Macrophages and glia are the dominant P2X7-expressing cell types in the gut nervous system-No evidence for the role of neuronal P2X7 receptors in colitis

The blockade or deletion of the pro-inflammatory P2X7 receptor channel has been shown to reduce tissue damage and symptoms in models of inflammatory bowel disease, and P2X7 receptors on enteric neurons were suggested to mediate neuronal death and associated motility changes. Here, we used P2X7-specific antibodies and nanobodies, as well as a bacterial artificial chromosome transgenic P2X7-EGFP reporter mouse model and P2rx7^-/- controls to perform a detailed analysis of cell type-specific P2X7 expression and possible overexpression effects in the enteric nervous system of the distal colon. In contrast to previous studies, we did not detect P2X7 in neurons but found dominant expression in glia and macrophages, which closely interact with the neurons. The overexpression of P2X7 per se did not induce significant pathological effects. Our data indicate that macrophages and/or glia account for P2X7-mediated neuronal damage in inflammatory bowel disease and provide a refined basis for the exploration of P2X7-based therapeutic strategies.

Increased expression of the ATP-gated P2X7 receptor reduces responsiveness to anti-convulsants during status epilepticus in mice

BACKGROUND AND PURPOSE

Refractory status epilepticus is a clinical emergency associated with high mortality and morbidity. Increasing evidence suggests neuroinflammation contributes to the development of drug-refractoriness during status epilepticus. The aim of the present study was to determine the contribution of the ATP-gated P2X7 receptor (P2X7R), previously linked to both inflammation and increased hyperexcitability, to drug-refractory status epilepticus and its therapeutic potential.

EXPERIMENTAL APPROACH

Status epilepticus was induced via a unilateral microinjection of kainic acid into the amygdala in adult mice. Severity of status epilepticus was compared in animals with overexpressing or knock-out of the P2X7R, after inflammatory priming by the pre-injection of bacterial lipopolysaccharide (LPS) and in mice treated with P2X7R-targeting and anti-inflammatory drugs.

KEY RESULTS

P2X7R overexpressing mice were unresponsive to several anticonvulsants (lorazepam, midazolam, phenytoin and carbamazepine) during status epilepticus. P2X7R expression was increased in microglia during status epilepticus, at a time-point when responses to anticonvulsant are reduced. P2X7R overexpression led to a pro-inflammatory phenotype in microglia during status epilepticus and the anti-inflammatory drug minocycline restored normal responsiveness to anticonvulsants in P2X7R overexpressing mice. Pre-treatment of wildtype mice with LPS increased P2X7R levels in the brain and reduced responsiveness to anticonvulsants during status epilepticus, which was overcome by either a genetic deletion of the P2X7R or the administration of the P2X7R antagonists AFC-5128 or ITH15004.

CONCLUSION AND IMPLICATIONS

Our results demonstrate that P2X7R-induced pro-inflammatory effects contribute to resistance to pharmacotherapy during status epilepticus and suggest therapies targeting the P2X7R as novel adjunctive treatments for drug-refractory status epilepticus.

147 Pre-incubation of bovine sperm used for IVF accelerates the developmental kinetics of the resulting embryos and possibly their sex ratio

The sex ratio of newborn calves and embryos produced in vivo is ~1:1. However, numerous studies on bovine in vitro-produced embryos suggest that the sex ratio may differ from 1:1 and that the rate of development may be influenced by the sex of the embryo under certain culture conditions. The duration of sperm-oocyte interaction and sperm pre-incubation also affect the sex ratio of bovine embryos produced in vitro. It is well documented that in vitro male embryos reach the more advanced stages earlier than do their female counterparts. Selection of developmentally more advanced embryos in anticipation that they have a greater developmental capacity may be one of the underlying causes of the disproportionate number of males among offspring born after transfer of in vitro-produced embryos. The aim of the present study is to test whether a pre-incubation of sperm before IVF might improve the developmental rates and also influence the sex ratio of the resulting embryos. Bovine cumulus-oocyte complexes were recovered from abattoir-derived ovaries by the slicing method. After 24h of maturation, fertilization was realised using a standard protocol. Prior to IVF, sperm cells from 2 different bulls were treated as follows: sperm within group A were pre-incubated in IVF medium for one hour. This step was omitted for sperm in group B (control). After 19h of co-culture of COC and sperm, presumptive zygotes were cultured in SOFaa for a period of 7 days. Cleavage and developmental rates were recorded at Day 3 and 7 (Day 0=IVF). Day 7 blastocysts from all groups were sexed using bovine and Y chromosome-specific primers. Data were analysed by ANOVA. As shown in Table 1, sperm pre-incubation did not affect the cleavage and developmental rates for the individual bull (P>0.05). On average, at Day 7 of development a higher number of blastocysts was determined when embryos had been produced from pre-incubated sperm (P ≤ 0.05). This held true for both bulls. The shift in favour of male embryos was detectable in all groups of embryos, with a drastic one for bull 1 after sperm pre-incubation. In conclusion, sperm pre-incubation accelerated embryo development and possibly enhanced the proportion of male embryos, which was already shifted toward males. Table 1.Developmental rates, developmental kinetics and sex ratio of embryos after sperm pre-incubation before IVF (mean±standard deviation)

SULFATION PATHWAYS: Formation and hydrolysis of sulfonated estrogens in the porcine testis and epididymis

Boars exhibit high concentrations of sulfonated estrogens (SE) mainly originating from the testicular-epididymal compartment. Intriguingly, in porcine Leydig cells, sulfonation of estrogens is colocalized with aromatase and steroid sulfatase (STS), indicating that de novo synthesis of unconjugated estrogens (UE), their sulfonation and hydrolysis of SE occur within the same cell type. So far in boars no plausible concept concerning the role of SE has been put forward. To obtain new information on SE formation and hydrolysis, the porcine testicular-epididymal compartment was screened for the expression of the estrogen-specific sulfotransferase SULT1E1 and STS applying real-time RT-qPCR, Western blot and immunohistochemistry. The epididymal head was identified as the major site of SULT1E1 expression, whereas in the testis, it was virtually undetectable. However, SE tissue concentrations are clearly consistent with the testis as the predominant site of estrogen sulfonation. Results from measurements of estrogen sulfotransferase activity indicate that in the epididymis, SULT1E1 is the relevant enzyme, whereas in the testis, estrogens are sulfonated by a different sulfotransferase with a considerably lower affinity. STS expression and activity was high in the testis (Leydig cells, rete testis epithelium) but also present throughout the epididymis. In the epididymis, SULT1E1 and STS were colocalized in the ductal epithelium, and there was evidence for their apocrine secretion into the ductal lumen. The results suggest that in porcine Leydig cells, SE may be produced as a reservoir to support the levels of bioactive UE via the sulfatase pathway during periods of low activity of the pulsatile testicular steroidogenesis.

