The Bacterial Connection between the Oral Cavity and the Gut Diseases

More than 100 trillion symbiotic microorganisms constitutively colonize throughout the human body, including the oral cavity, the skin, and the gastrointestinal tract. The oral cavity harbors one of the most diverse and abundant microbial communities within the human body, second to the community that resides in the gastrointestinal tract, and is composed of >770 bacterial species. Advances in sequencing technologies help define the precise microbial landscape in our bodies. Environmental and functional differences render the composition of resident microbiota largely distinct between the mouth and the gut and lead to the development of unique microbial ecosystems in the 2 mucosal sites. However, it is apparent that there may be a microbial connection between these 2 mucosal sites in the context of disease pathogenesis. Accumulating evidence indicates that resident oral bacteria can translocate to the gastrointestinal tract through hematogenous and enteral routes. The dissemination of oral microbes to the gut may exacerbate various gastrointestinal diseases, including irritable bowel syndrome, inflammatory bowel disease, and colorectal cancer. However, the precise role that oral microbes play in the extraoral organs, including the gut, remains elusive. Here, we review the recent findings on the dissemination of oral bacteria to the gastrointestinal tract and their possible contribution to the pathogenesis of gastrointestinal diseases. Although little is known about the mechanisms of ectopic colonization of the gut by oral bacteria, we also discuss the potential factors that allow the oral bacteria to colonize the gut.

50 Jahre Universitäts-Hautklinik am Biederstein in München

Die Klinik und Poliklinik für Dermatologie und Allergologie am Biederstein der Technischen Universität München (TUM) wurde 1969 in Betrieb genommen und feiert daher im Jahr 2019 ihr 50-jähriges Bestehen. Die Ursprünge dieser Klink gehen aber wie an vielen Orten auf ältere Versorgungsstrukturen zurück. Anlässlich des 50-jährigen Bestehens soll dieser Artikel die Entwicklung und aktuelle Ausrichtung der Klinik illustrieren und dabei auch die Wertschätzung für unsere Vorgänger ausdrücken, die sich auf den verschiedenen Positionen für unsere Patienten eingesetzt und so die Basis für eine erfolgreiche Klinik in Krankenversorgung, Forschung und Lehre geschaffen haben. Die Klinik und Poliklinik für Dermatologie und Allergologie am Biederstein gehört zum Universitätsklinikum, dem Klinikum rechts der Isar, der Technischen Universität München (TUM), sie selbst liegt jedoch links der Isar, im schönen Schwabing unweit des Englischen Gartens. Sie ist eine von 3 Hautkliniken in München, die im Rahmen der Münchner Dermatologischen Gesellschaft (MDG e. V.) regelmäßig Fortbildungen ausrichten. Die MDG am Biederstein wird sich im Jahr 2019 neben der Fortbildung auch dem Jubiläum dieser Klinik widmen.

Die Klinik als universitäre Einrichtung umfasst den Bereich medizinische Versorgung mit 74 Betten auf 4 Stationen, einen ambulanten Bereich mit einer großen Poliklinik für Allgemein- und Privatpatienten (jährlich mehr als 60 000 Patientenbesuche), den Bereich Forschung mit verschiedenen Forschungsgruppen und großen Laboratorien sowie den Bereich Lehre, Weiter- und Fortbildung. Ein Schwerpunkt in der klinischen Versorgung und in der Forschung war bereits zur Zeit der Gründung der Klinik 1969 die Allergologie. Weiterhin bestehen Schwerpunkte im Bereich der entzündlichen Hauterkrankungen, der Dermatoonkologie, der Dermatoinfektiologie, der Dermatochirurgie und der Wundversorgung. Die Klinik hat das Comprehensive Allergy Center der Technischen Universität München (ACTUM) und EU-Exzellenz-Zentrum für Allergie auf den Weg gebracht und ist Teil der Krebszentren Comprehensive Cancer Center München der Technischen Universität München (CCC MünchenTUM) und des Comprehensive Cancer Center München (CCCM). Pro Semester werden etwa 450 Studenten im Rahmen von Vorlesungen, Seminaren und Praktika betreut. Neben Kongressen wie der Jahrestagung der Arbeitsgemeinschaft Dermatologische Forschung (ADF) im Jahr 2019 oder der European Society for Dermatological Research (ESDR) im Jahre 2016 richten die Klinik und der Lehrstuhl regelmäßige Fortbildungsveranstaltungen im Rahmen des Biedersteiner Symposiums, des Biedersteiner Kolloquiums und der MDG aus.

