[From guilt and shame to professional handling of mistakes--risk management in surgical medicine]

Medical advances in diagnosis and therapy, especially in medical technology, lead to differenciated and more complex strategies in therapy with higher risks. Patients show higher expectations concerning the results of a therapy and claim more often that a mistake in treatment has been made. This makes patients turn to arbitration boards more often. They may also want to bring civil action against physicians and hospitals, claiming for compensation and damages. Personal liability insurances have to pay more for damages. Medical insurances have more recourse demands due to mistake in treatment. Hospital and especially operative medicine do have high chances of risks and mistakes. The implementation of a modern risk management system in the hospitals is becoming more and more important, for patients as well as for the surgical departments. A structured reporting system of critical incidents can produce indicators of potential sources of mistakes, which appears to be a successful approach to reduce or avoid typical risks and mistakes in medical treatment. Risk management in medical treatment must be more than just a trendy word, because its roots are in the medical principles of "primum nihil nocere". It is a challenge to today's and tomorrow's medicine. This article is a general overview of current strategies for avoiding mistakes: It is meant to be the basis of a new culture of mistake avoidance as a part of a future quality competition.

[Geriatric surgery or geriatrisation of surgical medicine]

In the western industrial nations the proportion of old people (according to WHO definition people over 75 years) has been rising for many years and with it the amount of surgical treatment on this group of the population. High age does not automatically mean a risk too high for surgical treatment. Very often the reasons for this age group being high-risk patients are hospital admission in an advanced stage of illness or complications due to the illness. Old people are biologically younger than they were years ago. Often they express their perfectly understandable wish for suitable treatment. New treatments and strategies in surgery such as minimal-invasive surgery, endoluminal techniques for heart and vascular surgery, fast-track-concepts, anaesthetising techniques like spinal anaesthesia or the use of better controllable narcotics, improves alleviation of pain, quick mobilisation and early oral nutrition contribute to a minimisation of the risk. Age-related multimorbidity defines the risks of major operations and requires an individual weighing up of benefit and risk. The decision for or against an operation must take the elderly patient's wishes into account. The most important aspect is not only to help the people survive but to enable them to participate in life. In this paper we try to give an overview of geriatric surgery with all its aspects relevant to insurance.

Studies on chromophore coupling in isolated phycobiliproteins: III. Picosecond excited state kinetics and time-resolved fluorescence spectra of different allophycocyanins from Mastigocladus laminosus

The excited state kinetics of three different allophycocyanin (AP) complexes has been studied by picosecond fluorescence spectroscopy. Both the fluorescence kinetics and the decay-associated fluorescence spectra of the different complexes can be understood on the basis of a structural model for AP which uses (a) an analogy to the known x-ray determined structure of C-phycocyanin, (b) the biochemical analogies of AP and C-phycocyanin, and (c) the biochemical composition of AP-B (AP-681). A model is developed that describes the excited state kinetics as a mixture of internal conversion processes within a coupled exciton pair and energy transfer processes between exciton pairs. We found excited state relaxation times in the range of 13 ps (AP with linker peptide) up to 66 ps (AP-B). The trimeric aggregates AP 660 and AP 665 show one fast relaxation component each, as was expected on the basis of their symmetry properties. The lower symmetry of AP-B (AP-681) gives rise to two fast lifetime components (tau(1) = 23 ps and tau(2) = 66 ps) which are attributed to internal conversion and/or energy transfer between excitonic states formed by the coupling of symmetrically and spectrally nonequivalent chromophores. It is proposed that the internal conversion between exciton states of strongly coupled chromophores fulfills the requirements of the small energy gap limit. Thus, internal conversion rates in the order of tens of picoseconds are feasible. The influence of the interaction of the linker peptide on the properties of the AP trimer are manifested in the fluorescence kinetics. Lack of the linker peptide in AP 660 gives rise to a heterogeneity in the chromophore conformations and chromophore-chromophore interactions.

[Quality assurance by routine data (QAR)--a new dimension in quality management of inpatient treatment?]

Patients, admitting doctors and payers want to have more and more valid information about the medical results in hospitals really are. The quality of medical care in hospitals is demonstrated in the quality reports through structure and process data, data of volume about the most common main diagnoses and procedures and, in the current version, also through data of external quality assurance. For patients and payers, this means that it may be difficult to obtain sufficient information on relevant quality criteria for different therapies in hospital departments. It may also mean that it is difficult to choose between hospitals. The project "Quality assurance of inpatient treatment by routine data" (QAR) is a new and extended attempt in quality management. By changing the reimbursement procedures of hospitals to DRG, one receives data from which one can easily deduce marks of quality. For special treatment the QAR marks of quality provide patients, insurance companies and the internal quality management of hospitals with information on the quality of the hospitals and their departments. In this paper, the opportunities and prospects of quality assurance by using routine date will be discussed.

