[Delays and pathways for patients with endometriosis in France: A multicenter study]

INTRODUCTION

The diagnosis of endometriosis is often difficult to make, generating a median diagnostic delay ranging from 2 to 10.7years. A study of the care pathway of these patients seems essential in order to evaluate the diagnostic delay of endometriosis in France and the factors related to the diagnostic delay.

METHODS

This is a prospective multicenter study, conducted between 2017 and 2019. A questionnaire concerning their care pathway and their feelings about the diagnosis was distributed to all patients consulting for endometriosis. Statistical analyses were performed using the Kruskal-Wallis, Chi² and Student's t tests.

RESULTS

Fifity-seven of the 84 patients (67.8%) who completed the questionnaire were included in the evaluation of diagnostic delays. The total diagnostic delay was 12years (min 0; max 33) and was comparable between all inclusion cities (P=0.68). Regarding the care pathway according to specialties, the diagnosis of endometriosis was made by gynecologists in 81% of patients versus 19% by general practitioners. The time between the onset of symptoms and the first consultation was significantly shorter in favor of the general practitioner (2years versus 4years, P=0.012). 60% of the patients reported that their symptoms were labelled as "normal" by the physicians and 35% of them considered them normal themselves.

CONCLUSION

Our study showed that the delay in diagnosis in France was still very long and that the mechanisms of the delay in management were multifactorial. Awareness raising and training of health care providers remains one of the major areas to be optimized.

Progress in Veno-Venous Long-Term Bypass Techniques for the Treatment of Ards

Extracorporeal CO2 removal combined with low-frequency positive pressure ventilation (ECCO2-R LFPPV) is a new therapeutic approach in treatment of ARDS. The main problem during long-term extracorporeal support is anticoagulation and related bleeding problems. We conducted a prospective, randomized and controlled clinical trial in 18 patients to compare the effect of the non-heparin-coated (Scimed = group 1) with the heparin-coated (Carmeda = group 2) extracorporeal circuit on clinical course and complication rate. In group 2 the daily blood loss, the amount of substituted red cells and the i.v. heparin dose were significantly lower than in group 1. Bleeding complications were less and more patients survived in group 2. The disadvantage of the hollow fiber oxygenators in the heparin-coated system was plasma leakage, which was more frequent in patients with pancreatitis and hyperbilirubinemia.

Effect of robotic-assisted gait rehabilitation on dynamic equilibrium control in the gait of children with cerebral palsy

Due to the intensity and repetition of movement, roboticassisted gait training therapy could have a beneficial effect on the recovery and improvement of postural and locomotor functions of the patient. This study sought to highlight the effects of robotic-assisted gait rehabilitation in gait of children with Cerebral Palsy (CP). We analyzed the different strategies before and after this rehabilitation which was used in order to generate forward motion while maintaining balance. Data were collected by a motion analysis system (Vicon® - Oxford Metrics, Oxford, UK). The children were divided into two groups in such a way as to obtain a randomized controlled population: i) a group of fourteen children (Treated Group) underwent 20 sessions of roboticassisted gait training therapy using the driven gait orthosis Lokomat®Pediatric (Hocoma AG, Volketswil, Switzerland) compared to ii) a group of sixteen children without sessions of Lokomat®Pediatric (Control Group). Significant differences are observed for the TG between the preand post-test values of the locomotor parameters and of the kinetic data of the propulsive forces of the Center of Mass (COM) and of the Center of Pressure (COP) dynamic trajectory. This first study, although performed on a limited number of patients, shows the usefulness of this robotic gait rehabilitation mainly in the balance control in gait. Indeed after this rehabilitation, these children improve their gait that is especially characterized by a more appropriate time lag between the time instant of COM-COP trajectory divergence and the time instant when the forward propulsive forces became apparent.

Robotic-assisted gait training improves walking abilities in diplegic children with cerebral palsy

