Characterization of the gut bacterial and viral microbiota in latent autoimmune diabetes in adults

Latent autoimmune diabetes in adults (LADA) is a heterogeneous disease characterized by autoantibodies against insulin producing pancreatic beta cells and initial lack of need for insulin treatment. The aim of the present study was to investigate if individuals with LADA have an altered gut microbiota relative to non-diabetic control subjects, individuals with type 1 diabetes (T1D), and individuals with type 2 diabetes (T2D). Bacterial community profiling was performed with primers targeting the variable region 4 of the 16S rRNA gene and sequenced. Amplicon sequence variants (ASVs) were generated with DADA2 and annotated to the SILVA database. The gut virome was sequenced, using a viral particle enrichment and metagenomics approach, assembled, and quantified to describe the composition of the viral community. Comparison of the bacterial alpha- and beta-diversity measures revealed that the gut bacteriome of individuals with LADA resembled that of individuals with T2D. Yet, specific genera were found to differ in abundance in individuals with LADA compared with T1D and T2D, indicating that LADA has unique taxonomical features. The virome composition reflected the stability of the most dominant order Caudovirales and the families Siphoviridae, Podoviridae, and Inoviridae, and the dominant family Microviridae. Further studies are needed to confirm these findings.

[Explosives-based vole traps-A novel injury pattern in the eye region]

BACKGROUND

A novel method for trapping voles is the use of pistol-like explosive tools loaded with bolt-action ammunition. When triggered the vole is killed by the very high gas pressure created. Accidental releases can result in facial and/or eye injuries. The aim of this work was to describe the injury pattern in the patient and to experimentally verify whether there is a risk of penetrating eye injuries.

METHODS

Two emergency patients presented to our eye clinic with eye injuries after unintentional triggering of the explosive trap. Based on the new pattern of injury noted, experiments were performed on enucleated porcine eyes to determine the possible severity. For this purpose, a vole trap was clamped in a holder and loaded with a Cal. 9 × 17 mm cartridge in each case. In front of the muzzle opening, 3 pig eyes each were fixed on Styrofoam at a distance of 20, 40, 60 and 80 cm. The foreign body indentations in the cornea were visualized and measured by spectral domain optical coherence tomography (SD-OCT). The pig eyes were then dissected and searched for foreign bodies using microscopy. The SD-OCT images of an injured patient were also included for human comparison.

RESULTS

On patient examination, in addition to the usual fine gunshot marks on the face and conjunctiva/eye area, wax-like, larger and heavier particles of approximately 0.1-0.2 mm in size were found, which originated from the cartridge end cap. Removal of these foreign bodies, some of which were injected more deeply into the cornea, conjunctiva, and tenon, is much more difficult and extensive than in usual blast trauma. There was no evidence of intraocular foreign bodies in either patient. Likewise, no intraocular foreign bodies could be detected experimentally in any pig eyeball (n = 12). Remnants of the wax-like cartridge end were found deeply penetrating into the corneal stroma. The maximum penetration depth measured against the total corneal thickness was 46% at 20 cm device distance and decreased with greater distance to the vole trap (penetration depth at 40 cm at 37%, at 60 cm at 28% and at 80 cm at 19%). For comparisons on the human eye, a penetration depth of 54% was measured at a distance of about 40 cm. In pig eyes the number of foreign bodies per cm2 decreased with increasing distance from the vole trap (mean: n = 174 foreign bodies, FB, at 20 cm distance, n = 46 FB at 40 cm, n = 23 FB at 60 cm, and n = 9 FB at 80 cm). The largest penetrating foreign bodies measured a mean of 383 ± 43 μm with a maximum of 451 μm.

CONCLUSION

New vole traps with gas-powered mechanisms result in larger deeply penetrating wax-like foreign bodies in the cornea, conjunctiva, and tenon of the eye, which are difficult to remove and only surgically possible. Despite the significant explosion during triggering, there was no evidence of penetrating ocular injury from the foreign bodies either in the patient or experimentally in the pig eyes. Safety goggles should be worn when handling the traps to avoid penetration of foreign bodies into the eye.

Oral supplementation of nicotinamide riboside alters intestinal microbial composition in rats and mice, but not humans

The gut microbiota impacts systemic levels of multiple metabolites including NAD⁺ precursors through diverse pathways. Nicotinamide riboside (NR) is an NAD⁺ precursor capable of regulating mammalian cellular metabolism. Some bacterial families express the NR-specific transporter, PnuC. We hypothesized that dietary NR supplementation would modify the gut microbiota across intestinal sections. We determined the effects of 12 weeks of NR supplementation on the microbiota composition of intestinal segments of high-fat diet-fed (HFD) rats. We also explored the effects of 12 weeks of NR supplementation on the gut microbiota in humans and mice. In rats, NR reduced fat mass and tended to decrease body weight. Interestingly, NR increased fat and energy absorption but only in HFD-fed rats. Moreover, 16S rRNA gene sequencing analysis of intestinal and fecal samples revealed an increased abundance of species within Erysipelotrichaceae and Ruminococcaceae families in response to NR. PnuC-positive bacterial strains within these families showed an increased growth rate when supplemented with NR. The abundance of species within the Lachnospiraceae family decreased in response to HFD irrespective of NR. Alpha and beta diversity and bacterial composition of the human fecal microbiota were unaltered by NR, but in mice, the fecal abundance of species within Lachnospiraceae increased while abundances of Parasutterella and Bacteroides dorei species decreased in response to NR. In conclusion, oral NR altered the gut microbiota in rats and mice, but not in humans. In addition, NR attenuated body fat mass gain in rats, and increased fat and energy absorption in the HFD context.