[Surgery on the fast track--"fast track" concepts in abdominal-/pediatric surgery and urology]

In surgical medicine there are traditions, myths, rites and dogmas which define concepts of treatment and strategies. Upheld and passed on without being examined or confirmed in further studies, these concepts and strategies include preoperative intestinal lavage and fasting, postoperative long-term drainage, tubes und catheters, long-term relaxation of the intestine after abdominal surgery or immobilisation for some days. New techniques and procedures in surgery and anaesthesia, including postoperative pain management like laparoscopic surgery and partial anaesthesia, reduce the need for surgery and minimize morbidity of treatment. For more than ten years now, the Copenhagen abdominal surgeon Henrik Kehlet and his team have systematically dealt with the question of how to reduce perioperative stress and improve postoperative conditions of recovery. The resulting concepts of an "enhanced recovery after surgery" (ERAS) seek to overcome handed-down myths und fix new clinical pathways. In current prospective studies of elective surgery, the clinical use of these fast track concepts have been confirmed in colon surgery, pediatric surgery and urology. Here, examples of some of these studies are discussed together with problems like general complications and length of stay, while aspects of insurance are also taken into consideration.

[Vestibular paroxysmia. A rare but important differential diagnosis]

The diagnosis and treatment of vertigo are very common in ear nose and throat medicine and neurology. As our case report demonstrates, an interdisciplinary approach is often useful for finding the correct diagnosis. Diagnosing disabling positional vertigo now seems uncomplicated using special MRI. More important is the history of frequent, short-term vertigo, sometimes accompanied by tinnitus. In analogy to trigeminal neuralgia, treatment should be started with carbamazepine or similar drugs. If unsuccessful, microvascular decompression as a neurosurgical intervention is recommended.

Possible role of MDR1 two-locus genotypes for young-age onset ulcerative colitis but not Crohn's disease

BACKGROUND

The role of the single nucleotide polymorphisms (SNPs) on positions 2677G>T/A and 3435C>T of the multi-drug-resistance gene 1 (MDR1) in inflammatory bowel disease (IBD) remains unclear.

AIMS

To further elucidate the potential impact of MDR1 two-locus genotypes on susceptibility to IBD and disease behaviour.

PATIENTS AND METHODS

Three hundred eighty-eight German IBD patients [244 with Crohn's disease (CD), 144 with ulcerative colitis (UC)] and 1,005 German healthy controls were genotyped for the two MDR1 SNPs on positions 2677G>T/A and 3435C>T. Genotype-phenotype analysis was performed with respect to disease susceptibility stratified by age at diagnosis as well as disease localisation and behaviour.

RESULTS

Genotype distribution did not differ between all UC or CD patients and controls. Between UC and CD patients, however, we observed a trend of different distribution of the combined genotypes derived from SNPs 2677 and 3435 (chi(2) = 15.997, df = 8, p = 0.054). In subgroup analysis, genotype frequencies between UC patients with early onset of disease and controls showed significant difference for combined positions 2677 and 3435 (chi(2) = 16.054, df = 8, p = 0.034 for age at diagnosis >or=25, lower quartile). Herein the rare genotype 2677GG/3435TT was more frequently observed (odds ratio = 7.0, 95% confidence interval 2.5 - 19.7). In this group severe course of disease behaviour depended on the combined MDR1 SNPs (chi(2) = 16.101, df = 6, p = 0.017 for age at diagnosis >or=25). No association of MDR1 genotypes with disease subgroups in CD was observed.

CONCLUSIONS

While overall genotype distribution did not differ, combined MDR1 genotypes derived from positions 2677 and 3435 are possibly associated with young age onset of UC and severe course of disease in this patient group.

The value of Ems Mineral Salts in the treatment of rhinosinusitis in children. Prospective study on the efficacy of mineral salts versus xylometazoline in the topical nasal treatment of children

The treatment of rhinosinusitis seen in the light of uncertain pathogenesis and variable symptoms is under discussion and ranges from the administration of antibiotics, decongestants and anti-allergic agents to no treatment. In this randomized, prospective, double-blind and controlled study the effect of a 14-day treatment (1-2 sprays into each nostril t.d.) with either isotonic Ems Mineral Salts (EMS) solution (Siemens & Co., Bad Ems, Germany) or xylometazoline solution (0.05%) was tested in children (n=66) aged 2-6 years.

MAIN OUTCOMES

the degree of mucosal inflammation, nasal patency, general state of health, condition of the middle ear, auditory function as well as an assessment of complaints by the parents. With the exception of the hearing defects, all parameters showed a clear improvement in both treatment groups at the end of the observation period (p>0.001). The hearing defects showed only a trend towards improvement. At the end of the study no differences between the treatment groups could be determined. However, at the intermediate examination after the first 7 days of treatment more favourable results were seen in the group treated with EMS. No undesired medicinal effects were observed, although in 7 out of 34 cases the nasal spray was improperly used in the group treated with xylometazoline. The results of the study show that there is no difference in efficacy between an exclusive treatment by EMS solution in children aged 2-6 years and a treatment with xylometazoline, but with the distinction that with EMS the length of use was not restricted, there were not the potential side effects of nasal decongestants, and there was no contraindication in the newborn and infants.

