Elektronenmikroskopische Untersuchungen an Thrombozyten des Menschen nach Einwirkung verschiedener Gase

Lebensfrische Thrombozyten von gesunden Erwachsenen wurden der Einwirkung von verschiedenen Gasen (CO, CO2, N2 und Luft) ausgesetzt und nach einer Einwirkungsdauer von 20 min sowie 1 und 2 Std. elektronenmikroskopisch untersucht.

Erst nach Inkubationszeiten von 1 und 2 Std. nach Einwirkung von Kohlenmonoxyd und von 2 Std. nach Einwirkung von Stickstoff weisen die Thrombozyten Membranläsionen auf. Eine Einwirkung der Gase von 20 min verursacht keine elektronenmikroskopisch sichtbaren Membranschäden. Wenn die Thrombozyten in Sequestren suspendiert sind, kann sich ihre Zellmembran nicht auflösen. Das Granulomer-α und das Granulomer-β (Mitochondrien) sind auch nach einer Gaseinwirkung von 2 Std. bei z. T. stark geschädigter Throm-bozytenmembran noch gut erhalten. Die unveränderte Mitochondrienstruktur nach einer bis zu 2 Std. dauernden Hyp- bzw. Anoxie ist als wesentlicher Be fund zu werten. Wahrscheinlich läuft der Thrombozytenstoffwechsel unter hypoxischen Bedingungen über die Glykolyse ab. An den Thrombozyten bestehen elektronenmikroskopisch keine wesentlichen Strukturänderungen, die mit Sicherheit auf die Einwirkung der Gase zurückzuführen sind. Die Befunde lassen darauf schließen, daß die Initialschädigungen bei der Thrombose nach CO-Intoxikationen und nach O2-Mangelatmung im Unterdruck zumindest nicht in erster Linie in den Thrombozyten, sondern in der Gefäßwand und in den Geweben liegen. Für die Agglutination der Plättchen dürften Stofffreisetzungen, in erster Linie eine Freisetzung von ADP, verantwortlich sein.

Mitarbeiterzufriedenheit im Arbeitszeitmodell: Längsschnittstudie zu Praxistauglichkeit und Gesetzeskonformität in einer chirurgischen Klinik der Maximalversorgung

Hintergrund In dem Spannungsfeld zwischen Klinikorganisation, Arbeitszeitgesetz, Patientensicherheit, Nachwuchsmangel und Wettbewerbsfähigkeit ist die Entwicklung bestmöglicher Arbeitszeitmodelle zur Aufrechterhaltung maximaler Versorgungsqualität bei gleichzeitiger Gesetzeskonformität unabdingbar. Hierzu ist die Evaluation der Auswirkungen der Dienstmodelle auf die Mitarbeiterzufriedenheit sinnvoll.

Material und Methoden Nach Abschaffung des traditionellen 24-Stunden-Dienstes 2007 in einer chirurgischen Klinik der Maximalversorgung wurden konsekutiv ein 18-Stunden-Dienst und nachfolgend 2008 ein 12-Stunden-Dienstmodell zur Verbesserung der Übergabequalität und Reduktion von Übergabeverlusten implementiert. In einer begleitenden Mitarbeiterbefragung wurden die Auswirkungen auf Arbeitsorganisation, Lebensqualität und Einkommen in anonymisierten Fragebögen evaluiert. 2014 wurde die Mitarbeiterbefragung erneut durchgeführt.

Ergebnisse Bei 95% Rücklaufquote der Fragebögen 2008 und 93% Rücklaufquote 2014 wurde das 12-Stunden-Modell aufgrund der deutlich höheren Dienstfrequenz mit entsprechend höherer sozialer Belastung schlechter bewertet. Ebenso wurde die körperliche Belastung und chronische Müdigkeit im 12-Stunden-Dienst am schlechtesten bewertet. Der 18-Stunden-Dienst war das Modell der 1. Wahl bei den Mitarbeitern. Der 24-Stunden-Dienst wurde als beste Kompromisslösung zwischen Erfordernissen der Arbeitsorganisation und Mitarbeiterbedürfnissen gewertet und das Dienstmodell daraufhin 2015 erneut angepasst.

Schlussfolgerung Essenzielle Grundlage einer chirurgischen Klinik ist ein an die Erfordernisse der Arbeitsabläufe, des Arbeitszeitgesetzes und Bedürfnisse der Mitarbeiter angepasstes Dienstmodell. Der optimalen Arbeitsorganisation kann ein 12-Stunden-Dienstmodell gerecht werden, aber nur bei entsprechendem Personalschlüssel gelingt dies ohne Inkaufnahme einer zu hohen Dienstfrequenz mit entsprechend stark empfundener Beeinträchtigung der Lebensqualität. Eine Mitarbeiterbefragung sollte regelmäßig durchgeführt werden, um die tatsächlichen Auswirkungen des Dienstsystems erfassen und weiter optimieren zu können. Das viel kritisierte 24-Stunden-Dienstsystem erscheint mit Augmentierung durch einen Entlastungsdienst in den Abendstunden deutlich besser als sein Ruf.

