Frequency of Anaplasma phagocytophilum, Borrelia spp., and coinfections in Ixodes ricinus ticks collected from dogs and cats in Germany

BACKGROUND

Changing geographical and seasonal activity patterns of ticks may increase the risk of tick infestation and tick-borne pathogen (TBP) transmission for both humans and animals.

METHODS

To estimate TBP exposure of dogs and cats, 3000 female I. ricinus from these hosts were investigated for Anaplasma phagocytophilum and Borrelia species.

RESULTS

qPCR inhibition, which was observed for ticks of all engorgement stages but not questing ticks, was eliminated at a template volume of 2 µl. In ticks from dogs, A. phagocytophilum and Borrelia spp. prevalence amounted to 19.0% (285/1500) and 28.5% (427/1500), respectively, while ticks from cats showed significantly higher values of 30.9% (464/1500) and 55.1% (827/1500). Accordingly, the coinfection rate with both A. phagocytophilum and Borrelia spp. was significantly higher in ticks from cats (17.5%, 262/1500) than dogs (6.9%, 104/1500). Borrelia prevalence significantly decreased with increasing engorgement duration in ticks from both host species, whereas A. phagocytophilum prevalence decreased only in ticks from dogs. While A. phagocytophilum copy numbers in positive ticks did not change significantly over the time of engorgement, those of Borrelia decreased initially in dog ticks. In ticks from cats, copy numbers of neither A. phagocytophilum nor Borrelia spp. were affected by engorgement. Borrelia species differentiation was successful in 29.1% (365/1254) of qPCR-positive ticks. The most frequently detected species in ticks from dogs were B. afzelii (39.3% of successfully differentiated infections; 70/178), B. miyamotoi (16.3%; 29/178), and B. valaisiana (15.7%; 28/178), while B. afzelii (40.1%; 91/227), B. spielmanii (21.6%; 49/227), and B. miyamotoi (14.1%; 32/227) occurred most frequently in ticks from cats.

CONCLUSIONS

The differences in pathogen prevalence and Borrelia species distribution between ticks collected from dogs and cats may result from differences in habitat overlap with TBP reservoir hosts. The declining prevalence of A. phagocytophilum with increasing engorgement duration, without a decrease in copy numbers, could indicate transmission to dogs over the time of attachment. The fact that this was not observed in ticks from cats may indicate less efficient transmission. In conclusion, the high prevalence of A. phagocytophilum and Borrelia spp. in ticks collected from dogs and cats underlines the need for effective acaricide tick control to protect both animals and humans from associated health risks.

Winter activity of questing ticks (Ixodes ricinus and Dermacentor reticulatus) in Germany - Evidence from quasi-natural tick plots, field studies and a tick submission study

Changing climatic conditions and other anthropogenic influences have altered tick distribution, abundance and seasonal activity over the last decades. In Germany, the two most important tick species are Ixodes ricinus and Dermacentor reticulatus, the latter of which has expanded its range across the country during the past three decades. While I. ricinus was rarely found during the colder months in the past, D. reticulatus is known to be active at lower temperatures. To quantify tick appearance during winter, specimens were monitored in quasi-natural tick plots three times a week. Additionally, the questing activities of these two tick species were observed throughout the year at nine field collection sites that were regularly sampled by the flagging method from April 2020 to April 2022. Furthermore, tick winter activity in terms of host infestation was analysed as part of a nationwide submission study from March 2020 to October 2021, in which veterinarians sent in ticks mainly collected from dogs and cats. All three study approaches showed a year-round activity of I. ricinus and D. reticulatus in Germany. During the winter months (December to February), on average 1.1% of the inserted I. ricinus specimens were observed at the tops of rods in the tick plots. The average questing activity of I. ricinus amounted to 2 ticks/100 m² (range: 1-17) in the flagging study, and 32.4% (211/651) of ticks found infesting dogs and cats during winter 2020/21 were I. ricinus. On average 14.7-20.0% of the inserted D. reticulatus specimens were observed at the tops of rods in the tick plots, while the average winter questing activity in the field study amounted to 23 specimens/100 m² (range: 0-62), and 49.8% (324/651) of all ticks collected from dogs and cats during winter 2020/21 were D. reticulatus. Additionally, the hedgehog tick Ixodes hexagonus was found to infest dogs and cats quite frequently during the winter months, accounting for 13.2% (86/651) of the collected ticks. A generalized linear mixed model identified significant correlations of D. reticulatus winter activity in quasi-natural plots with climatic variables. The combined study approaches confirmed a complementary main activity pattern of I. ricinus and D. reticulatus with climate change-driven winter activity of both species. Milder winters and a decrease of snowfall, and consequently high winter activity of D. reticulatus, among other factors, may have contributed to the rapid spread of this tick species throughout the country. Therefore, an effective year-round tick control is strongly recommended to not only efficiently protect dogs and cats with outdoor access from ticks and tick-borne pathogens (TBPs), but also to limit the further geographical spread of ticks and TBPs to so far non-endemic regions. Further measures, including information of the public, are necessary to protect both, humans and animals, in a One Health approach.

