Can Wrist-Worn Medical Devices Correctly Identify Ovulation?

(1) Background: Hormonal fluctuations across the menstrual cycle lead to multiple changes in physiological parameters such as body temperature, cardiovascular function, respiratory rate and perfusion. Electronic wearables analyzing those parameters might present a convenient alternative to urinary ovulation tests for predicting the fertile window. (2) Methods: We conducted a prospective observational study including women aged 18-45 years without current hormonal therapy who used a wrist-worn medical device and urinary ovulation tests for a minimum of three cycles. We analyzed the accuracy of both the retrospective and prospective algorithms using a generalized linear mixed-effects model. The findings were compared to real-world data from bracelet users who also reported urinary ovulation tests. (3) Results: A total of 61 study participants contributing 205 cycles and 6081 real-life cycles from 3268 bracelet users were included in the analysis. The mean error in identifying ovulation with the wrist-worn medical device retrospective algorithm in the clinical study was 0.31 days (95% CI -0.13 to 0.75). The retrospective algorithm identified 75.4% of fertile days, and the prospective algorithm identified 73.8% of fertile days correctly within the pre-specified equivalence limits (±2 days). The quality of the retrospective algorithm in the clinical study could be confirmed by real-world data. (4) Conclusion: Our data indicate that wearable sensors may be used to accurately detect the periovulatory period.

Evaluation of two rapid commercial assays for detection of Streptococcus agalactiae from vaginal samples

INTRODUCTION

Streptococcus agalactiae, also known as group B streptococci (GBS), is associated with invasive infections in neonates. Identification of GBS vaginal colonization in pregnant women before delivery is essential for treatment with antibiotics to prevent intrapartum vertical transmission to the newborn. This study was designed to evaluate applicability of two rapid real-time PCRs in comparison to standard culture identification.

MATERIAL AND METHODS

We compared the Xpert GBS assay, hereafter referred to as Xpert, and GenomEra GBS PCR, hereafter referred to as GenomEra. The standard culture identification consisted of two different agar plates as well as an enrichment broth.

RESULTS

We analyzed vaginal samples of 260 pregnant women; 42 samples were tested GBS-positive by using standard culture as a gold standard, 30 by Xpert, and 37 by GenomEra. Xpert and GenomEra assays performed with sensitivities of 71.4% and 88.1% as well as specificities of 98.6% and 99.1%, respectively. Twelve vaginal samples were false-negative by Xpert and five samples by GenomEra. Interestingly, three negative Xpert results of standard culture-positive samples exhibited high Ct-values indicating the presence of GBS. If higher Ct-values are taken into consideration, the sensitivity of Xpert increases up to 78.6%. Moreover, only three Xpert PCRs had to be repeated, whereas two Genomera were invalid even after repetition and further 15 GenomEra PCRs were repeated because of borderline results or inhibition of the PCR test.

CONCLUSIONS

In this study, GenomEra assay performed with a higher sensitivity than the Xpert PCR. On the other hand, the Xpert assay needs less hands-on-time for a sample preparation and requires approximately four-fold less repetitions as compared to the GenomEra assay. This robust performance of the Xpert assay make it applicable as a rapid intrapartum point-of-care test, although a higher sensitivity would be desirable. Therefore, culture in the 35-37 week of gestation remains the gold standard to detect vaginal colonization.

Impact of heatwaves and environmental ammonia on energy metabolism, nitrogen excretion, and mRNA expression of related genes in the indicator model system Daphnia magna

Due to increasing anthropogenic impacts, heatwaves and prolonged exposure to elevated concentrations of ammonia (HEA) may occur in aquatic environments as a single stressor or a combination thereof, potentially impacting the physiology of exposed animals. In the current study, common water fleas Daphnia magna were exposed for one week to either a 5°C increase in temperature, an increase of 300 µmol l^-1 total environmental ammonia, or to both of these stressors simultaneously. Exposure to elevated temperature caused a decrease in MO₂, ammonia excretion rates, a downregulation of mRNA coding for key Krebs cycle enzymes and the energy consuming Na⁺/K⁺-ATPase and V-type H⁺-ATPase, as well as the energy distributing crustacean hyperglycemic hormone Rh-protein. High environmental ammonia inflicted a lesser inhibitory effect on the energy metabolism of Daphnia, but initiated ammonia detoxification processes via urea synthesis evident by elevated urea excretion rates and a mRNA upregulation of arginase. Effects observed under the combined stressors resembled largely the effects seen after acclimation to elevated temperature alone, potentially due to the animals' capability to efficiently detoxify critical ammonia loads. The observed physiological effects and potential threats of the environmental stressor are discussed in detail.

Is there evidence for potential harm of electronic cigarette use in pregnancy?

BACKGROUND

Use of electronic cigarettes (e-cigarettes) and other nicotine containing products is increasing among women of reproductive age. The short- and long-term effects of these products on both mother and fetus are unknown.