The robotic-assisted gait training therapy (RAGT), based on intensity and repetition of movement, presents beneficial effects on recovery and improvement of postural and locomotor functions of the patient. This study sought to highlight the effect of this RAGT on the dynamic equilibrium control during walking in children with Cerebral Palsy (CP) by analyzing the different postural strategies of the fullbody (upper/lower body) before and after this RAGT in order to generate forward motion while maintaining balance. Data were collected by a motion analysis system (Vicon^® - Oxford Metrics). Thirty children with bilateral spastic CP were evaluated using a full-body marker set which allows assessing both the lower and upper limb kinematics. The children were divided into two groups in such a way as to obtain a randomized controlled population: i) a group of fourteen children (Treated Group) underwent 20 sessions of RAGT using the driven gait orthosis Lokomat^®Pediatric (Hocoma) compared to ii) a group of sixteen children without sessions of Lokomat^®Pediatric (Control Group) receiving only daily physiotherapy. Significant improvements are observed between the TG pre- and post-test values of i) the kinematic data of the full-body in the sagittal and frontal planes and ii) the Gross Motor Function Measure test (D and E). This study shows the usefulness of this RAGT mainly in the balance control in gait. Indeed, the Treated Group use new dynamic strategies of gait that are especially characterized by a more appropriate control of the upper body associated with an improvement of the lower limbs kinematics.

Quality of life assessment in patients with metastatic colorectal cancer receiving maintenance therapy after first-line induction treatment: a preplanned analysis of the phase III AIO KRK 0207 trial

BACKGROUND

First-line maintenance strategies are a current matter of debate in the management of mCRC. Their impact on patient's health-related quality of life (HRQOL) has not yet been evaluated. The objective of this study was to assess whether differences in HRQOL during any active maintenance treatment compared with no maintenance treatment exist.

PATIENT AND METHODS

Eight hundred and thirty-seven patients were enrolled in the AIO KRK 0207 trial. Four hundred and seventy-two underwent randomization (after 24 weeks of induction treatment) into one of the maintenance arms: FP plus Bev (arm A), Bev alone (arm B), or no active treatment (arm C). HRQOL were assessed every 6 weeks during induction and maintenance treatment independent from treatment stop, delay, or modification, and also continued after progression, using the EORTC QLQ-C30, QLQ-CR29. The mean value of the global quality of life dimension (GHS/QoL) of the EORTC QLQ-C30, calculated as the average of all available time points after randomization was considered as pre-specified main endpoint. Additionally, EORTC QLQ-C30 response scores were analyzed.

RESULTS

For HRQOL analysis, 413 patients were eligible (arm A: 136; arm B: 142, arm C: 135). Compliance rate with the HRQOL questionnaires was 95% at time of randomization and remained high during maintenance (98%, 99%, 97% and 97% at week 6, 12, 18 and 24). No significant differences between treatment arms in the mean GHS/QoL scores were observed at any time point. Also, rates of GHS/QoL score deterioration were similar (20.5%; 17.2% and 20.7% of patients), whereas a score improvement occurred in 36.1%; 43.8% and 42.1% (arms A, B and C).

CONCLUSION

Continuation of an active maintenance treatment with FP/Bev after induction treatment was neither associated with a detrimental effect on GHS/QoL scores when compared with both, less active treatment with Bev alone or no active treatment.

CLINICAL TRIALS NUMBER

NCT00973609 (ClinicalTrials.gov).

Mu and delta opioid receptor knockout mice show increased colonic sensitivity

BACKGROUND

Opiates act through opioid receptors to diminish pain. Here, we investigated whether mu (MOR) and delta (DOR) receptor endogenous activity assessed in the whole mouse body or in particular at peripheral receptors on primary nociceptive neurons, control colonic pain.

METHODS

We compared global MOR and DOR receptor knockout (KO) mice, mice with a conditional deletion of MOR and DOR in Nav1.8-positive nociceptive primary afferent neurons (cKO), and control floxed mice of both genders for visceral sensitivity. Visceromotor responses to colorectal distension (CRD) and macroscopic colon scores were recorded on naïve mice and mice with acute colitis induced by 3% dextran sodium sulphate (DSS) for 5 days. Transcript expression for opioid genes and cytokines was measured by quantitative RT-PCR.

RESULTS

Naïve MOR and DOR global KO mice show increased visceral sensitivity that was not observed in cKO mice. MOR and preproenkephalin (Penk) were the most expressed opioid genes in colon. MOR KO mice had augmented kappa opioid receptor and Tumour-Necrosis-Factor-α and diminished Penk transcript levels while DOR, preprodynorphin and Interleukin-1β were unchanged. Global MOR KO females had a thicker colon than floxed females. No alteration was detected in DOR mutant animals. A 5-day DSS treatment led to comparable hypersensitivity in the different mouse lines.

CONCLUSION

Our results suggest that mu and delta opioid receptor global endogenous activity but not activity at the peripheral Nav1.8 neurons contribute to visceral sensitivity in naïve mice, and that endogenous MOR and DOR tones were insufficient to elicit analgesia after 5-day DSS-induced colitis.

