Papain-Based Solubilization of Decellularized Extracellular Matrix for the Preparation of Bioactive, Thermosensitive Pregels

Solubilized, gel-forming decellularized extracellular matrix (dECM) is used in a wide range of basic and translational research and due to its inherent bioactivity can promote structural and functional tissue remodeling. The animal-derived protease pepsin has become the standard proteolytic enzyme for the solubilization of almost all types of collagen-based dECM. In this study, pepsin was compared with papain, α-amylase, and collagenase for their potential to solubilize porcine liver dECM. Maximum preservation of bioactive components and native dECM properties was used as a decisive criterion for further application of the enzymes, with emphasis on minimal destruction of the protein structure and maintained capacity for physical thermogelation at neutral pH. The solubilized dECM digests, and/or their physically gelled hydrogels were characterized for their rheological properties, gelation kinetics, GAG content, proteomic composition, and growth factor profile. This study highlights papain as a plant-derived enzyme that can serve as a cost-effective alternative to animal-derived pepsin for the efficient solubilization of dECM. The resulting homogeneous papain-digested dECM preserved its thermally triggered gelation properties similar to pepsin digests, and the corresponding dECM hydrogels demonstrated their enhanced bioadhesiveness in single-cell force spectroscopy experiments with fibroblasts. The viability and proliferation of human HepaRG cells on dECM gels were similar to those on pure rat tail collagen type I gels. Papain is not only highly effective and economically attractive for dECM solubilization but also particularly interesting when digesting human-tissue-derived dECM for regenerative applications, where animal-derived materials are to be avoided.

Immune Regulatory 1 Cells: A Novel and Potent Subset of Human T Regulatory Cells

A subset of T regulatory cells (Tregs), identified by TIRC7 (T cell immune response cDNA 7) expression is designated as Immune Regulatory 1 Cells (IR1 cells). TIRC7 is an immune checkpoint inhibitor, co-localized with the T- cell receptor, HLA-DR and CTLA-4 during T-cell activation, which delivers regulatory signals via binding to its ligand, HLA-DR α2 domain. IR1 cells express FOXP3, and multiple other markers associated with immune suppression. They constitute as much as 10% of Tregs. IR1 cells strongly inhibit proliferation in mixed lymphocyte reactions, where they express high levels of IL-10. Ex vivo expansion of Tregs over 2 weeks in the presence of an agonist TIRC7 antibody disproportionately expands the IR1 Treg subset, while maintaining high expression of suppressive markers including CD39, IL-10, LAP and GARP. Ex vivo expanded IR1 cells are a potent, homogeneous, stable set of suppressor Tregs with the potential to modulate immune dysregulation. The characteristics of IR1 cells suggest a therapeutic advantage over polyclonal Tregs for therapeutic interventions. Early restoration of immune homeostasis using IR1 cells has the potential to fundamentally alter the natural history of conditions characterized by abnormalities in the T regulatory cell compartment.

Ischemic-Type Biliary Lesions After Liver Transplant: Factors Causing Early-Onset Versus Late-Onset Disease

OBJECTIVES

Biliary complications such as an ischemic-type biliary lesion can increase morbidity and mortality after liver transplant. Former studies have investigated several risk factors, but the underlying pathomechanism remains unclear. The focus of this study was to investigate factors causing early-onset (< 12 mo after liver transplant) versus late-onset ischemic-type biliary lesions (> 12 mo after liver transplant).

MATERIALS AND METHODS

This retrospective study included 641 patients. Patients were grouped to those who developed ischemic-type biliary lesion and those who did not. Patients developing ischemic-type biliary lesions were further subgrouped into those diagnosed early (< 12 mo) and late (> 12 mo) after liver transplant. We analyzed demographic data, characteristics, and comorbidities of the recipients and donors, operative variables, and postoperative course, as well as laboratory values.

RESULTS

The incidence of ischemic-type biliary lesions was 4.9%. Retransplant was performed more frequently in patients developing ischemic-type biliary lesions. The number of transfusions of blood products was higher in ischemic-type biliary lesion patients, especially in the early-onset ischemic-type biliary lesion group. Bilirubin levels were higher in patients with ischemic-type biliary lesions starting from day 7 after the operation, particularly in the early-onset group. Survival tended to be best in the late-onset ischemic-type biliary lesion group; however, this difference was not significant.

CONCLUSIONS

This study serves as a supplement to current data and the understanding of ischemic-type biliary lesions with emphasis on the relevance of disease onset and causes. We could in fact determine transfusion of blood products as a determinant of an early onset of ischemic-type biliary lesion. Bilirubin could be a surrogate marker for ischemic-type biliary lesions, especially in its early-onset form.

How I Do It: New Dissector Device Allows for Effective Operative Field in Transoral Endoscopic Thyroid Surgery Using Vestibular Approach

Background. Minimally invasive thyroid and parathyroid resections are rarely performed. Promising new endoscopic transoral approaches to the anterior neck (transoral endoscopic thyroidectomy vestibular approach [TOETVA]) have been described with good results and few complications. This study evaluates a new device to allow the safe entrance of trocars in the subplatysmal space for TOETVA in a cadaver model. Methods. The technique was performed in 4 unilateral thyroidectomies in female cadavers. The technical steps consisted of a 10-mm incision made at the center of the oral vestibule followed by subplatysmal hydrodissection. The blunt dissector is a metallic stick with an olive at the end and promotes progressive gain in subplatysmal space enlarging the operative field. The instrument was inserted creating a space below the platysma to the anterior neck and the strap muscles. Three trocars were inserted in the vestibular area. The dissection begins by cutting the linea alba cervicalis. The isthmus was dissected and transected. Anatomical structures as the superior thyroid artery, parathyroid glands, and the recurrent laryngeal nerve could be safely identified with magnified vision. Results. Optimal operative field due to subplatysmal dissection by the device allowed for exposition of thyroid and parathyroid glands in all cases. Unilateral thyroidectomy was performed in a mean of 54 minutes with excellent aesthetic results. Conclusions. The new device is a promising feature to allow safe transoral thyroid surgery in a cadaver model. Further studies in clinical series are needed to evaluate the broad application of the device.