SULFATION PATHWAYS: Expression of SULT2A1, SULT2B1 and HSD3B1 in the porcine testis and epididymis

In the porcine testis, in addition to estrogen sulfates, the formation of numerous sulfonated neutral hydroxysteroids has been observed. However, their functions and the underlying synthetic pathways are still widely unclear. To obtain further information on their formation in postpubertal boars, the expression of sulfotransferases considered relevant for neutral hydroxysteroids (SULT2A1, SULT2B1) was investigated in the testis and defined segments of the epididymis applying real-time RT-qPCR, Western blot and immunohistochemistry (IHC). Sulfotransferase activities were assessed in tissue homogenates or cytosolic preparations applying dehydroepiandrosterone and pregnenolone as substrates. A high SULT2A1 expression was confirmed in the testis and localized in Leydig cells by IHC. In the epididymis, SULT2A1 expression was virtually confined to the body. SULT2B1 expression was absent or low in the testis but increased significantly along the epididymis. Immunohistochemical observations indicate that both enzymes are secreted into the ductal lumen via an apocrine mechanism. The results from the characterization of expression patterns and activity measurements suggest that SULT2A1 is the prevailing enzyme for the sulfonation of hydroxysteroids in the testis, whereas SULT2B1 may catalyze the formation of sterol sulfates in the epididymis. In order to obtain information on the overall steroidogenic capacity of the porcine epididymis, the expression of important steroidogenic enzymes (CYP11A1, CYP17A1, CYP19, HSD3B1, HSD17B3, SRD5A2) was monitored in the defined epididymal segments applying real-time RT-qPCR. Surprisingly, in addition to a high expression of SRD5A2 in the epididymal head, a substantial expression of HSD3B1 was detected, which increased along the organ.

[Lutetium-177-PSMA radioligand therapy : Consensus within the framework of GKV-funded care between the university hospitals in Aachen, Bonn, Düsseldorf, Essen, and Cologne and the MDK Nordrhein]

In the last 3 years, Lutetium-177 prostate-specific membrane antigen radioligand therapy (Lu-177-PSMA-RLT) has received increasing attention in nuclear medicine as a new form of treatment for castration-resistant metastatic prostate cancer. This therapy combines the radionuclide Lutetium-177, which has been therapeutically used in nuclear medicine for many years, with a molecular target of the transmembrane prostate-specific membrane antigen expressed by prostate cancer cells. Since there are no prospective randomized studies on Lu-177-PSMA-RLT and the question of reimbursement has repeatedly been the subject of review by the MDK Nordrhein (Medischenische Dienst der Krankenversicherung), there was a desire because of the increasing number of patients being treated to clarify under which circumstances Lu-177-PSMA-RLT can be reimbursed by German statutory health insurance. The goals of this article are to help treating physicians understand how this new therapy option works, to integrate it in the overall therapy concept for castration-resistant metastatic prostate cancer, and, above all, to use Lu-177-PSMA-RLT-based on the current data-at the right place in the therapy sequence of castration-resistant metastatic prostate cancer.

The oxidized linoleic acid metabolite 12,13-DiHOME mediates thermal hyperalgesia during inflammatory pain

Eicosanoids play a crucial role in inflammatory pain. However, there is very little knowledge about the contribution of oxidized linoleic acid metabolites in inflammatory pain and peripheral sensitization. Here, we identify 12,13-dihydroxy-9Z-octadecenoic acid (12,13-DiHOME), a cytochrome P450-derived linoleic acid metabolite, as crucial mediator of thermal hyperalgesia during inflammatory pain. We found 12,13-DiHOME in increased concentrations in peripheral nervous tissue during acute zymosan- and complete Freund's Adjuvant-induced inflammatory pain. 12,13-DiHOME causes calcium transients in sensory neurons and sensitizes the transient receptor potential vanilloid 1 (TRPV1)-mediated intracellular calcium increases via protein kinase C, subsequently leading to enhanced TRPV1-dependent CGRP-release from sensory neurons. Peripheral injection of 12,13-DiHOME in vivo causes TRPV1-dependent thermal pain hypersensitivity. Finally, application of the soluble epoxide hydrolase (sEH)-inhibitor TPPU reduces 12,13-DiHOME concentrations in nervous tissue and reduces zymosan- and CFA-induced thermal hyperalgesia in vivo. In conclusion, we identify a novel role for the lipid mediator 12,13-DiHOME in mediating thermal hyperalgesia during inflammatory pain and propose a novel mechanism that may explain the antihyperalgesic effects of sEH inhibitors in vivo.

