Perspectives on patients' history: methodological considerations on the example of recent German-speaking literature

Patient-history is a recently developed branch of medical-historical search, and its methodology has not yet been sufficiently developed. In particular, the specific character of patient-centered research still has not received sufficient attention. What kinds of questions can, and should, such research attempt to answer, and from which perspectives? This contribution to the discussion offers some help towards the development of ways of orienting such research towards achieving proximity to the patients' viewpoint. This aim is best achieved when the mental picture of patients is reconstructed and, in addition, the specific point of view of the patient is adopted. The article illustrates some possibilities and problems of this branch of research by citing the example of relevant recent German-language studies, especially in the field of the relationship of patients to approved doctors in the nineteenth century.

[Long-term outcome of sex reassignment of male transsexual patients]

We report on our experience and our results with gender reassignment during the past 20 years. This study investigates the cosmetic and functional adequacy of the neovagina and also the psychological and social status in 37 surgically reassigned male-to-female transsexuals after a mean postsurgical follow-up of 7.5 years. There were 169 subjects who desired operations to adjust sex. In 58 cases the diagnosis "transsexualism" was supported by two psychosomatic and psychiatric expert opinions. We carried out 52 such operations in two stages. The mean age of the patients was 29 (18-40) years. The depth of the neovagina was approximately 12 cm, a cosmetic and physiologic result which adds greatly to the patients' satisfaction. There were no complications such as rectal or urethral fistulas. In one patient, vaginal stenosis developed after reoperation at a different institution. Three patients complained about short vaginas (6-9 cm). Correspondingly, the psychosocial status showed good improvement after surgery.

dpa, a member of the MCM family, is required for mitotic DNA replication but not endoreplication in Drosophila

We have isolated the Drosophila disc proliferation abnormal (dpa) gene, a member of the MCM family of DNA replication factors. Members of this family of proteins are required for DNA replication in yeast. A dpa null mutant dies during pupal stages because imaginal tissues necessary for the formation of the adult fly fail to proliferate normally. Beginning in late embryogenesis BrdU labeling reveals DNA replication defects in mitotically proliferating cells. In contrast, dpa is dispensable for endoreplication, a specialized cell cycle consisting of consecutive rounds of S phases without intervening mitosis. Our studies suggest an essential role for dpa in mitotic DNA replication but not in endoreplication. Thus, dpa is not a general replication factor but may play a specialized regulatory role in DNA replication.

Calcitriol oral pulse therapy in children with renal osteodystrophy

A 6-month protocol of oral pulse calcitriol was used in nine uraemic children (2-14 years old) on dialysis who presented with renal osteodystrophy. Calcitriol was administered twice a week, 4 micrograms per dose for patients over 30 kg and 3 micrograms for patients less than 30 kg. Plasma levels of parathyroid hormone, calcium, phosphorus and alkaline phosphatase were carefully controlled during the study. Parathyroid hormone levels decreased by 68% and 56% by the 2nd and 6th months of treatment in seven patients, while they remained unchanged in two patients with focal segmental glomerulosclerosis and massive proteinuria. Eight hypercalcaemic episodes from 77 determinations were observed, all of them recovered after 1 week of vitamin D withdrawal. We conclude that oral calcitriol pulse therapy is a good alternative for renal osteodystrophy in uraemic children. Careful monitoring of plasma parathyroid hormone and calcium is needed during follow-up when using this approach in paediatric patients.

The human high mobility group (HMG)-box transcription factor TCF-1: novel isoforms due to alternative splicing and usage of a new exon IXA

The C-terminal peptide sequences of the human lymphocyte-specific high mobility group (HMG)-box transcription factor TCF-1 are determined by alternative splice mechanisms affecting the exons VIII to X. Here we report, in addition to four splice forms described previously (TCF-1A, B, C, D), the identification of three novel transcripts designated TCF-1E, F, G. Cloning and sequencing of the novel cDNAs revealed (i) joining of the exons VIII and IX to an internal exon X splice acceptor site resulting in a new open reading frame (ORF) of 99 amino acids derived from exon X sequences, (ii) the identification of an additional functional splice acceptor site within exon X, and (iii) a new 81-nucleotide insertion between exon VIII and exon X sequences in a novel transcript form. Genomic cloning and sequence analysis of this transcribed segment of 81 basepairs revealed that it was bordered by canonical splice consensus sites and located in a distance of some 400 bp from both the exons IX and X. It was therefore termed exon IXA. Novel ORFs were generated as a consequence of these alternative splice mechanisms resulting in TCF-1 gene products with significantly different C-terminal peptide sequences, which are prone to selective protein-protein interactions or transactivating functions.

