Experience with the Implementation of Continuous Medical Education among Mother-and-Child Healthcare Providers in Ukraine: A Case Study Based on Two International Collaboration Initiatives

BACKGROUND

Healthcare labor market shortages due to migration, inadequate investments, and lack of continuous training are essential concerns in the Eastern European region. This article aims to describe and reflect on the experience with the implementation of continuous medical education among mother-and-child healthcare providers in Ukraine, including achievements, challenges, and barriers. We analyze this case based on two international collaboration initiatives: the Swiss-Ukrainian program in mother-and-child health that ran from 2000 to 2015, supplemented by the recent Ukrainian-Swiss project "Medical education development" in 2018-2023.

METHODS

We use a case study approach as the methodology for our study. We collected data from documents (project reports reviews) and in-depth interviews with stakeholders. We apply the method of directed qualitative content analysis.

RESULTS

As a result of the Swiss-Ukrainian collaborations, the knowledge and awareness of medical personnel were greatly improved. Modern clinical concepts not well understood at the outset became commonplace and were incorporated into clinical activities. Nevertheless, obstacles to the implementation and rapid uptake of changes were found in the lack of knowledge of the English language among medical doctors, the fear of changes, and the lack of openness and readiness for novel evidence-based clinical practices. However, primary healthcare practitioners in this new project seem to be more inclined to change.

CONCLUSIONS

A modernized continuous medical education which is based on the values of openness, respect, dialogue, and professionalism can be implemented with the input of an international assistance program despite the resistance of the system towards change.

How to not induce SNAs: The insufficiency of directional force

People respond faster to smaller numbers in their left space and to larger numbers in their right space. Here we argue that movements in space contribute to the formation of spatial-numerical associations (SNAs). We studied the impact of continuous isometric forces along the horizontal or vertical cardinal axes on SNAs while participants performed random number production and arithmetic verification tasks. Our results suggest that such isometric directional force do not suffice to induce SNAs.

Assessment of water, sanitation, and hygiene services in district health care facilities in rural area of Mekong Delta, Vietnam

Access to sufficient water, sanitation, and hygiene (WASH) services is a crucial requirement for patients during therapy and general well-being in the hospital. However, in low- and middle-income countries, these services are often inadequate, resulting in increased morbidity and mortality of patients. This study aimed at assessing the current situation of WASH services in six District Health Care Facilities (DHCFs) in rural areas of the Mekong Delta provinces, Vietnam. The results showed that these services were available with inappropriate quality, which did not compromise the stakeholders' needs. The revealed WASH infrastructures have raised concerns about the prolonged hospital stays for patients and push nosocomial infections to a high level. The safety of the water supply was doubted as the high E. coli (> 60%) and total coliform incidence (86%) was observed with very low residual chlorine concentration (< 0.1 mg/L) in water quality assessment. Moreover, water supply contained a high concentration of iron (up to 15.55 mg/L) in groundwater in one DHCF. Technical assessment tool analysis proved that the improper management and lack of knowledge by human resources were the primary roots of the observed status WASH services. Improvement of the perceptions of WASH should be done for the hospital staff with collaboration and support from the government to prevent incidents in the future.

Coexisting multi-states in catalytic hydrogen oxidation on rhodium

Catalytic hydrogen oxidation on a polycrystalline rhodium foil used as a surface structure library is studied by scanning photoelectron microscopy (SPEM) in the 10-6 mbar pressure range, yielding spatially resolved X-ray photoemission spectroscopy (XPS) measurements. Here we report an observation of a previously unknown coexistence of four different states on adjacent differently oriented domains of the same Rh sample at the exactly same conditions. A catalytically active steady state, a catalytically inactive steady state and multifrequential oscillating states are simultaneously observed. Our results thus demonstrate the general possibility of multi-states in a catalytic reaction. This highly unusual behaviour is explained on the basis of peculiarities of the formation and depletion of subsurface oxygen on differently structured Rh surfaces. The experimental findings are supported by mean-field micro-kinetic modelling. The present observations raise the interdisciplinary question of how self-organising dynamic processes in a heterogeneous system are influenced by the permeability of the borders confining the adjacent regions.

Resolving multifrequential oscillations and nanoscale interfacet communication in single-particle catalysis

In heterogeneous catalysis research, the reactivity of individual nanofacets of single particles is typically not resolved. We applied in situ field electron microscopy to the apex of a curved rhodium crystal (radius of 650 nanometers), providing high spatial (~2 nanometers) and time resolution (~2 milliseconds) of oscillatory catalytic hydrogen oxidation, to image adsorbed species and reaction fronts on the individual facets. Using ionized water as the imaging species, the active sites were directly imaged with field ion microscopy. The catalytic behavior of differently structured nanofacets and the extent of coupling between them were monitored individually. We observed limited interfacet coupling, entrainment, frequency locking, and reconstruction-induced collapse of spatial coupling. The experimental results are backed up by microkinetic modeling of time-dependent oxygen species coverages and oscillation frequencies.