128 NEURONATIN TRANSCRIPT ANALYSES AS MARKER TO CONFIRM SUCCESSFUL FERTILIZATION IN BOVINE BLASTOCYSTS

In humans, intracytoplasmic sperm injection (ICSI) has become widely applied to overcome infertility. In addition to its clinical usefulness, ICSI is also a valuable research tool for studying fundamental aspects of gamete interaction during fertilization. Oocyte activation is a prerequisite for decondensation of the sperm head and formation of the male pronucleus regardless of whether the spermatozoon enters the oocyte by injection or by fertilization. In several species, the injection procedure itself is sufficient to activate the oocyte. However, the bovine oocyte is rarely activated by the mechanical stimulation of injection alone. Therefore, additional stimuli are required during ICSI, which may also initiate parthenogenetic development. Because blastocyst origin, either via IVF or after parthenogenetic activation, could not be distinguished at the morphological level via microscopic evaluation, the paternal genome needs to be determined, employing a molecular approach. Therefore, the aim of this study was to validate the expression of neuronatin (NNAT) mRNA, a paternally expressed gene, via RT-PCR, to verify whether bovine blastocysts were generated by fertilization or parthenogenesis. Bovine cumulus-oocyte-complexes were recovered from abattoir-derived ovaries by the slicing method. After 24 h of maturation, fertilization was achieved using a standard protocol. Presumptive zygotes were cultured in SOFaa for a period of 8 days. To generate parthenogenetic blastocysts, oocytes were activated, employing the following protocol. After 24 h of maturation, the oocytes were exposed to 5 µM ionomycin for 5 min and were then incubated in 1.9 mM 6-dimethylaminopurine for 4 h. Afterwards, treated oocytes were cultured in SOFaa for 8 days. Blastocysts from both experimental groups (IVF-derived and parthenogenetic) were stored at −80° until analysis. RT-PCR was performed as described previously (Stinshoff et al. 2014 Reprod. Fertil. Dev. 26, 502–510) for 6 embryos stemming from the IVF-group and 3 embryos out of the chemical-activated group. The NNAT mRNA was expressed in 5 blastocysts stemming from the IVF group; one blastocyst did not show NNAT mRNA expression, suggesting that it was derived from parthenogenesis. Conversely, NNAT mRNA could not be detected in all blastocysts derived from chemical activation, indicating that only the maternal genome was present. These results clearly demonstrate that NNAT mRNA expression is a reliable method to prove the paternal participation in early bovine embryo development.

179 DIFFERENT GONADOTROPIN SUPPLEMENTATIONS ALTER mRNA EXPRESSION PATTERN IN BOVINE OOCYTES DURING IN VITRO MATURATION

During final maturation (between LH surge and ovulation) in vivo, a switch from oestradiol to progesterone dominance within the follicle is well described. The aim was to mimic the in vivo situation during in vitro maturation via the supplementation of different gonadotropins. Groups of 30 cumulus-oocyte complex (abattoir-derived ovaries) were matured in TCM 199 plus different gonadotropins (eCG/hCG; FSH/LH, each in 0.05 or 0.01 IU; only FSH 0.05 IU; without gonadotropins) using a standard protocol without oil overlay. In Experiment 1, denuded oocytes were collected at 0 h (immature) and after 24 h of in vitro maturation (IVM; exhibit first polar body). In Experiment 2, oocytes were collected at different time points [0 (immature), 4, 8, 12, 16, 20, and 24 h] after IVM in eCG/hCG-supplemented medium. They were individually stored at −80°C until analyses. Transcripts of developmental competence (BMP15, GDF9, ZAR1), glucose or steroid metabolism (G6PD, STAR), and progesterone receptors (PGR, PGRMC1/2) were examined in individual oocytes via quantitative RT-PCR (n = 5). For statistical analyses, 1-way ANOVA followed by a Tukey test was used. Relative abundance of BMP15 transcripts was significantly lower (P ≤ 0.05) in oocytes of the group matured for 24 h with FSH/LH 0.01 IU, FSH 0.05 IU, and without gonadotropins than in immature oocytes. Relative amount of G6PD and PGRMC2 mRNA was significantly lower (P ≤ 0.05) in mature oocytes of the group with FSH/LH 0.01 IU, FSH 0.05 IU, and without gonadotropins than in immature ones. Relative abundance of GDF9, STAR, and ZAR1 transcripts was significantly lower (P ≤ 0.05) in oocytes of the group with eCG/hCG, FSH/LH 0.01 IU, FSH 0.05 IU, and without gonadotropins compared with immature oocytes. Relative abundance of PGR mRNA was significantly higher (P ≤ 0.05) in mature oocytes of the group with eCG/hCG than in immature oocytes, FSH/LH 0.01IU, FSH 0.05 IU, and without gonadotropins (Experiment 1). Relative amount of GDF9 transcripts was significantly lower (P ≤ 0.05) in mature oocytes collected after 24 h than in immature ones. Relative abundance of PGR mRNA was significantly higher (P ≤ 0.05) in oocytes collected after 20 and 24 h of IVM than in immature ones. Relative amount of ZAR1 transcripts was significantly lower (P ≤ 0.05) in oocytes collected after 16, 20, and 24 h of IVM than in immature oocytes; likewise, they were significantly lower (P ≤ 0.05) in oocytes collected after 12, 16, 20, and 24 h than in oocytes collected after 4 h of IVM. Relative amount of STAR mRNA was significantly lower (P ≤ 0.05) in oocytes collected after 24 h than in immature ones, and significantly lower (P ≤ 0.05) in oocytes collected after 16, 20, and 24 h than in oocytes collected after 4 h of IVM (Experiment 2). The results suggest a down-regulation of most transcripts during the period of IVM with different gonadotropin supplements with exception of PGR. Furthermore, most transcripts follow a timely regulated mRNA expression pattern during the entire IVM period. We gratefully acknowledge the financial support of the German Research Foundation (DFG; FOR 1369, WR 154/3–1).

Profiling of drugs and environmental chemicals for functional impairment of neural crest migration in a novel stem cell-based test battery

Developmental toxicity in vitro assays have hitherto been established as stand-alone systems, based on a limited number of toxicants. Within the embryonic stem cell-based novel alternative tests project, we developed a test battery framework that allows inclusion of any developmental toxicity assay and that explores the responses of such test systems to a wide range of drug-like compounds. We selected 28 compounds, including several biologics (e.g., erythropoietin), classical pharmaceuticals (e.g., roflumilast) and also six environmental toxicants. The chemical, toxicological and clinical data of this screen library were compiled. In order to determine a non-cytotoxic concentration range, cytotoxicity data were obtained for all compounds from HEK293 cells and from murine embryonic stem cells. Moreover, an estimate of relevant exposures was provided by literature data mining. To evaluate feasibility of the suggested test framework, we selected a well-characterized assay that evaluates ‘migration inhibition of neural crest cells.’ Screening at the highest non-cytotoxic concentration resulted in 11 hits (e.g., geldanamycin, abiraterone, gefitinib, chlorpromazine, cyproconazole, arsenite). These were confirmed in concentration–response studies. Subsequent pharmacokinetic modeling indicated that triadimefon exerted its effects at concentrations relevant to the in vivo situation, and also interferon-β and polybrominated diphenyl ether showed effects within the same order of magnitude of concentrations that may be reached in humans. In conclusion, the test battery framework can identify compounds that disturb processes relevant for human development and therefore may represent developmental toxicants. The open structure of the strategy allows rich information to be generated on both the underlying library, and on any contributing assay.