Have We Hatched the Addiction Egg: Reward Deficiency Syndrome Solution System™

This article co-authored by a number of scientists, ASAM physicians, clinicians, treatment center owners, geneticists, neurobiologists, psychologists, social workers, criminologists, nurses, nutritionist, and students, is dedicated to all the people who have lost loved ones in substance-abuse and "reward deficiency syndrome" related tragedies. Why are we failing at reducing the incidence of 'Bad Behaviors'? Are we aiming at the wrong treatment targets for behavioral disorders? We are proposing a paradigm shift and calling it "Reward Deficiency Solution System" providing evidence for its adoption.

Low and Normal IGF-1 Levels in Patients with Chronic Medical Disorders (CMD) is Independent of Anterior Pituitary Hormone Deficiencies: Implications for Treating IGF-1 Abnormal Deficiencies with CMD

Over time, based on evidence-based medicine, a number of hormonal test levels including IGF-1 had been raised or lowered to meet new criteria standards. In particular, IGF-1 plasma levels have been shown in several studies to be an independent diagnostic tool in Adult Growth Hormone Deficiency (AGHD). Many endocrinology studies link low IGF-1 plasma levels with low levels of other anterior pituitary hormones (i.e., LH, FSH, and TSH). Low IGF-1 is considered by most to be between 84-100 µ/l and numerous studies recommend that raising IGF-1 to high normal range reverses Chronic Medical Diseases (CMD), improves bone mineral density (BMD), and fibromyalgia. Moreover, some studies suggest that low levels of IGF-1 by itself independent of anterior pituitary deficiencies is sufficient to determine AGHD in humans. In order to determine the relationship of low IGF-1 with that of LH, FSH, and TSH levels in subjects with CMD, we evaluated these levels (± SD) in 944 patients. Patients with IGF-1 below 84 µ/l, 100 µ/l, and 150 µ/l were accessed. 9.22% had less than 84 µ/l (SD ± 12.52); 19.9% had less than 100 µ/l (SD ± 9.54); and 51.6 had less than 150 µ/l (SD ± 26.0). Specifically, the percentages found for low LH, FSH, and TSH were only 4.2%, 4.8%, and 6.5%. We conclude that IGF-1 deficiencies occur independent of comorbid deficiencies of LH, FSH, and TSH. Finally, we propose that based on the present investigation, IGF-1 low levels between the range of 84-100 µ/l may be too low to be considered as an independent diagnostic marker to treat AGHD with CMD.

Results of surgical and somatostatin analog therapies and their combination in acromegaly: a retrospective analysis of the German Acromegaly Register

BACKGROUND

Data on surgical and medical treatment outcomes in acromegaly mostly originate from specialized centers. We retrospectively analyzed the data on surgery, primary somatostatin analog (SSA) therapy, surgery preceded by SSA, and SSA preceded by surgery in 1485 patients from the German Acromegaly Register.

METHODS

Two trained nurses visited all centers (N=42) for data acquisition.

RESULTS

Primary surgery: out of 889 patients, 554 yielded analyzable data (microadenomas 22.9%, macroadenomas 77.1%). GH and IGF1 normalized in 54.3 and 67.2%. Partial or total pituitary insufficiency occurred in 28.6% initially and 41.2% post-surgery. Primary SSA (>or=3 months): out of 329 patients, 145 yielded analyzable data (microadenomas 26.7%, macroadenomas 73.3%). GH and IGF1 normalized in 36.3 and 30.5%, increasing to 40.8 and 41.5% with longer SSA (>or=360 days) in 54 patients. Pituitary function did not change. SSA (>or=3 months) prior to surgery: out of 234 patients, 93 yielded analyzable data. Post-surgery GH and IGF1 was normalized in 62.9 and 68.4%. GH improvement was slightly, but significantly better after SSA pretreatment. Surgery followed by SSA: out of 122 patients, 34 yielded analyzable data. GH and IGF1 normalized during SSA in 24.1 and 45.5%. Relative GH decrease was significantly larger compared with primary SSA.

CONCLUSIONS

Pituitary surgery was more effective to lower GH and IGF1 concentrations than primary SSA. Primary SSA may be an option in selected patients. SSA prior to surgery only marginally improved surgical outcome. Debulking surgery may result in better final outcome in patients with a high GH concentration and a large tumor.

[Epidemiology and perspectives in traumatology of the elderly]

Corresponding to the demographic development, fractures of the humerus, wrist, or hip will occur noticeably more often during the next four decades. The number of patients with hip fractures will increase to 170% of present-day numbers, and in the age group >80 years to 250%. Trauma surgical departments should train their staff as well as adapt their workflows and ambient conditions to this demanding clientele to be prepared for these changes. For the elderly, a fracture may lead to need for permanent home care, which is why postoperative transfer to ambulatory care is especially important. The expected cost progression in traumatology of the elderly may be moderated by the conjunction of inpatient and ambulatory care, the utilization of synergies among the different service types, and by implementation of prophylaxis for osteoporosis and falls.

