Validation of Microbiological Testing of Tissue Preparations with Different Incubation Temperatures.

INTRODUCTION: The European Pharmacopoeia (Ph. Eur.) provides principles for microbiological testing of tissue preparations. According to the Ph. Eur., tests should be performed at different temperatures for detection of aerobic bacteria and fungi (20-25°C) vs. anaerobic bacteria (30-35°C). Semiautomated systems using blood culture bottles are already widely used and they are adequate for growth detection. Resin-containing bottles and the addition of penicillinase permit testing of culture media containing antibiotics. MATERIALS AND METHODS: At 3 temperatures (21, 30, and 35°C) cornea culture media with and without dextran (CM II and CM I) and thermal disinfected femoral head medium (FH) were spiked with the 6 reference strains recommended by the Ph. Eur. (additionally: Enterococcus faecalis, Staphylococcus epidermidis, and Cutibacterium acnes). Microbial growth was monitored with the BACTECTM FX unit or visually at 21°C. RESULTS: Growth for all strains was detected with each medium at all 3 temperatures, except for C. acnes at 21°C (all media) and 30°C with FH. C. acnes had the highest times to detection, requiring test durations of 14 days. Microbial growth was faster at 30 and 35°C compared to 21°C. CONCLUSION: The requirements according to the Ph. Eur. for a successful method suitability test could be fulfilled for the semiautomated blood culture bottle system with the BACTECTM FX unit for the media and microorganisms used. In the presented validation study 35°C was shown to be the incubation temperature with the fastest growth, of the majority of the test strains used, and complete detection within 14 days.

Comparison of Total Immunoglobulin G in Ante- and Postmortem Blood Samples from Tissue Donors.

BACKGROUND: A serology testing for infectious diseases (HIV, hepatitis B and C, syphilis) is mandatory in tissue donors. In many donors postmortem blood is the only sample available. Even though serological tests and nucleic acid amplification tests (NAT) used are validated for postmortem blood, a characterization of those blood samples is not yet established. We therefore investigated the total immunoglobulin G (IgG) content in postmortem blood of tissue donors and compared it to a corresponding antemortem blood sample. METHODS: Ante- and postmortem blood samples were obtained from 100 consecutive tissue donors. The total IgG of all samples was measured using an immune-turbidometric test on the AU 480 Chemistry Analyzer (Beckman Coulter). RESULTS: The mean total IgG concentration of antemortem blood samples from all 100 donors was 8.9 g/L ± 3.7 g/L (median 8.9 g/L, range 1.5 to 23.8 g/L). In 80 donors the IgG concentration in the antemortem blood sample was within the normal range with values ≥6 g/L (mean 10.0 g/L ± 3.3 g/L, median 9.3 g/L,). The total IgG concentration of the postmortem blood samples was lower with 7.2 g/L ± 3.2 g/L (median 6.7 g/L, range 0.6 to 18.2 g/L). The difference between the values of the antemortem and postmortem blood samples was 1.7 g/L ± 2.6 g/L (16.3%) (median 1.6 g/L, range -7.7 to 10.1 g/L). In 36 donors this difference was less than 10%, in 23 it was between 10 and 25%, in 33 between 26 and 50%, and in 8 over 50%. In 57 donors the total IgG in the postmortem blood sample was within the normal range with ≥6 g/L, in 53 of them also the value of the antemortem blood sample was within the normal range. No correlation for total IgG was found regarding the donor characteristics (age, sex, disease) and the sample characteristics (hemolysis, postmortem time). CONCLUSION: Total IgG values in antemortem samples were below the lower limit of 6 g/L in 20% of the cases. Total IgG was significantly lower in the postmortem samples compared to the antemortem samples, while 57% were still above the lower limit. No correlation with the postmortem time could be found. This lowered IgG levels should be payed attention to when using postmortem blood for infectious serology testing. Additional NAT testing should be considered.

Risk Factor Analysis for Flap and Donor Site Related Complications in 1274 DIEP Flaps - Retrospective Single Center Study.

