Aggregation of human osteoblasts unlocks self-reliant differentiation and constitutes a microenvironment for 3D-co-cultivation with other bone marrow cells

Skeletal bone function relies on both cells and cellular niches, which, when combined, provide guiding cues for the control of differentiation and remodeling processes. Here, we propose an in vitro 3D model based on human fetal osteoblasts, which eases the study of osteocyte commitment in vitro and thus provides a means to examine the influences of biomaterials, substances or cells on the regulation of these processes. Aggregates were formed from human fetal osteoblasts (hFOB1.19) and cultivated under proliferative, adipo- and osteoinductive conditions. When cultivated under osteoinductive conditions, the vitality of the aggregates was compromised, the expression levels of the mineralization-related gene DMP1 and the amount of calcification and matrix deposition were lower, and the growth of the spheroids stalled. However, within spheres under growth conditions without specific supplements, self-organization processes occur, which promote extracellular calcium deposition, and osteocyte-like cells develop. Long-term cultivated hFOB aggregates were free of necrotic areas. Moreover, hFOB aggregates cultivated under standard proliferative conditions supported the co-cultivation of human monocytes, microvascular endothelial cells and stromal cells. Overall, the model presented here comprises a self-organizing and easily accessible 3D osteoblast model for studying bone marrow formation and in vitro remodeling and thus provides a means to test druggable molecular pathways with the potential to promote life-long bone formation and remodeling.

[Endogenous Candida endophthalmitis]

Endogenous Candida endophthalmitis is a rare but vision-threatening disease. In most cases, endogenous endophthalmitis caused by Candida species has a better prognosis than endogenous endophthalmitis caused by other fungal species or bacteria but the prognosis still depends heavily on the time required for diagnosis and subsequent treatment as well as the initial visual acuity. Suggestions for treatment algorithms have already been made in the past but binding guidelines in ophthalmology only exist sporadically due to the rarity of the disease. This review discusses the current knowledge on endogenous Candida endophthalmitis and draws conclusions from the current study situation.

[Endogenous Candida endophthalmitis: diagnostics and treatment options based on case studies]

BACKGROUND

Endogenous Candida endophthalmitis is an emergency that can threaten vision and the eye as a whole organ but also the life of the patient due to its systemic cause.

MATERIAL AND METHOD

Retrospective case evaluation of the University Hospital for Ophthalmology Halle (Saale) and the Eye Clinic of the Ernst von Bergmann Hospital Potsdam from 2017-2022. (Age, gender, side involvement, underlying diseases, symptoms, preoperative and postoperative visual acuity, diagnostics, treatment and complications). The standardized procedures for endogenous Candida endophthalmitis are explained, the data are compared with the literature and treatment suggestions are presented.

RESULTS

8 patients with 14 eyes were treated for endogenous Candida endophthalmitis. Of the patients 2 were women and 6 were men. The overall average age was 70.25 years (53-82 years), 6 patients had bilateral eye involvement and 2 patients were affected on one side. All patients had several serious immunocompromising underlying diseases that were the cause of the candidemia. All patients underwent a pars plana vitrectomy (ppV) on the affected eyes except for one male patient who did not obtain permission for anesthesia. In addition to systemic treatment with antimycotics, voriconazole was routinely administered intravitreally during ppV. The patients received further intravitreal doses of voriconazole based on the findings. Vitreous body samples were taken from all patients during the ppV and detection of Candida albicans was possible in all cases. As part of the local perioperative treatment 1 patient received parabulbar administration of a triamcinolone depot in both eyes, 7 patients received a dexamethasone depot in 11 eyes and all 8 patients received findings-oriented local treatment with prednisolone acetate eye drops. visual acuity increased from preoperatively 1.2 logMar to 1.0 logMar. Postoperative retinal detachment did not occur and there were no serious perioperative complications. 2 patients died from one of the underlying diseases after 3 and 25 months, respectively.

CONCLUSION

Despite an increasing number of case series, there are still no uniform guidelines for ophthalmologists in Germany. There is agreement regarding systemic treatment and the intravitreal administration of antifungal agents. The role of ppV has not yet been clearly defined and the question of the adjuvant use of steroids (systemic and/or local) has also not been conclusively clarified.

Body impedance analysis to estimate malnutrition in inflammatory bowel disease patients - A cross-sectional study

OBJECTIVE

Malnutrition is a common clinical problem in patients with inflammatory bowel diseases (IBD). However, a gold standard for the detection of malnutrition in IBD patients is lacking.

METHODS

A cross-sectional study to assess malnutrition in patients with IBD and healthy controls (HCs). Clinical characteristics (Montreal classification, disease activity, previous surgery) and mutations in the NOD2 gene in patients with Crohn's disease (CD) were obtained. We performed a nutritional assessment with screening for nutritional risk and diagnosis for malnutrition (Malnutrition Universal Screening Tool [MUST]) score, NRS-2002, European Society for Clinical Nutrition and Metabolism (ESPEN), and Global Leadership Initiative on Malnutrition (GLIM) criteria and performed body impedance analysis (BIA).

RESULTS

101 IBD patients (57 CD and 44 ulcerative colitis (UC) and 50 HC were included in a single northern German tertiary center. GLIM criteria detected malnutrition significantly more often compared to the ESPEN criteria. Active disease, a long-standing disease course, and previous surgery were associated with reduced muscle mass. IBD patients had a higher fat mass index compared to HC. Mutations in the NOD2 gene had no effect on nutritional status.

CONCLUSIONS

The GLIM criteria detect malnutrition at a higher rate compared to ESPEN. Specific disease factors might put IBD patients at a higher risk for the development of malnutrition, so these patients might benefit from a frequently performed screening, which might result in a favorable disease course.

OP0104 EXPANDED CD8+ T CELL CLONES FROM HLA-B*27-POSITIVE PATIENTS WITH SPONDYLOARTHRITIS SHOW SIGNS OF ANTIGEN-EXPERIENCE

Background

The pathogenesis of Spondyloarthritis (SpA) remains unknown but its strong association with some alleles of HLA-B*27 is peculiar. The arthritogenic antigen hypothesis assumes the existence of specific peptides presented by risk-conferring HLA-B*27 alleles to antigen-specific CD8+ T cells, which then initiate or sustain autoimmune reactions. Several studies analyzing T cell receptor (TCR) repertoire found preferred Variable TCR chains and motifs in the hypervariable complementary determining region (CDR) 3, but analyzed only TCR β-chains in bulk analyses1,2.