Association of general health and lifestyle factors with the salivary microbiota - Lessons learned from the ADDITION-PRO cohort

INTRODUCTION

Previous research indicates that the salivary microbiota may be a biomarker of oral as well as systemic disease. However, clarifying the potential bias from general health status and lifestyle-associated factors is a prerequisite of using the salivary microbiota for screening.

MATERIALS & METHODS

ADDDITION-PRO is a nationwide Danish cohort, nested within the Danish arm of the Anglo-Danish-Dutch Study of Intensive treatment in People with Screen-Detected Diabetes in Primary Care. Saliva samples from n=746 individuals from the ADDITION-PRO cohort were characterized using 16s rRNA sequencing. Alpha- and beta diversity as well as relative abundance of genera was examined in relation to general health and lifestyle-associated variables. Permutational multivariate analysis of variance (PERMANOVA) was performed on individual variables and all variables together. Classification models were created using sparse partial-least squares discriminant analysis (sPLSDA) for variables that showed statistically significant differences based on PERMANOVA analysis (p < 0.05).

RESULTS

Glycemic status, hemoglobin-A_1c (HbA_1c) level, sex, smoking and weekly alcohol intake were found to be significantly associated with salivary microbial composition (individual variables PERMANOVA, p < 0.05). Collectively, these variables were associated with approximately 5.8% of the observed differences in the composition of the salivary microbiota. Smoking status was associated with 3.3% of observed difference, and smoking could be detected with good accuracy based on salivary microbial composition (AUC 0.95, correct classification rate 79.6%).

CONCLUSIONS

Glycemic status, HbA_1c level, sex, smoking and weekly alcohol intake were significantly associated with the composition of the salivary microbiota. Despite smoking only being associated with 3.3% of the difference in overall salivary microbial composition, it was possible to create a model for detection of smoking status with a high correct classification rate. However, the lack of information on the oral health status of participants serves as a limitation in the present study. Further studies in other cohorts are needed to validate the external validity of these findings.

Advanced Dental Cleaning is Associated with Reduced Risk of COPD Exacerbations - A Randomized Controlled Trial

Purpose

Infections from the oral microbiome may lead to exacerbations of chronic obstructive pulmonary disease (COPD). We investigated whether advanced dental cleaning could reduce exacerbation frequency. Secondary outcomes were disease-specific health status, lung function, and whether the bacterial load and composition of plaque microbiome at baseline were associated with a difference in outcomes.

Patients and Methods

One-hundred-one primary and secondary care patients with COPD were randomized to intervention with advanced dental cleaning or to dental examination only, repeated after six months. At baseline and at 12 months, data of exacerbations, lung function, COPD Assessment Test (CAT) score, and periodontal status were collected from questionnaires, record review, and periodontal examination. Student’s t-test and Mann–Whitney-U (MWU) test compared changes in outcomes. The primary outcome variable was also assessed using multivariable linear regression with adjustment for potential confounders. Microbiome analyses of plaque samples taken at baseline were performed using Wilcoxon signed ranks tests for calculation of alpha diversity, per mutational multivariate analysis of variance for beta diversity, and receiver operating characteristic curves for prediction of outcomes based on machine learning models.

Results

In the MWU test, the annual exacerbation frequency was significantly reduced in patients previously experiencing frequent exacerbations (p = 0.020) and in those with repeated advanced dental cleaning (p = 0.039) compared with the non-treated control group, but not in the total population including both patients with a single and repeated visits (p = 0.207). The result was confirmed in multivariable linear regression, where the risk of new exacerbations was significantly lower in patients both in the intention to treat analysis (regression coefficient 0.36 (95% CI 0.25–0.52), p < 0.0001) and in the population with repeated dental cleaning (0.16 (0.10–0.27), p < 0.0001). The composition of microbiome at baseline was moderately predictive of an increased risk of worsened health status at 12 months (AUC = 0.723).

Conclusion

Advanced dental cleaning is associated with a reduced frequency of COPD exacerbations. Regular periodontal examination and dental cleaning may be of clinical importance to prevent COPD exacerbations.

Direct supplementation with Urolithin A overcomes limitations of dietary exposure and gut microbiome variability in healthy adults to achieve consistent levels across the population

BACKGROUND

Urolithin A (UA) is produced by gut microflora from foods rich in ellagitannins. UA has been shown to improve mitochondrial health preclinically and in humans. Not everyone has a microbiome capable of producing UA, making supplementation with UA an appealing strategy.

OBJECTIVE

This is the first detailed investigation of the prevalence of UA producers in a healthy population and the ability of direct UA supplementation to overcome both microbiome and dietary variability. Dietary intake of a glass of pomegranate juice (PJ) was used to assess UA producer status (n = 100 participants) and to characterize differences in gut microbiome between UA producers from non-producers.

METHODS

Subjects were randomized (1:1) to either PJ or a food product containing UA (500 mg). Prevalence of UA producers and non-producers were determined in the PJ group. Diet questionnaires and fecal samples were collected to compare differences between UA producers and non-producers along with plasma samples at different time points to assess levels of UA and its conjugates between the interventions.

RESULTS

Only 12% of subjects had detectable levels of UA at baseline. Following PJ intake ~40% of the subjects converted significantly the precursor compounds into UA. UA producers were distinguished by a significantly higher gut microbiome diversity and ratio of Firmicutes to Bacteroides. Direct supplementation with UA significantly increased plasma levels and provided a >6-fold exposure to UA vs. PJ (p < 0.0001).

CONCLUSIONS

Differences in gut microbiome and diet that dictate natural exposure to UA can be overcome via direct dietary UA supplementation.