[Impact of implementation strategies on adherence rates to colorectal cancer (CRC) guidelines after polypectomy in a university hospital]

BACKGROUND

Colorectal cancer (CRC) is the second most common malignancy in Germany. Screening colonoscopies with polypectomy have been demonstrated to reduce the incidence of CRC. Detailed recommendations on scheduling screening and follow-up colonoscopies have therefore been included into national guidelines. Knowledge about CRC guidelines and adherence to guideline recommendations varies greatly among physicians.

METHODS

We combined different implementation strategies (training courses, case discussion, handouts, wall charts) to improve adherence of recommendations for scheduling follow-up colonoscopy. To assess adherence, written recommendations given at discharge after inpatient treatment for polypectomy were analysed before (n = 111) and after (n = 83) the implementation of the above-mentioned implementation measures. Additional factors possibly influencing the recommendations of physicians were collected (histology, polyp size).

RESULTS

The adherence to the CRC guideline before implementation of the above-mentioned measures was moderate. After intervention, there was a non-significant increase from 47 % to 53 %. Senior physician review and editing of the discharge summaries improved guideline adherence of recommendations to 69 %. Neither the education level of residents nor their affiliation to a certain department had an impact on the quality of the recommendations. Histology and in particular information on the resection status of the polyps in the pathology report (complete versus incomplete resection) had an influence of the recommended schedule. Furthermore, size of the polyps, but not the number, had a statistically significant influence on the quality of the recommendations.

CONCLUSIONS

The inadequate improvement of guideline adherence can possibly be explained by the insufficient interactive and repetitive character of interventions. As the histology reports seem to have an influence on the recommendations in regards to the interval to the next colonoscopy, interdisciplinary teaching is necessary to improve guideline concurrent care.

[The communication of chronically III patients in an internet chat for aftercare of inpatient psychosomatic treatment]

AIM

E-Health applications open new avenues for seamless care of patients with a chronic disease. This study examines the demand and the usage pattern of an Internet-assisted aftercare group-treatment following inpatient treatment.

METHODS

The analysis uses data from telephone interviews which were conducted 12 months after discharge. 168 study participants of the prospective controlled effectiveness study (73.7%) participated. The frequency and the time of beginning an outpatient psychotherapy are compared between controls and chat participants. Computerized text-analyses of the chat-scripts are used to examine the usage pattern of the chat-aftercare. Statements of the patients with chronic symptoms at the beginning and at the end of their chat participation are quoted for illustration of the contents of the group therapy sessions.

RESULTS

Patients with chronic course of illness utilize the online-based aftercare more frequently and more actively than patients with short durations of illness. Words indicating cognitive processes are used more frequently by chat participant with chronic illness. Chat participants with chronic course of illness who are receiving no additional outpatient psychotherapy, relapse considerably less frequently than controls without any psychotherapeutic support.

CONCLUSION

Patients with chronic course of illness use online aftercare treatment to sustainably improve their health status.

[Contrast enhanced endosonography for improving differential diagnosis between chronic pancreatitis and pancreatic cancer]

BACKGROUND AND OBJECTIVE

The aim of this study was to evaluate contrast-enhanced endosonography as a method for improving the differentiation between chronic focal pancreatitis and ductal pancreatic cancer, based on perfusion characteristics of the microcirculation.

PATIENTS AND METHOD

In 194 patients [75 women, 119 men; age: 64 +/- 11 years] with chronic pancreatitis (n = 73) or pancreatic cancer (n = 121), pancreatic lesions were examined by conventional endoscopic B-mode ultrasound, power Doppler ultrasound and contrast-enhanced power mode, using the following criteria for malignant lesions: no detectable vascularization with conventional power Doppler scanning, irregular appearance of arterial vessels over a short distance using contrast-enhanced technique and no detection of venous vessels inside the lesion. A malignant lesion was assumed to be present if all criteria were detectable. The criteria of chronic pancreatitis without neoplasia were defined as no detectable vascularization before injection, regular appearance of vessels over a distance of at least 20 mm after injection of the contrast medium and detection of arterial and venous vessels. The gold standard was the histological diagnosis by endoscopic ultrasound (EUS)-guided fine needle aspiration cytology or operation.

RESULTS

Using conventional EUS the diagnosis was correct in 96 of 121 patients with pancreatic cancer (sensitivity 79.3 %; 95% confindence interval 71 - 85.2%) and in 60 of 73 patients with chronic pancreatitis (specificity 82.2 % [71.5 - 90.2%]). Using contrast-enhanced EUS malignant pancreatic lesions were correctly diagnosed in 111 of 121 patients, thus increasing sensitivity to 91.7 % (85.3 - 96%). In 70 of 73 patients chronic inflammatory pancreatitis was correctly diagnosed (specificity 95.9 % [88.5 - 99,1%]) .

CONCLUSION

Contrast-enhanced endoscopic ultrasound improves the differentiation between chronic pancreatitis and pancreatic carcinoma.

[The situation of patients with dementia may be rectified by Ginkgo biloba. Results of a health services research study concerning the ability of patients with dementia, quality of life of the nursing family members and total treatment costs]

BACKGROUND AND ISSSUES: Ginkgo biloba-extracts are often used in therapy of patients with dementia. In this study, benefit and structure of Ginkgo biloba-extract EGb 761 in treatment of patients with dementia was examined.

PATIENTS AND METHODS

For the assessment of quality of life of care-taking relatives and patients as well as treatment costs were documented. The study was conducted as a non-randomised, two-armed cohort study with an open design for 683 slightly or moderately demented patients, aged between 65 and 80 years. Society's perspective was taken. Barthel-Index and MMST were also documented. Because of significant differences at inclusion of both cohorts, a matched-pairs-analysis and multiple regression analysis conducted.

RESULTS

According to PLC a significant improvement in quality-of-life of care-taking relatives (p < 0.001) and patients (positive mood p = 0.018, negative mood p < 0.001) was only observed in the Ginkgo-cohort. Also Barthel-Index indicated an improvement in the Ginkgo-cohort (p < or = 0,001). MMST-scores increased significantly only in the Ginkgo-cohort (p < 0.001). Average total cost per patient amounted to 3.614,75 euro in the standard-cohort, whereas these costs per patient in the Ginkgo-cohort amounted to 3.031,78 euro (p = 0.067). Results were confirmed by matched-pairs-analysis.