SIGNIFICANCE

Knockout mice for mu and delta opioid receptor have augmented colon sensitivity in the CRD assay. It shows endogenous mu and delta opioid analgesia that may be explored as potential targets for alleviating chronic intestinal pain.

Balance control in gait children with cerebral palsy

This study sought to highlight the balance control process during gait in children with cerebral palsy (CP) by analyzing the different strategies used in order to generate forward motion while maintaining balance. Data were collected using a motion analysis system in order to provide a clinical gait analysis for 16 children with CP and 16 children with typical development. Significant differences between the two groups are observed in terms of kinetic data of the propulsive forces of the center of mass (COM) and of the center of pressure (COP) dynamic trajectory and for locomotor parameters. The imbalance generated by divergent trajectories of COM and COP produce the propulsive forces responsible for human gait initiation. Moreover, we observe in children with CP an "en bloc" postural strategy resulting in increasing divergence between trajectories of COM-COP. This particular strategy of the children with CP is characterized by a greater time duration between the moment of COM-COP trajectory divergence and the moment where the forward propulsive forces became apparent.

Capecitabine/irinotecan or capecitabine/oxaliplatin in combination with bevacizumab is effective and safe as first-line therapy for metastatic colorectal cancer: a randomized phase II study of the AIO colorectal study group

BACKGROUND

This randomized phase II trial investigated the efficacy and safety of capecitabine/oxaliplatin (CapOx) plus bevacizumab and dose-modified capecitabine/irinotecan (mCapIri) plus bevacizumab as first-line therapy in patients with metastatic colorectal cancer (mCRC).

PATIENTS AND METHODS

Patients received bevacizumab 7.5 mg/kg with oxaliplatin 130 mg/m(2)/day 1 plus capecitabine 1000 mg/m(2) bid/days 1-14 or with irinotecan 200 mg/m(2)/day 1 plus capecitabine 800 mg/m(2) bid/days 1-14 both every 21 days. The primary end point was 6 months progression-free survival (PFS).

RESULTS

A total of 255 patients were enrolled. The intent-to-treat population comprised 247 patients (CapOx-bevacizumab: n = 127; mCapIri-bevacizumab: n = 120). The six-month PFS rates were 76% (95% CI, 69%-84%) and 84% (95% CI, 77%-90%). Median PFS and OS were 10.4 months (95% CI, 9.0-12.0) and 24.4 months (95% CI, 19.3-30.7) with CapOx-bevacizumab, and 12.1 months (95% CI, 10.8-13.2) and 25.5 months (95% CI, 21.0-31.0) with mCapIri-bevacizumab. Grade 3/4 diarrhea as predominant toxic effect occurred in 22% of patients with CapOx-bevacizumab and in 16% with mCapIri-bevacizumab.

CONCLUSIONS

Both, CapOx-bevacizumab and mCapIri-bevacizumab, show promising activity and an excellent toxic effect profile. Efficacy is in the range of other bevacizumab-containing combination regimen although lower doses of irinotecan and capecitabine were selected for mCapIri.

Mercuric chloride-induced autoimmunity

This unit describes methods for inducing autoimmune disease in Brown Norway rats through HgCl(2) injections as well for assessing parameters that characterize the disease by serum IgE concentration assays, anti-laminin antibody measurement, and renal immunofluorescence studies to detect autoantibodies. Also covered are disease induction using autoreactive CD4(+) T(H)2 anti-self MHC class II molecules and preparation of T cell lines. IL-4 is produced very early after the first HgCl(2) injection (beginning at day 3, peaking at day 14, and continuing up to day 30). Thus, IL-4 mRNA expression may be detected in spleen and lymph nodes from HgCl(2)-injected BN rats. The fact that HgCl(2) induces in vitro mRNA IL-4 gene expression in normal BN T cells but not in LEW T cells is probably crucial to susceptibility to the development of autoimmunity in the sense that it may condition the development of autoreactive T cells into pathogenic T(H)2 cells; a test for this condition is therefore also included.