A diet-induced gut microbiota component and related plasma metabolites are associated with depressive-like behaviour in rats

It is well-established in preclinical studies that various probiotics may improve behaviours related to psychiatric disease. We have previously shown that probiotics protected against high-fat diet (HFD)-induced depressive-like behaviour in Flinders Sensitive Line (FSL) rats, whereas FSL rats on control (CON) diet were unaffected. Therefore, we hypothesised that a dysmetabolic component of depression may exist that involves the gut microbiota and that such component may be reflected in the plasma metabolome. The aims of the present study post hoc analyses were 1) to study the effect of probiotics on gut microbiota composition and its association with depressive-like behaviour in FSL rats, and 2) to identify plasma metabolites associated with gut microbiota and depressive-like behaviour. Forty-six FSL rats were fed CON or HFD and treated with multi-species probiotics (nine Bifidobacterium, Lactococcus and Lactobacillus species) for 12 weeks. Faecal samples were collected for 16S rRNA (VR4) gene amplicon sequencing (Illumina MiSeq), and an untargeted plasma metabolomics was performed. We found that probiotics increased the relative faecal abundance of the Bifidobacterium, Lactococcus and Lactobacillus genera in HFD-fed rats only. Also, a HFD-induced microbiota component associated with depressive-like behaviour was identified, and probiotics improved the component score. Finally, the plasma levels of 44 metabolites correlated with the depression-related microbiota component, and three such metabolites had good predictive ability for depressive-like behaviour. Potentially, our findings imply that a subtype of depression characterised by a diet-induced, pro-depressant gut microbiota may exist and that analysis of related plasma metabolites may reveal aberrant microbiota functioning related to depression.

Metformin-induced changes of the gut microbiota in healthy young men: results of a non-blinded, one-armed intervention study

AIMS/HYPOTHESIS

Individuals with type 2 diabetes have an altered bacterial composition of their gut microbiota compared with non-diabetic individuals. However, these alterations may be confounded by medication, notably the blood-glucose-lowering biguanide, metformin. We undertook a clinical trial in healthy and previously drug-free men with the primary aim of investigating metformin-induced compositional changes in the non-diabetic state. A secondary aim was to examine whether the pre-treatment gut microbiota was related to gastrointestinal adverse effects during metformin treatment.

METHODS

Twenty-seven healthy young Danish men were included in an 18-week one-armed crossover trial consisting of a pre-intervention period, an intervention period and a post-intervention period, each period lasting 6 weeks. Inclusion criteria were men of age 18-35 years, BMI between 18.5 kg/m² and 27.5 kg/m², HbA_1c < 39 mmol/mol (5.7%) and plasma creatinine within the normal range. No prescribed medication, including antibiotics, for 2 months prior to recruitment were allowed and no previous gastrointestinal surgery, discounting appendectomy or chronic illness requiring medical treatment. During the intervention the participants were given metformin up to 1 g twice daily. Participants were examined five times in the fasting state with blood sampling and recording of gastrointestinal symptoms. Examinations took place at Frederiksberg Hospital, Denmark before and after the pre-intervention period, halfway through and immediately after the end of intervention and after the wash-out period. Faecal samples were collected at nine evenly distributed time points, and bacterial DNA was extracted and subjected to 16S rRNA gene amplicon sequencing in order to evaluate gut microbiota composition. Subjective gastrointestinal symptoms were reported at each visit.

RESULTS

Data from participants who completed visit 1 (n=23) are included in analyses. For the primary outcome the relative abundance of 11 bacterial genera significantly changed during the intervention but returned to baseline levels after treatment cessation. In line with previous reports, we observed a reduced abundance of Intestinibacter spp. and Clostridium spp., as well as an increased abundance of Escherichia/Shigella spp. and Bilophila wadsworthia. The relative abundance at baseline of 12 bacterial genera predicted self-reported gastrointestinal adverse effects.

CONCLUSIONS/INTERPRETATION

Intake of metformin changes the gut microbiota composition in normoglycaemic young men. The microbiota changes induced by metformin extend and validate previous reports in individuals with type 2 diabetes. Secondary analyses suggest that pre-treatment gut microbiota composition may be a determinant for development of gastrointestinal adverse effects following metformin intake. These results require further investigation and replication in larger prospective studies.

TRIAL REGISTRATION

Clinicaltrialsregister.eu 2015-000199-86 and ClinicalTrials.gov NCT02546050 FUNDING: This project was funded by Danish Diabetes Association and The Novo Nordisk Foundation.

The antidepressant-like effect of probiotics and their faecal abundance may be modulated by the cohabiting gut microbiota in rats

Numerous studies have been published describing the effect of various probiotics (PRO) on behaviours related to psychiatric disease. We have previously shown a robust antidepressant-like effect of PRO in rats, but over time, the treatment effect seems to vary significantly between different sets of rats from the same commercial vendor. Therefore, we hypothesised that the antidepressant-like response may be modulated by the cohabiting gut microbiota. The aims of the present study were (1) to investigate any differences in the gut microbiota composition between responders (Resp) and non-responders (Non-resp) to PRO with regards to depressive-like behaviour, and (2) to evaluate the effects of PRO on the microbiota composition. Two sets of 20 male Sprague-Dawley rats each were treated with multi-species PRO (nine Bifidobacterium, Lactococcus and Lactobacillus species) for eight weeks and subjected to a behavioural assessment. Faecal samples were collected for 16 s rRNA (VR4) gene amplicon sequencing (Illumina MiSeq). As previously reported, PRO-treated Resp animals showed a marked decrease in depressive-like behaviour, whereas no such response was seen in Non-resp. We observed profound differences in the gut microbiota composition between the two sets of rats, and the relative faecal abundance of the genera that comprised PRO was higher in Resp than in Non-resp although treated with the same dose of PRO. Particularly, the relative abundance of the Lactobacillus genus was not increased in PRO-treated Non-resp animals. In conclusion, the cohabiting microbiota and the faecal abundance of PRO may modulate the antidepressant-like effect of PRO in rats.