Carbon monoxide poisoning with severe myonecrosis and acute renal failure

A case of carbon monoxide (CO) poisoning with severe myonecrosis and acute renal failure (ARF) is presented with extremely high values of CPK but with preservation of myocardial tissue. A discussion of the broad effects of CO intoxication is undertaken with a review of the pertinent literature. Diagnostic and therapeutic mainstays are presented with some pitfalls and alternatives to their implementation. Computed tomography of affected muscles is presented as an alternative to muscle biopsy, and a unique modality of noninvasive diagnosis of myonecrosis.

In vitro and in vivo characterization of BR96 sFv-PE40. A single-chain immunotoxin fusion protein that cures human breast carcinoma xenografts in athymic mice and rats

BR96 sFv-PE40 is a single-chain immunotoxin fusion protein targeted to the Ley Ag, which is expressed in many different human carcinomas as well as in normal gastrointestinal epithelium of humans and certain animals, including athymic rats but not mice. In vitro binding analysis determined that BR96 sFv-PE40 was similar in affinity to BR96 Fab. BR96 sFv-PE40 internalizes rapidly, similar to BR96 IgG. H3396 cells, derived from metastatic human breast carcinoma, have been established as tumor xenografts in estradiol-supplemented athymic mice and rats. H3396 tumor xenografts established in athymic mice (up to 350 mm3) and rats (up to 100 mm3) completely regressed after i.v. administration of BR96 sFv-PE40, given as 0.625 mg/kg (1.975 mg/m2) every 4th day for a total of five doses (mice) or 0.25 mg/kg (1.475 mg/m2) every 4th day for a total of four doses (rats). The tumors remained regressed for the duration of the study (> 85 days post-implant), which represents > 10 doubling times, indicating that the animals were cured. There was no toxicity in rats receiving a curative dose of 0.25 mg/kg, although liver and lung toxicity could be detected at a 16 times higher dose, 4 mg/kg or 23.6 mg/m2. We conclude, therefore, that BR96 sFv-PE40 can cure tumor xenografts at well tolerated doses and also in the presence of Ley expression in normal tissues.

In vitro and in vivo characterization of BR96 sFv-PE40. A single-chain immunotoxin fusion protein that cures human breast carcinoma xenografts in athymic mice and rats

BR96 sFv-PE40 is a single-chain immunotoxin fusion protein targeted to the Ley Ag, which is expressed in many different human carcinomas as well as in normal gastrointestinal epithelium of humans and certain animals, including athymic rats but not mice. In vitro binding analysis determined that BR96 sFv-PE40 was similar in affinity to BR96 Fab. BR96 sFv-PE40 internalizes rapidly, similar to BR96 IgG. H3396 cells, derived from metastatic human breast carcinoma, have been established as tumor xenografts in estradiol-supplemented athymic mice and rats. H3396 tumor xenografts established in athymic mice (up to 350 mm3) and rats (up to 100 mm3) completely regressed after i.v. administration of BR96 sFv-PE40, given as 0.625 mg/kg (1.975 mg/m2) every 4th day for a total of five doses (mice) or 0.25 mg/kg (1.475 mg/m2) every 4th day for a total of four doses (rats). The tumors remained regressed for the duration of the study (> 85 days post-implant), which represents > 10 doubling times, indicating that the animals were cured. There was no toxicity in rats receiving a curative dose of 0.25 mg/kg, although liver and lung toxicity could be detected at a 16 times higher dose, 4 mg/kg or 23.6 mg/m2. We conclude, therefore, that BR96 sFv-PE40 can cure tumor xenografts at well tolerated doses and also in the presence of Ley expression in normal tissues.

Use of high temperature-resistant sorbents as simulants for testing

The amended Council Directive 82/711/EEC will include the test conditions for plastic materials and articles intended to come into contact with foodstuffs at high temperature. The most stringent test condition (excluding susceptor materials) will be heating of the material for 2 h at 175 degrees C in a conventional oven. For fatty foodstuffs, olive oil (simulant D), synthetic triglycerides or sunflower oil shall be used for the test. If these simulants are found inappropriate, other simulants and conditions of time and temperature may be used. In order to perform a correct evaluation of such materials one must distinguish between volatile and non-volatile migrants, between additives and decomposition products, and between overall and specific migration. No universally applicable simulant has been found yet which is able to provide all the data needed for evaluation. The advantages and limitations of a high temperature-resistant simulant will be described.