[Improvement of functional deficits, physical mobility and cognitive function by treatment in a geriatric day hospital]

OBJECTIVES AND METHODS

Several studies showed the efficacy of inpatient geriatric treatment. Different outcomes were reported for geriatric patients treated in outpatient facilities. To analyze the course of rehabilitation, 312 patients (62.2% female) with a mean age of 77.2 years (SD = 7.4) in a geriatric day hospital were evaluated regarding a) changes of functional deficits and mobility, b) cognitive function and c) depression. Patients were examined with a geriatric assessment including activities of daily living, Tinetti, Timed-up and go, Mini Mental State Examination (MMSE), Clock Completion Test, Handgrip Strength-Test, Money-Counting Test and Geriatric Depression Scale (GDS) at admission and discharge.

RESULTS

All examined parameters had changed significantly after treatment. A clear decrease in the portion of patients with disability-related outcomes in the examined parameters (Barthel Index, Tinetti, Timed-up and go, MMSE, GDS) was demonstrated: a) the proportion of patients with a Barthel Index under 75 had decreased by 26.5%, the proportion of patients with an increased risk of falls was reduced by 27%, b) the proportion of patients with a MMSE Score less than 24 was decreased by 14.8% and c) mild effects were achieved in depression.

CONCLUSIONS

Day hospital geriatric treatment leads to an improvement of functional deficits, mobility and mental health of patients. The results contrast to other studies in day hospital treatment.

Fatty acids in colostrum from mothers of children at high risk of atopy in relation to clinical and laboratory signs of allergy in the first year of life

BACKGROUND

It remains controversial whether fatty acid (FA) composition of breast milk relates to development of atopy in the infant. This study evaluates FA in colostrum from mothers of children at high risk of atopy in association with atopy at the age of 1 year.

METHODS

The FA of colostrum were analyzed for 218 children (60 with low birth weight between 1500 and 2500 g, 84 with a history of maternal atopy, and 74 with an elevated cord blood immunoglobulin (Ig)E of >0.9 IU/ml). Total lipids were extracted, methylated and separated by gas-liquid chromatography. Laboratory screening for allergic sensitization and clinical examination took place within the Leipzig Allergy Risk Children's Study (LARS).

RESULTS

Low birth weight was correlated with low percentage levels of 20:2n-6, 22:2n-6, and 22:3n-3 (r = 0.14, P < 0.05; r = 0.14, P < 0.05 and r = 0.20, P < 0.01, respectively) and low gestational age at birth was correlated with low 22:3n-3 (r = 0.15, P < 0.05). There was no association between FA and atopic eczema at the age of 1 year. However, high linoleic acid (LA, 18:2n-6) was linked to high specific IgE against cow's milk protein (P < 0.05), and low docosapentaenoic acid (DPA, 22:5n-3) was associated with elevated total serum IgE (P < 0.05) at the age of 1 year, respectively.

CONCLUSIONS

The polyunsaturated fatty acid composition of colostrum in a high risk newborn population shows associations with atopic sensitization at the age of 1 year and may be predictive for later atopic disease.

[Age dependence of laboratory parameters in a health study--attempt at calculating a laboratory index for assessing biological aging]

The laboratory analyses of 404 participants of the health study GUNDULA, 201 men and 203 women between 30 and 80 years old, were performed to evaluate the variables for the determination of biological age. From the more than 70 laboratory variables resulting from clinical-chemical and hematologic tests and from urinalysis, less than 40 are significantly age-dependent. About half of these variables were examined by regression analysis to evaluate whether they are useful for the estimation of biological age by a laboratory index. Considerable sex differences were observed. The laboratory indexes for the participants altogether (resulting from 13 parameters) and separated for women (10 parameters) and men (8 parameters) show more variations than the biological age estimated by non-invasive parameters. In men only, there exists a significant but inverse correlation between laboratory index and relative aging rate, the difference between biological and chronological age. The results of some striking variables (e.g. dehydroepiandrosterone sulfate and others) and the results of an explorative factor analysis with regard to possible interconnections between variables and chronological age will be discussed.

[Soluble leukocyte adhesion molecules in vegetarians of various ages]

OBJECTIVES

Upregulation of leukocyte adhesion molecules under atherogenic conditions is accompanied by the release of soluble forms of adhesion molecules into the bloodstream. Vegetarians have a favorable cardiovascular risk profile. The aim of the present study was to assess the levels of circulating E-selectin (cE-selectin), circulating intercellular adhesion molecule-1 (cICAM-1), and circulating vascular adhesion molecule-1 (cVCAM-1) in both vegetarians and subjects of the average population and furthermore to evaluate the age dependence of cell adhesion molecules.

