Treatment of progressive multiple sclerosis with high-dose all-trans retinoic acid - no clear evidence of positive disease modifying effects

BACKGROUND

All-trans retinoic acid (ATRA) is an acid derivative of vitamin A which is discussed as a promising candidate to ameliorate the disease course of multiple sclerosis (MS) by immunomodulation or even by promoting regeneration in progressive MS. Here we report a patient who significantly improved for MS related disability following administration of chemotherapy including ATRA for mitoxantrone-related acute promyelocytic leukemia and assess the effect of high-dose ATRA in three additional patients with progressive MS.

METHODS

Patients with progressive MS who had failed previous therapies were treated with high-dose ATRA. Patients underwent clinical and routine laboratory monitoring. Additionally, PBMCs were analyzed by flow cytometry for lymphocyte subsets.

RESULTS

ATRA was well tolerated and no pathological laboratory abnormalities were observed. After initial mild (not statistically significant) improvement of EDSS and mean MSFC z-score, ongoing disease progression was observed. One patient subacutely experienced severe cognitive and motor worsening. Cerebral MRI revealed persistent gadolinium-enhancing lesions. Flow cytometric alterations of peripheral blood naïve, central memory and effector memory CD4 and CD8 T cells, B lymphocytes, plasma cells, memory B cells, plasmablasts and natural killer (NK) cells did not reach statistical significance.

CONCLUSIONS

Stand-alone therapy with ATRA did not ameliorate progressive MS in our limited cohort and we did not observe consistent alterations of T and B cell subsets. Intriguingly, application of ATRA may have caused marked disease exacerbation in one patient.

Resource Theory of Coherence Based on Positive-Operator-Valued Measures

Quantum coherence is a fundamental feature of quantum mechanics and an underlying requirement for most quantum information tasks. In the resource theory of coherence, incoherent states are diagonal with respect to a fixed orthonormal basis; i.e., they can be seen as arising from a von Neumann measurement. Here, we introduce and study a generalization to a resource theory of coherence defined with respect to the most general quantum measurements, i.e., to arbitrary positive-operator-valued measures (POVMs). We establish POVM-based coherence measures and POVM-incoherent operations that coincide for the case of von Neumann measurements with their counterparts in standard coherence theory. We provide a semidefinite program that allows us to characterize interconversion properties of resource states and exemplify our framework by means of the qubit trine POVM, for which we also show analytical results.

Use of the Microdialysis Technique in the Monitoring of Subcutaneous Tissue Glucose Concentration

For some time the subcutaneous (s.c.) tissue has been the target for continuous glucose measurement. The microdialysis technique permits an extracellular region approach, which has been used for about two decades for measuring various metabolites in dialysates obtained from different body regions. By connecting a s.c. implanted microdialysis probe to a flow chamber of an amperometric glucose sensor, the procedure of glucose sensing was transferred to ex vivo. Using this device it was possible to obtain, for up to 24 hours, s.c. tissue glucose profiles of healthy and diabetic people. The microdialysis theory, the calibration process and other microdialysis technique applications are discussed in this paper. Although the combination of the microdialysis technique and amperometric glucose sensing requires certain technical equipment, the combination of microdialysis and glucose sensor seems to be a promising approach to a continuously functioning glucose sensing system.

First use of flat-panel computed tomography during cochlear implant surgery : Perspectives for the use of advanced therapies in cochlear implantation

BACKGROUND

Cochlear implantation in routine cases with normal anatomy is commonly performed without intraoperative image guidance. Revision cochlear implantation as well as surgery in malformations require not only a precise understanding of the underlying complex anatomy, but surgeons need to transform two-dimensional computed tomography (2D CT) scans into the surgical field and use this information for intraoperative surgical navigation. So far, information about the exact position of the electrode during insertion cannot be provided to the surgeon. Here, we present our first operative experience with cochlear implant surgery supported by intraoperative Dyna-CT technology, providing the surgeon with detailed views of the electrode location.

METHODS

To prove the feasibility of the procedure, two cases of cochlear implantation were performed with intraoperative application of cone-beam CT acquired by a C-arm Dyna-CT system (Artis Zeego, Siemens Healthcare, Erlangen, Germany). Image reconstruction was performed intraoperatively in order to assess the correct positioning of the electrodes.

RESULTS

Intraoperative Dyna-CT enabled clear visualization of the surgical anatomy and intracochlear electrode position. Dyna-CT technology can be applied with acceptable additional time requirements without adding too much complexity to the surgical procedure.

CONCLUSION

Intraoperative data acquisition by Dyna-CT represents a suitable option for online surgical navigation during cochlear implant surgery. This imaging technology will push further advances in cochlear implant surgery and lateral skull base surgery, particularly if linked to intraoperative navigation.