METHODS

Because e-cigarettes are nicotine delivery systems, we sought to conduct a comprehensive review of the effects of nicotine on the fetus.

RESULTS

In utero nicotine exposure in animal models is associated with adverse effects for the offspring lung, cardiovascular system and brain. In the lung, this included reduced surface area, weight, and volume, as well as emphysema-like lesions. In adulthood, exposed offspring demonstrate elevated blood pressure and increased perivascular adipose tissue. In the brain, exposure alters offspring serotonergic, dopaminergic, and norepinephrine networks, which in turn are associated with behavioral and cognitive impairments. We also review current data on the lack of efficacy of nicotine replacement therapy in pregnant women, and highlight different nicotine containing products such as snuff, snus, and hookah.

CONCLUSION

We conclude that no amount of nicotine is known to be safe during pregnancy, and studies specifically addressing this risk are crucial and an imminent public health issue.

'Now I understand': consulting parents on chart design and parental information for the UK-WHO child growth charts

BACKGROUND

Regular assessment of growth is an important part of child health surveillance in the UK and most parents are very interested in their child's growth. UK parents are given a personal child health record (PCHR), including growth charts, which are plotted during baby clinic visits. Parents were consulted as part of the process of designing new UK charts to incorporate the World Health Organization growth standard. This paper describes the main themes that emerged and how they influenced the final design.

METHOD

Three sets of consultations with 47 parents were conducted to collect preliminary information, and to evaluate proposed chart designs, instructions and written information for parents.

RESULTS

  At every consultation, the impact of the depiction of the 50th centile line in bold was mentioned spontaneously by parents. They also found aspects of the charts unclear, including the implications of a recorded weight on any particular centile, the difficulty of understanding existing text about charts in the PCHR, their preference for using pounds and ounces rather than metric weights and confusion about how frequently babies should be weighed. This led to the production of parental information including explanation of these issues which were then tested in two further sets of focus groups.

CONCLUSION

Involving parents in the process of designing growth charts and information influenced the finished design and the text in the PCHR. Ensuring information meets parents' needs is important to ensure successful growth monitoring.

[Immunonutrition after trauma]

Immunonutrition may be superior to standard clinical nutrition in specific clinical situations. After severe trauma, an enteral immuno-enhancing diet, enriched with arginine, omega-3 fatty acids, and nucleotides, decreases infectious complications. During acute respiratory distress syndrome, a continuous enteral diet with high-dose omega-3 fatty acids, gamma-linolenic acid, and antioxidants improved clinical outcome. Glutamine should be administered enterally or parenterally whenever total parenteral nutrition is indicated.

Tuning spin-orbit coupling and superconductivity at the SrTiO{3}/LaAlO{3} interface: a magnetotransport study

The superconducting transition temperature T{c} of the SrTiO{3}/LaAlO{3} interface was varied by the electric field effect. The anisotropy of the upper critical field and the normal-state magnetotransport were studied as a function of gate voltage. The spin-orbit coupling energy epsilon{SO} is extracted. This tunable energy scale is used to explain the strong gate dependence of the mobility and of the anomalous Hall signal observed. Epsilon{SO} follows T{c} for the electric field range under study.

Microarray analysis of placental tissue in intrauterine growth restriction

OBJECTIVE

Besides foetal or maternal disorders, placental dysfunction is a major cause of intrauterine growth restriction (IUGR). Although numerous macro- and histopathological changes have been described, little is known about the precise aetiology and the contribution of foetal/placental genes in this disorder.

DESIGN

Placental tissues of 20 IUGR and control neonates were analysed by microarray technique. Four of the regulated genes with possible relevance in the pathogenesis of IUGR and its consequences were further studied in placentas of 27 IUGR and 35 control newborns.

RESULTS

Elevated gene expression of leptin, corticotrophin-releasing hormone (CRH), and IGF-binding protein-1 (IGFBP-1) in IUGR placentas could be confirmed in the larger group by real-time PCR, whereas prolactin showed no significant difference. Accordingly, protein expression of leptin and IGFBP-1 depicted by Western blot was elevated in IUGR, prolactin was not different. Birthweight standard deviation score (SDS) correlated negatively to leptin, IGFBP-1, and CRH, whereas placental weight correlated only to IGFBP-1. Leptin correlated negatively to gestational age of IUGR patients and positively to placental score, a marker of severity of impaired foeto-placental circulation.

CONCLUSIONS

As confirmed in a large group of IUGR and control samples, the up-regulated factors leptin, IGFBP-1, and CRH may serve as candidate genes for the prediction of subsequent metabolic consequences in IUGR newborns. These three factors may not only influence growth of the foetus, but might also interact with programming of its metabolic functions, which has to be determined in an ongoing study.

