially for emergency admission patients, would be desirable. In this context, we propose a universal algorithm for the (de-)isolation of suspect cases in the ED.

Automatic scanning of large tissue areas in neurosurgery using optical coherence tomography

BACKGROUND

With its high spatial and temporal resolution, optical coherence tomography (OCT) is an ideal modality for intra-operative imaging. One possible application is to detect tumour invaded tissue in neurosurgery, e.g. during complete resection of glioblastoma. Ideally, the whole resection cavity is scanned. However, OCT is limited to a small field of view (FOV) and scanning perpendicular to the tissue surface.

METHODS

We present a new method to use OCT for scanning of the resection cavity during neurosurgical resection of brain tumours. The main challenges are creating a map of the cavity, scanning perpendicular to the surface and merging the three-dimensional (3D) data for intra-operative visualization and detection of residual tumour cells.

RESULTS

Our results indicate that the proposed method enables creating high-resolution maps of the resection cavity. An overlay of these maps with the microscope images provides the surgeon with important information on the location of residual tumour tissue underneath the surface.

CONCLUSION

We demonstrated that it is possible to automatically acquire an OCT image of the complete resection cavity. Overlaying microscopy images with depth information from OCT could lead to improved detection of residual tumour cells.

Brain-mapping using robotized TMS

We present first results of brain-mapping using robotic Transcranial Magnetic Stimulation. This non-invasive procedure enables the reliable detection of the representation of individual muscles or muscle groups in the motor-cortex. The accuracy is only exceeded by direct electrical stimulation of the brain during surgery. Brain-mapping using robotic TMS can also be used to detect displacements of brain regions caused by tumors. The advantage of TMS is that it is non-invasive. In this study, we compare results from statistical mapping with robotic TMS to results achieved from direct stimulation done during tumor surgery. To our knowledge this is the first study of this type. We mapped the representation of three muscle groups (forearm, pinky and thumb) in tumor patients with the robot-aided TMS protocol and with direct stimulation. The resulting maps agree within 5mm.

Brain mapping with transcranial magnetic stimulation using a refined correlation ratio and Kendall's tau

Transcranial magnetic stimulation provides a mean to stimulate the brain non-invasively and painlessly. The effect of the stimulation hereby depends on the stimulation coil used and on its placement. This paper presents a mapping algorithm based on the assumption of a monotonous functional relationship between the applied electric field strength at the representation point of a muscle and the evoked motor potential. We combine data from coil characteristics, coil placement, and stimulation outcome to calculate a likelihood map for the representation of stimulated muscles in the brain. Hereby, correlation ratio (CR) and Kendall's rank coefficient tau are used to find areas in the brain where there is most likely a functional or monotonous relationship between electric field strength applied to this area and the muscle response. First results show a good accordance of our method with mapping from functional magnetic resonance imaging. In our case, classical evaluation of CR with binning is impossible, because sample data sets are too small and data are continuous. We therefore introduce a refined CR formula based on a Parzen windowing of the X-data to solve the problem. In contrast to usual windowing approaches, which require numeric integration, it can be evaluated directly in O(n2) time. Hence, its advantage lies in fast evaluation while maintaining robust applicability to small sample sets. We suggest that the presented formula can generally be used in CR-related problems where sample size is small and data range is continuous.

A clinical study in situ to assess the effect of a food approved polymer on the erosion potential of drinks

OBJECTIVES

The consumption of acidic soft drinks continues to rise as do concerns regarding effects of frequent intake. The aim of the study was to determine the effect of acidic soft drinks containing food approved polymers, on dental enamel.

METHODS

The study design was a single blind, randomised, five-treatment crossover clinical trial involving 15 healthy dentate subjects. Subjects wore an upper removable acrylic appliance retaining two enamel specimens and consumed 250ml of beverage four times/day for 10 days. The following beverages were tested: (1) unmodified acidic soft drink, (2) experimental acidic soft drink with 0.02% polyphosphate, (3) experimental acidic soft drink with 0.02% polyphosphate and 0.01% calcium, (4) experimental acidic soft drink with 0.02% polyphosphate and 0.03% xanthan gum, and (5) mineral water. Tissue loss was measured at days 5 and 10 of each study leg using a profilometer.