METHODS

24 male and 59 female vegetarians (mainly members of the German Society of Vegetarians) and 124 male and 179 female control subjects (volunteers, of the ILSE study Leipzig = Interdisciplinary Long Time Study of Health Adult Age and the Lipid-Study Leipzig), 18-89 years old were included in the study. The serum levels of circulating cell adhesion molecules were determined using monoclonal antibody-based ELISA assays (R & D Systems, Abingdon, Europe Ltd.).

RESULTS

Vegetarians were characterized by a favorable lipid profile and a low prevalence of common risk factors for atherosclerosis. This group showed a tendency towards lower cICAM-1 levels in comparison with control subjects. Furthermore, significantly lower cE-selectin levels were found in the group of vegetarians. An age-dependent increase of cVCAM-1 and cICAM-1 levels was found both in the group of vegetarians and control subjects. No significant differences were noted regarding the gender of the subjects included in the study.

CONCLUSION

Low cE-selectin levels of vegetarians may reflect the favorable cardiovascular risk profile of this group. Furthermore, the present data indicate that cVCAM-1 and cICAM-1 are age-dependent parameters independent of risk for atherosclerosis.

Eight novel LDL receptor gene mutations among patients under LDL apheresis in Dresden and Leipzig

LDL apheresis is highly efficient in reducing elevated plasma cholesterol. Due to strict indications only patients with severe, refractory hypercholesterolemia are treated with this method. Mutations in the LDL receptor gene are major genetic causes for severe hypercholesterolemia. Screening the entire gene in LDL apheresis patients from Saxony should determine whether an increased frequency of defined mutations is responsible for the atherogenic hypercholesterolemia in this group. 31 unrelated patients (15 male, 16 female, age 33-71 yrs.) were included in the analysis. The LDL-R gene was screened using SSCP and/or automated sequencing. The familial defective apolipoprotein B-100 (FDB) mutation was genotyped using established PCR techniques. Nineteen of 31 patients were carriers of an LDL-R mutation. Ten missense and two nonsense mutations, three insertions and two deletions were detected. The mutations C74S, C74R, T87M, 660delC, 662insCCCCG, 680insGGACAAATCTGA, 1428insC and 2167delG have not been previously described. One patient was compound heterozygous for two missense mutations. Two further patients were heterozygous for FDB. No mutations were found among controls. A genetic background for hypercholesterolemia in the LDL-R could be established in about 61% of the patients examined. Therefore, methods of DNA analysis allow to recognize and adequately treat a large portion of high-risk individuals at an early stage.

The exon 3-retaining and the exon 3-deleted forms of the growth hormone-binding protein (GHBP) in human serum are regulated differently

Recently, two isoforms of the growth hormone-binding protein (GHBP), which is identical with the extracellular domain of the growth hormone receptor (GHR), have been described. One isoform contains the exon 3 (E3+GHBP) and one excludes the exon 3 (E3-GHBP). The distribution of both isoforms in peripheral blood and their functional relevance is so far unknown. To study the molecular distribution of both species we have analysed sera of 141 subjects with average weight, overweight and obesity by newly developed immunoassays. The relationship between the different molecular forms of GHBP and specific parameters of body composition as well as risk factors of metabolic disturbances, were then examined. The extracellular domain of the exon 3-retaining and -deleted isoforms of the GHR are released as E3+GHBP and E3-GHBP into the peripheral circulation. Furthermore, both molecular species do not show any correlation to each other (r = 0.67) and their relative proportion in blood is gender-dependent with a higher E3-GHBP proportion in females (P < 0.01). E3+GHBP appears to have a considerably stronger correlation to indicators (BMI, fat mass, waist circumference) and metabolic risk factors (fasting insulin, uric acid, triglycerides, apolipoprotein B, diastolic blood pressure) of adiposity than E3-GHBP, indicating differences in their functional significance. The availability of assays for the determination of GHBP isoforms may be very important for the study of the GH receptor and its soluble extracellular domain, GHBP.

Amino acid sequence, crystallization and structure determination of reduced and oxidized cytochrome c6 from the green alga Scenedesmus obliquus

Cytochrome c6from the unicellular green alga Scenedesmus obliquus was sequenced, crystallized in its reduced and oxidized state and the three-dimensional structure of the protein in both redox states was determined by X-ray crystallography. Reduced cytochrome c6crystallized as a monomer in the space group P 21212, whereas the oxidized protein crystallized as a dimer in the space group P 3121. The structures were solved by molecular replacement and refined to 1. 9 and 2.0 A, respectively. Comparison of the structures of both redox states revealed only slight differences on the protein surface, whereas a distortion along the axis between the heme iron and its coordinating Met61 residue was observed. No redox-dependent movement of internal water molecules could be detected. The high degree of similarity of the surfaces and charge distributions of both redox states, as well as the dimerization of cytochrome c6as observed in the oxidized crystal, is discussed with respect to its biological relevance and its implications for the reaction mechanisms between cytochrome c6and its redox partners. The dimer of oxidized cytochrome c6may represent a molecular structure occurring in a binary complex with cytochrome b6f. This assembly might be required for the correct orientation of cytochrome c6with respect to its redox partner cytochrome b6f, facilitating the electron transfer within the complex. If the dimerization is not redox-dependent in vivo, the almost identical surfaces of both redox states do not support a long range differentiation between reduced and oxidized cyt c6, i.e. a random collision model for the formation of an electron transfer complex must be assumed.