Predicting the distribution of Ixodes ricinus and Dermacentor reticulatus in Europe: a comparison of climate niche modelling approaches

BACKGROUND

The ticks Ixodes ricinus and Dermacentor reticulatus are two of the most important vectors in Europe. Climate niche modelling has been used in many studies to attempt to explain their distribution and to predict changes under a range of climate change scenarios. The aim of this study was to assess the ability of different climate niche modelling approaches to explain the known distribution of I. ricinus and D. reticulatus in Europe.

METHODS

A series of climate niche models, using different combinations of input data, were constructed and assessed. Species occurrence records obtained from systematic literature searches and Global Biodiversity Information Facility data were thinned to different degrees to remove sampling spatial bias. Four sources of climate data were used: bioclimatic variables, WorldClim, TerraClimate and MODIS satellite-derived data. Eight different model training extents were examined and three modelling frameworks were used: maximum entropy, generalised additive models and random forest models. The results were validated through internal cross-validation, comparison with an external independent dataset and expert opinion.

RESULTS

The performance metrics and predictive ability of the different modelling approaches varied significantly within and between each species. Different combinations were better able to define the distribution of each of the two species. However, no single approach was considered fully able to capture the known distribution of the species. When considering the mean of the performance metrics of internal and external validation, 24 models for I. ricinus and 11 models for D. reticulatus of the 96 constructed were considered adequate according to the following criteria: area under the receiver-operating characteristic curve > 0.7; true skill statistic > 0.4; Miller's calibration slope 0.25 above or below 1; Boyce index > 0.9; omission rate < 0.15.

CONCLUSIONS

This comprehensive analysis suggests that there is no single 'best practice' climate modelling approach to account for the distribution of these tick species. This has important implications for attempts to predict climate-mediated impacts on future tick distribution. It is suggested here that climate variables alone are not sufficient; habitat type, host availability and anthropogenic impacts, not included in current modelling approaches, could contribute to determining tick presence or absence at the local or regional scale.

Year-round tick exposure of dogs and cats in Germany and Austria: results from a tick collection study

BACKGROUND

Ticks and tick-borne diseases play a major role in companion animal health. Additionally, the European tick fauna is changing, for instance due to the spread of Dermacentor reticulatus, displaying a higher likelihood of winter activity than Ixodes ricinus. Therefore, we investigated current tick infestations in dogs and cats in Germany and in parts of Austria and the seasonal infestation risk.

METHODS

Overall, 219 veterinary practices were invited to collect ticks from cats and dogs on a monthly basis. Ticks were morphologically identified and female I. ricinus specimens were measured to estimate attachment duration.