Background: Breast cancer is the most common cancer affecting women worldwide. In Germany, in almost 70% of cases, women require a complete mastectomy and wish for breast reconstruction which is especially difficult when the breast was previously irradiated. The DIEP flap is then the gold standard for autologous breast reconstruction and shows an overall low complication rate. This study aims to underline the safety of the procedure yet point out potential risk factors for flap edge and fat necrosis in a retrospective series of 1274 DIEP flaps in our center. Patients and Methods: 1274 autologous breast reconstructions with the DIEP flap were performed in 1124 patients between July 2004 and December 2014 in our department. Retrospective risk factor analysis included age, BMI, smoking, chemotherapy and/or radiotherapy and comorbidities. Mean follow-up constituted out of 24 months. Results: Out of 1274 free DIEP flap breast reconstructions, 150 were bilateral reconstructions. In 785 cases the primary indication was previous mastectomy, followed by prior implant-based reconstruction in 265 cases. The total flap loss rate was 0.6%. Patients with a higher BMI and smokers had significantly higher complication rates than the rest of the cohort. Elderly patients ( 65 years), patients with diabetes and ones who had undergone chemo-/ radiotherapy did not present with higher complication rates. Conclusions: The DIEP flap surgery is a well-established method for autologous breast reconstruction with a low complication rate. Yet patient characteristics in terms of risk factors need to be taken into account for result prognosis and satisfactory long-term reconstructive results.

Correlation between obesity and manual lymphatic drainage in Germany - a retrospective analysis from 2008 to 2016.

Backgrounds: Costs for manual lymphatic drainage (MLD) paid by the Statutory Health Insurances (SHI) have increased disproportionately in Germany in the last decade. There is no obvious reason that this increase is due to an increasing number of patients with lymph edema. We therefore assume that there are large numbers of patients with obesity and obesity-associated dependency syndrome who drive the cost of MLD and did a retrospective analysis of the correlation between hospitalization rates for lymph edema and obesity and MLD prescription rates in outpatients. PATIENTS AND METHODS: Roughly 90 % of the German population is insured by the Statutory Health Insurance. From its reports we extracted data regarding costs and numbers of MLD session prescribed annually. Hospitalization rates for lymph edema (codes I89.*, I97.2 and Q82.0) and for obesity (ICD E66.*) were provided by the Federal Statistical Office after a specific remote analyses. RESULTS: In the years 2008 to 2016, the MLD prescriptions in the individual federal states increased by + 43.5 % in Berlin to + 109.3 % in Mecklenburg-Western Pomerania. Number of hospitalizations with the principal diagnosis (condition, which caused the admission) hereditary and postmastectomy lymph edema are low and decreased in most federal states. Number of hospitalizations with the additional diagnosis (conditions that coexist at the time of admission or develop subsequently) obesity increased with a range from + 4.8 % in Baden-Württemberg to + 86.4 % in Mecklenburg-Western Pomerania. The correlation between the increase in prescribed MLD in the individual federal state and the increase in hospitalization rates per 1000 inhabitants of cases with obesity is greater (R2 0.4696) than with lymph edema (R2 0.0987). CONCLUSIONS: Our analysis is in line with the hypothesis that there is a correlation between the increasing prescription rate of MLD and the increasing burden of obesity in Germany.

Autologous Breast Reconstruction with SIEA Flaps: An Alternative in Selected Cases.

BACKGROUND: The deep inferior epigastric perforator flap has been shown to be a reliable option for autologous breast reconstruction. A further refinement in the transfer of lower abdominal tissue is the superficial inferior epigastric artery (SIEA) flap that does not require any incision of the rectus abdominis fascia or muscle and is superior regarding donor-site morbidity. OBJECTIVES: We conducted a retrospective study to assess reliability and outcomes of autologous breast reconstruction using SIEA flaps. METHODS: We performed autologous breast reconstruction in 1708 patients at our department between 2009 and 2018. Of those, 28 patients that underwent breast reconstruction using a SIEA flap were included for a retrospective chart review. RESULTS: Given an overall flap loss rate of 1.8%, we observed total flap necrosis following a SIEA flap in four patients (13%). All cases were secondary to arterial thrombosis. We further recognized a significant correlation between flap failure and a history of spontaneous deep vein thrombosis (p < 0.0001). There was no statistically significant relationship between flap failure and obesity (BMI > 30 kg/m2;p = 0.9) or flap failure and a history of abdominal operations (p = 0.6). CONCLUSIONS: The SIEA flap provides a reasonable option for autologous breast reconstruction with the great advantage of minimal donor-site morbidity. Nevertheless, its use should be preserved to selected cases with favorable anatomy. We therefore recommend proper patient selection based on preoperative computed tomography angiography, intraoperative clinical evaluation and history of hypercoagulable state. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Functional Analysis of the Alternative Sigma-28 Factor FliA and Its Anti-Sigma Factor FlgM of the Nonflagellated Legionella Species L. oakridgensis.

