The semiconstrained DRUJ prosthesis: blessing or curse?

PURPOSE

There are numerous operative procedures to treat osteoarthritic changes or a significant instability of the distal radioulnar joint (DRUJ). The key problem of most methods is the destabilization of the forearm leading to secondary painful impingement between the radius and ulna, as well as a significant limitation of forearm rotation. The Aptis-Prosthesis designed by Scheker represents a complete substitute for the DRUJ. It is mostly used after the failure of various treatment options to solve the primary problems (arthritis, instability). We have used this type of prosthesis mostly after multiple operative treatments for more than 25 years.

METHODS

In the following retrospective study, we analyzed the data of patients that received an Aptis-prosthesis between 2016 and 2021. We have implanted this prosthesis in 13 cases (11 female, 2 male). Routinely, we document the clinical outcome concerning range of motion (ROM), grip strength, and pain according to numeric rate scaling (NRS) after more than 12 months (month 12-24). In addition, complications, osseous changes, and the rate of loosening of the prosthesis were registered. Furthermore, DASH-Score and patients ' satisfaction were evaluated. Also-as with other implants-follow-up x-rays were performed.

RESULTS

Removal or significant revision of any of the prostheses was not needed. The ROM was 68.1° ± 19.7° for pronation and 72.3° ± 20.9° for supination, grip strength amounted to 27.7 kg ± 11.0 kg equaling 83% of the contralateral side. NRS was 0 at rest and 1.2 (0-2) under weight-bearing. A lysis margin of the radial tap was noted in the radiological examination in 2 patients but without any signs of loosening. The DASH-Score added up to 31.8 ± 13.8 (13-55). All patients were satisfied or very satisfied having this implant.

CONCLUSION

The semiconstrained Aptis-prosthesis is a safe and efficient treatment option after failed DRUJ surgeries. It is striking that of the 20 implanted prostheses no significant revision or explantations were necessary over a period of 25 years.

CD44+ and CD31+ extracellular vesicles (EVs) are significantly reduced in polytraumatized patients with hemorrhagic shock - evaluation of their diagnostic and prognostic potential

Background

Hemorrhagic shock (HS) is responsible for approximately 2 million deaths per year worldwide and is caused in 80% by polytrauma. These patients need a precise and quick diagnostic, which should be based on a combination of laboratory markers and radiological data. Extracellular vesicles (EVs) were described as potential new markers and mediators in trauma. The aim of the present study was to analyze, whether the surface epitopes of plasma-EVs reflect HS in polytraumatized patients and whether cell-specific EV subpopulations are useful diagnostic tools.

Material and methods

Plasma samples from polytraumatized patients (ISS ≥16) with HS (n=10) and without (n=15), were collected at emergency room (ER) and 24h after trauma. Plasma-EVs were isolated via size exclusion chromatography and EV-concentrations were detected by Coomassie Plus (Bradford) Assay. The EVs subpopulations were investigated by a bead-based multiplex flow cytometry measurement of surface epitopes and were compared with healthy controls (n=10). To investigate the diagnostic and prognostic potential of EVs subpopulations, results were correlated with clinical outcome parameters documented in the electronical patients' record.

Results

We observed a significant reduction of the total amount of plasma EVs in polytrauma patients with HS, as compared to polytrauma patients without HS and healthy controls. We found significant reduction of CD42a+ and CD41b+ (platelet-derived) EVs in all polytrauma patients, as well as a reduction of CD29+ EVs compared to healthy volunteers (*p<0.05). CD44+ and CD31+ EVs were specifically altered in patients with HS (*p<0.05). Both EV populations showed a moderate correlation (r² = 0.42) with the transfusion of erythrocyte concentrate, were associated with non-survival and the need for catecholamines (*p<0.05).

Conclusion

Our data reveal that polytrauma patients with a hemorrhagic shock are characterized by a reduction of CD44+ and CD31+ plasma-EVs. Both EV populations showed a moderate correlation with the need of erythrocyte transfusion, were associated with non-survival and the need for catecholamines.

Diagnostic and Prognostic Potential of Exosomal Cytokines IL-6 and IL-10 in Polytrauma Patients

Trauma remains a leading cause of morbidity and mortality. Polytraumatized patients need a precise, early diagnosis to avoid complications such as multiorgan failure or sepsis. Inflammatory cytokines, commonly used for diagnosis, have a short half-life, which limits their efficacy as a diagnostic or prognostic marker. In this study, we hypothesized that cytokines in exosomes could have a longer half-life, and therefore could be used as diagnostic and prognostic markers in polytrauma patients. Plasma samples from polytraumatized patients (ISS ≥ 16, n = 18) were collected in the emergency room (ER) 1, 2, 3 and 5 days after trauma. Plasma-exosomes were isolated via size exclusion chromatography from polytraumatized patients and healthy volunteers (n = 10). The systemic and exosomal concentrations of interleukin (IL)-6, IL-10, IL-1β and TNF were measured using high-sensitive ELISAs. To investigate the diagnostic and prognostic potential of exosomal cytokines, data were correlated with clinical outcome parameters (injury severity, ventilation time, time in ICU and survival) documented in the patients' electronic records. Despite the use of high-sensitive ELISAs, IL-1β and TNF alpha were not detected in exosomes. IL-6 and IL-10 were detectable in polytraumatized patient exosomes at all time points. A decrease over time of both systemic and exosomal IL-6 concentrations was observed. Furthermore, exosomal and systemic IL-6 concentrations moderately correlated (r = 0.63). Exosomal IL-6 in the ER moderately correlated with the Injury Severity Score (ISS) (mean 35.5 ± 11.5) (r = 0.45) and was associated with non-survival in polytrauma patients (p < 0.05). In contrast to IL-6, no correlation between systemic and exosomal IL-10 concentrations was found. Exosomal IL-10 concentrations remained unchanged throughout the observation time, whereas systemic IL-10 concentrations peaked in the ER and were significantly reduced after 24 h. Data from this study support our hypothesis that some cytokines (IL-10), but not all (IL-6), are detectable in exosomes significantly longer than they are in plasma. This might indicate that they are protected from degradation. Although we did not find a correlation between IL-10 exosomal concentration and patient outcome, our data confirm that exosomal cytokines are of interest as potential diagnostic and prognostic markers in polytrauma patients, and require further detailed research.

The sequence of the treatment of combined fractures of the pelvis, spine, and extremities in polytraumatized patients

'Damage control' is the therapeutic strategy in the treatment of polytraumatized patients and aims at securing vital functions and controlling bleeding with a favorable effect on the post-traumatic immune response. The post-traumatic immune dysfunction is based on a disturbed balance between immunostimulatory and anti-inflammatory mechanisms. The extent of the immunological 'second hit' can be limited by delaying deferable surgical therapies until organ stabilization has been achieved by the treating surgeon. Pelvic sling is easy to apply and noninvasive with effective pelvic reduction. Pelvic angiography vs pelvic packing are not antagonistic, but rather should be considered as complementary methods. Operating as early as possible on unstable spinal injuries with confirmed or suspected neurological deficits by decompression and stabilization with a dorsal internal fixator. Dislocations, unstable or open fracture, vascular involvement, and compartment syndrome are considered emergency indications. In extremity fracture treatment, primary definitive osteosynthesis is often dispensed with and instead, temporary stabilization with an external fixator is performed.