RESULTS

In total, 19,514 ticks, 17,789 (91.2%) from Germany and 1506 (7.7%) from Austria, were received between March 2020 and October 2021, with 10,287 specimens (52.7%) detached from dogs, 8005 from cats (41.0%) and 1222 from other species (6.3%). In Germany, the most common tick species collected from dogs were I. ricinus (78.0%) and D. reticulatus (18.8%), while cats mainly harboured I. ricinus (91.3%) and I. hexagonus (5.5%) and only few D. reticulatus (0.6%). In Austria, collected I. ricinus reached similar proportions in dogs (90.4%) and cats (95.3%), followed by D. reticulatus in both dogs (5.2%) and cats (1.5%), with I. hexagonus (0.9%) collected only marginally from cats. The average infestation intensity amounted to 1.62 ticks/dog and 1.88 ticks/cat. The single to multiple infestation ratio was 79.1% to 20.9% in dogs and 69.0% to 31.0% in cats, with cats being significantly more often multiple infested than dogs, while the proportion of mixed-species infestations was 2.0% for both dogs and cats. The average attachment duration of female I. ricinus specimens amounted to 78.76 h for dogs and 82.73 h for cats. Furthermore, year-round tick exposure was confirmed, with 108 D. reticulatus and 70 I. ricinus received on average per month during December 2020 to February 2021.

CONCLUSIONS

The study shows a year-round tick infestation risk, with activity of both D. reticulatus and I. ricinus during winter, and confirms the widespread occurrence of D. reticulatus in Germany. Additionally, long average attachment durations and frequent multiple infestations underline the need for adequate year-round tick control, even during the winter months.

Update and prognosis of Dermacentor distribution in Germany: Nationwide occurrence of Dermacentor reticulatus

A considerable range expansion of Dermacentor reticulatus has been observed in several European countries, which is concerning in the light of its vector function for several pathogens, including Babesia canis and tick-borne encephalitis virus (TBEV). The present study provides an update on the distribution of Dermacentor ticks in Germany, using a citizen science approach. Ticks were collected by citizens from March 2020 to May 2021, and submitted along with information on the date and location of collection, potential hosts and details about the circumstances of discovery. In total, 3,292 Dermacentor specimens were received, of which 76.4% (2,515/3,292) were identified as D. reticulatus and 23.0% (758/3,292) as D. marginatus, while 0.6% (19/3,292) were too damaged for species-level identification. Dermacentor reticulatus was received from all federal states of Germany. Maxent species distribution models predicted suitable environmental conditions for D. reticulatus throughout Germany. Findings on the vegetation or on pastured animals without travel history confirmed the occurrence of this tick species as far north as the most northern German federal state Schleswig-Holstein. In contrast, the distribution of D. marginatus still appears to be limited to southwestern Germany, although the northward shift of the distribution limit observed in the preceding citizen science study, as compared with previous published distributions, was confirmed. This shift was also predicted by Maxent species distribution models, reflecting the broader distribution of the tick occurrence data contributed by citizens. Most D. reticulatus ticks were found on dogs (1,311/1,960, 66.9%), while D. marginatus was mainly discovered on hoofed animals (197/621, 31.7%) and humans (182/621, 29.3%). Human tick bites were reported in 0.7% (14/1,960) of host-assigned D. reticulatus and 3.4% (21/621) of host-assigned D. marginatus. Further studies to investigate an increasing endemisation of Babesia canis in Germany as well as the relevance of D. reticulatus for TBEV spread throughout the country, e.g., by traveling dogs, are urgently needed. In view of the activity of D. reticulatus during winter or the colder months, which complements that of Ixodes ricinus, a year-round tick protection of at least dogs is strongly recommended.