Comparable safety and response rate with bevacizumab in combination with capecitabine/oxaliplatin (CapOx/Bev) versus capecitabine/irinotecan (CapIri/Bev) in advanced CRC (mCRC): A randomized phase II study of the AIO GI tumor study group

4034

Background: Bevacizumab (Bev) combined with 5-FU/FA and both, irinotecan or oxaliplatin are standard regimens for mCRC. Recently, a phase III trial has demonstrated that infusional 5-FU can be substituted by capecitabine (cape) when combined with oxaliplatin and Bev whereas conflicting data are available for feasibility and efficacy of cape/irinotecan combinations. This randomized phase II trial was to compare safety and efficacy of Bev with either CapOx or CapIri in untreated mCRC. Methods: Eligibility criteria: untreated mCRC pts, ECOG PS <= 2, measurable lesion(s), adequate hematologic and organ function. Primary endpoint was % of pts progression-free after 6 months. Treatment plan: Bev 7.5 mg/kg day (d)1 with either oxaliplatin (130 mg/m2 d1)/cape (1,000 mg/m2 bid d1–14; CapOx/Bev, arm A) or irinotecan (200 mg/m2 d1)/cape (800 mg/m2 bid d 1–14; CapIri/Bev, arm B), all q d22. Arm B doses were 20% lower for both, cape and irinotecan, compared to previous trials reporting an unacceptable toxicity profile (Köhne, ASCO 2005). Treatment was continued until progression or unacceptable toxicity. Results: So far, toxicity data are available on 228 (118/110 pts arm A/B) of total 240 pts. Baseline characteristics (arm A/B): median age 64/65 yrs, male 67%/68%. A total of 684/719 cycles (median 6/6 cycles) have been administered. Most common CTC grade 3/4 toxicities (% of pts): Diarrhea 17.0/15.5, hand-foot-syndrome 5.9/2.7, peripheral neuropathy 15.3/0.0. Specific AE′s such as thrombosis, 3° hypertension and GI perforation occurred in 3.4/4.5%, 3.4/0.9% and 0.9/0.9% of pts, respectively. Among 185 evaluable pts (96/89), tumor control rates (CR+PR+SD) in arm A/B were 81.4%/82.8%, overall response rates (CR+PR) were 49.0%/52.7%. Conclusions: Both regimens, CapOx/Bev and CapIri/Bev, are well tolerated without differences in toxicity (except neuropathy). Interestingly, despite the protocol defined dose reduction of CapIri there is seemingly no difference in efficacy as measured by tumor control and response rate. Meanwhile, the trial has finished accrual and data including PFS rate will be presented at the meeting.

[Table: see text]

Effects of liquid storage on amidase activity, DNA fragmentation and motility of turkey spermatozoa

Short-term liquid storage of turkey semen is of great interest in the management of turkey reproduction due to the extensive use of artificial insemination. This study examined changes in DNA fragmentation (using a comet assay), sperm motility characteristics (using computer-aided sperm analysis), and amidase activity (using a colorimetric assay) of turkey sperm stored for 24 and 48 h. In addition we found that turkey spermatozoa contain besides acrosin, additional two serine proteinases of molecular weight of 34 and 42 kDa. We found that, after 48 h of liquid storage, decreases in sperm motility characteristics and increases in amidase activity and DNA fragmentation occurred. An increase of amidase activity was found after 24h. Decreases in sperm motility and increase in DNA fragmentation were found after 48 h of storage. These data suggest that a decrease in turkey sperm quality during short-term storage is related to disturbances to the acrosome, presumably related to premature activation of acrosomal serine proteinases, and to a lesser extent a decrease in sperm motility characteristics and damage of sperm DNA.

Kinetics of Borrelia burgdorferi infection in larvae of refractory and competent tick vectors

The acquisition of Borrelia burgdorferi by the larvae of competent and refractory ixodid ticks was assessed by quantitative polymerase chain reaction (PCR). Larvae were fed on infected mice, and the spirochete loads were determined during feeding and up to 93 d postfeeding. Amblyomma americanum (L.) was refractory to B. burgdorferi infection, with almost no detection of spirochete DNA during or postfeeding. In contrast, Ixodes scapularis Say supported high loads of spirochetes (10(3)-10(4) per larva). In Dermacentor variabilis (Say), B. burgdorferi uptake was reduced, with an average of 16 spirochetes per larvae acquired after 4 d of feeding, representing 1/195 of the counts in I. scapularis. However, during the first day postfeeding, the spirochete growth rate in D. variabilis reached 0.076 generations per hour, 7.7 times greater than the highest growth rate detected in I. scapularis. D. variabilis supported intense spirochete growth up to the fourth day postinfection, when the counts increased to an average of 282 spirochetes per larvae or 1/8.5 of the I. scapularis counts 4 d postfeeding. The kinetics of spirochete growth was unstable in D. variabilis compared with I. scapularis, and transmission of B. burgdorferi by D. variabilis could not be demonstrated. A cofeeding experiment indicated that I. scapularis feeding increased A. americanum spirochete uptake. These collective results indicate suboptimal conditions for B. burgdorferi uptake and colonization within A. americanum or the presence of anti-Borrelia factor(s) in this nonpermissive tick species.

