Insight in Information Provision Prior to Obtaining Surgical Informed Consent-by Audiotaping Outpatient Consultations.

BACKGROUND: Literature suggests that patient-informing process prior to obtaining surgical informed consent (SIC) does not function well. This study aimed to provide insight into the current practice of SIC in the Netherlands. METHODS: This is a prospective, observational, and multicenter study, conducted in one academic and two non-academic teaching hospitals in the Netherlands. Audio recordings were made during outpatient consultations with patients presenting with Dupuytren Disease. The recorded informing process was scored according to a checklist. Written documentation of the SIC process in the patient's chart was compared to these scored checklists. Time spent on SIC during the consultations was also recorded. RESULTS: A total of 41 outpatient consultations were included in the study. Consultations were conducted by 25 plastic surgeons and their residents. Average time spent on SIC was 55.6% of the total consultation time. Considerable variation was observed concerning the amount and type of information given and discussed. In 59% of the consultations, discrepancies were observed between written documentation of consultations and audio recordings. Information on treatment risks, the postoperative period, and the operating surgeon was addressed the least. CONCLUSION: Despite a relatively large part of the consultation time being spent on SIC, patients received scarce information concerning treatment risks, postoperative period, and who their operating surgeon would be. Discrepancies were observed between the written documentation of SIC and information recorded on the audio recordings. This occurred predominantly in one hospital that used a pre-made list of 'discussed information' in its digital patient chart.

Distinct SagA from Hospital-Associated Clade A1 Enterococcus faecium Strains Contributes to Biofilm Formation.

Enterococcus faecium is an important nosocomial pathogen causing biofilm-mediated infections. Elucidation of E. faecium biofilm pathogenesis is pivotal for the development of new strategies to treat these infections. In several bacteria, extracellular DNA (eDNA) and proteins act as matrix components contributing to biofilm development. In this study, we investigated biofilm formation capacity and the roles of eDNA and secreted proteins for 83 E. faecium strains with different phylogenetic origins that clustered in clade A1 and clade B. Although there was no significant difference in biofilm formation between E. faecium strains from these two clades, the addition of DNase I or proteinase K to biofilms demonstrated that eDNA is essential for biofilm formation in most E. faecium strains, whereas proteolysis impacted primarily biofilms of E. faecium clade A1 strains. Secreted antigen A (SagA) was the most abundant protein in biofilms from E. faecium clade A1 and B strains, although its localization differed between the two groups. sagA was present in all sequenced E. faecium strains, with a consistent difference in the repeat region between the clades, which correlated with the susceptibility of biofilms to proteinase K. This indicates an association between the SagA variable repeat profile and the localization and contribution of SagA in E. faecium biofilms.

Clinical implementation of a fully automated quantitative perfusion cardiovascular magnetic resonance imaging workflow with a simplified dual-bolus contrast administration scheme.

This study clinically implemented a ready-to-use quantitative perfusion (QP) cardiovascular magnetic resonance (QP CMR) workflow, encompassing a simplified dual-bolus gadolinium-based contrast agent (GBCA) administration scheme and fully automated QP image post-processing. Twenty-five patients with suspected obstructive coronary artery disease (CAD) underwent both adenosine stress perfusion CMR and an invasive coronary angiography or coronary computed tomography angiography. The dual-bolus protocol consisted of a pre-bolus (0.0075 mmol/kg GBCA at 0.5 mmol/ml concentration + 20 ml saline) and a main bolus (0.075 mmol/kg GBCA at 0.5 mmol/ml concentration + 20 ml saline) at an infusion rate of 3 ml/s. The arterial input function curves showed excellent quality. Stress MBF ≤ 1.84 ml/g/min accurately detected obstructive CAD (area under the curve 0.79; 95% Confidence Interval: 0.66 to 0.89). Combined visual assessment of color pixel QP maps and conventional perfusion images yielded a diagnostic accuracy of 84%, sensitivity of 70% and specificity of 93%. The proposed easy-to-use dual-bolus QP CMR workflow provides good image quality and holds promise for high accuracy in diagnosis of obstructive CAD. Implementation of this approach has the potential to serve as an alternative to current methods thus increasing the accessibility to offer high-quality QP CMR imaging by a wide range of CMR laboratories.

Impact of sex on the assessment of the microvascular resistance reserve.

