Miniaturised ultrasound evaluation at the bedside

PURPOSE

"Point-of-Care Ultrasound" (POCUS) is now a familiar term. Although the European Federation of Societies for Ultrasound in Medicine and Biology (ESFUMB) published a position paper about its usage (Nielsen et al. in Ultraschall Med 40(1):30-39. https://doi.org/10.1055/a-0783-2303 , 2019), there has not been much scientific focus on its utility in uro-nephrological clinical practice thus far. The aim of this study was to evaluate the present usage of pocket ultrasound devices at the bedside.

METHODS

27 investigators (all medical doctors with at least 6 months of experience in sonography) performed 280 bedside examinations using a pocket ultrasound device for common clinical issues.

RESULTS

The most frequent indications included evaluation of hydronephrosis (147), volume management including assessment of dimension of the vena cava inferior (IVC) (195), detection of pleural, pericardial and abdominal effusions (113) as well as residual urine (52). In 90%, specific clinical questions were effectively answered by the pocket ultrasound device alone.

CONCLUSIONS

POCUS can be useful in the uro-nephrological field. In the hands of an experienced investigator, it saves time and, when it is realised that departmental ultrasound is not cheap, there is also an economic benefit with applicability within both inpatient and outpatient clinic settings. While acknowledging its technical limits, pocket ultrasound devices may nevertheless be helpful in targeted situations for triage or for bedside follow-up exams after earlier high-end ultrasound-based diagnosis.

Ultrasound-based "CEUS-Bosniak"classification for cystic renal lesions: an 8-year clinical experience

PURPOSE

Renal cysts comprise benign and malignant entities. Risk assessment profits from CT/MRI imaging using the Bosniak classification. While Bosniak-IIF, -III, and -IV cover complex cyst variants, Bosniak-IIF and -III stand out due to notorious overestimation. Contrast-enhanced ultrasound (CEUS) is promising to overcome this deficit but warrants standardization. This study addresses the benefits of a combined CEUS and CT/MRI evaluation of renal cysts. The study provides a realistic account of kidney tumor boards' intricacies in trying to validate renal cysts.

METHODS

247 patients were examined over 8 years. CEUS lesions were graded according to CEUS-Bosniak (IIF, III, IV). 55 lesions were resected, CEUS-Bosniak- and CT/MRI-Bosniak-classification were correlated with histopathological diagnosis. Interobserver agreement between the classifications was evaluated statistically. 105 lesions were followed by ultrasound, and change in CEUS-Bosniak-types and lesion size were documented.

RESULTS

146 patients (156 lesions) were included. CEUS classified 67 lesions as CEUS-Bosniak-IIF, 44 as CEUS-Bosniak-III, and 45 as CEUS-Bosniak-IV. Histopathology of 55 resected lesions revealed benign cysts in all CEUS-Bosniak-IIF lesions (2/2), 40% of CEUS-Bosniak-III and 8% of CEUS-Bosniak-IV, whereas malignancy was uncovered in 60% of CEUS-Bosniak-III and 92% of CEUS-Bosniak-IV. Overall, CEUS-Bosniak-types matched CT/MRI-Bosniak types in 58% (fair agreement, κ = 0.28). CEUS-Bosniak resulted in higher stages than CT/MRI-Bosniak (40%). Ultrasound follow-up of 105 lesions detected no relevant differences between CEUS-Bosniak-types concerning cysts size. 99% of lesions showed the same CEUS-Bosniak-type.

CONCLUSION

The CEUS-Bosniak classification is an essential tool in clinical practice to differentiate and monitor renal cystic lesions and empowers diagnostic work-up and patient care.

Sonography of the renal allograft: Correlation between doppler sonographic resistance index (RI) and histopathology

INTRODUCTION

Allograft rejection (AR), chronic allograft injury (CAI) and acute tubular necrosis (ATN) can lead to renal allograft dysfunction after kidney transplantation. Interstitial fibrosis/tubular atrophy (Banff classification 2005) describes chronic allograft injury with no specific etiology, thus explaining the common final endpoint of various (immunologic and non immunologic) etiologies. The aim of this study was to evaluate correlations between the Doppler sonographic RI-values and histopathological changes of renal allografts biopsies during rejection, acute tubular necrosis and chronic allograft injury as well as the influence of donor and recipient features on the intrarenal RI-values.

