Setting up a Decision Support System with Decision Tables

The aim of our study was to develop a decision support system using a conventional method which can be used as a shell for different applications. So it was necessary to find a method which allows separation of decision principles and decision algorithms. In addition, documentation of the patient records should be simplified. This could be attained by using the decision table technique and the programming language MUMPS.

The general system developed was applied to the therapy decision for patients with liver metastases. The application system was clinically evaluated in a randomized group of patients. In 84% of the study group the therapy proposal of the system concurred with the therapy actually applied.

Representation of knowledge in the form of tables is easily understandable by physicians. Since decision tables can be seen as a medium of communication between physician and system manager, knowledge acquisition is simplified.

Therapeutic drug monitoring of zuclopenthixol in a double-blind placebo-controlled discontinuation study in adults with intellectual disabilities and aggressive behaviour

The trial was a double-blind, placebo-controlled comparison with a discontinuation design. 49 mentally retarded patients with aggressive behaviour were treated with zuclopenthixol at a dose of 2-20 mg/d. At each visit the clinical effect was evaluated. Correlations between dose, serum concentration, and efficacy measures were calculated. The mean dose was 10.0 mg/day (±5.17); the mean serum concentration 4.19 ng/mL (±3.16). Associations of dosage, serum concentration and clinical efficiency did not result in coherent patterns. Correlations with clinical efficiency measures appeared to be contradictory for dosage and serum concentrations, respectively. As no consistent associations between dosage, serum concentration, and clinical efficiency measures were found, different hypotheses explaining the results are discussed.

[Dual role of interleukin-6 for development of insulin resistance]

The review describes physiological and pathological role of interleukin-6 (IL-6) in control of tissues insulin sensitivity and its contrary shifts in different tissues. Analysis of actual data for IL-6 sources and its molecular mechanisms of action is given.

Equation of State and Electrical Conductivity of Dense Fluid Hydrogen and Helium

The equation of state of fluid hydrogen, helium, and their mixtures is determined within fluid variational theory. Reactions between the constituents such as dissociation and ionization are considered. Results are given for densities and temperatures relevant for the interior of giant planets. Furthermore, the electrical conductivity is determined within linear response theory. Comparison is performed with available experiments and other theoretical work.

[Adiponectin: pathophysiological aspects]

The review presents the currently available data on the role of adipokines, adinonectin in particular, in the regulation of metabolic processes. The pathological role of adinonectin receptors in insulin resistance, diabetes mellitus, metabolic syndrome, atherosclerosis, and other cardiovascular diseases is discussed in detail.

[Therapeutic education in the field of infection diseases: the example of HIV infection]

The advent of antiretroviral therapies represent a major therapeutic progress which dramatically modifies HIV seropositive people's life during the past fifteen years. After the violence of a formerly rapidly fatal disease comes nowadays the heaviness of a chronic disease. If some problems are new for the patients, it also represents new challenges for the caregivers. Due to the lack of access to medications in certain context or because of nonadherence to treatment, the full potential of these therapies is difficult to reach. We present here the experience of a therapeutic patient educational program for HIV seropositive persons. This program aimed not only to develop patient's skills to elicit them to find a balance between their life and their disease, but also to improve the skills of the caregivers to face the problem of chronicity.

[Expression of the genes CelA and XylA isolated from a fragment of metagenomic DNA in Escherichia coli]

The glycosyl hydrolase genes cel5A and xyl3A previously isolated by ourselves within a fragment of DNA from the methagenomic library of cow rumen microflora DNA were sub-cloned and expressed in E. coli. The recombinant proteins Cel5A and Xyl3A were purified and characterized. Cellulase Cel5A belongs to the Family 5 glycosyl hydrolases and is a one-module 38.2 kDa enzyme that hydrolyses the 1,4-glycoside bonds of soluble cellulose substrates and amorphous cellulose, showing its maximal activity (31200 u/mg) on lichenan, a soluble substrate with mixed (beta-1,3-1,4) bonds. The end product of the amorphous cellulose hydrolysis is cellobiose. Cel5A is inactive toward the crystal forms of cellulose. Cel5A is an endoglucanase capable of exohydrolysis. The molecular mass of beta-xylosidase Xyl3A belonging to the Family 3 glycosyl hydrolases is 83.7 kDa. The enzyme is active only on xylooligosaccharides, with the maximal activity shown on xylobiose, the end product of the reaction being xylose. No activity on xylane was hitherto observed. Recombinant Cel5A and Xyl3A are stable over a wide range of pH and temperatures, their maximal activity being observed at pH 6.5 and at 55 degrees C.