NEW TECHNIQUE FOR OBESITY SURGERY: INTERNAL GASTRIC PLICATION TECHNIQUE USING INTRAGASTRIC SINGLE-PORT (IGS-IGP) IN EXPERIMENTAL MODEL

Background:

Bariatric surgery is currently the most effective method to ameliorate co-morbidities as consequence of morbidly obese patients with BMI over 35 kg/m². Endoscopic techniques have been developed to treat patients with mild obesity and ameliorate comorbidities, but endoscopic skills are needed, beside the costs of the devices.

Aim:

To report a new technique for internal gastric plication using an intragastric single port device in an experimental swine model.

Methods:

Twenty experiments using fresh pig cadaver stomachs in a laparoscopic trainer were performed. The procedure was performed as follow in ten pigs: 1) volume measure; 2) insufflation of the stomach with CO2; 3) extroversion of the stomach through the simulator and installation of the single port device (Gelpoint Applied Mini) through a gastrotomy close to the pylorus; 4) performance of four intragastric handsewn 4-point sutures with Prolene 2-0, from the gastric fundus to the antrum; 5) after the performance, the residual volume was measured. Sleeve gastrectomy was also performed in further ten pigs and pre- and post-procedure gastric volume were measured.

Results:

The internal gastric plication technique was performed successfully in the ten swine experiments. The mean procedure time was 27±4 min. It produced a reduction of gastric volume of a mean of 51%, and sleeve gastrectomy, a mean of 90% in this swine model.

Conclusion:

The internal gastric plication technique using an intragastric single port device required few skills to perform, had low operative time and achieved good reduction (51%) of gastric volume in an in vitro experimental model.

Living-Donor Liver Transplant: An Analysis of Postoperative Outcome and Health-Related Quality of Life in Liver Donors

OBJECTIVES

Living-donor liver transplant represents an established alternative to deceased-donor liver transplant. The procedure is considered safe for donors; however, concerns about the donors' health-related quality of life and health status have not been fully addressed. Here, we aimed to assess the health-related quality of life and postoperative and 1-year clinical outcomes in living liver transplant donors.

MATERIALS AND METHODS

All patients undergoing liver resection for adult-to-adult living-donor liver transplant at our center between December 1999 and March 2013 were evaluated retrospectively. Health-related quality of life was evaluated in a second assessment through written health-related quality of life questionnaires (the Short Form 36 assessment tool) sent to all patients who underwent liver resection for living-donor liver transplant between 1989 and 2012.

RESULTS

We identified 104 patients who underwent liver resection for living-donor liver donation between December 1999 and March 2013. Postoperative morbidity was 35.9%, with 56.8% of patients having minor complications. No postoperative, 30-day, or 90-day mortality was evident. At year 1 after transplant, 30 patients (28.8%) had (ongoing) complications, of which 80% were considered minor according to Clavien-Dindo classification. Regarding health-related quality of life, liver donors were characterized as having significantly higher scores in the general health perception component in the Short Form 36 assessment tool (P < .001). We found no significant results in other assessment components (all P > .05).

CONCLUSIONS

Liver donors are characterized by an excellent health-related quality of life that is comparable to the general population. Because some donors tend to have concerns regarding their employment status after the procedure, a comprehensive and critical evaluation of potential donors is needed.

Survival without biliary complications after liver transplant for primary sclerosing cholangitis

OBJECTIVES

Patients who have a liver transplant for primary sclerosing cholangitis may develop recurrent disease and biliary complications, organ loss necessitating revision liver transplant, or death. We evaluated long-term outcomes in patients who had liver transplant for primary sclerosing cholangitis.

MATERIALS AND METHODS

In 71 patients who had a liver transplant for end-stage liver disease because of primary sclerosing cholangitis, a retrospective review was done to evaluate biliary complication-free survival, transplanted organ survival, and death. Human leukocyte antigen typing and matching were reviewed.

RESULTS

There were 39 patients (55%) who had biliary complications, loss of the liver transplant, or death at a mean 12.1 years after transplant. The 5- and 10-year event-free survival reached 74.6% and 45% (53 patients after 5 years, and 32 patients after 10 years). Male sex of transplant recipients was a significant risk factor for biliary complications, revision liver transplant, or death. Most patients had inflammatory bowel disease, primarily ulcerative colitis. The human leukocyte antigen profile or number of mismatches had no effect on complication-free survival.

CONCLUSIONS

Biliary complications, revision liver transplant, and death are a useful combined primary endpoint for recurrent primary sclerosing cholangitis after liver transplant.

Identification of a novel human polyomavirus in organs of the gastrointestinal tract

Polyomaviruses are small, non-enveloped viruses with a circular double-stranded DNA genome. Using a generic polyomavirus PCR targeting the VP1 major structural protein gene, a novel polyomavirus was initially identified in resected human liver tissue and provisionally named Human Polyomavirus 12 (HPyV12). Its 5033 bp genome is predicted to encode large and small T antigens and the 3 structural proteins VP1, VP2 and VP3. Phylogenetic analyses did not reveal a close relationship to any known human or animal polyomavirus. Investigation of organs, body fluids and excretions of diseased individuals and healthy subjects with both HPyV12-specific nested PCR and quantitative real-time PCR revealed additional virus-positive samples of resected liver, cecum and rectum tissues and a positive fecal sample. A capsomer-based IgG ELISA was established using the major capsid protein VP1 of HPyV12. Seroprevalences of 23% and 17%, respectively, were determined in sera from healthy adults and adolescents and a pediatric group of children. These data indicate that the virus naturally infects humans and that primary infection may already occur in childhood.

