[Clinical performance measurement in surgery and orthopedics -- new aspects in 2004]. / Externe Qualitätssicherung Chirurgie und Orthopädie -- Was ändert sich im Jahr 2004?

In 2004, principles and practice of clinical performance measurement (CPM) in German hospitals were changed according to new legislative and administrative regulations. In many respects, focus and methods of clinical performance measurement were improved in favour of hospitals. Starting from January 1, 2004, the new Gemeinsamer Bundesausschuss (Joint Federal Board) has competence for decisions on future focus and scope of CPM. Former agreements on implementation of CPM in 2004 will be effective as long as Gemeinsamer Bundesausschuss passes new resolutions. Methods to identify relevant cases for CPM particularly changed in 2004. Until end of 2003, obligations to report case data were based on special types of hospital reimbursement. In 2004, obligations for reporting no longer derive from financial criteria, but from medical criteria such as diagnoses and procedures. In 2003, reporting for CPM covered more than 30 subjects in medicine and nursing. For 2004, the scope of CPM has been reduced by 13 subjects which need to be reconsidered in order to secure unified quality goals for out-patients as well as in-patients and to allow long-term follow-up of outcome data. For their CPM expenditure, hospitals receive an additional fee of euro 0.58 per case reimbursed by DRG. Financial sanctions will be effective for hospitals with overall CPM reporting rates below 80 %. Starting from 2005, hospitals are obliged to publish CPM reporting rates for each CPM subject in annual hospital quality reports.

Initiation of strand incision at G:T and O(6)-methylguanine:T base mismatches in DNA by human cell extracts.

Extracts of the human glioma cell line A1235 (lacking O(6)-methylguanine-DNA methyltransferase) are known to restore a G:T mismatch to a normal G:C pair in a G:T-containing model (45 bp) DNA substrate. Herein we demonstrate that substitution of G:T with O(6)-methylguanine:T (m6G:T) results in extract-induced intra-strand incision in the DNA at an efficiency comparable to that of complete repair of the G:T-containing substrate, although the m6G:T mispair serves as a poor substrate for later repair steps (e.g. gap filling, as judged by defective DNA repair synthesis). The A1235 extract, when supplemented with ATP and the four normal dNTPs, incises 5' to the mismatched T, as inferred by the generation of a single-stranded 20mer fragment. Unlike its parental (A1235) counterpart, an extract of the alkylation-tolerant derivative cell line A1235-MR4 produces no 20mer fragment, even when thymine-DNA glycosylase (TDG) is added to the reaction mixture. In contrast, the A1235 extract, when augmented with TDG, catalyzes enhanced incision at m6G:T in the 45 bp DNA, yielding 5-10-fold greater 20mer than that of either extract or TDG alone. Interestingly, the absence of m6G:T incision activity in the A1235-MR4 extract is similar to that seen for extracts of several known mismatch repair-deficient cell lines of colon tumor origin. Together these results suggest that derivative A1235-MR4 cells are defective in m6G:T incision activity and that the efficiency of this activity in the parental (A1235) cells may depend on the presence of several ill-defined mismatch repair recognition proteins along with TDG and ATP.

Decreased host-cell reactivation of UV-irradiated adenovirus in human colon tumor cell lines that have normal post-UV survival.