[A method for reassessment of cost-intensive cases in visceral surgery. Results of project by the German Society for Visceral Surgery]

Since the introduction of diagnosis-related groups (DRGs) many surgical departments report inappropriate reimbursement for complex cases and a shift in costly cases. To evaluate this situation, the German Society for Visceral Surgery inaugurated the present cost calculation project. In three university hospitals for 50 cases each, we depicted possible cost separators and utilized the complete cost calculation data (so-called Paragraph 21 data set) to test these separators. We identified "admission from another hospital", "severe surgically relevant concomitant disease", and "reoperation during the same hospital admission". The last was considered the economically most significant and medically most valid factor and was submitted as a possible modification to the german DRG system. The proposed cost separator "reoperation during the same hospital admission" was introduced into the DRG system after validation and leads to better allocation of reimbursements to complex and costly cases.

Proximale Femurfrakturen im Alter

BACKGROUND

The section of geriatric trauma ("AG-Alterstraumatologie") of the"Deutsche Gesellschaft für Unfallchirurgie" (DGU) and the"Lohmann & Birkner Health Care Consulting GmbH" in co-operation with the health insurance funds (VdAK and AEV) supplied the relevant data of approximately 23 million insured persons from the years 2002 to 2004. All data from patients over the age of 60 staying in hospital because of proximal femur fractures and without further injuries as the main diagnosis were extracted from the available amount of data and then analysed.

RESULTS

In comparison to the effective number of beds there was a significant increase in the treatment of proximal femur fractures in hospitals with 101-300 beds. There was no difference in the operative treatment of proximal femur fractures in comparison to the number of beds of the hospital. The average hospital expense for osteosynthesis was 6000 euro per each case and there was no difference in comparison to the different osteosynthetic procedures. The average hospital expense for hip replacement (7036-7201 euro) was about 1000 euro higher than osteosynthetic procedures. There was no difference in the average hospital expense in comparison to the age of the patients.

CONCLUSION

There was a significant age-dependent increase of acute hospital mortality with a maximum of 8.6% in the group of the patients older than 85 years. As a result of the demographic change fracture rates in the elderly population will rise significantly.

Proximale Femurfrakturen im Alter

BACKGROUND

The section of geriatric trauma ("AG-Alterstraumatologie") of the "Deutsche Gesellschaft für Unfallchirurgie" (DGU) and the "Lohmann & Birkner Health Care Consulting GmbH" in co-operation with the health insurance funds (VdAK and AEV) supplied the relevant data of approximately 23 million insured persons from the years 2002 to 2004.

METHODS

All data from patients over the age of 60 staying in hospital because of proximal femur fractures and without further injuries as the main diagnosis were extracted from the available amount of data and then analysed. There were 68,929 (9.5%) cases diagnosed with proximal femur fractures of 724,606 patients treated in hospital.

RESULTS

There was a significant age-dependent increase in incidents of proximal femur fractures with a maximum of 3,000 injuries around the age of 82 years. The surgical treatment of proximal femur fractures was carried out with a joint-preserving stabilising method (osteosynthesis-screws-"DHS"-nailing systems) in 49.5%, with endoprosthesis in 48.6 % as well as other methods in 1.9% of the cases. In comparison to hip replacement care, a shorter hospital stay could be proved with osteosynthetic methods.

The German Acromegaly Registry: Description of the Database and Initial Results

Patient registries are valuable tools to study long-term morbidity and mortality of rare diseases. Acromegaly is rare (incidence 3-4/mill/year, prevalence 40-70/mill; approx. 300 new patients/yr and up to 5700 patients in Germany). Diagnostic and therapeutic possibilities have considerably improved, but treatment results remain often unsatisfactory. The main cause is residual disease activity after surgery, most importantly due to invasive macroadenomas. The German Acromegaly Registry is an initiative of the Pituitary Study Group of the German Endocrine Society (DGE). Formally established in January 2003 by the Board of the DGE, long-term financial support is guaranteed by an unrestricted grant from Novartis Pharma GmbH to the DGE. The registry cooperates closely with the United Kingdom and the Austrian registries. The aim of the German Acromegaly Registry is to establish a database of sufficient epidemiological strength in order to (1) document co-morbidity and mortality, (2) provide data on diagnostic and therapeutic procedures/effectiveness, (3) enable comparison of procedures in different national centres, (4) provide information for patient support groups/interaction with health care providers, (5) enable comparison with other national registries within Europe. The registry has at present 82 participating centres, and 42 have included patients (20 university clinics, 8 non-university hospitals, 14 centres in private practice). The database aims to include all acromegalic patients in Germany who are cared for and treated at present. Up to December 2005 1543 patients have been entered in a retrospective manner. Data collection is by external monitoring by highly trained study nurses who visit the individual centres. Inclusion is planned to continue at a rate of 500 per year. Starting in 2005 centres are revisited every 3 years at a rate of 500 per year (prospective phase of the registry). Quality of the data has been validated by an independent monitoring team which demonstrated high data concordance.