Legionella oakridgensis causes Legionnaires' disease but is known to be less virulent than Legionella pneumophilaL. oakridgensis is one of the Legionella species that is nonflagellated. The genes of the flagellar regulon are absent, except those encoding the alternative sigma-28 factor (FliA) and its anti-sigma-28 factor (FlgM). Similar to L. oakridgensis, Legionella adelaidensis and Legionella londiniensis, located in the same phylogenetic clade, have no flagellar regulon, although both are positive for fliA and flgM Here, we investigated the role and function of both genes to better understand the role of FliA, the positive regulator of flagellin expression, in nonflagellated strains. We demonstrated that the FliA gene of L. oakridgensis encodes a functional sigma-28 factor that enables the transcription start from the sigma-28-dependent promoter site. The investigations have shown that FliA is necessary for full fitness of L. oakridgensis Interestingly, expression of FliA-dependent genes depends on the growth phase and temperature, as already shown for L. pneumophila strains that are flagellated. In addition, we demonstrated that FlgM is a negative regulator of FliA-dependent gene expression. FlgM seems to be degraded in a growth-phase- and temperature-dependent manner, instead of being exported into the medium as reported for most bacteria. The degradation of FlgM leads to an increase of FliA activity.IMPORTANCE A less virulent Legionella species, L. oakridgensis, causes Legionnaires' disease and is known to not have flagella, even though L. oakridgensis has the regulator of flagellin expression (FliA). This protein has been shown to be involved in the expression of virulence factors. Thus, the strain was chosen for use in this investigation to search for FliA target genes and to identify putative virulence factors of L. oakridgensis One of the five major target genes of FliA identified here encodes the anti-FliA sigma factor FlgM. Interestingly, in contrast to most homologs in other bacteria, FlgM in L. oakridgensis seems not to be transported from the cell so that FliA gets activated. In L. oakridgensis, FlgM seems to be degraded by protease activities.

Implementation of the Single European Code in a Multi-Tissue Bank.

INTRODUCTION: The traceability of tissue and cells transplants is important to ensure a high level of safety for the recipients. With the final introduction of the Single European Code (SEC) in April 2017 in the EU a consistent system among all member states became mandatory. METHODS: The regulations for the SEC on EU and national level were evaluated. An overview on the different parts of the SEC with detailed explanations is given. Our own experiences with the implementation of the SEC in our multi-tissue bank are reported in addition. RESULTS: The implementation of the SEC in our multi-tissue bank could be successfully realized. However, it revealed a number of difficulties, especially the sterile labeling of certain tissue transplants and the complex update of the existing database. CONCLUSION: The introduction of the SEC has made a contribution to the safety of recipients of tissue and cells transplants through a system of comprehensive and transparent traceability.

Immediate-DElayed AutoLogous (IDEAL) Breast Reconstruction with the DIEP Flap.

Background: The most common cancer worldwide in women is breast cancer. The increasing number of cases each year, requires a novel curative approach that can combine oncological treatments and breast reconstruction yielding a pleasing and aesthetic breast that is a definitive and long lasting solution. Thus, the Immediate-DElayed AutoLogous (IDEAL) breast reconstruction principle was created to hold up to the standards of the needs of contemporary women. METHOD: The IDEAL protocol for breast reconstruction was developed in our department in cooperation with our breast surgery unit and describes a two-stage approach that implicates neoadjuvant radio-/ chemotherapy treatment regimes and tumor staging before the mastectomy in order to avoid post-mastectomy radiation. In a second step the breast is then reconstructed with autologous tissue for optimal and natural results. CONCLUSION: More and more patients decide to undergo breast reconstruction after breast cancer. The IDEAL concept offers a life-long and safe solution with a low rate of late complications.