3-Hydroxy-3-methylglutaryl-coenzyme A lyase deficiency: Clinical presentation and outcome in a series of 37 patients

3-Hydroxy-3-methylglutaryl-coenzyme A lyase deficiency (HMGCLD) is a rare inborn error of ketone body synthesis and leucine degradation, caused by mutations in the HMGCL gene. In order to obtain a comprehensive view on this disease, we have collected clinical and biochemical data as well as information on HMGCL mutations of 37 patients (35 families) from metabolic centers in Belgium, Germany, The Netherlands, Switzerland, and Turkey. All patients were symptomatic at some stage with 94% presenting with an acute metabolic decompensation. In 50% of the patients, the disorder manifested neonatally, mostly within the first days of life. Only 8% of patients presented after one year of age. Six patients died prior to data collection. Long-term neurological complications were common. Half of the patients had a normal cognitive development while the remainder showed psychomotor deficits. We identified seven novel HMGCL mutations. In agreement with previous reports, no clear genotype-phenotype correlation could be found. This is the largest cohort of HMGCLD patients reported so far, demonstrating that HMGCLD is a potentially life-threatening disease with variable clinical outcome. Our findings suggest that the clinical course of HMGCLD cannot be predicted accurately from HMGCL genotype. The overall outcome in HMGCLD appears limited, thus rendering early diagnosis and strict avoidance of metabolic crises important.

Sex-specific variation in signaling pathways and gene expression patterns in human leukocytes in response to endotoxin and exercise

Background

While exercise effects on the immune system have received increasing attention in recent years, it remains unclear to what extent gender and fluctuations in sex hormones during menstrual cycle influence immunological responses to exercise.

Methods

We investigated mRNA changes induced through exhaustive exercise (half-marathon; pre-exercise and post-exercise [30 min, 3 h, 24 h] on whole blood cultures ± lipopolysaccharide [LPS] [1 h]) with a specific focus on sex differences (men vs women in luteal phase) as an extension of our previous study.

Results

Inflammation related signaling pathways, TLRs, cytosolic DNA sensing and RIG-I like receptors were differentially activated between sexes in LPS-stimulated cultures. Genes differentially regulated between sexes included TNIP-1, TNIP-3, IL-6, HIVEP1, CXCL3, CCR3, IL-8, and CD69, revealing a bias towards less anti-inflammatory gene regulation in women compared to men. In addition, several genes relevant to brain function (KMO, DDIT4, VEGFA, IGF1R, IGF2R, and FGD4) showed differential activation between sexes. Some of these genes (e.g., KMO in women, DDIT4 in both sexes) potentially constitute neuroprotective mechanisms.

Conclusions

These data reveal that the exercise-induced change in gene expression might be gender and menstrual cycle phase dependent.

Electronic supplementary material

The online version of this article (doi:10.1186/s12974-016-0758-5) contains supplementary material, which is available to authorized users.

[Emergency Doctor Training for Psychiatric Emergencies: Evaluation of an Interactive Training Program]

Aim Emergency physicians are often confronted with psychiatric emergencies, but are not well trained for it and often feel unable to cope sufficiently with them. The aim of this investigation was to examine whether multisensoric training may improve learning effects in the training of emergency physicians with regard to psychiatric emergencies. Method Participation in a multi-modal, multi-media training program with video case histories and subsequent evaluation by questionnaire. Results 66 emergency physicians assessed their learning effects. 75 % or 73 % rated it as "rather high" or "very high". In particular, in comparison with classical training/self-study 89 % assessed the effects in learning as "rather high" or "very high" . Conclusion This training receives a high level of acceptance. Using videos, learning content may be provided more practice-related. Thus, emergency physicians are able to develop a greater understanding of psychiatric emergencies.

Low frequencies of central memory CD4 T cells in progressive multifocal leukoencephalopathy

OBJECTIVES

To assess alterations in the composition of peripheral immune cells in acute progressive multifocal leukoencephalopathy (PML).

METHODS

Fresh blood samples from 5 patients with acute PML and 10 healthy controls were analyzed by flow cytometry for naive, central memory and effector memory CD4 and CD8 T cells, B lymphocytes, plasma cells, memory B cells, plasma blasts, and natural killer (NK) cells. The frequency of central memory CD4 T cells was determined longitudinally during the course of PML in 2 patients.

RESULTS

The frequencies of naive, central memory and effector memory CD8 T cells, B cells, plasma cells, and NK cells were not altered in patients with PML. In contrast, the frequencies of naive CD4 T cells (p = 0.04) and central memory CD4 T cells (p < 0.00001) were reduced and the frequencies of effector memory CD4 T cells were increased (p = 0.01). Longitudinal analysis showed that this pattern was preserved in a patient with fatal PML outcome and restored in one patient who recovered from PML.

CONCLUSIONS

These data indicate that PML is associated with reduced frequencies of peripheral central memory helper T cells but not with alterations in the frequencies of cytotoxic T cell populations, B lymphocytes, plasma cells, or NK cells.

Case report of a patient with progressive multifocal leukoencephalopathy under treatment with dimethyl fumarate

Background

Progressive multifocal leukoencephalopathy is a severe demyelinating disease caused by the polyoma JC virus in patients with reduced immunocompetence. A few cases of progressive multifocal leukoencephalopathy have been reported in patients treated with fumaric acid esters.

Case presentation

A 53-year-old Caucasian woman reported to our clinic with a first focal epileptic seizure and mild cognitive impairment. Since 1.5 years, she was treated with fumaderm for her psoriasis. During that time, her lymphocyte counts ranged between 450 and 700/μl. Cerebral magnet resonance imaging showed multifocal subcortical T2 hyperintense lesions with partial gadolinium enhancement. She did not have antibodies against human immunodeficiency virus 1 and 2 and cerebrospinal fluid-polymerase chain reaction for viral infections including a sensitive JC-virus polymerase chain reaction were negative. The diagnosis of progressive multifocal leukoencephalopathy was established by histological analysis and detection of JC-virus desoxyribonucleic acid in brain biopsy specimens. Dimethyl fumarate was stopped and Mirtazapin and Mefloquin were initiated. Neurological examination and imaging remained stable.