[The medical history as a historical source. As an example, the story of a war comrade of the "English patient", Count László Ede Almásy (1895-1951) is presented]

The medical history is an important prerequisite for making a diagnosis and for establishing a trust- based doctor-patient relationship. Sometimes they can also serve as a historical source, as this example of an 89-year old patient shows. The patient worked with the Hungarian Count László Ede Almásy (1895-1951) during a German military secret service operation in North Africa during the Second World War. Graf Almásy became internationally famous through the novel "The English Patient" by Michael Ondaatje or rather, through the film of the same name. In the film however, the historical facts were very distorted as the medical history of our patient shows.

Sex differences in baseline neuropsychological function and concussion symptoms of collegiate athletes

OBJECTIVE

To investigate sex differences in baseline neuropsychological function and concussion symptoms between male and female collegiate athletes.

METHODS

A post-test only design was used to examine baseline neuropsychological test scores and concussion symptoms. A total of 1209 NCAA Division I collegiate athletes from five northeastern universities in the USA completed a baseline ImPACT test. ImPACT, a computerised neuropsychological test battery, was administered during an athlete's pre-season.

RESULTS

Female athletes performed significantly better than male athletes on baseline verbal memory scores (p = 0.001), while male athletes performed significantly better than female athletes on baseline visual memory scores (p = 0.001). Female athletes endorsed a significant number of mild baseline symptoms as compared to male athletes.

CONCLUSIONS

Male and female athletes exhibit differences on baseline neuropsychological test performance and concussion symptoms.

Anwendung der optischen Kohärenztomographie (OCT) bei der Darstellung von Urothelerkrankungen der Harnblase

PURPOSE

The technique of optical coherence tomography (OCT) has significantly improved over the last few years. This new diagnostic procedure allows imaging of tissue structure of the bladder wall during cystoscopy with high resolution.

MATERIALS AND METHODS

The penetration depth of OCT is limited to 2.5 mm. The resolution is approximately 15 microm. Fifty patients with different clinical conditions of the bladder were examined. Altogether 488 OCT images were generated.

RESULTS

OCT of normal bladder mucosa clearly shows a differentiation between urothelium, lamina propria, and smooth muscle. Cystitis and metaplasia are characterized by blurring of the laminated structure and thickening of the epithelial layer. In malignant areas there is complete loss of the regular layered tissue structure.

CONCLUSION

OCT improves the diagnosis of flat lesions of the urothelium. It has the potential for facilitating intraoperative staging of malignant areas in the bladder.

Posterior "nutcracker" phenomenon: hemodynamic relevant aorto-retroaortal renal vein fistula leading to fatal right heart failure

A rare complication of an aneurysm of the abdominal aorta is the so-called "posterior nutcracker phenomenon", which describes compression of a retroaortal renal vein between the abdominal aorta and the vertebral column. The clinical presentation is flank pain and hematuria, which are usually caused by a renal (respectively ureteral) calculus or neoplasia. Another rare differential diagnosis for these very common clinical symptoms is an aorto-left renal vein fistula (ALRVF), which is a spontaneous vascular fistula, usually also associated with an aortic aneurysm, infrequently a result of abdominal trauma.

[The impact of ALA (5-aminolevulinic acid)-fluorescence detection on the prognosis of superficial bladder cancer]

PURPOSE

Throughout the past years, several studies have shown that fluorescence cystoscopy with ALA (5-aminolevulinic acid) improves the detection rate of superficial bladder tumors by approximately 20 % compared to standard white light cystoscopy. These results suggest a reduced rate of residual/recurrent tumors with the routine use of ALA fluorescence technique prior to bladder tumor resection. The present prospectively randomized study was performed to verify this hypothesis.

MATERIALS AND METHODS

A total of 115 bladder tumor patients were randomized for initial resection under white light or ALA fluorescence. After 6 to 8 weeks, a second-look resection was performed in all patients guided by ALA fluorescence. Additional white light cystoscopies were performed after 3, 6 and 12 months.

RESULTS

The second-look resection did not find a tumor in 31 of 51 (59 %) patients initially resected under white light guidance compared to 43 of 51 (84 %) patients in the fluorescence group. This difference was statistically significant (p = 0.005). At 12 months, a tumor was not found in 17 of 48 patients from the white light group vs. 25 of 47 patients from the fluorescence group (p = 0.03). Seven patients were lost to follow-up.

CONCLUSIONS

By reducing otherwise inevitable re-operations, fluorescence cystoscopy decreases morbidity and lowers treatment costs.