Objectives

To analyze full sequence information of TCR including matching α- and β-chains from single CD8+ T cells and characterize the transcriptomes of expanded and non-expanded clonotypes in synovial fluid (SF) of SpA patients.

Methods

We included 17 patients with active gonarthritis: 10 patients with HLA-B27 positive (B27pos) SpA, 4 with HLA-B27 negative (B27neg) SpA and 3 rheumatoid arthritis (RA) patients. Antigen-experienced CD8+ T cells were sorted out of SF by flow cytometry. Single cell sequencing was performed for all patients to analyze matching TCR α- and β-chains. For 7 patients (3 B27pos SpA, 2 B27neg SpA, 2 RA), additionally whole transcriptome analyses were performed.

Results

We found strong biases when analyzing α and β chains of TCR Variable regions and CDR1 and CDR2 sequences (Figure 1 a,b): AV21, AV12-2, and AV17 were highly enriched in B27pos SpA as compared to B27neg subjects. Amongst the highest expressed clones, we could confirm enrichment for previously described TRBV genes as BV19, BV5-1 and BV6-2. We examined TCR α/β combinations and focused on those detected in at least three different B27pos SpA but not in any of the B27neg patients (Figure 1 c-f). The combinations TRBV19/TRAV21 and TRBV6-2/TRAV21 were most likely specific for B27pos SpA and might reflect interaction of these TCR chains with HLA-B*27. Sequences of CDR3 loops, which predominantly interact with HLA-bound antigenic peptides, revealed striking common structural motifs in α- and β-chains. Focusing on the most prominent TRAV21 chains pairing with TRBV19, 5-1 and 6-2 chains, revealed identical sequences in different patients and striking common structural motifs in α- and β-CDR3 sequences in other patients. Such marked similarities in the antigen-recognition loops of the β-chains associated with TRAV21 suggest common or highly similar antigens. Gene expression levels provided evidence that expanded cell populations had tissue resident memory (TRM) phenotypes (elevated expression of activation, migration and tissue retention markers, downregulated genes characteristic for T cell egress), while this phenotype was not very pronounced in non-expanded cells. Furthermore, markers for T cell exhaustion and apoptosis were elevated in expanded cells of B27pos SpA patients.

Figure 1.

Distinct TCRαβ V chain usage in expanded clones from HLA-B27 positive SpA patients. A,B Mean number of all productive TRAV (A) and TRBV (B) genes used in expanded, antigen-experienced CD8 T cell clones (>1% of all cells) from SF of 10 B27pos SpA, 4 B27neg SpA and 3 B27neg RA patients. C-F TRAV chains paired with TRBV19 (C), TRBV5-1 (D), TRBV6-2 (E), or TRBV chains paired with TRAV21 (F) with corresponding TRAJ spanning partners in expanded cells (frequency ≥2) from all 10 B27pos SpA. Number of chains are 1250 (C), 886 (D), 1220 (E), and 4006 (F).

Conclusion

Analysis of single antigen experienced CD8+ T cells from SF of B27pos SpA patients revealed significant clonal expansions and common motifs in the CDR loops. Two of the four CDR1 and CDR2 loops were highly homologous suggesting that these loops interact with α-helices of HLA-B*27. Common motifs in CDR3 loops of expanded clonotypes suggest recognition of a limited set of antigenic peptides presented by HLA-B*27. Many of the expanded clonotypes showed a TRM phenotype, were exhausted and on the way to become apoptotic, which suggests that these clones had sustained contact to specific antigens.

References

[1]Komech, et al. Rheumatology 2018

[2]Hanson, et al. A&R 2020

Acknowledgements

We thank all patients included in this study for their participation. This work was funded by the German Research Foundation (DFG) through grants DO 420/4 to KDo, PO 2124/2-1 to DP, and SyNergy (EXC 2145 SyNergy – ID 390857198) to KDo. Judith Rademacher and Katharina Deschler contributed equally. JR is participant in the BIH-Charité Clinician Scientist Program funded by the Charité –Universitätsmedizin Berlin and the Berlin Institute of Health. The authors would like to thank Martina Seipel for excellent technical assistance, Sabrina Sron for patient recruitment and study coordination, and Hildrun Haibel, Mikhail Protopopov, Fabian Proft, Valeria Rios Rodriguez and Laura Spiller for recruiting patients for this study.

Disclosure of Interests

None declared

[High myopia in vitrectomized eyes : Contraindication for minimally invasive glaucoma surgery implant?]

Minimally invasive glaucoma surgery (MIGS) implants, such as XEN® gel stent are additional procedures in glaucoma treatment, which were designed to reduce the postoperative risk of severe hypotony and further complications. Until now the contraindications for every implant have not yet been identified. This case report describes the disastrous follow-up after implantation of a XEN® gel stent in the only high myopic eye of a patient. Despite elaborate subsequent interventions massive choroidal hemorrhage occurred with loss of the remaining visual field and total loss of visual acuity. The ocular pressure could be stabilized only after explantation of the XEN® gel stent. Patients with high myopia and the associated thin sclera, vitrectomized eyes and previous treatment with mitomycin C should be selected very carefully for XEN® gel stent. If these criteria are present the XEN® gel stent should be avoided whenever possible.

Genetic association analysis of CLEC5A and CLEC7A gene single-nucleotide polymorphisms and Crohn’s disease

BACKGROUND

Crohn’s disease (CD) is characterized by a multifactorial etiology and a significant impact of genetic traits. While NOD2 mutations represent well established risk factors of CD, the role of other genes is incompletely understood.

AIM

To challenge the hypothesis that single nucleotide polymorphisms (SNPs) in the genes CLEC5A and CLEC7A, two members of the C-type lectin domain family of pattern recognition receptors, may be associated with CD.

METHODS

SNPs in CLEC5A, CLEC7A and the known CD risk gene NOD2 were studied using real time PCR-based SNP assays. Therefore, DNA samples from 175 patients and 157 healthy donors were employed. Genotyping data were correlated with clinical characteristics of the patients and the results of gene expression data analyses.

RESULTS

In accordance with previous studies, rs2066844 and rs2066847 in NOD2 were found to be significantly associated with CD (allelic P values = 0.0368 and 0.0474, respectively). Intriguingly, for genotype AA of rs1285933 in CLEC5A, a potential association with CD (recessive P = 0.0523; odds ratio = 1.90) was observed. There were no associations between CD and SNPs rs2078178 and rs16910631 in CLEC7A. Variants of rs1285933 had no impact on CLEC5A gene expression. In contrast, genotype-dependent differences of CXCL5 expression in peripheral blood mononuclear cells were observed. There is no statistical interaction between the tested SNPs of NOD2 and CLEC5A, suggesting of a novel pathway contributing to the disease.