The effect of drinking water pH on the human gut microbiota and glucose regulation: results of a randomized controlled cross-over intervention

Studies in rodent models have shown that alterations in drinking water pH affect both the composition of the gut microbiota and host glucose regulation. To explore a potential impact of electrochemically reduced alkaline (pH ≈ 9) versus neutral (pH ≈ 7) drinking water (2 L/day) on human intestinal microbiota and host glucose metabolism we conducted a randomized, non-blinded, cross-over study (two 2-week intervention periods, separated by a 3-week wash-out) in 29 healthy, non-smoking Danish men, aged 18 to 35 years, with a body mass index between 20.0 to 27.0 kg m-2. Volunteers were ineligible if they had previously had abdominal surgery, had not been weight stabile for at least two months, had received antibiotic treatment within 2 months, or had a habitual consumption of caloric or artificially sweetened beverages in excess of 1 L/week or an average intake of alcohol in excess of 7 units/week. Microbial DNA was extracted from faecal samples collected at four time points, before and after each intervention, and subjected to 16S rRNA gene amplicon sequencing (Illumina MiSeq, V4 region). Glycaemic regulation was evaluated by means of an oral glucose tolerance test.No differential effect of alkaline versus neutral drinking water was observed for the primary outcome, overall gut microbiota diversity as represented by Shannon's index. Similarly, neither a differential effect on microbiota richness or community structure was observed. Nor did we observe a differential effect on the abundance of individual operational taxonomic units (OTUs) or genera. However, analyses of within period effects revealed a significant (false discovery rate ≤5%) increase in the relative abundance of 9 OTUs assigned to order Clostridiales, family Ruminococcaceae, genus Bacteroides, and species Prevotella copri, indicating a potential effect of quantitative or qualitative changes in habitual drinking habits. An increase in the concentration of plasma glucose at 30 minutes and the incremental area under the curve of plasma glucose from 0 30 and 0 120 minutes, respectively, was observed when comparing the alkaline to the neutral intervention. However, results did not withstand correction for multiplicity. In contrast to what has been reported in rodents, a change in drinking water pH had no impact on the composition of the gut microbiota or glucose regulation in young male adults. The study is registered at www.clinicaltrials.gov (NCT02917616).

Loss-of-function variants in ADCY3 increase risk of obesity and type 2 diabetes

We have identified a variant in ADCY3 (encoding adenylate cyclase 3) associated with markedly increased risk of obesity and type 2 diabetes in the Greenlandic population. The variant disrupts a splice acceptor site, and carriers have decreased ADCY3 RNA expression. Additionally, we observe an enrichment of rare ADCY3 loss-of-function variants among individuals with type 2 diabetes in trans-ancestry cohorts. These findings provide new information on disease etiology relevant for future treatment strategies.

The Thermus thermophilus comEA/comEC operon is associated with DNA binding and regulation of the DNA translocator and type IV pili

Natural transformation systems and type IV pili are linked in many naturally competent bacteria. In the Gram-negative bacterium Thermus thermophilus, a leading model organism for studies of DNA transporters in thermophilic bacteria, seven competence proteins play a dual role in both systems, whereas two competence genes, comEA and comEC, are suggested to represent unique DNA translocator proteins. Here we show that the T. thermophilus ComEA protein binds dsDNA and is anchored in the inner membrane. comEA is co-transcribed with the flanking comEC gene, and transcription of this operon is upregulated by nutrient limitation and low temperature. To our surprise, a comEC mutant was impaired in piliation. We followed this observation and uncovered that the impaired piliation of the comEC mutant is due to a transcriptional downregulation of pilA4 and the pilN both playing a dual role in piliation and natural competence. Moreover, the comEC mutation resulted in a dramatic decrease in mRNA levels of the pseudopilin gene pilA1, which is unique for the DNA transporter. We conclude that ComEC modulates transcriptional regulation of type IV pili and DNA translocator components thereby mediating a response to extracellular parameters.

Environmental factors affecting the expression of type IV pilus genes as well as piliation of Thermus thermophilus

The thermophilic bacterium Thermus thermophilus HB27 is known for its highly efficient natural transformation system, which has become a model system to study the structure and function of DNA transporter in thermophilic bacteria. The DNA transporter is functionally linked to type IV pili (T4P), which are essential for twitching motility and adhesion to solid surfaces. However, the pilus structures themselves are dispensable for natural transformation. Here, we report that the cellular mRNA levels of the major structural subunit of the T4P, PilA4, are regulated by environmental factors. Growth of T. thermophilus in minimal medium or low temperature (55 °C) leads to a significant increase in pilA4 transcripts. In contrast, the transcript levels of the minor pilin pilA1 as well as other T4P genes are nearly unaffected. The elevated pilA4 mRNA levels are accompanied by an increase in piliation of the cells but not by elevated natural transformation frequencies. Hyperpiliation leads to increased adhesion to plastic surfaces. The increased cell-surface interactions are suggested to represent an adaptive response to temperature stress and may be advantageous for survival of T. thermophilus.