Sensitivity and Specificity of Autoantibodies Against CD74 in Nonradiographic Axial Spondyloarthritis

OBJECTIVE

Autoantibodies against CD74 (anti-CD74) are associated with ankylosing spondylitis (AS). The present multicenter study, the International Spondyloarthritis Autoantibody (InterSpA) trial, was undertaken to compare the sensitivity and specificity of anti-CD74 and HLA-B27 in identifying patients with nonradiographic axial spondyloarthritis (axSpA).

METHODS

Patients ages 18-45 years with inflammatory back pain of ≤2 years' duration and a clinical suspicion of axSpA were recruited. HLA-B27 genotyping and magnetic resonance imaging of sacroiliac joints were performed in all patients. One hundred forty-nine patients with chronic inflammatory back pain (IBP) not caused by axSpA served as controls, and additional controls included 50 AS patients and 100 blood donors whose specimens were analyzed.

RESULTS

One hundred patients with inflammatory back pain received a diagnosis of nonradiographic axSpA from the investigators and fulfilled the Assessment of SpondyloArthritis international Society (ASAS) criteria. The mean age was 29 years, and the mean symptom duration was 12.5 months. The sensitivity of IgA anti-CD74 and IgG anti-CD74 for identifying the 100 axSpA patients was 47% and 17%, respectively. The specificity of both IgA anti-CD74 and IgG anti-CD74 was 95.3%. The sensitivity of HLA-B27 was 81%. The positive likelihood ratios were 10.0 (IgA anti-CD74), 3.6 (IgG anti-CD74), and 8.1 (HLA-B27). Assuming a 5% pretest probability of axSpA in chronic back pain patients, the posttest probability, after consideration of the respective positive test results, was 33.3% for IgA anti-CD74, 15.3% for IgG anti-CD74, and 28.8% for HLA-B27. A combination of IgA anti-CD74 and HLA-B27 results in a posttest probability of 80.2%.

CONCLUSION

IgA anti-CD74 may be a useful tool for identifying axSpA. The diagnostic value of the test in daily practice requires further confirmation.

iDermatoPath - a novel software tool for mitosis detection in H&E-stained tissue sections of malignant melanoma

BACKGROUND

Malignant Melanoma (MM) is characterized by a growing incidence and a high malignant potential. Besides well-defined prognostic factors such as tumour thickness and ulceration, the Mitotic Rate (MR) was included in the AJCC recommendations for diagnosis and treatment of MM. In daily routine, the identification of a single mitosis can be difficult on haematoxylin and eosin slides alone. Several studies showed a big inter- and intra-individual variability in detecting the MR in MM even by very experienced investigators, thus raising the question for a computer-assisted method.

OBJECTIVE

The objective was to develop a software system for mitosis detection in MM on H&E slides based on machine learning for diagnostic support.

METHODS

We developed a computer-aided staging support system based on image analysis and machine learning on the basis of 59 MM specimens. Our approach automatically detects tumour regions, identifies mitotic nuclei and classifies them with respect to their diagnostic relevance. A convenient user interface enables the investigator to browse through the proposed mitoses for fast and efficient diagnosing.

RESULTS

A quantitative evaluation on manually labelled ground truth data revealed that the tumour region detection yields a medium spatial overlap index (dice coefficient) of 0.72. For the mitosis detection, we obtained high accuracies of above 83%.

CONCLUSION

On the technical side, the developed iDermatoPath software tool provides a novel approach for mitosis detection in MM, which can be further improved using more training data such as dermatopathologist annotations. On the practical side, a first evaluation of the clinical utility was positive, albeit this approach provides most benefit for difficult cases in a research setting. Assuming all slides to be digitally processed and reported in the near future, this method could become a helpful additional tool for the pathologist.

Transferring innovative freehand SPECT to the operating room: first experiences with sentinel lymph node biopsy in malignant melanoma

PURPOSE

The purpose of this study was to report on the first experiences with freehand single-photon emission-computed tomography (freehand SPECT) in sentinel lymph node biopsy (SLNB) in patients with malignant melanoma. Freehand SPECT is a novel imaging modality combining gamma probes, surgical navigation systems, and emission tomography algorithms, designed to overcome some of the limitations of conventional gamma probes.

METHODS

In this study 20 patients with malignant melanoma underwent conventional planar scintigraphy prior to surgery. In the operating room, the number and location of separable SLNs were detected first by a pre-incisional scan with freehand SPECT to render a 3D-image of the target site and afterwards by a scan with a conventional gamma probe. After SLNB another scan was performed to document the removal of all targeted SLNs.