[Inflammation as a factor of the pathogenesis of insulin resistance and type 2 diabetes]

Insulin resistance (IR) is a leading factor of type 2 diabetes (T2D), the central and governing component of the metabolic syndrome (MS), that also appears as obesity, glucose intolerance, dyslipidemia, and essential hypertension. Recent experimental studies have indicated that proinflammatory cytokines, adipocytokines, and transcription factors are implicated in the pathogenesis of IR, as evidenced by a number of clinical observations in patients with MS and T2D, in whom IR correlates with the status of chronic mild inflammation. Based on the results of these studies, a search for methods for exposure of IR has been initiated, by controlling inflammation. The first results encourage and suggest that anti-inflammatory agents improve tissue susceptibility to insulin and they are promising for the treatment of MS and T2D.

Observations of plasmons in warm dense matter

We present the first collective x-ray scattering measurements of plasmons in solid-density plasmas. The forward scattering spectra of a laser-produced narrow-band x-ray line from isochorically heated beryllium show that the plasmon frequency is a sensitive measure of the electron density. Dynamic structure calculations that include collisions and detailed balance match the measured plasmon spectrum indicating that this technique will enable new applications to determine the equation of state and compressibility of dense matter.

Photodynamic therapy of locoregional breast cancer recurrences using a chlorin-type photosensitizer

Chest wall recurrences are a frequent problem in patients treated by mastectomy for breast cancer. Surgery and ionizing radiation are established treatment modalities in these cases. Photodynamic therapy (PDT) provides an alternative treatment modality using a photosensitizer and laser light to induce selective tumor necrosis. PDT was performed as compassionate use in 7 patients aged 57.6 years (+/-12.6 SD). A total of 89 metastatic skin nodes were treated in 11 PDT sessions. As photosensitizer meta-tetra(hydroxyphenyl)chlorin (m-THPC) was applied intravenously. Patients (n = 3) photosensitized with a drug dose of 0.10 mg/kg bodyweight were irradiated 48 hr after drug application at a lightdose of 5 J/cm(2). Patients (n = 4) were illuminated by an optical dose of 10 J/cm(2) 96 hr after photosensitization with 0.15 mg/kg. Laser light at a wavelength of 652 nm was generated by a diode laser and applied by a front lens light diffuser using a fluence rate of 20--25 mW/cm(2). PDT using m-THPC resulted in complete response in all patients. Response to treatment did not differ when using the 2 different drugdose protocols. Healing time depended mainly on the size of the illumination field but not on the lightdose. Pain score usually raised 1 day after PDT and lasted at higher levels for about 10 days. Healing time usually ranged between 8--10 weeks. Photodynamic technique offers a minimal-invasive, outpatient treatment modality for recurrent breast cancer on the chest wall with few side effects, high patient's satisfaction and with possible repetitive application.

Non-Hodgkin's lymphoma after kidney or heart transplantation: frequency of occurrence during the first posttransplant year

The incidence of non-Hodgkin's lymphoma was analysed in over 70,000 kidney transplant recipients and over 10,000 heart, heart-lung or lung transplant recipients. An increased incidence of lymphomas during the first posttransplant year was observed in cadaver kidney recipients as compared to related kidney recipients, in thoracic organ recipients as compared to kidney recipients, in heart-lung recipients as compared to heart or lung recipients, in patients transplanted in North America as compared to patients transplanted in Europe, in patients receiving cyclosporine in combination with azathioprine as compared to patients with other immunosuppressive regimens, and in patients receiving ATG/ALG or monoclonal OKT3 for rejection prophylaxis.

Polymers with thiol groups: a new generation of mucoadhesive polymers?

PURPOSE

To improve the mucoadhesive properties of polycarbophil by the introduction of sulfhydryl groups.

METHODS

Mediated by a carbodiimide, cysteine was covalently bound to polycarbophil (PCP) forming amide bonds between the primary amino group of the amino acid and the carboxylic acid moieties of the polymer. The amount of covalently attached cysteine and the formation of disulfide bonds within the modified polymer were determined by quantifying the share of thiol groups on the polymer conjugates with Ellman's reagent. The adhesive properties of polycarbophil-cysteine conjugates were evaluated in vitro on excised porcine intestinal mucosa by determining the total work of adhesion (TWA).