RESULTS

The order of erosion from most to least at day 10 was unmodified acidic soft drink>experimental acidic soft drink with polyphosphate>experimental acidic soft drink with polyphosphate+gum>experimental acidic soft drink with polyphosphate+calcium>mineral water. At day 10 the unmodified acidic soft drink was significantly (p=0.001) more erosive than all other drinks.

CONCLUSIONS

Unmodified acidic soft drink with the addition of polyphosphate alone or combined with calcium or xanthan gum are all effective at reducing erosion of enamel compared with the unmodified soft acidic drink.

The relationship between enamel softening and erosion caused by soft drinks at a range of temperatures

OBJECTIVES

Investigations of the erosive potential of soft drinks are usually performed at room or body temperature, but drinks are more frequently served chilled, with ice, or hot. Since the rate of chemical reactions usually increases with temperature, it is predicted that erosion is more severe at high temperatures and reduced at low temperatures. The aim of this study was to investigate the correlation between enamel softening, enamel erosion, and temperature.

METHODS

Atomic force microscopy nanoindentation and non-contact optical profilometry were used to assess changes in enamel nanomechanical properties after 5 min and erosive material loss after 30 min exposure to two different non-carbonated soft drinks at 4, 25, 50 and 75 degrees C.

RESULTS

For one drink (Robinson's Original Juice Drink), there was a statistically significant difference between nanomechanical properties and erosion depth at all temperatures, with softening and erosion increasing with temperature. For another drink (Ribena ToothKind Juice Drink), there was a slight softening and virtually no material loss, and temperature had no statistically significant impact on erosion. There was a good linear correlation (R2 = 0.94) between nanomechanical properties and material loss.

CONCLUSIONS

The difference between the drinks can be explained by their composition. For the erosive drink, material loss increased, and nanohardness decreased, approximately linearly with temperature. The correlation between softening and erosion demonstrated that nanomechanical properties after very short erosion times can be considered a good predictor of bulk material loss after considerably longer erosion times.

Relationship between enamel erosion and liquid flow rate

The association of severe erosion with certain habits of consuming soft drinks prompted a study of erosion in relation to fluid flow. In the main experiments, citric acid solution (pH 3.2) was directed at polished enamel surfaces at flow rates of 26, 67 or 126 ml min(-1) through outlets of diameters 1.0, 2.6 or 5.0 mm for up to 20 min. Erosion depth increased with time of exposure and total volume of solution, with increasing flow rate and with decreasing outlet diameter. Scanning electron microscopy of acid-treated surfaces and of the subsurface enamel indicated that the clearance of dissolution products, rather than the mechanical dislodgement of partly dissolved crystal bundles, was the main process involved. For an exposure time of 20 min, erosion increased with (liquid velocity)(1/4). In a secondary experiment, it was found that the erosive potential of a low-erosive drink did not increase with increasing liquid velocity. The rapid increase in the rate of erosion caused by citric acid at low liquid velocities shows that reproducible stirring is essential for precision and intercomparison of in vitro studies. It also accounts for the rapid erosion seen when erosive drinks are consumed from a straw placed labial to the anterior teeth, or are "swished" between the teeth.

Erosive Effect of a New Sports Drink on Dental Enamel during Exercise

PURPOSE

To compare the potential erosive effect of a prototype carbohydrate-electrolyte drink (PCE) with a neutral control (water) and a commercially available carbohydrate-electrolyte drink (CCE) during exercise.

METHODS

: Nineteen healthy adults (male, N = 16; female, N = 3) took part in this single blind, three-way crossover study. Subjects were given each of the three drinks according to a randomization schedule, approximately balanced for first-order carryover effects. At the beginning of each of the three study periods, the volunteers were fitted with an intraoral appliance containing two human enamel blocks. During each study period, volunteers exercised for 75 min.d(-1) (5 repetitions of 15 min of exercise, with 5-min rests between exercise repetitions), 5 d.wk(-1) for 3 wk. Each day, drink aliquots of 200 mL were consumed during a 5-min period before exercise and after every 15-min bout of exercise, followed by a final 400-mL aliquot ingested over a 10-min period: a total of 1400 mL per study day. Dental erosion was measured as tissue loss from the enamel blocks by profilometry at the end of each study period.