RESULTS

Ginkgo treatment has a valid place in caretaking structure of health services. Gingko attributes to a higher quality of life for both care-takers and patients, the progression of disease is slowed down and treatment costs are lower.

Orthodontic space closure without contralateral extraction through mesial movement of lower molars in patients with aplastic lower second premolars

METHOD AND PATIENTS

A method is presented that allows unilateral space closure in patients with aplastic lower second premolars. Based on a straight-wire appliance, space closure was achieved with a combination of "push mechanics" using the second molar as an anchorage unit and Class II "pull mechanics", thus avoiding the application of any distalizing force on the lower incisors. The results from 13 consecutively treated subjects (five boys, eight girls, mean age 12 years and 6 months) were analyzed.

RESULTS

Complete bodily space closure was achieved in all 13 cases within a mean treatment time of 2 years and 7 months. The desired Angle Class III molar relationship of one premolar width (+/- 1/4 premolar width) on the aplastic side was successful in eleven patients, an additional 4.7 mm of space being created for the third molar on the aplastic side compared with the contralateral side (p < or = 0.01). However, adverse effects could be kept to a minimum, with no method-dependent side effects being recorded with regard to canine and molar relationships on the contralateral side, or to overbite, overjet, or upper and lower incisor inclination. The mean lower midline shift of 0.8 mm was in accordance with the mean distal canine relationship of 1/3 premolar width on the aplastic side.

CONCLUSION

These results confirm that orthodontic space closure in cases of unilateral aplastic lower second premolars can be performed successfully with the presented treatment method without the need for additional premolar extractions, prosthodontic treatment or implants. Furthermore, the prognosis for the lower wisdom tooth on the aplastic side is improved.

Serologic examination of hepatitis B infection and immunization in HIV-positive youth and associated risks. The Pediatric AIDS Clinical Trials Group Protocol 220 Team

This seroprevalence report examines serologic evidence of hepatitis B immunization or infection and associated demographic/behavioral factors in adolescent (aged 12-20) subjects enrolled in a nontherapeutic clinical trial at 43 Pediatric AIDS Clinical Trials Group (PACTG) clinical centers. Subjects (n = 94) infected with the human immunodeficiency virus (HIV) through sexual activity were categorized as hepatitis B virus (HBV)-immunized, HBV-infected, or nonimmune by hepatitis B serology performed on specimens collected within the subject's first 48 weeks on study (1993-1995). Sixteen percent of the 94 serologically classified subjects were immunized; 19% HBV-infected; 65% nonimmune. Of the three risk factor scores examined (sociodemographic, sexual, and substance abuse), substance use alone demonstrated a significant difference among groups (despite virtually no reported injecting drug behavior), with the sexual risk score exhibiting marginally significant differences. Logistic regression analysis (restricted to nonimmunized subjects) showed that male-male sexual activity raised the odds of HBV infection by a factor of 5.14 (95% confidence interval [CI]: 1.45-18. 23) relative to heterosexual activity; and that for every one point increase on the substance abuse risk scale the odds of infection increased 5% (95% CI: 0.99-1.10). The HBV infection rate in PACTG 220 HIV-positive females is twice United States population-based rates; the rate in PACTG 220 HIV-positive males is nearly seven times higher. Past immunization efforts in this population appear to have been based on sexual activity volume without regard to injecting-drug use in sex partners.

Methods for diagnosing onychomycosis: a comparative study and review of the literature

OBJECTIVE

To identify the sensitivity of several readily available diagnostic tests for onychomycosis.

DESIGN

Cross-sectional study.

SETTING

Dermatology and podiatry departments at a teaching hospital.

PATIENTS

Sixty-three adult men and women with a clinical examination highly suggestive of onychomycosis.

MAIN OUTCOME MEASURES

Sensitivity of each test and of several test combinations.

RESULTS

Nail samples underwent 6 diagnostic tests. Routine histopathologic examination with periodic acid-Schiff stain (PAS) (PATHPAS) was 85% sensitive. Sensitivities for potassium hydroxide dissolution and centrifugation combined with PAS, fluorescent brightener, or chlorazol black E were 57%, 53%, and 53%, respectively. Culture on Sabouraud agar withchloramphenicol and cycloheximide (Mycosel agar) was 32% sensitive; on Littman-oxgall agar, 23% sensitive. The most sensitive combination of tests, both culture methods plus PATHPAS, was 94% sensitive (not statistically different from the sensitivity of PATHPAS alone [P = .26]).

CONCLUSIONS

When onychomycosis is suspected clinically, PATHPAS of the nail is the single most sensitive of the diagnostic tests we evaluated. Because it is quickly performed and relatively operator independent, PATHPAS is practical for clinical and research purposes. Further study is needed to determine if sensitivity may be enhanced by combining PATHPAS with cultures obtained by several collection methods (clipping, curettage, and shaving). Such combinations may serve as sensitive and efficient strategies for diagnosing onychomycosis.

Single-dose pharmacokinetics and safety of the oral antiviral compound adefovir dipivoxil in children infected with human immunodeficiency virus type 1. The Pediatrics AIDS Clinical Trials Group

The acyclic phosphonate analog adefovir is a potent inhibitor of retroviruses, including human immunodeficiency virus (HIV) type 1, and, unlike some antiviral nucleosides, does not require the initial phosphorylation step for its activity. Two oral dosages of the adefovir prodrug adefovir dipivoxil were evaluated in a phase I study with children with HIV infection. A total of 14 patients were stratified into age groups ranging from 6 months to 18 years of age. Eight patients received 1.5 mg of adefovir dipivoxil per kg of body weight, and six patients received 3.0 mg of adefovir dipivoxil per kg. Serum samples were obtained at intervals during the 8 h postdosing and were analyzed for adefovir concentrations. Patients were monitored for adverse effects. All samples collected resulted in quantifiable levels of adefovir (lower limit of quantitation, 25 ng/ml) from each patient. The areas under the concentration-versus-time curves (AUCs) were similar (P = 0.85) for the 1.5- and 3.0-mg/kg doses, while the apparent oral clearance (CL/F) was significantly higher (P = 0.05) for the 3-mg/kg dose. Pharmacokinetic parameters differed by patient age. In comparing those children older and younger than the median age of 5.1 years, AUC (P = 0.03), maximum concentration of drug in serum (P = 0.004), and the concentration at 8 h postdosing (P = 0.02) were significantly lower for the younger children. There were no significant differences for apparent volume of distribution and CL/F normalized to body surface area, but there was a suggestive difference in half-life (P = 0.07) among the subjects in the older and younger age groups. No significant adverse events were encountered. These data provide the basis for a multidose phase II study of adefovir dipivoxil in HIV-infected infants and children.