Acute alcohol consumption increases systemic endotoxin bioactivity for days in healthy volunteers-with reduced intestinal barrier loss in female

OBJECTIVE

Trauma is the most common cause of death among young adults. Alcohol intoxication plays a significant role as a cause of accidents and as a potent immunomodulator of the post-traumatic response to tissue injury. Polytraumatized patients are frequently at risk to developing infectious complications, which may be aggravated by alcohol-induced immunosuppression. Systemic levels of integral proteins of the gastrointestinal tract such as syndecan-1 or intestinal fatty acid binding proteins (FABP-I) reflect the intestinal barrier function. The exact impact of acute alcohol intoxication on the barrier function and endotoxin bioactivity have not been clarified yet.

METHODS

22 healthy volunteers received a precisely defined amount of alcohol (whiskey-cola) every 20 min over a period of 4 h to reach the calculated blood alcohol concentration (BAC) of 1‰. Blood samples were taken before alcohol drinking as a control, and after 2, 4, 6, 24 and 48 h after beginning with alcohol consumption. In addition, urine samples were collected. Intestinal permeability was determined by serum and urine values of FABP-I, syndecan-1, and soluble (s)CD14 as a marker for the endotoxin translocation via the intestinal barrier by ELISA. BAC was determined.

RESULTS

Systemic FABP-I was significantly reduced 2 h after the onset of alcohol drinking, and remained decreased after 4 h. However, at 6 h, FABP-I significantly elevated compared to previous measurements as well as to controls (p < 0.05). Systemic sCD14 was significantly elevated after 6, 24 and 48 h after the onset of alcohol consumption (p < 0.05). Systemic FABP-I at 2 h after drinking significantly correlated with the sCD14 concentration after 24 h indicating an enhanced systemic LPS bioactivity. Women showed significantly lower levels of syndecan-1 in serum and urine and urine for all time points until 6 h and lower FABP-I in the serum after 2 h.

CONCLUSIONS

Even relative low amounts of alcohol affect the immune system of healthy volunteers, although these changes appear minor in women. A potential damage to the intestinal barrier and presumed enhanced systemic endotoxin bioactivity after acute alcohol consumption is proposed, which represents a continuous immunological challenge for the organism and should be considered for the following days after drinking.

The Influence of Alcohol on the Base Excess Parameter in Trauma Patients

BACKGROUND

The base excess (BE) parameter can be used as an indicator of mortality. However, study results on the influence of alcohol on the validity of BE as a prognostic parameter in alcohol-intoxicated patients are controversial. Thus, this study examined the hypothesis: An increasing blood alcohol level reduces the prognostic value of the BE parameter on mortality.

PATIENTS AND METHODS

In a retrospective analysis of the multicenter database of the TraumaRegister DGU, patients from 2015 to 2017 were grouped depending on their blood alcohol level (BAL) into a BAL+ and BAL- group. The hypothesis was verified using logistic regression with an assumed significance level of 1% (P < 0.01).

RESULTS

Eleven thousand eight hundred eighty-nine patients were included; 9,472 patients in the BAL- group and 2,417 patients in the BAL+ group. Analysis of the BE showed lower values in the BAL+ group (BAL-: -1.8 ± 4.4 mmol/L vs. BAL+: -3.4 ± 4.6 mmol/L). There is a trend toward lower BE levels when BAL increases. Assuming a linear relationship, then BE decreases by 0.6 points per mille alcohol (95% CI: 0.5-0.7; P < 0.001). The mortality rate was significantly lower in the BAL+ group (BAL-: 11.1% vs. BAL+: 7.9%). The logistic regression analysis showed a significant beneficial influence of BAL+ on the mortality rate (OR 0.706, 95% CI 0.530-0.941, P = 0.018). To analyze whether a low BE (≤-6 mmol/L) has different prognostic effects in patients with and without alcohol, logistic regression models were calculated. However, the effect of BE ≤ -6 mmol/L was similar in both models (regression coefficients in BAL-/+ patients: 0.379/0.393).

CONCLUSIONS

The data demonstrate an existing influence of alcohol on the BE parameter; however, this does not negatively affect the BE as a prognostic parameter at a threshold of ≤ -6 mmol/L.

Falls from Great Heights: Risk to Sustain Severe Thoracic and Pelvic Injuries Increases with Height of the Fall

Falls from a height are a common cause of polytrauma care in Level I Trauma Centers worldwide. The expected injury consequences depend on the height of the fall and the associated acceleration, as well as the condition of the ground. In addition, we further hypothesize a correlation between the cause of the fall, the age of the patient, and the patient’s outcome. A total of 178 trauma patients without age restriction who were treated in our hospital after a fall >3 m within a 5-year period were retrospectively analyzed. The primary objective was a clinically and radiologically quantifiable increase in the severity of injuries after falls from different relevant heights (>3 m, >6 m, and >9 m). The cause of the fall, either accidental or suicidal; age and duration of intensive care unit stay, including duration of ventilation; and total hospital stay were analyzed. Additionally, the frequency of urgent operations, such as, external fixation of fractures or hemi-craniectomies, laboratory parameters; and clinical outcomes were also among the secondary objectives. Sustaining a thoracic trauma or pelvis fractures increases significantly with height, and vital parameters are significantly compromised. We also found significant differences in urgent pre- and in-hospital emergency interventions, as well as organ complications and outcome parameters depending on the fall’s height.

Acute Alcohol Intoxication Modulates Monocyte Subsets and Their Functions in a Time-Dependent Manner in Healthy Volunteers

Background

Excessive alcohol intake is associated with adverse immune response-related effects, however, acute and chronic abuse differently modulate monocyte activation. In this study, we have evaluated the phenotypic and functional changes of monocytes in acutely intoxicated healthy volunteers (HV).

Methods

Twenty-two HV consumed individually adjusted amounts of alcoholic beverages until reaching a blood alcohol level of 1‰ after 4h (T4). Peripheral blood was withdrawn before and 2h (T2), 4h (T4), 6h (T6), 24h (T24), and 48h (T48) after starting the experiment and stained for CD14, CD16 and TLR4. CD14^brightCD16^-, CD14^brightCD16⁺ and CD14^dimCD16⁺ monocyte subsets and their TLR4 expression were analyzed by flow cytometry. Inflammasome activation via caspase-1 in CD14⁺ monocytes was measured upon an ex vivo in vitro LPS stimulation. Systemic IL-1β and adhesion capacity of isolated CD14⁺ monocytes upon LPS stimulation were evaluated.

Results

The percentage of CD14⁺ monocyte did not change following alcohol intoxication, whereas CD14^brightCD16^- monocyte subset significantly increased at T2 and T24, CD14^brightCD16⁺ at T2, T4 and T6 and CD14^dimCD16⁺ at T4 and T6. The relative fraction of TLR4 expressing CD14⁺ monocytes as well as the density of TLR4 surface presentation increased at T2 and decreased at T48 significantly. TLR4⁺CD14⁺ monocytes were significantly enhanced in all subsets at T2. TLR4 expression significantly decreased in CD14^brightCD16^- at T48, in CD14^brightCD16⁺ at T24 and T48, increased in CD14^dimCD16⁺ at T2. IL-1β release upon LPS stimulation decreased at T48, correlating with TLR4 receptor expression. Alcohol downregulated inflammasome activation following ex vivo in vitro stimulation with LPS between T2 and T48 vs. T0. The adhesion capacity of CD14⁺ monocytes decreased from T2 with significance at T4, T6 and T48. Following LPS administration, a significant reduction of adhesion was observed at T4 and T6.