CO Oxidation on Stepped Rh Surfaces: μm-Scale Versus Nanoscale

Abstract

The catalytic CO oxidation reaction on stepped Rh surfaces in the 10−6 mbar pressure range was studied in situ on individual μm-sized high-Miller-index domains of a polycrystalline Rh foil and on nm-sized facets of a Rh tip, employing photoemission electron microscopy (PEEM) and field-ion/field-emission microscopy (FIM/FEM), respectively. Such approach permits a direct comparison of the reaction kinetics for crystallographically different regions under identical reaction conditions. The catalytic activity of the different Rh surfaces, particularly their tolerance towards poisoning by CO, was found to be strongly dependent on the density of steps and defects, as well as on the size (µm vs. nm) of the respective catalytically active surface.

Graphic Abstract

Can the use of digital algorithms improve quality care? An example from Afghanistan

BACKGROUND

Quality of care is a difficult parameter to measure. With the introduction of digital algorithms based on the Integrated Management of Childhood Illness (IMCI), we are interested to understand if the adherence to the guidelines improved for a better quality of care for children under 5 years old.

METHODS

More than one year after the introduction of digital algorithms, we carried out two cross sectional studies to assess the improvements in comparison with the situation prior to the implementation of the project, in two Basic Health Centres in Kabul province. One survey was carried out inside the consultation room and was based on the direct observation of 181 consultations of children aged 2 months to 5 years old, using a checklist completed by a senior physicians. The second survey queried 181 caretakers of children outside the health facility for their opinion about the consultation carried out through the tablet and prescriptions and medications given.

RESULTS

We measured the quality of care as adherence to the IMCI's guidelines. The study evaluated the quality of the physical examination and the therapies prescribed with a special attention to antibiotic prescription. We noticed a dramatic improvement (p<0.05) of several indicators following the introduction of digital algorithms. The baseline physical examination was appropriate only for 23.8% [IC% 19.9-28.1] of the patients, 34.5% [IC% 30.0-39.2] received a correct treatment and 86.1% [IC% 82.4-89.2] received at least one antibiotic. With the introduction of digital algorithms, these indicators statistically improved respectively to 84.0% [IC% 77.9-88.6], >85% and less than 30%.

CONCLUSIONS

Our findings suggest that digital algorithms improve quality of care by applying the guidelines more effectively. Our experience should encourage to test this tool in different settings and to scale up its use at province/state level.

Effectiveness and safety of pharmacological sedation for aggressive or agitated adult patients in a prehospital emergency situation: a systematic review protocol

REVIEW QUESTION/OBJECTIVE

The objective of this systematic review is to identify, evaluate and synthesize evidence on the effectiveness and safety of pharmacological sedation for aggressive or agitated adult patients in a prehospital emergency situation.

The ALMANACH Project: Preliminary results and potentiality from Afghanistan

INTRODUCTION

ALMANACH (ALgorithms for the MANagement of Acute CHildhood illnesses) is an electronic version of IMCI (Integrated Management of Childhood Illness) running on tablets. ALMANACH enhances its concept, it integrates well into health staff's daily consultation work and facilitates diagnosis and treatment. ALMANACH informs when to refer a child or to perform a rapid diagnostic test (RDT), recommends the right treatment dosage and synchronizes collected data real time with a Health Management Information System (DHIS2) for epidemiological evaluation and decision making.

OBJECTIVES

Since May 2016, ALMANACH is under investigational deployment in three primary health care facilities in Afghanistan with the goal to improve the quality of care provided to children between 2 months and 5 years old.

METHODS

IMCI's algorithms were updated in considering latest scientific publications, national guidelines, innovations in RDTs, the target population's epidemiological profile and the local resources available. Before the implementation of the project, a direct observation of 599 consultations was carried out to assess the daily performance at three selected health facilities in Kabul.

RESULTS

The baseline survey showed that nutritional screening, vitamin A supplementation and deworming were not systematically performed: few patients were diagnosed for malnutrition (1.8%), received vitamin A (2.7%) or deworming (7.5%). Physical examination was appropriate only for 23.8% of the diagnoses of respiratory or gastrointestinal diseases, ear infection and sore throat. Respiratory rate was checked only in 33.5% of the children with fever and cough, dehydration status was assessed in only 16.5% of the diarrhoea cases. Forty-seven percent of patients received incorrect treatment. Sixty-four percent of the children, before the introduction of ALMANACH, received at least one antibiotic, although for 87.1% antibiotic therapy was unnecessary. The review of 8'047 paediatric consultations between May 2016 and September 2017 showed that with ALMANACH, malnutrition detection, deworming and Vitamin A supplementation increased respectively to 4.4%, 50.2% and 27.5%. Antibiotic prescription decreased to 21.83% and all children were examined and treated in compliance with the protocols.