Adjuvant therapy with edrecolomab versus observation in stage II colon cancer: a multicenter randomized phase III study

BACKGROUND

In a phase III study recruiting patients with stage II colon cancer the effect of adjuvant therapy with edrecolomab, a murine monoclonal antibody to the cell-surface glycoprotein 17-1A, was compared to observation alone.

PATIENTS AND METHODS

From January 1997 until July 2000 a total of 377 patients were postoperatively stratified according to tumor stage (T3 vs. T4) and center, and randomly allocated to either treatment with edrecolomab (cohort A, n = 183) or observation (cohort B, n = 194). Patients in cohort A received a total of 900 mg edrecolomab. The study was terminated prematurely because of discontinuation of drug supply in Germany.

RESULTS

305 patients were eligible for the primary endpoint of overall survival and 282 patients for disease-free survival. After a median follow-up of 42 months overall survival and disease-free survival were not significantly different. Toxicity was mild.

CONCLUSIONS

In the present study, postoperative adjuvant treatment with edrecolomab in patients with resected stage II colon cancer did not improve overall or disease-free survival.

Differential infectivity of the Lyme disease spirochete Borrelia burgdorferi derived from Ixodes scapularis salivary glands and midgut

Blood fed nymphal Ixodes scapularis Say infected with Borrelia burgdorferi were dissected to obtain salivary gland and midgut extracts. Extracts were inoculated into C3H/HeJ mice, and ear, heart, and bladder were cultured to determine comparative infectivity. Aliquots of extracts were then analyzed by quantitative polymerase chain reaction to determine the number of spirochetes inoculated into mice. A comparative median infectious dose (ID50) was determined for both salivary gland and midgut extract inoculations. Our data demonstrated a statistically significant difference (P < 0.002) in the ID50 derived from salivary gland (average = 18) versus midgut (average = 251) extracts needed to infect susceptible mice. A rationale for the differential infectivity of salivary and midgut derived spirochetes is discussed.

Borreliacidal activity of saliva of the tick Amblyomma americanum

Amblyomma americanum (Linneaus) (Acari: Ixodidae), an important tick vector of human and animal disease, is not a competent vector of the bacterial agent of Lyme disease, Borrelia burgdorferi, although its range overlaps the geographical distribution of Lyme disease within the United States. A possible mechanism that could prevent acquisition of B. burgdorferi spirochetes from infected hosts is the toxic effect of A. americanum saliva on B. burgdorferi. The data presented here indicate that after 24 and 48 h of exposure to A. americanum saliva, significantly fewer B. burgdorferi were alive compared to treatment controls as assessed by spirochete motility under dark-field microscopy and resistance to the dead stain, propidium iodide. After 48 h, fewer than 13% of saliva-exposed B. burgdorferi were alive. In contrast, significantly more B. burgdorferi exposed to Ixodes scapularis (Acari: Ixodidae) saliva survived after 24 or 48 h compared to A. americanum saliva or treatment controls.

Molar incisor hypomineralisation in a group of children and adolescents living in Dresden (Germany)

AIM

This was to determine the prevalence of Molar Incisor Hypomineralisation (MIH) and to evaluate possible causes of these enamel defects.

METHODS

The study group consisted of 2,408 10-17 year old children born during 1985-1992 and living in Dresden (Germany). Enamel defects were recorded using the modified DDE index. Children with enamel defects and their parents were invited for a re-examination to record the medical history of the children during the first 3 years of life; these children were matched by age with other children with apparently normal first molars (control group).

RESULTS

135 (5.6%) of the children had demarcated opacities in at least one first molar, i.e. MIH. A significantly higher prevalence of MIH was seen in children born between 1989 and 1991 compared with those born before and after that period (p<0.01). The number of children returning for the medical history questionnaire was low, 31 out of 135 responded (test group). Although there were no significant differences between the test and control groups in terms of peri and neonatal complications or other health problems, the low return precluded any definitive interpretation.

CONCLUSION

The overall prevalence of MIH in this study was low by comparison with other previous epidemiological reports.