Conclusions

Progressive multifocal leukoencephalopathy can occur in patients with lymphocyte counts between 450 and 700/μl, produce only faint symptoms and is not excluded by negative JC-virus-polymerase chain reaction in cerebrospinal fluid. The incidence of progressive multifocal leukoencephalopathy may thus be underestimated and a more careful surveillance of patients would be necessary.

The role of the ubiquitin-editing enzyme A20 in diseases of the central nervous system and other pathological processes

In recent years, the ubiquitin-editing enzyme A20 has been shown to control a large set of molecular pathways involved in the regulation of protective as well as self-directed immune responses. Here, we assess the current and putative roles of A20 in inflammatory, vascular and degenerative diseases of the central nervous system and explore future directions of research.

Zoomed EPI DWI of Acute Spinal Ischemia Using a Parallel Transmission System

PURPOSE

A new method for diffusion-weighted imaging (DWI) using independent parallel transmission technique resulting in zoomed DWI was applied in four patients suffering from acute spinal cord ischemia.

METHODS

Four patients with clinical symptoms of acute spinal cord ischemia were examined on a 3 T MR-system equipped with a two-channel transmit array. Scans included T2-weighted turbo spin echo, conventional DWI, and zoomed DWI. Image evaluation was performed with regard to overall image quality, anatomic delineation of the spinal cord, and the level of confidence to establish the diagnosis of spinal cord ischemia.

RESULTS

Through spatially selective excitation, zoomed DWI allows for acquisition of high-resolution images with reduced scan time due to a reduced field of view in phase-encoding direction, resulting in zoomed images. In all cases the ischemia was demonstrated in conventional DWI as well as zoomed DWI.

CONCLUSIONS

Compared to conventional DWI, zoomed DWI enables a faster image acquisition and allowed a more detailed analysis of the spinal lesion which may be critical to attribute the lesion to a particular vessel territory.

Dendritic cells and anergic type I NKT cells play a crucial role in sulfatide-mediated immune regulation in experimental autoimmune encephalomyelitis

CD1d-restricted NKT cells can be divided into two groups: type I NKT cells use a semi-invariant TCR, whereas type II express a relatively diverse set of TCRs. A major subset of type II NKT cells recognizes myelin-derived sulfatides and is selectively enriched in the CNS tissue during experimental autoimmune encephalomyelitis (EAE). We have shown that activation of sulfatide-reactive type II NKT cells by sulfatide prevents induction of EAE. In this article, we have addressed the mechanism of regulation, as well as whether a single immunodominant form of synthetic sulfatide can treat ongoing chronic and relapsing EAE in SJL/J mice. We have shown that the activation of sulfatide-reactive type II NKT cells leads to a significant reduction in the frequency and effector function of myelin proteolipid proteins 139-151/I-A(s)-tetramer(+) cells in lymphoid and CNS tissues. In addition, type I NKT cells and dendritic cells (DCs) in the periphery, as well as CNS-resident microglia, are inactivated after sulfatide administration, and mice deficient in type I NKT cells are not protected from disease. Moreover, tolerized DCs from sulfatide-treated animals can adoptively transfer protection into naive mice. Treatment of SJL/J mice with a synthetic cis-tetracosenoyl sulfatide, but not α-galactosylceramide, reverses ongoing chronic and relapsing EAE. Our data highlight a novel immune-regulatory pathway involving NKT subset interactions leading to inactivation of type I NKT cells, DCs, and microglial cells in suppression of autoimmunity. Because CD1 molecules are nonpolymorphic, the sulfatide-mediated immune-regulatory pathway can be targeted for development of non-HLA-dependent therapeutic approaches to T cell-mediated autoimmune diseases.

Feasibility of Noninvasive Diagnosis and Treatment Planning in a Case Series with Carotid-Cavernous Fistula using High-Resolution Time-Resolved MR-Angiography with Stochastic Trajectories (TWIST) and Extended Parallel Acquisition Technique (ePAT 6) at 3 T

PURPOSE

The evaluation of carotid-cavernous fistulas (CCFs) and the intracranial vasculature has been predominantly carried out using conventional digital subtraction angiography (DSA). Recent developments in time-resolved magnetic resonance angiography (MRA) provide the opportunity to assess both multiple arterial and venous phases with high temporal and spatial resolution. Here, we investigated the feasibility of this technique to functionally assess CCF prior to intervention.

METHODS

Six consecutive patients with clinical symptoms of a CCF were scheduled for clinically indicated MRA and underwent a protocol that comprised conventional imaging sequences and high resolution time-resolved MRA with interleaved stochastic trajectories (TWIST). The location of the fistulous communication, the flow pattern, and venous drainage were determined by time-resolved MRA and compared with DSA which was available in five out of six patients.

RESULTS

Typical morphological findings (including enlargement of the superior ophthalmic vein, exophthalmos) were found in all cases in both conventional MRI and time-resolved MRA source data. The temporal resolution of time-resolved MRA enabled a good separation of the early filling of the cavernous sinus during the arterial phase. Direct fistulous communication was assessed in three patients with good correlation to DSA, whereas indirect CCF could not definitely be visualized. The time-resolved MRA provided information about the flow pattern and the venous drainage of the fistula in all patients, which is essential for therapy planning.