RESULTS

Depending on the weight-ratio of polycarbophil to cysteine at the coupling reaction, e.g., 16:1 and 2:1, 0.6+/-0.7 micromole and 5.3+/-2.4 micromole cysteine, respectively, were covalently bound per g polymer. The modified polymer displayed improved internal cohesive properties due to the formation of interchain disulfide bonds within the polymer in aqueous solutions at pH-values above 5. Adhesion studies revealed strongly improved adhesive properties. Whereas the TWA was determined to be 104+/-21 microJ for the unmodified polymer, it was 191+/-47 microJ for the polymer-cysteine conjugate 16:1 and 280+/-67 microJ for the polymer-cysteine conjugate 2:1.

CONCLUSIONS

Polymers with thiol groups might represent a new generation of mucoadhesive polymers displaying comparatively stronger adhesive properties.

Comparison of serological and DNA PCR-SSP typing results for HLA-A and HLA-B in 421 Black individuals: a Collaborative Transplant Study report

In a recent study, we observed a discrepancy rate of 8.5% between the results of molecular and serological HLA class I typing in Caucasian kidney donors and recipients. In the present study we addressed the question how often black individuals are mistyped using the serological technique. 421 Blacks whose HLA typing results were reported to the Collaborative Transplant Study (CTS) were typed retrospectively for HLA-A and -B using a PCR-SSP method. 78 of the 421 individuals (18.5%) showed a discrepancy for HLA-A and 107 individuals (25.4%) for HLA-B. 36.3% of all individuals tested showed either an HLA-A or an HLA-B discrepancy. 13.1% of the discrepancies at the HLA-A locus were due to antigen misassignments and 4.8% were due to missed antigens. HLA-B discrepancies were caused in 15.7% by antigen misassignments and in 10.5% by missed antigens. These results demonstrate an impressive advantage of the PCR-SSP method for HLA-A and HLA-B locus typing over serological typing in black individuals. The high typing discrepancy rate observed in Blacks provides a strong argument for replacing serological typing by the DNA method. It is likely that this will improve the HLA matching correlation in clinical transplantation in Blacks.

Solvent composition and viscosity effects on the kinetics of CO binding to horse myoglobin

Ligand binding to myoglobin in aqueous solution involves two kinetic components, one extramolecular and one intramolecular, which have been interpreted in terms of two sequential kinetic barriers. In mixed solvents and sub-zero temperatures, the outer barrier increases and the inner barrier splits into several components, giving rise to fast intramolecular recombination. The nature of these barriers and their relation to structural relaxation are examined using the effect of solvent composition and viscosity on the kinetics of CO binding to horse myoglobin in 60% ethylene glycol/water, 75% and 90% glycerol/water, 80% and 92% sucrose/water solutions. Measurements of the corresponding solvent structural relaxation rates by frequency resolved calorimetry allow us to discriminate between solvent composition and viscosity-related effects. The outer kinetic barrier controlling ligand entry and release depends on the viscosity consistent with Kramers-Stokes law of activated escape in the presence of friction. At high cosolvent concentration, we observe deviations from Stokes law, implying a smaller microviscosity at the protein-solvent interface as compared to the bulk. The inner barrier and its coupling to structural relaxation appears to be independent of viscosity but changes with solvent composition. As a possible explanation, we discuss the role of distal water molecules in the formation of the effective inner barrier. At low temperatures, this barrier has a distributed height, depending only slightly on the nature of the cosolvent and temperature at low cosolvent concentrations. In contrast, myoglobin embedded in a sucrose glass (92% sucrose/water) exhibits a temperature-dependent and bimodal enthalpy distribution. This result demonstrates that the exchange between protonation states of His64, A0 left and right arrow A1, can take place in the glass and at temperatures as low as 80 K.

Prospective evaluation of pretransplant blood transfusions in cadaver kidney recipients

BACKGROUND

A beneficial effect of pretransplant transfusions on graft survival was demonstrated in the early 1970s. In the mid-1980s, however, retrospective studies showed that transfusions had lost their graft-protective effect in the cyclosporine era. During the last 10 years, deliberate transfusion pretreatment of transplant patients has been discontinued.