Tick-borne zoonoses and commonly used diagnostic methods in human and veterinary medicine

Around the world, human health and animal health are closely linked in terms of the One Health concept by ticks acting as vectors for zoonotic pathogens. Animals do not only maintain tick cycles but can either be clinically affected by the same tick-borne pathogens as humans and/or play a role as reservoirs or sentinel pathogen hosts. However, the relevance of different tick-borne diseases (TBDs) may vary in human vs. veterinary medicine, which is consequently reflected by the availability of human vs. veterinary diagnostic tests. Yet, as TBDs gain importance in both fields and rare zoonotic pathogens, such as Babesia spp., are increasingly identified as causes of human disease, a One Health approach regarding development of new diagnostic tools may lead to synergistic benefits. This review gives an overview on zoonotic protozoan, bacterial and viral tick-borne pathogens worldwide, discusses commonly used diagnostic techniques for TBDs, and compares commercial availability of diagnostic tests for humans vs. domestic animals, using Germany as an example, with the aim of highlighting existing gaps and opportunities for collaboration in a One Health framework.

Instrumental Color Classification of Honey: Collaborative Study

A collaborative study was carried out to test the use of the Lovibond 2000 honey color comparator. Fourteen collaborators classified 6 honeys in the test. Results were generally favorable and the method has been adopted official first action.

[Patients' rights--doctors' duties]

On 26 February 2013 the new "Law on Patients' Rights" (hereinafter also the "Law") became effective. This Law strengthens patients' rights vis-à-vis the insurdnce company and also regulates patients' rights regarding their relation to the doctor. This has consequences for the laws on medical liability all doctors must consider. The doctor's performance is and remains a service and such service does not hold any guarantee of success. Nevertheless, this Law primarily reads as a "law on the duties of physicians". To duly take into account these duties and to avoid mistakes and misinterpretation of the Law, the Ethics Committee of the Consortium of Osteosynthesis Trauma Germany (AOTRAUMA-D) has drafted comments on the Law. Brief summaries of its effects are to be found at the end of the respective comment under the heading "Consequences for Practice". The text of the law was influenced particularly by case law, as continuously developed by the German Federal Court of Justice ("BGH"). The implementation of the Law on Patients' Rights was effected by the newly inserted sections 630a to 630h of the German Civil Code (the "BGB"), which are analysed below. The following comments are addressed to physicians only and do not deal with the specific requirements and particularities of the other medical professions such as physiotherapy, midwifery and others so on. Special attention should be paid to the comments on the newly inserted Duty to inform, which has to be fullfilled prior to any diagnostic or therapeutic procedure (sec. 630c para 2 sentence 1 BGB). Under certain conditions the doctor also has to inform the patient about the circumstances that lead to the presumed occurance of a therapeutic or diagnostic malpractice (sec. 630c para. 2 sentence 2 BGB), based on the manifestation of an undesired event or an undesired outcome. As before, the patient's valid consent to any procedure (sec. 630d BGB) is directly linked to the comprehensive and timely provision of information (sec. 630e BGB). Comprehensive documentation obligations regarding all procedures are stipulated in sec. 630f BGB. As before, the burden of proof still rests with the patient, unless a severe malpractice has been established (sec. 630h BGB). The definition of "severe malpractice" remains unchanged and is based on the case law of the Federal Court of Justice (BGH). The patient's obligations to preserve his or her health and to actively support the process of recovery and securing a positive outcome of the treatment are not explicitly mentioned in the Law. Nevertheless, the patient and the physician need to work closely together to achieve a successful result of the treatment. In case the patient does not give his or her cooperation, the physician should consider terminating the treatment relationship.

Spontaneous cellular uptake of exogenous messenger RNA in vivo is nucleic acid-specific, saturable and ion dependent

The development of new treatments in the post-genomic era requires methods for safe delivery of foreign genetic information in vivo. As a transient, natural and controllable alternative to recombinant viruses or plasmid DNA (pDNA), purified or in vitro transcribed messenger RNA (mRNA) can be used for the expression of any therapeutic protein in vitro and in vivo. As it has been shown previously, the simple injection of naked mRNA results in local uptake and expression. We show here that this process, in the skin, can greatly be modulated according to the injection solution composition and blocked by an excess of competing nucleic acids or a drug affecting cytosolic mobility. Different cell types at the site of injection can take up the foreign nucleic acid molecules and the protein translated from this is detected for no more than a few days. To test this gene transfer method in humans, we produced in vitro transcribed mRNA under good manufacturing practice (GMP) conditions in a dedicated facility. After injection into the human dermis, we could document the translation of the exogenous mRNA. Our results pave the way toward the use of mRNA as a vehicle for transient gene delivery in humans.