RESULTS

Water, PCE, and CCE produced 0.138 microm (SD 0.090 microm), 0.138 microm (SD 0.038 microm), and 4.238 microm (SD 3.872 microm) of enamel loss, respectively. A Wilcoxon t statistic showed a significant statistical difference between the PCE and CCE drinks (P < 0.001), whereas no significant difference could be detected between the PCE drink and water (P = 0.740).

CONCLUSION

The PCE solution showed minimal erosion compared with the commercially available drink, and was statistically indistinguishable from water under the conditions of this study. Use of CE solutions formulated to minimize erosion during exercise may provide significant dental benefits.

Rates and predictors for relapse in medication overuse headache: a 1-year prospective study

The authors prospectively studied 98 patients with medication overuse headache. The 1-year relapse rate was 38% but was lower for patients with migraine compared with tension-type headache (22% vs 73%, p < or = 0.002) and combination of migraine and tension-type headache (22% vs 77%, p < or = 0.0001). The rate was also lower for patients overusing triptans than ergots (19% vs 20%, NS) and analgesics (19% vs 58%, p < or = 0.001). The long-term success of withdrawal depends on the type of primary headache and the type of overused medication.

The Early Stages of Native Enamel Dissolution Studied with Atomic Force Microscopy

Food-induced demineralization (erosion) is one of the key factors in surface structural changes of tooth enamel, with soft drinks being a significant etiological agent. The objective of this study was to measure early stages of enamel loss with high accuracy on native enamel surfaces combined with qualitative observations of changes in the surface morphology using the atomic force microscope (AFM). Native unerupted third molar surfaces were partly covered with a gold reference layer. Samples were imaged with the AFM before dissolution (at baseline) and after exposure to three different drinks (mineral water, a "toothkind" blackcurrant drink, and a lemon and lime juice drink) at five different exposure times (15 min, 30 min, 1 h, 2 h, and 3 h). The changes in the surface morphology were investigated qualitatively as well as quantitatively. This study showed that the maximum material loss occurred at the aprismatic parts of the enamel close to the perikymata. The maximum enamel loss was greatest for the lemon and lime juice drink and lowest for water. A two-way ANOVA of the transformed data, employing the natural logarithm, showed a statistically significant difference between both the drinks and the exposure time at a 95% confidence level (P=0.000). This demonstrates that the AFM is a suitable tool for measuring early stages of enamel demineralization. Copyright 2000 Academic Press.

Molecular biological observations in some rare neoplasms: DNA ploidy and cell cycle data in liposarcoma and malignant fibrous histiocytoma

INTRODUCTION

The prognostic significance of tumor DNA ploidy and cell cycle analysis for long-term survival has been examined in 19 patients with liposarcoma or malignant fibrous histiocytoma. In many cases, different tumor areas of primary tumors and local recurrences have been analyzed to reveal intratumoral heterogeneity.

RESULTS

Among the primary tumors, there were eight aneuploid tumors, three of which showed diploid and aneuploid tumor regions. Correlations among DNA ploidy, grading, percentage of S-phase cells and infiltrative growth pattern of the tumors could be demonstrated. Poorly differentiated tumors (G3) showed aneuploidy in six of eight patients. Aneuploid tumors showed S-phase cells in 17.2% (range 3.2-38.1%), which was higher than the percentage of S-phase cells in diploid tumors (9.4%, range 2.1-27.4%). Aneuploid tumors showed a more infiltrative growth pattern (6 of 8 patients) than diploid tumors (6 of 11 patients). The median survival time of patients with diploid tumors was 86.5 months (8-144 months), compared with 40.9 months (11-54 months) for patients with aneuploid tumors.