RESULTS

Planar scintigraphy identified 40 SLNs in 26 nodal basins. Pre-incisional freehand SPECT mapped 38 of these nodes as well as one additional node in one patient (95.0% node based sensitivity). The results of freehand SPECT were identical to those of planar scintigraphy in 25 basins, while it missed one basin (96.2% basin based sensitivity). In comparison, the gamma probe failed to detect 7 nodes in 4 basins (82.5% node based sensitivity and 84.6% basin based sensitivity). After resection freehand SPECT detected 9 remaining radioactive spots, two of whichwere resected as they matched the position of SLNs detected on preoperative planar scintigraphy.

CONCLUSIONS

Freehand SPECT provides a real-time, intraoperative 3D-image of the radioactive labelled SLNs, facilitating their detection and resection.

[Rehabilitation in geriatric patients after ischemic stroke--a comparison of 2 organisational systems in Germany using claims data of a statutory health insurance fund]

Due to historical aspects in some federal states in Germany rehabilitation of geriatric patients is organized in geriatric departments in hospitals (§ 109 SGB V). In other states rehabilitation of these patients is mainly realized in geriatric rehabilitation facilities outside hospital care after approval by the health insurance (§ 111 SGB V). Thus, it is of interest to compare both types of health care with respect to differences in population characteristics, resource utilization and outcome parameters (i.e., excess costs, rehospitalization, fracture risk and mortality) using a common geriatric indication, the ischemic stroke, as an example.

METHODS

Claims data of the AOK (Local Health Care Fund) from seven federal states in Germany were used. Insured persons with a documented hospital stay with discharge diagnosis cerebral infarction/stroke (ICD-10 I63, I64, below denoted by "ischemic stroke") in 2007 (N=39,887) were included and allocated to the respective form of rehabilitative health care via the OPS (German procedure classification for inpatient procedures) procedure 8-550 (§ 109, N=1,272) or via admission to a geriatric rehabilitation unit within 1 month after hospital discharge (§ 111, N=2,200). All direct costs were ascertained and presented with and without costs of long-term care. Excess costs were calculated as the difference of costs between the first year after insult and the costs in the previous year. Excess costs in the 2 types of care were compared using multivariate quantile regression analysis. Risk of hospitalization (due to ischemic stroke or fracture) and risk of death in a 1-year follow-up was analysed using multivariate cox regression.

RESULTS

Insured members treated according to health care type § 109 were somewhat older (mean: 81 vs. 80 years of age), more frequently female (72 vs. 67%), more often receiving long-term care (27 vs. 19%) and had more often documented sequelae after insult (>=4 diseases 39 vs. 28%). No significant differences in excess costs between both types of care were observed (quantile regression: 25%-percentile-comparison: p=0.49 and 0.11; median-comparison: p=0.99 and 0.13; 75%-percentile-comparison: p=0.13 and 0.30, with and without costs of long-term care, respectively). Moreover, no significant differences were observed related to the outcomes 'rehospitalization due to ischemic stroke' (hazard ratio - HR [95% confidence interval - CI])=1.12 [0.85-1.48], p=0.43) and death (HR [95% CI]=1.03 [0.88-1.20], p=0.75) in the multivariate model (reference: health care type § 111). Insured members in health care type § 109 had a significant lower risk of rehospitalization due to fracture (HR [95% CI]=0.61 [0.40-0.93], p=0.02).

CONCLUSION

According to health care type § 109 and § 111, geriatric patients differ in certain characteristics such as gender, statutory care and documented sequelae after insult. Except for the outcome 'fracture', no significant differences between both types of care have been observed in the selected outcomes. Primary studies with more differentiated data collection may focus on specific treatment and on aims and achievements of rehabilitation.

Polymorphism Thr160Thr in SRD5A1, involved in the progesterone metabolism, modifies postmenopausal breast cancer risk associated with menopausal hormone therapy