Conclusions

Alcohol intoxication immediately redistributes monocyte subsets toward the pro-inflammatory phenotype with their subsequent differentiation into the anti-inflammatory phenotype. This is paralleled by a significant functional depression, suggesting an alcohol-induced time-dependent hyporesponsiveness of monocytes to pathogenic triggers.

Reduced phagocytosis, ROS production and enhanced apoptosis of leukocytes upon alcohol drinking in healthy volunteers

Background

Alcohol drinking is associated with a serious risk of developing health problems as well as with a large number of traumatic injuries. Although chronic alcohol misuse is known to contribute to severe inflammatory complications, the effects of an acute alcohol misuse are still unclear. Here, the impact of acute alcohol drinking on leukocyte counts and their cellular functions were studied.

Methods

Twenty-two healthy volunteers (12 female, 10 male) received a predefined amount of a whiskey-cola mixed drink (40% v/v), at intervals of 20 min, over 4 h to achieve a blood alcohol concentration of 1‰. Blood samples were taken before drinking T₀, 2 h (T₂), 4 h (T₄), 6 h (T₆), 24 h (T₂₄) and 48 h (T₄₈) after starting drinking alcohol. Leukocytes, monocytes and granulocyte counts and their functions regarding the production of reactive oxidative species (ROS), phagocytosis and apoptosis were analyzed by flow cytometry.

Results

Total leukocyte counts significantly increased at T₂ and T₄, while granulocyte and monocyte counts decreased at T₄ and T₆ vs. T₀. Monocytes increased significantly at T₂₄ and T₄₈ vs. T₀. While the total number of ROS-producing leukocytes and notably granulocytes significantly increased, in parallel, the intracellular ROS intensity decreased at T₂ and T₆. The numbers of ROS-positive monocytes have shown a delayed modulation of ROS, with a significant reduction in the total number of ROS-producing cells at T₄₈ and a significantly reduced intracellular ROS-intensity at T₂₄. Phagocyting capacity of leukocytes significantly decreased at T₄ and T₆. In general leukocytes, and notably granulocytes demonstrated significantly increased early (T₂), while monocyte exerted significantly increased late apoptosis (T₂₄ and T₄₈).

Conclusions

Alcohol drinking immediately impacts leukocyte functions, while the impact on monocytes occurs at even later time points. Thus, even in young healthy subjects, alcohol drinking induces immunological changes that are associated with diminished functions of innate immune cells that persist for days.

Short Exposure to Ethanol Diminishes Caspase-1 and ASC Activation in Human HepG2 Cells In Vitro

This paper discusses how the assembly of pro-caspase-1 and apoptosis-associated speck-like protein containing a caspase-recruitment domain (ASC) in macromolecular protein complexes, inflammasomes, activates caspase-1. The present study investigates the molecular mechanisms of inflammasome activation in HepG2 cells and examines how short exposures to ethanol (EtOH) affect inflammasome activation. HepG2 cells were treated with lipopolysaccharide (LPS), ATP or nigericin (NIG) in a two-step model. After LPS priming, ATP or NIG were added. As inhibitors, sodium orthovanadate (general inhibitor of tyrosine phosphatases), AC-YVAD-CMK (caspase-1 inhibitor) or AZ10606120 (purinergic receptor P2X7R inhibitor) were applied after LPS priming. To monitor the inflammasome activation, the caspase-1 activity, ASC speck formation, reactive oxygen species (ROS) production and cell death were analyzed. To elucidate the mechanistical approach of EtOH to the inflammasome assembly, the cells were treated with EtOH either under simultaneous LPS administration or concurrently with ATP or NIG application. The co-stimulation with LPS and ATP induced a significant ASC speck formation, caspase-1 activation, cell death and ROS generation. The inhibition of the ATP-dependent purinoreceptor P2X7 decreased the caspase-1 activation, whereas sodium orthovanadate significantly induced caspase-1. Additional treatment with EtOH reversed the LPS and ATP-induced caspase-1 activation, ASC speck formation and ROS production. The ASC speck formation and caspase-1 induction require a two-step signaling with LPS and ATP in HepG2 cells. Inflammasome activation may depend on P2X7. The molecular pathway of an acute effect of EtOH on inflammasomes may involve a reduction in ROS generation, which in turn may increase the activity of tyrosine phosphatases.

Regulatory T Cells Modulate CD4 Proliferation after Severe Trauma via IL-10

Objective: Severely injured patients frequently develop an immunological imbalance following the traumatic insult, which might result in infectious complications evoked by a persisting immunosuppression. Regulatory T cells (Tregs) maintain the immune homeostasis by suppressing proinflammatory responses, however, their functionality after trauma is unclear. Here, we characterized the role of Tregs in regulating the proliferation of CD4⁺ lymphocytes in traumatized patients (TP). Methods: Peripheral blood was obtained daily from 29 severely injured TP (Injury Severity Score, ISS ≥16) for ten days following admission to the emergency department (ED). Ten healthy volunteers (HV) served as controls. The frequency and activity of Tregs were assessed by flow cytometry. Proliferation of CD4⁺ cells was analyzed either in presence or absence of Tregs, or after blocking of either IL-10 or IL-10R1. Results: The frequencies of CD4⁺CD25^high and CD4⁺CD25⁺CD127⁻ Tregs were significantly decreased immediately upon admission of TP to the ED and during the following 10 post-injury days. Compared with HV CD4⁺ T cell proliferation in TP increased significantly upon their admission and on the following days. As expected, CD4⁺CD25⁺CD127⁻ Tregs reduced the proliferation of CD4⁺ cells in HV, nevertheless, CD4⁺ proliferation in TP was increased by Tregs. Neutralization of IL-10 as well as blocking the IL-10R1 increased further CD4⁺ T cell proliferation in Tregs-depleted cultures, thereby confirming an IL-10-mediated mechanism of IL-10-regulated CD4⁺ T cell proliferation. Neutralization of IL-10 in TP decreased CD4⁺ T cell proliferation in Tregs-depleted cultures, whereas blocking of the IL-10R1 receptor had no significant effects. Conclusions: The frequency of Tregs in the CD4⁺ T lymphocyte population is reduced after trauma; however, their inductiveness is increased. The mechanisms of deregulated influence of Tregs on CD4⁺ T cell proliferation are mediated via IL-10 but not via the IL-10R1.

Enhanced pro-inflammatory response and higher mortality rates in geriatric trauma patients

BACKGROUND

Age has been associated with increased morbidity and mortality after traumatic injury. Disregarding trauma-related factors, this may be caused by the diminished ability to cope with stressors due to limited reserve, the so-called frailty. Inflammation is assumed to promote frailty, and thus, pro-inflammatory markers may constitute as being predictive factors in geriatric trauma patients (TP). Here, we analyzed the influence of age on systemic inflammatory markers and outcome parameters in TP.

PATIENTS AND METHODS

204 TP with injury severity score (ISS) ≥ 16 were included and grouped to younger vs. geriatric, defining an age of 65 as cut-off. ISS, vital signs, physiological parameters, stay at the intensive-care unit (ICU) or in-hospital, and outcome parameters were analyzed. Systemic fibrinogen, interleukin (IL)-6, and IL-10 levels were determined upon admission. A p value < 0.05 was considered statistically significant.