CONCLUSION

Time-resolved MRA provides important morphological and functional information in patients with CCF. Although DSA remains the gold standard for diagnosis and exact classification of fistulas, time-resolved MRA can provide the relevant hemodynamic information to plan interventional treatment as a one-step procedure with a focused diagnostic workup.

Suppression of experimental autoimmune encephalomyelitis by interleukin-10 transduced neural stem/progenitor cells

Neural stem/progenitor cells (NSPCs) have the ability to migrate into the central nervous system (CNS) to replace damaged cells. In inflammatory CNS disease, cytokine transduced neural stem cells may be used as vehicles to specifically reduce inflammation and promote cell replacement. In this study, we used NSPCs overexpressing IL-10, an immunomodulatory cytokine, in an animal model for CNS inflammation and multiple sclerosis (MS). Intravenous injection of IL-10 transduced neural stem/progenitor cells (NSPC^IL-10) suppressed myelin oligodendrocyte glycoprotein aa 35–55 (MOG35-55)- induced experimental autoimmune encephalomyelitis (EAE) and, following intravenous injection, NSPC^IL-10 migrated to peripheral lymphoid organs and into the CNS. NSPC^IL-10 suppressed antigen-specific proliferation and proinflammatory cytokine production of lymph node cells obtained from MOG35-55 peptide immunized mice. In this model, IL-10 producing NSPCs act via a peripheral immunosuppressive effect to attenuate EAE.

[Total hip arthroplasty with shortening subtrochanteric osteotomy and custom-made prosthesis in Crowe type IV developmental dysplasia]

AIM

Total hip arthroplasty in patients with a Crowe type IV developmental dysplasia is a technically demanding procedure with a higher complication rate compared to a standard total hip replacement. Specific anatomic features and the necessity of a femoral shortening osteotomy are the reasons for more complications. In this retrospective study we intended to find out whether the use of a custom-made stem based on a CT scan will lead to a better outcome including a lower complication rate. MATERIAL UND METHOD: From 2003 to 2010 we implanted a cementless CTX® individual stem in combination with a subtrochanteric Z-shaped shortening osteotomy in 25 patients with a high hip dislocation, four of them were men (one bilateral) and 16 women (four bilateral). Mean age of the patients was 44.6 years. In all cases the cup was implanted at the level of the anatomic hip centre. Patients were followed with a clinical and radiographic assessment. The morphology of the femur was analysed by CT scans.

RESULTS

The average amount of femoral shortening was 3.4 cm (max. 4.2/min. 2.6 cm). Lengthening of the leg was achieved with an average of 3.8 cm (max. 4.4/min. 3.2 cm). The remaining leg length discrepancy was 0.8 cm (max. 1.2/min. 0.4 cm). In none of the cases did an intraoperative fracture of the femur occur, either in the proximal or in the distal part of the femur. Enlargement of the intramedullary canal was not necessary in any case. The planned depth of the prosthesis could be achieved in all patients. We did not observe any problems with wound healing in our patients. The average Harris hip score was 90 (83 up to 100). Additional cerclage wires are not necessary with this technique when the osteotomy is well adapted. After complete healing the osteotomy can just be noticed by a certain hypertrophy of the cortical bone. In our cases we had a complication rate of 16 %, significantly lower in comparison to literature values.

CONCLUSIONS

Total hip arthroplasty in type IV developmental dysplasia with a custom-made stem based on a CT scan is a procedure that respects the special anatomic features preoperatively und is able to correct the deformity with the individually manufactured prosthesis. High femoral anteversion is corrected at the level of the neck of the stem. There is no necessity for a derotation at the level of the osteotomy. The osteotomy is stabilised by the Z-shape and through a perfect intramedullary fit of the stem. The anatomic shape of the subtrochanteric region is perfectly suitable to perform a femoral shortening.

Pilot-scale anaerobic submerged membrane bioreactor (AnSMBR) treating municipal wastewater: the fouling phenomenon and long-term operation

An anaerobic submerged membrane bioreactor (AnSMBR) on pilot-scale treating a mixture composed of municipal wastewater and glucose under mesophilic temperature conditions was operated for 206 days. The performance of the AnSMBR was evaluated at different fluxes, biomass concentrations and gas sparging velocities (GSV). GSV was used to control fouling. In addition, the AnSMBR was operated in cycles that included relaxation and backwashing phases. The increase in the transmembrane pressure (fouling rate) was measured under different operational conditions and was used to evaluate the stability of the process. The fouling rate could be controlled for a long period of time at a flux of 7 l m(-2) h(-1) with a GSV of 62 m/h and an average biomass concentration of 14.8 g TSS/L. The membrane was physically cleaned after 156 days of operation. The cleaning efficiency was almost 100% indicating that no irreversible fouling was developed inside the pores of the membrane. The COD removal efficiency was close to 90%. As in anaerobic processes, nutrients were not exposed to degradation and almost no pathogens were found in the effluent, hence the effluent could be used for irrigation in agriculture.

CD62L(high) Treg cells with superior immunosuppressive properties accumulate within the CNS during remissions of EAE

The role of regulatory T cell populations within the CNS in the regulation of CNS-autoimmunity is controversial. We show that during recovery from relapsing remitting experimental autoimmune encephalomyelitis, regulatory T cells accumulate within the CNS that express high levels of CD62L. These CD62L(high) Treg cells express increased amounts of CTLA-4, ICOS and TGF-β and are more potent than CD62L(low) Treg cells in suppressing proliferation and inducing apoptosis in effector T cells. CD62L(high) Treg cells thus represent a population of Treg cells that display superior immunosuppressive properties and accumulate in the CNS during recovery from CNS-autoimmunity.