Human peripheral blood monuclear cells transfected with messenger RNA stimulate antigen-specific cytotoxic T-lymphocytes in vitro

The efficiency of test vaccines needs to be evaluated by quantification of the triggered cellular immune response. Usually, for these assays, autologous target cells expressing the vaccine antigen are required. In the context of messenger RNA (mRNA)-based vaccinations, the target cells used for the read-out are mRNA-transfected monocyte-derived dendritic cells (Mo-DCs). Their production typically requires samples of 100 ml blood from the patients, and limits the number of assays that can be performed. We show here that fresh peripheral blood mononuclear cells (PBMCs) can be transfected with mRNA by electroporation. Such cells are as efficient as mRNA-transfected Mo-DCs for their ability to activate memory T cells in vitro. Thus, mRNA-transfected PBMCs are a convenient replacement of mRNA-transfected Mo-DCs for the in vitro monitoring of natural or vaccine-induced immune responses.

Polarization of immunity induced by direct injection of naked sequence-stabilized mRNA vaccines

In the context of developing a safe genetic vaccination strategy we tested and studied globin-stabilized mRNA-based vaccination in mice. This vaccination strategy has the advantages of genetic vaccination (easy production, adaptability to any disease and inexpensive storage when lyophilized), but not the drawbacks of DNA vaccination (long-term uncontrolled expression of a transgene, possibility of integration into the host genome and possible induction of anti-DNA antibodies). We report here that injection of naked β-globin untranslated region (UTR)-stabilized mRNA coding for β-galactosidase is followed by detectable translation in vivo. In addition, we show that such a vaccination strategy primes a T helper 2 (Th2) type of response which can be enhanced and shifted to a Th1-type immune response by application of recombinant granulocyte/macrophage colony-stimulating factor 1 day after mRNA injection. Our data demonstrate that the administration of globin UTR-stabilized mRNA is a versatile vaccination strategy that can be manipulated to fit the requirement of antiviral, antibacterial or antitumor immunity.

Surface properties of calcium phosphate particles for self setting bone cements

Calcium phosphate cements (CPC), consist of multicomponent powder mixtures of calcium orthophosphates with grain sizes in the region of 1-20 microm. Due to the small particle sizes surface properties as the zeta potential and adsorption processes play a significant role during manufacturing and application. In the context of this work zeta potentials of different calcium phosphates, like dicalcium phosphate anhydride (DPCA) tetracalcium phosphate (TTCP) and hydroxyapatite were measured in various organic/aqueous media with different pH values. The results show a strong dependency of the zeta potential on the kind of suspension medium used associated with different milling properties. The addition of sodium phosphate leads to a pH value dependent stabilization of the particles in the liquid phase; the zeta potential of the surface increases from about -15 to -18 mV in water and from -35 to -45 mV in 0.05 mol/l sodium phosphate solution. Besides the interaction of particles with various antibiotics was determined on the basis of the zeta potential of the surface. The substances partly cause a tremendous change of the surface load. This is accompanied by a change of the rheological properties of the cement paste, the morphology of the hardened cement matrix and a significant deterioration of the application-relevant properties as setting time or mechanical strength.