CONCLUSIONS

Initial results of the German Acromegaly Registry show that it was possible to include a large number of patients within 3 years into the registry. Data quality has been validated and shown to be satisfactory. Therefore, the registry will be a useful tool to study long-term morbidity and mortality in a large series of patients.

[Changes in the G-DRG System from 2003 to 2005 in Ophthalmology--Ophthalmologic G-DRG 2003 to 2005]

BACKGROUND

The objective of the study was to illustrate the effect of the extensive changes of the German DRG System on reimbursement of clinical ophthalmology during the years 2003, 2004 and 2005.

METHODS

All ophthalmologic patients treated as in-patients at the Department of Ophthalmology at the University Munich during the year 2003 served as a reference data basis. By means of appropriate software those cases were then re-grouped according to the G-DRG classification of the years 2003, 2004 and 2005. This resulted in different reimbursements caused only by system changes for an exemplary hospital of maximum medical care. In addition, the same calculations were performed for four virtual, typical clinics based on the calculation data of the "Institut für Entgeltsysteme (InEK)". For those four clinics it was assumed that 80 % of the cases came from one of the subspecialties retina, glaucoma, cataract or strabismus surgery.

RESULTS

Changes in the G-DRG system caused the sample hospital of maximum care to loose 8.5 % case mix index (CMI) during the period of 2003 to 2005. For three of the four virtual, typical ophthalmological clinics the theoretic reimbursement conditions also deteriorated: retina surgery -- 10.6 %, glaucoma surgery - 15.8 % and cataract surgery -- 17.9 % CMI. Only strabismus surgery showed an increase of + 5.6 % in CMI during the period examined.

CONCLUSION

Over the years 2003 to 2005 the CMI clearly deteriorated for many ophthalmological subspecialties given otherwise identical conditions. To calculate the changes specifically for an individual hospital, the individual base rates have to be considered.

Importance of black carbon to sorption of native PAHs, PCBs, and PCDDs in Boston and New York harbor sediments

The solid-water distribution ratios (Kd values) of "native" PAHs, PCBs, and PCDDs in Boston and New York Harbor sediments were determined using small passive polyethylene samplers incubated for extended times in sediment-water suspensions. Observed solid-water distribution coefficients exceeded the corresponding f(oc)Koc products by 1-2 orders of magnitude. It was hypothesized that black carbon (fBC), measured in the Boston harbor sediment at about 0.6% and in the New York harbor sediment at about 0.3%, was responsible for the additional sorption. The overall partitioning was then attributed to absorption into the organic carbon and to adsorption onto the black carbon via Kd = f(oc)Koc + f(BC)K(BC)C(w)n-1 with Cw in microg/L. Predictions based on published Koc, K(BC), and n values for phenanthrene and pyrene showed good agreement with observed Kd,obs values. Thus, assuming this dual sorption model applied to the other native PAHs, PCBs, and PCDDs, black carbon-normalized adsorption coefficients, K(BC)S, were deduced forthese contaminants. Log K(BC) values correlated with sorbate hydrophobicity for PAHs in Boston harbor (log K(BC) approximately 0.83 log gamma w(sat) - 1.6; R2 = 0.99, N= 8). The inferred sorption to the sedimentary BC phase dominated the solid-water partitioning of these compound classes, and its inclusion in these sediments is necessary to make accurate estimates of the mobility and bioavailability of PAHs, PCBs, and PCDDs.

Ergebnisse aus drei Monaten Konstanzprüfung an Röntgeneinrichtungen im Bayerischen Mammographie-Screening

PURPOSE

To find out whether the quality requirements in daily, weekly or monthly tests of the "European protocol for the quality control of the physical and technical aspects of mammographic screening (EPQC)" can be maintained when screening the population of a large area. Furthermore, to check the specific tolerances of different test positions given by the EPQC for redundancy and statistical correlation.

MATERIALS AND METHODS

Daily test images were obtained with an additional exposition of a sensitometric step wedge according DIN 6868 - 2. Weekly densitometry and visual inspection were performed at the University of Applied Sciences, Cologne.

RESULTS

All units were able to maintain basic requirements on image quality as long as films of the same batch number were used. Some tolerance requirements of the EPQC are inconsistent and redundant.

CONCLUSION

The occasionally considerable fluctuations of film processing require a daily check on the processing conditions. Daily test images of the units are only obligatory in the first 4 to 5 weeks of a new operation. All test results should be analyzed retrospectively in an independent test laboratory with emphasis on the statistical behavior of the unit. The tolerances prescribed by the EPQC are not always consistent and should be adapted to today's scientific standard when applied in mammography screening centers.