CONCLUSION

A survey will be conducted one year after the implementation to validate these initial promising results. If the efficacy of the approach is confirmed, ALMANACH could establish as a powerful innovation for primary health care.

Homer1 (VesL-1) in the rat esophagus: focus on myenteric plexus and neuromuscular junction

Homer1, a scaffolding protein of the postsynaptic density (PSD), enriched at excitatory synapses is known to anchor and modulate group I metabotropic glutamate receptors (mGluRs) and different channel- and receptor-proteins. Homer proteins are expressed in neurons of different brain regions, but also in non-neuronal tissues like skeletal muscle. Occurrence and location of Homer1 and mGluR5 in myenteric plexus and neuromuscular junctions (NMJ) of rat esophagus have yet not been characterized. We located Homer1 and mGluR5 immunoreactivity (-iry) in rat esophagus and focused on myenteric neurons, intraganglionic laminar endings (IGLEs) and NMJs, using double- and triple-label immunohistochemistry and confocal laser scanning microscopy. Homer1-iry was found in a subpopulation of vesicular glutamate transporter 2 (VGLUT2) positive IGLEs and cholinergic varicosities within myenteric ganglia, but neither in nitrergic nor cholinergic myenteric neuronal cell bodies. Homer1-iry was detected in 63% of esophageal and, for comparison, in 35% of sternomastoid NMJs. Besides the location in the PSD, Homer1-iry colocalized with cholinergic markers, indicating a presynaptic location in coarse VAChT/CGRP/NF200- immunoreactive (-ir) terminals of nucleus ambiguus neurons supplying striated esophageal muscle. mGluR5-iry was found in subpopulations of myenteric neuronal cell bodies, VGLUT2-ir IGLEs and cholinergic varicosities within the myenteric neuropil and NMJs of esophagus and sternomastoid muscles. Thus, Homer1 may anchor mGluR5 at presynaptic sites of cholinergic boutons at esophageal motor endplates, in a small subpopulation of VGLUT2-ir IGLEs and cholinergic varicosities within myenteric ganglia possibly modulating Ca²⁺-currents and neurotransmitter release.

ESCRT III repairs nuclear envelope ruptures during cell migration to limit DNA damage and cell death

In eukaryotic cells, the nuclear envelope separates the genomic DNA from the cytoplasmic space and regulates protein trafficking between the two compartments. This barrier is only transiently dissolved during mitosis. Here, we found that it also opened at high frequency in migrating mammalian cells during interphase, which allowed nuclear proteins to leak out and cytoplasmic proteins to leak in. This transient opening was caused by nuclear deformation and was rapidly repaired in an ESCRT (endosomal sorting complexes required for transport)-dependent manner. DNA double-strand breaks coincided with nuclear envelope opening events. As a consequence, survival of cells migrating through confining environments depended on efficient nuclear envelope and DNA repair machineries. Nuclear envelope opening in migrating leukocytes could have potentially important consequences for normal and pathological immune responses.

Moving your Eyes to Solution: Effects of Movements on the Perception of a Problem-Solving Task

There is ample evidence suggesting a bidirectional connection between bodily movements and cognitive processes, such as problem solving. Current research suggests that previous movements can influence the problem-solving process, but it is unclear what phase of this process is affected. Therefore, we investigated participants’ gaze behaviour in the first phase of arithmetic problem solving with two groups (plus group, minus group) to explore a spatial bias toward the left or the right while perceiving a problem-solving task (the water-jar problem) after two different movements—that is, for the plus group, sorting marbles from two outer bowls into one in the middle, and for the minus group, sorting marbles from the middle bowl to the outer ones. We showed a right shift of spatial bias for the plus and to the left for the minus group in the perception and problem tasks. Although movements affected gaze, the groups did not differ in their overall problem-solving strategies; however, the first correct solutions did differ. This study provides further evidence of sensorimotor effects on problem solving and spatial bias and offers insight into how a two-phase problem-solving process is guided by sensorimotor information.

Muscarinic acetylcholine receptors in the mouse esophagus: focus on intraganglionic laminar endings (IGLEs)

BACKGROUND

IGLEs represent the only low-threshold vagal mechanosensory terminals in the tunica muscularis of the esophagus. Previously, close relationships of vesicular glutamate transporter 2 (VGLUT2) immunopositive IGLEs and cholinergic varicosities suggestive for direct contacts were described in almost all mouse esophageal myenteric ganglia. Possible cholinergic influence on IGLEs requires specific acetylcholine receptors. In particular, the occurrence and location of neuronal muscarinic acetylcholine receptors (mAChR) in the esophagus were not yet characterized.

METHODS

This study aimed at specifying relationships of VGLUT2 immunopositive IGLEs and vesicular acetylcholine transporter (VAChT)-immunopositive varicosities using pre-embedding electron microscopy and the location of mAChR1-3 (M1-3) within esophagus and nodose ganglia using multilabel immunofluorescence and retrograde tracing.