METHODS

102 allograft biopsies and ultrasound reports of 69 patients with kidney transplantation performed at the hospital Klinikum rechts der Isar (Technische Universität München, Germany) between 2009 and 2013 were analyzed retrospectively (41 biopsies of living donors, 61 biopsies of deceased donors). Chronic allograft injury was described using the IFTA (interstitial fibrosis and tubular atrophy) or the ECAI score (extended chronic allograft injury score). The ECAI score was built out of the chronic histological lesions glomerulopathy, interstitial fibrosis, tubular atrophy and fibrous intimal thickening (cg + ci + ct + cv) of the BANFF scoring.

RESULTS

Intrarenal RI-values were significantly higher in patients with allograft rejection than without rejection (median 0,79 vs. 0,73; inter quartile range: 0,20 vs. 0,13; p = 0,018). The same was found for T-and non-T cell mediated rejection (median 0,78 vs. 0,73; inter quartile range 0,20 vs. 0,13; p = 0,039). There were no significant differences in the RI-values between the subtypes of T-cell mediated rejection (type IA-IIB). Furthermore, there were no significant differences of RI-values regarding antibody-mediated rejection (present vs. not present) or type of rejection (T-cell- vs. antibody mediated rejection). Patients with rejection and simultaneously chronic allograft injury showed significantly higher RI-values than patients with only chronic allograft injury. Analyses using the IFTA or the ECAI score showed comparable results (IFTA p = 0,043; Score p = 0,021). The intrarenal RI-value was neither able to detect chronic allograft injury nor to distinguish between acute tubular necrosis and rejection. The intrarenal RI-value showed a significant correlation with recipient age (p < 0,001) but not with donor features.

CONCLUSION

In summary, the intrarenal RI-value can indicate a rejection but gives no clear hint to acute tubular necrosis and cannot differentiate from it. Since patients with rejection can have normal RI-values, a biopsy should always be performed in case of suspected rejection. The intrarenal RI-value has no unambiguous validity to determine intrinsic values of the renal allograft, but should rather be understood and interpreted as a systemic parameter influenced by multiple factors.

Neuraxial analgesia is not associated with an increased risk of post-partum relapses in MS

Background:

Obstetrical analgesia remains a matter of controversy because of the fear of neurotoxicity of local anesthetics on demyelinated fibers or their potential relationship with subsequent relapses.

Objective:

To assess the impact of neuraxial analgesia on the risk of relapse during the first 3 months post-partum, with a focus on women who experienced relapses during pregnancy.

Methods:

We analyzed data of women followed-up prospectively during their pregnancies and at least 3 months post-partum, collected in the Pregnancy in Multiple Sclerosis (PRIMS) and Prevention of Post-Partum Relapses with Progestin and Estradiol in Multiple Sclerosis (POPARTMUS) studies between 1992–1995 and 2005–2012, respectively. The association of neuraxial analgesia with the occurrence of a post-partum relapse was estimated by logistic regression analysis.

Results:

A total of 389 women were included, 215 from PRIMS and 174 from POPARTMUS. In total, 156 women (40%) had neuraxial analgesia. Overall, 24% experienced a relapse during pregnancy and 25% in the 3 months post-partum. Women with a pregnancy relapse were more likely to have a post-partum relapse (odds ratio (OR) = 1.83, p = 0.02), independently of the use of neuraxial analgesia. There was no association between neuraxial analgesia and post-partum relapse (OR = 1.08, p = 0.78).

Conclusion:

Neuraxial analgesia was not associated with an increased risk of post-partum relapses, whatever multiple sclerosis (MS) activity during pregnancy.

Drug-eluting stents versus bare metal stents for the prevention of restenosis in patients with renovascular disease

AIMS

The aim of this study was to assess the impact of drug-eluting stents (DES) compared to bare metal stents (BMS) for the endovascular treatment of atherosclerotic renal artery stenosis (ARAS).