[Basophil activation test as in vitro assay for cisplatin allergy]

During chemoembolization with gemcitabine, mitomycin and cisplatin of a cholangiocellular carcinoma and after receiving iodide contrast media, a 49-year-old patient developed a grade III anaphylactic reaction. We were asked to verify an adverse reaction to contrast media. Using the basophil activation test, we demonstrated a hypersensitivity reaction to cisplatin with distinct induction of CD63-expression on basophilic granulocytes.

[Basophil activation tests in the diagnosis of drug reactions]

Over the past 10 years a number of studies on basophil activation tests (BAT) have been published which focus on their use as diagnostic methods in clarifying IgE-mediated hypersensitivity reactions to various allergens including drugs. These BAT are based on flow cytometric quantification of allergen- induced CD63 or CD203 expression or measurement of sulfo leukotriene release by ELISA. In the diagnosis of penicillin allergy, the combined use of the CD63-BAT and specific IgE increases sensitivity. The role of BAT in the diagnosis of non-IgE-mediated reactions to non-steroidal anti- inflammatory drugs remains to be clarified. This article focuses on (1) the principles of BAT, (2) technical aspects, (3) clinical applications and (4) recommendations for further development.

In vitro Analysis of Birch-Pollen-Associated Food Allergy by Use of Recombinant Allergens in the Basophil Activation Test

BACKGROUND

Basophil activation is associated with the expression of CD63. In birch-pollen-associated food allergy to celery, carrot and apple, Bet v 1, Api g 1, Dau c 1 and Mal d 1 are major allergens. Recombinant allergens have not yet been used in the CD63-based basophil activation test (BAT).

OBJECTIVE

To evaluate the feasibility of using recombinant allergens in the BAT in the diagnosis of allergy to apple, carrot and celery and to compare results with routine tests, i.e. skin prick tests (SPTs) and specific IgE.

METHODS

Thirty-two patients with an oral allergy syndrome induced by apple, carrot or celery and 22 controls were studied. SPTs were performed with native foods. Specific IgE was determined by the CAP method and basophil activation by flowcytometry upon double staining with anti-IgE/anti-CD63 monoclonal antibodies after incubating with purified recombinant Bet v 1, Bet v 2, Api g 1, Dau c 1 and Mal d 1.

RESULTS

By the combined use of the BAT and the CAP method, sensitization to Bet v 1 and Bet v 2 was detected in 100 and 25% of all subjects, respectively. Sensitivity of specific IgE for apple, carrot and celery was 60, 70 and 75% with corresponding specificities of 64, 86 and 82%. Sensitivity of the BAT for Mal d 1, Dau c 1 and Api g 1 was 75, 65 and 75% with corresponding specificities of 68, 100 and 77%.

CONCLUSIONS

The BAT using recombinant allergens provides a valuable new in vitro method for the detection of sensitization to foods. Although double-blind placebo-controlled food challenges remain the gold standard to confirm food allergy, the CD63-based BAT with recombinant allergens may supplement routine tests for allergy diagnosis.

Bilirubin-adsorption in 23 critically ill patients with liver failure

PURPOSE

Previous studies suggest that high levels of bilirubin exert cytotoxic, neurotoxic and encephalopathic effects that themselves may lead to further deterioration of liver function and multiorgan failure. Although extracorporeal BA is not a causal therapy, there are case reports of clinical benefits of BA. The present retrospective study investigated the clinical utility and effectiveness of BA in 23 patients with liver failure.

METHODS

Twenty-three patients (61+/-11 years) with excessive hyperbilirubinemia (>25 mg/dL) after liver transplantation (n=7), partial liver resection (n=12) and others (n=4) were treated with BA (3.6 liters plasma per BA, BR350, Asahi) and followed for 45+/-8 days.

RESULTS

A mean of 6.6 treatments (3-16) were performed per patient. On average, a single BA treatment reduced bilirubin-levels from 31+/-12 to 23.7+/-9 mg/dL (p<0.001). Levels of bile acid were reduced from 41.8+/-6 to 33.5+/-5 mg/dL. The 30-day mortality was 50%. BA was able to halt and stabilize the progressive increase in bilirubin levels in all patients. In contrast to survivors, non-survivors were characterized by a repeated rapid rise in bilirubin levels after cessation of BA treatment.

CONCLUSIONS

BA is able to stabilize or decrease bilirubin levels in patients with liver failure. Our experience suggests that BA is a safe and promising short-term treatment option for patients with acute deterioration of hepatic function.

The basophil activation test in wasp venom allergy: sensitivity, specificity and monitoring specific immunotherapy

BACKGROUND

As in vitro diagnosis of wasp venom sensitization by specific serum IgE has a sensitivity of only 60-80%, additional in vitro tests are desirable. Basophil activation is associated with the expression of CD63 and its measurement has been proposed as a novel in vitro test for immediate-type allergy. Furthermore, to date, no in vitro test exists to monitor successful specific immunotherapy (SIT) with wasp venom. Therefore, the potentially harmful sting challenge is still recommended.

OBJECTIVE

We compared the CD63-based basophil activation test (BAT) in the diagnosis of wasp venom allergy with skin tests and measurement of specific IgE. Furthermore, we investigated whether BAT can predict the outcome of the sting challenge in patients on SIT.

METHODS

Fifty patients with a systemic reaction caused by a wasp sting and 20 controls were studied. Intracutaneous tests were performed with wasp and bee venom in the suspected allergics. Specific IgE was determined by the CAP-FEIA method and basophil activation by flow cytometry upon double staining with anti-IgE/anti-CD63 mAb. Twenty-five patients were sting challenged 6 months after starting SIT and the BAT was repeated before challenge.