BACKGROUND: The microvascular resistance reserve (MRR) is an innovative index to assess the vasodilatory capacity of the coronary circulation while accounting for the presence of concomitant epicardial disease. The MRR has shown to be a valuable diagnostic and prognostic tool in the general coronary artery disease (CAD) population. However, considering the fundamental aspects of its assessment and the unique hemodynamic characteristics of women, it is crucial to provide additional considerations for evaluating the MRR specifically in women. AIM: The aim of this study was to assess the diagnostic and prognostic applicability of the MRR in women and assess the potential differences across different sexes. METHODS: From the ILIAS Registry, we enrolled all patients with a stable indication for invasive coronary angiography, ensuring complete physiological and follow-up data. We analyzed the diagnostic value by comparing differences between sexes and evaluated the prognostic value of the MRR specifically in women, comparing it to that in men. RESULTS: A total of 1494 patients were included of which 26% were women. The correlation between MRR and CFR was good and similar between women (r = 0.80, p < 0.005) and men (r = 0.81, p < 0.005). The MRR was an independent and important predictor of MACE in both women (HR 0.67, 0.47-0.96, p = 0.027) and men (HR 0.84, 0.74-0.95, p = 0.007). The optimal cut-off value for MRR in women was 2.8 and 3.2 in men. An abnormal MRR similarly predicted MACE at 5-year follow-up in both women and men. CONCLUSION: The MRR seems to be equally applicable in both women and men with stable coronary artery disease.

Evaluation of MeningoFinder, a novel multiplex ligation-dependent probe amplification assay for simultaneous detection of six virus species causing central nervous system infections.

A multiplex ligation-dependent probe amplification assay for simultaneous detection of six virus species was developed and tested on clinical cerebrospinal fluid (CSF) samples. The assay, termed MeningoFinder, showed an accordance of 97%, concordance of 96%, interlaboratory sensitivity of 90%, and interlaboratory specificity of 94% compared to PCRs.

Chemokines and chemokine receptors encoded by cytomegaloviruses.

CMVs carry several genes that are homologous to genes of the host organism. These include genes homologous to those encoding chemokines (CKs) and G protein-coupled receptors (GPCRs). It is generally assumed that these CMV genes were hijacked from the host genome during the long co-evolution of virus and host. In light of the important function of the CK and GPCR families in the normal physiology of the host, it has previously been hypothesized that the CMV homologs of these proteins, CMV vCKs and vGPCRs, may also have a significant impact on this physiology, such that lifelong maintenance and/or replication of the virus within the infected host is guaranteed. In addition, several of these homologs were reported to have a major impact in the pathogenesis of infection. In this review, the current state of knowledge on the CMV vCKs and vGPCRs will be discussed.

Comparative expression analysis of isolated human adipocytes and the human adipose cell lines LiSa-2 and PAZ6.

OBJECTIVE: To obtain insight in the extent to which the human cell lines LiSa-2 and PAZ6 resemble isolated primary human adipocytes. DESIGN: A combination of cDNA subtraction (representative difference analysis; RDA) and cDNA microarray analysis was used to select adipose specific genes to compare isolated (pre-)adipocytes with (un)differentiated LiSa-2 and PAZ6 cells. MEASUREMENTS: RDA was performed on adipose tissue against lung tissue. A total of 1400 isolated genes were sequenced and cDNA microarray technology was used for further adipose related gene selection. 30 genes that were found to be enriched in adipose tissue were used to compare isolated human adipocytes and LiSa-2 and PAZ6 cells in the differentiated and undifferentiated states. RESULTS: RDA and microarray analysis resulted in the identification of adipose enriched genes, but not in adipose specific genes. Of the 30 most differentially expressed genes, as expected, most were related to lipid metabolism. The second category consisted of methyltransferases, DNMT1, DNMT3a, RNMT and SHMT2, of which the expression was differentiation dependent and higher in differentiated adipocytes. Using the 30 adipose expressed genes, it was found that isolated adipocytes on one hand, and PAZ6 and LiSa-2 adipocytes on the other, differ primarily in lipid metabolism. Furthermore, LiSa-2 cells seem to be more similar to isolated adipocytes than PAZ6 cells. CONCLUSION: The LiSa-2 cell line is a good model for differentiated adipocytes, although one should keep in mind that the lipid metabolism in these cells deviates from the in vivo situation Furthermore, our results imply that methylation may have an important function in terminal adipocyte differentiation.