Atmospheric distribution of polychlorinated dibenzo-p-dioxins, dibenzofurans (PCDD/Fs), and non-ortho biphenyls (PCBs) along a North-South Atlantic transect

Air samples were taken on board the RRS Bransfield (typically for 24-72 h), during an Atlantic cruise from the U.K. to Antarctica in October-December 1998, to investigate the global scale distribution of PCDD/Fs and coplanar PCBs. Highest concentrations of Cl2-8DD/Fs all occurred between 25 and 52 degrees N; lowest concentrations were measured around approximately 60 degrees S and further south. Cl3DFs showed highest overall concentrations (up to 9800 fg/m3), followed by Cl2DFs (up to 5300 fg/m3) and OCDD (up to 1300 fg/m3). Lowest concentrations, measured in the remote Southern hemisphere, were generally 2 orders of magnitude lower than their highest concentrations over the North Atlantic. Concentrations of PCB-77 were higher in the northern hemisphere, while PCB-126 and PCB-169 exhibited highest concentrations around the equator. Evidence was obtained for substantial emissions of PCDD/Fs off west Africa and while in the port of Montevideo, Uruguay. Shifts in PCDD/F profile distribution were observed on increasing distance from source regions, such that those from the most remote locations were dominated by Cl3DF (approximately 40% of the total) and OCDD (approximately 20%). Gas-particle partition data was obtained for all samples. Cl4-6DD/Fs showed the widest range, varying between 10 and 90% of the total in the gas phase, depending on location/ temperature. The study gave limited evidence for the influence of OH-radical initiated depletion reactions of gaseous PCDD/Fs. The global atmospheric burden is estimated to be on the order of 350 kg sigmaCl4-8DD/Fs and approximately 3 kg sigmaTEQ.

Further developments in the use of semipermeable membrane devices (SPMDs) as passive air samplers for persistent organic pollutants: field application in a spatial survey of PCDD/Fs and PAHs

Semipermeable membrane devices (SPMDs) were deployed at 19 sites in northwest England to test their efficacy as passive atmospheric samplers for polychlorinated dibenzo-p-dioxins and -furans (PCDD/Fs) and polycyclic aromatic hydrocarbons (PAHs). SPMDs were found to be efficient samplers for vapor phase species in the atmosphere, with good reproducibility between samplers. Species which are partially or completely particle associated under ambient U.K. conditions were also sampled by the SPMDs but with poorer reproducibility. It is suggested that SPMDs could be used to indicate "hotspots" of particulate associated species, however. Differences in absolute and relative concentrations of all PCDD/Fs and PAHs sequestered bythe SPMDs were observed between sites. High amounts were sequestered in SPMDs at sites where previous active monitoring has indicated relatively high atmospheric concentrations, confirming the potential of SPMDs as a tool for semiquantitative spatial monitoring of atmospheric species. SPMDs also respond to differences in the mixture of compounds present in the atmosphere, thereby aiding source apportionment studies.

Does concommitant splenectomy raise the mortality of liver transplant recipients?

Within a 17-month period, 130 orthotopic liver transplantations were performed in our hospital. Nine of these were retransplantations and were not included in our analysis. In the remaining 121 patients, splenectomy was performed in 34 patients, either synchronously with the transplant procedure (27 patients) or in the postoperative period (7 patients). Indications for splenectomy were lienalis-steal syndrome in 15 patients and hypersplenism in 15 cases. The number of rejection episodes was fairly equal in both groups (splenectomized vs. non-splenectomized, 61.7% vs. 63.9%, respectively). There was a marked difference in the frequency of infectious episodes (61.7% vs. 25.3%) that resulted in a decreased survival rate (77.5% vs. 95.4%) for splenectomized patients. Therefore, we recommend splenectomy only for very selected patients and investigate the banding of the splenic artery as an alternative.

Results of liver transplantation in acute liver failure caused by viral hepatitis

Fulminant liver failure due to acute viral hepatitis is the most common emergency indication for liver transplantation. The postoperative course is highly correlated with the type and duration of infection. The complication rate is lowest in fulminant hepatitis B patients and highest in subacute hepatitis C/NANB patients.

An object-oriented approach for structuring the electronic medical record

We implemented a framework for modelling the electronic medical record on top of an object-oriented model. Clinical patient data are structured in a uniform way through the use of a comprehensive data model. The meaning of the information elements is explicitly determined by a medical data dictionary. The data structures of both, medical record and data dictionary are implemented, using a semantically rich, object-oriented data model. We examined several possibilities for the graphical preparation of the inherently recursive data structures. Again, we use object-oriented frameworks for the implementation of flexible user interfaces to the electronic medical record with a consistent look-and-feel.

The significance of PCBs in the atmosphere of the southern hemisphere

Air monitoring stations were set up at 2 sites in the southern hemisphere--Moody Brook, Falkland Island (51 degrees 25' S, 57 degrees 56' W) and Halley, Research Station, Antarctica (75 degrees 35' S, 26 degrees 30' W). PCBs were monitored at the stations throughout 1999. Highest concentrations were observed when temperatures were greater. In general, concentrations were greater at Moody Brook than at Halley, although the difference in concentrations between sites was less for more chlorinated congeners. Air concentrations at both sites were compared with samples collected nearby over-water. Over water air concentrations were found to be greater than over land air concentrations. Concentrations were also compared with literature data for air concentrations at a remote site in the Canadian Arctic. Atmospheric concentrations of tri-chlorinated biphenyls were found to be approximately double those reported for Ellesmere Island in the Canadian Arctic, whilst concentrations in samples from Antarctica were very similar to those found in the high Arctic. Most other PCBs were a factor of 2-4 greater in the Canadian Arctic.