RESULTS

Sensitivity of the intracutaneous tests, specific IgE and BAT was 100, 76, and 92%, respectively. Specificity of specific IgE and the BAT was 85 and 80%, respectively. The cut-off for a positive BAT was 15% CD63+ basophils. There was a positive correlation between IgE reactivity to wasp venom and the number of CD63+ basophils (r = 0.65). Although no patient had a systemic reaction upon sting challenge, in most subjects basophil activation did not decrease when compared with the BAT before SIT.

CONCLUSIONS

Quantitation of basophil activation by CD63 expression is a valuable new in vitro method for diagnosis of allergy to hymenopteran venoms. The CD63-based BAT is a helpful tool for the complementation of routine diagnostic tests such as specific IgE as it increases sensitivity of in vitro detection of sensitization. However, this in vitro method does not offer an alternative to the sting challenge in monitoring successful SIT.

Recovery of preservation-injured primary human hepatocytes and nonparenchymal cells to tissuelike structures in large-scale bioreactors for liver support: an initial transmission electron microscopy study

This study investigated large-scale regeneration and tissue reorganization of adult human liver cells from preservation injured transplant organs. The use of basement membrane protein gels and growth factor enriched culture medium in standard culture flasks promotes liver tissue formation in isolated rat and pig hepatocytes, resulting in prolongation of phenotypic stability and metabolic competence of primary cells in vitro. A special bioreactor construction for high-density three-dimensional cell recovery was developed and isolation of cells from discarded human donor livers was enabled. In vitro regeneration of adult human liver cells isolated from preservation-injured organs took place over a period of 2 weeks in a purpose-built bioreactor. Basement membrane protein and growth factors were avoided. Reorganization of tissue structures was studied using transmission electron microscopy (TEM). This showed regeneration and tissue reorganization of adult human cells from preservation-injured organs by coculture with nonparenchymal cells in the bioreactor. The majority of the aggregated hepatocytes in the bioreactors showed morphological similarities to those in vivo (although not re-formed to hepatocyte plates), exhibiting cell-cell junctions and reconstituted bile canaliculi-like spaces between neighboring hepatocytes. Perfusion channels appeared regularly between cell aggregates. The arrangement of nonparenchymal cells between the hepatocyte aggregates exhibited similarities to liver sinusoids. Endothelial cells often covered the aggregates and formed a borderline to the perfusion channels between the capillaries. Similar to the space of Disse, further nonparenchymal cells were located between the endothelial cells and the parenchymal aggregates. Deposits of biomatrix fibers occurred spontaneously. The regenerated cell mass was close to that of a single liver lobe. In conclusion, the further optimization of bioreactors that enable cell recovery from preservation injury may lead to the utilization of cells from discarded whole or split transplants for extracorporeal temporary liver support therapy or hepatocyte transplantation.

A method to assess biochemical activity of liver cells during clinical application of extracorporeal hybrid liver support

Biochemical activity of a hybrid liver support system based on porcine liver cells was investigated in patients suffering from acute liver failure, coma stage III-IV Patient plasma was drawn systemically and after circulation through the bioreactor at four hour intervals. A method is used that takes into account the rate of plasma flow and the differences in plasma concentration systemically and after circulation through the liver support system to determine the net release or uptake of metabolites such as ammonia, urea and glucose. Urea release (mean 2.28+/-0.37 micromol/h/g cells) and ammonia uptake (mean 0.17+/-0.11 micromol/h/g cells) was seen during treatment, an active role of the system in glucose metabolism was observed. All patients were bridged successfully to liver transplantation.

[Age dependence of laboratory parameters in a health study--attempt at calculating a laboratory index for assessing biological aging]

The laboratory analyses of 404 participants of the health study GUNDULA, 201 men and 203 women between 30 and 80 years old, were performed to evaluate the variables for the determination of biological age. From the more than 70 laboratory variables resulting from clinical-chemical and hematologic tests and from urinalysis, less than 40 are significantly age-dependent. About half of these variables were examined by regression analysis to evaluate whether they are useful for the estimation of biological age by a laboratory index. Considerable sex differences were observed. The laboratory indexes for the participants altogether (resulting from 13 parameters) and separated for women (10 parameters) and men (8 parameters) show more variations than the biological age estimated by non-invasive parameters. In men only, there exists a significant but inverse correlation between laboratory index and relative aging rate, the difference between biological and chronological age. The results of some striking variables (e.g. dehydroepiandrosterone sulfate and others) and the results of an explorative factor analysis with regard to possible interconnections between variables and chronological age will be discussed.

[Clinical laboratory diagnosis and aging. 3: Evaluation of a study of aging--complete blood and urine status]

The results of the determination of hematologic values from 262 men and 242 women, participants of an aging study and half of each group 44.4 +/- 0.9 and 63.0 +/- 0.9 (men) and 44.4 +/- 0.9 and 62.8 +/- 0.8 years old (women), respectively, are compared. In men, one analyte (hemoglobin decreasing) and four indices show significant differences (MCV increasing, MCH decreasing, MCHC decreasing, RDW increasing). In the older group, the iron level and the transferrin saturation are also significantly lower. In women, erythrocytes and the hematocrit are significantly higher in the older group whereas the indices MCH and MCHC are lower and the RDW increases. At the same time, the iron level, transferrin and the transferrin saturation decrease whereas ferritin doubles. The sex differences of the hematologic parameters are more pronounced in the younger participants and especially remarkable in ferritin in both age groups. The results of the semiquantitative analysis of ten urine parameters by reagent strip show differences with respect to sex (e.g., leucocytes and erythrocytes) and age (e.g., specific gravity, pH, nitrite, protein, erythrocytes). The usefulness of the estimation of glucose in urine is discussed in connection with the corresponding serum glucose levels.

