Topical corticosteroid phobia in atopic dermatitis: International feasibility study of the TOPICOP score

BACKGROUND

Adherence to topical corticosteroids (TCS) is essential for the effective treatment of atopic dermatitis but can be limited by concerns about their use. This study examined the feasibility of applying the validated TOPICOP score for assessing TCS phobia across different countries.

METHODS

This was a prospective multicentre feasibility study conducted in 21 hospitals in 17 countries. Patients >3 months of age with atopic dermatitis or their parents or legal representatives completed a validated translation of the TOPICOP questionnaire in the country's native language. Respondents also completed questionnaires collecting opinions about the feasibility and acceptability of the TOPICOP questionnaire.

RESULTS

A total of 1564 participants in 15 countries were included in the analysis. 81% of respondents considered the questions clear or very clear, and 79% reported that it took less than 5 minutes to complete. Each of the individual items in the TOPICOP questionnaire was considered to be not at all difficult to answer by 49% to 74% of participants. The mean global TOPICOP score was 44.7%±20.5. Mean TOPICOP subscores were 37.0±22.8% for knowledge and beliefs, 54.7±27.8% for fears and 50.1±29.1% for behaviours. Global scores and subscores differed between countries, although the subscores did not always vary in parallel, suggesting different levels of TCS phobia and different drivers for each country.

CONCLUSIONS

The TOPICOP score can be feasibly applied across countries and may therefore be useful for obtaining qualitative and quantitative data from international studies and for adapting patient education and treatment.

[S2k-Guideline on Meniscus Diseases: from Aetiology to Scoring]

The number of patients with meniscal injuries is increasing constantly, but the treatment algorithms are undergoing continuous change. The effects of meniscal surgery, as well as the indications for the procedure, are currently a matter of heated debate. Various German speaking associations addressing topics related to the knee have joined forces to develop guidelines for the diagnosis, evaluation and therapy of meniscal lesions. The hope is that this first of two publications will shed light on some of the ongoing issues and offer guidance to health care professionals treating these patients.

Anisotropic Polar Magneto-Optic Kerr Effect of Ultrathin Fe/GaAs(001) Layers due to Interfacial Spin-Orbit Interaction

We report the observation of the anisotropic polar magneto-optical Kerr effect in thin layers of epitaxial Fe/GaAs(001) at room temperature. A clear twofold symmetry of the Kerr rotation angle depending on the orientation of the linear polarization of the probing laser beam with respect to the crystallographic directions of the sample is detected for ultrathin magnetic films saturated out of the film plane. The amplitude of the anisotropy decreases with increasing Fe film thickness, suggesting that the interfacial region is the origin of the anisotropy. The twofold symmetry is fully reproduced by model calculations based on an interference of interfacial Bychkov-Rashba and Dresselhaus spin-orbit coupling.

Childhood atopic dermatitis-Brain-derived neurotrophic factor correlates with serum eosinophil cationic protein and disease severity

Several studies have shown that neurotrophins including brain-derived neurotrophic factor (BDNF) play a role in chronic inflammatory skin diseases such as atopic dermatitis (AD). BDNF is increased in the serum samples of adults with AD. Interestingly, eosinophils of these patients can release and produce BDNF. We analyzed BDNF serum levels with ELISA and their correlation with SCORAD score, eosinophil cationic protein (ECP), total IgE, IL-4, IL-13 and IL-31 in children with AD (n = 56) compared to nonatopic healthy children (n = 25). In addition, we analyzed FLG loss-of-function mutations in 17 children with AD and their connection to BDNF. BDNF serum levels were significantly higher in children with AD. Further, BDNF correlated with disease activity, serum ECP, and total IgE serum levels in AD. There was no difference in BDNF levels of filaggrin-positive or filaggrin-negative children with AD, and there was no correlation of BDNF with IL-31 and Th2 cytokines including IL-4 and IL-13. Together, our data add new insights into the pathophysiology of AD, suggesting that serum BDNF which correlates with disease severity contributes to the regulation of inflammation in an eosinophil-, but not Th2-dependent manner.

TSLP, IL-31, IL-33 and sST2 are new biomarkers in endophenotypic profiling of adult and childhood atopic dermatitis

BACKGROUND

Recent years have seen growing interest in identifying new biomarkers in atopic dermatitis (AD) that could serve as indicators of disease severity and predictors of treatment response.