KEY RESULTS

Electron microscopy confirmed synaptic contacts between cholinergic varicosities and IGLEs. M1- and M2-immunoreactivities (-iry; -iries) were colocalized with VGLUT2-iry in subpopulations of IGLEs. Retrograde Fast Blue tracing from the esophagus showed nodose ganglion neurons colocalizing tracer and M2-iry. M1-3-iries were detected in about 80% of myenteric ganglia and in about 67% of myenteric neurons. M1- and M2-iry were present in many fibers and varicosities within myenteric ganglia. Presynaptic M2-iry was detected in all, presynaptic M3-iry in one-fifth of motor endplates of striated esophageal muscles. M1-iry could not be detected in motor endplates of the esophagus, but in sternomastoid muscle.

CONCLUSIONS & INFERENCES

Acetylcholine probably released from varicosities of both extrinsic and intrinsic origin may influence a subpopulation of esophageal IGLEs via M2 and M1-receptors.

Moving to Solution

Embodied cognition theories suggest a link between bodily movements and cognitive functions. Given such a link, it is assumed that movement influences the two main stages of problem solving: creating a problem space and creating solutions. This study explores how specific the link between bodily movements and the problem-solving process is. Seventy-two participants were tested with variations of the two-string problem (Experiment 1) and the water-jar problem (Experiment 2), allowing for two possible solutions. In Experiment 1 participants were primed with arm-swing movements (swing group) and step movements on a chair (step group). In Experiment 2 participants sat in front of three jars with glass marbles and had to sort these marbles from the outer jars to the middle one (plus group) or vice versa (minus group). Results showed more swing-like solutions in the swing group and more step-like solutions in the step group, and more addition solutions in the plus group and more subtraction solutions in the minus group. This specificity of the connection between movement and problem-solving task will allow further experiments to investigate how bodily movements influence the stages of problem solving.

Pitfalls using tyramide signal amplification (TSA) in the mouse gastrointestinal tract: endogenous streptavidin-binding sites lead to false positive staining

Highly sensitive immunohistochemical detection systems such as tyramide signal amplification (TSA) are widely used, since they allow using two primary antibodies raised in the same species. Most of them are based on the streptavidin-biotin-peroxidase system and include streptavidin-coupled secondary antibodies. Using TSA in cryostat-sectioned tissues of mouse esophagus, we were puzzled by negative controls with unexpected staining mostly in the ganglionic areas. This prompted us to search for the causing agent and to include also other parts of the mouse gastrointestinal tract for comparison. Streptavidin-coupled antibodies bound to endogenous binding sites yet to be characterized, which are present throughout the mouse intestines. Staining was mainly localized around neuronal cell bodies of enteric ganglia. Thus, caution is warranted when applying streptavidin-coupled antibodies in the mouse gastrointestinal tract. The use of endogenous biotin-blocking kits combined with a prolonged post-fixation time could significantly reduce unintentional staining.

First long term in vivo study on subdurally implanted micro-ECoG electrodes, manufactured with a novel laser technology

A novel computer aided manufacturing (CAM) method for electrocorticography (ECoG) microelectrodes was developed to be able to manufacture small, high density microelectrode arrays based on laser-structuring medical grade silicone rubber and high purity platinum. With this manufacturing process, we plan to target clinical applications, such as presurgical epilepsy monitoring, functional imaging during cerebral tumor resections and brain-computer interface control in paralysed patients, in the near future. This paper describes the manufacturing, implantation and long-term behaviour of such an electrode array. In detail, we implanted 8-channel electrode arrays subdurally over rat cerebral cortex over a period of up to 25 weeks. Our primary objective was to ascertain the electrode's stability over time, and to analyse the host response in vivo. For this purpose, impedance measurements were carried out at regular intervals over the first 18 weeks of the implantation period. The impedances changed between day 4 and day 7 after implantation, and then remained stable until the end of the implantation period, in accordance with typical behaviour of chronically implanted microelectrodes. A post-mortem histological examination was made to assess the tissue reaction due to the implantation. A mild, chronically granulated inflammation was found in the area of the implant, which was essentially restricted to the leptomeninges. Overall, these findings suggest that the concept of the presented ECoG-electrodes is promising for use in long-term implantations.