Backbone and side-chain 1H, 15N and 13C assignment of apo- and imipenem-acylated L,D-transpeptidase from Bacillus subtilis

The D,D-transpeptidase activity of Penicillin Binding Proteins (PBPs) is essential to maintain cell wall integrity. PBPs catalyze the final step of the peptidoglycan synthesis by forming 4 → 3 cross-links between two peptide stems. Recently, a novel β-lactam resistance mechanism involving L,D-transpeptidases has been identified in Enterococcus faecium and Mycobacterium tuberculosis. In this resistance pathway, the classical 4 → 3 cross-links are replaced by 3 → 3 cross-links, whose formation are catalyzed by the L,D-transpeptidases. To date, only one class of the entire β-lactam family, the carbapenems, is able to inhibit the L,D-transpeptidase activity. Nevertheless, the specificity of this inactivation is still not understood. Hence, the study of this new transpeptidase family is of considerable interest in order to understand the mechanism of the L,D-transpeptidases inhibition by carbapenems. In this context, we present herein the backbone and side-chain (1)H, (15)N and (13)C NMR assignment of the L,D-transpeptidase from Bacillus subtilis (Ldt(Bs)) in the apo and in the acylated form with a carbapenem, the imipenem.

Examples of model-free implant restorations using Cerec inLab 4.0 software

This case report demonstrates two ways to fabricate model-free implant restorations with the Cerec inLab 4.0 software. Because the patient, a woman with a history of periodontal disease, did not wish to have a removable partial denture, implant therapy was planned for the restoration of her edentulous areas 14/15 and 24/25. In addition, the restoration was to provide functional relief of the natural maxillary anterior teeth. The two implants for the first quadrant were planned as single-tooth restorations. Each was designed as a full contour implant supra-structure using the Cerec Biogeneric abutment design technique. After completing the design phase, each restoration proposal was split into two parts: a zirconia abutment and a lithium disilicate crown. For the restoration of the second quadrant, custom 20-degree-angled abutments were individualized and acquired with the Cerec camera. A block crown was then designed, milled in burn-out acrylic resin, and fabricated from a lithium disilicate glass-ceramic ingot according to the press ceramic technique. Additionally methods of provisional restorations are discussed.

[Health care systems and aspects of health care economics. Sector ophthalmology - part 1: development of the German health care system]

Although many health care reforms have been enacted in the last few years in Germany, many of the key points in the current social health care system have been retained from former times. All those introductions for an effective health care system from the last 150 years beginning with mandatory guild membership via Bismarck's social laws to the modern health care systems in Germany with the current problems of financing the heavy burden in the German budget are reported. Data and facts on the current health care system are provided. In the following two articles of this series ambulatory and inpatient treatment in the light of economic aspects of health care are reported.

Komplikationen nach refraktiver Chirurgie im Ausland

BACKGROUND

In this article a retrospective analysis of patients presenting at a German university following refractive surgery abroad is presented.

PATIENTS AND METHODS

A total of 20 cases of patients who had undergone treatment between 1998 and 2006 in China (1 case), Greece (1 case), Iran (1 case), Russia (2 cases), Switzerland (1 case), Slovakia (1 case), Spain (2 cases), South Africa (3 cases), Turkey (6 cases) and the USA (2 cases) were analyzed retrospectively.

RESULTS

The following complications were observed: epithelial ingrowth into the interface with or without melting of the flap (6 cases), corneal ectasia (2 cases), dislocation of a phakic posterior chamber intraocular lens and prolapse into the anterior chamber with endothelial cell loss (1 case), secondary increase of intraocular pressure following implantation of a phakic intraocular lens (1 case), flap-related complications following laser-in-situ keratomileusis (LASIK) (2 cases), keratitis (1 case), dislocation of the complete flap (1 case), diffuse lamellar keratitis (DLK) grade IV (1 case), hyperopia as a consequence of radial keratotomy (1 case), and under correction/over correction and poor optical quality following laser epithelial keratomileusis (LASEK) and LASIK for high myopia (5 cases) with possible early corneal ectasia.

CONCLUSIONS

There are four important problems arising from refractive surgery abroad, often referred to as "LASIK tourism": wrong indications, insufficient management of complications, lack of postoperative care and the health economic aspect.

[Treatment of infected total knee arthroplasty. When does implant salvage make sense?]

Infection of a total knee arthroplasty can be classified as acute, chronic and haematogenic with and without implant loosening. A differentiated treatment concept for all types of infection is necessary. Furthermore, specific treatment has to be initiated early, as any delay is associated with a worsening of the prognosis. Treatment of infection with implant salvage may be one therapeutic option if the implant is not loose. According to the current literature, therapy with retention of the prosthesis may be promising: (1) in the case of early infection (<3 weeks of ongoing symptoms), (2) with unconstrained implants, (3) in the case of infection with a single organism that is susceptible to antibiotic therapy, (4) if soft tissue coverage is not affected, and (5) if the immune system is not compromised. Chronic infections, (semi-)constrained implants and soft tissue defects have to be considered as contraindications and implants should be removed. Early and consequent therapy with operative débridement and specific long-term antibiotic therapy are necessary to achieve implant salvage. The additional application of antibiotics addressing bacterial biofilms have helped to improve the prognosis. Due to the fact that revision arthroplasty is often associated with limited function after infection of the total knee joint, retention of the implant has to be considered a therapeutic alternative in early infection.

Penetration of fosfomycin into inflammatory lesions in patients with cellulitis or diabetic foot syndrome

We investigated the distribution of the broad-spectrum antibiotic fosfomycin in infected soft tissue of patients with uncomplicated cellulitis of the lower extremities or diabetic foot infection using in vivo microdialysis. Our findings suggest that fosfomycin exhibits good and similar penetration into the fluid in the interstitial space in inflamed and noninflamed soft tissue in patients.