OBJECTIVES

We compared serum levels of thymic stromal lymphopoietin (TSLP), interleukin(IL)-31, IL-33 and soluble(s)ST2 in AD patients and healthy controls, investigated the possible correlation with disease severity, investigated if other atopic comorbidities could play a role, and assessed their potential as biomarkers in AD.

METHODS

Using standard enzyme-linked immunosorbent assay techniques, we measured target serum levels in 71 adults and 61 children with AD, and 31 adult controls. We characterized our cohort by disease severity, radioallergosorbent test status concerning both dietary and inhalant allergens, and anamnestic reports of food allergy, concomitant allergic asthma and/or allergic rhinitis.

RESULTS

Serum levels of TSLP, IL-31 and IL-33, but not sST2, were significantly elevated in AD patients compared with controls. In AD patients, both IL-31 and IL-33 serum levels were higher in children than in adults, while the opposite was the case for sST2. We observed no correlation between disease severity and any of the investigated targets. While serum TSLP levels were unaffected by concomitant allergies and atopic comorbidities, serum levels of IL-31, IL-33 and sST2 were affected to a small extent. We found a positive correlation between TSLP, IL-31 and IL-33, and an inverse relationship between IL-33 and sST2.

CONCLUSIONS

The studied targets hold little potential as indicators of disease severity. The serum values of our targets show robustness against atopic comorbidities, allergies and changes in disease severity. This robustness strengthens their potential use in biomarker-based stratification and could be instrumental in identifying subgroups and predicting the possible benefit of therapeutic and prevention approaches.

Therapy outcome after multidisciplinary treatment for chronic neck and chronic low back pain: a prospective clinical study in 365 patients

OBJECTIVES

This prospective longitudinal clinical study analyses the therapy outcome of 365 patients with either chronic neck (n = 134) or low back (n = 231) pain treated with a multidisciplinary biopsychosocial therapy approach.

METHODS

Patients with chronic neck pain (NP) or low back pain (LBP) for 3 months or longer, corresponding sick leave for longer than 6 weeks, and clearly defined inclusion and exclusion criteria underwent a 3-week standardized inpatient multidisciplinary biopsychosocial therapy. Baseline sociodemographic, occupational, functional, and psychological data at entry into the study (T0) were comparable in both groups. At the 6-month follow-up (T1), five different therapy outcomes were analysed in both groups: back-to-work status, generic health status (the 36-item Short Form Health Survey, SF-36), pain intensity (visual analogue scale), functional capacity (Hannover back capacity score), and satisfaction with the therapy.

RESULTS

Both treatment groups improved significantly in all outcome criteria between T0 and T1. In the total group, the back-to-work rate was 67.4%. At the final follow-up there were no significant differences between the group with chronic NP and the group with chronic LBP in the outcome criteria back-to-work status, improvement of health status and functional capacity, satisfaction with therapy, and reduction of pain.

CONCLUSION

Evaluation of the main results of this study suggests that patients with chronic NP also derive significant benefit from a multidisciplinary treatment strategy, demonstrated in the literature so far mainly for patients with chronic LBP.

[Comorbidity in patients with chronic low back pain]

BACKGROUND

Studies concerning comorbidity in patients with chronic low back pain and its correlation to the stage of chronification are rare.

METHODS

This case-control study (matched-pair analysis) examines the number and specificity of comorbidity as well as the extent of disability due to comorbidity in 51 patients with chronic low back pain compared to age- and sex-matched control persons. Moreover, the correlation of comorbidity and the stage of chronification was analysed in these patients.

RESULTS

Patients with chronic low back pain had significantly more comorbidities and a higher disability due to comorbidity compared to the control persons. The higher the stage of chronification according to the Mainz Pain Staging System (MPSS) the higher was the number of comorbidities.

CONCLUSION

Comorbidity should be given due consideration when evaluating diagnosis, therapy, prognosis and therapy outcome in patients with chronic low back pain.

Multimodale Therapie bei chronischem HWS- und LWS-Schmerz

BACKGROUND

Multimodal therapy has been established for patients with chronic low back pain, but studies reporting results in patients with chronic neck pain are rare.

METHODS

This prospective clinical study compared the results in 97 patients with chronic cervical pain and 231 patients with chronic lumbar pain after three weeks of multimodal therapy. The following factors were analyzed in both groups at the beginning and after 6 months: ability to work, pain intensity and functional back capacity.