Genome sequence and phenotypic analysis of a first German Francisella sp. isolate (W12-1067) not belonging to the species Francisella tularensis.

BACKGROUND: Francisella isolates from patients suffering from tularemia in Germany are generally strains of the species F. tularensis subsp. holarctica. To our knowledge, no other Francisella species are known for Germany. Recently, a new Francisella species could be isolated from a water reservoir of a cooling tower in Germany. RESULTS: We identified a Francisella sp. (isolate W12-1067) whose 16S rDNA is 99% identical to the respective nucleotide sequence of the recently published strain F. guangzhouensis. The overall sequence identity of the fopA, gyrA, rpoA, groEL, sdhA and dnaK genes is only 89%, indicating that strain W12-1067 is not identical to F. guangzhouensis. W12-1067 was isolated from a water reservoir of a cooling tower of a hospital in Germany. The growth optimum of the isolate is approximately 30°C, it can grow in the presence of 4-5% NaCl (halotolerant) and is able to grow without additional cysteine within the medium. The strain was able to replicate within a mouse-derived macrophage-like cell line. The whole genome of the strain was sequenced (~1.7 mbp, 32.2% G + C content) and the draft genome was annotated. Various virulence genes common to the genus Francisella are present, but the Francisella pathogenicity island (FPI) is missing. However, another putative type-VI secretion system is present within the genome of strain W12-1067. CONCLUSIONS: Isolate W12-1067 is closely related to the recently described F. guangzhouensis species and it replicates within eukaryotic host cells. Since W12-1067 exhibits a putative new type-VI secretion system and F. tularensis subsp. holarctica was found not to be the sole species in Germany, the new isolate is an interesting species to be analyzed in more detail. Further research is needed to investigate the epidemiology, ecology and pathogenicity of Francisella species present in Germany.

Legionella oakridgensis ATCC 33761 genome sequence and phenotypic characterization reveals its replication capacity in amoebae.

Legionella oakridgensis is able to cause Legionnaires' disease, but is less virulent compared to L. pneumophila strains and very rarely associated with human disease. L. oakridgensis is the only species of the family legionellae which is able to grow on media without additional cysteine. In contrast to earlier publications, we found that L. oakridgensis is able to multiply in amoebae. We sequenced the genome of L. oakridgensis type strain OR-10 (ATCC 33761). The genome is smaller than the other yet sequenced Legionella genomes and has a higher G+C-content of 40.9%. L. oakridgensis lacks a flagellum and it also lacks all genes of the flagellar regulon except of the alternative sigma-28 factor FliA and the anti-sigma-28 factor FlgM. Genes encoding structural components of type I, type II, type IV Lvh and type IV Dot/Icm, Sec- and Tat-secretion systems could be identified. Only a limited set of Dot/Icm effector proteins have been recognized within the genome sequence of L. oakridgensis. Like in L. pneumophila strains, various proteins with eukaryotic motifs and eukaryote-like proteins were detected. We could demonstrate that the Dot/Icm system is essential for intracellular replication of L. oakridgensis. Furthermore, we identified new putative virulence factors of Legionella.

FliA expression analysis and influence of the regulatory proteins RpoN, FleQ and FliA on virulence and in vivo fitness in Legionella pneumophila.