Interaction of Neisseria meningitidis with human dendritic cells

Infection with Neisseria meningitidis serogroup B is responsible for fatal septicemia and meningococcal meningitis. The severity of disease directly correlates with the production of the proinflammatory cytokines tumor necrosis factor alpha (TNF-alpha), interleukin-1 (IL-1), IL-6, and IL-8. However, the source of these cytokines has not been clearly defined yet. Since bacterial infection involves the activation of dendritic cells (DCs), we analyzed the interaction of N. meningitidis with monocyte-derived DCs. Using N. meningitidis serogroup B wild-type and unencapsulated bacteria, we found that capsule expression significantly impaired neisserial adherence to DCs. In addition, phagocytic killing of the bacteria in the phagosome is reduced by at least 10- to 100-fold. However, all strains induced strong secretion of proinflammatory cytokines TNF-alpha, IL-6, and IL-8 by DCs (at least 1,000-fold at 20 h postinfection [p.i.]), with significantly increased cytokine levels being measurable by as early as 6 h p.i. Levels of IL-1beta, in contrast, were increased only 200- to 400-fold at 20 h p.i. with barely measurable induction at 6 h p.i. Moreover, comparable amounts of cytokines were induced by bacterium-free supernatants of Neisseria cultures containing neisserial lipooligosaccharide as the main factor. Our data suggest that activated DCs may be a significant source of high levels of proinflammatory cytokines in neisserial infection and thereby may contribute to the pathology of meningococcal disease.

PM25 measurements in ambient aerosol: comparison between Harvard impactor (HI) and the tapered element oscillating microbalance (TEOM) system

A comparison, based on the regression of 32 daily mean PM25 aerosol loadings determined by a tapered element oscillating microbalance (TEOM) and by a Harvard impactor (HI), is reported for the ambient aerosol of Erfurt (Germany). The PM2.5 concentrations measured by the TEOM were systematically lower then those obtained by the HI. The ratio of the means TEOM/HI was 0.74 and the regression equation is TEOM = 0.69 x HI + 0.071. This result is consistent with reports elsewhere suggesting that semi-volatile aerosol material is lost from the heated sample filter on the TEOM. To verify this assertion, a heating system was developed for the HI which was able to keep the HI sample filter at 50+/-1 degrees C. After the implementation of this heating system, no systematically differences were observed between the TEOM and the heated HI system. The ratio of means was 1.06 and the regression equation TEOM = 1.10 x HI - 0.668. Because the measured levels of ammonium nitrate were very low in Erfurt, we concluded that other compounds like semi-volatile organics were responsible for the loss of particulate material at 50 degrees C.

The use of an anesthesia information management system for prediction of antiemetic rescue treatment at the postanesthesia care unit

We used an anesthesia information management system (AIMS) to devise a score for predicting antiemetic rescue treatment as an indicator for postoperative nausea and vomiting (PONV) in the postanesthesia care unit (PACU). Furthermore, we wanted to investigate whether data collected with an AIMS are suitable for comparable clinical investigations. Over a 3-yr period (January 1, 1997, to December 31, 1999), data sets of 27,626 patients who were admitted postoperatively to the PACU were recorded online by using the automated anesthesia record keeping system NarkoData(R) (IMESO GmbH, Hüttenberg, Germany). Ten patient-related, 5 operative, 15 anesthesia-related, and 4 postoperative variables were studied by using forward stepwise logistic regression. Not only can the probability of having PONV in the PACU be estimated from the 3 previously described patient-related (female gender, odds ratio [OR] = 2.45; smoker, OR = 0.53; and age, OR = 0.995) and one operative variables (duration of surgery, OR = 1.005), but 3 anesthesia-related variables (intraoperative use of opioids, OR = 4.18; use of N(2)O, OR = 2.24; and IV anesthesia with propofol, OR = 0.40) are predictive. In implementing an equation for risk calculation into the AIMS, the individual risk of PONV can be calculated automatically.

IMPLICATIONS

The aim of this study was to investigate predictors for postoperative nausea and vomiting by using online anesthesia records. With the help of computerized data evaluation, 7 of 34 variables could be detected as risk factors. By implementing an automatic score into the record keeping system, an individual risk calculation could be made possible.

Intracellular bacteria as targets and carriers for vaccination

In this review we discuss intracellular bacteria as targets and carriers for vaccines. For clarity and ease of comprehension, we focus on three microbes, Mycobacterium tuberculosis, Listeria monocytogenes and Salmonella, with an emphasis on tuberculosis, one of the leading causes of death from infectious disease. Novel vaccination strategies against these pathogens are currently being considered. One approach favors the use of live attenuated vaccines and vaccine carrier strains thereof, either for heterologous antigen presentation or DNA vaccine delivery. This strategy includes both the improvement of attenuated vaccine strains as well as the 'de novo' generation of attenuated variants of virulent pathogens. An alternative strategy relies on the application of subunit immunizations, either as nucleic acid vaccines or protein antigens of the pathogen. Finally, we present a short summary of the vaccination strategies against tuberculosis.