CAIR-1/BAG-3 forms an EGF-regulated ternary complex with phospholipase C-gamma and Hsp70/Hsc70

CAIR-1/BAG-3 forms an EGF-regulated ternary complex with Hsp70/Hsc70 and latent phospholipase C-gamma (PLC-gamma). The expression of CAIR-1, CAI stressed-1, was induced in A2058 human melanoma cells by continuous exposure to CAI, an inhibitor of nonvoltage-gated calcium influx. CAIR-1 sequence is identical, save 2 amino acids, to BAG-3 also cloned recently as Bis, a member of the bcl-2-associated athanogene family. We show that CAIR-1/BAG-3 binds to Hsp70/Hsc70 in intact cells and this binding is increased by short term exposure to CAI (P<0.007). CAIR-1/BAG-3 is phosphorylated in vivo in the absence of stimulation. Basal phosphorylation is inhibited by treatment with d-erythrosphingosine (d-ES), a broad inhibitor of the protein kinase C family. CAIR-1/BAG-3 contains several PXXP SH3 binding domains leading to the hypothesis that it is a partner protein of phospholipase C-gamma. PLC-gamma is bound to CAIR-1/BAG-3 in unstimulated cells. It is increased by CAI or d-ES (P=0.05) treatment, and abrogated by EGF (r2=0.99); d-ES treatment blocks the EGF-mediated dissociation. We show that CAIR-1/BAG-3 binds to PLC-gamma and Hsp70/Hsc70 through separate and distinct domains. Hsp70/Hsc70 binds to the BAG domain of BAGs-1 and -3. CAIR-1/BAG-3 from control and EGF-treated cell lysates bound selectively to the SH3 domain of PLC-gamma, but not its N-SH2 or C-SH2 domains. Confirming the SH3 interaction, PLC-gamma was pulled down by CAIR-1/BAG-3 PXXP-GST fusions, but GST-PXXP constructs confronted with lysates from EGF-treated cells did not bind PLC-gamma as was seen in intact cells. Hsp70/Hsc70 was brought down by the PLC-gamma SH3 construct equally from native and EGF-treated cells, but did not bind the PXXP construct under either condition. We propose that CAIR-1/BAG-3 may act as a multifunctional signaling protein linking the Hsp70/Hsc70 pathway with those necessary for activation of the EGF receptor tyrosine kinase signaling pathways.

Effect of carotid body denervation on breathing in neonatal goats

The objective of the present study was to determine in goats whether carotid body denervation (CBD) at 1-3 days of age causes permanent changes in breathing greater than those that occur after CBD in adult goats. Goats underwent CBD (n = 6) or sham CBD (n = 3) surgery at 1-3 days of age. In addition, one unoperated control animal was studied. Bolus intravenous injections of NaCN 2 days postsurgery verified successful CBD surgery. However, at 3, 11, and 18 mo of age, the CBD goats had regained a NaCN response that did not differ (P > 0.10) from that of intact goats. Intracarotid NaCN injections elicited a hyperpnea in the sham CBD but not the CBD goats. Only one animal exhibited highly irregular breathing [characterized by prolonged (>9-s) apneas] after CBD, and the irregularity disappeared by 3 mo of age. One CBD goat died at 35 days of age, and autopsy revealed that death was associated with pneumonia. After 3 mo of age, there were no statistically significant differences (P > 0.10) between sham and CBD goats in eupneic breathing, hypoxia and CO(2) sensitivity, and the exercise hyperpnea. It is, therefore, concluded that CBD at 1-3 days of age in goats does not appear to affect selected aspects of respiratory control after 3 mo of age, conceivably because of the emergence of other functional chemoreceptors that compensate for the loss of the carotid chemoreceptor.

Regulation of cell spreading during differentiation in the muscarinic M5 receptor tumor-suppressor model