In Legionella pneumophila, the regulation of the flagellum and the expression of virulence traits are linked. FleQ, RpoN and FliA are the major regulators of the flagellar regulon. We demonstrated here that all three regulatory proteins mentioned (FleQ, RpoN and FliA) are necessary for full in vivo fitness of L. pneumophila strains Corby and Paris. In this study, we clarified the role of FleQ for fliA expression from the level of mRNA toward protein translation. FleQ enhanced fliA expression, but FleQ and RpoN were not necessary for basal expression. In addition, we identified the initiation site of fliA in L. pneumophila and found a putative σ(70) promoter element localized upstream. The initiation site was not influenced in the ΔfleQ or ΔrpoN mutant strain. We demonstrated that there is no significant difference in the regulation of fliA between strains Corby and Paris, but the FleQ-dependent induction of fliA transcription in the exponential phase is stronger in strain Paris than in strain Corby. In addition, we showed for the first time the presence of a straight hook at the pole of the non-flagellated ΔfliA and ΔfliD mutant strains by electron microscopy, indicating the presence of an intact basal body in these strains.

Randomized Single-Center Study of Effectiveness and Safety of a Resorbable Lysine-Based Urethane Adhesive for a Drain-Free Closure of the Abdominal Donor Site in a DIEP Flap Breast Reconstruction Procedure.

OBJECTIVE: The hypothesis of this parallel group randomized trial testifies if TissuGlu is a safe and an effective alternative to the conventional drainage placement in regard to post-operative fluid management in the abdominal donor site for autologous (DIEP flap) breast reconstruction with a higher postoperative patient quality of life. PATIENTS AND METHODS: Data was collected for 58 women who required to be at min.18 years old with a BMI < 30 and not taking any SSRIs (Selective Serotonin Reuptake Inhibitors).Exclusion criteria: Discharge with indwelling suction drains at the abdominal site or signs of wound infection during hospital stay.The patients were randomized into a study group (donor site closure with application of surgical adhesive without drains) and a control group (donor site closure with drains) using a randomly sorted sealed envelope system.Th e primary outcome was defined as the number of post-operative seroma formations.The secondary endpoint was the evaluation of patient satisfaction with both methods. RESULTS: 58 patients underwent a DIEP reconstruction (29 in the control- and 29 in the study group).Both groups were homogenous. Rate of seroma was 17%(5/29) in the study group and 10%(3/29) in the control group which showed no statistical significance (p-value = 0.71).Smoking and previous abdominal surgery turned out to be a risk factor for seroma formation in the study group.Overall satisfaction was evaluated with a questionnaire and was higher in the study group. CONCLUSION: The abdominal closure with the surgical adhesive seems to be a safe procedure that contributes to patient satisfaction and increases the independence upon discharge in patients with adequate inclusion criteria.

Preoperative Perforator Mapping in DIEP Flaps for Breast Reconstruction. The Impact of New Contrast-Enhanced Ultrasound Techniques.

Deep inferior epigastric artery flaps (DIEP) represent the gold standard of autologous breast reconstruction. Due to significant variations in vascular anatomy, preoperative perforator mapping (PM) is mandatory in order to ensure the presence of a sufficient perforator within the flap. In this regard, CT angiography (CTA) is currently the method of choice. Therefore, we investigated the value of contrast-enhanced ultrasound (CEUS) techniques for preoperative PM in comparison to CTA. Patients underwent PM, utilizing both CTA and CEUS techniques. Documentation included the course of the vascular pedicle through the rectus muscle (M), fascial penetration (F), the subcutaneous plexus (P) and the skin point (SP) on either side of the abdomen. Thus, contrast-enhanced B-Flow (BCEUS), B-Flow ultrasound (BUS), CEUS, color Doppler ultrasound (CDUS) and CTA were evaluated in terms of the diagnostic consistency and effectiveness of PM. Precision (∆L) was then calculated in relation to the actual intraoperative location. Statistical analysis included Kruskall-Wallis, Levene and Bonferroni tests, as well as Spearman correlations. A total of 39 DIEP flaps were analyzed. Only CTA (∆L = 2.85 mm) and BCEUS (∆L = 4.57 mm) enabled complete PM, also including P and SP, whereas CDUS, CEUS and BUS enabled clear PM throughout M and F only. Regarding the number of detected perforators, PM techniques are ranked from high to low as follows: CTA, BCEUS, BUS, CEUS and CDUS. CTA and BCEUS showed sufficient diagnostic consistency for SP, P and F, while CDUS and CTA had a superior performance for M. BCEUS offers precise image-controlled surface tags and dynamic information for PM without imposing radiation and may, therefore, be considered a feasible add-on or alternative to CTA. However, BCEUS requires an experienced examiner and is more time-consuming.