Distribution of vesicular glutamate transporter 1 (VGLUT1) in the mouse esophagus

In rat and mouse esophagus, vesicular glutamate transporter 2 (VGLUT2) has been demonstrated to identify vagal intraganglionic laminar endings (IGLEs); this has recently also been shown for VGLUT1 in rat esophagus. In this study, we have investigated the distribution of VGLUT1 in the mouse esophagus and compared these results with the recently published data from the rat esophagus. Unexpectedly, we have discovered that VGLUT1 mostly fails to identify IGLEs in the mouse esophagus. This is surprising, since the distribution of VGLUT2 shows comparable results in both species. Confocal imaging has revealed substantial colocalization of VGLUT1 immunoreactivity (-ir) with cholinergic and nitrergic/peptidergic markers within the myenteric neuropil and in both cholinergic and nitrergic myenteric neuronal cell bodies. VGLUT1 and cholinergic markers have also been colocalized in fibers of the muscularis mucosae, whereas VGLUT1 and nitrergic markers have never been colocalized in fibers of the muscularis mucosae, although this does occur in fibers of the muscularis running to motor endplates. Thus, VGLUT1 is contained in the nitrergic innervation of mouse esophageal motor endplates, another difference from the rat esophagus. VGLUT1-ir is therefore present in extrinsic and intrinsic innervation of the mouse esophagus, but the significant differences from the rat indicate species variations concerning the distribution of VGLUTs in the peripheral nervous system.

Benefits of an external focus of attention: Common coding or conscious processing?

We conducted two experiments to assess the effect attentional focus has on learning a complex motor skill and subsequent performance under secondary task loading. Participants in Experiment 1 learnt a golf putting task (300 practice trials) with a single instruction to either focus on their hands (internal focus) or the movement of the putter (external focus). No group differences were evident during learning or retention. Differences between the groups were only apparent under secondary task load; the external group's performance remained robust, while the internal group suffered a drop in performance. Verbal protocols demonstrated that the internal group accumulated significantly more internal knowledge and more task-relevant knowledge in general than the external group. Experiment 2 was designed to establish whether greater internal focus knowledge or greater explicit rule build up in general was responsible for performance breakdown. Two groups were presented with a set of six internal or external rules. Again, no performance differences were found during learning or retention. During the secondary task, both groups experienced performance deterioration. It was concluded that accumulation of explicit rules to guide performance was responsible for the internal group's breakdown in performance under secondary task loading and may be responsible for some of the performance differences reported previously.

Vesicular glutamate transporter 1 immunoreactivity in extrinsic and intrinsic innervation of the rat esophagus

Encouraged by the recent finding of vesicular glutamate transporter 2 (VGLUT2) immunoreactivity (-ir) in intraganglionic laminar endings (IGLEs) of the rat esophagus, we investigated also the distribution and co-localization patterns of VGLUT1. Confocal imaging revealed substantial co-localization of VGLUT1-ir with selective markers of IGLEs, i.e., calretinin and VGLUT2, indicating that IGLEs contain both VGLUT1 and VGLUT2 within their synaptic vesicles. Besides IGLEs, we found VGLUT1-ir in both cholinergic and nitrergic myenteric neuronal cell bodies, in fibers of the muscularis mucosae, and in esophageal motor endplates. Skeletal neuromuscular junctions, in contrast, showed no VGLUT1-ir. We also tested for probable co-localization of VGLUT1-ir with markers of extrinsic and intrinsic esophageal innervation and glia. Within the myenteric neuropil we found, besides co-localization of VGLUT1 and substance P, no further co-localization of VGLUT1-ir with any of these markers. In the muscularis mucosae some VGLUT1-ir fibers were shown to contain neuronal nitric oxide synthase (nNOS)-ir. VGLUT1-ir in esophageal motor endplates was partly co-localized with vesicular acetylcholine transporter (VAChT)/choline acetyltransferase (ChAT)-ir, but VGLUT1-ir was also demonstrated in separately terminating fibers at motor endplates co-localized neither with ChAT/VAChT-ir nor with nNOS-ir, suggesting a hitherto unknown glutamatergic enteric co-innervation. Thus, VGLUT1-ir was found in extrinsic as well as intrinsic innervation of the rat esophagus.

Number and distribution of intraganglionic laminar endings in the mouse esophagus as demonstrated with two different immunohistochemical markers

Intraganglionic laminar endings (IGLEs) represent the only vagal mechanosensory terminals in the tunica muscularis of the esophagus. Two specific markers for IGLEs were recently described in mouse: the purinergic P2 x 2 receptor and the vesicular glutamate transporter 2 (VGLUT2). This study aimed at comparing both markers with respect to their suitability for quantitative analysis. We counted IGLEs immunostained for VGLUT2 and P2 x 2, respectively, and mapped their distribution in esophageal wholemounts of C57Bl/6 mice. Numbers and distribution of IGLEs were compared with those of myenteric ganglia as demonstrated by cuprolinic blue histochemistry. Whereas the distribution of VGLUT2-immunopositive IGLEs closely matched that of myenteric ganglia, P2 x 2-immunopositive IGLEs were rarely found in upper and middle esophagus but increasingly in its lower parts. P2 x 2 stained only half the number of IGLEs found with VGLUT2 immunostaining. We also investigated the correlation between anterograde tracing and immunohistochemistry for identifying IGLEs. Confocal microscopy revealed colocalization of all three markers in approximately 50% of IGLEs. The remaining IGLEs showed only tracer and VGLUT2 labeling but no P2 x 2 immunoreactivity. Thus, VGLUT2 and P2 x 2 represent two specific markers for qualitative demonstration of esophageal IGLEs. However, VGLUT2 may be superior to P2 x 2 as a quantitative marker for IGLEs in the esophagus of C57Bl/6 mice.

