[Postoperative manifestation of acute compartment syndrome by previously unknown heterozygote sickle cell anemia. A clinical case report]

Patients suffering from sickle cell disease show an increased ischemic intolerance due to continuous pro-inflammatory activation and dysfunction of the endothelium by recurrent vaso-occlusive episodes. The presented case shows the manifestation of a postoperative compartment syndrome of the lower leg following the intraoperative use of blood arrest in a patient with previously unknown sickle cell disease. Preexisting vulnerability for tissue hypoxia in patients at risk should be a major concern for intraoperative use of blood arrest during surgery of the extremities.

Mass spectrometry for monitoring protease reactions

More than 560 genes are annotated as proteases in the human genome. About half of the genes are not or are only marginally characterized. Over the past decade, mass spectrometry has become the basis for proteomics, especially for protein identification, performed in a high-throughput manner. This development was also very fruitful for exploring the complex systems associated with protease functions, as briefly reviewed here. Mass spectrometry is an ideal tool for monitoring protease reactions, as will be highlighted in this review.

Antidepressive therapy with escitalopram improves mood, cognitive symptoms, and identity memory for angry faces in elderly depressed patients

Depression is a common disorder in the elderly handicapping patients with affective and cognitive symptoms. Because of their good tolerability relative to the older tricyclic compounds, selective serotonin reuptake inhibitors (SSRIs) are increasingly used for the treatment of depression in the elderly. Little is known about their effects on cognition in elderly patients. In the present 4-wk, single-centre, randomized, open-label trial we investigated the antidepressive effects of escitalopram, an SSRI, in 18 elderly depressed patients [mean age (+/-s.e.m.) 76.2+/-1.8 yr] compared to 22 healthy age-matched controls (mean age 76.9+/-1.8 yr). Affective and cognitive symptoms were assessed using the Geriatric Depression Scale (GDS), Mini-Mental State Examination (MMSE), and a face portrait recognition test to assess memory for happy and angry faces. Depressed patients prior to treatment had markedly reduced memory performance. Treatment with escitalopram improved affective and cognitive symptoms significantly. Furthermore, escitalopram treatment improved memory for negative facial stimuli. Control subjects confirmed the well- established memory bias favouring recognition of identities acquired with happy expressions. Importantly, this bias was absent in depressed patients prior to, but also after treatment. In conclusion, escitalopram, even after a relatively short treatment period, was effective in treating depression in the elderly and may help improve cognitive performance for social stimuli.

Post-learning intranasal oxytocin modulates human memory for facial identity

The nanopeptide oxytocin has physiological functions during labour and lactation. In addition, oxytocin is known to modulate aggression, anxiety, social behaviour and cognition. Little is known about its effects on memory for emotional stimuli. In the present single-blind, placebo-controlled, randomised study we have investigated the short- and long-term effects of a single post-learning dose (20 IU) of intranasal oxytocin on memory for facial identity and expression in 36 healthy young females and males using a face portrait recognition test. In the acquisition phase of the test, 60 different male faces with happy, angry or neutral expressions were presented to the volunteers. Thirty minutes and 24h after oxytocin administration, recognition memory tests were performed using portraits with neutral facial expressions, only. Oxytocin improved identity recognition memory independently of participant's gender, for neutral and angry faces, whereas this effect was not present for happy faces. Oxytocin-treated subjects had a lower bias to judge not previously seen faces as being previously seen. Oxytocin had no effect on facial expression memory. In conclusion, oxytocin has distinct effects on memory performance for facial identity and may contribute to the modulation of social behaviour.

[Percutaneous lumbar interbody fusion using autogenous osteoblasts in vivo]

AIM

In the present study we have investigated the potential of autogenous osteoblasts for osteoinduction in a spinal arthrodesis model.

METHOD

After posterolateral instrumentation of 3 segments of a sheep spine the intervertebral space was filled with cancellous bone, osteoblasts or left empty after nucleotomy and elimination of cartilage.

RESULTS

Radiological and histological analyses proved a significant osseous reaction in segments treated with cancellous bone or osteoblasts in contrast to the control segment. This outcome provides evidence of spondylodeses by spinal instrumentation in combination with osteoblasts in a sheep model.

CONCLUSION

The results suggest a possible application of autologous osteoblasts as an osteoinductor after percutaneous nucleotomy in spinal fusion. The possible application in a human model should be examined.