Structural analysis at 2.2 A of orthorhombic crystals presents the asymmetry of the allophycocyanin-linker complex, AP.LC7.8, from phycobilisomes of Mastigocladus laminosus

An electrophoretically purified allophycocyanin-linker complex, AP. LC7.8, from phycobilisomes of Mastigocladus laminosus has been crystallized in the orthorhombic space group P212121. Cryocrystallographic x-ray measurements enabled the structural analysis of the complex at a resolution of 2.2 A. The asymmetric unit contains two side-to-side associated "trimeric" (alphabeta)3 allophycocyanin complexes comprising the linker polypeptide in a defined orientation inside the trimer. The linker representing a protein fold related to the prosegment of procarboxypeptidase A is in contact with only two of the three beta-subunits and directly interacts with the corresponding chromophores of these proteins. In addition to a modulation of the chromophores' spectral properties, the linker polypeptide attracts the alphabeta-subcomplexes, thereby bringing the beta-chromophores closer together. These results will enable interpretations of energy-transfer mechanisms within phycobiliproteins.

Extended high frequency audiometry in pre-school children

Since adequate and reliable earphones are now available and standards have been established, clinical audiometry can be performed at extended high frequencies (EHFs). In the present study, 47 preschool children (aged 4-7 years) were examined with EHFs (8-16 kHz) using the new Sennheiser HDA 200 earphone. The hearing thresholds correspond to those of other studies; the median thresholds and range increase with increasing frequency. The medians and quartiles were: 10 kHz: 25 (5-35) dB(SPL), 11.2 kHz: 35 (20-40) dB(SPL), 14 kHz 40 (30-50) dB(SPL) and 16 kHz: 50 (40-60) dB(SPL). The hearing thresholds could be more reliably determined in the older children (> 5 years) and were 5 dB better than in the younger ones (< 5 years). Thresholds in the 10-12.5 kHz range correspond to those of adults but are more sensitive by 5-12 dB in the 14-16 kHz range.

Structures of class pi glutathione S-transferase from human placenta in complex with substrate, transition-state analogue and inhibitor

BACKGROUND

Glutathione S-transferases (GSTs) are detoxification enzymes, found in all aerobic organisms, which catalyse the conjugation of glutathione with a wide range of hydrophobic electrophilic substrates, thereby protecting the cell from serious damage caused by electrophilic compounds. GSTs are classified into five distinct classes (alpha, mu, pi, sigma and theta) by their substrate specificity and primary structure. Human GSTs are of interest because tumour cells show increased levels of expression of single classes of GSTs, which leads to drug resistance. Structural differences between classes of GST can therefore be utilised to develop new anti-cancer drugs. Many mutational and structural studies have been carried out on the mu and alpha classes of GST to elucidate the reaction mechanism, whereas knowledge about the pi class is still limited.

RESULTS

We have solved the structures of the pi class GST hP1-1 in complex with its substrate, glutathione, a transition-state complex, the Meisenheimer complex, and an inhibitor, S-(rho-bromobenzyl)-glutathione, and refined them to resolutions of 1.8 A, 2.0 A and 1.9 A, respectively. All ligand molecules are well-defined in the electron density. In all three structures, an additionally bound N-morpholino-ethansulfonic acid molecule from the buffer solution was found.

CONCLUSIONS

In the structure of the GST-glutathione complex, two conserved water molecules are observed, one of which hydrogen bonds directly to the sulphur atom of glutathione and the other forms hydrogen bonds with residues around the glutathione-binding site. These water molecules are absent from the structure of the Meisenheimer complex bound to GST, implicating that deprotonation of the cysteine occurs during formation of the ternary complex which involves expulsion of the inner bound water molecule. The comparison of our structures with known mu class GST structures show differences in the location of the electrophile-binding site (H-site), explaining the different substrate specificities of the two classes. Fluorescence measurements are in agreement with the position of the N-morpholino-ethansulfonic acid, close to Trp28, identifying a possible ligandin-substrate binding site.

[Hearing tests in extended high frequency range in pre-school age children. Initial results]

Since reliable headphones are now available, clinical audiometry can also be performed in extended high frequencies (EHF). Hearing in frequencies over 10 kHz is more influenced by age, noise and toxicity. Thus it is useful to take additionally results in children to establish the normal hearing threshold. In the present study, 35 pre-school children (ages 4-7 years) were tested by EHF (8 kHz-16 kHz) using a new Sennheiser HDA-200 headphone. The hearing thresholds recorded corresponded to those of other studied. Median and standard deviations for 10 kHz were 25 dB(SPL) +/- 12 dB(SPL), 35 dB(SPL) +/- 12 dB(SPL) for 12.5 kHz and 50 dB(SPL) +/- 15 dB(SPL) for 16 kHz. In the older children (> 5 years), hearing thresholds could be more reliably determined and were 10 dB(SPL) better than in the younger children (< 5 years). Thresholds at 10 kHz-12.5 kHz corresponded to those found in adults, but were more sensitive by 5 dB(SPL)-15 dB(SPL) in the 14 kHz-16 kHz range.