METHODS AND RESULTS

We retrospectively evaluated all of our endovascular BMS and DES implantations performed in de novo ARAS between 2000 and 2014 at our institution. The occurrence of in-stent restenosis (ISR) detected by ultrasound or angiography, kidney function, blood pressure (BP), and the number of antihypertensive drugs were analysed as endpoints. Overall, 338 renal arteries were treated in 298 patients. BMS were implanted in 163 (48%), and DES in 175 lesions (52%). Of the 175 lesions treated with DES, 55 (31%) were treated with a BMS-in-DES hybrid technique. For reasons of comparability, only lesions treated with balloon sizes of 4-6.5 mm were included in the final analysis. After 12 months, the rate of ISR >50% was 18.6% in the BMS group and 7.2% in the DES group (p=0.031). None of the BMS-in-DES-treated (hybrid) lesions developed ISR (hybrid technique vs. BMS only p=0.008, hybrid technique vs. DES only p=0.034). Systolic BP and number of antihypertensive drugs remained unchanged in the BMS group but declined in the DES group (p=0.02). Renal function significantly deteriorated in the BMS group (p=0.03) but did not change significantly in the DES group (p=0.188).

CONCLUSIONS

DES were superior to BMS in preventing ISR. Overall, the BMS-in-DES-technique (hybrid) achieved the lowest risk for ISR.

Retrospective Analysis of Ultrasound-Detected Bleeding Complications after Ultrasound-Guided Transcutaneous Kidney Biopsies

The aim of this retrospective single-center study was to examine ultrasound-detected complications after diagnostic parenchymal renal biopsies. After 471 ultrasound-guided kidney biopsies (225 native kidneys and 246 renal allografts), ultrasound revealed hematomas (21.9%), arterio-venous fistulas (8.9%), active bleeding (1.1%) and hematuria (0.4%). Only 0.8% of all patients required invasive intervention such as coiling (n = 3) and surgical procedures (n = 1). Three episodes of bleeding (0.6%) were solved with manual compression. One patient (0.2%) needed an irrigation catheter because of hematuria. Furthermore, six patients (1.3%) received blood transfusion. Ultrasound-guided biopsies are safe. With modern ultrasound machines using multi-frequency transducers with high resolution and harmonic imaging, even marginal bleeding after renal biopsy is detected.

Concentration of three branched-chain fatty acids in adipose tissue does not affect meat sensory traits in crossbred and purebred German "Merinolandschaf" lambs

Abstract. Intense sheep odour and flavour in lamb is often associated with lower consumer acceptance. Branched-chain fatty acids (BCFAs) are suggested as possible reasons. Therefore, muscle and subcutaneous adipose tissue samples of 98 lamb chops were analysed for three BCFAs (4-methyloctanoic, 4-ethyloctanoic and 4-methylnonanoic fatty acid). Samples were derived from a previous study, in which lambs were raised and fattened under intensive conditions and tested for sensory quality. BCFA contents of fat extracts from muscle tissue were very low and quantification was not possible. In subcutaneous adipose tissue different concentrations of BCFA and differences between crosses were detected. The sex of lambs had a significant influence. The BCFA correlations were significant, while correlations between BCFA of adipose tissue and sensory traits were not significant. Therefore, it seems likely that BCFA concentrations were too low and/or other substances are involved in causing the lamb flavour detected through sensory analysis.

The role of hypoxia-inducible factor-1α and vascular endothelial growth factor in late-phase preconditioning with xenon, isoflurane and levosimendan in rat cardiomyocytes

OBJECTIVES

The protective effects of late-phase preconditioning can be triggered by several stimuli. Unfortunately, the transfer from bench to bedside still represents a challenge, as concomitant medication or diseases influence the complex signalling pathways involved. In an established model of primary neonatal rat cardiomyocytes, we analysed the cardioprotective effects of three different stimulating pharmaceuticals of clinical relevance. The effect of additional β-blocker treatment was studied as these were previously shown to negatively influence preconditioning.

METHODS

Twenty-four hours prior to hypoxia, cells pre-treated with or without metoprolol (0.55 µg/ml) were preconditioned with isoflurane, levosimendan or xenon. The influences of these stimuli on hypoxia-inducible factor-1α (HIF-1α), vascular endothelial growth factor (VEGF) as well as inducible and endothelial nitric synthase (iNOS/eNOS) and cyclooxygenase-2 (COX-2) were analysed by polymerase chain reaction and western blotting. The preconditioning was proved by trypan blue cell counts following 5 h of hypoxia and confirmed by fluorescence staining.