CYP1A1 alleles in women with focal nodular hyperplasia of the liver (FNH)

OBJECTIVE

Disorders of steroid hormone metabolism might be related to the etiology of focal nodular hyperplasia of the liver (FNH), a benign tumor, especially prevalent in women. The cytochrome P450 1A1 (CYP1A1) enzyme is implicated in the bioactivation of multiple precarcinogens as well as in the metabolism of steroids. Genetic polymorphisms of CYP1A1 have been associated with altered catalytic activity in the hydroxylation of sex hormones and this may account for interindividual variability in exposure to hormone-mediated cell proliferation signals and reactive steroid metabolites. In the study at hand, we aimed to evaluate a possible association between CYP1A1*1, *2A, *2B, and *4 alleles and FNH.

METHOD

Genotyping of 26 affected female patients of Caucasian origin was carried out using PCR/RFLP.

RESULTS

Allele frequencies for the CYP1A1 variants *2A, *2B and *4 in 26 female patients with FNH were 0.058, 0.019 and 0.058, respectively. Crude odds ratios for the individual alleles were 0.75 (95% CI 0.23-2.44), 0.72 (95% CI 0.10-5.34) and 1.96 (95% CI 0.59-6.50), respectively. There were no significant differences between these values and corresponding allele frequencies obtained in a large German sample of unaffected Caucasian women.

CONCLUSION

The present data do not suggest a relevant association between CYP1A1 polymorphisms and focal nodular hyperplasia of the liver in female Caucasians.

[The prohibition of lithotomy within the Hippocratic Oath: historical and ethical considerations on the history of surgery]

A passage with one of the most contradictory interpretations of the so-called Hippocratic Oath, which was presumably created between 500 and 300 before Christ, is the prohibition of lithotomy. The oldest handwritten traditions of the Hippocratic Oath are dating back to the 11th-12th century. However the section of the prohibition of lithotomy is missing in the oldest preserved tradition (Codex Urbinas gr. 64), which led to some authors interpretation of being added later on. Beyond all doubt the analysis of the texture of the Hippocratic Oath leads to the conclusion that the prohibition of bladder stone lithotomy must have been an integrative part of the oath from the very first beginning. The author could have been inspired by the following reasons to have a non oath related doctor let done the medical operation: the removal of a bladder stone by an operation, which was outfitted with many complications, was one of the most difficult surgical interventions in the antique. Celsus (1st century A. D.) mentioned "severe fever, urine fistula and deadly inflammations" after lithotomy. Since the operation was done perineally, presumably a negative sexual potency was feared. No doctor engaged to help and not to harm his patients was allowed to make this kind of operation, which was often followed by many complications. Nevertheless sometimes patients were "tantalised to death by suffering dreadful pain" through those bladder stone diseases. Consequently "practising men" (the term "surgeon" was created at a later date), those who had been specialised in that operation and had not been linked to the oath, were allowed to make this kind of dangerous operation. Due to a greater experience of those specialists (named as "Lithotomos" by Celsus ih the 1st century A. D.) the danger of this kind of operation was reduced. The prohibition of lithotomy could be interpreted as a commitment to realize the limits of ones own medical actions.

[Wound management with coconut oil in Indonesian folk medicine]

The medical plants which are used to treat wounds and injuries by the ethnic group of Ngada on Flores, an Eastern Indonesian island, will be presented. Additionally, the coconut oil used to treat wounds and to conserve medicinal plants will be analysed biochemically. The people of Ngada use the following plants for wound treatment: seeds of the betel nut (Areca catechu L.), fruits of papaya (Carica papaya L.), leaves of the Indian Hydrocotyle (Centelle asiatica L.), the rhizome of turmeric (Curcuma domestica Val. and Curcumara xanthorrhiza Roxb.), leaves of betel (Piper betel L.). Coconut oil is particularly useful because of its biochemical structure: unlike olive oil and animal fatty tissue, it consists of short-chained and saturated fatty acids. These qualities in coconut oil prevent it from becoming oxidized and rancid, thus making it suitable for the preservation of medicinal plants and for wound treatment.

Novel p62dok family members, dok-4 and dok-5, are substrates of the c-Ret receptor tyrosine kinase and mediate neuronal differentiation

Docking proteins are substrates of tyrosine kinases and function in the recruitment and assembly of specific signal transduction molecules. Here we found that p62dok family members act as substrates for the c-Ret receptor tyrosine kinase. In addition to dok-1, dok-2, and dok-3, we identified two new family members, dok-4 and dok-5, that can directly associate with Y1062 of c-Ret. Dok-4 and dok-5 constitute a subgroup of dok family members that is coexpressed with c-Ret in various neuronal tissues. Activated c-Ret promotes neurite outgrowth of PC12 cells; for this activity, Y1062 in c-Ret is essential. c-Ret/dok fusion proteins, in which Y1062 of c-Ret is deleted and replaced by the sequences of dok-4 or dok-5, induce ligand-dependent axonal outgrowth of PC12 cells, whereas a c-Ret fusion containing dok-2 sequences does not elicit this response. Dok-4 and dok-5 do not associate with rasGAP or Nck, in contrast to p62dok and dok-2. Moreover, dok-4 and dok-5 enhance c-Ret-dependent activation of mitogen-activated protein kinase. Thus, we have identified a subclass of p62dok proteins that are putative links with downstream effectors of c-Ret in neuronal differentiation.