[Keratoconjunctivitis sicca in patients with lipoprotein (a) elevation]

BACKGROUND

Elevated Lp(a) levels are known as risk factor for premature coronary artery disease and apoplexy. To our knowledge ophthalmologic alterations have not been described in combination with elevated Lp(a) levels. We examined whether patients with LP (a) elevation had an increased incidence of keratoconjunctivitis sicca.

PATIENTS AND METHODS

27 patients, 16 women and 11 men were examined. The Lp(a) value was in all patients definitively pathological. The following examinations were performed: history, slitlamp examination, Schirmer-test, impressioncytology, fluorescein staining of the cornea, applanation tonometry and examination of the ocular fundus.

RESULTS

The results show a pathologic Schirmer-test in 70.3% of the eyes, in 81.5% a pathologic impressioncytology, and in 48.1% a pathologic fluorescein staining. The Schirmer-test is not sufficiently sensitive and specific in diagnosing the dry eye, whereas impression cytology is highly sensitive and specific.

CONCLUSIONS

We could show, that in more than 80% of the examined patients at least one sign of keratoconjunctivitis sicca was found; however we did not find a correlation between the height of the Lp(a) level and the degree of pathologic impression cytology. Further examinations are needed to investigate the causal connection between keratoconjunctivitis sicca and Lp(a) elevation.

[Vitamin E distribution of lipoproteins in patients with coronary heart disease]

The oxidative modification of LDL could play an important role for the development of atherosclerosis. The present study was undertaken to compare the concentration of vitamin E in serum and lipoproteins between patients with coronary heart disease and a healthy control group. The study included 36 male patients with angiographically established coronary three-vessel disease and 32 healthy volunteers. Cholesterin, triglyceride, LDL-cholesterin, HDL-cholesterin, and vitamin E in serum and in lipoproteins were determined. The serum vitamin E concentration in the patients group was significantly higher than in controls. However, vitamin E was correlated with cholesterin in both groups. The distribution of vitamin E in healthy volunteers was LDL 53%, HDL 34% and VLDL 13%, whereas that in patients was LDL 57%, HDL 26% and VLDL 16%. The level of vitamin E in LDL was in the patient group significantly higher and correlated with the vitamin E- and the cholesterin-concentration in serum. The ratio vitamin E/cholesterin in LDL was in patients discretely lower, whereas the same ratio in HDL was higher. The results suggest that also in patients with coronary artery disease vitamin E is related to the lipid concentration. The decreased ratio vitamin E/cholesterin in LDL could be attributed to the oxidative modification of LDL.

Multicentre evaluation of a non-wipe system for the rapid determination of total cholesterol in capillary blood, Accutrend Cholesterol on Accutrend GC

Accutrend Cholesterol, a non-wipe test for the determination of total cholesterol in capillary blood, was evaluated at four clinical centres. Cholesterol determinations with the Accutrend system using capillary blood were compared with results obtained with the cholesterol oxidase/p-aminophenazone (CHOD-PAP) method using the respective capillary sera. Triacylglycerols, uric acid and haematocrit were determined to evaluate potential interference. Imprecision measurements were performed with venous blood. To examine the reproducibility of results from lot to lot, three different lots of test strips were included in these investigations. Results with Accutrend Cholesterol agree with those of the comparison method within systematic differences of +2.5% to -3.2%, depending on the lot. There was no interference by triacylglycerols up to 10.28 mmol/l (900 mg/dl), by uric acid 60 to 400 mumol/l (1 mg/dl to 7 mg/dl), or by haematocrits between 0.35 and 0.54. Impression data show coefficients of variation of generally less than 5%. Thus Accutrend Cholesterol proved to be a reliable system for the determination of total cholesterol.

[Effect of olive oil and fish oil on parameters of lipids and antioxidants in hyperlipoproteinemia]

In 56 patients with HLP (40 with hypertriglyceridemia and mixed HLP respectively and 16 with hypercholesterolemia), changes in the lipid state and in the parameters of the antioxidative potential before and after a 4-week olive-oil phase, and after 8-, 20- and 32-week intakes of salmon-oil capsules were determined. The treatment with salmon-oil led to a decrease of triglycerides in patients with hypertriglyceridemia and mixed HLP respectively, on the other hand, it led to an increase of cholesterol in hypercholesterolemia. The increase of malondialdehyde as measure of lipid peroxidation in both patient groups underlines the necessity of a substitution of antioxidants. Further investigations are necessary before wide use of fish-oil capsules can be recommended, especially to avoid side-effects.