RESULTS

43 geriatric and 161 younger TP were included. ISS (24.19 ± 9.59 vs. 26.93 ± 9.68) was comparable between both groups. Abbreviated Injury Scale (AIS) ≥ 3 of head trauma was more prevalent in geriatric TP (74.42 vs. 64.59%). In both groups, there were significantly more male than female patients; however, this disparity was significantly more distinct in younger TP. Geriatric group showed significantly lower shock indices, higher fibrinogen, and lower IL-10 levels (all p < 0.05). A significant spearman´s rank correlation with age was found for fibrinogen (positive correlation, r = 0.364, p < 0.05), and for IL-10 (negative correlation, r = - 0.168, p < 0.05). In-hospital mortality was significantly increased in geriatric TP.

CONCLUSIONS

An enhanced inflammatory response is associated with higher mortality rates in geriatric trauma patients.

Comparative Analysis of the Regulatory T Cells Dynamics in Peripheral Blood in Human and Porcine Polytrauma

Background

Severely injured patients experience substantial immunological stress in the aftermath of traumatic insult, which often results in systemic immune dysregulation. Regulatory T cells (Treg) play a key role in the suppression of the immune response and in the maintenance of immunological homeostasis. Little is known about their presence and dynamics in blood after trauma, and nothing is known about Treg in the porcine polytrauma model. Here, we assessed different subsets of Treg in trauma patients (TP) and compared those to either healthy volunteers (HV) or data from porcine polytrauma.

Methods

Peripheral blood was withdrawn from 20 TP with injury severity score (ISS) ≥16 at the admittance to the emergency department (ED), and subsequently on day 1 and at day 3. Ten HV were included as controls (ctrl). The porcine polytrauma model consisted of a femur fracture, liver laceration, lung contusion, and hemorrhagic shock resulting in an ISS of 27. After polytrauma, the animals underwent resuscitation and surgical fracture fixation. Blood samples were withdrawn before and immediately after trauma, 24 and 72 h later. Different subsets of Treg, CD4+CD25+, CD4+CD25+FoxP3+, CD4+CD25+CD127-, and CD4+CD25+CD127-FoxP3+ were characterized by flow cytometry.

Results

Absolute cell counts of leukocytes were significantly increasing after trauma, and again decreasing in the follow-up in human and porcine samples. The proportion of human Treg in the peripheral blood of TP admitted to the ED was lower when compared to HV. Their numbers did not recover until 72 h after trauma. Comparable data were found for all subsets. The situation in the porcine trauma model was comparable with the clinical data. In porcine peripheral blood before trauma, we could identify Treg with the typical immunophenotype (CD4+CD25+CD127-), which were virtually absent immediately after trauma. Similar to the human situation, most of these cells expressed FoxP3, as assessed by intracellular FACS stain.

Conclusion

Despite minor percental differences in the recovery of Treg populations after trauma, our findings show a comparable decrease of Treg early after polytrauma, and strengthen the immunological significance of the porcine polytrauma model. Furthermore, the Treg subpopulation CD4+CD25+CD127- was characterized in porcine samples.

Simvastatin exerts anticancer effects in osteosarcoma cell lines via geranylgeranylation and c-Jun activation

Osteosarcoma is the leading primary bone cancer in young adults and exhibits high chemoresistance rates. Therefore, characterization of both alternative treatment options and the underlying mechanisms is essential. Simvastatin, a cholesterol-lowering drug, has among its pleiotropic effects anticancer potential. Characterizing this potential and the underlying mechanisms in osteosarcoma is the subject of the present study. Human osteosarcoma cells (SaOS-2 and U2OS) were treated with simvastatin (4-66 µM) for 48 or 72 h. The effects of downstream substrate mevalonate (MA) or substrates for isoprenylation farnesyl pyrophosphate (FPP) and geranylgeranyl-pyrophosphate (GGPP) were evaluated using add-back experiments. Tumour growth using MTT assay, apoptosis, cell cycle and signalling cascades involved in simvastatin-induced manipulation were analysed. The results revealed that simvastatin dose-dependently inhibited cell growth. Simvastatin significantly induced apoptosis, increased the Bax/Bcl-2 ratio, and cleavage of caspase-3 and PARP protein. Simvastatin impaired cell cycle progression as shown by significantly increased percentages of cells in the G0/G1 phase and lower percentages of cells in the S phase. Gene expression levels of cell cycle-regulating genes (TP53, CDKN1A and CDK1) were markedly altered. These effects were not completely abolished by FPP, but were reversed by MA and GGPP. JNK and c-Jun phosphorylation was enhanced after simvastatin treatment, while those were abolished when either MA or GGPP were added. In conclusion, simvastatin acts primarily by reducing prenylation to induce apoptosis and reduce osteosarcoma cell growth. Particularly enhanced activation of c-Jun seems to play a pivotal role in osteosarcoma cell death.

Early decreased TLR2 expression on monocytes is associated with their reduced phagocytic activity and impaired maturation in a porcine polytrauma model

In their post-traumatic course, trauma patients suffering from multiple injuries have a high risk for immune dysregulation, which may contribute to post-injury complications and late mortality. Monocytes as specific effector cells of the innate immunity play a crucial role in inflammation. Using their Pattern Recognition Receptors (PRRs), notably Toll-Like Receptors (TLR), the monocytes recognize pathogens and/or pathogen-associated molecular patterns (PAMPs) and organize their clearance. TLR2 is the major receptor for particles of gram-positive bacteria, and initiates their phagocytosis. Here, we investigated the phagocytizing capability of monocytes in a long-term porcine severe trauma model (polytrauma, PT) with regard to their TLR2 expression. Polytrauma consisted of femur fracture, unilateral lung contusion, liver laceration, hemorrhagic shock with subsequent resuscitation and surgical fracture fixation. After induction of PT, peripheral blood was withdrawn before (-1 h) and directly after trauma (0 h), as well as 3.5 h, 5.5 h, 24 h and 72 h later. CD14+ monocytes were identified and the expression levels of H(S)LA-DR and TLR2 were investigated by flow cytometry. Additionally, the phagocytizing activity of monocytes by applying S. aureus particles labelled with pHrodo fluorescent reagent was also assessed by flow cytometry. Furthermore, blood samples from 10 healthy pigs were exposed to a TLR2-neutralizing antibody and subsequently to S. aureus particles. Using flow cytometry, phagocytizing activity was determined. P below 0.05 was considered significant. The number of CD14+ monocytes of all circulating leukocytes remained constant during the observational time period, while the percentage of CD14+H(S)LA-DR+ monocytes significantly decreased directly, 3.5 h and 5.5 h after trauma. The percentage of TLR2+ expressing cells out of all monocytes significantly decreased directly, 3.5 h and 5.5 h after trauma. The percentage of phagocytizing monocytes decreased immediately and remained lower during the first 3.5 h after trauma, but increased after 24 h. Antagonizing TLR2 significantly decreased the phagocytizing activity of monocytes. Both, decreased percentage of activated as well as TLR2 expressing monocytes persisted as long as the reduced phagocytosis was observed. Moreover, neutralizing TLR2 led to a reduced capability of phagocytosis as well. Therefore, we assume that reduced TLR2 expression may be responsible for the decreased phagocytizing capacity of circulating monocytes in the early post-traumatic phase.

Ethanol Decreases Inflammatory Response in Human Lung Epithelial Cells by Inhibiting the Canonical NF-kB-Pathway

BACKGROUND/AIMS

Alcohol (ethanol, EtOH) as significant contributor to traumatic injury is linked to suppressed inflammatory response, thereby influencing clinical outcomes. Alcohol-induced immune-suppression during acute inflammation (trauma) was linked to nuclear factor-kappaB (NF-ĸB). Here, we analyzed alcohol`s effects and mechanisms underlying its influence on NF-ĸB-signaling during acute inflammation in human lung epithelial cells.