[Thiamin deficiency is common in Israel]

Diseases due to vitamin B1 (thiamin) deficiency are considered to be uncommon in Israel. We present 13 patients admitted during the course of a year who were found to have thiamin deficiency. 5 had classic syndromes such as beri-beri, Wernicke's encephalopathy and cerebellar degeneration. In another 8 the thiamin deficiency was found during workup for less specific neurological abnormalities. Only a minority were alcoholics. Mainly at risk for developing nutritional deficiency were the solitary elderly of low socio-economic status with poor nutrition. Other reasons for thiamin deficiency were drug abuse and hyperemesis gravidarum. Thiamin levels should be determined not only in alcoholics and those with classic B1 deficiency syndromes, but in the routine workup of patients with sensory-motor neuropathy, dementia, gait disorders, cerebellar syndromes and confusional states. It is advised to give vitamins prophylactically to asymptomatic high risk patients.

prospero is expressed in neuronal precursors and encodes a nuclear protein that is involved in the control of axonal outgrowth in Drosophila

Neurogenesis in Drosophila begins with the formation of neuronal precursors, which give rise to neurons of individual identity. To find out whether there are genes that are expressed in most or all neuronal precursors and are involved in controlling particular aspects of neuronal differentiation, we used the enhancer-trap method to screen for such "neuronal precursor genes." One gene of this group is prospero. Our mutant analysis indicates that prospero regulates other neuronal precursor genes and is essential for the axonal outgrowth and pathfinding of numerous central and peripheral neurons. prospero encodes a large nuclear protein with multiple homopolymeric amino acid stretches and is expressed in neuronal precursors early during their formation. It is probably generally required for proper neuronal differentiation.

Pharmacokinetic and pharmacodynamic analysis of a human immunoglobulin M monoclonal antibody in neonatal Macaca fascicularis

We have developed a human MAb that opsonizes group B streptococci, the major cause of gram-positive bacterial sepsis in newborns. It is an IgM class human MAb that possess unique protective activity against experimental infections caused by the predominant group B capsule serotypes III and I. Preliminary preclinical studies with the IgM human MAb were designed to provide initial information useful for predicting its safety and pharmacokinetic properties. Two neonatal Macaca fascicularis monkeys were infused with the human MAb at either 17.8 or 230 mg/kg. Safety was evaluated by visually monitoring postinfusion clinical status and by standard clinical chemistry analyses and quantitative hematology on blood samples collected for 30 d. The serum antibody levels were determined by ELISA and antibody functional activity in serum samples by opsonophagocytic assays. The IgM human MAb appeared safe (normal laboratory values and clinical status) with a half-life of 2.5 d, a period compatible with the 5-d half-life reported for human IgM in adult serum. In addition, the human MAb retained functional opsonic activity for at least 30 d. Human MAb may offer a safe alternative for treating severe bacterial infections.

Comparison of functional activities between IgG1 and IgM class-switched human monoclonal antibodies reactive with group B streptococci or Escherichia coli K1

The influence of valence and heavy chain on antibody activity was investigated using transfectoma-derived, class-switched IgG1 and IgM human monoclonal antibodies (MAbs) reactive with the bacterial pathogens Escherichia coli K1 and group B Streptococcus species. IgG-IgM pairs were compared in vitro for antigen binding and opsonic activities and in vivo for protective efficacy in neonatal rats. For the anti-E. coli pair, the IgM MAb was 1000-fold more potent in all assay formats. Importantly, the 50% protection dose (PD50) of the IgM MAb was 10-20 ng/rat, while 100 micrograms of the IgG MAb was only minimally protective. For the group B streptococcal MAbs, the IgM was 100- and 4500-fold more potent in binding and opsonization assays, respectively. However, while 20 micrograms of IgM protected neonatal rats, 100 micrograms of IgG MAb was partly protective. These experiments demonstrate the utility of recombinant DNA technology for creating a panel of antibodies that may aid in selecting potential immunotherapeutic candidates.

Freeze-drying of Streptococcus thermophilus: a comparison between the vacuum and the atmospheric method

Frozen suspensions of Streptococcus thermophilus were freeze-dried in a vacuum or a fluidized adsorbent bed at atmospheric pressure. Optimum operating conditions for each process were defined. For the duration of processing and survival rate of bacteria, in each case vacuum freeze-drying seemed more satisfactory than atmospheric pressure freeze-drying. The use of reconstituted skimmed milk as a suspension medium provides good protection for S. thermophilus.