Utilization of Light for Nitrogen Fixation by a New Synechocystis Strain Is Extended by Its Low Photosynthetic Efficiency

Performance of photosynthesis and nitrogenase activity in a novel cyanobacterium, Synechocystis sp. strain BO 8402, isolated from Lake Constance, located at the northern fringe of the Alps in central Europe, and of a stable derivative, strain BO 9201, were examined. Strain BO 8402 is characterized by an extraordinarily high level of autofluorescence originating from paracrystalline phycobiliprotein-linker complexes located in inclusion bodies (W. Reuter, M. Westermann, S. Brass, A. Ernst, P. Böger, and W. Wehrmeyer, J. Bacteriol. 176:896-904, 1994). Energy transfer between paracrystalline phycobiliproteins and the photosystems is inefficient, resulting in a high oxygen compensation point and a decreased growth rate. The derivative strain BO 9201 exhibits hemidiscoidal phycobilisomes that support a high growth rate, even under low light intensities. Because of the differences in photosynthetic performance, anaerobic light-stimulated nitrogenase activity is maintained at higher light intensity in the original strain BO 8402 than in the derivative strain BO 9201. The results indicate that the formation of paracrystalline phycobiliproteins in Synechocystis sp. strain BO 8402 represents a hitherto-unknown means for a unicellular cyanobacterium to extend its capacity to fix nitrogen in the light.

[Changes in parameters of lipid metabolism and anti-oxidative potentials in elderly hyperlipoproteinemic patients treated with omega-3 fatty acids]

Omega-3-fatty acids play a protective role in the prevention of CHD, however, they can have a negative influence on LDL-oxidation and aging processes by the formation of peroxides. In 56 patients with HLP (40 with mixed HLP and hypertriglyceridemia, respectively, and 16 with hypercholesterolemia) changes in the lipid state and in the parameters of the antioxidative potential before and after a 4-week-olive-oil phase and after 8, 20, and 32 weeks intakes of salmon-oil capsules were determined. The treatment with salmon-oil capsules were determined. The treatment with salmon oil led to a decrease of triglycerides in patients with hypertriglyceridemia and to an increase of cholesterol in hypercholesterolemia. Following the increase of malondialdehyde as measure of the lipid peroxidation a substitution of antioxidants, like vitamin E and vitamin C, seems to be useful. Further investigations are necessary before wide use of fish-oil capsules, not least to avoid side-effects.

Structure, composition, and assembly of paracrystalline phycobiliproteins in Synechocystis sp. strain BO 8402 and of phycobilisomes in the derivative strain BO 9201

The phycobiliproteins of the unicellular cyanobacterium Synechocystis sp. strain BO 8402 and its derivative strain BO 9201 are compared. The biliproteins of strain BO 8402 are organized in paracrystalline inclusion bodies showing an intense autofluorescence in vivo. These protein-pigment aggregates have been isolated. The highly purified complexes contain phycocyanin with traces of phycoerythrin, corresponding linker polypeptides LR35PC and LR33PE (the latter in a small amount), and a unique colored polypeptide with an M(r) of 55,000, designated L55. Allophycocyanin and the core linker polypeptides are absent. The substructure of the aggregates has been studied by electron microscopy. Repetitive subcomplexes of hexameric stacks of biliproteins form extraordinary long rods associated side by side in a highly condensed arrangement. Evidence that the linker polypeptides LR35PC and LR33PE stabilize the biliprotein hexamers is presented, while the location and function of the colored linker L55 remain uncertain. The derivative strain BO 9201 contains established hemidiscoidal phycobilisomes comprising phycoerythrin, phycocyanin, and allophycocyanin as well as the corresponding linker polypeptides. The core-membrane linker protein (LCM), and two polypeptides with M(r)s of 40,000 and 45,000 which are present in small amounts, exhibit strong cross-reactivity in Western blot (immunoblot) analysis using an antibody directed against the colored LCM of a Nostoc sp. In contrast, strain BO 8402 exhibits no polypeptide with a significant immunological cross-reactivity in Western blot analysis. Physiological and genetic implications of the unusual pigment compositions of both strains are discussed.

[Specific parent training in alalia. 1: Introduction and presentation of the seminar concept]

Developmental aphasia is the most severe form of speech retardation and needs therapeutic intervention. The young age of these children (< 3 years) makes therapy difficult. A specified speech therapy is not possible at this age. Intensive stimulation of verbal communication by the parents is necessary. Therefore we developed a specialized training program for parents. This preparation is very useful for later therapy and should prevent disturbance of interaction between parents and child. We will present our concept.

[Specific parent training in alalia. 2: Study of experiences of parents in the seminar]

Specified training for parents of children with developmental aphasia has been offered for several years. We want to guide the parents to a controlled stimulation of speech at home. We asked the former participants about their experiences with this training program. We also studied the realization of the program by parents in everyday life before their children started therapy. The experiences were mainly considered positive, realizing the program did not present difficulties.