Phospholipase PlaB is a new virulence factor of Legionella pneumophila.

We previously identified Legionella pneumophila PlaB as the major cell-associated phospholipase A/lysophospholipase A with contact-dependent hemolytic activity. In this study, we further characterized this protein and found it to be involved in the virulence of L. pneumophila. PlaB was mainly expressed and active during exponential growth. Active PlaB was outer membrane-associated and at least in parts surface-exposed. Transport to the outer membrane was not dependent on the type I (T1SS), II (T2SS), IVB (T4BSS) or Tat secretion pathways. Furthermore, PlaB activity was not dependent on the presence of the macrophage infectivity potentiator (Mip) or the major secreted zinc metalloproteinase A (MspA). Despite the fact that PlaB is not essential for replication in protozoa or macrophage cell lines, we found that plaB mutants were impaired for replication in the lungs and dissemination to the spleen in the guinea pig infection model. Histological sections monitored less inflammation and destruction of the lung tissue after infection with the plaB mutants compared to L. pneumophila wild type. Taken together, PlaB is the first phospholipase A/lysophospholipase A with a confirmed role in the establishment of Legionnaires' disease.

The DIEP Flap as Well-established Method of Choice for Autologous Breast Reconstruction with a Low Complication Rate - Retrospective Single-centre 10-Year Experience.

Background Breast cancer is the most common cancer affecting women in Germany. Despite breast-conserving therapy (BCT) being carried out in almost 70% of cases, a high number of women still require complete mastectomy. Prophylactic mastectomy is also indicated for women with a BRCA 1/2 gene mutation. In addition to implant-based heterologous breast reconstruction, autologous breast reconstruction using a DIEP flap has been found to be beneficial, particularly for patients who had prior radiotherapy. This study aims to show that DIEP flap reconstruction surgery is the method of choice for autologous breast reconstruction with a low rate of complications. Patients and Methods Autologous breast reconstruction using a DIEP flap was performed in 1124 patients between July 2004 and December 2014. Retrospective study criteria included potential risk factors such as age, BMI, smoking, chemotherapy and/or radiotherapy, and comorbidities as well as outcome parameters such as postoperative complications. Outcomes were evaluated with a mean follow-up of 24 months. Results A total of 1124 patients underwent 1274 free DIEP flap breast reconstructions, of which 150 were bilateral reconstructions. The primary indication was previous mastectomy in 785 cases, followed by prior implant-based reconstruction in 265 cases. The total flap loss rate was 0.6%. Postoperative surgical revision for abdominal wall hernia was required in 0.2% of cases. The group with a higher BMI and the group of smokers had significantly higher complication rates. Elderly patients (> 65 years), patients who had undergone chemo-/radiotherapy and patients with diabetes did not have higher complication rates. Conclusion DIEP flap surgery is an excellent option for autologous breast reconstruction, with a low rate of donor site morbidity and low complication rates. DIEP flap surgery carried out in a specialised interdisciplinary breast centre in a standardised clinical setting after prior careful patient selection to take account of risk factors such as high BMI and smoking is a reliable method with a low complication rate and satisfactory long-term reconstruction results.

Increased risk of recurrence associated with certain risk factors in breast cancer patients after DIEP-flap reconstruction and lipofilling-a matched cohort study with 200 patients.