Recombinant attenuated bacteria for the delivery of subunit vaccines

Using attenuated intracellular bacteria as carriers, we have developed two different approaches for the delivery of subunit vaccines encoding heterologous antigens. The first system is based on the direct secretion of the heterologous antigens in Gram-negative bacteria via the hemolysin secretion system of Escherichia coli into either phagosome or cytosol of infected cells. The second approach is based on the transport of eukaryotic antigen expression vectors by intracellular bacteria like Listeria and Salmonella into the host cell and here, preferably, into the cytosolic compartment. After release of the plasmid DNA from the bacteria, the plasmid-encoded antigens can be expressed directly by the host cell. Finally, we combined both types of subunit vaccines in one live vector - we equipped Salmonella strains with a phagosomal escape function by utilization of the hemolysin secretion system and used this recombinant vaccine strain for the delivery of a eukaryotic antigen expression vector into the cytosol of macrophages.

Gram-positive and Gram-negative bacteria as carrier systems for DNA vaccines

Vaccination by intradermal or intramuscular injection of eukaryotic antigen expression vectors (so-called DNA vaccines) elicits strong cellular and humoral immune responses. A novel approach employs attenuated mutant strains of Gram-positive and Gram-negative intracellular bacteria as carriers for the delivery of DNA vaccines. This strategy allows the administration of the DNA vaccines via mucosal surfaces and a direct delivery of the plasmid DNA to professional antigen presenting cells (APC), such as macrophages and dendritic cells (DC). In this work, we have found that several Gram-negative bacteria are capable of delivering plasmid vectors to human DC. In addition, we tested the suitability of the Gram-positive bacterium Listeria monocytogenes as a vaccine carrier for the immunization of fish.

Current status and future perspectives of DNA vaccine delivery by attenuated intracellular bacteria

Vaccination by intradermal or intramuscular injection of antigen-encoding plasmid-DNA elicits strong cellular and humoral immune responses. Professional antigen presenting cells (APC) seem to induce these responses, making it, therefore, desirable to deliver the plasmid molecules directly to these cells. The exploitation of attenuated intracellular bacteria as DNA delivery vehicles makes the direct targeting of DNA vaccine vectors to professional APC feasible.

Identification of mu-opioid receptor epitopes recognized by agonistic IgG

We have previously reported the presence of IgG antibodies with a morphine-like activity in the serum of healthy individuals. The agonistic activity of IgG was dependent on their binding to the first and the third extracellular loops of the human mu opioid receptor. In this study we show that IgG antibodies obtained by immunizing rats with peptides corresponding to these two loops exhibited a similar morphine-like activity. Residues corresponding to Y(130), M(132), G(133), T(134) within the first and F(315) within the third extracellular segment were required for antibody binding and conferred to IgG a high mu-opioid selectivity.

From evil to good: a cytolysin in vaccine development

Current vaccination strategies mainly target antigens into the phagosomal, major histocompatibility complex class II antigen-processing pathway and thus lead predominantly to humoral immune responses. The elicitation of cytotoxic T-cell responses instead requires introduction of antigens into the cytosol of professional antigen-presenting cells (APCs). The intracellular bacterium Listeria monocytogenes gains access to the host cell cytosol by means of a cytolysin, listeriolysin O. Vaccine researchers have successfully employed listeriolysin in novel vaccination approaches to provide access to the cytosol of professional APCs for purified protein antigens, attenuated bacterial vaccine strains, DNA vaccines and liposome contents.

Secretion of different listeriolysin cognates by recombinant attenuated Salmonella typhimurium: superior efficacy of haemolytic over non-haemolytic constructs after oral vaccination

Viable antigen (Ag) delivery systems expressing defined pathogen-derived proteins represent powerful candidates for future vaccination strategies. Here, recombinant (r)Salmonella typhimurium aroA strains secreting listeriolysin (Hly) of Listeria monocytogenes in haemolytic or non-haemolytic form were constructed to direct these carriers into cytosolic or phagosomal host cell compartments, respectively. Oral and intravenous (i.v.) vaccination of mice with either construct induced 'transporter associated with antigen processing'-dependent protection against the intracellular bacterial pathogen L. monocytogenes. Comparison of oral immunization with both rSalmonella constructs revealed superior vaccine efficacy of the haemolytic rS. typhimurium Hlys construct as compared to the non-haemolytic rSalmonella Hlys(492) strain. In contrast, efficacy of i.v. vaccination with either rSalmonella strain did not significantly differ. Therefore, rSalmonella strains secreting biologically active Hly represent valuable delivery systems for heterologous rAg or DNA which should be exploited for future mucosal vaccination strategies.