Methods for improved detection of oxacillin resistance in coagulase-negative staphylococci: results of a multicenter study

A multilaboratory study was undertaken to determine the accuracy of the current National Committee for Clinical Laboratory Standards (NCCLS) oxacillin breakpoints for broth microdilution and disk diffusion testing of coagulase-negative staphylococci (CoNS) by using a PCR assay for mecA as the reference method. Fifty well-characterized strains of CoNS were tested for oxacillin susceptibility by the NCCLS broth microdilution and disk diffusion procedures in 11 laboratories. In addition, organisms were inoculated onto a pair of commercially prepared oxacillin agar screen plates containing 6 microg of oxacillin per ml and 4% NaCl. The results of this study and of several other published reports suggest that, in order to reliably detect the presence of resistance mediated by mecA, the oxacillin MIC breakpoint for defining resistance in CoNS should be lowered from >/=4 to >/=0.5 microg/ml and the breakpoint for susceptibility should be lowered from </=2 to </=0.25 microg/ml. In addition, a single disk diffusion breakpoint of </=17 mm for resistance and >/=18 mm for susceptibility is suggested. Due to the poor sensitivity of the oxacillin agar screen plate for predicting resistance in this study, this test can no longer be recommended for use with CoNS. The proposed interpretive criteria for testing CoNS have been adopted by the NCCLS.

Systematic decalcification prophylaxis during treatment with fixed appliances

In a practical setting, 4 different prophylactic methods were compared with regard to their effects on the incidence of decalcification during orthodontic fixed appliance therapy and on the frequency of premature debonding resulting from imminent or already manifest decalcification. This study showed that the use of a system in which selection and care were oriented solely along the clinical impression was associated with the highest rate of decalcification and premature debonding. The findings were significantly better (p < 0.05), when a prophylactic regimen of oral hygiene was implemented which was based on patient selection (API < 30%) and regular oral hygiene check-ups during the treatment. When the DMFT index was considered in addition to the API value, and the number of the initial lesions at the beginning of treatment were included for selecting patients, the incidence of decalcification was significantly reduced even further (p < 0.05). A more comprehensive or "optimized prophylaxis" utilizing saliva test parameters and active prophylactic interventions implemented by a dental hygienist during the treatment phase also had a favorable impact on the main outcome parameters. The present findings indicate that decalcification can be markedly reduced by using a treatment regimen that targets the decalcification risk and a systematic, individualized prophylaxis during active treatment with fixed appliances.

The emergence of decreased susceptibility to vancomycin in Staphylococcus epidermidis

BACKGROUND

Coagulase-negative staphylococci (CNS) are the major cause of nosocomial bloodstream infection. Emergence of vancomycin resistance among CNS is a serious public health concern, because CNS usually are multidrug-resistant, and glycopeptide antibiotics, among which only vancomycin is available in the United States, are the only remaining effective therapy. In this report, we describe the first bloodstream infection in the United States associated with a Staphylococcus epidermidis strain with decreased susceptibility to vancomycin.

METHODS

We reviewed the hospital's microbiology records for all CNS strains, reviewed the patient's medical and laboratory records, and obtained all available CNS isolates with decreased susceptibility to vancomycin. Blood cultures were processed and CNS isolates identified by using standard methods; antimicrobial susceptibility was determined by using minimum inhibitory concentration (MIC) and disk-diffusion methods. Nares cultures were obtained from exposed healthcare workers (HCWs) to identify possible colonization by CNS with decreased susceptibility to vancomycin.

RESULTS

The bloodstream infection by an S. epidermidis strain with decreased susceptibility to vancomycin occurred in a 49-year-old woman with carcinoma. She had two blood cultures positive for CNS; both isolates were S. epidermidis. Although susceptible to vancomycin by the disk-diffusion method (16-17 mm), the isolates were intermediate by MIC (8-6 microg/mL). The patient had received an extended course of vancomycin therapy; she died of her underlying disease. No HCW was colonized by CNS with decreased susceptibility to vancomycin.

CONCLUSIONS

This is the first report in the United States of bloodstream infection due to S. epidermidis with decreased susceptibility to vancomycin. Contact precautions likely played a role in preventing nosocomial transmission of this strain, and disk-diffusion methods may be inadequate to detect CNS with decreased susceptibility to vancomycin.

Attempting to enhance the enrollment of adolescents into AIDS clinical trials: the design of ACTG Protocol 220

The epidemic of HIV infection continues to grow in adolescents and young adults. Unfortunately, because treatment regimens have been developed based on data derived from clinical trials, little data are available on adolescents because they are infrequently included in these trials. In an effort to facilitate the enrollment of more adolescents into AIDS Clinical Trials Group (ACTG) clinical trials, we designed a nontreatment protocol to familiarize adolescents with clinical trials requirements. Two hundred fifty-six adolescents (150 females, 106 males) between the ages of 13 and 21 years were enrolled at 43 different clinical trials sites throughout the United States. The majority of patients (50%) were enrolled at sites that had specific programs for adolescents. Most of the young women (85%) had acquired their infection via heterosexual transmission, whereas the largest transmission categories in men were blood or factor transfusions (43%) or same-sex contact (34%). Admission CD4 counts were lower in males (mean = 396 cells/mm3) than in females (mean = 513 cells/mm3) (p = 0.01). Psychosocial profiles revealed a variety of ongoing risk behaviors in HIV-infected adolescents. Two years into the study, 223 patients are still being observed. We conclude that adolescents can be enrolled in an observational protocol. The success of this trial will be determined by how many ACTG Protocol 220 participants are ultimately enrolled in therapeutic trials.