Recurrent myelitis after allogeneic stem cell transplantation. Report of two cases

BACKGROUND

Allogeneic and autologous haematopoietic stem cell transplantation are established treatment options for haematological malignancies and may possibly be employed to treat a range of genetic and autoimmune diseases.

CASE PRESENTATION

We report two patients who developed an acute myelitis within their thoracic spinal cord after allogeneic stem cell transplantation. Myelitis in these patients was not related to graft versus host disease or immune reconstitution and was responsive to intravenous methylprednisolone and cyclophosphamide.

CONCLUSIONS

Myelitis is a possibly disabling consequence of haematopoietic stem cell transplantation.

[Electromagnetic fields of mobile telephone systems--thresholds, effects and risks for cochlear implant patients and healthy people]

Every day life is detectably affected by manifold natural sources of electromagnetic fields (EMF), e. g. infrared radiation, light and the terrestrial magnetic field. However, there is still uncertainty about the consequences or hazards of artificial EMF, which emerge from mobile phone or wireless network (wireless local area network [WLAN]) services, for instance. Following recommendations of the International Commission on Non-Ionizing Radiation Protection (ICNIRP) the German Commission on Radiation Protection (SSK) defined corresponding thresholds for high frequency electromagnetic fields (HF-EMF) in 2003. By observing those thresholds HF-EMF is thought to be innocent so far. However, there is still controversial discussion about induction of cancer or neurovegetative symptoms due to inconsistent study results. Patients with cochlea implants are of particular interest within the speciality of otorhinolaryngology due to specific hazards, which arise during mobile telephone use from the distance between brain and inductive metal implants (electrode) on the one hand and the electronic system of the cochlear implant and the source of HF-EMF on the other hand. Besides many studies about the impact of HF-EMF on common welfare, there are only very few surveys (n = 6) covering the effects on patients with cochlear implants. The purpose of this paper is to overview sources, thresholds and subsequently harmful or harmless effects of HFEMF. Due to the current state of knowledge about the impact of mobile phone use on health, we assume, that HF-EMF are harmless both for healthy people and patients with cochlea implants, provided that legal thresholds are observed.

Dendritic cell-regulatory T-cell interactions control self-directed immunity

In addition to their immunostimulatory capacity, dendritic cells (DCs) play a crucial role in central and peripheral tolerance mechanisms. In the absence of an infection, immature DCs constantly take up, process and present self-antigens to specific T cells, which leads to the induction of T-cell anergy or deletion. In recent years, several additional mechanisms have been identified by which DCs constantly downregulate immune responses to maintain immunological tolerance. Among these are the complex interactions between several DC subtypes and different types of regulatory T cells. In this review, we summarize recent key findings and concepts in this field.

Suppression of verbal hallucinations and changes in regional cerebral blood flow after intravenous lidocaine: a case report

Simple and complex auditory phantom-perceptions such as tinnitus and musical hallucinations occur predominantly in elderly subjects and are often associated with hearing impairment. Isolated verbal hallucinations without other psychotic features are rare. It has been shown that an intravenous (i.v.) injection of lidocaine can transiently suppress tinnitus. Here we present the case of a 74 year old left-handed women with severely distressing, continuous verbal auditory hallucinations without other psychotic features. I.v. injections of 100 mg lidocaine but not saline resulted in substantial transient suppressions of the hallucinations for several hours. Using [(15)O]H(2)O positron-emission tomography (PET) decreased regional cerebral blood flow associated with reduced perception of voices was found in the right angular and supramarginal gyrus, right inferior frontal gyrus, orbitofronal cortex and in major parts of the cingulate cortex. These data suggest to further investigate the clinical relevance of i.v. lidocaine in patients with therapy-resistant verbal hallucinations, support the notion of common pathophysiological mechanisms in different forms of auditory phantom-perception and demonstrate the feasibility of a new strategy for imaging studies on auditory hallucinations.

Thermophilic anaerobic digestion in compact systems: investigations by modern microbiological techniques and mathematical simulation

Thermophilic anaerobic digestion in compact systems can be an economical and ecological reasonable decentralised process technique, especially for rural areas. Thermophilic process conditions are important for a sufficient removal of pathogens. The high energy demand, however, can make such systems unfavourable in terms of energy costs. This is the case when low concentrated wastewater is treated or the system is operated at low ambient temperatures. In this paper we present experimental results of a compact thermophilic anaerobic system obtained with fluorescent in situ hybridisation (FISH) analysis and mathematical simulation. The system was operated with faecal sludge for a period of 135 days and with a model substrate consisting of forage and cellulose for a period of 60 days. The change in the microbial community due to the two different substrates treated could be well observed by the FISH analysis. The Anaerobic Digestion Model no. 1 (ADM1) was used to evaluate system performance at different temperature conditions. The model was extended to contribute to decreased methanogenic activity at lower temperatures and was used to calculate energy production. A model was developed to calculate the major parts of energy consumed by the digester itself at different temperature conditions. It was demonstrated by the simulation study that a reduction of the process temperature can lead to higher net energy yield. The simulation study additionally showed that the effect of temperature on the energy yield is higher when a substrate is treated with high protein content.