Prune-belly syndrome: therapeutic options including in utero placement of a vesicoamniotic shunt

The prune-belly syndrome (PBS) consists of abdominal wall distention with deficiency of the abdominal wall musculature, urinary tract abnormalities, and cryptorchidism. The impaired drainage of the bladder leads to oligohydramnios and pulmonary hypoplasia. We present 4 cases of PBS diagnosed by prenatal sonography. In 2 cases, vesicoamniotic shunt therapy was not indicated because of a poor prognosis based on sonographic and laboratory findings; the pregnancies were terminated. In another case, treatment was not performed because of a twin pregnancy, and the neonate with PBS died the day of delivery by cesarean section at 31 weeks' menstrual age. In the other case, vesicoamniotic shunt therapy was successfully performed, and a healthy child was delivered. Several conditions must be met for vesicoamniotic shunt therapy to have a good chance of success: the karyotype must be normal, other malformations must be excluded by careful sonographic examination, and renal function must be normal, as determined by serial analyses of fetal urine. Generally, the shunt should be inserted as early as possible.

Comparative immunoglobulin G antibody profiles between mother and child (CGMC test) for early diagnosis of congenital toxoplasmosis

Early diagnosis of congenital toxoplasmosis is rendered difficult when specific immunoglobulin M (IgM) and/or IgA antibodies are absent in the blood of the newborn infant. Since maternal IgG antibodies can cross the placenta, determination of IgG antibodies in newborn infants has hitherto not been used routinely for the diagnosis of congenital infection. The aim of this study was to assess the diagnostic usefulness of an immunoblot assay which compares the early IgG profiles between the mother and her child (comparative IgG profile between mother and child; CGMC test) directed against a total cell lysate of Toxoplasma gondii tachyzoites. Serum samples from 97 newborn infants at risk of toxoplasma infection were obtained from umbilical cord blood at birth or postnatally until 3 months of life and were directly compared with serum samples from the respective mothers. Congenital toxoplasmosis was diagnosed only when IgG-reactive protein bands that were present in any newborn serum samples were absent in the corresponding maternal serum sample. Congenital infection was defined by conventional serological assays when IgM and/or IgA antibodies were present in newborn infant blood or when IgG titers rose within the first 12 months or were persistently stable for more than 8 months. Using these criteria, congenital infection was definitely confirmed in 11 cases. Three additional cases were diagnosed based on indicative data. The CGMC test, which was performed without knowledge of the results of conventional serologal assays, had sensitivity and specificity of 82.4 and 93.0%, respectively, and positive and negative predictive values of 73.7 and 95.7%, respectively. When true positives and true negatives were considered, the comparative IgG profile had a ratio of 90.9% true results. The CGMC test thus is useful as an additional assay for the rapid diagnosis of congenital toxoplasmosis when paired serum samples from mother and child are available.

[Significance of detecting impaired uteroplacental perfusion for diagnosis of antiphospholipid antibody syndrome--a case report]

INTRODUCTION

The antiphospholipid antibody syndrome (APA) is a potentially life-threatening disease in pregnancy, associated with spontaneous abortion, intrauterine growth retardation (IUGR), preeclampsia and foetal death in utero. One of the sequelae of the antiphospholipid-antibodies is an impaired uteroplacental circulation. We present a case where we diagnosed an antiphospholipid antibody syndrome (APA) on the basis of a highly pathological Doppler flow in both uterine arteries.

CASE REPORT

A 35-year-old G2P0 with a history of intrauterine foetal death in the 24th week was seen at 15 weeks in her second pregnancy for an ultrasound scan. The Doppler study of both uterine arteries showed highly pathological resistance indices and bilateral notching. Laboratory studies revealed elevated levels of antibodies against Cardiolipin and phospholipids. Therapy trials with low-dose aspirin, heparin, corticosteroids, hemodilution therapy and immunoglobulin remained unsuccessful. The foetus developed severe IUGR, anhydramnios and foetal distress. In the 26th week the parents insisted on a caesarean section because of a pathological heart rate pattern. The birth weight was 365 grams and the infant died immediately.

DISCUSSION

There are several mechanisms which impair the uteroplacental circulation in an APA syndrome. Therefore it is essential to perform laboratory tests when detecting a pathological blood flow in both uterine arteries. In this case all therapies failed, and the preterm infant died due to severe IUGR and distress. The diagnosis, however, facilitated the introduction of early anticoagulation therapy for the mother, the exclusion of systemic lupus erythematodes and the counselling of the parents with regard to further pregnancies.

[Nausea and vomiting in early pregnancy/hyperemesis gravidarum. Current status of psychosomatic factors]

BACKGROUND

Although Hyperemesis gravidarum (HG) is still a disease of unknown aetiology psychosocial aspects are involved in the genesis of this disease.

MATERIALS AND METHODS

Based on experiences in our department and on actual literature psychosocial aspects and therapeutic approaches of HG are presented.

RESULTS

Predisposing factors of HG are stress, inadequate information about pregnancy or delivery and problems in the marital relationship. Feelings of ambivalence towards pregnancy, a distorted perception of reality, the unconscious refusing of a wanted child and the worry about a relation between nutrition of the foetus and the HG have influence on the development of the HG. The role of the social context, especially the mother, of expectations towards vomiting and of secondary gain in the genesis and the evaluation of HG is explained. Therapeutical approaches beside the known somatic therapies are acupuncture, the electric stimulation of the N. vestibularis and different methods of psychotherapy, which can include the partner or other persons from the social context. In some cases an intensified therapy under in-patient conditions can improve therapeutic results.

DISCUSSION

Psychosocial factors are involved not only in the genesis of HG, but also in the duration and intensity of symptoms as well as in the resistance especially, towards isolated somatic therapeutical approaches.