RESULTS

Both groups had improved significantly after 6 months in all outcome parameters. Functional back capacity and ability to work at 6 months were not different between the two groups, but pain intensity was significantly lower in patients with low back pain compared to patients with neck pain.

CONCLUSION

Multimodal therapy is also an efficient treatment strategy for patients with chronic cervical pain as has already been shown for patients with chronic lumbar pain.

[Bone and soft-tissue tumors of the foot and ankle]

BACKGROUND

This study reports the epidemiology of bone and soft-tissue tumors of the foot and ankle, presents therapy strategies, and evaluates mid-term clinicofunctional outcome after surgery for malignant tumors.

METHODS

Two hundred four patients with tumors of the foot and ankle were analyzed (163 benign and 41 malignant). Epidemiology and surgical therapy are reported.

RESULTS

The most frequent tumors were exostosis, bone cyst, and osteoid osteoma for benign tumors and metastases and chondrosarcoma and Ewing's sarcoma for malignant tumors. In more than 90% of the benign tumors, local resection could be carried out, whereas in malignant tumors, ablative procedures and arthrodeses were almost as common as limb- and joint-sparing techniques. However, follow-up revealed good functional results and a 5-year survival rate of 84% for patients with primary malignant tumors.

CONCLUSION

Tumors of the foot and ankle require a thorough therapeutic strategy. Mid-term functional results and survival rate after surgical treatment are good, although a high percentage of ablative procedures or fusions could not be avoided in our patients.

Pain and high sensitivity C reactive protein in patients with chronic low back pain and acute sciatic pain

BACKGROUND

The severity of pain from musculoskeletal disorders might be associated with high sensitivity C reactive protein (hsCRP), a sensitive marker of low grade systemic inflammation.

OBJECTIVE

To study the association between pain as assessed by a visual analogue scale (VAS) and hsCRP in patients with chronic low back pain and acute sciatic pain.

METHODS

Information on pain severity, determinants of hsCRP, and hsCRP values were obtained prospectively at up to 10 time points during six months in 72 consecutive patients (mean age 43.3 years; 59.7% female): 41 with chronic low back pain and 31 with acute sciatic pain. The association between severity of pain and raised (highest quartile) hsCRP values at any time point was estimated by multivariable logistic regression using generalised estimating equations to adjust odds ratios (OR) and their confidence intervals (CI) for intraindividual dependence of measurements.

RESULTS

Mean intensity of pain (VAS 0-10) at baseline was 4.9 and 5.5 in patients with chronic low back and acute sciatic pain, respectively. Highest v lowest tertile of average intensity of pain during the last 24 hours was associated with increased hsCRP levels among patients with acute sciatic pain (adjusted OR = 3.4 (95% CI, 1.1 to 10), but not in patients with chronic low back pain (adjusted OR = 0.87 (0.25 to 3.0)).

CONCLUSIONS

Mean intensity of pain during the previous 24 hours as assessed by VAS was independently associated with high levels of hsCRP in patients with acute sciatic pain but not in those with chronic low back pain.

Druckverteilungsmessung nach Scarf-Osteotomie bei Hallux valgus

AIM

This study evaluates the pressure distribution, the radiological and clinical results in patients before surgery and 6 months after scarf osteotomy for hallux valgus.

METHODS

29 patients were examined before surgery and 6 months after surgery for symptomatic hallux valgus. Pedographic analysis was performed by dividing the footprint of the patients into 8 regions of interest. For each region the maximum mean pressure and the peak pressure were evaluated. Moreover, clinicofunctional results (AOFAS score) and radiological results were evaluated.

RESULTS

6 months postoperatively, maximum mean pressure increased significantly under the medial forefoot where as the peak pressure in this region revealed indifferent results. Significant improvement of clinicofunctional results and a significant reduction of the intermetatarsal and metatarsophalangeal angle could be seen.

CONCLUSION

These results confirm the clinical and radiological findings of other studies, but this study shows for the first time an increase of pressure under the first ray of the foot after hallux valgus surgery and an adaptation to the pressure distribution of normal feet.

Complications following operative treatment of primary malignant bone tumours in the pelvis

AIM

To report the complication rates of limb-salvage reconstruction in the pelvis. Detailed analyses about the type, treatment and outcome of post-operative complications, various reconstruction options are presented.

METHODS

Factors that might influence the occurrence of complications were evaluated of 50 consecutive surgically treated patients.