Development of an empirical mathematical model for describing and optimizing the hygiene potential of a thermophilic anaerobic bioreactor treating faeces

Poor sanitation and insufficient disposal of sewage and faeces are primarily responsible for water associated health problems in developing countries. Domestic sewage and faeces are prevalently discharged into surface waters which are used by the inhabitants as a source for drinking water. This paper presents a decentralized anaerobic process technique for handling of such domestic organic waste. Such an efficient and compact system for treating faeces and food waste may be of great benefit for developing countries. Besides a stable biogas production for energy generation, the reduction of bacterial pathogens is of particular importance. In our research we investigated the removal capacity of the reactor concerning pathogens, which has been operated under thermophilic conditions. Faecal coliforms and intestinal enterococci have been detected as indicator organisms for bacterial pathogens. By the multiple regression analysis technique an empirical mathematical model has been developed. The model shows a high correlation between removal efficiency and both, hydraulic retention time (HRT) and temperature. By this model an optimized HRT for defined bacterial pathogens effluent standards can be easily calculated. Thus, hygiene potential can be evaluated along with economic aspects. In this paper not only results for describing the hygiene potential of a thermophilic anaerobic bioreactor are presented, but also an exemplary method to draw the right conclusions out of biological tests with the aid of mathematical tools.

Induction of autoimmunity by expansion of autoreactive CD4+CD62Llow cells in vivo

The prerequisites of peripheral activation of self-specific CD4(+) T cells that determine the development of autoimmunity are incompletely understood. SJL mice immunized with myelin proteolipid protein (PLP) 139-151 developed experimental autoimmune encephalomyelitis (EAE) when pertussis toxin (PT) was injected at the time of immunization but not when injected 6 days later, indicating that PT-induced alterations of the peripheral immune response lead to the development of autoimmunity. Further analysis using IA(s)/PLP(139-151) tetramers revealed that PT did not change effector T cell activation or regulatory T cell numbers but enhanced IFN-gamma production by self-specific CD4(+) T cells. In addition, PT promoted the generation of CD4(+)CD62L(low) effector T cells in vivo. Upon adoptive transfer, these cells were more potent than CD4(+)CD62L(high) cells in inducing autoimmunity in recipient mice. The generation of this population was paralleled by higher expression of the costimulatory molecules CD80, CD86, and B7-DC, but not B7-RP, PD-1, and B7-H1 on CD11c(+)CD4(+) dendritic cells whereas CD11c(+)CD8alpha(+) dendritic cells were not altered. Collectively, these data demonstrate the induction of autoimmunity by specific in vivo expansion of CD4(+)CD62L(low) cells and indicate that CD4(+)CD62L(low) effector T cells and CD11c(+)CD4(+) dendritic cells may be attractive targets for immune interventions to treat autoimmune diseases.

Microglial expression of the B7 family member B7 homolog 1 confers strong immune inhibition: implications for immune responses and autoimmunity in the CNS

Inflammation of the CNS is usually locally limited to avoid devastating consequences. Critical players involved in this immune regulatory process are the resident immune cells of the brain, the microglia. Interactions between the growing family of B7 costimulatory ligands and their receptors are increasingly recognized as important pathways for costimulation and/or inhibition of immune responses. Human and mouse microglial cells constitutively express B7 homolog 1 (B7-H1) in vitro. However, under inflammatory conditions [presence of interferon-gamma (IFN-gamma) or T-helper 1 supernatants], a significant upregulation of B7-H1 was detectable. Expression levels of B7-H1 protein on microglial cells were substantially higher compared with astrocytes or splenocytes. Coculture experiments of major histocompatibility complex class II-positive antigen-presenting cells (APC) with syngeneic T cells in the presence of antigen demonstrated the functional consequences of B7-H1 expression on T-cell activation. In the presence of a neutralizing anti-B7-H1 antibody, both the production of inflammatory cytokines (IFN-gamma and interleukin-2) and the upregulation of activation markers (inducible costimulatory signal) by T cells were markedly enhanced. Interestingly, this effect was clearly more pronounced when microglial cells were used as APC, compared with astrocytes or splenocytes. Furthermore, B7-H1 was highly upregulated during the course of myelin oligodendrocyte glycoprotein-induced and proteolipid protein-induced experimental allergic encephalomyelitis in vivo. Expression was predominantly localized to areas of strongest inflammation and could be colocalized with microglial cells/macrophages as well as T cells. Together, our data propose microglial B7-H1 as an important immune inhibitory molecule capable of downregulating T-cell activation in the CNS and thus confining immunopathological damage.

3-hydroxy-3-methylglutaryl-CoA lyase deficiency in an adult with leukoencephalopathy

3-Hydroxy-3-methylglutaryl-CoA lyase deficiency is a disorder of leucine metabolism that usually presents with recurrent episodes of life-threatening hypoglycemia during early childhood. We report on a 36-year-old woman with seizures, recurrent metabolic disturbances, and severe leukoencephalopathy. The diagnosis was made by analysis of amino acids in urine and serum and was confirmed by demonstration of the deficient enzyme in cultured skin fibroblasts. The patient improved clinically on oral L-carnitine substitution. This treatable condition can remain unrecognized in adults and should be considered a potential cause of leukoencephalopathy.