Serum and urine markers of bone metabolism during the year after hip fracture

OBJECTIVE

As part of a larger study to describe indices of recovery during the year after hip fracture, the current prospective study investigated longitudinal changes in serum and urine markers of bone metabolism for the year after hip fracture and related them to bone mineral density (BMD).

DESIGN

A representative subset of participants provided serum and urine samples and had bone density measured at 3, 10, 60, 180, and 365 days postfracture.

SETTING

Two Baltimore hospitals.

PARTICIPANTS

The subjects were 205 community-dwelling, white women age 65 and older with fresh proximal femur fractures.

MEASUREMENTS

Samples were assayed for specific bone-related proteins and bone turnover markers, including serum osteocalcin (OC), procollagen type 1 carboxy-terminal extension peptide (PICP), bone-specific alkaline phosphatase (BAP), and urinary deoxypyridinoline (DPD) cross-links. Selected hormonal regulators of bone metabolism, including parathyroid hormone (PTH), calcitonin (CT), 1,25-dihydroxy vitamin D(3) (1,25 (OH)(2)D), and estrone (E(1)) were measured from serum samples. Repeated measures analyses were used to evaluate postfracture changes in each of the markers.

RESULTS

BAP, OC, and PICP were most active during the early postfracture period (3-60 days). BAP and OC remained elevated at 365 days compared with 3 days. DPD rose 48% from 3 days to 60 days, but this difference was not statistically significant. PTH and 1,25 (OH)(2)D increased steadily and significantly from 3 to 365 days. E(1) was highest at baseline and decreased at each time point, whereas CT showed no significant changes. When subjects were stratified into high-, medium-, and low-BMD groups based on their measurement at 3 days, both osteoclastic and osteoblastic markers in the low-BMD group displayed exaggerated and different patterns over time compared with the other groups.

CONCLUSION

Currently, the standard treatment of care for hip fractures still results in high morbidity and mortality and failure to regain prefracture quality of life. Gaining an understanding of bone cell activity in these patients after hip fracture, derived by measuring markers longitudinally during recovery, provides a baseline by which to measure the effectiveness of new interventions to improve recovery from hip fracture.

[Observations on traditional healers ("medicine men") of Indonesian aborigines]

The observations were done during expeditions to tribes of Indonesian aborigines on the islands of New Guinea/Irian Jaya (Korowai-tribe) and Borneo/Kalimantan (Benuaq-tribe). Neither the Korowai people, who are still living under stone age-like circumstances in up to 30 m high tree-houses, nor the Benuaq people of Borneo, being already influenced by missionary men, do treat injuries or wounds by traditional healers. All the "internal" disorders, not being suffered by injuries, are diagnosed and treated in certain ceremonies, during which the healer tries to get in contact to the spirits triggering the disease. The idea is to know the reason of the disorder caused by demons, though the patient can be treated with bringing offerings or confirmations. This way of treating is due to the image of a magic-demoniac relationship between patient and his disease.

Essential role of Gab1 for signaling by the c-Met receptor in vivo

The docking protein Gab1 binds phosphorylated c-Met receptor tyrosine kinase directly and mediates signals of c-Met in cell culture. Gab1 is phosphorylated by c-Met and by other receptor and nonreceptor tyrosine kinases. Here, we report the functional analysis of Gab1 by targeted mutagenesis in the mouse, and compare the phenotypes of the Gab1 and c-Met mutations. Gab1 is essential for several steps in development: migration of myogenic precursor cells into the limb anlage is impaired in Gab1-/- embryos. As a consequence, extensor muscle groups of the forelimbs are virtually absent, and the flexor muscles reach less far. Fewer hindlimb muscles exist, which are smaller and disorganized. Muscles in the diaphragm, which also originate from migratory precursors, are missing. Moreover, Gab1-/- embryos die in a broad time window between E13.5 and E18.5, and display reduced liver size and placental defects. The labyrinth layer, but not the spongiotrophoblast layer, of the placenta is severely reduced, resulting in impaired communication between maternal and fetal circulation. Thus, extensive similarities between the phenotypes of c-Met and HGF/SF mutant mice exist, and the muscle migration phenotype is even more pronounced in Gab1-/-:c-Met+/- embryos. This is genetic evidence that Gab1 is essential for c-Met signaling in vivo. Analogy exists to signal transmission by insulin receptors, which require IRS1 and IRS2 as specific docking proteins.