RESULTS

The mean follow-up was 57 months. Limb-salvage procedures were used in 42/50 patients, amputations in 8/50 patients. After limb-salvage procedures complications occurred in 32/42 patients, after hemipelvectomy in 6/8 patients. The 1 and 5-year overall survival rate was 92 and 68%, respectively.

CONCLUSION

There is a high complication rate in reconstructive techniques using hemipelvic autografts and/or allografts. These procedures are appropriate only in well selected patients. The complication rates following endoprosthetic reconstruction are comparably low.

Primary malignant tumours of bone and soft tissue in the elderly

AIMS

This study reports outcome, functional results and quality of life of 45 elderly patients with age over 70 after surgery for primary malignant bone and soft tissue tumours.

METHODS

There were 24 primary malignant bone tumours and 21 soft tissue sarcomas. The most frequent diagnoses were: chondrosarcoma, malignant fibrous histiocytoma and liposarcoma. Local tumour resection with and without osteosynthesis, endoprostheses, and amputations had been performed for surgery. The patients were prospectively followed in a tumour register.

RESULTS

Complication and revision rate, functional outcome using the Musculoskeletal Tumor Society score, 5-year survival rate, median survival time and quality of life according to the Life Satisfaction Index A and the global health and quality-of-life scale of the QLQ-C30 revealed results that are only slightly inferior to those reported in younger tumour patients.

CONCLUSIONS

The results of this study generally justify even extensive tumour surgery in the elderly patient over 70 although outcomes are not quite as good as those reported for younger adults. However, especially in the old patient indications like general condition and comorbidity should be given due consideration before any decision is made on whether surgery should be performed and if so what surgical technique should be applied.

[External or internal fixation for arthrodesis of the ankle -- a comparative study of perioperative and long-term results]

SUBJECT

This study evaluates the results of external and internal fixation techniques for arthrodesis of the ankle.

METHODS

Perioperative and subjective, clinical, and radiological long-term results (average follow-up: 9 years) in 55 patients following arthrodesis of the ankle due to posttraumatic arthritis were compared in two groups with different fixation techniques--compression arthrodesis with external fixator (AO) or internal screw fixation.

RESULTS

Patients with external fixation revealed a significantly higher deep infection rate, which was treated conservatively, while the rates of nounion, revision surgery due to infection, and total revision surgery did not show any difference in the two groups.

CONCLUSION

Both surgical techniques applied mostly guarantee a safe and stabile fixation in arthrodesis of the ankle and provide convincing long-term results without showing a difference in comparing the outcome.

Intraoperative extrakorporale Irradiation und Replantation (IEIR) in der lokalen Behandlung prim�r maligner Knochentumoren

In 13 patients with primary malignant bone tumors (10 Ewing's sarcoma, 1 parosteal osteosarcoma, 1 adamantinoma recurrence, and 1 MFH) local therapy was performed as intraoperative extracorporeal irradiation and replantation (IEIR) of the involved bone segment (5 tibia, 2 femur, and 6 pelvis). Of the 13 patients (69%), 9 are alive at the time of the follow-up (5 CDF, 4 AWM(treated)) and 4 patients died of disease (DOD). Up to now during the follow-up of 32 months (6-57), no local recurrence was observed in the replanted bone segments. The complication rate was very high (18 complications in 11 of the 13 patients, including 6 cases with complication V degrees according to Ruggieri with loss of the reconstruction). The typical complication is severe local infection necessitating removal of the replant. In cases of mechanical failure, the replanted segment could mostly be preserved by surgical revision and autologous bone grafting. If serious complications can be managed or avoided, functional results can be achieved. IEIR must be seen as an extraordinary reconstruction procedure in cases where established procedures such as endoprosthesis, biological reconstructions, or rotationplasties cannot be used or are refused by the patient.

Esomeprazole-based one-week triple therapy with clarithromycin and metronidazole is effective in eradicating Helicobacter pylori in the absence of antimicrobial resistance

AIM

This study aimed to investigate the effectiveness of a one-week triple therapy with esomeprazole, clarithromycin and metronidazole for eradication of Helicobacter pylori infection in the absence of antimicrobial resistance.

METHODS

Patients testing positive for H. pylori susceptible to metronidazole and clarithromycin (E-test) were randomized to receive a one-week regimen with either esomeprazole 2 x 20 mg or omeprazole 2 x 20 mg in combination with clarithromycin 2 x 250 mg and metronidazole 2 x 400 mg. Follow-up endoscopy with histology and culture and/or rapid urease test was performed 4-8 weeks after the end of treatment.