A Structurally Available Encephalitogenic Epitope of Myelin Oligodendrocyte Glycoprotein Specifically Induces a Diversified Pathogenic Autoimmune Response

Multiple sclerosis is an inflammatory disease of the CNS that involves immune reactivity against myelin oligodendrocyte glycoprotein (MOG), a type I transmembrane protein located at the outer surface of CNS myelin. The epitope MOG92-106 is a DR4-restricted Th cell epitope and a target for demyelinating autoantibodies. In this study, we show that the immune response elicited by immunization with this epitope is qualitatively different from immune responses induced by the well-defined epitopes myelin basic protein (MBP) 84-96 and proteolipid protein (PLP) 139-151. Mice with MOG92-106-, but not with MBP84-96- or PLP139-151-induced experimental autoimmune encephalomyelitis developed extensive B cell reactivity against secondary myelin Ags. These secondary Abs were directed against a set of encephalitogenic peptide Ags derived from MBP and PLP as well as a broad range of epitopes spanning the complete MBP sequence. The observed diversification of the B cell reactivity represents a simultaneous spread toward a broad range of antigenic epitopes and differs markedly from T cell epitope spreading that follows a sequential cascade. The Abs were of the isotypes IgG1 and IgG2b, indicating that endogenously recruited B cells receive help from activated T cells. In sharp contrast, B cell reactivity in MBP84-96- and PLP139-151-induced experimental autoimmune encephalomyelitis was directed against the disease-inducing Ag only. These data provide direct evidence that the nature of the endogenously acquired immune reactivity during organ-specific autoimmunity critically depends on the disease-inducing Ag. They further demonstrate that the epitope MOG92-106 has the specific capacity to induce a widespread autoimmune response.

Analysis of autoreactive CD4 T cells in experimental autoimmune encephalomyelitis after primary and secondary challenge using MHC class II tetramers

Experimental autoimmune encephalomyelitis (EAE), an animal model of multiple sclerosis, is primarily mediated by CD4 T cells specific for Ags in the CNS. Using MHC class II tetramers, we assessed expansion and phenotypic differentiation of polyclonal self-reactive CD4 T cells during EAE after primary and secondary challenge with the specific Ag. After EAE induction in SJL mice with proteolipid protein 139-151, CNS-specific T cells up-regulated activation markers and expanded in the draining lymph nodes and in the spleen. Less than 20% of total autoreactive T cells entered the CNS simultaneously with Th cells of other specificities. Almost all tetramer-positive cells in the CNS were activated and phenotypically distinct from the large peripheral pool. When EAE was induced in Ag-experienced mice, disease symptoms developed earlier and persisted longer; autoreactive T cells were more rapidly activated and invaded the CNS earlier. In striking contrast to specific CTLs that respond after secondary viral challenge, the absolute numbers of autoreactive CD4 T cells were not increased, indicating that the accelerated autoreactivity in Ag-experienced mice is not related to higher frequencies of autoreactive CD4 T cells.

MICA/NKG2D-mediated immunogene therapy of experimental gliomas

The failure of conventional cancer therapy renders glioblastoma an attractive target for immunotherapy. Tumor cells expressing ligands of the activating immunoreceptor NKG2D stimulate tumor immunity mediated by natural killer (NK), gammadelta T, and CD8(+) T cells. We report that human glioma cells express the NKG2D ligands MICA, MICB, and members of the UL16-binding protein family constitutively. However, glioma cells resist NK cell cytolysis because of high MHC class I antigen expression. Plasmid-mediated or adenovirus-mediated overexpression of MICA in glioma cells enhances their sensitivity to NK and T-cell responses in vitro and markedly delays the growth of s.c. and intracerebral LN-229 human glioma cell xenografts in nude mice and of SMA-560 gliomas in syngeneic VMDk mice. Glioma cells forming progressive tumors after implantation of stably MICA-transfected human LN-229 cells lost MICA expression, indicating a strong selection against MICA expression in vivo. Rejection of MICA-expressing SMA-560 cells in VMDk mice resulted in protective immunity to a subsequent challenge with wild-type tumor cells. Finally, the growth of syngeneic intracerebral SMA-560 tumors is inhibited by peripheral vaccination with adenovirus-mediated, MICA-infected irradiated tumor cells, and vaccination results in immune cell activation in the NK and T-cell compartments in vivo. These data commend MICA immunogene therapy as a novel experimental treatment for human malignant gliomas.

Pathological long-bone fractures in residents with cerebral palsy in a long-term care facility in South Africa

A high incidence of long-bone fractures has been observed in children and young adults with quadriplegic cerebral palsy in residential care. This study aimed to determine factors that contribute to these fractures and to institute preventive treatment. Twenty individuals (12 males, eight females) of a cohort of 88 residents with spastic quadriplegia in residential care in Gauteng, South Africa who had sustained fractures were compared with a random sample of age-matched control participants (10 males, 10 females) from the same facility. Participants ranged in age from 6 to 29 years (median 17.5 years). The majority of fractures were in the upper extremities. There was radiological and biochemical evidence of rickets and osteomalacia in both groups. However, the severity of the disease was more pronounced in the group with fractures. There was a significant relation (p=0.002) between the number of fractures and the use of anticonvulsant therapy (ACT). Three months of vitamin D administration (calciferol 5000 iu/day) resulted in a marked clinical improvement. There were no fractures during this period in either group. In addition, the mean serum calcium (Ca) and phosphate (Pi) levels increased (Ca from 2.17 to 2.35 mmol/L and Pi from 1.13 to 1.66 mmol/L) and mean total alkaline phosphatase level decreased (from 1123 to 423 U/L). We concluded that vitamin D deficiency was the major factor contributing to the occurrence of fractures in this population. Unless sunlight exposure can be guaranteed, vitamin D supplementation should be considered for children and adults in residential care, especially if they are on ACT, even in areas with year-round sunshine.