[Chronic hemodialysis in children]

The clinical features of eight patients, four females, aged 4 to 15 years under chronic hemodialysis for terminal renal failure (creatinine clearance 10 ml.min.1,73 m2 or less) are reported. Initial diseases were Alport syndrome, systemic lupus erythematosus, chronic glomerulonephritis (n = 2), bilateral polycystic kidney, prune belly syndrome and reflux nephropathy (n = 2). Distal vascular approach by means of arteriovenous fistulas was preferred for these patients and the kinetic urea model was used to evaluate the performance of the procedure. Patients required nine to twelve hours of hemodialysis per week for optimal results. Mean weight decreases of 1 to 3 kg and reductions in blood urea nitrogen and serum potassium of 40 mg.dl and 2,5 mEq.1, respectively, were observed. The main complications of hemodialysis were the disequilibrium syndrome, infections at the site of insertion of the arteriovenous fistulae and congestive heart failure. Three patients were submitted to renal transplantation with live donors homografts: one died and the other two remain alive but under chronic hemodialysis. Five children are attending school regularly, and two of them are waiting a kidney donor for transplantation. Despite encouraging results chronic hemodialysis in children constitutes only primary supportive therapy prior to renal transplantation.

[Idiopathic hypercalciuria. Differential diagnosis]

In 50 children with hematuria or urolithiasis and idiopathic hypercalciuria, and in 15 control children, urinary calcium/creatinine concentration rates were measured after fasting and after calcium loading. Patients were classified into two groups depending on the results of an orally administered calcium loading test. Children were considered to have absorptive hypercalciuria (42%) when they had low fasting urinary calcium/creatinine concentration ratio (less than 0.21), and a large increase of this index after calcium administration (greater than 0.28). Patients were labeled as renal hypercalciuria (32%) if they had high fasting urinary calcium/creatinine concentration ratio (greater than 0.21), and variable increases of it after calcium overload. A third group of children (26%), were not classifiable by means of this test. Our data support the contention that this simple ambulatory test is very useful in the diagnostic workup of idiopathic hypercalciuria.

[Hemodialysis and urea kinetics. An elementary computational program]

An elementary computational program to optimize dialysis in children with chronic renal failure was developed. The program is based on the urea kinetics model. Parameters involved in the efficiency of hemodialysis such as time and clearance, hemofilter performance and body surface area, as well as nutritional needs of the child are considered in the program.

Fine structure DNA mapping studies of the chromosomal region harboring the genetic defect in neurofibromatosis type I

To better map the location of the von Recklinghausen neurofibromatosis (NF1) gene, we have characterized a somatic cell hybrid designated 7AE-11. This microcell-mediated, chromosome-transfer construct harbors a centromeric segment and a neo-marked segment from the distal long arm of human chromosome 17. We have identified 269 cosmid clones with human sequences from a 7AE-11 library and, using a panel of somatic cell hybrids with a total of six chromosome 17q breakpoints, have mapped 240 of these clones on chromosome 17q. The panel included a hybrid (NF13) carrying a der(22) chromosome that was isolated from an NF1 patient with a balanced translocation, t(17;22) (q11.2;q11.2). Fifty-three of the cosmids map into a region spanning the NF13 breakpoint, as defined by the two closest flanking breakpoints (17q11.2 and 17q11.2-q12). RFLP clones from a subset of these cosmids have been mapped by linkage analysis in normal reference families, to localize the NF1 gene more precisely and to enhance the potential for genetic diagnosis of this disorder. The cosmids in the NF1 region will be an important resource for testing DNA blots of large-fragment restriction-enzyme digests from NF1 patient cell lines, to detect rearrangements in patients' DNA and to identify the 17;22 NF1 translocation breakpoint.

Localization of the genetic defect in familial adenomatous polyposis within a small region of chromosome 5

Familial adenomatous polyposis (FAP), a Mendelian disorder that includes familial polyposis coli (FPC) and Gardner syndrome (GS), has an autosomal dominant mode of inheritance. It is characterized by hundreds to thousands of adenomatous polyps that can progress to carcinoma of the colon, suggesting that the gene that harbors the FAP germ-line mutation may play an important role in the somatic genetic pathway to colon cancer. The defect responsible for FAP was recently mapped to the long arm of chromosome 5 by linkage between the FPC phenotype and a locus defined by DNA probe pC11p11 (D5S71), located at 5q21-22. Because an important next step in the paradigm for identification of a disease gene is to obtain a more precise localization, we isolated and mapped by linkage six additional polymorphic DNA markers in the FAP region. Subsequent linkage analysis in six pedigrees, three having the FPC phenotype and three segregating GS, placed the FAP locus very close to a new marker, YN5.48 (D5S81), that is approximately 17 centimorgans distal to C11p11 on the genetic map. The analysis revealed no evidence of genetic heterogeneity between the two phenotypes, a question that had not been clearly resolved by the earlier studies. The new set of markers in the near vicinity of the FAP locus represents a further step toward isolation of the genetic defect and provides the opportunity for preclinical diagnosis of risk status for colon cancer among individuals in families that are segregating adenomatous polyposis.