[Intravenous immunoglobulins (IVIG) in treatment of an antiphospholipid syndrome in pregnancy]

A patient with a history of early onset preeclampsia and repeated fetal death, high titer IgG anticardiolopin antibodies and prolonged aPTT was treated during her third pregnancy with intravenous immunoglobulins (IVIG) from the seventh month of pregnancy onwards. Every month--after a loading dose of 30 g immunoglobulins--a daily infusion of 3 g immunoglobulin was for three days was given during six consecutive cycles. The patients pregnancy ended preterm with a life birth, delivered by cesarean section, because of a severe preeclampsia. The 1600 g weighing boy was in good health. Each treatment with IVIG resulted in a reduction of anticardiolipin-antibodies. During the seventh months observation period, a gradual increase in PAI activity/factor VIIIR:Ag was found. A partial transient reduction of antiphospholipid-antibody levels was observed immediately following each treatment course resulting in an accelerated fetal outcome.

Antidepressant efficacy and cardiovascular safety of venlafaxine in young vs old patients with comorbid medical disorders

OBJECTIVE

To determine whether venlafaxine exerts a differential effect on blood pressure in young versus old depressed patients.

METHOD

We compared thirty-four consecutive patients treated with 50-250 mg/day venlafaxine for major depressive disorder or another major mood disorder at our medical college's ambulatory neuropsychiatry program. We obtained baseline and follow-up blood pressure measurements. Each patient also received a baseline and final Clinical Global Impressions (CGI) score; global improvement was determined by consensus of two clinicians.

RESULTS

Sixteen nongeriatric patients (age, 13 to 56 years) were compared with eighteen elderly patients (age, 65 to 86 years). Most patients (88%) had serious medical comorbidities or histories. Despite a higher mean daily venlafaxine dosage for patients in the young group, no significant changes in systolic blood pressure were noted in either group. For the older group, we found a non-statistically significant 4.7 mm Hg mean increase in diastolic blood pressure. No patient became hypertensive. We also found a negative correlation between baseline diastolic blood pressure and change in diastolic blood pressure during treatment with venlafaxine. This inverse relationship was statistically significant in the older patients.

CONCLUSIONS

Venlafaxine was not associated with significant, sustained changes in blood pressure in any patient receiving dosages of 50-250 mg/day. Minimal changes in diastolic blood pressure were no more likely to occur in older venlafaxine-treated patients than in younger ones. Higher baseline diastolic blood pressure in older patients, but not in younger ones, seemed to protect against diastolic adrenergic blood pressure effects of venlafaxine.

Evaluation of pharmacokinetics, safety, tolerance, and activity of combination of zalcitabine and zidovudine in stable, zidovudine-treated pediatric patients with human immunodeficiency virus infection. AIDS Clinical Trials Group Protocol 190 Team

A double-blind phase II trial compared zalcitabine (0.03 mg/kg/day) in combination with zidovudine (720 mg/m2/day) and zidovudine monotherapy in 250 clinically stable, previously zidovudine-treated, human immunodeficiency virus-infected children. The combination was well-tolerated except for an increased incidence of neutropenia (14%) compared with that in children receiving monotherapy (5%). No differences were noted for time to first AIDS-defining illness or death, neuropsychologic status, or weight Z scores. In patients in the combination arm, the CD4 cell count decline was slower (13% per year) than in patients receiving monotherapy (25% per year) (P = .03), and quantitative peripheral blood mononuclear cell virus load remained lower at all time points (P = .08). Deaths were fewer in patients receiving combination therapy (4) compared with those in patients receiving monotherapy (10) (P = .083). Thus, administration of zidovudine with zalcitabine to children with prior zidovudine treatment did not result in a significant increase in toxicity compared with that resulting from zidovudine monotherapy and demonstrated improvement in immunologic and virologic surrogate markers.

Generation of progenitor-cell precursors in long-term bone-marrow cultures after marrow purging with ether lipids

Alkyl-lysophospholipid derivates (ALP) are currently being tested as bone marrow (BM) purging agents prior to autologous BM transplantation in different malignancies. We evaluated the toxicity of the ALP ET-18-OCH3 (ET-18; Edelfosine, 1-0-octadecyl-2-0-methyl-rac-glycero-3-phosphocholine) towards early hematopoietic precursors by testing progenitor regeneration of non-purged and ET-18-purged BM (75 mu g and 125 mu g ET-18/ml/2x10(7) BM cells) in autologous long-term bone marrow cultures (LTBMC) from 3 different patients in complete remission. LTBMC feeder layers were irradiated with 875 rad for complete elimination of hematopoietic progenitors and recharged with cryopreserved purged and non-purged BM. In weekly intervals, adherent layer and supernatant LTBMC cells were completely removed and evaluated in colony forming unit (CFU)-assays. We have seen sufficient CFU-regeneration out of ET-18-purged BM up to 8 weeks of LTBMC (>40 CFU/flask). Total CFU-counts from LTBMC with purged BM were slightly reduced compared to non-purged control. High dose purging with 125 mu g ET-18/ml partly inhibited initial CFU-proliferation, but demonstrated elevated CFU-counts after 4 and 8 weeks of LTBMC compared to control. In conclusion, in our LTBMC series ET-18-purging yielded tolerable toxicity towards committed BM-progenitors, but no remarkable decline of early hematopoietic precursors regenerating CFU-progenitors for up to 8 weeks of culture.

Tuberculosis in human immunodeficiency virus-exposed or -infected United States children

This study was designed to provide a preliminary assessment of the occurrence of tuberculosis exposure, infection and disease within a national sample of infants and children with human immunodeficiency virus (HIV) exposure or infection, and to determine the prevalence of Mycobacterium tuberculosis isolates resistant both to isoniazid and rifampin in these patients or their adult source contacts. A retrospective questionnaire survey was conducted of infants and children with HIV exposure or infection evaluated by pediatric HIV referral centers in the United States comprising the pediatric units or subunits of the Pediatric Acquired Immunodeficiency Syndrome Clinical Trials Group (PACTG). Seventy of 72 sites during a mean period of 5 (range, 1 to 12) years participated in this study and had provided care for 14,038 patients. There were 75 cumulative total cases of tuberculosis disease seen since each site was established. Therapy for asymptomatic infection was given to another 40 children and for tuberculosis exposure to 71 children. Annualized case rates were 478/100,000 for sites established in 1990 to 1992, 117/100,000 for 1988 to 1989, 63/100,000 for 1986 to 1987 and 58/100,000 for 1981 to 1985 (P = 0.05, Spearman's p test for trend). By comparison, the 1992 age-specific tuberculosis case rate for all U.S. children < 5 years was 5.5/100,000. Twenty percent of isolates from PACTG patients and 15% of isolates from adult source contacts were resistant to isoniazid and rifampin.(ABSTRACT TRUNCATED AT 250 WORDS)