METHODS

Within a collaborative project of 14 transplant centers, prospective recipients of cadaver kidney grafts were randomized to receive either three pretransplant transfusions or transplants without transfusions. RESULTS; The graft survival rate was significantly higher in the 205 transfusion recipients than in the 218 patients who did not receive transfusions (at 1 year: 90+/-2% vs. 82+/-3%, P=0.020; at 5 years: 79+/-3% vs. 70+/-4%, P=0.025). Cox regression analysis showed that this effect was independent of age, gender, underlying disease, prophylaxis with antilymphocyte antibodies, and preformed lymphocytotoxins. CONCLUSIONS; Transfusion pretreatment improves the outcome of cadaver kidney transplants even with the use of modern immunosuppressive regimens.

Maximal lactate steady state during the second decade of age

Maximal lactate steady state (MLSS) presumably corresponds to the highest constant workload that can be performed by oxidative metabolism. The anaerobic and, to a minor extent, the oxidative metabolism have been reported to be affected by age. The second decade of life is the key period in the change in energy metabolism between children and adults. The aim of this study was to evaluate the effects of age on MLSS in 34 male subjects (age: 15.4 +/- 2.8 yr, range: 11-20 yr; height: 171.8 +/- 14.9 cm, range: 134-191 cm; body mass: 59.6 +/- 15.5 kg, range: 27-90 kg) performing an incremental load test to determine maximal workload and several constant load tests for MLSS measurement on a cycle ergometer. MLSS (4.2 +/- 0.7 mmol.l-1, range: 2.8 to 5.5 mmol.l-1) and MLSS intensity related to maximal workload (66.5 +/- 7.7%, range: 50-84%) were independent of age. MLSS heart rate (180.1 +/- 10.1 min-1, range: 156-208 min-1) decreased (P < 0.01) with increasing age, whereas absolute (157.2 +/- 54.8 W, range: 65-240 W) and relative MLSS workload (2.6 +/- 0.5 W.kg-1, range: 1.5 to 4.1 W.kg-1) and absolute (236.9 +/- 79.0 W, range: 100-350 W) and relative maximal workload (3.9 +/- 0.6 W.kg-1, range: 2.7 to 5.5 W.kg-1) increased (P < 0.001) with age. The age independence of MLSS supports the theory that neuromuscular factors may contribute to the frequently observed changes in response to given exercise with physical maturity more than changes in oxidative metabolism and/or glycolysis.

Interaction of heart-rate fluctuations and respiration in 12 to 14-year-old children during sleeping and waking

Our study was designed to investigate and quantitatively characterise the interaction of breathing and instantaneous heart rate. Comparisons were made during consciousness at rest, and during non-REM sleep. 31 12-14-year-old healthy children were subjected to a 24-h polygraphic electrocardiogram, respirogram, electrooculogram and actogram measurements. The data were analysed by means of power spectral analysis and coherence spectra. The peak frequency of high-frequency heart rate fluctuations was always clearly related to the breathing frequency, i.e., respiratory sinus arrhythmia is present in both states. Moving squared coherence analysis demonstrates the stability of the cardiorespiratory coupling to remain constant during wakefulness or non-REM sleep. However, coherence increases from waking state to non-REM sleep. The lower coherence during waking state may be explained by greater additional central and peripheral influences on the cardiorespiratory coupling or by increased non-linear properties of the transfer system due to operating point shifting.

[Sleep structure in relation to respiration and heart rate in children in puberty]

The different expression of respiratory sinus arrhythmia in REM- versus nonREM-sleep indicates a dependence of cardiorespiratory interaction on patterns of sleep. Investigations of the intensity of respiratory entrainment on heart rhythmicity during various stages of sleep will provide an insight into the coupling of cardiorespiratory interaction and sleep patterns. 42 healthy children (12 to 15 years old) were polygraphically investigated over 24 h. An ECG, EOG, and actogram were performed, respiratory movements were observed, and the skin temperature was taken. The power spectra of the instantaneous heart rate and the respirograms were calculated. The analysis of coherence was carried out to determine how pronounced the cardiorespiratory interaction is. REM-sleep, nonREM-phases, and wakefulness were compared. The spectral parameters of instantaneous heart rate show differences between both stages of sleep and the waking state. Due to a dependence of spectral power on breathing patterns, drawing quantitative conclusions is not possible. The analysis of coherence provides more information about sleep patterns within the cardiorespiratory interaction. It is very pronounced during non-REM-sleep (0.80 +/- 0.07; mean +/- standard deviation). Heart rhythmicity proceeds independent of breathing during REM-sleep (0.52 +/- 0.11). The coupling is weaker than during wakefulness (0.64 +/- 0.09).