Activation of the muscarinic receptor in Chinese hamster ovary (CHO) cells results in a reversal of the malignant phenotype for which spreading into a bipolar, fibroblastic morphology is a marker. The process of morphologic change requires multiple events, including alterations in adhesions to substrates and cytoskeletal re-arrangement. In this report, we demonstrate the calcium-dependent involvement of p125FAK in this cellular shape change using an inhibitor of ligand-induced calcium influx, carboxyamido-triazole (CAI). p125FAK becomes tyrosine-phosphorylated after exposure to the agonist carbachol (CC), reaching maximal phosphorylation prior to initiation of cellular shape change at 1 hr into CC exposure (386 +/- 103%). Phosphorylation remained elevated through the shape change (4-12 hr). CHOm5 cell exposure to the Ca2+-mobilizing agents maitotoxin and ionomycin also resulted in p125FAK phosphorylation. Inhibition of Ca2+ influx with CAI, an inhibitor of ligand-induced Ca2+ influx, had little effect on CC-induced phosphorylation but partially inhibited ionomycin-mediated p125FAK phosphorylation. While the intracellular Ca2+ chelator BAPTA failed to prevent CC-induced p125FAK tyrosine phosphorylation, it inhibited phosphorylation due to ionomycin. CC induced Ca2+-independent binding of phosphorylated p125FAK selectively to the C-terminal SH2 domain of phosphatidylinositol-3'-kinase (PI3K). Further, CC, maitotoxin and ionomycin induced in vitro kinase activity of p125FAK for the exogenous substrate poly(Glu4Tyr1). Kinase activity stimulated by all 3 agonists was inhibited by preincubation with either CAI or BAPTA. Our results indicate that increasing intracellular Ca2+ can stimulate both p125FAK autophosphorylation and kinase activity; however, p125FAK phosphorylation in response to CC also may be induced through a Ca2+-independent pathway.

Identification and molecular characterization of a m5 muscarinic receptor in A2058 human melanoma cells. Coupling to inhibition of adenylyl cyclase and stimulation of phospholipase A2

We report the identification and biochemical characterization of an endogenous m5 muscarinic acetylcholine receptor (mAChR) in the A2058 human melanoma cell line. This is the first demonstration of a m5AChR outside the central nervous system. The unusual effector coupling of this endogenous m5AChR is presented. The coding region amplified by polymerase chain reaction was identical to the known m5AChR sequence. Binding studies indicated a Kd of 99 +/- 6 pM and a Bmax of 45 +/- 4 fmol/mg membrane protein. This m5AChR coupled to stimulation of arachidonic acid release and to a 50% inhibition of forskolin-stimulated cAMP accumulation. The inhibition of cAMP production was insensitive to pertussis toxin treatment, but was dependent upon extracellular calcium. In contrast to the odd mAChR pattern, no cAMP was produced in response to carbachol (CC) stimulation. Moreover, no release of inositol phosphates could be measured after CC treatment despite the presence of at least 2 phospholipase C isoforms in A2058 cells. CC-stimulated arachidonic acid release (EC50 = 17.8 +/- 0.1 microM) was dependent upon external Ca2+, with marked reduction after coincubation with EGTA, Co2+, or high doses of verapamil (IC50 = 166 microM) or diltiazem (IC50 = 243 microM). Brief exposure to phorbol 12-myristate 13-acetate augmented CC-stimulated arachidonic acid release, whereas prolonged phorbol 12-myristate 13-acetate treatment resulted in down-regulation of release. Activation of the m5AChR resulted in Ca2+ influx that was attenuated by muscarinic antagonism and removal of extracellular Ca2+. A2058 cells exposed to CC had no alteration of cell shape or growth potential in monolayer culture, however, a statistically significant reduction in density-independent growth was observed over the range of CC concentrations from 0.1 to 100 microM. This endogenous m5AChR has a novel signal transduction coupling profile and receptor activation reduces clonogenic potential.

[Quality of life and economical significance]

A good healing result is, of itself, not a measure of life-quality, but only a factor within a complex of values. Throughout time, its significance corresponds to the degree of evolution of the medical profession, and especially that of preservation and reconstructive surgery. Subjective perception, satisfaction with treatment, preservation or impairment of physical abilities, illness in the broadest sense, and finally terminal despair or even death are criteria of the value termed life quality. A key function of the rehabilitation process lies in the confrontation with its result, only the acceptance of a deficient state leads to the regaining of life-quality, this may necessitate a reappraisal of values (delcredere). To secure life-quality after injury is not only a question of financing the individual case, but a matter of economical significance in view of the reclaiming of resources once the injured are reintegrated. This reclamation will be the greater, the more quickly and thoroughly rehabilitation is accomplished. Rehabilitation, in turn, depends upon the adequate development of treatment possibilities, including hospital structures within which performance standards must be conveyed.