In vitro differentiation of skin sensitizers by cell signaling pathways

Animal testing causes ethical problems and in view of EU regulations (e.g. EU-Guideline (76/768/EEC, February 2003)) or REACH the development of reliable in vitro assays has become even more important. Up to now, we use the modified local lymph node assay (IMDS) for toxicological hazard identification of sensitizing and irritant properties of chemicals in accordance with OECD Guideline 429. In this study, we investigated whether analyses of cell signaling pathways can provide a methodology for the detection of sensitizing compounds in vitro. Murine and human skin explants as well as reconstituted skin models (epidermal model EST-1000 and full-thickness model AST-2000) were exposed to sensitizing (oxazolone and DNFB) or irritant compounds (SDS and TritonX-100). Phosphorylation of MAP-kinases (p38, ERK1/2 and JNK1/2), STAT1 and PLCgamma were determined by cytometric bead array (CBA). In skin explants, all three MAP-kinases were exclusively activated after exposure to sensitizing compounds. For the reconstituted skin models phosphorylations of p38 and JNK1/2 were obtained after stimulation with allergens, whereas treatments with irritant compounds led to ERK1/2 activation. Activation of PLCgamma and STAT1 were never detected. In conclusion, MAP-kinase activation provides a promising in vitro tool for the discrimination between sensitizers and irritants.

Severe combined immunodeficiency signalized by eosinophilia and lymphopenia in rotavirus infected infants

BACKGROUND

Severe combined immunodeficiency (SCID) is a heterogeneous disease consisting of several different subtypes. Most subtypes present during infancy and without treatment, infections usually lead to early death. Diagnosis of SCID can be difficult as new subtypes are expected to be discovered soon. Late diagnosis is associated with a poorer outcome. Infections like rotavirus enteritis cannot be cleared in children with SCID due to impaired immunity. The aim of our study was to identify clues in children with rotavirus enteritis that aid to diagnose SCID early.

PATIENTS AND METHODS

Total white blood counts in a cohort of SCID patients with persistent rotavirus infection at diagnosis (n=18) were compared to total white blood counts in matched control patients without SCID but with rotavirus infection.

RESULTS

Relative and absolute lymphopenia and eosinophilia were more common in SCID patients (p<0.005).

CONCLUSION

In infants with rotavirus infection, a full blood count should be performed: Eosinophilia and/or lymphopenia raise a high suspicion of SCID.

Glomerular hypertrophy precedes albuminuria and segmental loss of podoplanin in podocytes in Munich-Wistar-Frömter rats

Focal segmental glomerulosclerosis (FSGS) is a common cause of end-stage renal disease. Albuminuria is a risk factor for FSGS and is influenced by environmental, genetic, and sex-specific factors. Podocytes play a central role in the development of albuminuria, but the precise relationship between early glomerular and podocyte-associated damage and albuminuria is unclear. Furthermore, experimental findings demonstrate a sex difference in development of albuminuria and FSGS. We investigated the early glomerular changes in male Munich-Wistar-Frömter (MWF) rats, which spontaneously develop albuminuria, and male albuminuria-resistant spontaneously hypertensive rats (SHR). In addition, since female MWF rats are protected from overt proteinuria and progressive renal disease, we compared the phenotypic changes in podocytes during early development of albuminuria in male and female MWF rats. In male MWF rats, glomerular hypertrophy preceded the onset of albuminuria and was greater than in male SHR. Albuminuria developed starting at 6 wk of age and coincided with focal and segmental loss of podoplanin, increased expression of desmin, entrapment of albumin in affected podocytes, and focal and segmental foot process effacement at the ultrastructural level. Other podocyte-associated molecules, such as nephrin and zonula occludens 1, were unaffected. Early glomerular hypertrophy and podocyte damage did not differ between male and female MWF rats. Our data show for the first time that albuminuria in male and female MWF rats is preceded by glomerular hypertrophy and accompanied by focal and segmental loss of podoplanin when FSGS was not yet present.

[An improved model of a catheterised human bladder for screening bactericidal agents]

PURPOSE

Catheter encrustation and associated blockage by a crystalline Proteus mirabilis biofilm constitute a continuous problem in long-term catheterised patients. The objective of the present work was to verify a new, physiological bladder model possessing the ability to show that triclosan-blocking solutions exert bactericidal and bacteriostatic activities.

MATERIAL AND METHODS

Catheterised sterile infusion bags served as human bladder models. Artificial urine inoculated with Proteus mirabilis was administered by a further aperture. Samples for measurement of pH value and microbial count were collected at intervals of 24 h. Upon completion of testing catheter encrustation was assessed and visualised by scanning electron microscopy.

RESULTS

In contrast to the application of placebo solution, in models filled with triclosan-blocking solution the catheters drained freely for the experimental period. Similar results were obtained for pH values and microbial count. The pH of the artificial urine did not exceed a critical value of pH 7 and the numbers of organisms correspond approximately to the initially inoculated number of organisms.

CONCLUSION

In the model developed here, triclosan inhibits the growth of Proteus mirabilis over the test period by diffusing into the artificial urine through the catheter balloon. Thus, triclosan acts against the pH increase as well as the formation of a crystalline biofilm. Taken together, the adaptability of this new, physiological model of the human bladder could be shown.