Coupling of Gab1 to c-Met, Grb2, and Shp2 mediates biological responses

Gab1 is a substrate of the receptor tyrosine kinase c-Met and involved in c-Met-specific branching morphogenesis. It associates directly with c-Met via the c-Met-binding domain, which is not related to known phosphotyrosine-binding domains. In addition, Gab1 is engaged in a constitutive complex with the adaptor protein Grb2. We have now mapped the c-Met and Grb2 interaction sites using reverse yeast two-hybrid technology. The c-Met-binding site is localized to a 13-amino acid region unique to Gab1. Insertion of this site into the Gab1-related protein p97/Gab2 was sufficient to confer c-Met-binding activity. Association with Grb2 was mapped to two sites: a classical SH3-binding site (PXXP) and a novel Grb2 SH3 consensus-binding motif (PX(V/I)(D/N)RXXKP). To detect phosphorylation-dependent interactions of Gab1 with downstream substrates, we developed a modified yeast two-hybrid assay and identified PI(3)K, Shc, Shp2, and CRKL as interaction partners of Gab1. In a trk-met-Gab1-specific branching morphogenesis assay, association of Gab1 with Shp2, but not PI(3)K, CRKL, or Shc was essential to induce a biological response in MDCK cells. Overexpression of a Gab1 mutant deficient in Shp2 interaction could also block HGF/SF-induced activation of the MAPK pathway, suggesting that Shp2 is critical for c-Met/Gab1-specific signaling.

Signaling of hepatocyte growth factor/scatter factor (HGF) to the small GTPase Rap1 via the large docking protein Gab1 and the adapter protein CRKL

Hepatocyte growth factor (HGF; scatter factor) is a multipotent protein with mitogenic, motogenic, and developmental functions. Upon activation, the HGF-receptor c-Met binds and phosphorylates the multisite docking protein Gab1. Besides binding motifs for phosphatidylinositol 3-kinase and Grb2, Gab 1 contains multiple Tyr-X-X-Pro (YXXP) motifs which, when phosphorylated, are potential binding sites for the adapter proteins c-Crk and Crk-like (CRKL). Stimulation of human embryonic kidney cells (HEK293) with HGF leads to Gab1 association with CRKL. The Gab1-CRKL interaction requires both, the SH2 domain of CRKL and the region containing the YXXP motifs in Gab1. CRKL binds via its first SH3 domain to several downstream signal transducers, including C3G an activator of the small GTPase Rap1. Indeed, Rap1 was rapidly activated after HGF stimulation of HEK293 cells. Rap1 activation through HGF was suppressed through transfection of a truncated C3G protein which only contains the SH3-binding motifs of C3G. Transfection of nonmutated Gab1 led to a strong increase of Rap1.GTP in the absence of HGF. In contrast, transfection of the GabDeltaYXXP mutant abolished the elevation of Rap1.GTP by HGF. A replating assay indicated that HGF decreases the adhesion of HEK293 cells. The results presented here delineate a novel signaling pathway from HGF to the GTPase Rap1 which depends on the interaction of the adapter protein CRKL with the exchange factor C3G and could be linked to cell migration.

[History of surgical instruments. 9. Surgical instruments and development of surgical technique of lithotomy incision]

Lithotomy, i.e. the surgical method of cutting for stone in the bladder, belongs to the oldest and, due to the high risk, most notorious operating techniques. Records of stone-cuttings date as far back as Ancient Greece. The first detailed description of the procedure and instrumentation of lithotomy is to be found by Celsus (1. century AD). The patient in the lithotomy position, the neck of the bladder is approached by a median incision of the perineum. Celsus is also the first to mention special stone-hooking instruments ("uncus") to aid in extracting the bladder-stones. Medico-historical development lead to constant changes in the technique as well as in the instrumentation, since the lack of analgesia and anaesthesia necessitated quick operations of only a few minutes. A key step in the progress of operation was the introduction of so-called path-finders and directing probes in the 16th century. The opening of the bladder from the perineal incision was now accompanied by the simultaneous admission of a metal catheter into the bladder via urethra, thus providing the "Lithotomist", through manual control of the catheter, with an enhanced orientation towards the position of urethra and bladder. At that time, the dissection was conducted bluntly and without direct view of the situation, i.e. without an exact representation of the structures to be separated. Thanks to the improved instrumentation, the instruments could now be guided along a probe directly into the bladder, thus alleviating the tedious search for the opening after changing instruments, all the while with an agitated, pressing patient. Famous names in the development of the lithotomy with an perineal incision are the medical doctor Mariano Santo (around 1488-1564), the barber-surgeon Frère Jacques de Beaulieu (1651-1719) and later Johann Jakob Rau M.D. (1668-1719). Only later, to avoid injury to the perineum, the suprasymphyseal approach ("Sectio alta") was adopted (primarily by Pierre Franco 1556). Due to the construction of arrow-like probe by the barber-surgeon Frère Come (Jean Baseilhac [1703-1781]), which was pushed through the urethra into the bladder and up and above the symphysis, the danger of damaging or penetrating the peritoneum was greatly reduced. In the 19th century the upper lithotomy prevailed as the standard operating method over the perineal approach, known even by the ancient Greeks, but marked by its high complication rate. Since the end of the 19th century, however, the upper lithotomy in ist turn, has been nearly completely replaced by the cystoscopic transurethral lithotripsy.