RESULTS

Eighty patients were randomized. Helicobacter pylori infection was cured in 38/39 patients of the esomeprazole group and 31/33 patients of the omeprazole group (per protocol 97.4% (95% confidence interval [CI], 86.2-99.9), 93.7% (95% CI, 79.2-99.2), P=0.59); intention-to-treat 90.4% (95% CI: 77.4-97.3), 81.6% (95% CI: 65.7-92.3), respectively. No major side effects occurred. Minor side effects occurred in eight (20%) and six (23%) patients during esomeprazole and omeprazole therapy, respectively. Post-treatment susceptibility testing revealed resistance to both metronidazole and clarithromycin in two of the three patients who failed.

CONCLUSION

We conclude that esomeprazole, clarithromycin and metronidazole as one-week triple therapy is effective for eradication of H. pylori in the absence of antimicrobial resistance.

Epidural corticosteroid injection in the conservative management of sciatica

In this prospective randomized clinical trial, the results of epidural corticosteroid injections were evaluated in patients with lumbosciatic pain caused by herniated nucleus pulposus. Thirty-six patients with radicular lumbosciatic pain and positive straight leg raising test because of confirmed prolapsed intervertebral lumbar discs were randomized into two groups with (17 patients) and without (19 patients) epidural corticosteroid injection. Members of the treatment groups received three injections of 100 mg methylprednisolone in 10 mL bupivacaine 0.25% each. Additional therapy was standardized and identical in both groups. Followup examinations were performed at 2 weeks, 6 weeks, and 6 months. The examinations included pain level (visual analogue scale), straight leg raising test, and functional status (Hannover Functional Ability Questionnaire). At 2 weeks, patients receiving methylprednisolone injection showed a significant improvement in straight leg raising test results compared with patients in the control group. Results were better in the methylprednisolone group, although not statistically significant for pain relief and mobility. At 6 weeks and 6 months, pain relief, improvement of straight leg raising, and improvement of functional status showed no statistical significance. Epidural corticosteroid injections can be recommended as additional therapy only in the acute phase of the conservative management of lumbosciatic pain.

Therapeutic efficacy of L-ornithine-L-aspartate infusions in patients with cirrhosis and hepatic encephalopathy: results of a placebo-controlled, double-blind study

One hundred twenty-six patients with cirrhosis, hyperammonemia (>50 micromol/L), and chronic (persistent) hepatic encephalopathy (HE), which developed spontaneously without the existence of known precipitating factors, were enrolled in a randomized, double-blind, placebo-controlled clinical trial of intravenously administered L-ornithine-L-aspartate (OA). Patients with subclinical (grade 0, West-Haven criteria) hepatic encephalopathy (SHE), characterized by a prolonged number connection test A (NCT-A) time, and manifest HE (grades I and II, West-Haven criteria) were included in the investigation. The trial was planned as a confirmatory clinical trial OA administered in a dose of 20 g/d, as well as placebo, were dissolved in 250 mL of 5% fructose and infused intravenously for a period of 4 hours during 7 consecutive days with a superimposed protein load at the end of the daily treatment period. Primary variables were postprandial venous ammonia and NCT-A performance time measured following OA or placebo infusions to evaluate the net effect of the treatment on the prevention of the protein-induced hyperammonemia, and on parameters such as NCT-A influenced by hyperammonemia. Mental state gradation, portal systemic encephalopathy index (PSEI), and fasting ammonia levels were estimated as additional efficacy parameters. The data presented are based on the total study sample (intent-to-treat analysis), which included 63 patients in the placebo group and 63 patients in the OA group. Of the 126 patients, 114 met all the criteria for inclusion and completed the trial and treatment as outlined in the protocol (treated-per-protocol analysis). During baseline, the placebo and treatment groups were homogeneous with regard to mental states, NCT-A performance time, fasting venous blood ammonia levels, and Child-Pugh criteria. Although a slight improvement occurred in the placebo group, NCT-A performance times (P < .001) and postprandial venous ammonia concentrations in the OA-treated group showed improvements in comparison with placebo. In addition, venous fasting blood ammonia concentration (P < .01), mental state gradation (P < .001), and PSEI (P < .01), which includes the mental state gradation, NCT-A time, and postprandial venous ammonia in this trial, improved to a much higher degree in the OA group than in the placebo group. In subgroups retrospectively classified according to their initial mental state gradation, OA showed differential but uniformly significant efficacies in patients with manifest HE with respect to ammonia-lowering, improvement in NCT times, and mental state gradation. In patients with initial SHE, OA revealed differences between the medications in the psychometric test used. Adverse events consisting of mild gastrointestinal disturbances were observed in 3 of the OA-treated patients (5%). OA infusion appears to be a safe, effective treatment of chronic (persistent) manifest HE in cirrhotic patients. Additional investigations are required to assess the efficacy of OA in patients with SHE, as well as in patients with more severe grades of HE.