Bacterial systems for the delivery of eukaryotic antigen expression vectors

Attenuated bacterial strains allow the administration of recombinant vaccines via the mucosal surfaces. Whereas attenuated bacteria are generally engineered to express heterologous antigens, a novel approach employs intracellular bacteria for the delivery of eukaryotic antigen expression vectors (so-called DNA vaccines). This strategy allows a direct delivery of DNA to professional antigen-presenting cells (APC), such as macrophages and dendritic cells (DC), through bacterial infection. The bacteria used for DNA vaccine delivery either enter the host cell cytosol after phagocytosis by the APC, for example, Shigella and Listeria, or they remain in the phagosomal compartment, such as Salmonella. Both intracellular localizations of the bacterial carriers seem to be suitable for successful delivery of DNA vaccine vectors.

Delivery of protein antigens and DNA by virulence-attenuated strains of Salmonella typhimurium and Listeria monocytogenes

Two different plasmid-vector systems were developed which allow the efficient production and presentation of protein antigens in antigen-presenting cells (APC) by means of virulence-attenuated bacteria. The first antigen-delivery system is based on the secretion machinery of the Escherichia coli hemolysin (HlyA-type I secretion system), which transports proteins, possessing the specific HlyA secretion signal (HlyA(s)) at the C-terminus, across both membranes of gram-negative bacteria. This system functions in all gram-negative bacteria that possess the TolC-analogous protein in the outer membrane. This outer membrane protein is necessary for the stable anchoring of the type I secretion apparatus in the cell envelope. Suitable HlyA(s)-fused antigens are secreted with high efficiency by E. coli and by virulence-attenuated strains of Salmonella, Shigella, Vibrio cholerae and Yersinia enterocolitica. The other vector system expresses the heterologous antigen under the control of an eukaryotic promoter in a similar fashion as in plasmids commonly used for vaccination with naked DNA. This plasmid DNA is introduced into APCs with the help of virulence-attenuated self-destructing Listeria monocytogenes mutants. After synthesis of the heterologous protein, epitopes of the antigen are presented by the APC together with MHC class I molecules. This system functions in macrophages and dendritic cells in vitro and can also be used in a modified form in animal models.

DNA vaccine delivery by attenuated intracellular bacteria

Vaccination by intramuscular or intradermal injection of antigen-encoding DNA is a promising new approach leading to strong cellular and humoral immune responses. Since bone-marrow derived antigen presenting cells (APC) seem to induce these immune responses after migration to the spleen, it is desirable to deliver DNA vaccines directly to splenic APC. Recently, attenuated intracellular bacteria have been exploited for the introduction of DNA vaccine vectors into different cell types in vitro as well as in vivo and offer an attractive alternative to the direct inoculation of naked plasmid DNA.

Isolation of RNA from mycobacteria grown under in vitro and in vivo conditions

Isolation of RNA from mycobacteria is very difficult to perform, and the yields are generally very low. We describe an approach to isolate RNA from mycobacterial species which combines the disruption of mycobacterial cells by a silica/ceramic matrix in a reciprocal shaker with the ease and efficiency of subsequent RNA purification on spin columns with silica gel-based membranes. This method is rapid, easy to perform and yields high amounts of pure, intact total RNA. Due to its safety, this method is applicable even to group 3 biological hazard organisms like Mycobacterium tuberculosis. By combining a method for the isolation of phagosomal bacteria from infected primary macrophages with the novel RNA isolation technique, we are able to monitor gene expression during infection even in bacteria which are rather resistant to genetic manipulation, like Mycobacterium bovis.

Novel bacterial systems for the delivery of recombinant protein or DNA

On the basis of attenuated intracellular bacteria, we have developed two delivery systems for either heterologous proteins or DNA vaccine vectors. The first system utilizes attenuated strains of Gram-negative bacteria which are engineered to secrete heterologous antigens via the alpha-hemolysin secretion system of Escherichia coli. The second system is based on attenuated suicide strains of Listeria monocytogenes, which are used for the direct delivery of eukaryotic antigen expression vectors into professional antigen presenting cells (APC) like macrophages in vitro as well as in vivo.