The human immunodeficiency virus integrase protein.

The DNA integration step in the replication cycle of the human immunodeficiency virus (HIV) has been recognized as an important target in antiviral strategies. There are two main reasons for this. First, integration of HIV DNA into the human genome is required for replication of this retrovirus. Second, since the integration reaction does not have an obvious cellular counterpart, drugs that specifically inhibit integration may not be toxic for the cell. Here, we focus on the only protein known to be required for retroviral integration, the integrase (IN) protein.

A viral conspiracy: hijacking the chemokine system through virally encoded pirated chemokine receptors.

Several herpesviruses and poxviruses contain genes encoding for G protein-coupled receptor (GPCR) proteins that are expressed on the surface of infected host cells and/or the viral envelope. Most of these membrane-associated proteins display highest homology to the subfamily of chemokine receptors known to play a key role in the immune system. Virally encoded chemokine receptors have been modified through evolutionary selection both in chemokine binding profile and signaling capacity, ultimately resulting in immune evasion and cellular reprogramming in favor of viral survival and replication. Insight in the role of virally encoded GPCRs during the viral lifecycle may reveal their potential as future drug targets.

The molecular evolution of methicillin-resistant Staphylococcus aureus.

Staphylococcus aureus is a potentially pathogenic bacterium that causes a broad spectrum of diseases. S. aureus can adapt rapidly to the selective pressure of antibiotics, and this has resulted in the emergence and spread of methicillin-resistant S. aureus (MRSA). Resistance to methicillin and other beta-lactam antibiotics is caused by the mecA gene, which is situated on a mobile genetic element, the Staphylococcal Cassette Chromosome mec (SCCmec). To date, five SCCmec types (I-V) have been distinguished, and several variants of these SCCmec types have been described. All SCCmec elements carry genes for resistance to beta-lactam antibiotics, as well as genes for the regulation of expression of mecA. Additionally, SCCmec types II and III carry non-beta-lactam antibiotic resistance genes on integrated plasmids and a transposon. The epidemiology of MRSA has been investigated by pulsed-field gel electrophoresis (PFGE), multilocus sequence typing (MLST), spa typing and SCCmec typing. Numerous MRSA clones have emerged and disseminated worldwide. SCCmec has been acquired on at least 20 occasions by different lineages of methicillin-sensitive S. aureus. Although most MRSA strains are hospital-acquired (HA-MRSA), community-acquired MRSA (CA-MRSA) strains have now been recognised. CA-MRSA is both phenotypically and genotypically different from HA-MRSA. CA-MRSA harbours SCCmec types IV or V, and is associated with the genes encoding Panton-Valentine leukocidin. The prevalence of MRSA ranges from 0.6% in The Netherlands to 66.8% in Japan. This review describes the latest developments in knowledge concerning the structure of SCCmec, the molecular evolution of MRSA, the methods used to investigate the epidemiology of MRSA, and the risk-factors associated with CA-MRSA and HA-MRSA.

[Menstruation disorders more frequent in women with a history of sexual abuse]. / Meer menstruatieklachten bij vrouwen met seksueel misbruik in de anamnese.

OBJECTIVE: To determine the relationship between menstruation disorders and prior sexual abuse. DESIGN: Questionnaire investigation. METHOD: A questionnaire was developed consisting of 50 questions about menstruation disorders, premenstrual syndrome and sexual abuse. The questionnaire was mailed to all female patients aged 12-54 years (n = 1805) of one family practice in Den Helder, the Netherlands. RESULTS: The response rate to the questionnaire was 69% (n = 1254). After excluding women who were postmenopausal, pregnant, without a uterus, or who did not answer the questions on sexual abuse, 947 remained. Of these women, 83 (8.7%) reported having experienced sexual abuse. These women had significantly more dysmenorrhoea, more dysfunctional menstrual bleeding and significantly more menstrual cycle irregularities. CONCLUSION: A statistically significant association was found between menstrual problems and prior sexual abuse. Sexual abuse should be considered in the differential diagnosis and treatment of women who seek medical help for inexplicable menstrual disorders.

International Mycoplasma pneumoniae typing study: interpretation of M. pneumoniae multilocus variable-number tandem-repeat analysis.