CONCLUSION

Our data encourage enlarged follow-up studies to further address an association of SNP rs1285933 in CLEC5A with CD. The C-type lectin domain family member also deserves attention regarding a potential role in the pathophysiology of CD.

[When the "lantern goes out"-maximum surgery pays off in the case of severe eye trauma]

Trauma surgeons are often confronted with severe complex eyeball injuries. The primary wound treatment and internal reconstruction are carried out depending on the surgical experience. The following case report describes a patient with severe eyeball rupture, from the preoperative findings up to the current status 1 year after the injury. After the initial severe trauma and complex primary reconstruction with subsequent pole to pole surgery in the irritation-free interval, a good functional and cosmetic result was achieved. Even after severe eyeball injuries the best possible primary reconstruction should be strived for. Secondary corrections are possible in irritation-free periods and can help the patient to achieve functional and cosmetic rehabilitation.

Mutations in the NOD2 gene are associated with a specific phenotype and lower anti-tumor necrosis factor trough levels in Crohn's disease

OBJECTIVE

Nucleotide-binding oligomerization domain-containing protein 2 (NOD2) gene mutations are known to be an important risk factor in the pathogenesis of Crohn's disease (CD). Specific disease phenotypes are associated with the presence of NOD2 gene mutation. One treatment option is to use an anti-tumor necrosis factor (TNF)-α agent. Therapeutic drug monitoring (TDM) is usually performed in cases of a loss of response. Our aim was to explore whether NOD2 gene mutations have an effect on the disease phenotype, vitamin D levels, and on TDM in CD patients.

METHODS

This was a retrospective genotype-phenotype association study on NOD2 gene mutations in 161 patients with CD.

RESULTS

Altogether 55 (34.2%) patients carried at least one mutant allele of NOD2. NOD2 gene mutations were associated with ileocecal disease, ileocecal resection, stricturing and perianal disease, and patients with NOD2 gene mutation had significantly less frequent colonic disease and received an ostomy less frequently. TDM in patients with NOD2 gene mutation showed more frequent anti-TNF trough levels in the subtherapeutic range and lower anti-TNF trough levels than in NOD2 wild-type (WT) patients.

CONCLUSIONS

CD patients with NOD2 gene mutation have a specific clinical phenotype and they may require higher doses of anti-TNF agents to achieve sufficient anti-TNF trough levels. They may therefore benefit from a proactive TDM than a reactive approach. This could be another step in the direction of personalized medicine.

Epidural needle insertion : A large registry analysis

BACKGROUND

Dural puncture, paraesthesia and vascular puncture are the most common complications of epidural catheter insertion. Their association with variation in midline needle insertion depth is unknown.

OBJECTIVE

This study evaluated the risk of dural and vascular punctures and the unwanted events paraesthesia and multiple skin punctures related to midline needle insertion depth.

MATERIAL AND METHODS

A total of 14,503 epidural catheter insertions including lumbar (L1-L5; n = 5367), low thoracic (T7-T12, n = 8234) and upper thoracic (T1-T6, n = 902) insertions, were extracted from the German Network for Regional Anaesthesia registry between 2007 and 2015. The primary outcomes were compared with logistic regression and adjusted (adj) for confounders to determine the risk of complications/events. Results are presented as odds ratios (OR, [95% confidence interval]).

MAIN RESULTS

Midline insertion depth depended on body mass index, sex, and spinal level. After adjusting for confounders increased puncture depth (cm) remained an independent risk factor for vascular puncture (adjOR 1.27 [1.09-1.47], p = 0.002) and multiple skin punctures (adjOR 1.25 [1.21-1.29], p < 0.001). In contrast, dural punctures occurred at significantly shallower depths (adjOR 0.73 [0.60-0.89], p = 0.002). Paraesthesia was unrelated to insertion depth. Body mass index and sex had no influence on paraesthesia, dural and vascular punctures. Thoracic epidural insertion was associated with a lower risk of vascular puncture than at lumbar sites (adjOR 0.39 [0.18-0.84], p = 0.02).

CONCLUSION

Variation in midline insertion depth is an independent risk factor for epidural complications; however, variability precludes use of depth as a reliable guide to insertion in individual patients.

NOD2- and disease-specific gene expression profiles of peripheral blood mononuclear cells from Crohn’s disease patients

AIM

To investigate disease-specific gene expression profiles of peripheral blood mononuclear cells (PBMCs) from Crohn’s disease (CD) patients in clinical remission.

METHODS

Patients with CD in clinical remission or with very low disease activity according to the Crohn’s disease activity index were genotyped regarding nucleotide-binding oligomerization domain 2 (NOD2), and PBMCs from wild-type (WT)-NOD2 patients, patients with homozygous or heterozygous NOD2 mutations and healthy donors were isolated for further analysis. The cells were cultured with vitamin D, peptidoglycan (PGN) and lipopolysaccharide (LPS) for defined periods of time before RNA was isolated and subjected to microarray analysis using Clariom S assays and quantitative real-time PCR. NOD2- and disease-specific gene expression profiles were evaluated with repeated measure ANOVA by a general linear model.

RESULTS

Employing microarray assays, a total of 267 genes were identified that were significantly up- or downregulated in PBMCs of WT-NOD2 patients, compared to healthy donors after challenge with vitamin D and/or a combination of LPS and PGN (P < 0.05; threshold: ≥ 2-fold change). For further analysis by real-time PCR, genes with known impact on inflammation and immunity were selected that fulfilled predefined expression criteria. In a larger cohort of patients and controls, a disease-associated expression pattern, with higher transcript levels in vitamin D-treated PBMCs from patients, was observed for three of these genes, CLEC5A (P < 0.030), lysozyme (LYZ; P < 0.047) and TREM1 (P < 0.023). Six genes were found to be expressed in a NOD2-dependent manner (CD101, P < 0.002; CLEC5A, P < 0.020; CXCL5, P < 0.009; IL-24, P < 0.044; ITGB2, P < 0.041; LYZ, P < 0.042). Interestingly, the highest transcript levels were observed in patients with heterozygous NOD2 mutations.

CONCLUSION

Our data identify CLEC5A and LYZ as CD- and NOD2-associated genes of PBMCs and encourage further studies on their pathomechanistic roles.