An ongoing study in our laboratories is to examine the relationship of DNA repair defects to human cancer. Our underlying hypothesis has been that human tumors may arise that lack interesting DNA repair pathways if these pathways are important in preventing cancer. In this study, we found that the UV-irradiated adenoviruses showed hypersensitivity when assayed on monolayers of certain human colon tumor cell lines, including three that are reported to have defects in long patch DNA mismatch repair genes and one with no reported defect in mismatch repair. The survival curves showed two components. The first sensitive component was characteristic of 77-95% of the infections depending upon the cell line and the experiment and had an average slope indicating 4.8-fold hypersensitivity to UV. The average of the second-component slopes indicated that the remainder of the infections was accompanied by near-normal repair. Although the value of the first component indicated that the colon tumor lines supported the growth of UV-damaged adenoviruses poorly, the cell lines themselves showed the same post-UV colony-forming ability as did normal human fibroblasts, and their ability to support the growth of N-methyl-N'-nitro-N-nitrosoguanidine-damaged adenoviruses was normal, i.e. it parallelled their ability to repair O6-methylguanine in vitro. We previously observed two-component survival curves when assaying UV-irradiated adenovirus on monolayers of all of seven strains of fibroblasts from Cockayne's syndrome patients. By contrast, single-component curves have been obtained using 21 strains of normal human fibroblasts and seven other tumor lines. We interpret the two-component survival curves in terms of the defective transcription-coupled repair of UV-induced DNA damage that is characteristic both of Cockayne's and certain colon tumor cell lines. In addition, four mismatch repair-deficient colon tumor lines were resistant to killing by elevated levels of dG.

Ectopic expression of human and feline CD9 in a human B cell line confers beta 1 integrin-dependent motility on fibronectin and laminin substrates and enhanced tyrosine phosphorylation.

Few molecules have been shown to confer cell motility. Although the motility-arresting properties of anti-CD9 monoclonal antibody (mAb) suggest the transmembrane 4 superfamily (TM4SF) member CD9 can induce a motorgenic signal, gene transfection studies have failed to confirm this hypothesis. We report here that ectopic expression of human CD9 (CD9h) and feline CD9 (CD9f) in the CD9-negative, poorly motile, human B cell line Raji dramatically enhances migration across fibronectin- and laminin-coated polycarbonate filters. Migration of Raji/CD9h and Raji/CD9f on either substrate was inhibited by the anti-CD9 mAb 50H.19 and by the anti-beta 1 integrin mAb AP-138. Migration of Raji/CD9h on laminin was potently inhibited by the anti-VLA-6 integrin mAb GoH3 and by the anti-VLA-4 integrin mAb 44H6, whereas migration of Raji/CD9h on fibronectin was inhibited only by mAb 44H6. Since CD9h-transfected Raji cells adhered to fibronectin as effectively as mock transfectants, expression of CD9 enhanced motility, but not adhesion. CD9-enhanced migration was inhibited by the protein tyrosine kinase inhibitor herbimycin A suggesting that tyrosine phosphorylation played a role in the generation of a motorgenic signal. Raji/CD9h transfectants adherent to fibronectin expressed 6-fold higher levels of phosphotyrosine than Raji. Raji/CD9f transfectants also phosphorylated proteins on tyrosine more effectively than Raji including a protein of 110 kDa which was phosphorylated on the motility-inducing substrates laminin and fibronectin, but not on bovine serum albumin. Our results support a role for CD9 in the amplification of a motorgenic signal in B cells involving beta 1 integrins and the activation of protein tyrosine kinases.

Isolation of two cell lines from a human malignant glioma specimen differing in sensitivity to radiation and chemotherapeutic drugs.

Two aneuploid cell lines which differ in their inherent sensitivity to ionizing radiation and chemotherapeutic agents were established concurrently from a single tumor specimen obtained from a patient with glioblastoma. M059J cells are approximately 30-fold more sensitive to radiation than are M059K cells (surviving fractions at 2 Gy were 0.02 and 0.64, respectively). This relative difference in radiation sensitivity has remained a stable feature of the cell lines during 2 years in continuous culture. In addition, cells of the M059J line are more sensitive than those of the M059K line to the cytotoxic effects of bleomycin, N,N-bis(2-chloroethyl)-N-nitrosourea, and nitrogen mustard. These cell lines may prove to provide a useful model system for evaluating the cellular and molecular processes which confer resistance or sensitivity in cancer treatment.

Lack of expression of tumor-suppressor genes in human malignant glioma cell lines.