METHODS

A549-cells were stimulated with interleukin (IL)-1β, or sera from trauma patients (TP) or healthy volunteers, with positive/negative blood alcohol concentrations (BAC), and subsequently exposed to EtOH (170 Mm, 1h). IL-6-release and neutrophil adhesion to A549 were analyzed. Specific siRNA-NIK mediated downregulation of non-canonical, and IKK-NBD-inhibition of canonical NF-ĸB signaling were performed. Nuclear levels of activated p50 and p52 NF-ĸB-subunits were detected using TransAm ELISA.

RESULTS

Both stimuli significantly induced IL-6-release (39.79±4.70 vs. 0.58±0.8 pg/ml) and neutrophil adhesion (132.30±8.80 vs. 100% control, p<0.05) to A549-cells. EtOH significantly decreased IL-6-release (22.90±5.40, p<0.05) and neutrophil adherence vs. controls (105.40±14.5%, p<0.05). IL-1β-induced significant activation of canonical/p50 and non-canonical/p52 pathways. EtOH significantly reduced p50 (34.90±23.70 vs. 197.70±36.43, p<0.05) not p52 activation. Inhibition of canonical pathway was further increased by EtOH (less p50-activation), while p52 remained unaltered. Inhibition of non-canonical pathway was unchanged by EtOH.

CONCLUSION

Here, alcohol`s anti-inflammatory effects are mediated via decreasing nuclear levels of activated p50-subunit and canonical NF-ĸB signaling pathway.

Impaired Surface Expression of HLA-DR, TLR2, TLR4, and TLR9 in Ex Vivo-In Vitro Stimulated Monocytes from Severely Injured Trauma Patients

Objective. Trauma patients (TP) frequently develop an imbalanced immune response that often causes infectious postinjury complications. Monocytes show a diminished capability of both producing proinflammatory cytokines and antigen presentation after trauma. TLR2, TLR4, and TLR9 recognize pathogens and subsequently activate monocytes. While there are conflictive data about TLR2 and TLR4 expression after trauma, no studies about the expression of TLR2, TLR4, TLR9, and HLA-DR on monocytes from TP after their secondary ex vivo-in vitro "hit" have been reported. Methods/Results. Ex vivo-in vitro lipopolysaccharide- (LPS-) stimulated blood from TP showed diminished interleukin- (IL-) 1β-release in TP for five postinjury days compared to healthy volunteers (HV). The recovery was observed at day 5. In parallel, monocytes from TP showed an impaired capability of TLR2, TLR4, and TLR9 expression after secondary stimulation compared to HV, while the measurement of unstimulated samples showed significant reduction of TLR4 and TLR9 at ED. Furthermore, HLA-DR decreased after trauma and was even more profound by stimulation of monocytes. Ratio of monocytes to leukocytes was significantly increased at days 6 and 7 after trauma compared to HV. Conclusion. Impaired expression of TLRs and HLA-DR in acute inflammatory conditions may be responsible for the well-described monocyte paralysis after severe trauma.

Phagocytizing activity of PMN from severe trauma patients in different post-traumatic phases during the 10-days post-injury course

OBJECTIVE

Phagocytizing leukocytes (granulocytes and monocytes) play a fundamental role in immunological defense against pathogens and clearance of cellular debris after tissue injury due to trauma. According to the "two-hit hypothesis", phagocytes become primed due to/after trauma. Subsequently, a secondary stimulus may lead to their exaggerated response. This immune dysfunction can result in serious infectious complications, also depending on trauma injury pattern. Here, we investigated the phagocytizing capacity of leukocytes, and its correlation to trauma injury pattern.

MATERIAL/METHODS

Peripheral whole blood was taken daily from 29 severely injured trauma patients (TP, Injury Severity Score, ISS≥28) for ten days (1-10) following admission to the emergency department (ED). Sixteen healthy volunteers served as controls (HV). Samples were incubated with opsonized Staphylococcus aureus labelled with pHrodo fluorescent reagent and the percentage of phagocytizing activity was assessed by flow cytometry. Abbreviated Injury Scales (AIS)≥3 of head, chest and extremities were used for injury pattern analysis.

RESULTS

Overall distribution of active phagocytes (out of 100% phagocytizing leukocytes) in TP included granulocytes with 28.6±1.5% and monocytes with 59.3±1.9% at ED, and was comparable to HV (31.5±1.6% granulocytes and 60.1±1.6% monocytes). The percentage of phagocytizing granulocytes increased significantly after D2 (39.1±1.2%), while the percentage of phagocytizing monocytes (52.0±1.2%, p<0.05) decreased after D2. These changes persisted during the whole time course. Phagocytizing activity of granulocytes (27.9±2.8%) and monocytes (55.2±3.3%) was significantly decreased at ED compared to HV (42.4±4.1% and 78.1±3.1%, respectively). After D2 up to D10, phagocytizing activity was significantly enhanced in granulocytes. Phagocytizing activity of monocytes remained decreased on D1 and has risen continuously during the ten days time course to values comparable to HV. No significant differences in phagocytosis could be associated to certain injury pattern.

CONCLUSIONS

Our data demonstrate that the increasing percentage of phagocytizing granulocytes may indicate their enhanced mobilization out of bone marrow persisting until post-injury day 10. Furthermore, an initially decreased phagocytizing activity of granulocytes is strongly increased in the 10-days post-injury course. The altered activity of phagocytes due to injury could not be linked to any trauma injury pattern, and emerged rather as a general characteristic of phagocytes after severe trauma.

Morbid obesity rates continue to rise rapidly in the United States

Clinically severe or morbid obesity (body mass index (BMI) >40 or 50 kg m(-2)) entails far more serious health consequences than moderate obesity for patients, and creates additional challenges for providers. The paper provides time trends for extreme weight categories (BMI >40 and >50 kg m(-2)) until 2010, using data from the Behavioral Risk Factor Surveillance System. Between 2000 and 2010, the prevalence of a BMI >40 kg m(-2) (type III obesity), calculated from self-reported height and weight, increased by 70%, whereas the prevalence of BMI >50 kg m(-2) increased even faster. Although the BMI rates at every point in time are higher among Hispanics and Blacks, there were no significant differences in trends between them and non-Hispanic Whites. The growth rate appears to have slowed down since 2005. Adjusting for self-report biases, we estimate that in 2010 15.5 million adult Americans or 6.6% of the population had an actual BMI >40 kg m(-2). The prevalence of clinically severe obesity continues to be increasing, although less rapidly in more recent years than prior to 2005.

Is there a robust relationship between neighbourhood food environment and childhood obesity in the USA?

OBJECTIVES

To examine the robustness of the relationship between neighbourhood food environment and youth body mass index (BMI) percentile using alternative measures of food environment and model specifications.

STUDY DESIGN

Observational study using individual-level longitudinal survey data of children in fifth and eighth grades merged with food outlet data based on student residential census tracts.

METHODS

The relationship between food environment and BMI was examined with two individual outcomes (BMI percentile in eighth grade and change in BMI percentile from fifth to eighth grade) and three alternative measures of food environment (per-capita counts of a particular outlet type, food environment indices, and indicators for specific combinations of outlet types).