Clinical factors are associated with vitamin D levels in IBD patients: A retrospective analysis

OBJECTIVE

There is growing evidence that vitamin D deficiency plays a role in the development and the course of inflammatory bowel disease (IBD). However, the correlation between vitamin D deficiency and clinical parameters in IBD is still not completely understood.

METHODS

A retrospective study of IBD patients was performed. Vitamin D values were analyzed, regardless of vitamin D substitution administration, and correlated with clinical parameters such as medical therapy, anatomical situation, location of the disease and disease activity. Level of 25-hydroxyvitamin D [25(OH)D] <50 nmoL/L was regarded as vitamin D deficiency and <75 nmoL/L as insufficiency.

RESULTS

In total, 208 IBD patients were analyzed, including 123 with Crohn's disease (CD) and 85 with ulcerative colitis (UC). Therapy with azathioprine did not affect the vitamin D values of either disease entity. But CD patients benefited from therapy with tumor necrosis factor-α inhibitor and exhibited significantly higher vitamin D levels than those without. Furthermore, significantly lower vitamin D levels were found if CD was located in the small bowel or if the small bowel had been resected. Moreover, significantly lower levels of vitamin D were detectable for high disease activity (reflected by high simple clinical colitis activity index values) in patients with UC.

CONCLUSIONS

Vitamin D deficiency is common in patients with IBD. However, certain clinical situations lead to significantly lower vitamin D levels and may therefore require close monitoring for vitamin D deficiency.

Vedolizumab Treatment for Ulcerative Colitis in an Elderly Multimorbid Patient with Hemophilia A

The treatment of inflammatory bowel diseases (IBD) can be challenging, especially in elderly multimorbid patients. Since incidence and prevalence rates of IBD are rising steadily, treatment of older patients with relevant and also rare comorbidities will be of increasing relevancy for caregivers. Here we report on a 74-year-old multimorbid patient with severe ulcerative colitis (UC) and hemophilia A. Because of the chronic active disease, therapy with a tumor necrosis factor-α inhibitor was started. He suffered from a severe infectious complication (pneumonia) under therapy with infliximab. The therapy was changed to vedolizumab, with which the patient stayed in long-term clinical and endoscopic remission. Because the patient had a non-ST-segment elevation myocardial infarction in April 2016, he received dual platelet inhibitor therapy with aspirin and clopidogrel. Because of consecutive aspirin intolerance, the therapy was changed to clopidogrel monotherapy. Although the UC was treated appropriately with vedolizumab and the patient was in endoscopic mucosal remission, recurrent bleeding episodes from multiple inflammatory pseudopolyps occurred. The bleeding episodes resolved quickly after immediate treatment with factor VIII (Kogenate®). In conclusion, we describe the first patient in the literature with UC and hemophilia A who stayed in long-term remission under therapy with vedolizumab. From our point of view, vedolizumab can be safely administered in the setting of UC and hemophilia A. Antiplatelet drugs which inhibit primary hemostasis must be used with caution in this setting. Bleeding episodes can be treated safely and effectively with factor VIII (Kogenate®).

Improving the forecast for biodiversity under climate change

New biological models are incorporating the realistic processes underlying biological responses to climate change and other human-caused disturbances. However, these more realistic models require detailed information, which is lacking for most species on Earth. Current monitoring efforts mainly document changes in biodiversity, rather than collecting the mechanistic data needed to predict future changes. We describe and prioritize the biological information needed to inform more realistic projections of species' responses to climate change. We also highlight how trait-based approaches and adaptive modeling can leverage sparse data to make broader predictions. We outline a global effort to collect the data necessary to better understand, anticipate, and reduce the damaging effects of climate change on biodiversity.

A randomized trial on chlorhexidine dressings for the prevention of catheter-related bloodstream infections in neutropenic patients

BACKGROUND

Central venous catheter (CVC)-related bloodstream infections (CRBSI) are a frequent cause of morbidity and mortality in patients with chemotherapy-induced neutropenia. Chlorhexidine containing catheter securement dressings may prevent CRBSI.

PATIENTS AND METHODS

A multicenter randomized, controlled trial was conducted at 10 German hematology departments. We compared chlorhexidine-containing dressings with non-chlorhexidine control dressings in neutropenic patients. The primary end point was the incidence of definite CRBSI within the first 14 days (dCRBSI14) of CVC placement. Secondary end points included combined incidence of definite or probable CRBSI within 14 days (dpCRBSI14), overall (dpCRBSI), incidence of unscheduled dressing changes and adverse events.

RESULTS

From February 2012 to September 2014, 613 assessable patients were included in the study. The incidence of dCRBSI14 was 2.6% (8/307) in the chlorhexidine and 3.9% (12/306) in the control group (P = 0.375). Both dpCRBSI14 and dpCRBSI were significantly less frequent in the study group with dpCRBSI14 in 6.5% (20/307) of the chlorhexidine group when compared with 11% (34/306) in the control group (P = 0.047), and dpCRBSI in 10.4% (32/307) versus 17% (52/306), respectively (P = 0.019). The frequency of dressing intolerance with cutaneous and soft tissue abnormalities at the contact area was similar in both groups (12.4% and 11.8%; P = 0.901).

CONCLUSIONS

Although the trial failed its primary end point, the application of chlorhexidine containing catheter securement dressings reduces the incidence of definite or probable CRBSI in neutropenic patients.

CLINICAL TRIALS NUMBER

NCT01544686 (Clinicaltrials.gov).

Defense chemicals from abdominal glands of 13 rove beetle species of subtribe staphylinina (Coleoptera: Staphylinidae, Staphylininae)

Forty-one volatile constituents have been characterized from the abdominal defensive glands of 13 Staphylinina rove beetle species (Staphylinidae). The major secretion component, a rapidly polymerizing iridoid dialdehyde (in most cases iridodial), is mainly accompanied by variable amounts of some iridoid lactones, traces of actinidine, some possible monoterpene precursors, short-chain ketones, cyclic compounds, and spiroacetals. The secretion mixtures even of single Staphylinina genera are very heterogenously composed of a variety of active substances with different structures. This situation may be a typical feature of iridoid defense systems based upon a primary fixative major compound and clearly differs from other chemical defense systems (for example the quinone system) which have a toxic main component.

Patient satisfaction with anaesthesia care: development of a psychometric questionnaire and benchmarking among six hospitals in Switzerland and Austria

BACKGROUND

We describe the development and comparison of a psychometric questionnaire on patient satisfaction with anaesthesia care among six hospitals.