Preemptive therapy in CMV-antigen positive patients after liver transplantation--a prospective trial

OBJECTIVE

Preemptive therapy with intravenous ganciclovir and CMV-hyperimmunoglobulin in asymptomatic CMV pp65-antigen positive patients was compared with treatment of only symptomatic CMV-disease after liver transplantation in an open prospective study.

PATIENTS AND METHODS

48 out of 200 liver transplant recipients became positive during six weeks follow-up after transplantation. 17 out of these 48 patients who were already symptomatic at the time of positive antigen testing were successfully treated with ganciclovir and CMV-hyperimmunoglobulin. 31 asymptomatic antigen-positive patients were randomised to receive preemptive therapy or to receive therapy only at onset of clinical symptoms.

RESULTS

Only two out of 15 patients in this latter group without preemptive therapy developed CMV-syndrome and were successfully treated with intravenous ganciclovir. 13 patients did not experience any clinical symptoms or disease and were therefore spared unneccessary toxicity and costs. The overall incidence of CMV-infection and -disease in the whole study population of 200 liver transplant recipients was 25% and 10%. As expected, CMV-negative patients who received an organ from a seropositive donor were at a higher risk of CMV-infection and -disease, but did not show more severe infections clinically. Patients with IL-2 receptor antibody induction therapy seemed to have a higher risk for CMV-infection and -disease.

Quadruple tacrolimus-based induction therapy including azathioprine and ALG does not significantly improve outcome after liver transplantation when compared with standard induction with tacrolimus and steroids: results of a prospective, randomized trial

BACKGROUND

Tacrolimus in combination with prednisolone has been proven to be a safe and effective immunosuppressive induction therapy in solid organ transplantation. However, it remains unclear whether a tacrolimus-based quadruple induction regimen with azathioprine and an antilymphocytic preparation could further improve the results after orthotopic liver transplantation. Therefore, we designed a prospective, randomized study to compare the immunosuppressive efficacy of dual (tacrolimus and prednisolone) and quadruple (tacrolimus, azathioprine, ALG Merieux and prednisolone) induction after liver transplantation.

METHODS

After randomization, 120 consecutive patients of primary liver transplants were divided into the dual group (n=59) and the quadruple group (n=61) and followed for a minimum of 3 years.

RESULTS

Patient survival at 3 years was 88.2% in the dual versus 94.9% in the quadruple group. Overall 25 patients in each group (41 and 42%, respectively) developed acute rejection. There was no difference in the number and severity of rejections. In each group only four patients required OKT3-therapy, however, although three of four patients in the quadruple group responded to OKT3 and cleared rejection, none of the four patients in the dual group were treated successfully with OKT3 (P<0.02). Rejection in these patients resolved only after additional treatment with mycophenolate mofetil. Adverse events and infections were equally distributed in both groups. Asymptomatic Cytomegalovirus infections were more common in the quadruple group (P<0.02). As of today, only one patient developed posttransplant lymphoproliferative disease (dual group).

CONCLUSIONS

The data from our single-center study indicate that both tacrolimus-based dual and quadruple immunosuppressive induction regimens yield similar safety and effectiveness after liver transplantation.

Hepatic glutamine transporter activation in burn injury: role of amino acids and phosphatidylinositol-3-kinase

Burn injury elicits a marked, sustained hypermetabolic state in patients characterized by accelerated hepatic amino acid metabolism and negative nitrogen balance. The transport of glutamine, a key substrate in gluconeogenesis and ureagenesis, was examined in hepatocytes isolated from the livers of rats after a 20% total burn surface area full-thickness scald injury. A latent and profound two- to threefold increase in glutamine transporter system N activity was first observed after 48 h in hepatocytes from injured rats compared with controls, persisted for 9 days, and waned toward control values after 18 days, corresponding with convalescence. Further studies showed that the profound increase was fully attributable to rapid posttranslational transporter activation by amino acid-induced cell swelling and that this form of regulation may be elicited in part by glucagon. The phosphatidylinositol-3-kinase (PI3K) inhibitors wortmannin and LY-294002 each significantly attenuated transporter stimulation by amino acids. The data suggest that PI3K-dependent system N activation by amino acids may play an important role in fueling accelerated hepatic nitrogen metabolism after burn injury.