Typing of Mycoplasma pneumoniae by multiple-locus variable-number tandem repeat analysis (MLVA) is increasingly in use. However, no specific internationally agreed guidance is available. Thirty M. pneumoniae DNA samples including serial dilutions of a type strain were sent to six international laboratories to perform MLVA and results were compared. Good correlation was observed, indicating that this methodology can be robustly performed in multiple sites. However, differences due to interpretation of fragment size, repeat sequence identification and repeat numbering led to inconsistency in the final profiles assigned by laboratories. We propose guidelines for interpreting M. pneumoniae MLVA typing and assigning the number of repeats.

Virally encoded G protein-coupled receptors: targets for potentially innovative anti-viral drug development.

Various herpes- and poxviruses contain DNA sequences encoding proteins with homology to cellular chemokine receptors, which belong to the family of G protein-coupled receptors (GPCRs). Since GPCRs play a crucial role in cellular communication and chemokine receptors play a prominent role in the immune system, the virally encoded GPCRs may be crucial determinants of viral action. The Kaposi's sarcoma-associated herpesvirus (KSHV, or human herpesvirus 8), implicated in the pathogenesis of Kaposi's sarcoma (KS), a highly vascularized tumor, encodes a GPCR, referred to as ORF74. This virally encoded receptor was found to induce tumorigenesis and transgenic expression of ORF74 induces an angioproliferative disease resembling KS. Cytomegalovirus (CMV), suggested to play a role in atherosclerosis, encodes four GPCRs, among which US28. This virally encoded GPCR is able to induce migration of smooth muscle cells, a feature essential for the development of atherosclerosis. Remarkably, the KSHV and some CMV-encoded GPCRs display constitutive activity, while their cellular homologs do not. It remains to be determined whether this phenomenon contributes to the pathogenesis of viral action. Also, the family of poxviruses encodes GPCRs of which the function is not clear yet. In this review we will give an overview of the different virally encoded GPCRs, and discuss their putative role in viral action and potential as drug target.

Rat cytomegalovirus R89 is a highly conserved gene which expresses a spliced transcript.

In all sequenced herpesvirus genomes, a homolog of the herpes simplex virus type 1 UL15 gene has been identified. This gene encodes a protein that is involved in viral genome maturation. Although transcription of the alphaherpesvirus UL15 gene has been analyzed in detail, not much is known about the expression of its betaherpesvirus homologs. We therefore set out to characterize transcription of the rat cytomegalovirus counterpart of UL15, R89. Here we report that R89 consists of two exons separated by a 4.7-kb intron. The spliced R89 transcript, which is expressed at late times postinfection (p.i.), has the capacity to encode a protein of 670 amino acids with a calculated molecular mass of 77.1 kDa. The predicted amino acid sequence of this protein is highly similar to that of the proteins predicted to be encoded by the human cytomegalovirus UL89 and murine cytomegalovirus M89 genes (64.3 and 84.5% overall identity, respectively). The region between R89 exon 1 and exon 2 was found to contain five additional genes, r90, R91, R92, R93 and R94, the latter two of which are conserved among all herpesviruses. We show that these genes are transcribed in a highly complex fashion, resulting in numerous mono- and polycistronic mRNAs.

The role of cytomegalovirus-encoded homologs of G protein-coupled receptors and chemokines in manipulation of and evasion from the immune system.

Cytomegaloviruses (CMVs) have the ability to persist lifelong within the infected host. This ability implies that these viruses are highly adapted to their hosts. Most importantly, they will have to employ strategies to remain hidden from the host's immune system. Virus genes predicted to be involved in these strategies include genes encoding homologs of cellular immune effector or regulatory proteins, such as chemokine (CK) receptor-like G protein-coupled receptors (GPCRs), CKs and MHC class I molecules. These genes may have been pirated by the virus during the long co-evolution of pathogen and host. In light of the crucial roles that GPCRs, CKs and MHC class I molecules play in the normal physiology of the host, it is to be expected that the CMV homologs of these proteins may have a profound impact on this physiology and, at the same time, serve vital functions in maintenance as well as replication of the virus within the infected host. As a consequence, these viral homologs can be envisaged as attractive targets for novel anti-viral strategies. The aim of this report is to present an overview of the current state of knowledge on the (putative) functions of the CMV homologs of GPCRs and CKs.

Different profiles of cytomegalovirus RNA transcripts and anti-cytomegalovirus IgM antibodies in renal transplant recipients.