Human malignant gliomas (glioblastomas and anaplastic astrocytomas) are the most frequent brain tumors and are associated with a variety of genetic alterations including retinoblastoma (RB) and p53 gene mutations, loss of interferon alpha and beta (IFNA, IFNB) genes and lack of O6-methylguanine-DNA methyltransferase (MGMT) expression. Yet, in the studies performed to date, the relationship between these alterations has not been addressed. In this report, we have studied gene expression in 29 malignant glioma cell lines and have determined that, although loss of the interferon genes and loss of RB, p53 and MGMT mRNAs are frequent events, combinations of genetic alterations involving these four proven or putative tumor-suppressor genes are relatively infrequent. The exception was loss of RB mRNA, which may be associated with lack of MGMT mRNA.

Heterogeneity in response to treatment with buthionine sulfoximine or interferon in human malignant glioma cells.

Two tumor cell lines were established from each of three human malignant glioma biopsy specimens (M059, M067, M071) and sensitivity to treatment with radiation or chemotherapeutic agents (BCNU, nitrogen mustard) was determined. The effects of recombinant human interferon-alpha (rIFN) on the radiation response and of buthionine sulfoximine (BSO) on the drug response were investigated as well. For tumor M059, two cell lines that differed significantly in radiosensitivity were isolated (surviving fractions at 2 Gy = 0.02 and 0.64). The chemosensitivity and response to chemical modification differed as well. Cell lines established from tumor M071 differed in their response to rIFN only and were not sensitized by BSO. M067 cell lines showed little difference and were not sensitized by either agent. These results suggest that differences may exist both within and among human malignant gliomas with regard to their sensitivity to drugs, radiation, and the ability of chemical agents to modify treatment responses.

Effect of passaging on Mer phenotype of human fetal cell cultures.

With increasing passage in culture, the human fibroblast cell strain GM11 lost the Mer+ phenotype (the ability to support the growth of adenovirus 5 damaged prior to infection by MNNG). All of 46 embryonic strains prepared either from various organs of 20 fetuses from 6-7 to 13-14 weeks of gestational age or from two hydatidiform moles showed normal repair of MNNG-treated virus. We conclude that human fetal strains are not usually deficient in such repair, and that the behavior of GM11 is atypical.

[Do elevated blood and cerebrospinal fluid glucose levels and other factors modify the density of cerebrospinal fluid and the spread of isobaric spinal anesthesia?]. / Beeinflussen erhöhte Blut- und Liquorglukosekonzentrationen und andere Faktoren die Dichte des Liquor cerebrospinalis und die Ausbreitung der isobaren Spinalanaesthesie?

When isobaric spinal anesthesia is applied the level of analgesia is of special interest. This level is influenced by many factors of varying importance. One major factor is the relation between cerebrospinal fluid (CSF) density and the density of local anesthetic solutions. The density of CSF changes with the concentrations of its constituents, e.g., glucose or protein. Because glucose concentrations in CSF change in parallel with blood glucose levels, this may have effects on CSF density and the spread of spinal anesthesia. In 43 patients in two groups (diabetic n = 32, non-diabetic n = 11) the influence of CSF density on the analgesia level achieved with isobaric spinal anesthesia was investigated with special reference to increased glucose levels in blood and CSF. The influence of body height and weight, age and CSF protein content were also studied. There were no statistically significant correlations between any of these factors and the extension of analgesia. The mean blockade level was 1.6 segments lower in the non-diabetic group: this difference was statistically not significant (P greater than 0.05). Anesthesia spread faster in the diabetic group, but this difference was also not significant (P greater than 0.05). For bupivacaine 0.5% alone a density of 1.0010 g/cc was found, while for bupivacaine 0.5% with epinephrine (1:200,000) the density measured was 1.0022 g/cc. There is no correlation (r2 = 0.083) between CSF glucose concentration and CSF density, other factors such as sodium, chloride or CO2, apparently being more important. With CSF density ranging between 1.000 and 1.003 g/cc there was no correlation with the blockade level (r2 = 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Absence of IFNA and IFNB genes from human malignant glioma cell lines and lack of correlation with cellular sensitivity to interferons.