Menopausal hormone therapy (MHT) is associated with an increased breast cancer risk in postmenopausal women, with combined estrogen-progestagen therapy posing a greater risk than estrogen monotherapy. However, few studies focused on potential effect modification of MHT-associated breast cancer risk by genetic polymorphisms in the progesterone metabolism. We assessed effect modification of MHT use by five coding single nucleotide polymorphisms (SNPs) in the progesterone metabolizing enzymes AKR1C3 (rs7741), AKR1C4 (rs3829125, rs17134592), and SRD5A1 (rs248793, rs3736316) using a two-center population-based case-control study from Germany with 2,502 postmenopausal breast cancer patients and 4,833 matched controls. An empirical-Bayes procedure that tests for interaction using a weighted combination of the prospective and the retrospective case-control estimators as well as standard prospective logistic regression were applied to assess multiplicative statistical interaction between polymorphisms and duration of MHT use with regard to breast cancer risk assuming a log-additive mode of inheritance. No genetic marginal effects were observed. Breast cancer risk associated with duration of combined therapy was significantly modified by SRD5A1_rs3736316, showing a reduced risk elevation in carriers of the minor allele (p (interaction,empirical-Bayes) = 0.006 using the empirical-Bayes method, p (interaction,logistic regression) = 0.013 using logistic regression). The risk associated with duration of use of monotherapy was increased by AKR1C3_rs7741 in minor allele carriers (p (interaction,empirical-Bayes) = 0.083, p (interaction,logistic regression) = 0.029) and decreased in minor allele carriers of two SNPs in AKR1C4 (rs3829125: p (interaction,empirical-Bayes) = 0.07, p (interaction,logistic regression) = 0.021; rs17134592: p (interaction,empirical-Bayes) = 0.101, p (interaction,logistic regression) = 0.038). After Bonferroni correction for multiple testing only SRD5A1_rs3736316 assessed using the empirical-Bayes method remained significant. Postmenopausal breast cancer risk associated with combined therapy may be modified by genetic variation in SRD5A1. Further well-powered studies are, however, required to replicate our finding.

First Experiences with Navigated Radio-Guided Surgery Using Freehand SPECT

Background

Sentinel lymph node biopsy (SLNB) in melanoma using one-dimensional gamma probes is a standard of care worldwide. Reports on the performance are claimed by most groups to successfully detect the SLNs during the surgical procedure in almost 100% of the patients. In clinical practice, however, several issues remain which are usually not addressed: the difficulty of intraoperative detection of deeply located nodes, SLN detection in obese patients or in the groin and the impossibility to make a scan of the entire wound after SLN resection to avoid false negative testing for eventually remaining SLNs.

Materials and Methods

The concept behind freehand SPECT is to combine a gamma probe as used for conventional radio-guided surgery with a tracking system as used in neurosurgical navigation. From this combination and a proper algorithm framework the 3D reconstruction of radioactivity distributions and displaying these intraoperatively is possible.

Conclusion

In summary, the feasibility of freehand SPECT could be shown and provides an image-guided SLNB and a truly minimally invasive and optimized surgical procedure.

Association of genetic polymorphisms in ESR2, HSD17B1, ABCB1, and SHBG genes with colorectal cancer risk

The incidence rates and relative risks for colorectal cancer (CRC) are higher in men than in women. Sex steroids may play a role in this gender-associated difference in CRC risk. This study was conducted to explore the relationship of single nucleotide polymorphisms (SNPs) in steroid hormone signaling (ESR1, ESR2, PGR, NR1I2, and SHBG), phase I- and II-metabolizing enzyme (COMT, HSD17B1, CYP1A1, CYP17A1, CYP1A2, CYP1B1, CYP2C9, CYP3A4, CYP2C19, and GSTP1), and hormone transporter (ABCB1) genes with the risk of CRC in German women and men, separately. From the population-based DACHS study (South Germany), 47 putatively functional SNPs were genotyped in 1798 CRC cases (746 women and 1052 men) and 1810 controls (732 women and 1078 men). Significant allele dose-response associations were observed with ESR2_rs1255998, ESR2_rs928554, HSD17B1_rs605059, and ABCB1_rs2229109 in women (P trend=0.004, 0.05, 0.03, and 0.05 respectively) and with ABCB1_rs1045642, ABCB1_rs9282564, and SHBG_rs6259 in men (P trend=0.01, 0.03, and 0.02 respectively). The ESR2_rs1255998_G allele showed the most significant association with risk for CRC in women, with a per-allele odds ratio (OR) of 0.68 (95% confidence interval (CI) 0.52-0.88). This finding was replicated in an independent study from North Germany including 1076 female CRC cases and 1151 controls (OR=0.84, 95% CI 0.71-1.04), yielding a per-allele OR of 0.80 (95% CI 0.69-0.93, P trend=0.003) in the pooled sample. These findings implicate a role of ESR2 in the risk for developing CRC in women and suggest that HSD17B1, ABCB1, and SHBG genes may contribute to sex steroid-mediated effects on CRC development.