BACKGROUND: A difference in anti-cytomegalovirus IgM antibody profile has been found between sera from acutely cytomegalovirus (CMV)-infected patients and sera from CMV-infected patients with subclinical infection. OBJECTIVES: The aim of this study is to investigate whether such different IgM antibody responses are correlated with differences in the expression of CMV immediate early and late mRNAs. STUDY DESIGN: We have investigated the anti-CMV IgM response in 46 renal transplant recipients by employing two commercially available IgM kits (AxSYM and IMX) as well as two novel enzyme-linked immunosorbent assays (ELISAs), which were developed using recombinant ppUL32 (pp150) and pUL80a (p38), respectively. The results were compared with four direct CMV diagnostic tests: pp65 antigenemia, viral culture and nucleic acid sequence-based amplification (NASBA), detecting either CMV immediate early 1 (IE1) mRNA (IE1-NASBA), or CMV pp67 (late) mRNA (pp67-NASBA). RESULTS: Analysis of all CMV-infected recipients (n=28) showed that in 16 recipients (group I) more than one direct test became positive after transplantation, while in the other 12 recipients (group II), IE1-NASBA was the only direct test to become positive. In group I, 100, 81, 100 and 50% of the recipients were IgM-positive with AxSYM, IMX, p38 and pp150, respectively. In group II, 100, 83, 17 and 83% of the recipients were IgM-positive with AxSYM, IMX, p38 and pp150, respectively. CONCLUSIONS: Our data indicate that the IgM-response against p38 and pp150 differs significantly (P<0.01) between group I recipients with productive CMV infection, and group II recipients with a non-productive CMV infection which may be of diagnostic and prognostic relevance.

The influence of viscosity on dilution methods. Its problems in the determination of serum sodium.

Dilution with a roller-pump is a well known procedure in clinical chemistry. This method may be influenced by viscosity. A higher viscosity of the sample yields a lower sample output and consequently a larger dilution. If the substance to be determined in the diluted sample can be measured accurately, the influence of viscosity may be analysed easily. This was performed for serum sodium. It was shown that with extreme pathological viscosities (as are found e.g. in multiple myeloma and Waldenström's macroglobinemia) underestimations of more than 15% may occur. Especially for serum sodium, the physiological range of which is fairly small, this may provoke serious diagnostic and therapeutic problems. We propose to use viscosity independent dilution systems.

Gelatin derivatives in blood: interference with the determination of inorganic phosphate in serum.

The method of Goldenberg and Fernandez (1966) Clin. Chem. 12, 871--882) for the determination of inorganic phosphate in serum is significantly influenced by turbidity after intravenous application of gelatin derivatives, even at low quantities. This turbidity can be eliminated by the addition of sodium dodecyl sulphate to the reaction solution.

On standardizing the determination of the plasma renin activity.

Basically, the determination of the plasma renin activity (PRA) consists of the in vitro generation of angiotensin I and the radioimmunological determination of angiotensin I. Since both steps can be performed in several ways, the results from different laboratories can hardly be compared. In this paper we have described the results of our attempts to standardize both steps of the PRA determination currently in use in our laboratory, against Research Standard A for Angiotensin I and the International Reference Preparation of Human Renin, both obtained from the Medical Research Council.

Influence of ions on the antigen-antibody complex formation as measured by radioimmunoassay.

In this study, using radioimmunoassay techniques, we found that ions at concentrations in the order of 0.1 molar influence the antigen-antibody complex formation. The angiotensin I/anti-angiotensin I reaction was studied in detail. Particularly bivalent cations and anions with a strong chaotropic effect (SCN-, I- and ClO4-) were found to influence strongly the specific immunological reaction. However, NO3- had also a remarkably strong influence. We found that the equilibrium constant, rather than the number of binding sites of the antibody, is influenced by the ions. It should be borne in mind that relatively high concentrations of electrolyte (as compared with the concentrations of antigen and antibody) show this effect. Consequently, this effect is of less practical importance for routine radioimmunoassay than is, for example, the effect of pH. However, this phenomenon shows that the radioimmunoassay technique might be valuable not only for quantization of very low hormone concentrations in biological fluids, but has also important potential applications in physical and protein chemistry. Particularly, the high sensitivity of this technique and the possibility of studying a homogeneous reaction system might give it advantages over other techniques.