METHODS

We used a rigorous protocol: generation of items, construction of the pilot questionnaire, pilot study, statistical analysis (construct validity, factor analysis, reliability analysis), compilation of the final questionnaire, main study, repeated analysis of construct validity and reliability. We compared the mean total problem score and the scores for the dimensions: 'Information/Involvement in decision-making', and 'Continuity of personal care by anaesthetist'. The influence of potential confounding variables was tested (multiple linear regression).

RESULTS

The average problem score from all hospitals was 18.6%. Most problems are mentioned in the dimensions 'Information/Involvement in decision-making' (mean problem score: 30.9%) and 'Continuity of personal care by anaesthetist' (mean problem score: 32.2%). The overall assessment of the quality of anaesthesia care was good to excellent in 98.7% of cases. The most important dimension was 'Information/Involvement in decision-making'. The mean total problem score was significantly lower for two hospitals than the total mean for all hospitals (significantly higher at two hospitals) (P<0.05). Amongst the confounding variables considered, age, sex, subjective state of health, type of anaesthesia and level of education had an influence on the total problem score and the two dimensions mentioned. There were only marginal differences with and without the influence of the confounding variables for the different hospitals.

CONCLUSIONS

A psychometric questionnaire on patient satisfaction with anaesthesia care must cover areas such as patient information, involvement in decision-making, and contact with the anaesthetist. The assessment using summed scores for dimensions is more informative than a global summed rating. There were significant differences between hospitals. Moreover, the high problem scores indicate a great potential for improvement at all hospitals.

17alpha-estradiol induces aromatase activity in intact human anagen hair follicles ex vivo

For topical treatment of androgenetic alopecia (AGA) in women, solutions containing either estradiol benzoate, estradiol valerate, 17beta- or 17alpha-estradiol are commercially available in Europe and some studies show an increased anagen and decreased telogen rate after treatment as compared with placebo. At present it is not precisely known how estrogens mediate their beneficial effect on AGA-affected hair follicles. We have shown recently that 17alpha-estradiol is able to diminish the amount of dihydrotestosterone (DHT) formed by human hair follicles after incubation with testosterone, while increasing the concentration of weaker steroids such as estrogens. Because aromatase is involved in the conversion of testosterone to estrogens and because there is some clinical evidence that aromatase activity may be involved in the pathogenesis of AGA, we addressed the question whether aromatase is expressed in human hair follicles and whether 17alpha-estradiol is able to modify the aromatase activity. Herewith we were able to demonstrate that intact, microdissected hair follicles from female donors express considerably more aromatase activity than hair follicles from male donors. Using immunohistochemistry, we detected the aromatase mainly in the epithelial parts of the hair follicle and not in the dermal papilla. Furthermore, we show that in comparison to the controls, we noticed in 17alpha-estradiol-incubated (1 nM) female hair follicles a concentration- and time-dependent increase of aromatase activity (at 24 h: 1 nM = +18%, 100 nM = +25%, 1 micro M = +57%; 24 h: 1 nM = +18%, 48 h: 1 nM = +25%). In conclusion, our ex vivo experiments suggest that under the influence of 17alpha-estradiol an increased conversion of testosterone to 17beta-estradiol and androstendione to estrone takes place, which might explain the beneficial effects of estrogen treatment of AGA.

[Well-informed on health matters--how well? The German 'Clearinghouse for Patient Information'--objective, background and methods]

OBJECTIVE

Health information for lay people in print or electronic form are internationally recognised as useful tools and as necessary in the decision-making process of individuals. The effectiveness of offered patient information depends on quality and accessibility. Because much of the available health information is significantly deficient, the Agency for Quality in Medicine developed a programme for assessing the quality of specialised health and medical information for all non-medically trained persons. The German 'Clearinghouse for Patient Information' project is an adjunct to the already established German 'Clearinghouse for Clinical Guidelines'.

METHOD

The basis for quality improvement for specialised medical information consists 1. in the determination of demands on quality for patient information published in the German language, 2. development of a standardised instrument for assessing the quality of specialised medical information by non-medically trained persons, 3. establishment of an Internet portal for evaluated and rated material, and 4. the establishment and organisation of relevant partnerships with information providers and users of health and medical information. The principle building block to rate medical information for lay people are the DISCERN criteria for good patient information. The results of the quality rating of specialised medical information are made available to the public with emphasis on promoting transparency of the assessment and rating processes used.

RESULTS

The Internet-based patient information service of the Agency for Quality in Medicine (www.patienten-information.de 19.06.02) has currently a selection of approximately 800 information items covering fifty disease topics with fully or partially evaluated and rated information. Partnerships to appropriate information providers and users are already established and have been tested in special single projects.

CONCLUSION

To advance the process of quality improvement for medical information for non-medical and lay persons, it is essential to develop and to intensify the cooperation with stake holders and partners at different levels. Only through close cooperation with others it is possible to create a basis to continuously develop and improve the information quality assessment instrument further. In addition, effective strategies need to be developed to disseminate these endeavours to patients and consumers of health information in a user-friendly and transparent way.

The process-based stand growth model Formix 3-Q applied in a GIS environment for growth and yield analysis in a tropical rain forest

Managing tropical rain forests is difficult because few long-term field data on forest growth and the impact of harvesting disturbance are available. Growth models may provide a valuable tool for managers of tropical forests, particularly if applied to the extended forest areas of up to 100,000 ha that typically constitute the so-called forest management units (FMUs). We used a stand growth model in a geographic information system (GIS) environment to simulate tropical rain forest growth at the FMU level. We applied the process-based rain forest growth model Formix 3-Q to the 55,000 ha Deramakot Forest Reserve (DFR) in Sabah, Malaysia. The FMU was considered to be composed of single and independent small-scale stands differing in site conditions and forest structure. Field data, which were analyzed with a GIS, comprised a terrestrial forest inventory, site and soil analyses (water, nutrients, slope), the interpretation of aerial photographs of the present vegetation and topographic maps. Different stand types were determined based on a classification of site quality (three classes), slopes (four classes), and present forest structure (four strata). The effects of site quality on tree allometry (height-diameter curve, biomass allometry, leaf area) and growth (increment size) are incorporated into Formix 3-Q. We derived allometric relations and growth factors for different site conditions from the field data. Climax forest structure at the stand level was shown to depend strongly on site conditions. Simulated successional pattern and climax structure were compared with field observations. Based on the current management plan for the DFR, harvesting scenarios were simulated for stands on different sites. The effects of harvesting guidelines on forest structure and the implications for sustainable forest management at Deramakot were analyzed. Based on the stand types and GIS analysis, we also simulated undisturbed regeneration of the logged-over forest in the DFR at the FMU level. The simulations predict slow recovery rates, and regeneration times far exceeding 100 years.