Intraganglionic laminar endings and their relationships with neuronal and glial structures of myenteric ganglia in the esophagus of rat and mouse

Intraganglionic laminar endings (IGLEs) represent the only vagal mechanosensory terminals in the tunica muscularis of the esophagus and may be involved in local reflex control. We recently detected extensive though not complete colocalization of the vesicular glutamate transporter 2 (VGLUT2) with markers for IGLEs. To elucidate this colocalization mismatch, this study aimed at identifying markers for nitrergic, cholinergic, peptidergic, and adrenergic neurons and glial cells, which may colocalize with VGLUT2 outside of IGLEs. Confocal imaging revealed, besides substantial colocalization of VGLUT2 and substance P (SP), no other significant colocalizations of VGLUT2 and immunoreactivity for any of these markers within the same varicosities. However, we found close contacts of VGLUT2-positive structures to vesicular acetylcholine transporter, choline acetyltransferase, neuronal nitric oxide synthase, galanin, neuropeptide Y, and vasoactive intestinal peptide immunoreactive cell bodies and varicosities, as well as to glial cells. Neuronal perikarya were never positive for VGLUT2. Thus, VGLUT2 was almost exclusively found in IGLEs and may serve as a specific marker for them. In addition, many IGLEs also contained SP. The close contacts established by IGLEs to myenteric cell bodies, dendrites, and varicose fibers suggest that IGLEs modulate various types of enteric neurons and vice versa.

Binge-eating episodes are not characteristic of carriers of melanocortin-4 receptor gene mutations

Recently, Branson and coworkers reported a strong association between binge-eating disorder (BED) and variants in the melanocortin-4 receptor gene (MC4R). In the current study, we compared the eating behavior of 43 obese probands with functionally relevant MC4R mutations and of 35 polymorphism carriers (V103I or I251L) with wild-type carriers. The module for eating disorders of the Composite International Diagnostic Interview was used to identify binge-eating behavior. The Three-Factor Eating Questionnaire and the Leeds Food Frequency Questionnaire were used to assess restrained eating, disinhibition, hunger and percent total energy intake as fat. No significant differences between carriers of MC4R variants and wild-type carriers were detected. In particular, we found no evidence for an increased rate of binge-eating behavior in obese carriers of MC4R variants. Our findings do not support the strong association between BED and MC4R carrier status.

Vesicular glutamate transporter 2 immunoreactivity in putative vagal mechanosensor terminals of mouse and rat esophagus: indication of a local effector function?

Intraganglionic laminar endings (IGLEs) represent the major vagal afferent structures throughout the gastrointestinal tract. Previous ultrastructural investigations have revealed synaptic contacts of IGLEs on myenteric neurons. Thus, in addtion to functioning probably as mechanosensors, IGLEs may also synaptically influence myenteric neurons. In search of clues for potential transmitters in IGLEs, we investigated, by combined neuronal tracing and immunocytochemistry in the esophagus, the correlation between IGLEs and vesicular glutamate transporter 2 (VGLUT2), which is considered a reliable marker for glutamatergic neurons. In rat esophagus, IGLEs were immunostained with calretinin. In the mouse, anterograde wheat germ agglutinin/horseradish peroxidase (WGA-HRP) tracing from nodose ganglion was used in order to label esophageal IGLEs. Confocal laser scanning microscopy demonstrated that VGLUT2 immunoreactivity was highly colocalized with synaptophysin and that both calretinin and tyramide amplified WGA-HRP in rat and mouse esophagus, respectively. No colocalization was found with calcitonin gene-related peptide, a marker for spinal primary afferents. Thus, VGLUT2 is found in vagal afferent endings in the esophagus, suggesting that glutamate is contained in, and probably released from, synaptic vesicles previously described in IGLEs. Functional evidence pending, this finding is in favor of a local effector function of IGLEs onto myenteric neurons.

Determination of fifteen nucleotides in cultured human mononuclear blood and umbilical vein endothelial cells by solvent generated ion-pair chromatography

The paper describes the development of a method for the determination of 15 nucleotides in cultured mononuclear blood and umbilical vein endothelial cell lysates by solvent generated ion-pair chromatography. The phase system is generated via a mobile phase of 100 mM phosphoric acid adjusted to pH 6.2 with triethylamine. Nucleotides are eluted by applying a linear magnesium ion gradient. The method is robust, highly reproducible and easily adaptable to other cell lysates and allows the separation and quantitation of the nucleotides with detection limits in the range from 17 (ADP) to 126 (CDP) pmol in 20-microl aliquots.

Surgery of a splenic artery aneurysm during pregnancy

We report a case of ligation of the splenic artery with splenectomy during pregnancy due to a splenic artery aneurysm. The risk of aneurysmal rupture is increased in multipara and during pregnancy. As a result of high maternal and fetal morbidity and mortality elective surgery should be performed.