RESULTS

No consistent evidence was found across measures (counts of a particular type of food outlet per population, food environment indices, and indicators for the presence of specific combinations of types of food stores) and outcomes to support the hypothesis that improved access to large supermarkets results in lower youth BMI; or that greater exposure to fast food restaurants, convenience stores and small food stores increases BMI.

CONCLUSIONS

To the extent that there is an association between food environment and youth BMI, the existence of more types of food outlets in an area, including supermarkets, is associated with higher BMI.

Increases in morbid obesity in the USA: 2000-2005

BACKGROUND

It is well known that citizens of developed countries are more likely to be overweight than they were 20 years ago. The most serious health problems are not associated with overweight or moderate obesity, however, but with clinically severe or morbid obesity (e.g. more than 100 pounds (45kg) overweight). There is no reason to expect that morbid obesity trends parallel overweight or moderate obesity. If morbid obesity is a rare pathological condition that has biological causes, the more than 10-fold increase in bariatric surgery procedures over the past eight years in the USA could have even lowered the prevalence of morbid obesity-and may very well stem the problem in other countries.

OBJECTIVE

To estimate trends for extreme weight categories (BMI>40 and >50) for the period between 1986 and 2005 in the USA, and to investigate whether trends have changed since 2000.

METHODS

Data from The Behavioral Risk Factor Surveillance System (a random-digit telephone survey of the household population of the USA), for the period from 1986 to 2005, were analysed. The main outcome measure was body mass index (BMI), calculated from self-reported weight and height.

RESULTS

From 2000 to 2005, the prevalence of obesity (self-reported BMI over 30) increased by 24%. However, the prevalence of a (self-reported) BMI over 40 (about 100 pounds (45kg) overweight) increased by 50% and the prevalence of a BMI over 50 increased by 75%, two and three times faster, respectively. The heaviest BMI groups have been increasing at the fastest rates for 20 years.

CONCLUSIONS

The prevalence of clinically severe obesity is increasing at a much faster rate among adults in the USA than is the prevalence of moderate obesity. This is consistent with the public health idea that the population weight distribution is shifting, which disproportionately increases extreme weight categories. Because comorbidities and resulting service use are much higher among severely obese individuals, the widely published trends for overweight/obesity underestimate the consequences for population health. The aggressive and costly expansion of bariatric surgery in recent years has had no visible effect on containing morbid obesity rates in the USA.

Childhood overweight and elementary school outcomes

OBJECTIVE

To examine the link between childhood overweight status and elementary school outcomes.

DESIGN

Prospective study design: multivariate regression models examining the association between changes in overweight status and school outcomes between kindergarten entry and end of third grade, after controlling for various child, family and school characteristics.

SUBJECTS

Nationally representative sample of US children who entered kindergarten in 1998, with longitudinal data on body mass index (BMI) and school outcomes at kindergarten entry and end of third grade.

MEASUREMENTS

Wide range of elementary school outcomes collected in each wave including academic achievement (math and reading standardized test scores); teacher reported internalizing and externalizing behavior problems (BP), social skills (self-control, interpersonal skills) and approaches to learning; school absences; and grade repetition. Measurements of height and weight in each wave were used to compute BMI and indicators of overweight status based on CDC growth charts. A rich set of control variables capturing child, family, and school characteristics.

RESULTS

Moving from not-overweight to overweight between kindergarten entry and end of third grade was significantly associated (P<0.05) with reductions in test scores, and teacher ratings of social-behavioral outcomes and approaches to learning among girls. However, this link was mostly absent among boys, with two exceptions - boys who became overweight had significantly fewer externalizing BPs (P<0.05), but more absences from school compared to boys who remained normal weight. Being always-overweight was associated with more internalizing BP among girls but fewer externalizing BPs among boys.

CONCLUSION

Change in overweight status during the first 4 years in school is a significant risk factor for adverse school outcomes among girls but not boys. Girls who become overweight during the early school years and those who start school being overweight and remain that way may need to be monitored carefully.

A multi-compartment model for slow bronchial clearance of insoluble particles--extension of the ICRP human respiratory tract models

To incorporate the various mechanisms that are presently assumed to be responsible for the experimentally observed slow bronchial clearance into the HRTM, a multi-compartment model was developed to simulate the clearance of insoluble particles in the tracheobronchial tree of the human lung. The new model considers specific mass transfer paths that may play an important role for slow bronchial clearance. These include the accumulation of particulate mass in the periciliary sol layer, phagocytosis of stored particles by airway macrophages and uptake of deposited mass by epithelial cells. Besides the gel layer representing fast mucociliary clearance, all cellular and non-cellular units involved in the slow clearance process are described by respective compartments that are connected by specific transfer rates. The gastrointestinal tract and lymph nodes are included into the model as final accumulation compartments, to which mass is transferred via the airway route and the transepithelial path. Predicted retention curves correspond well with previously published data.

Body mass index in elementary school children, metropolitan area food prices and food outlet density

OBJECTIVE

The aim of this study was to examine the association between food prices and food outlet density and changes in the body mass index (BMI) among elementary school children in the USA.

METHODS

The Early Childhood Longitudinal Study followed a nationally representative sample of kindergarten children over 4 years. We merged individual-level data to (a) metropolitan data on food prices and (b) per capita number of restaurants, grocery stores and convenience stores in the child's home and school zip code. The dependent variables were BMI changes over 1 and 3 years. We analysed mean changes with least-squares regression, and median changes and 85th percentile changes with quantile regression. We controlled for baseline BMI, age, real family income and sociodemographic characteristics.

RESULTS

Lower real prices for vegetables and fruits were found to predict a significantly lower gain in BMI between kindergarten and third grade; half of that effect was found between kindergarten and first grade. Lower meat prices had the opposite effect, although this effect was generally smaller in magnitude and was insignificant for BMI gain over 3 years. Differences across subgroups were not statistically significant due to smaller sample sizes in subgroup analyses, but the estimated effects were meaningfully larger for children in poverty, children already at risk for overweight or overweight in kindergarten, and Asian and Hispanic children. There were no significant effects for dairy or fast-food prices, nor for outlet density, once we had controlled for individual characteristics and random intercepts to adjust standard errors for the sampling design.

DISCUSSION

The geographic variation in fruit and vegetable prices is large enough to explain a meaningful amount of the differential gain in BMI among elementary school children across metropolitan areas. However, as consumption information was not available, we cannot confirm that this is the actual pathway. We found no effects of food outlet density at the neighbourhood level, possibly because availability is not an issue in metropolitan areas.

Stochastic simulation of alveolar particle deposition in lungs affected by different types of emphysema

In the present study, disease-specific stochastic models were developed for the computation of particle deposition in lungs affected by COPD, emphysema, or both, distinguishing between four types of pulmonary emphysema-centriacinar, paraseptal, panacinar, and bullous. To simulate COPD, airway calibers of the tracheobronchial tree were randomly reduced between 20% and 50% in each airway. For the study of pure COPD ("blue bloaters"), alveolated airway dimensions of the healthy lung were used, while for the simulation of emphysema without COPD ("pink puffers"), normal conductive airway diameters were assumed. Deposition calculations in diseased lungs were carried out by assuming (a) identical inspiration and expiration times (no breath-hold time) and (b) a continuous increase of the functional residual capacity (from 3,300 to 5,000 mL), accompanied by a simultaneous drop of the tidal volume (from 1,000 to 500 mL). Independent of particle size, total alveolar deposition in emphysematous lungs was significantly decreased relative to normal lungs. In particular, the deposition maximum at large particle sizes, which is a characteristic for healthy subjects, completely disappeared. Among the various emphysema models, deposition was smallest in lungs with bullous emphysema due to strongly enhanced settling and diffusion distances within the alveolar structures. A change of the lung volume caused a further decrease in particle deposition. Alveolar deposition in "blue bloaters" and "pink puffers" was very similar to the deposition in patients suffering from COPD and emphysema. Alveolar deposition per acinar airway generation was also strongly reduced in diseased lungs compared to normal lungs. Besides this reduction, deposition patterns became more uniform throughout the alveolar region.