Muscle-dependent and hormone-dependent differentiation of the vocal control premotor nucleus robustus archistriatalis and the motornucleus hypoglossus pars tracheosyringealis of the zebra finch

Sex differences in the vertebrate brain (brain sex) are thought to develop owing to the tissue specific action of gonadal hormones similar to the development of secondary sex characteristics of the body. Small sex differences in body anatomy could, however, retrogradely control the sexual differentiation of the central nervous system. This possibility has so far been verified only for motorneuron pools, since the connectivity of sex-specific higher brain areas to the sexual dimorphic periphery is frequently not well known. Here, we tested whether somatic sex differences feed back on higher brain areas by bilateral denervation of the syringeal musculature of zebra finches before, during, and after onset of estrogen-sensitive sexual differentiation of forebrain vocal nuclei such as RA (nucleus robustus archistriatalis). In the zebra finch, the sound-producing musculature (the syrinx), the syrinx motornucleus hypoglossus pars tracheosyringealis (nXIIts), and the RA are much larger in males compared to females. Tract tracing studies revealed that the volume and neuron size distribution of the nXIIts was sexually dimorphic in intact but not in animals denervated as juveniles. In contrast, the volume of RA and size of RA neurons of denervated animals were highly sexually dimorphic. Furthermore, estrogen masculinized the RA of denervated females. Thus, sexual differentiation of the RA but not of the nXIIts appears independent of somatic sex differences. The syrinx muscles are, however, important for the soma size of those RA neurons that project to the nXIIts.

Extended resections for hilar cholangiocarcinoma

OBJECTIVE

To evaluate different strategies for extended resections of hilar cholangiocarcinomas on radicality and survival.

SUMMARY BACKGROUND DATA

Surgical resection of hilar cholangiocarcinoma is the only potentially curative treatment. Resection of central bile duct carcinomas, however, cannot always comply with the general principles of surgical oncology to achieve wide tumor-free margins with no-touch techniques.

METHODS

From 1988 to 1998, 95 patients underwent resection of hilar cholangiocarcinoma. Eighty patients had hilar and hepatic resections and 15 had liver transplantation and partial pancreatoduodenectomy (LTPP; i.e., eradication of the entire biliary tract using a no-touch technique).

RESULTS

The 60-day death rate was 8%. The overall 1- and 5-year survival rates were 67% and 22%, respectively. Five-year survival rates after R0, R1, and R2 resections were 37%, 9%, and 0%. In a multivariate analysis, surgical radicality was the strongest determinant of survival (p < 0.001). The rate of formally curative resection (R0 resection) was significantly lower in hilar resections (29%) than in liver resections (left hemihepatectomy 59%, right hemihepatectomy 55%, right trisegmentectomy 65%; p < 0.05). The highest rate of R0 resection was observed after LTPP (93%; p < 0.05). Right trisegmentectomies achieved the highest rate of 5-year survival after R0 resection (57%). In a multivariate analysis of patient survival after R0 resection, additional portal vein resection was the only significant factor. The 5-year survival rate after formally curative liver resection with portal vein resection was 65% versus 28% without.

CONCLUSION

Extended resections, especially right trisegmentectomies and LTPP, resulted in the highest rate of R0 resection. Right trisegmentectomy together with portal vein resection best represents the principles of surgical oncology and may be regarded as the surgical procedure of choice. Immunosuppression limits the applicability of LTPP.

Strain and substrain differences in context- and tone-dependent fear conditioning of inbred mice

The performance of C57BL/6J (6J), C57BL/6N (6N), DBA/2J (2J) and DBA/2N (2N) mice in context- and tone-dependent fear conditioning was determined 24 h after fear conditioning to evaluate and compare different behavioral measures as indices of emotional learning. Freezing, the change in activity and the size of the explored area were evaluated as behavioral parameters indicating fear. Additionally, the heart rate (HR) increase elicited by tone presentation was evaluated as an autonomic indicator of fear. During the context-dependent memory test, freezing was high only in 6J and 6N mice, whereas a drop of activity and a reduced exploratory area was measured in all strains. During the tone-dependent memory test, high freezing, low activity, reduced exploratory area and a strong HR increase were demonstrated only in 6N and 6J mice, whereas behavioral and HR changes of 2J and 2N mice were always low. In extinction tests, context- and tone-dependent freezing of 6J mice decayed significantly faster than the freezing of 6N mice, whereas in both substrains the conditioned tachycardia to tone extinguished similarly in the home cage. The data demonstrate that monitoring of additional behavioral measures besides freezing and autonomic measures is necessary to interpret differences in associative learning performance of mouse strains that could be related to a differential expression of fear.

[Psychogenic impairment and current feelings in the elderly. Which options are offered by the biographical perspective?]

In the Eldermen study funded by the German Research Association (DFG), a consecutive sample of patients, aged > or = 60 (n = 120) and being treated for a variety of internal medical complaints in an acute geriatric hospital were examined with the help of comprehensive somatic diagnostics, standardised questionnaires, and a semi-structured biographical interview. The study investigates the relationship between burdensome and supportive biographical experiences and the extent of psychogenic impairment as well as aspects of feeling tone and self-concept in later life. For the degree of psychogenic impairment (Impairment Score. IS; Schepank 1995), subjectively experienced burdens and support were found to be more relevant than "objective" burdens. As expected, subjective burdens consistently experienced over several life phases, particularly in association with limited experienced support, were found to be associated with greater psychogenic impairment and a higher "case risk" in later life. However, the patients with the highest values for current life satisfaction as well as a more positive self-concept were not those patients who never experienced more burdens than support in their biographies, but rather those who experienced more burden than support in one life phase. The results are presented in relation to models of learning theory and object relation theory and discussed for their clinical relevance.