Case report. Atypical cutaneous pseudallescheriosis refractory to antifungal agents

We report on a 65-year-old male heart transplant recipient who was otherwise in good condition. The patient was immunocompromised secondarily due to cyclosporin, prednisolone and azathioprine when widespread pustular skin lesions with erythematous margins subsequently developed on his left forearm. There was no history of trauma or septic temperature. Bacterial cultures were sterile and the results of native and cultural investigation studies were negative. A biopsy specimen of the lesion demonstrated hyalohyphomycosis with numerous septate hyphae within granulomas throughout the dermis. Subcutaneous tissues were not involved. Culture plates inoculated with pus and skin from the punch biopsy showed growth of a mould yielding Pseudallescheria boydii. Sensitivity testing was performed with miconazole, ketoconazole and itraconazole showing the best in vitro activity against P. boydii. In spite of treatment with itraconazole, the erythema and pustules continued to spread and therapy was changed to intravenous miconazole. Due to ongoing progression after 3 months of antifungal therapy surgical debridement was required. After 2 years of follow up, he had no recurrence.

["Topless" cardiopulmonary resuscitation? Should heart-lung resuscitation be preformed without artificial resuscitation?]

A paper published in various US journals on Emergency Medicine in 1997, has raised considerable concerns. The authors question if it is justified to continue to recommend initial ventilation as part of basic CPR when performed by lay-bystanders. A few aspects need to be discussed and some questions have to be answered before any changes in the current recommendations may even be considered: e.g. 1. How convincing does the available evidence support the following hypotheses: 1.1. Lay CPR without mouth-to-mouth-ventilation provides better outcome after cardiac arrest than lay CPR with mouth-to-mouth-ventilation. 1.2. Endotracheal intubation may be detrimental in patients suffering from hemodynamic compromises, particularly from VF. 2. Is it scientifically and ethically acceptable to design and perform prospective randomized controlled trials (RCTs) to evaluate the efficacy of those components of BCLS and ACLS which have in accordance with AHA-, ERC Guidelines and ILCOR Statements in the past been applied in millions of cardiac arrest victims and have obviously enabled the patients to lead a meaningful life after survival; under conditions of the proposed study design patients of the study group would be left without the treatment option ventilation, thus diminishing their chances of survival. Ad 1: The arguments presented by the authors are hardly convincing. The authors themselves state elsewhere that reluctance to perform mouth-to-mouth-ventilation should not represent a major problem because most cardiac arrests of cardiac etiology occur at home and in the presence of a relative or friend. Moreover, unreliable recommendations for mouth-to-mouth-ventilation (AHA), lack of training, retention of skills and knowledge, and a deficit in motivation include the main causes of the disappointingly low figures of bystander CPR worldwide. This situation cannot be improved simply by eliminating a lifesaving component of CPR-ventilation. Instead, the proposal to abandon the administration of unreasonably high ventilation volumes (800-1200 ml/breath) from the present guidelines and to recommend volumes ranging from 400-500 ml/breath recently made by the ERC should be given serious consideration. Furthermore, equipment and training manikins need to be adapted to these more reasonable volumes. Independently of the mechanisms of slow decreases in SaO2 after cardiac arrest (provided no compressions are performed) independently of gasping, ventilatory effects of standard compression or ACD-HCPR in the absence of mouth-to-mouth-ventilation, it is essential to realise that the patient's airways need to be maintained open at all times (this is unlike animal experiments where the airways are primarily kept open by the respective tissue structures): The minimum requirement of First Responder CPR is the guarantee that open airways are maintained. It may possibly be discussed if the present sequence of ABC might be changed to CAB, a practice adopted in the Netherlands many years ago, however, outcome trials an CAB have not been published to date. In addition, greater demands should be made of training requirements in BLS, attendance of refresher courses should be required, and other groups of the population should be included into these programmes than only relatives or friends of patients at risk of a cardiac arrest. The programmes need to be made mandatory for greater variety of groups and individuals to increase the efficacy and efficiency of bystander resuscitation. The hypotheses made by the above-mentioned authors are neither scientifically nor ethically acceptable. Ad 2: Pepe's argument regarding the efficacy of endotracheal intubation (ETI) in VF-patients has not been scientifically proven and lacks conclusive evidence. ETI serves to protect the airways and lungs against aspiration of regurgitated material and to facilitate artificial ventilation including PEEP, both under anaesthesia and resuscitation. The efficacy of ETI in the OR has long b

False-positive LSD testing in urine samples from intensive care patients

Unexpected positive results for lysergic acid diethylamide (LSD) were found in urine samples from 12 patients in an intensive care unit in a routine screening using the CEDIA DAU assay. None of these test results could be confirmed by high-performance liquid chromatography analysis, but all samples contained the mucolytic drug ambroxol. Further studies demonstrated that ambroxol exhibits a significant cross-reactivity in the CEDIA DAU LSD assay. Therefore, positive LSD results obtained with the CEDIA DAU assay have to be critically evaluated, particularly during the cold season, when infections of the respiratory tract often result in more frequent use of mucolytic medications.

Imbalance between the endothelial cell-derived contracting factors prostacyclin and angiotensin II and nitric oxide/cyclic GMP in human primary varicosis