We report that 5 of 19 human malignant glioma cell lines have neither interferon alpha (IFNA) nor interferon beta (IFNB) genes that are detectable by Southern blotting. Of 5 other of these malignant glioma lines that have a single IFNB gene copy, 3 lack the IFNA genes entirely and two have one copy. One of the lines that lacks the IFNA genes entirely but has one copy of the IFNB gene has a rearrangement near the IFNB gene that is most easily interpreted as an insertion of a large segment of DNA (at least 50 kilobases) the 3' end of which is less than 1.3 kilobases 5' to the known regulatory sequences of the IFNB gene. In spite of the rearrangement, IFNB-specific RNA is highly inducible in this line by poly(I)-poly(C). The ability of interferon alpha or interferon beta to inhibit cell growth does not depend upon the presence or absence of the respective gene. This finding adds solid tumors to those tumor cell lines (acute lymphocytic leukemia, chronic myelogeneous leukemia) previously determined to lack the IFNA and IFNB genes (Diaz et al., Proc. Natl. Acad. Sci. USA, 85:5259-5263, 1988).

[Disoprivan (Propofol) sedation during regional anesthesia. A pilot study]. / Disoprivan (Propofol) zur Sedierung während der Regionalanaesthesie. Eine Pilotstudie.

In a preliminary pilot study, the effect of disoprivan for sedation during regional anesthesia was investigated. In 15 patients (ASA I or II), lumbar epidural anesthesia with bupivacaine 0.75% was performed at L 3/4. For premedication morphine or pethidine combined with scopolamine was given. After injection of the local anesthetic, a 30-min period was allowed for establishing the physiological side effects of epidural blockade, to present any further changes in circulatory and/or cardiac function. Disoprivan (1 mg/kg body weight) was injected i.v. followed by continuous disoprivan infusion. Three groups of 5 patients each were given 1, 1.5, or 2 mg/kg per hour disoprivan. Changes in heart rate, blood pressure, and respiratory rate were studied. Recovery time and personal assessment of sleep were registered. Side-effects of clinical relevance from the cardiovascular and pulmonary systems were also registered. A dose-dependent upper airway obstruction that could easily be managed by an oral or nasal airway was seen in 9 of 15 patients. Eight patients had postoperative nausea or vomiting; 9 complained of pain during the bolus injection that they could not remember postoperatively. All patients described their sleep as pleasant. Recovery time from sleep was between 1 and 12 min. All changes from normal values increased in percentage with increasing disoprivan dosage. Disoprivan (1 or 1.5 mg/kg per hour) seems to be excellent for sedation during regional anesthesia and is perhaps even superior to other available drugs.

The impact of AIDS on artificial insemination by donor.

Artificial insemination by donor (AID) provides a necessary service to a significant number of infertile couples. Its practice has been well controlled in Australia by careful donor screening and selection of suitable recipients. The potential for transmission of several infectious diseases has demanded a vigorous protocol for donor assessment and a strong movement away from the use of fresh semen. The description of human immunodeficiency virus (HIV) transmission by AID has increased the need for vigilance and has mandated, both by common sense and by Health Department Requirement (in Australia), the universal use of frozen donations. Antibody testing for HIV is not fail safe and must be supported by a carefully constructed lifestyle declaration form and a drive to recruit monogamous donors. The recruitment of sufficient donors has always been a problem and the advent of the HIV has not helped. Whilst transmission to laboratory staff appears to represent an extremely low risk, this possibility has required the development of safety protocols and appropriate staff training. This review outlines the current problems of running an AID programme given the knowledge that the HIV can be maintained in liquid nitrogen and transmitted atraumatically to a recipient.