CONCLUSION

DNA ploidy and percentage of S-phase cells may be considered as prognostic factors.

Free clinics

The simplicity and joy of practicing medicine in free clinics has been discovered by numerous Iowa physicians. They tell of the need to practice pure medicine for Iowans who truly need free medical care. They also share how to start a free clinic, step by step. It's simple, they say, with a little help from colleagues and the community.

A numerical study on learning curves in stochastic multilayer feedforward networks

The universal asymptotic scaling laws proposed by Amari et al. are studied in large scale simulations using a CM5. Small stochastic multilayer feedforward networks trained with backpropagation are investigated. In the range of a large number of training patterns t, the asymptotic generalization error scales as 1/t as predicted. For a medium range t a faster 1/t2 scaling is observed. This effect is explained by using higher order corrections of the likelihood expansion. It is shown for small t that the scaling law changes drastically, when the network undergoes a transition from strong overfitting to effective learning.

Effect of diet and training on muscle glycogen storage and utilization in sled dogs

Two groups of eight Alaskan huskies fed either a high-fat (HFD; 60% kcal from fat and 15% kcal from carbohydrate) or a high-carbohydrate diet (HCD; 60% kcal from carbohydrate and 15% kcal from fat) performed standard aerobic (1 h at 4 m/s on a 0% slope) and anaerobic (3 min at 6.7 m/s on a 10% slope) tests before and after training. Before and immediately after each exercise test, venous blood samples were collected and analyzed for lactate and pyruvate, and muscle biopsies were obtained under local anesthesia from the semitendinosus muscle and analyzed for total muscle glycogen (TMG) concentration. Training was associated with a significant increase in preexercise TMG in both diet groups; this effect was most marked in the HCD. There was no effect of diet or training on TMG utilization during the aerobic tests. The rate of TMG utilization during the anaerobic tests was between 20 and 40 times greater than that measured during the aerobic tests. The pre- to postexercise change in TMG was dependent on preexercise TMG in the HCD and HFD for both anaerobic tests (HCD: P < 0.01, r = 0.81; HFD: P < or = 0.03, r = 0.66). It is concluded that the increased glycogen storage associated with the HCD was more than offset by the more rapid rate of glycogen utilization in this group. HFD facilitated carbohydrate sparing during intense exercise and should thus be a better dietary strategy for endurance in sled dogs.

Assessment of female reproductive status in captive-housed Hanuman langurs (Presbytis entellus) by measurement of urinary and fecal steroid excretion patterns

The study reports on the use of urinary and fecal hormone measurements for monitoring female reproductive status in captive-housed Hanuman langurs (Presbytis entellus). Matched urine and fecal samples collected throughout 7 complete menstrual cycles of two females, and during part of one pregnancy in a third female were analyzed. Estrone conjugates (E1C) and immunoreactive pregnanediol glucuronide (PdG) in urine and immunoreactive estradiol (E2), progesterone (P4), pregnanediol (Pd) and 20α-hydroxyprogesterone (20αOHP) in feces were measured by enzymeimmunoassay. E1C and PdG in urine were excreted in a cyclic pattern with E1C levels increasing 3- to 4-fold during the follicular phase to reach preovulatory peak values 2 days before a defined rise in PdG concentrations. Cycle lengths ranged between 20 and 34 days comprising a variable follicular phase of 7-21 days and a more consistent luteal phase of 12-14 days. High pressure liquid chromatography (HPLC) analysis of fecal extracts confirmed the presence of all fecal hormones measured, but indicated large amounts of additional immunoreactivity in the three progestin assays. The patterns of excretion of fecal E2 and all three fecal progestins corresponded well with those of steroid metabolites in urine in showing a clear and well defined follicular phase E2 rise followed by a luteal phase progestin increase. Measurement of 20αOHP immunoreactivity revealed the most stable baseline and the highest follicular/luteal phase differential. Levels of all hormones were clearly elevated during pregnancy although urinary E1C and PdG showed a more pronounced increase compared to fecal metabolites. The results indicate that urinary and fecal hormone analysis can be applied to noninvasive monitoring of reproductive status in the Hanuman langur. © 1995 Wiley-Liss, Inc.