1. The role of the endothelium in the vasomotor control of human veins in the lower extremity is little understood. We tested the hypothesis that the production of relaxing and contracting factors is altered in endothelial cells from varicose saphenous veins which may predispose to the decreased vessel tone observed in primary varicosis. 2. We determined the intracellular accumulation of guanosine 3':5'-cyclic monophosphate cyclic GMP; a measure of nitric oxide production and the release of endothelin and prostacyclin (measured as its stable metabolite 6-keto-prostaglandin F1alpha) from cultured cells derived from the long saphenous veins of patients with primary varicosis (Varicose saphena group, n = 27) or from patients undergoing coronary artery bypass surgery (Healthy saphena group, n = 22). In addition, levels of endothelin, angiotensin II, bradykinin, cyclic GMP and cyclic AMP in plasma from patients with primary varicosis and healthy volunteers (n = 8-11 in each group) were determined. 3. Although basal cyclic GMP levels were similar, more cyclic GMP accumulated in response to histamine (1-100 micromol l[-1]) in cells from varicose saphenous veins (0.75 +/- 0.1 pmol per well) than in cells from veins without varicosis (0.27 +/- 0.05 pmol per well). Furthermore, the relaxant potency of nitroprusside (1 nmol l(-1) - 300 micromol l[-1]) in vitro was higher for varicose veins (mean EC50 = 5.9 micromol l(-1); n = 8) than healthy veins (mean EC50 = 20.0 micromol l(-1); n = 7). 4. The production of prostacyclin was significantly less in cells from varicose than healthy saphenous veins (66 +/- 8.7 and 121 +/- 20.1 nmol g(-1) protein), but the production of endothelin was similar in both groups. Prostacyclin (3 nmol l(-1) 30 micromol l[-1]) consistently contracted rings of varicose saphenous vein in vitro with a mean EC50 value of 10-20 micromol l(-1) (n = 7); the maximum tension generated was approximately 50% of that of a completely depolarizing solution of K+ (120 mmol l[-1]). 5. In plasma from patients with varicose veins, levels of cyclic GMP were higher than in healthy controls (9.2 +/- 0.03 and 7.2 +/- 0.02 nmol l[-1]), levels of angiotensin II were lower (81 +/- 11.5 and 147 +/- 21.7 pmol l[-1]), and levels of endothelin, cyclic AMP, and bradykinin were not different. 6. It is concluded that endothelial cells from diseased saphenous veins secrete less constrictor mediators than cells from healthy veins and that in diseased veins the nitric oxide/cyclic GMP system is up-regulated which may shift the balance of vasoactive factors towards vasodilatation and contribute to the development of primary varicosis.

Methodological considerations in participant event monitoring of low-base-rate events in health psychology: children's injuries as a model

The present article outlines the advantages of the participant event monitoring methodology for the investigation of unpredictable, low-base-rate events in children. Several methods for assessing the quality of participant event monitoring data are advanced with a data set showing participant event monitoring of children's minor injuries by 61 children and their mothers. Child-mother correspondence and debriefing data suggest good accuracy for frequency estimates. Home- and laboratory-based simulations illustrate the participant event monitors' accuracy for major details. Traditional measures of data quality show good overall coder and test-retest reliability, and cross-observer reports show acceptable estimates of validity for objective aspects of the events and the expected lower estimates for the more subjective aspects. Conceptual and pragmatic difficulties of the method are considered, and suggestions for future research are advanced.

Long-cane modification for carpal tunnel syndrome: a case report

BACKGROUND

Low vision rehabilitation services should be multidisciplinary and should provide patients with as many options as are necessary to help partially sighted individuals maintain independence and quality of life.

METHODS

A case report is presented of a 30-year-old insulin-dependent diabetic patient with carpal tunnel syndrome. Team management resulted in referral for occupational therapy evaluation and resulted in long cane modification.

RESULTS

Modification of a long cane was accomplished using a piece of PVC plastic glued at a right angle to the long cane, thus acting as a handle. Fabric straps with Velcro fasteners made the cane movable with forearm rather than wrist motion and allowed the patient to maintain independent travel.

CONCLUSIONS

This case presents an example of appropriate referral for an occupational therapy evaluation. Low vision rehabilitation demands an interdisciplinary approach.

Methodological considerations in participant event monitoring of low-base-rate events in health psychology: children's injuries as a model

The present article outlines the advantages of the participant event monitoring methodology for the investigation of unpredictable, low-base-rate events in children. Several methods for assessing the quality of participant event monitoring data are advanced with a data set showing participant event monitoring of children's minor injuries by 61 children and their mothers. Child-mother correspondence and debriefing data suggest good accuracy for frequency estimates. Home- and laboratory-based simulations illustrate the participant event monitors' accuracy for major details. Traditional measures of data quality show good overall coder and test-retest reliability, and cross-observer reports show acceptable estimates of validity for objective aspects of the events and the expected lower estimates for the more subjective aspects. Conceptual and pragmatic difficulties of the method are considered, and suggestions for future research are advanced.

[Local efficiency of percutaneous radiotherapy in lung cancer. Analysis of 215 repeated bronchoscopies in relation to applied radiation dosage]

PURPOSE

During a locoregional radiotherapy with curative attempts of lung cancer patients bronchoscopic examinations with biopsies and/or cytologic lavages were repeated to assess the accuracy of limiting the total dose to 60 Gy. In order of the applied dose macroscopic changements of the endoluminal tumor and microscopic elimination should be made out. The correlation between macro- and microscopical regression should allow a statement about reliability of single results. The clinical course and a conventional thoracic X-ray examination seemed to be a to large-meshed screen to evaluate the effect at the end of therapy. The aim was to improve the criterias of success and to adapt and optimize the radiation dose individually.

PATIENTS AND METHODS

The prospective, together with the pneumologists, defined treatment concept included the repetition of bronchoscopic evaluations after the application of 60 Gy and 80 Gy. These radiation doses from 60 Gy up to 80 Gy have been given with a shrinking-field technique to the mediastinum and the primary. In order to record statistically the optical tumor changements we were urged to create a so-called bT-score. The structure of this score was orientated towards the periphery of the tracheobronchial tree.

RESULTS

Hundred and forty-four patients with endoscopically and histologically verified bronchogenic carcinomas were treated. On the subjects 215 re-bronchoscopies accomplished with biopsies were performed and allowed to analyze the macro- and microscopical behavior under treatment. A histological/cytological elimination of tumor was achieved after 60 Gy in 35.1%, after 80 Gy in 62.3%. Macroscopically no tumor was visible after 60 Gy in 43.6%, after 80 Gy in 82%. A correlation between identical micro- and macroscopical observations was only seen in 61%, respectively in 71%.