Core substructure of the hemiellipsoidal phycobilisome from the red alga Porphyridium cruentum

The allophycocyanin core of hemiellipsoidal phycobilisomes from the red alga, Porphyridium cruentum, was isolated by chromatography on hydroxylapatite and subsequent density gradient centrifugation. Electron microscopy of negatively stained core complexes revealed a tricylindrical structure with a width of 21 to 23 nm in face view and a depth of 12 to 14 nm in side view. Fluorescence emission spectra of these complexes were similar to those of whole phycobilisomes confirming the presence of the two "terminal energy acceptors" allophycocyanin B (APB) and the high molecular linker polypeptide LCM. The polypeptide composition analyzed by SDS-PAGE showed the "anchor" polypeptide LCM, alpha AP, alpha APB, beta AP subunits, a low molecular weight linker with M(r) 13,500 and a blue-colored polypeptide of M(r) 19,800. A complex containing APB could be isolated from a "trimeric" allophycocyanin fraction of the density gradient by agarose gel electrophoresis in the presence of ampholytes. This complex shows a polypeptide composition of (alpha APB alpha AP2 beta AP3).L13.5C and contributes to the core with 30 to 35% of total "trimers". In comparison to the allophycocyanin cores from hemidiscoidal phycobilisomes of cyanobacteria and red algae, all data concerning the core of the hemiellipsoidal phycobilisomes from Porphyridium cruentum strongly suggest that there is no increase in size but an increase in its APB content. A model comprising the allophycocyanin core and the membrane integral photosystem II particles presents the structural and possible functional consequences of the results.

[Population screening on a population level in Leipzig within the scope of the Bavarian cholesterol project]

Cholesterol determinations of 15.391 inhabitants of Leipzig were carried out in November 1990 within the Bavarian Cholesterol-Screening-Project. The aim of this screening on population basis was to identify individuals with elevated blood cholesterol levels as one of the risk factors of atherosclerosis. Capillary blood cholesterol was measured by means of the Reflotron dry-chemistry system (Boehringer, Mannheim). 27% of the inhabitants of Leipzig show cholesterol levels lower than 5.2 mmol/l as recommended by the European Society of Atherosclerosis Research. Furthermore the characteristic age dependence is seen. In comparison with the town Nürnberg lower mean cholesterol values were found in Leipzig.

[The effect of oral trapidil therapy on clinical and hemorheological parameters in arteriosclerosis obliterans in comparison to pentoxifylline--a pilot study]

20 male patients from 44 to 61 years of age with arteriosclerotic disturbances of the blood supply of the legs (stage II after Fontaine) were in the cross-over treated with 3 x 200 mg trapidil or 3 x 200 mg pentoxifylline daily. The duration of the therapy was in each case 6 weeks with a one-week elutriation phase. Statistically ascertained was an increase of the distance of intermittent claudication for the two drugs in patients with initial values lower than 550 m. On the other hand the tibio-brachial Doppler quotient and the submaximal blood supply established by the venous-occlusion plethysmography did not change. The post-ischaemic recovery phase of the transcutaneous oxygen partial pressure at the lower leg shortened in particular under the influence of trapidil. Lipid parameter, haematocrit, fibrinogen and plasma viscosity remained unchanged. The subjective tolerance of the two remedies was good.

[Oral fat tolerance test in obese patients]

19 adipose patients, 10 of them women, underwent an oral fat tolerance test with circa 50 g triglycerides. Before the loading test as well as 2 and 4 hours after it the serum lipids were determined. While in the cholesterol components (including the index of arteriosclerosis) no significant shiftings were the result, after 2 hours in the triglycerides a significant increase (p less than 0.05) by 21% from 1.62 +/- 0.76 to 1.96 +/- 0.91 mmol/l could be stated. The further increase after 4 hours by 10% was not significant. A standardized fat tolerance test concerning the triglycerides is apparently better suited for the estimation of the atherogenic risk than the determination of the fasting value alone.-By an additional determination of LPL and insulin as key enzyme and hormone, respectively, probably better statements could be made, which under equal conditions explain the interindividual differences of adipose persons in weight gain and weight reduction.

Isolation of allophycocyanin B from Rhodella violacea results in a model of the core from hemidiscoidal phycobilisomes of rhodophyceae

Two 'trimeric' allophycocyanin complexes could be isolated from the hemidiscoidal phycobilisomes of Rhodella violacea. AP = (alpha *AP alpha 2AP beta 2AP beta *AP) and APB = (alpha *AP alpha AP alpha APB beta 2AP beta *AP). Lc13.5APB. The isolation was performed by combined methods of gradient centrifugation, hydroxylapatite chromatography and 'native' polyacrylamide gel electrophoresis. AP showed the well-known spectral characteristics of allophycocyanin without linker polypeptide. APB is characterized by its long wavelength absorbing shoulder (675 nm) and fluorescence emission (682 nm), respectively. The existence of two low molecular linker polypeptides Lc12.5 and Lc13.5APB in the phycobilisomes of Rhodella violacea, their stoichiometric calculations and the localization of Lc13.5APB in allophycocyanin B facilitated the construction of a model of the phycobilisome core.