RESULTS

Five hours of hypoxia reduced cell survival in unpreconditioned control cells to 44 ± 4%. Surviving cell count was significantly higher in cells preconditioned either by 2 × 15 min isoflurane (70 ± 16%; P = 0.005) or by xenon (59 ± 8%; P = 0.049). Xenon-preconditioned cells showed a significantly elevated content of VEGF (0.025 ± 0.010 IDV [integrated density values when compared with GAPDH] vs 0.003 ± 0.006 IDV in controls; P = 0.0003). The protein expression of HIF-1α was increased both by levosimendan (0.563 ± 0.175 IDV vs 0.142 ± 0.042 IDV in controls; P = 0.0289) and by xenon (0.868 ± 0.222 IDV; P < 0.0001) pretreatment. A significant elevation of mRNA expression of iNOS was measureable following preconditioning by xenon but not by the other chosen stimuli. eNOS mRNA expression was found to be suppressed by β-blocker treatment for all stimuli. In our model, independently of the chosen stimulus, β-blocker treatment had no significant effect on cell survival.

CONCLUSIONS

We found that the stimulation of late-phase preconditioning involves several distinct pathways that are variably addressed by the different stimuli. In contrast to isoflurane treatment, xenon-induced preconditioning does not lead to an increase in COX-2 gene transcription but to a significant increase in HIF-1α and subsequently VEGF.

PERMANENT GENETIC RESOURCES: Polymorphic microsatellite loci and interspecific cross-amplification in the parasitoid wasps Megastigmus stigmatizans and Megastigmus dorsalis

We isolated and characterized 19 polymorphic microsatellite loci in the congeneric parasitoid wasps Megastigmus stigmatizans and Megastigmus dorsalis associated with cynipid oak galls. Loci isolated from species-specific libraries showed extensive cross-amplification, resulting in a total of 15 polymorphic loci for M. stigmatizans and 13 for M. dorsalis.

[Multimorbid patients with poor soft tissue conditions: treatment of distal tibia fractures with retrograde intramedullary nailing]

The appropriate treatment of a distal tibia fracture in multimorbid patients with poor soft tissue and skin conditions, poor peripheral blood supply and osteopenic bone is challenging. In this case report we present two patients with these characteristics. Given these exceptional conditions none of the conventional therapies (e.g. cast, internal plate fixation, external fixation, anterograde intramedullary nailing) appeared feasible. To achieve sufficient fracture healing, we chose an unconventional treatment approach of retrograde tibial nailing with inclusion of the ankle and subtalar joint.

Mapping QTL for growth and muscling traits in three connected porcine F₂ crosses

Abstract. QTL experiments in pigs are often analysed separately, although similar or same founder breeds are frequently used to establish the experimental design. The aim of the present study was to jointly analyse three porcine F2-crosses for six growth and four muscling traits. The crosses were a Meishan × Pietrain cross, a Wild Boar × Pietrain cross, and a Wild Boar × Meishan cross. In some cases, same founder animals were used to establish the crosses. 966 F2-individuals were genotyped for 242 genetic markers (mostly microsatellites) and phenotyped for birth weight, 21 and 35 day weight, slaughter weight, carcass length, food conversion ratio, ham meat weight, shoulder meat weight, loin and neck meat weight, and meat area. A multi-allele multi-QTL model was applied that estimated an additive QTL effect for each founder breed and parental origin (either paternally or maternally derived), and a dominant QTL effect for each cross. This model was previously introduced in plant breeding. Numerous QTL were mapped on the autosomes. Most QTL were localised on SSC1, 2, 3, 4, 6 and 8, and no QTL were on SSC9, 11, 13, 15, 17 and 18. The confidence intervals were short in many cases. QTL with an exceptionally high test statistic were found for carcass length on SSC1, 4, 7 and 17. The coefficient of variation was remarkably small for this trait, which suggests that carcass length is affected by only a few genes with large effects. Positional and functional candidates underlying promising QTL are suggested for further study.