Endothelial cell compatibility of azithromycin and erythromycin

Phlebitis is a severe local adverse event related to the use of parenteral macrolides. In order to evaluate the effect of azithromycin and erythromycin on human venous endothelial cells, we set up an in vitro model. The intracellular levels of purine nucleotides, as adenosine 5'-triphosphate (ATP), adenosine 5'-diphosphate (ADP) and guanosine 5'-triphosphate (GTP), were measured by means of high-performance liquid chromatography. Incubation of cells with 2 mg/mL azithromycin and erythromycin resulted in a rapid decline of intracellular ATP from 12.5 +/- 0.9 nmol/million cells to 4.1 +/- 0.3 and 2.6 +/- 0.4 nmol/million cells, respectively, after 60 min. In addition, ADP was extensively depleted from 2.1 +/- 0.17 nmol/million cells to 0.8 +/- 0.09 and 0.8 +/- 0.13 nmol/million cells after 60 min. After exposure of 0.5 mg/mL azithromycin and erythromycin, no significant decline of intracellular high-energy phosphate levels occurred after 20 and 60 min. Based on these results, solutions of azithromycin and erythromycin may not be well tolerated and may cause local adverse reactions even if diluted according to the manufacturer's recommendation.

CD28 signaling via VAV/SLP-76 adaptors: regulation of cytokine transcription independent of TCR ligation

Since CD28 provides cosignals in T cell responses, a key question is whether the coreceptor operates exclusively via TCRzeta/CD3 or also operates as an independent signaling unit. In this study, we show that CD28 can cooperate with VAV/SLP-76 adaptors to upregulate interleukin 2/4 transcription independently of TCR ligation. CD28 signaling is dependent on VAV/SLP-76 complex formation and induces membrane localization of these complexes. CD28-VAV/SLP-76 also functions in nonlymphoid cells to promote nuclear entry of NFAT, indicating that these adaptors are the only lymphoid components needed for this pathway. Further downstream, CD28-VAV/SLP-76 synergizes with Rac1 and causes F-actin remodelling proximal to receptor. Autonomous CD28 signaling may account for the distinct nature of the second signal and in trans amplification of T cell responses.

Positive regulation of T cell activation and integrin adhesion by the adapter Fyb/Slap

The molecular adapter Fyb/Slap regulates signaling downstream of the T cell receptor (TCR), but whether it plays a positive or negative role is controversial. We demonstrate that Fyb/Slap-deficient T cells exhibit defective proliferation and cytokine production in response to TCR stimulation. Fyb/Slap is also required in vivo for T cell-dependent immune responses. Functionally, Fyb/Slap has no apparent role in the activation of known TCR signaling pathways, F-actin polymerization, or TCR clustering. Rather, Fyb/Slap regulates TCR-induced integrin clustering and adhesion. Thus, Fyb/Slap is the first molecular adapter to be identified that couples TCR stimulation to the avidity modulation of integrins governing T cell adhesion.

In vitro effects of mycophenolic acid on the nucleotide pool and on the expression of adhesion molecules of human umbilical vein endothelial cells