[Effect of HLA compatibility on kidney transplantation]

The influence of the HLA system on the success rate of kidney transplantations was evaluated in a worldwide collaborative study. The results confirm the influence of the HLA chromosome on transplants from related donors. Moreover, a highly significant effect of compatibility for the HLA-A, -B, -DR antigens was observed in cadaver transplants (p < 0.0001). The great importance of a good quality of tissue typing was emphasized by a) the observation that a significant influence of compatibility for the HLA-A, -B antigens was evident only if donors and recipients were typed for 'split' specificities and not when they were typed for 'broad' antigens, and b) an improved effect of HLA-DR compatibility when serological typing errors were corrected by molecular (DNA) typing. Computations show that kidney allocation according to the best possible HLA compatibility results in a gain of 800 transplant function years per 1,000 transplantations over a 10-year period.

Einfluß der HLA-Kompatibilität auf die Nierentransplantation

Der Einfluß des HLA-Systems auf die Erfolgsrate von Nierentransplantationen wurde in einer weltweiten Studie ausgewertet. Der Einfluß der HLA-Chromosomen auf Transplantationen von Verwandtenspendern wurde bestätigt. Bei Transplanta-tionen von Leichenspendern wurde ein hochsignifikanter Effekt der Kompatibilität zwischen Spender und Empfänger für die HLA-A-, -B- und -DR-Antigene festge-stellt (p < 0,0001). Die große Bedeutung einer guten Typisierungs<i>qualität</i> wurde verdeutlicht durch a) einen signifikanten Einfluß der HLA-A-, -B-Antigene, wenn die Typisierung auf «Split»-Untergruppen durchgeführt wurde, nicht jedoch wenn lediglich «breite» Antigene typisiert wurden, und b) einen verbesserten Effekt der HLA-DR-Kompatibilität, wenn serologische Typisierungsfehler mittels einer molekularbiologischen Typisierung korrigiert wurden. Durch eine Nierenzuteilung nach der HLA-Kompatibilität ist ein Gewinn von 800 Nierenfunktionsjahren je 1000 Transplantationen über einen 10-Jahres-Zeitraum erreichbar.

Current status of HLA matching in renal transplantation. The Collaborative Transplant Study

The impact of HLA compatibility on the success rate of kidney transplants was studied in over 80,000 recipients of primary transplants. The transplants were done from 1982 to 1991 at over 300 transplant centers in 43 countries. The results show that matching the HLA chromosomes in related donor transplants has a striking influence. It is also important that matching for individual HLA antigens in cadaver transplants provides a highly significant improvement in graft survival (P less than 0.0001). After 5 years, matched grafts have a survival rate approximately 20% higher than completely mismatched grafts. The matching effect is particularly strong in presensitized and second graft recipients. There is now direct evidence that even if it is necessary to transport well-matched kidneys a long way, they have a significantly higher success rate than locally transplanted poorly matched kidneys. New data based on molecular technology show that the precise identification of HLA-DR antigens by DNA typing further improves the success rate of HLA-matched transplants.

Outcome after emergency surgery for cancer of the large intestine

The data for 77 patients with colorectal cancer who underwent emergency surgery for acute intestinal obstruction (57 patients) or perforation (20 patients) within 24 h of admission were evaluated. The patients were older and had more advanced disease than patients undergoing elective surgery for colorectal cancer. Emergency surgery for carcinoma of the right colon consisted of primary resection in 95 per cent of cases and was followed by a 28 per cent mortality rate. Perforated tumours of the left colon and rectum were managed by primary resection in 82 per cent of cases with a 22 per cent mortality rate. In contrast, obstructing tumours of the left colon and rectum were treated by primary resection in 38 per cent of cases with a 6 per cent mortality rate, and by primary decompression in 62 per cent of cases with a 25 per cent mortality rate. The overall postoperative mortality rate was 23 per cent and increased with advanced tumour disease, perforation and peritonitis. Cardiac decompensation and intraabdominal sepsis were the major causes of death. Although the long-term survival rate following emergency surgery was worse than after elective surgery, improvements in outcome should be achieved by better management of the initial emergency situation.