3D-Visualization of particle deposition patterns in the human lung generated by Monte Carlo modeling: methodology and applications

An advanced stochastic model is described which enables the generation of three-dimensional particle deposition patterns in the human lung. While particle trajectories are represented as a combination of randomly oriented vectors in a coordinate system with the trachea defining the z direction, deposition sites of single particles are determined by using a grid of specific volume elements (voxels). After storage in an array, the spatial coordinates are visualized with an appropriate graphic editor, enabling the combination of respective deposition images with lung outlines and the creation of two-dimensional distributions by sectioning the three-dimensional structures at pre-defined positions.

Suburban sprawl and physical and mental health

OBJECTIVE

To study the association between objective measures of suburban sprawl and chronic medical conditions and mental health disorders in the USA.

METHODS

Cross-sectional analysis of survey data merged with objective measures of suburban sprawl. Outcomes are self-reported medical conditions, mental health disorders and health-related quality of life.

RESULTS

Sprawl significantly predicts chronic medical conditions and health-related quality of life, but not mental health disorders. An increase in sprawl from one standard deviation less to one standard deviation more than average implies 96 more chronic medical problems per 1000 residents, which is approximately similar to an aging of the population of 4 years.

CONCLUSIONS

A robust association between sprawl and physical (but not mental) health suggests that suburban design may be an important new avenue for health promotion and disease prevention.

Imaging of growth banding of minerals using 2-stage sectioning: application to accessory zircon

In the past, investigations of mineral growth were routinely carried out by the application of light-microscopic methods and, later on, by the production of single crystal sections and their documentation using specific imaging techniques (CL, BSEI, etc.). In the present work, a method is described which enables the precise sectioning of elongate crystals parallel and perpendicular to their longest axis. By examining backscattered electron images of parallel and perpendicular sections of the same grain, growth of all faces may be evaluated without major geometric correction. The new technique is applied to zircon crystals of a granitoid exposed in the southwestern Bohemian Batholith, Austria. For the studied zircon population, pyramidal and prism development during crystal growth is worked out very clearly by the imaging procedure. Besides its significance in crystal studies, the introduced method could also find a use in material science for the growth study of synthetic mineral phases.

Multi-channel magnetocardiography for detecting beat morphology variations in fetal arrhythmias

OBJECTIVE

Over the last few years, a number of studies have shown that fetal magnetocardiography (fMCG) is useful in describing fetal cardiac activity. A 55-channel MCG system in Ulm was used to record fetal cardiac activity in 12 pregnant women (with normal fetal heart activity in echocardiography) and in 5 pregnant women in whom the echocardiography showed fetal arrhythmias.

METHOD

The recorded MCG data were treated in order to eliminate the maternal signal and three MCG channels with the best signals were used to emulate a standard electrocardiogram (ECG) recording so that standard MCG analysis could be performed.

RESULTS

The results in assessing fetal electrophysiology, demonstrating its potential, are presented here for two fetuses with recorded supraventricular extrasystoles (SVES) and for one with ventricular extrasystoles (VES). Concerning the SVES, the analysis software OMEGA was able to separate three different beat morphologies. The VES could be detected exactly and have been confirmed by postnatal ECG.

CONCLUSION

The beat morphology and the beat-to-beat variations allow new insights into the electrophysiology of the fetal heart.

Stochastic model of ultrafine particle deposition and clearance in the human respiratory tract

Deposition and clearance of insoluble ultrafine particles, ranging from 1 to 100 nm, were simulated by stochastic models using Monte Carlo methods. Brownian motion is the dominant mode of deposition in human airways. The additional effects of convective diffusion in bifurcations and axial diffusion (convective mixing) primarily affect particle transport and deposition of particles in the 1-10 nm range. Regarding total deposition, the effects of both convective mechanisms are practically compensated by the concomitant effect of molecular radial diffusion (Brownian motion). During the first hours following inhalation, 1 nm particles are predicted to be cleared much faster than particles in the size range from 10 to 100 nm, with a retained fraction of about 80% after 24 h. For 1-10 nm particles, extracellular transfer to blood is the most likely mode of clearance, while uptake and subsequent accumulation in epithelial cells are assumed to be the preferential mechanisms for 10-100 nm particles.

Simulation of deposition and clearance of inhaled particles in central human airways

In this study local distributions of deposited inhaled particles such as radon progenies in realistic human airway bifurcation models of bronchial generations one to six are computed for different geometries, inlet flow profiles, flow rates and particle sizes with computational fluid particle dynamics methods. The movement of the mucus layer in the large central human airways is also simulated by computational fluid dynamic techniques. There is experimental evidence that bronchogenic carcinomas mainly originate at the central zone of the large airway bifurcations, where primary hot-spots of deposition have been found. However, current lung deposition models do not take into consideration the inhomogeneity of deposition within the airways. The inhomogeneous movement of the mucus layer may strongly influence the effect of primary deposition. On the basis of our results, both the deposition and the clearance patterns are highly non-uniform, especially in the vicinity of the carinal ridge of the bifurcations.

Mechanistic interpretation of the slow bronchial clearance phase

A slow bronchial clearance phase, describing the removal of insoluble particles from the sol layer, has recently been incorporated into the ICRP human respiratory tract model. A striking feature of that clearance phase is the size dependence of the slowly cleared fraction. In the theoretical approach presented here, it is suggested that the slow bronchial clearance phase includes three main mechanisms: (1) re-transfer of particles onto the gel layer after a certain time delay, (2) intra- or intercellular transfer of particles through the airway epithelium and subsequent transport to the blood or lymph nodes, and (3) uptake of particles by airway macrophages. The experimentally observed inverse relationship between the slow clearance fraction and geometric particle size is interpreted as an increasing capture probability in the sol layer and transepithelial transport with decreasing particle diameter.

Application of a 1.48-microm diode laser for bisecting oocytes into two identical hemizonae for the hemizona assay

Laser systems are very promising new technical tools in assisted reproduction. It was investigated if laser radiation can replace the mechanical cutting procedure via micromanipulator in the hemizona assay (HZA), a commonly used bioassay to determine the sperm-zona pellucida binding capacity. An oocyte was bisected precisely into two identical hemizonae with approximately 20 laser pulses (pulse length 30 msec) using a 1.48-microm diode laser. Compared with the conventional method using microscalpels for zona bisection, laser treated hemizonae showed equivalent sperm-binding and within the two groups there was no detectable difference between matching hemizonae in their capacity for tight sperm-binding. To evaluate whether laser radiation affects the outcome of the HZA when effects of certain substances are investigated, the spermatozoa were preincubated with human follicular fluid (hFF), which inhibits the binding of spermatozoa to zona pellucida in vitro. Supplementation with follicular fluid exerted an inhibitory effect in both groups. The hemizona index (HZI) showed no statistical differences between the two methods. Therefore, the 1.48-microm diode laser is a suitable new instrument for generating equally sized hemizonae. There is no use for holding pipettes and microscalpels, on the contrary, for performing the HZA the laser is a precise, very quick and easy to use new working tool.