The clinical effects and cost-avoidance of a change in perioperative bronchodilator use

The clinical effects and financial impact of a change in prescribing habits from routine to occasional use of perioperative bronchodilators, following the presentation of drug information, were assessed retrospectively by comparing the outcomes of patients admitted for major thoracic surgery. Eighteen of 24 (75%) patients in Period A (prior to change) received salbutamol bronchodilator therapy versus 10 of 17 (59%) in Period B (following the change) (p = .448). Of the patients who did receive salbutamol aerosols, the mean dose in grams per patient was greater in Period A than in Period B (6.85 +/- 5.96 vs. 2.64 +/- 4.44 respectively p < 0.05). Two patients from Period A and one from Period B were receiving digoxin prior to admission. In the remaining patients, 5 of 22 (23%) in Period A and 1 of 16 (6%) in Period B developed atrial fibrillation requiring digoxin (p = .36). The proportion of patients with obstructive airways disease (OAD) who developed an arrhythmia was not different between the two groups. However, in those patients without OAD an arrhythmia was reported in 9 of 16 patients (56%) receiving salbutamol, versus only 1 of 11 (9%) of those not receiving it (p = 0.032). The number of days patients were hospitalized during Period A and Period B were 10.2 +/- 4.97 and 9.4 +/- 3.68 respectively (p = 0.85). A potential average cost-avoidance of $68.46 per patient could be realized with this new practice. We conclude that a change in prescribing habits had no adverse clinical outcome and resulted in a considerable cost-avoidance.

[Mucinous cystadenomas and cystadenocarcinomas of the pancreas--the pancreaticoscopy as a new device for endoscopic and histological diagnosis]

Recent advances in diagnostic imaging procedures offer the opportunity for detection of rare cystic neoplasms of the pancreas. Cystadenomas of the pancreas have been reported to represent 10% of cystic pancreatic lesions. Serous microcystic cystadenoma, megacystic mucinous and duct-ectatic mucinous cystadenoma were distinguished. While the serous cystadenoma is benign, in general the megacystic and the duct-ectatic mucinous cystadenoma have a significant malignant potential. With pancreatoscopy, a rather new endoscopic technique, five cases of mucinous megacystic cystadenoma were diagnosed preoperatively by macroscopic and microscopic means. In one case, development of malignant neoplasm was diagnosed, one patient did not undergo surgery because of her age. Three patients were operated (total pancreatectomy in one case, duodeno-hemipancreatectomy in two cases) and are without any further signs of recurrence and free of symptoms in a one year to four year clinical follow-up.

Lovastatin increases arachidonic acid levels and stimulates thromboxane synthesis in human liver and monocytic cell lines

The effect of lovastatin (LOV), the inhibitor of 3-hydroxy-3-methyl-glutaryl coenzyme A reductase, on linoleic acid (LA, 18:2n-6) metabolism was examined in human monocytic Mono Mac 6 (MM6) and hepatoma Hep G2 cells. The desaturation of LA was examined after LOV (72 h, 10 microM) or dimethylsulfoxide (LOV carrier, < 0.1%) and [14C]LA (last 18 h, 0.3 microCi, 5 microM). In both cell lines, LOV reduced the percentage of 14C label associated with LA and increased the percentage of label in the 20:4n-6 and the 22:5n-6 fractions. In Hep G2 but not MM6 cells, this effect was fully reversible by means of coincubation with mevalonic acid (500 microM), but not with cholesterol or lipoproteins. In both cell lines, the LOV-mediated increase in LA desaturation resulted in dose-dependent reductions of LA and elevations of AA in cellular phospholipids. The lipids secreted by LOV-treated Hep G2 cells were also enriched in arachidonic acid (AA). In the MM6 cells, LOV increased release of thromboxane upon stimulation with the calcium ionophore A23187. In summary, our findings of higher LA desaturation and AA enrichment of lipids secreted by the Hep G2 cells suggest that LOV treatment may increase the delivery of AA from the liver to extrahepatic tissues. The changes in membrane fatty acid composition can influence a variety of cellular functions, such as eicosanoid synthesis in monocytic cells. The mechanism appears to be related to the reduced availability of intermediates of cholesterogenesis.

Crystal and molecular structures of beta-cellobiosylnitromethane and of beta-maltosylnitromethane heptaacetate

The structures of the title compounds have been determined by X-ray crystallography, using direct methods, and have been refined to conventional final residual factors of R = 0.063 and R = 0.046, respectively.

Correlations between the loss of acoustic TMJ symptoms and alterations in mandibular mobility after surgical mandibular advancement

A longitudinal clinical-axiographic study including 10 patients who had undergone surgical mandibular advancement to correct a dental and skeletal Class II anomaly, produced evidence of correlations between alterations of acoustic symptoms and of mandibular mobility. In 7 of 11 movements, where TMJ-sounds disappeared, post-operative mandibular mobility was reduced to such a degree that the point at which the acoustic symptom originated pre-operatively could no longer be attained. On the other hand, in all cases, where TMJ sounds remained uninfluenced by the surgical intervention, reductions in mobility occurred only beyond this point. Even the persistence of losses of TMJ sounds during the further post-operative follow-up period could, in the majority of cases (4 of 7) be well explained by the persistence of mobility restriction. Accordingly, in the future a differentiation between mobility- and non-mobility-dependent alterations of TMJ symptoms should be made.

[Temporomandibular joint function after orthognathic surgery--the individual factors]

Case studies presented in the literature present evidence that individual factors may influence mandibular mobility unfavorably after mandibular advancement osteotomies. These factors are, respectively: high preoperative dysfunction index, preoperative articular pain in movement, preoperative reciprocal clicking, advanced patient age, and significant overjet reduction. This study identifies these individual factors, which can influence postoperative functional condition, and documents conclusively the importance of individual, function oriented preoperative planning in orthognathic surgery. Taken together these factors indicate that the adaptation ability of the effected tissue should be given greater attention in planning the operation.