Protection of immunosuppressed mice against infection with Pseudomonas aeruginosa by recombinant P. aeruginosa lipoprotein I and lipoprotein I-specific monoclonal antibodies

Outer membrane protein I (OprI) is one of the major proteins of the outer membrane of Pseudomonas aeruginosa. The protective effect of OprI vaccination and that of three OprI-specific monoclonal antibodies (MAbs) against infection with P. aeruginosa were tested in immunosuppressed mice. The combination of Oprl and MAb 2A1 protected the mice against a challenge with a 96-fold 50% lethal dose. The binding site of MAb 2A1 was mapped, resulting in the identification of a protective epitope (amino acids 7 to 20).

Protection against experimental Pseudomonas aeruginosa infection by recombinant P. aeruginosa lipoprotein I expressed in Escherichia coli

Lipoprotein I (OprI) is one of the major proteins of the outer membrane of Pseudomonas aeruginosa. OprI is a candidate for a vaccine against P. aeruginosa, because it cross-reacts antigenically in all serotype strains of the International Antigenic Typing Scheme. We recently cloned and expressed the gene coding for OprI in Escherichia coli. This heterologously expressed OprI was used successfully to immunize mice against P. aeruginosa. In addition, OprI from serogroup 12 of P. aeruginosa was highly purified by preparative isoelectric focusing and used for immunization of mice. Both vaccines protected the mice against a challenge with a four- to fivefold 50% lethal dose of P. aeruginosa.

Enteroclysis: double contrast examination of the small bowel

Enteroclysis is a double contrast study of the small bowel. This procedure allows the radiologist to evaluate the small bowel for disease processes including Crohn's disease, Meckel's diverticulum, and malabsorption diseases--all disease processes sometimes missed through single contrast SBFT. Through the use of enteroclysis, the radiologist can detect mucosal fold pattern changes, ulceration of the lumen, dilation of the loops, and intussusception, which can cause an obstruction. Even though the procedure is costly and time consuming, it provides a more accurate evaluation of the small bowel.

Dynamic imaging of the wrist

Dynamic imaging of the wrist can be performed through the use of fluoroscopy, arthrography, and arthrotomography. These methods of imaging have proved valuable in the diagnosis of many pathologic conditions of the wrist. Fluoroscopy has proved valuable as it captures the kinematics of the wrist. Arthrography utilizes contrast media to demonstrate anatomic structures not normally visualized on plain radiographs. Last, the technique of arthrotomography improves evaluation by helping to eliminate the problem of superimposition of structures within the wrist. Dynamic imaging of the wrist has proved to be a valuable tool in the diagnosis of chronic conditions of the wrist.

An auto-anti-b in an a1b person. Serological studies

The serum of a patient (Mr. Lat) with the regular blood group A1 B contains an anti-B reacting with all cells having a B antigen except Bx and cis AB. The anti-B reacts at 4 degrees C and occasionally at room temperature as shown by agglutination, absorption-eluction and by thermo-dynamic assays. The antibody is regarded as an irregular autoantibody belonging to the group of the so called "suppressed" or "latent" antibodies.

[Frequency of Lewis blood groups and ABH and Lewis substance secretion in Schleswig-Holstein]

According to the hypothesis of Ceppellini and Morgan the Lewis blood groups are formed by the secondary attachment of the Lewis substances to the red blood cells and this process is genetically controlled by the genes of the ABH und Lewis(a)-substance secretion (SE, se, L and 1). The correctness of this hypothesis is demonstrated by determination of the Lewis blood groups and the ABH and Lewis secretor status with different suitable antisera and by estimation of the gene frequencies Se, se, L and 1 in a sample of 382 blood donors from Schleswig-Holstein and by determination of the same groups in 73 pairs of parents with 156 children. There are no significant differences between observation and expectation in the sample as well as in the family investigation and there are no critical pairs of parents having children with "impossible" Lewis blood group. The results suggest to make more use of the Lewis blood groups.