A two-step approach to map quantitative trait loci for meat quality in connected porcine F(2) crosses considering main and epistatic effects

The aim of this study was to map QTL for meat quality traits in three connected porcine F(2) crosses comprising around 1000 individuals. The three crosses were derived from the founder breeds Chinese Meishan, European Wild Boar and Pietrain. The animals were genotyped genomewide for approximately 250 genetic markers, mostly microsatellites. They were phenotyped for seven meat quality traits (pH at 45 min and 24 h after slaughter, conductivity at 45 min and 24 h after slaughter, meat colour, drip loss and rigour). QTL mapping was conducted using a two-step procedure. In the first step, the QTL were mapped using a multi-QTL multi-allele model that was tailored to analyse multiple connected F(2) crosses. It considered additive, dominance and imprinting effects. The major gene RYR1:g.1843C>T affecting the meat quality on SSC6 was included as a cofactor in the model. The mapped QTL were tested for pairwise epistatic effects in the second step. All possible epistatic effects between additive, dominant and imprinting effects were considered, leading to nine orthogonal forms of epistasis. Numerous QTL were found. The most interesting chromosome was SSC6. Not all genetic variance of meat quality was explained by RYR1:g.1843C>T. A small confidence interval was obtained, which facilitated the identification of candidate genes underlying the QTL. Epistasis was significant for the pairwise QTL on SSC12 and SSC14 for pH24 and for the QTL on SSC2 and SSC5 for rigour. Some evidence for additional pairwise epistatic effects was found, although not significant. Imprinting was involved in epistasis.

Mapping quantitative trait loci for metabolic and cytological fatness traits of connected F2 crosses in pigs

In the present study 3 connected F(2) crosses were used to map QTL for classical fat traits as well as fat-related metabolic and cytological traits in pigs. The founder breeds were Chinese Meishan, European Wild Boar, and Pietrain with to some extent the same founder animals in the different crosses. The different selection history of the breeds for fatness traits as well as the connectedness of the crosses led to a high statistical power. The total number of F(2) animals varied between 694 and 966, depending on the trait. The animals were genotyped for around 250 genetic markers, mostly microsatellites. The statistical model was a multi-allele, multi-QTL model that accounted for imprinting. The model was previously introduced from plant breeding experiments. The traits investigated were backfat depth and fat area as well as relative number of fat cells with different sizes and 2 metabolic traits (i.e., soluble protein content as an indicator for the level of metabolic turnover and NADP-malate dehydrogenase as an indicator for enzyme activity). The results revealed in total 37 significant QTL on chromosomes 1, 2, 4, 5, 6, 7, 8, 9, 14, 17, and 18, with often an overlap of confidence intervals of several traits. These confidence intervals were in some cases remarkably small, which is due to the high statistical power of the design. In total, 18 QTL showed significant imprinting effects. The small and overlapping confidence intervals for the classical fatness traits as well as for the cytological and metabolic traits enabled positional and functional candidate gene identification for several mapped QTL.

Landscape genetics of the key African acacia species Senegalia mellifera (Vahl)- the importance of the Kenyan Rift Valley

Acacias across Africa have enormous ecological and economic importance, yet their population genetics are poorly studied. We used seven microsatellite loci to investigate spatial genetic structure and to identify potential ecological and geographic barriers to dispersal in the widespread acacia, Senegalia (Acacia) mellifera. We quantified variation among 791 individuals from 28 sampling locations, examining patterns at two spatial scales: (i) across Kenya including the Rift Valley, and (ii) for a local subset of 11 neighbouring locations on Mpala Ranch in the Laikipia plateau. Our analyses recognize that siblings can often be included in samples used to measure population genetic structure, violating fundamental assumptions made by these analyses. To address this potential problem, we maximized genetic independence of samples by creating a sibship-controlled data set that included only one member of each sibship and compared the results obtained with the full data set. Patterns of genetic structure and barriers to gene flow were essentially similar when the two data sets were analysed. Five well-defined geographic regions were identified across Kenya within which gene flow was localized, with the two strongest barriers to dispersal splitting the Laikipia Plateau of central Kenya from the Western and Eastern Rift Valley. At a smaller scale, in the absence of geographic features, regional habitat gradients appear to restrict gene flow significantly. We discuss the implications of our results for the management of this highly exploited species.