CONCLUSIONS

When psychosocial factors are taken into account in the search for a cause and the treatment of HG results of treatment are more successful and persist over a longer time.

[Lethal osteochondrodysplasias: prenatal and postnatal differential diagnosis]

PURPOSE

Lethal osteochondrodysplasias show an abnormal maturation and a disturbed growth of cartilage and bones. They represent a heterogeneous group of rare genetic diseases. Their incidence is 1 to 3 in 10,000 births.

MATERIAL AND METHODS

We report altogether 5 cases: two of thanatophoric dysplasia, one of achondrogenesis type II and two cases of the rare fibrochondrogenesis. The differential diagnosis in respect to ultrasonographic, morphologic, radiographic and histopathologic criteria of the most common of these diseases are discussed together with a review of the literature.

RESULTS

On the basis of the ultrasound finding of the short-rib-syndrome, it is possible to differentiate between viable and lethal osteochondrodysplasias at 19 to 22 weeks of gestation. The short-rin-syndrome leads to pulmonary hypoplasia.

CONCLUSIONS

It is essential to obtain an exact diagnosis postnatally by radiographic and histopathological examinations to counsel the parents concerning the risk of recurrency. The risk in this heterogeneous group of genetic diseases ranges between less than 1% up to 50% depending on the final diagnosis. Our two cases of fibrochondrogenesis in a consanguineous couple strongly suggest an autosomal recessive inheritance in this disease.

[Prune belly syndrome--diagnosis and therapeutic possibilities]

The Prune Belly Syndrome combines dilation of the bladder and a laxity of the abdominal wall, and is of unknown etiology. The sequelae are a pulmonary hypoplasia and a deterioration of the kidney function, which determine prognosis. Via early ultrasound diagnosis, intrauterine application of a vesico-amniotic shunt can be performed and can improve survival rates. Inclusion criteria for a vesicoamniotic shunt are a lack of further sonomorphological abnormalities, a lack of an indication for an alteration of the kidney function by ultrasound or laboratory tests, and a normal karyotype.

[Clinical laboratory diagnosis and aging. 1: Results of data evaluation of clinico-chemical laboratory values in a study of aging]

The results of the determination of 24 basic blood chemistry variables from 262 men and 239 women, half of each group 44.4 +/- 0.9 and 63.0 +/- 0.9 (men) and 44.4 +/- 0.9 and 62.8 +/- 0.8 years old (women), resp., are compared. In men, only 6 analytes show significant differences between the age groups: Alanine aminotransferase decreases, aspartate aminotransferase decreases, iron decreases with p < 0.05; sodium increases, calcium decreases, protein (serum) decreases with p < 0.001. In women, 16 analytes, compared between both groups, are significantly different: Urea, uric acid, creatinine, triglycerides, total cholesterol, LDL cholesterol, LDL-C/HDL-C ratio, alanine aminotransferase, alkaline phosphatase, gamma-glutamyltransferase, sodium and ferritin are increased in the older group, whereas HDL cholesterol, iron, transferrin, and total protein are decreased. The sex differences are more distinct in the group of 44 years old persons than in the 63 years old one. These results will be completed by the comparison with the evaluation of the stored laboratory values of 9923 patients between 20 and 89 years old.

[Clinical laboratory diagnosis and aging. 2: Suitability of clinico-chemical basic parameters as markers ob biological aging]

In 262 men (about half of them 44.4 +/- 0.9 and 63.0 +/- 0.9 years old, resp.) and 239 women (about half of them 44.4 +/- 0.9 and 62.8 +/- 0.8 years old, resp.) the results of 12 clinical chemical analytes were used to calculate laboratory indices which were compared with the biological age in accordance with Ries. The indices were calculated by using concentrations of alkaline phosphatase, iron, total protein, total cholesterol, glucose, uric acid, urea, HDL cholesterol, creatinine, LDL cholesterol, transferrin, and triglycerides. Only in the younger group of women are the correlations between laboratory indices and biological age significant. In the same group, several single parameters also significantly correlate with pre-aging. Among them are alkaline phosphatase, the LDL-C/HDL-C ratio, bilirubin, triglycerides, and glucose.

[Sepsis and SIRS (systemic inflammatory response syndrome) in the puerperium--pathogenesis and clinical management]

PURPOSE

We report about 5 cases of "puerperal sepsis" to elucidate the clinical significance and resulting therapeutic management of Sepsis, SIRS (Systemic inflammatory response syndrome) and MODS (Multiple organ dysfunction syndrome), whose definitions were introduced at the Consensus Conference of the American College of Chest Physicians/Society of Critical Care Medicine in 1992.

RESULTS

All patients had documented endomyometritis, 3 of them in combination with ovarian vein thrombosis. None of the patients responded adequately to conservative treatment with antibiotics and intravenously applied Heparin. After 12 to 72 hours, because of clinical deterioration, all women underwent laparotomy with hysterectomy combined with an ovarectomy in 3 cases. Although the inflammatory "septic" source was removed by the surgical intervention, the clinical condition of 3 of the patients further deteriorated; they were suffering from SIRS, and 2 developed MODS. Symptoms of MODS were DIC, hypotension, kidney failure and encephalopathy.

CONCLUSIONS

Our results support the theory that infection or trauma may initiate an endogenous inflammatory response which could progress to MODS even after removal of the initial source. Our findings, however, do not support the view that septic endomyometritis and postpartum ovarian vein thrombosis should be treated nonsurgically, because the clinical course in our patients was less complicated the earlier the surgical intervention was initiated.