Families, informal supports, and Alzheimer's disease. Current research and future agendas

With the aging of most Western populations, there is growing research attention to the social and behavioral aspects of age-related chronic diseases and disabilities. Research is just beginning to focus on how families and other social supports affect and are affected by Alzheimer's Disease and related disorders. This article reviews the current state of knowledge in this area and suggests a future research agenda.

[Prednisolone reduction by benoxaprofen]

The prednisolone sparing effect of benoxaprofen has been examined in only 13 cases of rheumatoid arthritis. The examination was terminated prematurely because of an accumulation of side effects of the skin. The results of these 13 cases are not significant, but the drug seems to show a relatively high mean value of its prednisolone sparing effect but it seems to cause a high proportion of side effects, especially of the skin. This preliminary result should be reported in regard to possibly following studies with simular observations.

[Fibrosarcoma of the right heart. Contribution to the problem of primary heart tumors]

Report on a fibrosarcoma of the right ventricle in a 70-year-old woman. The tumour was diagnosed by autopsy. Clinically were of importance the chronic insufficiency of the right heart, in the ECG the low voltage, a bifascicular block and a subepicardiac lesion in the area of the anterior wall. Roentgenogram of the thorax and the laboratory findings corresponded to a massive cardiac decompensation. The cytology from the effusion of the pericardium which often occurred gives a possibility of making a diagnosis intra vitam, if it is thought of a cardiac tumour.

[Investigations on the clinical effect of the antirheumatic agent piroxicam (author's transl)]

In the glucocorticoid-sparing test, which shows certain advantages compared with other experimental procedures, the clinical efficacy of the new antirheumatic substance piroxicam (Feldene) was investigated. It was shown that a single daily dose of 20 mg piroxicam gave at least an equal, if not better, effect compared with other substances tested earlier, as far as comparison is permissible between two collectives treated with different substance. The mean saving of prednisone was 5.7 mg/day and according to another evaluation 64.7% of the previously required dose of prednisolone. It is worth noting that owing to the long half-life there is a remarkable clinical effect over at least 24 hours with a single daily dose. Tolerance was good. Pathological laboratory values which were definitely to be attributed to the preparation were not seen in a trial period of a maximum of four weeks.

Growth and glucocorticoids in children with kidney disease

Glucorticoid therapy inhibits statural growth. Alternate-day therapy causes less growth suppression than does daily therapy, and, in experimental animals and children with asthma, it has been associated with normal growth. Although catch-up growth may occur after cessation of steroid therapy, this is not always the case, especially when therapy has been prolonged. In children treated with steroids for glomerulonephritis or nephrotic syndrome and especially in children after renal transplantation, factors other than steroid therapy may contribute to growth retardation. Steroids may suppress growth by direct action on cell metabolism, by inhibition of growth hormone or somatomedin and/or by effects on calcium and phosphorus metabolism. Present knowledge of mechanisms of action and dose-response relationships is complete, and it is difficult to prescribe therapy which will achieve a predictable therapeutic effect without inhibiting growth.

[Rooming-in at the maternity department. Results of a questionnaire-action]

The authors report from the Univ.-Frauenklinik in Giessen, where rooming-in was first introduced in 1976; the newborn baby's bed is now put in the mother's room. When 171 outpatients, who had never heard of rooming-in, and 81 patients in the maternity ward were consulted, the women agreed to a trial period for rooming-in. It was shown that more than 70% of the women would have prefered a clinic where rooming-in was possible to a traditional type clinic. This tendency was particularly strongly felt among women with a higher level of secondary education and among women who held the view that the fathers should be more involved in the family and in the upbringing of small children. The results of individual questionnaires showed that support for rooming-in was significantly strong on the grounds of interhuman relations; also, the rejection of the traditional mother-image was apparent. Reasons for the introduction of rooming-in, as well as the difficulties involved in putting it into practice are outlined.