Comparison of DNA variants in the PRNP and NF1 regions between bovine spongiform encephalopathy and control cattle

DNA from 252 bovine spongiform encephalopathy (BSE) cattle and 376 non-diseased control cattle were genotyped for nine loci in the prion protein (PRNP) gene region, three loci in the neurofibromin 1 (NF1) region and four control loci on different chromosomes. The allele and genotype frequencies of the control loci were similar in BSE and control cattle. In the analysed 7.4 Mb PRNP region, the largest differences between BSE and control cattle were found for the loci REG2, R16 and R18, which are located between +300 and +5600 bp, spanning PRNP introns 1 to 2. Carriers of the REG2 genotype 128/128 were younger at BSE diagnosis than those with the other genotypes (128/140 or 140/140). The predominant haplotype REG2 128 bp-R18 173 bp occurred more frequently (P < 0.001), and the second-most frequent haplotype (REG2 140 bp-R18 175 bp) occurred less frequently (P < 0.05) in BSE than in control cattle. The largest frequency differences between BSE and control groups were observed in the Brown Swiss breed. Across all breeds, most of the same alleles and haplotypes of the PRNP region were associated with BSE. In the 23-cM NF1 region, associations with BSE incidence were found for the RM222 allele and for the DIK4009 genotype frequencies. Cattle carrying RM222 genotypes with the 127- or 129-bp alleles were about half a year older at BSE incidence than those with other genotypes. Across the breeds, different alleles and genotypes of the NF1 region were associated with BSE. The informative DNA markers were used to localize the genetic disposition to BSE and may be useful for the identification of the causative DNA variants.

[Gender-specific health reporting in the Bodenseekreis: future theme of " health in boys and men"]

Population prognoses predict a far over-proportional increase in the number of male seniors, entailing substantial implications for the planning of health supply and care, as well as various possibilities to intervene preventively by specific risk avoidance or boosting health responsibility. In the future men's health and male-specific health reporting will become eminently important. A gender-specific life table analysis for the years 1998 - 2002 shows which causes of death are more responsible for loss of life expectancy of men compared to women in both the Bodenseekreis and Baden-Württemberg. Baden-Württemberg and the Bodenseekreis are regions with a well above-average life expectancy compared to other regions in Germany. The average life expectancy in Baden-Württemberg in the year 2000 amounted to 82 years (Bodenseekreis: 82.2) in women, and 76.4 years (Bodenseekreis: 77.3) in men. Among the main causes for the 5.6 year difference in life expectancy are cardiovascular diseases, cancer illnesses, traffic accidents and suicide. These groups of causes of death explain the major part of the difference in average life expectancy. An analysis of death risks specific to age and gender shows some promising approaches for health promotion and prevention based on identification of critical phases of life. In this case, special attention should be paid to infancy, as examinations made within the scope of enrolment at schools identify considerable differences in the prevalence of various disturbances. However, early adulthood and old age also prove to be important periods concerning men-specific interventions. The presented results show first possible starting points which, however, should above all make a contribution to the establishment of the topic of men's health as a focus on gender-specific health reporting, health promotion and prevention. The described target group for health promotion and prevention is, on the one hand, sufficiently large, on the other hand, sufficiently disadvantaged in terms of health to demand more attention in the future.

Analysis of polymorphic PRNP microsatellite and ORF sites in German sheep breeds

Polymorphic microsatellite and open-reading frame (ORF) sites in the prion protein coding gene (PRNP) were analysed in eight sheep breeds. The three microsatellite sites S11, S15 and S24 were genotyped by fragment length analysis, and the ORF codons 136, 154 and 171 were analysed after direct sequencing. Unexpected polymerase chain reaction (PCR) products of microsatellite sites and ORF haplotypes with more than one heterozygous site were submitted to cloning and then sequenced. The microsatellite sites were polymorphic in all breeds with two to five alleles per site. On average of breeds and sites, the microsatellites had higher degrees of polymorphism than the ORF sites. The ARR/ARR ORF genotype occurred always together with the microsatellite genotypes S11 152/152, S15 179/179 and S24 144/144. As ORF and microsatellite alleles of the PRNP were observed in typical combinations, the microsatellite genotypes were significantly associated with scrapie incidences or risk classes based on the ORF genotypes. The microsatellite sites were highly polymorphic and therefore are advantageous markers for evaluation of scrapie disposition and fine mapping of effects on scrapie pathogenesis within the gene.