Rat liver endothelial cell glutamine transporter and glutaminase expression contrast with parenchymal cells

Despite the central role of the liver in glutamine homeostasis in health and disease, little is known about the mechanism by which this amino acid is transported into sinusoidal endothelial cells, the second most abundant hepatic cell type. To address this issue, the transport of L-glutamine was functionally characterized in hepatic endothelial cells isolated from male rats. On the basis of functional analyses, including kinetics, cation substitution, and amino acid inhibition, it was determined that a Na+-dependent carrier distinct from system N in parenchymal cells, with properties of system ASC or B0, mediated the majority of glutamine transport in hepatic endothelial cells. These results were supported by Northern blot analyses that showed expression of the ATB0 transporter gene in endothelial but not parenchymal cells. Concurrently, it was determined that, whereas both cell types express glutamine synthetase, hepatic endothelial cells express the kidney-type glutaminase isozyme in contrast to the liver-type isozyme in parenchymal cells. This represents the first report of ATB0 and kidney-type glutaminase isozyme expression in the liver, observations that have implications for roles of specific cell types in hepatic glutamine homeostasis in health and disease.

Dioxins and furans in air and deposition: a review of levels, behaviour and processes

This paper is a comprehensive, critical review of the levels, behaviour and processes affecting polychlorinated dibenzo-p-dioxins and -furans (PCDD/Fs) in air and deposition. Aspects of sampling, analysis and quality assurance/control are discussed initially, before a review of the PCDD/F concentrations in ambient air is presented. The general trend in sigma P4-8 CDD/F (and sigma TEQ) is: remote sites < 0.5 pg/m3 (sigma TEQ < 10 fg/m3); rural sites approximately 0.5-4 pg/m3 (sigma TEQ approximately 20-50 fg/m3); and urban/industrial sites approximately 10-100 pg/m3 (sigma TEQ approximately 100-400 fg/m3). The commonly held view that a consistent mixture of PCDD/Fs in air exists is evaluated and questioned. Issues of seasonality and short-term changes in air concentrations are also critically discussed, with respect to the possibility of seasonal emission sources to air and seasonally dependent loss processes. Data on the gas-particle partitioning of PCDD/Fs in air are reviewed; the limited database to date is believed to provide evidence for an exchangeable transfer of PCDD/Fs between these two phases. The potential importance of photolytic and radical reaction degradation processes and wet/dry deposition processes in modifying the mixture of PCDD/Fs in air is discussed. Some homologue/congener specific 'weathering' of the mixture of PCDD/Fs emitted to the atmosphere clearly occurs, but in general PCDD/Fs have 'long' atmospheric residence times, rendering them subject to long-range atmospheric transport. Data are reviewed which relate the mixture of PCDD/Fs in air to that in deposition; this leads to the conclusion that different homologue groups (which are partitioned differently between the gas and particulate phase) are transferred to the earth's surface with broadly similar efficiencies.

A randomized, placebo-controlled trial with anti-interleukin-2 receptor antibody for immunosuppressive induction therapy after liver transplantation

The introduction of quadruple induction therapy after liver transplantation with the murine anti-interleukin-2 receptor (IL-2R) antibody (BT563) has decreased the incidence of serious side effects, such as tachycardia, hypertension, rash, fever and nausea since it does not lyse its target cell. To investigate the immunosuppressive efficacy of BT563, a placebo-controlled trial was performed and BT563 was added to the standard triple induction after liver transplantation. Forty consecutive recipients of primary orthotopic liver transplants (OLT) (median age 47 yr [range 18-65]) were randomized. All patients received triple immunosuppression with cyclosporine A (CyA), prednisolone (PRED) and azathioprine (AZA). In addition, 19 patients received BT563 (Biotest, Dreieich, Germany) at a dose of 10 mg/d from day 0 until day 12. The remaining 21 patients received a placebo infusion at the same days after transplantation. Minimal follow-up for all patients was 3 yr. Patient survival at 3 yr was 74% in the BT563 group and 90% in placebo group. Similar results were observed for graft survival. Two acute rejection episodes were detected in the BT563 group and 9 acute rejections (5 steroid-resistant) were observed in the placebo group (p < 0.034). The incidences of sepsis, pneumonia, cholangitis, urinary tract infections as well as cytomegalo-virus (CMV) infections were similar in both groups. Side effects of the BT563 therapy and/or post-transplant lymphoproliferative disease (PTLD) were not detected. Quadruple induction therapy with BT563 significantly reduces the incidence of rejection episodes after liver transplantation, while infectious complications and/or PTLD is not increased. Therefore, the anti-IL2 receptor antibody BT563 constitutes a safe and efficient addition to the immunosuppressive induction regimen following OLT.