Benzoquinones and hydroquinones in defensive secretions of tropical millipedes

The defensive secretions of two tropical species of millipedes (the spirostreptid Telodeinopus aoutii and a species of Harpagophoridae) contain a complex mixture of closely related benzoquinones and hydroquinones. The major compounds are toluquinone and 2-methoxy-3-methylbenzoquinone, accompanied by the minor components, 2,3-dimethoxybenzoquinone and toluhydroquinone. Because of the large size and the geographic separation of the test animals a common defensive strategy of tropical, large millipedes against predation by vertebrates is assumed.

Tissue-specific translational regulation of alternative rabbit 15-lipoxygenase mRNAs differing in their 3'-untranslated regions

By screening a rabbit reticulocyte library, an alternative 15-LOX transcript of 3.6 kb (15-LOX mRNA2) was detected containing a 1019 nt longer 3'-untranslated region (UTR2) than the main 2.6 kb mRNA (15-LOX mRNA1). In anaemic animals, northern blotting showed that 15-LOX mRNA2 was predominantly expressed in non-erythroid tissues, whereas 15-LOX mRNA1 was exclusively expressed in red blood cells and bone marrow. The 15-LOX 3'-UTR2 mRNA2 contained a novel 8-fold repetitive CU-rich motif, 23 nt in length (DICE2). This motif is related but not identical to the 10-fold repetitive differentiation control element (DICE1) of 19 nt residing in the 15-LOX UTR1 mRNA1. DICE1 was shown to interact with human hnRNP proteins E1 and K, thereby inhibiting translation. From tissues expressing the long 15-LOX mRNA2, two to three unidentified polypeptides with molecular weights of 53-55 and 90-93 kDa which bound to DICE2 were isolated by RNA affinity chromatography. A 93 kDa protein from lung cytosol, which was selected by DICE2 binding, was able to suppress translational inhibition of 15-LOX mRNA2, but not of 15-LOX mRNA1, by hnRNP E1. A possible interaction between DICE1/DICE2 cis / trans factors in translational control of 15-LOX synthesis is discussed. Furthermore, the 3'-terminal part of the highly related rabbit leukocyte-type 12-LOX gene was analysed. Very similar repetitive CU-rich elements of the type DICE1 (20 repeats) and DICE2 (nine repeats) were found in the part corresponding to the 3'-UTR of the mRNA.

ZK200775: a phosphonate quinoxalinedione AMPA antagonist for neuroprotection in stroke and trauma

Stroke and head trauma are worldwide public health problems and leading causes of death and disability in humans, yet, no adequate neuroprotective treatment is available for therapy. Glutamate antagonists are considered major drug candidates for neuroprotection in stroke and trauma. However, N-methyl-D-aspartate antagonists failed clinical trials because of unacceptable side effects and short therapeutic time window. alpha-Amino-3-hydroxy-5-methyl-4-isoxazolepropionate (AMPA) antagonists derived from the quinoxalinedione scaffold cannot be used in humans because of their insolubility and resulting renal toxicity. Therefore, achieving water solubility of quinoxalinediones without loss of selectivity and potency profiles becomes a major challenge for medicinal chemistry. One of the major tenets in the chemistry of glutamate antagonists is that the incorporation of phosphonate into the glutamate framework results in preferential N-methyl-D-aspartate antagonism. Therefore, synthesis of phosphonate derivatives of quinoxalinediones was not pursued because of a predicted loss of their selectivity toward AMPA. Here, we report that introduction of a methylphosphonate group into the quinoxalinedione skeleton leaves potency as AMPA antagonists and selectivity for the AMPA receptor unchanged and dramatically improves solubility. One such novel phosphonate quinoxalinedione derivative and competitive AMPA antagonist ZK200775 exhibited a surprisingly long therapeutic time window of >4 h after permanent occlusion of the middle cerebral artery in rats and was devoid of renal toxicity. Furthermore, delayed treatment with ZK200775 commencing 2 h after onset of reperfusion in transient middle cerebral artery occlusion resulted in a dramatic reduction of the infarct size. ZK200775 alleviated also both cortical and hippocampal damage induced by head trauma in the rat. These observations suggest that phosphonate quinoxalinedione-based AMPA antagonists may offer new prospects for treatment of stroke and trauma in humans.

Simultaneous expression of leukocyte-type 12-lipoxygenase and reticulocyte-type 15-lipoxygenase in rabbits

In rabbit reticulocytes an arachidonic acid 15-lipoxygenase (15-LOX) is expressed at high yield. Rescreening a rabbit reticulocyte cDNA library for alternative 15-LOX transcripts, a full length cDNA which encodes a novel lipoxygenase was isolated. The predicted amino acid sequence of this enzyme shared a high degree (99%) of identity with the reticulocyte-type 15-lipoxygenase. Among the six amino acid residues different in both enzymes a Phe-Leu exchange was detected at position 353. Recently, site-directed mutagenesis studies have revealed that this amino acid exchange converts a 15-lipoxygenase to a 12-lipoxygenase. In fact, when the novel enzyme was expressed in Escherichia coli, mainly 12-lipoxygenation of arachidonic acid was observed. The recombinant enzyme exhibited a rather broad substrate specificity. Various C-18 and C-20 polyenoic fatty acids and even complex substrates such as biomembranes were effectively oxygenated. Thus, the novel enzyme may be classified as leukocyte-type 12-lipoxygenase. Genomic polymerase chain reaction of the 3' region of the leukocyte-type 12-lipoxygenase gene indicated that introns 10 to 13 differed to about 10% from the corresponding sequences of the 15-lipoxygenase gene although their size and the intron-exon organization were very similar. In the 3'-untranslated region of the novel mRNA a C+U-rich, 20-fold repetitive element was found which appears to be highly related to the differentiation control element of the 15-lipoxygenase mRNA. Activity assays with a variety of cells and tissues prepared from normal rabbits suggested that only peripheral monocytes abundantly express the enzyme, suggesting a tissue-specific regulation of gene expression. These data indicate for the first time the co-expression of two separate genes for a reticulocyte-type 15-lipoxygenase and for a leukocyte-type 12-lipoxygenase in one species. This is of importance for the implication of both enzymes in red blood cell development and atherogenesis.