ICF syndrome: high variability of the chromosomal phenotype and association with classical Hodgkin lymphoma

We report on two sibs with ICF syndrome (immunodeficiency, centromeric heterochromatin instability, and facial anomalies) diagnosed in the elder brother based on the typical chromosomal abnormalities present in 56% of metaphases from cultured lymphocytes. In a previous cytogenetic analysis this diagnosis had been missed due to low manifestation of the ICF chromosomal phenotype. Hypomethylation of classical satellites 2 and 3, and of alpha-satellite DNA was shown in the lymphocytes of the younger sister. At 7 years of age the boy presented with hemiplegia due to tumerous invasion of the right brachial plexus. Histopathology revealed classical Hodgkin lymphoma, a neoplasia which might have been facilitated by the underlying genetic defect.

Gene variations in GSTM3 are a risk factor for Alzheimer's disease

Oxidative stress is a relevant pathomechanism in Alzheimer's disease (AD) and gene variations in the glutathione S-transferase M3 gene (GSTM3), involved in the detoxification of oxygen radicals, might influence the risk of AD. We investigated the effect of three polymorphisms in GSTM3: rs1332018 (C/A); rs1799735 (del/AGG); rs7483 (G/A), on the risk of AD in 363 AD patients and 358 healthy controls. Single marker association analyses revealed that the AGG/AGG genotype of the GSTM3 rs1799735 (del/AGG) polymorphism was associated with an increased risk of AD (p=0.05), especially in the group of APOE4-allele non-carriers (p=0.004; OR=2.07). Examination of the haplotypes identified a two-marker haplotype (C/AGG) consisting of rs1332018 (C/A) and rs1799735 (del/AGG) to increase the risk of AD (p=0.029), this effect was also most prevalent in APOE4-allele non-carriers (p=0.009; OR=1.95). The population attributable risk of this haplotype in APOE4-allele non-carriers was 32.2%. Our results suggest that there is a group of AD patients in which variations in metabolism of oxidative stress play an important role.

[A prospective two-year follow-up of thoracic and lumbar osteolytic vertebral fractures caused by multiple myeloma treated with balloon kyphoplasty]

PURPOSE

Balloon kyphoplasty is a minimally invasive procedure for the stabilization of osteoporotic and osteolytic vertebral fractures. The purpose of this prospective study was to evaluate this operative procedure in the treatment of osteolytic vertebral fractures with regard to the reduction of pain and functional improvement of the patients and further to evaluate the restoration of vertebral height postoperatively.

MATERIALS AND METHODS

In this study 26 patients (21 male, 5 female) with osteolytic vertebral fractures were treated with balloon kyphoplasty. In total, 59 vertebral fractures were treated with balloon kyphoplasty. Preoperatively conventional radiographs in lateral and a. p. views, CT and/or MRI were preformed. Pre- and postoperatively the clinical parameters using VAS (visual analogue scale) and the Oswestry score were evaluated. Radiographic scans were performed pre- and postoperatively and after 3, 6, 12 and 24 months. The vertebral height and endplate angles were measured.

RESULTS

The median pain scores (VAS) decreased from pre- to post-treatment significantly (p < 0.05) as also did the Oswestry score (p < 0.05). Balloon kyphoplasty led to a significant and sustained reduction of pain resulting in a significant functional improvement for the patients. A significant restoration of vertebral height and reduction of the kyphotic angle could be achieved with the balloon technique (p < 0.05). Furthermore, the minimal-invasive procedure was able to stabilize the spine also over a longer period of 24 months. A radiation therapy and/or chemotherapy could be performed without loss of time.

CONCLUSION

In the treatment of osteolytic vertebral fractures balloon kyphoplasty led to a quick and sustained reduction of pain and as well as a functional improvement for the patients. A restoration of the vertebral height and reduction of the kyphotic angle was especially attributable to the balloon technique. The balloon kyphoplasty was able to stabilize the fractured vertebrae in the long-term and was able to prevent an increase of kyphotic deformity. Balloon kyphoplasty is an outstanding alternative in comparison to the established therapeutic concepts in the treatment of osteolytic vertebral fractures.