[Partial causality in case of physician liability]

The specific theories about causality related to the different branches of law do have importance in the politics of rules. In civil law and physician liability law as well the theory of adequacy is valid. This theory selects only certain conditions as legally effective out of the abundance of all existing conditions. In physician liability law it typically happens, that indifferent chains of cause and effect coincide, what matters is to distinguish one from another and according to conditions to determine the partial causality which has to be attributes to the physician. The example of the untreated peri-lunar luxation and subsequent lunar necrosis illustrates the legally effective problematic nature of two causes.

[Resection of the coracoacromial ligament. A simple surgical procedure for decompression of the subacromial space]

Resection of the coracoacromial ligament is a simple method for decompression of the subacromial space. The operation can be performed under arthroscopic control or by means of a small incision above the ligament. 61 patients were operated on by this method during the period between July 1987 and August 1988. 37 patients were questioned regarding the results. In 40% of these there was an alleviation of pain, 48% had an improved motility and 67% would again agree to the operation that appeared indicated (in the patients referred for surgery) both in the impingement syndrome and in antiquated ruptures of the rotator cuffs.

[Technics of primary and secondary amputation of the foot]

Maintenance therapy of the traumatized foot by partial amputation, in contrast to lower-leg amputation with subsequent artificial leg adjustment, should always be attempted if there is any possibility of shaping a stump that is independent of the prosthesis. As in former years, the disarticulation technique is performed; however, today the technique has been modified to obtain more functional results and to conserve tissue, which may mean that transosseous amputation is practicable. The quality of the soft-tissue flap and stability are the determining factors in the quality of the stump. These prerequisites mean that the operative technique must be adapted to the requirements of the patients; the soft tissue must be preserved and procedures used that will permit reconstructive procedures later.

[Synergistic joint diagnosis]

Many methods are useful in the diagnosis of diseases of the joints. Noninvasive methods deserve preference; invasive techniques such as arthrography and arthroscopy are second choice, after noninvasive methods have been applied. The synergic combination of the two last-named methods has proved successful. Arthrography, performed before arthroscopy in the operation theatre, supplements arthroscopy findings and extends the diagnostic value of the arthroscopic findings, in a similar manner as the combination of computed tomography and arthrography.

[Special aspects in the evaluation of patients with burn injuries]

A severe burn should be considered as not only damage to the skin surface but also as an injury to the whole metabolism. All the life endangering complications should be checked by the internist, the urological, and the neurological physician. Special consideration has to be given to contraction of the scars and their influence on strength and flexibility. The formation of keloid scars and instability are further problems to be overcome.

[Deficient precision in medical treatment--role of the expert witness in the liability process]

The medical expert as evidence in a liability process is himself under the criteria of accuracy which he has to proof by the doctor of his choice, for presentation at court. To know the viewpoints and circumstances are an assumption to judge the apparent lack of accuracy of the concerned person.

[Significance of ultrasound study in accident surgery]

Diagnosis via sonography has recently become firmly established also in accident surgery because of its manifold possibilities of application. The fact that the equipment is very mobile is of particular advantage in this field. It enables detection of intra-abdominal and intra-thoracic lesions, and to diagnose sequelae as well as associated diseases, especially in polytraumatised patients. If applied to the limbs, it becomes possible to discover particularly well all changes in the soft parts, such as haematomas, abscess formation, or effusions. This supplies important pointers towards deciding whether surgery should be performed, and in what way. The importance that sonography has gained in accident surgery is illustrated by the multifarious case reports covering a broad spectrum of different accidents and lesions.