The immunosuppressive drug mycophenolate mofetil (MMF) and its active metabolite mycophenolic acid (MPA) selectively inhibit inosine 5'-monophosphate dehydrogenase (IMPDH), and therefore interfere with cellular guanine nucleotide biosynthesis. IMPDH is additionally involved in the synthesis of membrane glycoproteins, some of which are adhesion receptors known to play an active part in the regulation of cell-cell contacts, which are crucial in the process of recruitment and transendothelial infiltration of activated leucocytes in the transplanted organ. As a consequence, MPA leads to a reduction of cellular infiltrates in the course of transplant rejection. In the present study, the effects of MPA on human umbilical vein endothelial cells (HUVEC) are investigated at both molecular and cellular levels. In our experiments, HUVECs are treated with tumor necrosis factor-alpha (TNF-alpha; 10 ng/ml) in order to mimic activation occurring at a rejection crisis. The dose-dependent influence of concomitant incubation with MPA (5-20 micromol/l; 48 h, 37 degrees C, 5% CO2) on their intracellular nucleotide profile is observed by determining the concentrations of purine and pyrimidine nucleotides, using a HPLC method based on solvent generated ion-exchange. The possibility of synergistic effects is investigated by incubating endothelial cells with mixtures of three different immunosuppressants (mycophenolic acid; cyclosporin A, 100 ng/ml; prednisolone, 1 micromol/l)--a combination commonly used after transplantation--varying the amount of MPA (5-20 micromol/l). Stimulation with TNFalpha does not significantly modulate the intracellular levels of nucleotides quantitated. In the presence of MPA concentrations of at least 5 micromol/l, GTP levels (68+/-12%) are significantly decreased compared to controls (100%). At a concentration of 20 micromol/l MPA, the GTP amount is reduced to 58+/-7%. In contrast to these observations, the levels of UDP and UTP are increasing significantly under coincubation with MPA concentrations greater than 5 micromol/l. At 20 micromol/l MPA, UDP and UTP are increased to 147+/-19% and 114+/-11%, respectively. All other nucleotides (CTP, ADP, ATP) reveal no significant alterations in their intracellular concentrations under the conditions applied. Incubation of TNFalpha-treated HUVEC monolayers, with a mixture of three immunosuppressive drugs varying the amount of MPA, show no significant differences compared with the data observed after incubation with MPA alone. In addition, the influence of MPA (10 micromol/l) on a cellular level is observed by measuring the cell surface expression of adhesion molecules on cytokine-stimulated HUVECs, using TNFalpha (10 ng/ml), interferon-gamma (100 ng/ml), interleukin-1beta (10 ng/ml) and interleukin-8 (20 ng/ml). Expression of the intercellular adhesion molecule-1 (ICAM-1), vascular cell adhesion molecule-1 (VCAM-1), endothelial leucocyte adhesion molecule-1 (ELAM-1) and platelet endothelial cell adhesion molecule-1 (PECAM-1) was assessed by flow cytometry. Activation of endothelial cell monolayers with TNFalpha significantly increases the mean fluorescence intensity of VCAM-1 (361+/-14%) and ICAM-1 (429+/-47%) surface expression, compared to controls, and additionally induces E-selectin expression (2919+/-134%). The same tendencies, but in a lesser degree, are observed under stimulation of cells with either IFNgamma or IL-1beta. Incubation with a combination of TNFalpha and MPA leads to a significant reduction in VCAM-1 (329+/-13%) and E-selectin (2613+/-167%) expression, compared to the values obtained for HUVEC incubated with the cytokine alone. Treatment of the cells with IL-1beta/MPA also reduces the expression of VCAM-1 to a level significantly lower than the level observed after stimulation with IL-1beta. Incubation with MPA alone reveals no significant modulation in the expression of all surface molecules tested compared to the values of unstimulated HUVECs. The experiments show that the immunosuppressive action of MPA not only inhibits lymphocyte proliferation but also decreases the expression of adhesion molecules on endothelial cells, which are the first target of the cellular rejection process.

Determination of the effects of mycophenolic acid on the nucleotide pool of human peripheral blood mononuclear cells in vitro by high-performance liquid chromatography

Immunosuppressive drugs are needed to prevent the rejection of transplanted organs by the immune system. Immunosuppressive antimetabolites act by interrupting cell metabolism. Their mechanism of action can be studied in vitro by measuring the inhibition of biochemical activities which is reflected by changes in the nucleotide content. In our experiments, human peripheral blood mononuclear cells (PBMC) isolated from healthy volunteers were used. After PBMC stimulation with phytohaemagglutinin (PHA) to mimic activation occurring at a rejection crisis, cells were exposed to varying concentrations of different immunosuppressants (i.e., mycophenolic acid, cyclosporin A and prednisolone) for 68 h at 37 degrees C. Changes in nucleotide content were observed by determining the concentrations of 15 nucleotides using a newly developed HPLC method. The results obtained for mycophenolic acid (MPA; final concentrations in a range between 0.1 and 5 micromol/l), cyclosporin A (CsA; final concentrations between 100 ng/ml and 1 microg/ml) and prednisolone (final concentrations between 0.5 and 10 micromol/l) are given as percentage changes in nucleotide content versus controls and are expressed as mean +/- confidence interval. The possibility of synergistic effects was investigated by incubating the cells with mixtures of all three immunosuppressive drugs varying the amount of mycophenolic acid. In addition, we have shown the effects of MPA/guanosine co-incubation on the intracellular nucleotide levels. Stimulation of peripheral blood mononuclear cells with phytohaemagglutinin led to a significant increase of pyrimidine and purine nucleotides versus control values (100%). Pyrimidine (CTP, UDP, UTP) and purine nucleotides (GDP, GTP, ADP, ATP) were elevated up to 153+/-14% and 142+/-17%, respectively. Under co-incubation of cells with MPA, the GTP level decreased in a dose-related manner to 56+/-3% of control at a MPA final concentration of 5 micromol/l. Concomitantly, an increase of UTP values to 203+/-18% versus control was observed under co-incubation with 1 micromol/l MPA. Co-incubation of mononuclear cells with guanosine (50 micromol/l) compensated for the effects of MPA on intracellular GTP levels. Combination of MPA, CsA and prednisolone did not alter intracellular nucleotide profiles of PBMC compared to those under MPA incubation alone. The depletion of the guanine nucleotide pool and concomitant increase of uridine nucleotides under the influence of the immunosuppressive drug mycophenolic acid is caused by its inhibitory effects on the key enzyme of de novo purine biosynthesis, inosine 5'-monophosphate dehydrogenase (IMPDH).