CONCLUSIONS

The escalation of the radiation dose from 60 Gy up to 80 Gy with shrinked fields could increase the local tumor sterilization rate by 1.8 times from 35.1% to 62.3%. The refining and completion of usually known parameters by endoscopical and histological examinations seems to be an acceptable way to define individual radiation doses. The quality of the performed therapy can be better determined. A predestination of the total dose to a limit of 60 Gy does not ensure a macro- and microscopical elimination of the tumor and may be inferior to an individually adaptation of the dose.

[Breast-preserving treatment of breast carcinoma: analysis of surgical, pathologic-anatomic and radiotherapeutic data of 291 cases]

291 breast cancer patients treated with conserving surgery and subsequent locoregional irradiation were studied. The method of surgery consisted of 200 lumpectomies, 76 quadrantectomies and 15 with either a wide excision or with an atypical resection. In at least 42.6% (124 out of 291), the tumor had been within 10 mm distance to the margin of resected specimen, in 13.4% (39 out of 291) the tumor even reached the border. In the other reports, a numerical description of the distance to the margins was not given. Postoperative radiotherapy was applied with 50 Gy cobalt-60/6-MeV photons to include the whole breast. A boost of tangentially opposed photon beams was added, replacing a technique with direct electron fields used in an earlier period during three years. The supraclavicular fossa received 46 Gy, the retrosternal pathway was covered with 45 to 50 Gy photons/electrons. Locoregional failure after an average observation time of 39.5 months was 4.5% (13 out of 291), within the target volume 3.8% (11 out of 291. The 39 cases on which the tumor reached the margin of resection, 92.3% (36 out of 39) remained free of recurrences. With a tumor-free resection line but a maximal distance of 10 mm, one recurrence (1.2% or 1 out of 85) was found. With the application of tangential photon beams to the tumor bed, which technically allowed sparing skin parts but also slightly reduced daily doses, the incidence of telangiectasis could be lowered to 2.5%. An anatomical was model was constructed to resemble a patient in the treatment position. Dosimeters were implanted and verified by computed tomography. Measurements of the radiation fields were performed within the breast, the lung and along the mammaria-interna chain. Minimal angle changes of 5 degrees decreased the retrosternal dose down with the amount of 56.5%, 10 degrees of 75% and 15 degrees of 85.7%. In contrast, moving the central axis medially by 1 cm and 2 cm increased the lung dose 2.2 and 4.4 times, respectively, whereas the dose within the breast remained almost equal. This emphasizes the importance of identical positioning, which must be realized 25 to 35 times throughout the course of therapy, often with different staff! Precision and consistent positioning are the main priorities. If these goals are achieved, lumpectomy with subsequent high-dose radiotherapy respecting cosmetics provides patients with excellent quality of life.

Parents' socialization of children's injury prevention: description and some initial parameters

In a year-long participant observation study of remediative action following actual injury, 61 8- and 9-year-old children and their 27-46-year-old mothers wrote records and reported on more than 1,000 minor injuries in branching biweekly interviews. Mothers reported that 80.1% of injuries received no parent-initiated remediation, 14% received only a lecture, and less than 3% of injuries were followed by parental action. Children reported that 96.1% of their injuries were followed by no remediative action and recalled lectures after only 1.2% of injuries. Remediative action was related to type of child activity (e.g., unstructured play was followed by remediation more often than more purposive behavior) and to mother's affect (e.g., anger) and beliefs (e.g., that injury was the child's fault or due to rule violation). The parameters that influenced remediative consequences, and thus that may influence future injury, are discussed.

[Endoscopic, biopsy and functional results in irradiated esophageal carcinoma]

83 patients of average age 64 (36-86) years with esophageal cancer were irradiated according to a prospectively defined treatment concept. After 60 Gy, re-endoscopy with biopsy was scheduled. If the tumor was still macro- or microscopically described, a boost to 70 Gy was given. During consistent weekly monitoring particular attention was focused on patients' ability to feed themselves. While initially only 7.2% could swallow solid food, by the end 84% of patients with a radiation dose of 60 Gy or more reported normal daily eating. Patients in whom the tumor was no longer present endoscopically or histologically survived four times longer (13.5 months) than those with persistent malignoma.

Visual accommodation in the flying fox (Pteropus giganteus)

The flying fox, Pteropus giganteus, possesses a papillated retina and was previously thought to lack a mechanism for active accommodation. An investigation of the anatomy and physiology of accommodation in this megachiropteran bat revealed that it has a well developed ciliary muscle and that it can actively accommodate through a range of at least 3.12 D. In addition, it was found that the origin of the retinoscopic reflex does not reside in the receptor layer of the retina, because the focus of the eye is invariant for small changes of angle of refraction.

Long-term effects of minoxidil therapy on renal function of patients with refractory hypertension: the significance of albuminuria

The addition of minoxidil therapy reduced blood pressure effectively for 6--52 months (average, 24) in 25 of 28 patients with refractory hypertension. One patient was nonresponsive; 2 were noncompliant. Patients who had a serum creatinine up to 4 mg% and greater than 750 mg of albuminuria per day had further deterioration of renal function of 5.3 +/- 1.4% per month compared to that of 0.2 +/- 0.4% per month in patients without albuminuria (p less th5% was not as helpful predicting preservation of renal function in patients with refractory hypertension after adding minoxidil as was the absence of albuminuria.

Papillomas in black and white colobus monkeys (Colobus polykomus)

Numerous Papillomas ranging in size from 10-25 mm were found on two Colobus monkeys, Colobus polykomus. These cauliflower-shaped growths were located on the palms and soles of all four feet and on the dorsal surfaces of several fingers and toes.