Akute Atemwegsverlegung durch erworbene Hämophilie A

We report the case of a 67 year old patient suffering from acute airway obstruction caused by hemorrhage localized to the tongue, mouth cavity and hypopharynx, with no evidence of bleeding in his history. The patient presented initially with a globus feeling of the neck, dysphagia and a sore throat. CT scan revealed a swelling of the lingual and sublingual areas and the pharyngeal wall. Next day, there was an immediate life-threatening event caused by progressive bleeding with airway obstruction and an inability to intubate requiring coniotomy. The etiology of the hemorrhage was confirmed by finding a depletion of factor VIII and the presence of auto-antibody directed against this factor. Based on this case report and a review of the literature, we discuss the diagnosis and treatment of acquired hemophilia.

Analysis of polymorphic microsatellites within the bovine and ovine prion protein (PRNP) genes

Twenty-four microsatellite sites with at least three repeats were found in the bovine prion protein gene (PRNP) and 23 in the ovine PRNP gene. Eight microsatellite sites were polymorphic in cattle and six in sheep with up to 10 alleles per site. In many cases allelic DNA fragments had variants in microsatellite sites and in flanking regions. Distances between microsatellite sites in eight genes from cattle and sheep occurred on average every 0.9 kb. The numerous polymorphic microsatellite sites will improve analysis of phylogenetic origin of different PRNP alleles and trait association studies for bovine spongiform encephalopathy (BSE) and scrapie.

Multilayer capsules: a promising microencapsulation system for transplantation of pancreatic islets

In 1980, Lim and Sun introduced a microcapsule coated with an alginate/polylysine complex for encapsulation of pancreatic islets. Characteristic to this type of capsule is, that it consists of a plain membrane which is formed during a single procedural step. With such a simple process it is difficult to obtain instantly a membrane optimized with respect to all the properties requested for islet transplantation. To overcome these difficulties, it is recommended to build up the membrane in several consecutive steps, each optimized for a certain property. In this study, we have analysed such a multilayer microcapsule for the encapsulation of pancreatic islets. Therefore, empty and islet containing alginate beads were coated with alternating layers of polyethyleneimine, polyacrylacid or carboxymethylcellulose and alginate. By scanning electron microscopy the thickness of the covering multilayer-membrane was estimated to be less than 800 nm by comparison with an apparatus scale. Ellipsometric measurements showed that the membrane thickness is in the range of 145 nm. Neither the encapsulation procedure, nor the membrane-forming step did impede the stimulatory response of the islets. The encapsulation even lead to a significantly better stimulatory response of the encapsulated islets during week three and five of cell culture. Furthermore, the multilayer-membrane did not deteriorate the biocompatibility of the transplanted microcapsules, allowing an easy tuning of the molecular cut-off and the mechanical stability depending on the polycation-polyanion combination used. The multilayer membrane capsule has obvious advantages compared to a one-step encapsulation procedure. These beads guarantee a high biocompatibility, a precisely adjusted cut-off, an optimal insulin-response and high mechanical stability although the membrane is only 145 nm thick.

[Comparison of severity of chronic pain in patients differing in pain diagnosis: an analysis by means of the Mainz Pain Staging System]

INTRODUCTION

Testing the validity of the Mainz Pain Staging System (MPSS) is often carried out by pain classification according to chronic stage. It is assumed that pain syndromes distribute equally over the chronic stages. This analysis was carried out to answer three questions: Do different pain syndromes vary in chronicity, do the four axes of the MPSS differ between pain syndromes, and are there any specific item responses with respect to a pain syndrome?

METHODS

406 patients with different pain diagnoses were included in this analysis. Patients were chosen from the PAIN-Documentation-System of the pain outpatients' department of the Medical University of Luebeck. The pain score according to MPSS had been assessed, and a diagnosis attributed according to the Multidimensional Classification of Pain (MASK).