Quality of life in localised malignant melanoma

BACKGROUND

The incidence of melanoma is still increasing in fair-skinned populations. At least 80% of patients have localised disease and expect a 5-year relative survival of >90%.

PATIENTS AND METHODS

In 2003-2004, disease-free patients with localised melanoma were recruited from the Munich Cancer Registry to answer quality-of-life (QoL) questionnaires 2 years after treatment.

RESULTS

A response rate of 72% was achieved from a total of 1085 distributed questionnaires. Hundred and seventeen questionnaires had to be excluded because of updated information about secondary tumour and progression events. Thus, questionnaires from 664 patients were evaluated. QoL scores in melanoma patients were essentially similar to those of a general population. Differences were detected between women and men concerning emotional and sexual functioning. Age and number of comorbidities were the strongest factors influencing most all aspects of QoL. Fifty percent of patients referred to deficits in communication with their doctors.

CONCLUSIONS

Patients who overcome melanoma do not necessarily have a reduced QoL. Strategies used by these melanoma patients resulted in similar levels of coping as previous studies in comparable general populations. Nevertheless, doctor-patient communication was correlated with emotional and social functioning and should be emphasised in treatment and care of melanoma patients.

[Reticular erythematous plaques]

Reticular erythematous mucinosis (REM) syndrome primarily affects young women; the skin lesions usually appear on the chest and upper back. REM is diagnosed on the basis of the clinical picture and histological findings. REM syndrome is often associated with lupus erythematosus tumidus. Both diseases respond well to treatment with chloroquin. Topical tacrolimus and the use of a pulsed dye laser have fewer side effects and have also proved to be effective.

The registry of the German Network for Systemic Scleroderma: frequency of disease subsets and patterns of organ involvement

Objective. Systemic sclerosis (SSc) is a rare, heterogeneous disease, which affects different organs and therefore requires interdisciplinary diagnostic and therapeutic management. To improve the detection and follow-up of patients presenting with different disease manifestations, an interdisciplinary registry was founded with contributions from different subspecialties involved in the care of patients with SSc.

Methods. A questionnaire was developed to collect a core set of clinical data to determine the current disease status. Patients were grouped into five descriptive disease subsets, i.e. lcSSc, dcSSc, SSc sine scleroderma, overlap-syndrome and UCTD with scleroderma features.

Results. Of the 1483 patients, 45.5% of patients had lcSSc and 32.7% dcSSc. Overlap syndrome was diagnosed in 10.9% of patients, while 8.8% had an undifferentiated form. SSc sine scleroderma was present in 1.5% of patients. Organ involvement was markedly different between subsets; pulmonary fibrosis for instance was significantly more frequent in dcSSc (56.1%) than in overlap syndrome (30.6%) or lcSSc (20.8%). Pulmonary hypertension was more common in dcSSc (18.5%) compared with lcSSc (14.9%), overlap syndrome (8.2%) and undifferentiated disease (4.1%). Musculoskeletal involvement was typical for overlap syndromes (67.6%). A family history of rheumatic disease was reported in 17.2% of patients and was associated with early disease onset (P < 0.005).

Conclusion. In this nationwide register, a descriptive classification of patients with disease manifestations characteristic of SSc in five groups allows to include a broader spectrum of patients with features of SSc.

Isolation of high quality protein samples from punches of formalin fixed and paraffin embedded tissue blocks

In general, it is believed that the extraction of proteins from formalin-fixed paraffin embedded samples is not feasible. However, recently a new technique was developed, presenting the extraction of non-degraded, full length proteins from formalin fixed tissues, usable for western blotting and protein arrays. In the study presented here, we applied this technique to punch biopsies of formalin fixed tissues embedded in paraffin to reduce heterogeneity of the tissue represented in sections, and to ensure analysing mainly defined cellular material. Successful extraction was achieved even from very small samples (0.7 mm(3)). Additionally, we were able to detect highly glycosylated proteins and protein modification, such as phosphorylation. Interestingly, with this technique it is feasible to extract high quality proteins from 14 year old samples. In summary, the new technique makes a great pool of material now usable for molecular analysis with high throughput tools.

Erythema-anulare-centrifugum-artige Psoriasis cum pustulatione

Erythema annulare centrifugum-type psoriasis with pustules represents a subtype of psoriasis pustulosa generalisata von Zumbusch. It presents with a typical morphology characterized by a lack of classical erythematosquamous skin lesions during its acute eruption phase. Diagnosis is usually established on the basis of clinical presentation and dermatopathology, which often shows a substrate typical for psoriasis, sometimes with spongiform pustules.