Specific treatment of autoimmunity with recombinant invariant chains in which CLIP is replaced by self-epitopes

The invariant chain (Ii) binds to newly synthesized MHC class II molecules with the CLIP region of Ii occupying the peptide-binding groove. Here we demonstrate that recombinant Ii proteins with the CLIP region replaced by antigenic self-epitopes are highly efficient in activating and silencing specific T cells in vitro and in vivo. The Ii proteins require endogenous processing by antigen-presenting cells for efficient T cell activation. An Ii protein encompassing the epitope myelin basic protein amino acids 84-96 (Ii-MBP84-96) induced the model autoimmune disease experimental allergic encephalomyelitis (EAE) with a higher severity and earlier onset than the peptide. When applied in a tolerogenic manner, Ii-MBP84-96 abolished antigen-specific T cell proliferation and suppressed peptide-induced EAE more effectively than peptide alone. Importantly, i.v. administration of Ii proteins after EAE induction completely abrogated the disease, whereas peptides only marginally suppressed disease symptoms. Ii fusion proteins are thus more efficient than peptide in modulating CD4(+) T cell-mediated autoimmunity, documenting their superior qualities for therapeutic antigen delivery in vivo.

Aerobic thermophilic treatment of sewage sludge contaminated with 4-nonylphenol

4-Nonylphenol (4-NP) occurs in sewage sludge as a result of the breakdown of detergents which contains nonylphenol ethoxylates (NPEs). 4-NP is of environmental concern because of its toxicity to biological systems. The present paper reports results of aerobic treatment under thermophilic conditions of sewage sludge artificially contaminated with 4-NP. Experiments were carried out using three parallel laboratory-scale batch reactors operating with blank, 50 and 100 mg/l of 4-NP concentration. For the two studied concentrations up to 66% 4-NP reduction was achieved at a specific air flow rate of 16 l/(l.h) and a thermophilic temperature of 60 degrees C, within 10 days of operation. The presence of 4-NP has minor effect on the rate of sludge oxidation and the nitrogen and phosphorous content in the sludge.

[Individual cement-free total hip endoprosthesis in a patient with a rare form of dwarfism (Fuhrmann syndrome)]

We present a single case study of a 47-year-old female patient with a rare form of primary dysostotic dwarfism. This syndrome was first described by Fuhrmann in 1972. Seven years ago, this patient underwent bilateral cementless total hip arthroplasties for severe osteoarthritis about her hips. Custom-made components were used. While achondroplastic patients present with wide femoral medullary canals, it is clinically relevant that Fuhrmann Syndrome features narrow femoral medullary canals. This complicating anatomical factor in Fuhrmann syndrome as well as the increased anteversion angles were overcome by the use of CAD stems. We conclude that the custom-made stems, although in our case measuring half the size of the smallest commercially available design, have proved to be durable and able to withstand physiological loads at follow-up period of 72 months.

Arthroscopic labrum refixation for post-traumatic anterior shoulder instability: suture anchor versus transglenoid fixation technique

SUMMARY

The aim of this retrospective study was to compare recurrence rates following transglenoid labrum refixation or fixation using the suture anchor (FASTak, Arthrex, Naples, FL) technique. Additionally, parameters that apparently influence the rate of redislocation were investigated. There were 163 patients with post-traumatic anterior shoulder instability treated with an arthroscopic labrum refixation; 108 patients (66.3%) were stabilized with the transglenoid suture technique (group I) and 55 patients (33. 7%) with the suture anchor (FASTak) technique (group II). The average follow-up was 4.5 years (range, 2.0 to 7.9 years) in group I and 3.2 years (range, 2.0 to 5.0 years) in group II. The Rowe score increased from a preoperative average of 35.0 points in group I and 35.4 points in group II to a postoperative average of 68.3 points in group I and 84.6 points in group II (P <.01). There was recurrence in 35 patients (32.4%) in group I and 9 patients (16.4%) in group II (P <.05). All incidents of redislocation occurred during the first 21 postoperative months; 58.4% of the patients (n = 63) in group I and 16.4% of the patients in group II (n = 9) had to reduce their sporting activity (P <.001). Independent of the type of surgery, there was a significant correlation of the postoperative rate of redislocation and age (P <.001), number of preoperative dislocations (P <.01), and degree of labrum lesion (P <.001). No correlation with the rate of redislocation was shown for gender, handedness, dislocation-operation interval, degree of Hill-Sachs lesion, or number of transglenoid sutures or anchors. Concerning post-traumatic anterior shoulder instability, the arthroscopic labrum reconstruction with the suture anchor (FASTak) technique was superior to the transglenoid technique but has not yet achieved the level of success obtained by open surgery. With fewer than 5 preoperative redislocations after a first traumatic shoulder dislocation, the arthroscopic treatment is recommended. In cases of more frequent preoperative dislocations, open surgery in combination with a capsular shift should be performed.