Sequential flow cytometry and fluorescence in situ hybridization for the study of formalin-fixed, paraffin-embedded breast cancer cells

Both flow cytometry and fluorescence in situ hybridization (FISH) are useful techniques in the analysis of cancer tissues. When the two are used in the study of the same specimens, they are usually performed in parallel, separately. This is problematic where there is a scarcity of material, making completion of both studies impossible. Fluorescence in situ hybridization procedures that will utilize excess material discarded from flow cytometry would be advantageous. The present report describes an optimized protocol for performing sequential flow cytometry and FISH using formalin-fixed paraffin-embedded archival material. Although breast cancer tissues were used in this initial study, the protocol is applicable to other cancer tissues as well.

Stage I and stage II infiltrating ductal carcinoma of the breast analyzed for chromosome 8 copy number using fluorescent in situ hybridization

We previously reported the results of 30 informative samples (from a total of 34 specimens gathered) of archival breast cancer tissue, including infiltrating ductal carcinoma (NOS), ductal carcinoma in situ, lobular carcinoma, papillary carcinoma and benign lesions of the breast. The study was conducted using fluorescent in situ hybridization (FISH) and a chromosome 8 alpha-satellite probe. Subsequently, a total of 34 cases of infiltrating ductal carcinoma of the breast (NOS, 17 cases stage I and 17 cases stage II) were studied, again using interphase cytogenetics. The aim of the present study is to confirm and extend the results of our initial study of stage I and stage II disease. Towards this end, 36 additional specimens of formalin-fixed paraffin-embedded breast cancer tissue have been analyzed cytogenetically under blinded conditions for the frequency of abnormal chromosome 8 copy numbers using FISH and the previously described protocol optimized for our laboratory. Of these, 18 were stage I and 18 were stage II. The frequency of trisomy 8 among stage I tumors was found to be 28% (5 out of 18). The frequency of trisomy 8 among stage II tumors was found to be 61% (11 out of 18). These results, while less striking, are consistent with those reported in our initial study of stage I and stage II disease, where the frequencies of trisomy 8 among stage I and stage II tumors were 24% (4 out of 17) and 82% (14 out of 17). These results not only establish that chromosome 8 trisomy is a recurrent finding in breast cancer, but also confirm that a higher frequency of trisomy 8 was observed with a higher clinical stage (stage II) than with a lower stage (stage I). It will be of interest to extend the findings in stage I and stage II breast cancer to other stages as well.

Phorbol-myristate-acetate, but not interleukin-1 beta or insulin-like growth factor-I, regulates protein kinase C isoenzymes in human dermal papilla cells

The in vitro growth of human hair follicles is inhibited by interleukin (IL)-1 beta and phorbol esters, such as phorbol-myristate-acetate (PMA), but enhanced by insulin-like growth factor (IGF)-I. Although this process is only incompletely understood, the dermal papilla as a pivotal part of the hair follicle is almost certainly involved. Since protein kinase C (PKC) isoenzymes are activated by phorbol esters and are key enzymes in signalling pathways of several hormones, neurotransmitters, and growth factors, we addressed the question whether the action of the above-mentioned hair growth-modulating substances may affect PKC isoenzymes in cultured dermal papilla cells (DPC). By Western blot analysis, protein kinase C alpha, -epsilon, -gamma, -iota, -lambda, and the RACK1 receptor protein were detected in dermal papilla cell cultures, whereas the isoenzymes delta and mu were expressed only at low levels and protein kinase C-beta, -theta, and -zeta, were not present. After PMA stimulation, the PKC alpha, -epsilon, and -gamma were translocated from the cytosol to the membrane fraction and subsequently down-regulated. PKC iota was down-regulated but not translocated, and PKC lambda and RACK1 were not affected by PMA. Neither, IL-1 beta nor IGF had an effect on PKC or RACK1 expression. We conclude that cultured DPC express a distinct PKC isoenzyme pattern and that the PMA-induced growth arrest in cultivated hair follicles may be transmitted via protein kinases, whereas the effects of IL-1 beta or IGF may be transduced via other signal transduction pathways or other cell types.

History of childhood sexual abuse and general psychopathology

Reported history of childhood sexual abuse (CSA) was correlated with general measures of psychopathology on the SCL-90-R in a sample that included inpatients with borderline personality disorder (BPD), inpatients with major depression, and a nonpatient control group. When subjects who reported abuse were compared with those who did not, scores for the Global Severity Index (GSI) and all subscales of the SCL-90-R, except for the obsessive-compulsive and somatization subscales, were significantly-higher. When only those subjects who reported CSA were studied and when specific measures of CSA were the independent variables and SCL-90-R subscales were the dependent variables, scores on the hostility, interpersonal sensitivity, and paranoia subscales of the SCL-90-R were significantly higher. Because a large proportion of the sample consisted of borderline patients, and because both the specific measures of CSA and the borderline diagnosis could predict similar SCL-90-R subscale results, a series of stepwise regressions were performed. In the first regression, diagnosis, gender, and specific measures of CSA were the predictor variables and SCL-90-R subscale scores were the dependent variables; in the second regression, SCL-90-R subscales and specific measures of CSA were the predictor variables and diagnosis was the dependent variable. Interpersonal sensitivity was the only significant predictor of the borderline diagnosis. We suggest that, at least in some cases, interpersonal sensitivity may be the constitutional/environmental substrate on which traumatic experiences interact to arrive at the borderline diagnosis.

Cytokines and growth factors influence hair growth in vitro. Possible implications for the pathogenesis and treatment of alopecia areata

Factors that influence the growth of the anagen hair follicle or initiate the switch to a catagen growth pattern have so far not been definitely determined, but there is increasing evidence that cytokines and growth factors play an important role during these processes. Recently we detected an aberrant in situ expression pattern of cytokines of the Th1 type (IFN gamma, IL-2) plus IL-1 beta expression in untreated alopecia areata (AA), and a switch to high levels of IL-10 TGF-beta 1 expression after successful treatment with the contact allergen diphenylcyclopropenone (DCP). Hence the question arose as to whether cytokines are able to arrest hair growth and whether IL-10 or TGF beta 1 have the capacity to antagonize this process. Using whole-organ cultures of microdissected human hair follicles we studied the effect of a panel of cytokines and growth factors on hair growth and on the gross morphology of the hair follicles in vitro. IL-2, IL-10 and IFN-gamma had no effect in this regard, whereas TGF beta 1 partially inhibited hair growth and EGF, TNF alpha and IL-1 beta completely abrogated it. EGF and TNF alpha induced the formation of a club-like hair follicle, similar to catagen morphology of the hair bulb, whereas hair follicles grown in the presence of IL-1 beta or TGF beta 1 showed no particular morphological changes. We conclude that cytokines and growth factors are pivotal regulators of hair growth at least in vitro. IL-1 is suggested as playing an important role during the pathogenesis of AA. Possible mediators of therapeutic contact dermatitis (IL-10, TGF beta 1, TNF alpha, PGE2) are, at least in vitro, not able to antagonize the IL-1 beta-triggered hair growth inhibition. Therefore, we infer that these mediators rather "modulate' the immune response in AA.