BACKGROUND: Lipofilling is performed in breast cancer patients to optimize the aesthetic outcome following breast reconstruction after mastectomy. Despite its common usage worldwide, little is known about the interaction of the lipoaspirate and dormant cancer cells. Up to date, no risk factors that increase the risk for cancer recurrence have been established. This study aims to identify risk factors for lipofilling candidates after breast cancer and questions the oncological safety of lipofilling in lymph node positive disease. METHODS: Matched retrospective cohort study: the disease-free survival (DFS) between 100 breast cancer patients undergoing a lipofilling after their DIEP-flap reconstruction and 100 matched control patients with no subsequent lipofilling was analyzed. Further, patients were subdivided according to risk factors, which were categorized as patient-dependent factors (PDFs) and tumor-dependent factors (TDFs). DFS and hazard ratios (HR) were compared to identify potential risk factors that may increase cancer recurrence. RESULTS: Median follow-up was 76.5 months from the mastectomy, and 31 months from the startpoint to the end of follow-up. Seven and eleven patients had recurrence in the lipofilling and control group, respectively, presenting with comparable DFS rates and an insignificant HR =0.57, 95% confidence interval (CI): 0.22-1.47, P=0.24. According to subgroup survival analysis, lipofilling increased the risk of recurrence in women with a positive nodal status (P=0.035) and a high-grade neoplasia (P=0.049). CONCLUSIONS: No general increased recurrence risk was observed between the lipofilling and control group. The subgroup analysis identified high-grade neoplasia and positive nodal status to be a risk factor for cancer recurrence. Patients with a known node positive disease have an increased risk of occult micrometastases in their lymph nodes. Further studies are necessary to clarify whether dormant breast cancer cells in form of micrometastases in the lymph nodes can be reactivated by the factors secreted by adipose derived stem cells.

Blends of canal surfaces from polyhedral medial transform representations.

We present a new method for constructing [Formula: see text] blending surfaces between an arbitrary number of canal surfaces. The topological relation of the canal surfaces is specified via a convex polyhedron and the design technique is based on a generalization of the medial surface transform. The resulting blend surface consists of trimmed envelopes of one- and two-parameter families of spheres. Blending the medial surface transform instead of the surface itself is shown to be a powerful and elegant approach for blend surface generation. The performance of our approach is demonstrated by several examples.

Modifying effects of the R389G beta1-adrenoceptor polymorphism on resting heart rate and blood pressure in patients with obstructive sleep apnoea.

OSA (obstructive sleep apnoea) stimulates sympathetic nervous activity and elevates resting HR (heart rate) and BP (blood pressure). In the present study in a cohort of 309 untreated OSA patients, the resting HR and BP during the daytime were correlated with AHI (apnoea/hypopnea index) and compared with patients with R389R (n = 162), R389G (n = 125) and G389G (n = 22) genotypes of the beta1-adrenoreceptor R389G polymorphism. We analysed the impact of the genotype on the decline of HR and BP in a subgroup of 148 patients (R389R, n = 86; R389G, n = 54; G389G, n = 8) during a 6-month follow-up period under CPAP (continuous positive airway pressure) therapy during which cardiovascular medication remained unchanged. In untreated OSA patients, we found an independent relationship between AHI and resting HR (beta = 0.096, P < 0.001), systolic BP (beta = 0.09, P = 0.021) and diastolic BP (beta = 0.059, P = 0.016). The resting HR/BP, however, did not differ among carriers with the R389R, R389G and G389G genotypes. CPAP therapy significantly reduced HR [-2.5 (-1.1 to -4.0) beats/min; values are mean difference (95% confidence intervals)] and diastolic BP [-3.2 (-1.5 to -5.0) mmHg]. The decline in HR was more significantly pronounced in the R389R group compared with the Gly(389) carriers [-4.1 (-2.3 to -5.9) beats/min (P < 0.001) compared with -0.2 (2.1 to -2.6) beats/min (P = 0.854) respectively; Student's t test between groups, P = 0.008]. Diastolic BP was decreased significantly (P < 0.001) only in Gly389 carriers (R389G or G389G) compared with R389R carriers [-5.0 (-2.3 to -7.6) mmHg compared with -2.0 (0.4 to -4.3) mmHg respectively]. ANOVA revealed a significant difference (P = 0.023) in HR reduction between the three genotypes [-4.1 (+/-8.4) beats/min for R389R, -0.5 (+/-9.3) beats/min for R389G and +1.9 (+/-7.2) beats/min for G389G]. In conclusion, although the R389G polymorphism of the beta1-adrenoceptor gene did not influence resting HR or BP in untreated OSA patients, it may modify the beneficial effects of CPAP therapy on these parameters.