Can utility-weighted health-related quality-of-life estimates capture health effects of quality improvement for depression?

BACKGROUND

Utility methods that are responsive to changes in desirable outcomes are needed for cost-effectiveness (CE) analyses and to help in decisions about resource allocation.

OBJECTIVES

Evaluated is the responsiveness of different methods that assign utility weights to subsets of SF-36 items to average improvements in health resulting from quality improvement (QI) interventions for depression.

DESIGN

A group level, randomized, control trial in 46 primary care clinics in six managed care organizations. Clinics were randomized to one of two QI interventions or usual care.

SUBJECTS

One thousand one hundred thirty-six patients with current depressive symptoms and either 12-month, lifetime, or no depressive disorder identified through screening 27,332 consecutive patients.

MEASURES

Utility weighted SF-12 or SF-36 measures, probable depression, and physical and mental health-related quality of life scores.

RESULTS

Several utility-weighted measures showed increases in utility values for patients in one of the interventions, relative to usual care, that paralleled the improved health effects for depression and emotional well being. However, QALY gains were small. Directly elicited utility values showed a paradoxical result of lower utility during the first year of the study for intervention patients relative to controls.

CONCLUSIONS

The results raise concerns about the use of direct single-item utility measures or utility measures derived from generic health status measures in effectiveness studies for depression. Choice of measure may lead to different conclusions about the benefit and CE of treatment. Utility measures that capture the mental health and non-health outcomes associated with treatment for depression are needed.

Changes in alcohol-related inpatient care--an international trend comparison

This paper studies two utilization measures of alcoholism treatment, discharge rate and average length of stay, in the United States, Australia, Sweden and Canada. The results suggest that the decline in length of stay and discharges in the past 15 years was an international phenomenon and not unique to the U.S. However, data for length of stay also suggests that the biggest decline in the United States coincided with the fastest growth of managed behavioral health care.

Effects of cost-containment strategies within managed care on continuity of the relationship between patients with depression and their primary care providers

BACKGROUND

Continuity of the relationship between patients and primary care providers (PCPs) is an important component of care from the consumer perspective that may be affected by variation in cost containment strategies within managed care.

OBJECTIVE

To evaluate the effects of cost containment strategies on the continuity of the relationship between their patients with depression and their PCPs.

DESIGN

Observational analysis of a 2-year panel of depressed patients who participated in a quality improvement intervention trial in 46 managed care practices.

PARTICIPANTS

One thousand two hundred four patients with current depression who enrolled in a longitudinal study, completed the baseline survey, and were followed for 2 years.

MAIN MEASURES

The dependent variable is probability of continuing the relationship between patients and their PCPs; explanatory variables include individual patient mental health benefits and cost-sharing, individual provider financial incentives, supply-side managed care policies, and patient ratings of the care received.

RESULTS

The average duration of the patient-PCP relationship was significantly longer among depressed patients who initially had less generous benefits for specialty care (higher copays, P = 0.02 and fewer visits covered, P = 0.002) and for patients whose PCPs received a performance-based salary bonus from a risk pool (P = 0.07).

CONCLUSIONS

For depressed patients, cost containment strategies, such as limits on specialty benefits and presence of clinician bonus payments typically used within managed care may increase, rather than decrease, PCP continuity. Whether increased PCP continuity is a desirable outcome depends on whether health care systems can provide high quality primary care and this merits further study.

National estimates of mental health utilization and expenditures for children in 1998

No recent national data on expenditures and utilization are available to provide a benchmark for reform of mental health systems for children and adolescents. The most recent estimates, from 1986, predate the dramatic growth of managed care. This study provides updated national estimates. Treatment expenditures are estimated to be $11.68 billion ($172 per child). Adolescents have the highest expenditures at $293 per child followed by $163 per child aged 6 to 11 and $35 per preschool-aged child. Outpatient services account for 57%, inpatient for 33%, and psychotropic medications for 9% of the total. Unlike earlier reports, outpatient care now accounts for the majority of expenditures. This finding replicates the differences between recent managed care data and earlier actuarial databases for privately insured adults and confirms the trend from inpatient toward outpatient care.

Gonadotropin-releasing hormone antagonist protocol: a novel method of ovarian stimulation in poor responders

OBJECTIVE

To estimate the efficacy of gonadotropin-releasing hormone (GnRH) antagonist 'Cetrorelix' in poor responders comparing with the standard long protocol.

DESIGN

The study population consisted of 21 poor responders who underwent ICSI and treated with Cetrorelix according to the multiple-dose protocol and who were compared with 21 poor responders treated according to the long protocol and who also underwent ICSI. Patients in both groups were matched for chronological age, the number of follicles found by ultrasound at the retrieval day and cause of infertility. Fifteen patients of GnRH antagonist group were treated with the combination of GnRH antagonist with clomiphene citrate (CC) plus gonadotropins, while six patients were treated with the combination of GnRH antagonist plus gonadotropins, but without CC.

RESULTS

The use of GnRH antagonist in a multiple dose protocol gave a pregnancy rate of 14.28% which was in the range expected for patient with poor response, but with shorter treatment duration and with fewer ampoules of gonadotropins as compared with the use of a GnRH agonist protocol in a depot formulation. Within Cetrorelix group patients who received CC had a significant shorter duration of stimulation and needed fewer ampoules as compared with patients in the same group who did not receive CC.

CONCLUSIONS

A GnRH antagonist multiple dose protocol may be the protocol of choice for the treatment of poor responders. The use of GnRH antagonist Cetrorelix ended with significantly less ampoules of gonadotropins and a shorter duration of stimulation.

Toward full mental health parity and beyond

The 1996 Mental Health Parity Act (MHPA), which became effective in January 1998, is scheduled to expire in September 2001. This paper examines what the MHPA accomplished and steps toward more comprehensive parity. We explain the strategic and self-reinforcing link of parity with managed behavioral health care and conclude that the current path will be difficult to reverse. The paper ends with a discussion of what might be behind the claims that full parity in mental health benefits is insufficient to achieve true equity and whether additional steps beyond full parity appear realistic or even desirable.

Does obesity contribute as much to morbidity as poverty or smoking?

The prevalence of obesity is increasing in America, but its impact on morbidity relative to other health risks is unclear. This paper compares the effects of overweight, poverty, smoking and problem drinking on occurrence of chronic conditions and health-related quality of life. The data were collected from a nationally representative household telephone survey of 9585 adults fielded in 1998, using self-reported measures of height and weight, poverty, smoking status, problem drinking, chronic conditions and SF-12 global scales. Regression analyses were used to estimate effects of health risk factors on morbidity. Thirty-six percent of adults are overweight but not obese (25< or =BMI<30) and another 23% are obese (BMI> or =30). Controlling for demographics, obesity is associated with more chronic conditions and worse physical health-related quality of life (P<0.01). Smoking history and poverty predict having chronic conditions, but their effect sizes are significantly smaller. Even after controlling for chronic conditions, obesity predicts physical health-related quality of life, in that case with an effect size similar to poverty. The effect of problem drinking is always smaller. Obesity is highly prevalent and associated with at least as much morbidity as are poverty, smoking and problem drinking. Nevertheless, the latter have achieved more consistent attention in recent decades in clinical practice and public health policy.