Growth factor mRNA levels in alopecia areata before and after treatment with the contact allergen diphenylcyclopropenone

The early immune response in alopecia areata is characterized by a Th1 T helper cell cytokine pattern and an aberrant expression of ICAM-1 and HLA-DR molecules on lesional hair bulbs. A counteracting cytokine pattern induced by a therapeutic contact dermatitis is supposed to mediate the hair regrowth. In addition to cytokines, growth factors have been shown to influence immune responses, and we therefore investigated the expression levels for a panel of growth factors in untreated versus alopecia areata after treatment with the contact sensitizer diphenylcyclopropenone. Using semiquantitative reverse transcriptase polymerase chain reaction we detected a striking overexpression of transforming growth factor beta 1 mRNA in successfully treated patients. This cytokine has been shown to be a potent immune response modifier, which can suppress Th1 immune responses. The way in which topical immunotherapy induces hair regrowth in alopecia areata is unknown, but a lesional increased expression of transforming growth factor beta 1 may be a possible mechanism.

Cytokine mRNA levels in Alopecia areata before and after treatment with the contact allergen diphenylcyclopropenone

Although the nature of the noxious signal and the anatomical target in alopecia areata (AA) are still unknown, it has been assumed that CD4+ T lymphocytes surrounding and infiltrating the hair bulb might trigger the hair loss. As these T lymphocytes do not promote cytotoxic activity we hypothesize that AA is triggered by cytokines. Topical immunotherapy with diphenylcyclopropenone (DCP) is at present the most effective approach. If it is true that AA results from a distinct cytokine pattern, we can hypothesize that the beneficial effect of DCP should be mediated by locally secreted cytokines during the contact allergy. Using semiquantitative reverse transcription-polymerase chain reaction with RNA extracted from scalp biopsies from patients with AA before and after successful treatment with DCP, and from healthy controls we detected a T-cell response with increased steady state mRNA levels for interferon (IFN)-gamma, interleukin (IL)-1 beta, and IL-2 in untreated AA of the totalis type. After DCP treatment, the IFN-gamma expression was reduced but still above the constitutive level found in controls, whereas mRNA expression of IL-2, IL-8, IL-10, and tumor necrosis factor-alpha was increased. Our results point towards cytokines involved in the pathogenesis in AA. A TH1 type cytokine pattern is present in untreated AA, and this is modified by cytokines secreted during DCP treatment. IL-10 has recently been described as an immunomodulator of the TH1 response and, therefore, we hypothesize that basal keratinocytes or lesional T cells secrete bioactive IL-10 after DCP application, resulting in an inhibitory effect on lesional T lymphocytes. This hypothesis would explain the effectiveness of DCP and implies the theoretical possibility of a response to topical or intralesional application of recombinant IL-10.

Serial evaluation of left ventricular function by radionuclide ventriculography at rest and during exercise after orthotopic heart transplantation

Discrepant results have previously been reported concerning long-term left ventricular function in the human transplanted heart as assessed by radionuclide ventriculography. In this study, radionuclide ventriculograms were obtained at rest and during exercise in 19 patients < 6 months, 7-12 months, 13-24 months and > 24 months after transplantation. Ejection fraction decreased significantly from < 6 months to 13-24 months after transplantation (rest: 69.1% +/- 9.7% to 56.7% +/- 8.3%, P < 0.05; exercise: 70.4% +/- 11.3% to 59% +/- 8%, P < 0.05). Heart rate increased significantly during exercise after > 2 years (90.2 +/- 10.5 beats/min to 103.5 +/- 15 beats/min, P < 0.05) but not within 6 months after transplantation (98.5 +/- 12.8 beats/min to 99.07 +/- 15.8 beats/min). Left ventricular end-diastolic volume remained unchanged. Peak filling rate at rest decreased significantly from 4.2 +/- 0.96 edv/s < 6 months after transplantation to 3.3 +/- 0.66 edv/s (P < 0.05) 13-24 months and 3.3 +/- 0.64 edv/s (P < 0.05) > 24 months after cardiac transplantation. Exercise peak filing rate did not change significantly. It is concluded that radionuclide ventriculography demonstrates a decrease in systolic left ventricular function in the long-term course after cardiac transplantation. A significant increase in exercise peak heart rate may be due to autonomic reinnervation. Differences in the literature concerning left ventricular function may be due to different observation intervals following cardiac transplantation.

[Experiences with the application of monoclonal Indium-111 antimyosin scintigraphy in the diagnosis of rejection episodes following orthotopic heart transplantation]

Indium-111-labeled Fab fragment imaging using a murine antimyosin monoclonal antibody (Myoscint, Centocor, Leiden) was evaluated for efficacy in detecting cardiac allograft rejection. Diagnosis of rejection was made by endomyocardial biopsy with four to five samples taken for each procedure. Eighty-one studies were performed in 25 patients (21 men, four women, mean age 50 +/- 9 years) from 2 weeks to 45 months after cardiac transplantation. 0.5 mg of the monoclonal antibody labeled with 60 MBq Indium-111 (Antimyosin-Fab-DTPA) was administered i.v. Planar scintigraphic images were obtained in LAO 45 and anterior projections as well as "half-body-scintigrams" 48 h after injection. Using the regions-of-interest-(ROI)technique the relative uptake over the lung and the heart was determined and an index of In-111 uptake was calculated. A heart-to-lung ratio of 1.5 or higher was considered indicative for moderate to severe rejection. Specificity was 86% (nine false-positive In-111 studies in 68 negative biopsy studies), sensitivity was 85% (two false-negative In-111 studies in 13 pathological biopsy studies). It is concluded that the In-111 method has a high sensitivity and specificity in detecting heart transplant rejection and may be useful in the monitoring of patients in the chronic phase after heart transplantation. The 48-h delay in establishing the diagnosis limits the applicability in acute severe rejection.

Polymerase chain reaction for detection of the pMP6d-9/MspI RFLP, a marker closely linked to the cystic fibrosis mutation

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