Chirurgisches Management von Wirbelsäulenmetastasen

The spine is the most frequent site of skeletal metastases. Among all spinal malignancies metastatic disease is most frequent and indicative of disseminating tumor disease. Depending on primary tumor entity, estimated survival time, general health status of the patient, presence of spinal instability and neurological deficits an oncological useful and patient-specific therapeutic intervention should be performed. New anterior approaches, resections and reconstruction techniques are making surgery a preferred method over radiation therapy. For differential indication of the multiple surgical treatment modalities prognostic scores are available to assist individual decision making. Indications for surgery include survival prognosis of minimum 3 months, intractable pain, progress of myelon compression and/or neurological deficits under radiochemotherapy, spinal instability and necessity for histological diagnosis. Resulting quality of life depends on efficient decompression of the spinal cord and restoration of spinal stability. To achieve these ultimate goals there are different anterior and posterior approaches, instrumentations and vertebral body replacement implants available. Preoperative embolization should be performed in hypervascular tumors, e.g., renal cell cancer. Vertebro-/Kyphoplasty as a percutaneous intervention should be considered for painful multisegmental disease and symptomatic osteolysis without epidural tumor compression to reach analgesia and stability. A multidisciplinary approach in patient selection, decision making and management is an essential precondition for complication avoidance and acceptable quality of life.

Perioperatives Schmerzmanagement in der Orthopädie

Organized orthopaedic pain management is a major part of successful patient treatment. Therefore pain management should start before surgery. Patients need to be informed about the operation and the subsequent procedures. Clinical pain management is based on continuous pain documentation with pain as the fifth vital sign. Surgery should be minimally invasive bewaring a peripheral modulated nociceptive sensitization. In order to prevent chronic pain preemptive analgesia should be employed followed by an individually tailored regimen of post-operative analgesia. In consideration of the documented pain levels post-operative pain therapy consisting of a standing medication and a rescue medication should by adjusted daily. Due to the fact that the highest pain levels after surgery were reported within the first 48 h pain medication should be reduced in the ensuing days, again taking the documented pain levels into account. Supportive treatment approaches such as cryotherapy or transcutaneous electrical nerve stimulation (TENS) are useful in the post-operative period. Physiotherapy after surgery should be extended stepwise regarding the operative device and it is of particular importance to respect pain intensities. The post-hospital regimen for a continuous pain medication should be given to the orthopaedic specialist.

Luteolin protects rat PC12 and C6 cells against MPP+ induced toxicity via an ERK dependent Keap1-Nrf2-ARE pathway

Oxidative stress is central to neuronal damage in neurodegenerative diseases such as Parkinson's disease and Alzheimer's disease. In consequence, activation of the cerebral oxidative stress defence is considered as a promising strategy of therapeutic intervention. Here we demonstrate that the flavone luteolin confers neuroprotection against oxidative stress via activation of the nuclear factor erythroid-2-related factor 2 (Nrf2), a transcription factor central to the maintenance of the cellular redox homeostasis. Luteolin protects rat neural PC12 and glial C6 cells from N-methyl-4-phenyl-pyridinium (MPP+) induced toxicity in vitro and effectively activates Nrf2 as shown by ARE-reporter gene assays. This protection critically depends on the activation of Nrf2 since downregulation of Nrf2 by shRNA completely abrogates the protection of luteolin in vitro. Furthermore, the neuroprotective effect of luteolin is abolished by the inhibition of the luteolin-induced ERK1/2-activation. Our results highlight the relevance of Nrf2 for neural cell survival conferred by flavones. In particular, we identified luteolin as a promising lead for the search of orally available, blood brain barrier permeable compounds to support the therapy of neurodegenerative disorders.

Insuffizienzfrakturen in der Rheumatologie

Stress fractures occur as insufficiency fractures, with a prevalence of 0.8% in patients with rheumatological illness. The main sites of insufficiency fractures are the pelvis and sacrum, parts of the tibia and fibula that are close to the joints, and the calcaneus and hip. Since the painful symptoms overlap with the clinical picture of the painful joint diseases and because of the low sensitivity of conventional diagnostic X-ray, insufficiency fractures are not diagnosed directly or their diagnosis is delayed. The high sensitivity of computer tomography, skeletal scintigraphy and nuclear magnetic resonance imaging should be exploited in the diagnosis of insufficiency fractures. The case report presented describes insufficiency fractures of the distal right tibia and fibula in an elderly female patient with rheumatoid arthritis being treated with long-term glucocorticoids. In addition to advanced age, female gender, immobility and rheumatoid arthritis requiring long-term cortisone, there are further risk factors for insufficiency fractures: fluoride treatment over many years in the past, hypovitaminosis D3, renal failure. The DXA bone density values of the neck of the femur and the lumbar vertebrae do not show any osteoporosis, and the calcium concentration in the serum is low; phosphate is raised and parathormone is normal; osteocalcin, beta crosslaps and alkaline phosphatase are raised. Bone biopsy specimens taken from the iliac crest and the proximal femur and investigated for the purpose of differential diagnosis revealed renal osteopathy with secondary hyperparathyroidism and osteomalacia. In elderly patients with kidney failure, the possibility of renal osteopathy must be considered as the possible cause of reduced bone quality with a raised risk of insufficiency fractures, even when the parathormone levels are normal. In view of the frequency of osteopathies in rheumatological patients, osteology is of enormous significance in rheumatology.