[Mid-term outcome after surgically managed re-rupture of the anterior cruciate ligament]

This retrospective study shows the results in 30 patients of revision surgery on their reruptured ACL. The follow-up time was 30 months on average (range 10-54 months). The follow-up examination included subjective (Lysholm score, Tegner activity level rating score), clinical and radiological criteria and also instrumental laxity testing with the KT-1000 arthrometer. The overall evaluation was done according to the IKDC score. The follow up showed subjective and objective results almost equal to those after primary surgery on ACL. The IKDC score revealed certain abnormal and highly abnormal results, which demonstrated that revision ACL surgery gives poorer results than primary surgery. Nevertheless, we recommend reconstruction of a torn ACL even in a revision case to restore the knee function and prevent further menisceal and chondral damage and degeneration.

[Anti-oxidative therapy of pancreatitis--an 18-month interim evaluation]

99 patients affected with acute pancreatitis of different genesis were treated in hospital (necrotizing n = 38, mild form n = 61) from May 1990 to November 1991. Nearly 80% of these illnesses were ethanol-induced, 12% were of biliary origin. 90 patients were submitted to an adjuvant antioxidant therapy with selenium and D-alpha-tocopherol (necrotizing form n = 29, mild form n = 61). The average lethality rate of 34% (1982-1989) fell to 1.1% (1 female patient with biliarily induced pancreatitis). No lethal courses were observed in alcohol-induced, idiopathic, post-traumatic, and post-operative forms. Clinical courses proceeded more easily under adjuvant antioxidant therapy, surgical treatment was not necessary. A treatment at reasonable costs can be made in all general internal wards.

[Acute pancreatitis--a free radical disease. Decrease in fatality with sodium selenite (Na2SeO3) therapy]

Malonic dialdehyde as an indirect marker of the lipid peroxidation was found increased in the acute pancreatitis compared with persons of the same age and sex. Its concentrations inversely correlated to those of the serum calcium during the course of the disease and additionally they proved to be indicator of the prognosis. Postulating that the acute pancreatitis must be a "free radical disease", in a randomized clinical study the adjuvant therapy of the acute necrotizing pancreatitis (n = 8) with sodium selenite was carried out in a daily dose of 500 micrograms. The lethality of the control group was 89% (8 out of altogether 9 patients), no patient died in the therapy group. By the selenium therapy within 24 hours a normalization of the serum calcium and a decrease of the increased MDA-values could be achieved. It was concluded that by selenium increased activities of the phospholipid-hydroperoxide-glutathione peroxidase were induced, by means of which a peroxidation protection of membrane fatty acids, an inhibition of the activity of phospholipase A2 and an interruption of the arachidonic acid cascade must have been reached.

[Distribution of aflatoxin M1 in whey and curd during cheese processing (author's transl)]

In model experiments on the distribution of aflatoxin M1 in whey and curd, the influence of the different processing steps was investigated. Taking the same weight ratio between whey and curd, the following results were obtained: a) The aflatoxin M1-distribution in whey and curd was not changed with increasing amounts of rennet, thus decreasing the renneting time at constant renneting temperatures. b) With increasing renneting temperatures, however, the toxin's percentage in the curd decreased at constant amounts of rennet, whereas the whey's content remained stable. For the commonly used temperature variations between 28 and 35 degrees C, the toxin content of the cheese varied in the range of about 12%. c) Processing of curd by acidification with different organic acids at constant temperatures did not show any change in the aflatoxin M1 distribution as compared to rennet coagulation. d) Curd processing by means of starter cultures led to a decrease in the aflatoxin M1 in curd only at higher temperatures; the toxin's percentage in whey remained practically the same. e) Washing of the curd with the 2 1/2 volumes of water decreased the aflatoxin M1 content of cheese by 22%.