RESULTS

Pain diagnoses do differ in pain chronification. Patients with headache showing the lowest chronification, and patients with back pain describing the most severe chronification, formed the extreme patient groups. Further analysis using the axes of the MPSS demonstrate different sensitivity with respect to pain syndromes, i. e. intake of drugs being the least sensitive and aspects of time being the most sensitive axes. Statistical analysis using configural frequency analysis indicated a relation between pain syndromes and specific item responses.

CONCLUSION

Using pain stages of the MPSS as an experimental factor in studies of pain, it is imperative either to control pain syndromes or to confine to a single pain syndrome, to avoid confusion between pain syndromes and severity of pain chronification.

[Communication in environmental health protection and in environmental medicine counseling]

Practically all municipal health authorities, including the Bremen health authorities, now offer advice with regard to healthy environmental protection, i. e. environmental-medical consulting activities. The majority of the consultantcy services deal with individual inquiries made by citizens. This is supplemented by counselling and discussions with groups in various contexts. It is frequent for extremely difficult counselling contents, situations and deficits in the conducting of the discussions by the consultants who are specialised in natural science subjects to coincide. Within the framework of a further training course designed for these specific needs, the staff of the Bremen health authorities, with specialist instruction, were successful in acquitting skill in the communication of risks, which is a qualification that should become self-evident also in this sphere.

Hypometric primary saccades of schizophrenics in a delayed-response task

In this study, the execution of delayed saccades in 15 DSM-III-R-schizophrenic patients and 15 normal subjects was investigated. While looking at a central fixation cross, a peripheral target was randomly presented at 10 degrees eccentricity. Subjects were instructed to saccade to the target when the fixation cross was switched off after 500 ms. Two experiments were conducted: (a) a delayed-saccade task and, (b) a memory-guided saccade task, that is, the peripheral target was switched off together with the fixation cross. In the delayed-saccade task, amplitudes of regular saccades did not differ between schizophrenic patients and normals. In the memory-guided saccade task, schizophrenic subjects showed marked hypometric saccades. Incorrect delayed saccades (while the fixation cross was on) were also hypometric in schizophrenics, but not in normal controls. The final eye position, i.e., the position reached after the execution of correction saccades, however, did not differ between patients and controls. This means that schizophrenics show a deficit in the programming of primary saccades, if the fixation point and the peripheral target are (a) both visually presented or (b) both memorized. The results support the hypothesis that these saccades are the result of an averaging effect between the fixation point and the peripheral target. It is further hypothesized that these deficits might be explained by a lack of prefrontal inhibition of ocular fixation areas.

[Disulfiram neuropathy]

Two chronically alcohol-addicted patients, a 37-year old woman and a 22-year old man, developed a severe polyneuropathy after being treated with very high doses of disulfiram. In the first case there was a high-grade proximal tetraparesis, especially of the legs; in the other there was a similar largely motor, but predominantly distal, neuropathy. Electrophysiological tests established a pattern of axonal damage. Guillain-Barré syndrome was excluded by analysis of cerebrospinal fluid. Over a period of observation of 6 months and 2 1/2 years, respectively, the paresis continued even after disulfiram had been discontinued. 2 1/2 years later the electrophysiological changes were still present. As disulfiram treatment may cause severe side effects it is recommended that the lowest possible dosage by employed.

Effects of cholecystokinin and calcitonin on evoked brain potentials and satiety in man

Central nervous effects of the peptides cholecystokinin (CCK) and calcitonin (CT) were tested in an attention task for their effects on Auditory Event Related Potentials (AERPs) and for their effects on satiety and activation as measured in self-rating scales. Thirteen healthy subjects received either 3 IDU/kg bodyweight CCK 1-33, 0.1 IU/kg bodyweight CT and placebo according to a double-blind within-subject cross-over design. Subjects had fasted for at least 16 hr prior to the experiment. CCK induced the feeling of satiety after stimulation with the preparation of a meal. The peptides prevented an attenuation of the N2-component of the AERP after the preparation of a meal, indicating that the subjects were less distracted by the food cues. The results suggest that the central nervous effects of CCK and CT may constitute an aspect of satiated behavior.