Die Methoden der Blutstillung in ihrer historischen Entwicklung

Die historische Entwicklung der chirurgischen Methoden der Blutstillung wird dargestellt. Die digitale Kompression und der Kompressionsverband dürften in der schriftlosen Früh- und Vorgeschichte die ältesten Maßnahmen zur Blutstillung bei Verletzungen gewesen sein. Aus der Zeit, als man noch an krankheitsauslösende Geister glaubte, stammten das »Besprechen« von blutenden Wunden und andere magische Handlungen. Im Zeitalter der Humoralpathologie (von der Antike bis in das 19. Jh. hinein) wurde die lokale oder orale Applikation von »Haematostyptica« pflanzlicher oder tierischer Herkunft bevorzugt (z.B. von Harz des Drachenblut-Baumes oder Mastix). Anfänge einer chirurgischen Blutstillung durch Gefäßumstechung lassen sich zuerst bei Celsus im 1. Jh. n. Chr. und bei Antyllos (3./4. Jh. n. Chr.) nachweisen. Aber erst im 16. Jh. wurde die Gefäßligatur nach Fassen des blutenden Gefäßes mit einer speziellen Klemme zum Standardverfahren bei blutenden Amputationswunden (Ambroise Paré 1585). Erste erfolgreiche Versuche von rekonstruktiven Gefäßnähten unter Erhalt des Blutflusses stammen aus dem 18. Jh. (Hallowell 1759). Reproduzierbare Gefäßnahttechniken wurden erst um die letzte Jahrhundertwende publiziert (Max Nitze 1897, Alexis Carrel 1902).

SF/HGF is a mediator between limb patterning and muscle development

Scatter factor/hepatocyte growth factor (SF/HGF) is known to be involved in the detachment of myogenic precursor cells from the lateral dermomyotomes and their subsequent migration into the newly formed limb buds. As yet, however, nothing has been known about the role of the persistent expression of SF/HGF in the limb bud mesenchyme during later stages of limb bud development. To test for a potential role of SF/HGF in early limb muscle patterning, we examined the regulation of SF/HGF expression in the limb bud as well as the influence of SF/HGF on direction control of myogenic precursor cells in limb bud mesenchyme. We demonstrate that SF/HGF expression is controlled by signals involved in limb bud patterning. In the absence of an apical ectodermal ridge (AER), no expression of SF/HGF in the limb bud is observed. However, FGF-2 application can rescue SF/HGF expression. Excision of the zone of polarizing activity (ZPA) results in ectopic and enhanced SF/HGF expression in the posterior limb bud mesenchyme. We could identify BMP-2 as a potential inhibitor of SF/HGF expression in the posterior limb bud mesenchyme. We further demonstrate that ZPA excision results in a shift of Pax-3-positive cells towards the posterior limb bud mesenchyme, indicating a role of the ZPA in positioning of the premuscle masses. Moreover, we present evidence that, in the limb bud mesenchyme, SF/HGF increases the motility of myogenic precursor cells and has a role in maintaining their undifferentiated state during migration. We present a model for a crucial role of SF/HGF during migration and early patterning of muscle precursor cells in the vertebrate limb.

Historical evolution of limb amputation

The amputation of a limb is one of the oldest surgical procedures. In the course of medical history operative techniques and surgical instruments have been improved continuously. As early as the first century Celsus described an amputation. A major step in the development of the operative technique was the introduction of an artery forceps by Paré during the sixteenth century. Nevertheless, due to a lack of analgesics and narcotics the operation had to take only a few minutes. Therefore the amputation was completed in one cut (i.e., detachment of the skin, muscles, and bone at the same level). This technique, known as "classic circular cut," was modified several times in the following period: to reduce suture tension Petit recommended that we transect the skin first and the muscles and bone more proximally ("two-stage circular cut," 1718), and Bromfield approved that the skin be cut first, the muscles more proximally and the bone most proximal ("three-stage circular cut," 1773). Lowdham (1679), Verduyn (1696), and Langenbeck (1810) changed the operative technique in that they used a soft-tissue flap to cover the bone without tension ("flap amputation").

[The common surgical heritage]

The mutual and dreadful history of Poland and Germany has left behind wounds and scars on both sides. This session is dedicated to the common surgical heritage and joint development of the presence and future. Important pioneering contributions of German surgery were achieved at the University of Breslau (Wroclaw), especially by Johann von Mikulicz-Radecki and his associate Ferdinand Sauerbruch. Our Polish colleagues have further developed the surgical tradition in Poland since World War II.