[Vitamin E distribution of lipoproteins in patients with coronary heart disease]

The oxidative modification of LDL could play an important role for the development of atherosclerosis. The present study was undertaken to compare the concentration of vitamin E in serum and lipoproteins between patients with coronary heart disease and a healthy control group. The study included 36 male patients with angiographically established coronary three-vessel disease and 32 healthy volunteers. Cholesterin, triglyceride, LDL-cholesterin, HDL-cholesterin, and vitamin E in serum and in lipoproteins were determined. The serum vitamin E concentration in the patients group was significantly higher than in controls. However, vitamin E was correlated with cholesterin in both groups. The distribution of vitamin E in healthy volunteers was LDL 53%, HDL 34% and VLDL 13%, whereas that in patients was LDL 57%, HDL 26% and VLDL 16%. The level of vitamin E in LDL was in the patient group significantly higher and correlated with the vitamin E- and the cholesterin-concentration in serum. The ratio vitamin E/cholesterin in LDL was in patients discretely lower, whereas the same ratio in HDL was higher. The results suggest that also in patients with coronary artery disease vitamin E is related to the lipid concentration. The decreased ratio vitamin E/cholesterin in LDL could be attributed to the oxidative modification of LDL.

[Biological age in patients with progressive scleroderma]

In 25 patients (10 male, 15 female) with systemic sclerosis aged between 28 and 79 years the biological age was determined. Alterations in the sense of "premature aging" were observed in the mean and developed stronger in male patients. They have to be counted in a greater part on the real process of disease. Compared to a healthy reference group, the expected diminishing of hand grip strength and tendon extensibility, vital capacity and partial oxygen pressure in the arteries could be confirmed. The latter correlated to an increase in rest pulse. Auditory acuity and the condition of the teeth were also reduced. Beyond that, noteworthy differences in psychological and social parameters not presumed at the beginning point to a decrease in social activities and to psychic changes. They underline the necessity of psychological counseling of the patients.

[Effect of olive oil and fish oil on parameters of lipids and antioxidants in hyperlipoproteinemia]

In 56 patients with HLP (40 with hypertriglyceridemia and mixed HLP respectively and 16 with hypercholesterolemia), changes in the lipid state and in the parameters of the antioxidative potential before and after a 4-week olive-oil phase, and after 8-, 20- and 32-week intakes of salmon-oil capsules were determined. The treatment with salmon-oil led to a decrease of triglycerides in patients with hypertriglyceridemia and mixed HLP respectively, on the other hand, it led to an increase of cholesterol in hypercholesterolemia. The increase of malondialdehyde as measure of lipid peroxidation in both patient groups underlines the necessity of a substitution of antioxidants. Further investigations are necessary before wide use of fish-oil capsules can be recommended, especially to avoid side-effects.

[Changes in parameters of lipid metabolism and anti-oxidative potentials in elderly hyperlipoproteinemic patients treated with omega-3 fatty acids]

Omega-3-fatty acids play a protective role in the prevention of CHD, however, they can have a negative influence on LDL-oxidation and aging processes by the formation of peroxides. In 56 patients with HLP (40 with mixed HLP and hypertriglyceridemia, respectively, and 16 with hypercholesterolemia) changes in the lipid state and in the parameters of the antioxidative potential before and after a 4-week-olive-oil phase and after 8, 20, and 32 weeks intakes of salmon-oil capsules were determined. The treatment with salmon-oil capsules were determined. The treatment with salmon oil led to a decrease of triglycerides in patients with hypertriglyceridemia and to an increase of cholesterol in hypercholesterolemia. Following the increase of malondialdehyde as measure of the lipid peroxidation a substitution of antioxidants, like vitamin E and vitamin C, seems to be useful. Further investigations are necessary before wide use of fish-oil capsules, not least to avoid side-effects.

[Conventional roentgen functional diagnosis--videodensitometry. 4. Conventional roentgen videodensitometry exemplified with peri-cardiac vessels]

It is possible to record movement-parameters by means of roentgen videodensitometry of the great central vessels as well the pulmonary artery as the thoracic aorta visible in fluoroscopic image (provided by videorecorder). We could noninvasively measure pre-ejection periods (PEP) for the right heart (PEP f) as well for the left heart (PEP g) by synchronous electrocardiography for each cardiac action and for each examination process. It is important to form a quotient between PEP f and PEP g in the individual case. First findings in patients with cardiac septal defects (with and without right heart block and pulmonary hypertension) show characteristic quotients and figures of the curves. In cases with electrocardiographic left heart block the elongated PEP g can be stated in graduated form. Further investigations on the mechanic interaction between the right and left heart, especially in cases of disorders in the heart conduction system, might be of interest.

[Conventional roentgen functional diagnosis--videodensitometry. 3. Conventional roentgen videodensitometry exemplified by the heart]

It is possible to record movement parameters video densitometrically and synchronously by means of a video signal analysator at various points of the organ surface visible via fluoroscopic images (provided by videorecorder). Movement parameters of the heart surface were signed just in the same cardiac action by synchronous electrocardiography. There are some difficulties in this method according to evaluation with reference to laevocardiography in consequence of functional variety of the heart and the different exercise conditions. Small aneurysms of the cardiac apex were only seen when they were separated and located at the cardiac margin. Extended cardiac aneurysms were video densitometrically recorded as a paradoxical movement at the cardiac surface. A paradoxical movement was never seen with negative findings in laevocardiography.

[The relation of anthropometric parameters and echocardiography findings in the evaluation of left ventricular form and function in extreme obesity]

For the characterization of the left-ventricular thickness of the wall, of the diameter and of the functional parameters in obesity in a short-term investigation on 18 extremely adipose female normotonics and 17 normotonics with normal weight the echocardiographic investigation in the M-mode in the short parasternal axis was performed. The women with overweight had a by 28% (p less than 0.001) greater fractional shortening, a by 8% (p less than 0.01) greater ejection fraction, a by 23% (p less than 0.05) greater stroke volume and a by 34% (p less than 0.001) greater cardiac output as well as a by 13% smaller left-ventricular end-systolic volume than normotonic women with normal weight. Index of stroke volume and cardiac output did not differ. The women with overweight had a significantly larger left-ventricular end-diastolic diameter and a thicker interventricular septum as well as a larger thickness of the left-ventricular posterior wall in the systole. The results allowed the conclusion that changed left-ventricular parameters both with regard to the form and to the function in obesity per se might be the expression of the physiological adaptation to an increased requirement and the borderlines to the transition into a disturbed left-ventricular function and development of a left-ventricular hypertrophy were not fixed. Long-term studies should bring further explanation concerning these problems.