[History of surgical instruments: 8. Instruments and development of amputation technique exemplified by amputation sets from the middle of the 19th century]

The amputation of a limb is one of the oldest surgical procedures. However, in the course of medical history operative techniques and surgical instruments have been improved continuously. With an example of an amputation case of the last century we will summarize this development until the middle of the nineteenth century. Even in the first century Celsus gave a description of an amputation (circular cut). A major step in the development of the operative technique was the introduction of artery forceps by A. Paré in the sixteenth century. Nevertheless, due to a lack of analgesics and narcotics the operation had to take only a few minutes. Therefore the amputation was completed in one cut, i.e. detachment of the skin, muscles and bone at the same level. This technique known as "classic circular cut" was modified several times in the following period: in order to reduce suture tension Petit recommended to transect the skin first and the muscles and bone more proximal ("two-stage circular cut", 1718) and Bromfield approved to cut in turn the skin first, the muscles more proximal and the bone most proximal ("three-stage circular cut", 1773). Finally, Lowdham (1679), Verduyn (1696) and C. J. M. Langenbeck (1810) changed the operative technique to the effect that they used a soft-tissue flap in order to cover the bone without tension ("flap amputation").

Reconstitution of mammary gland development in vitro: requirement of c-met and c-erbB2 signaling for branching and alveolar morphogenesis

We have established a cell culture system that reproduces morphogenic processes in the developing mammary gland. EpH4 mouse mammary epithelial cells cultured in matrigel form branched tubules in the presence of hepatocyte growth factor/scatter factor (HGF/SF), the ligand of the c-met tyrosine kinase receptor. In contrast, alveolar structures are formed in the presence of neuregulin, a ligand of c-erbB tyrosine kinase receptors. These distinct morphogenic responses can also be observed with selected human mammary carcinoma tissue in explant culture. HGF/SF-induced branching was abrogated by the PI3 kinase inhibitors wortmannin and LY294002. In contrast, neuregulin- induced alveolar morphogenesis was inhibited by the MAPK kinase inhibitor PD98059. The c-met-mediated response could also be evoked by transfection of a c-met specific substrate, Gab1, which can activate the PI3 kinase pathway. An activated hybrid receptor that contained the intracellular domain of c-erbB2 receptor suffices to induce alveolar morphogenesis, and was observed in the presence of tyrosine residues Y1028, Y1144, Y1201, and Y1226/27 in the substrate-binding domain of c-erbB2. Our data demonstrate that c-met and c-erbB2 signaling elicit distinct morphogenic programs in mammary epithelial cells: formation of branched tubules relies on a pathway involving PI3 kinase, whereas alveolar morphogenesis requires MAPK kinase.

[History of surgical instruments: 7. The first electrosurgical instruments: galvanic cauterization and electric cutting snare]

In 1854 the surgeon Albrecht Theodor Middeldorpf (1824-1868) published the first monography on the application of electrical current in surgical operations ("galvanocautery"). By galvanocautery Middeldorpf defined a procedure in which specially constructed parts of surgical instruments (usually thin platinum wires) were transformed into glowing heat by means of galvanic current from a zinc-platinum-battery. In this manner it was possible to perform dissection and destruction of tissue as well as coagulation of vessels for hemostasis. His most important electrosurgical instruments comprised an electrosurgical knife ("galvanocautery") and the electrical cutting snare ("ligatura candens") for removal of polypoid tumors. These instruments are the direct ancestors of modern electrocautery or cautery snare. The glowing platinum wire was later also applied as a light source of cystoscopes. Thus, galvanocautery enabled development of endoscopy. Modern diathermy with high-frequent alternating current was introduced in medicine by the Dermatologist Franz Nagelschmidt from Berlin.

[The so-called Spigelian hernia--a rare lateral hernia of the abdominal wall]

A patient with Spigelian hernia is presented and the main pathological and clinical features are discussed. Its true incidence is probably greater than the small number of patients reported in the literature due to failure to recognize the clinical picture. A hernia through a defect in the Spigelian fascia (aponeurosis of the transverse muscle of the abdomen) is called Spigelian hernia. The semilunar (Spigelian) line is defined as the line forming the transition from muscle to aponeurosis in the transverse muscle of the abdominal wall. It is a lateral convey line between the costal arch and the pubic tubercle. The part of the aponeurosis that lies between this semilunar line and the lateral edge of the rectus muscle is called the "Spigelian fascia" (correct: Spigelian aponeurosis). The hernia is located intramurally because the hernia is covered by the aponeurosis of the external oblique aponeurosis, so that both, the hernial sac and the orifice, can often not be detected by palpation. Clinical symptoms are not characteristic but most patients have a distinct tender point above the hernial orifice.