[Clinical, biochemical and anthropometric studies and determination of biological age in relation to body mass in a longitudinal study]

On 46 adipose persons (25 males and 21 females) and 53 test persons with normal weight (35 males and 18 females) at the age of 25-40 years since 1976 clinical, biochemical and anthropometric investigations as well as the determination of the biological age have annually been performed. Several of the parameters established (e.g. cholesterol, triglycerides, fasting blood sugar, blood pressure among others) in the course of 9 years within the well-known normal regions draw towards the adequate valid limit value to the pathological entity. The results of the study distinctly show the central role of obesity for the development of risk factors. Despite the partly only with a certain tendency recognizable behaviour of single parameters after 9 years from our point of view the longitudinal method represents itself as a very well suitable method for establishing dynamic processes and risk factors of age.

[Relation between obesity and atherogenic risk factors in a longitudinal study]

Since 1980 clinical, biochemical and anthropometric examinations have been performed annually on 46 adipose patients (25 males, 18 females) and 53 test persons (35 males, 18 females) at the age of 25 to 40 years. Several of the established parameters (e. g. cholesterol, triglycerides, uric acid, blood pressure among others) in the course of the 5 years within the known normal regions drew towards the adequate limiting value to the pathological. The results of the study clearly show the central role of the overweight for the formation of risk factors. Despite the partly only in a certain tendency recognizable behaviour of individual signs after 5 years from our point of view the longitudinal technique represents itself as a very well suitable method to realize dynamic processes and risk factors of ageing.

[Treatment of disorders of lipid metabolism with the new lipid regulator X50]

With the newly developed lipid regulant X 50 = 1-benzyl-3-(1-carboxyl-methylethoxy)-4-methylpyrazol 15 patient with primary hypercholesterolaemia and hypertriglyceridaemia were treated for 3 months. A significant decrease of the serum triglycerides by 47% in all patients and of the total cholesterol by 32% in half the patients (LDL cholesterol decrease 25%) was the result. Altogether an increase of the linoleic acid of 14% and a decrease of the uric acid of 16% were furthermore the result. There were practically no side effects.

[Behavior of the biological aging index and serum lipids in treatment with X50]

Lipid metabolic disorders are clinical relevant for the middle and old age. The presented paper shows that decreased HDL-cholesterol and increased triglycerides enlarge the value of pre-ageing. Therefore is a lipid lowering treatment a special problem of gerontology. We have treated 15 patients (age 56.7 +/- 7.8 years) with hypercholesterolemia and hypertriglyceridemia with the new developed lipids regulans X50 = 1-benzyl-3-(1-carboxy-1-methylethoxy)-4-methylpyrazol. There was a significant decreases of serumtriglycerides (47%) in all patients. Half of the patients showed a significant decreases of total cholesterol (32%). Biological age index and biological age were not influenced. To demonstrate an influence of biological age there are needed longterm treatments in patients with lipid metabolic disorders.

[Development of body weight in males of the Wurzen district 1961-1983]

In 1961, 1971 and 1983 additional medical parameters, among them body length and body weight, were established during the mass radiographies in the district of Wurzen. From the data of 7,670 males from the year 1983 for two 10-year age groups regression equations between body weight and body length were determined. The calculation of relative weights was performed on the basis of the optimum weights after Ott. The longitudinal comparison from 1961 to 1971 resulted in an increase of the number of persons with overweight by 17.7% during 10 years. The results of the examinations of the year 1983 showed that the trend to the increase of body weight continues in the male inhabitants of the district of Wurzen.

[Noninvasive roentgen diagnosis of right heart function in patients with recirculation disorders and chronic nonspecific lung changes]

The non-invasive x-ray functional diagnostic electroradiographic method at the large vessels near the heart may enrich the radiological preliminary diagnostics of recirculation abnormalities. In chronic unspecific pulmonary diseases it can characterize the load of the right heart. Our studies should serve as a pilot study for the in future possible, simply to be handled non-invasive video-densitometry of the vessels near the heart in the preliminary diagnostics of cardiovascular diseases.

[Changes in noninvasive cardiovascular parameters by inpatient weight reduction]

36 normotensive obese and 23 hypertensive obese were treated with an isokaloric reduction diet of 800 kcal/a day under clinical conditions over a 4-week span. Blood pressure and cardiac performance were investigated by means of non-invasive techniques such as systolic time intervals (STI) and calculated indices. A significant decrease was established in systolic time intervals such as left ventricular ejection time and total electromechanical systole, systolic and diastolic blood pressure, myocardial oxygen consumption and cardiac output. Heart rate, preejection index and stroke volume were not diminished under dietary treatment. No decrease of all parameters was found in obese normotensives with a weight reduction greater than 5% after dietary treatment.

[12 years' analysis of serum fatty acids--final results of the Leipzig Longitudinal Gerontologic Study]

In the Leipzig longitudinal study performed from 1968 to 1980 in 383 test persons with healthy metabolism in 2-3 years time intervals gas-chromatographic analyses of the serum fatty acid pattern were carried out. In dependence upon age, sex, and body-weight the vasoprotective linoleic, linolenic and arachidonic acid increased and the vasoaggressive palmitic and eicosatrienic acid decreased. Influences of age as well as the change of the feeding habits are causally discussed for this purpose.