[Metabolic syndrome: diagnosis and dietary intervention]. / Metabolisches Syndrom Diagnose und Ernährungstherapie.

The metabolic syndrome is diagnosed according to criteria set by either WHO (obesity, high blood pressure, dyslipidemia, insulin resistance) or more recently by ATP III (National Cholesterol Education Program's Adult Treatment Panel III report). The latter emphasizes abdominal obesity, atherogenic dyslipidemia, high blood pressure and increased fasting glucose. Without presuming a nosologic entity, the metabolic syndrome is emerging as by far the most important precursor of an epidemic of cardiovascular disease, not only in Western countries. This epidemic calls for action at a time when our understanding of dietary intervention for maintaining weight loss remains primitive and cannot withstand critical scrutiny (because of a lack of long term randomised, prospective studies). Dietary therapy in metabolic syndrome therefore has to be aimed where success is most likely, i.e. at a reduction in energy intake and increase in output by physical activity, a prudent balance of carbohydrates, proteins and fats, taking into account secondary changes in lipid profiles and the glycemic load of nutrients. All nutritional advice must be incorporated in long term programs with continuous guidance, preferably in group therapy targeting all individual risk factors.

[Identification of wrong or inadequate nutrition of elderly patients in an acute-admissions hospital]. / Erfassung von Fehl- und Mangelernährung kranker Senioren in Akutkliniken.

BACKGROUND AND OBJECTIVE: Wrong or inadequate nutrition can lead to an increased morbidity and mortality as well as a raised perioperative rate of complications. Endangered patients should be identified quickly, reliably and cost-effectively on admission. This study aimed at developing a 3-step assessment, using a previously evaluated questionnaire. PATIENTS AND METHODS: Between February and July 2001, the nutritional state was prospectively obtained, in the first three days after admission, by questionnaire (based on a questionnaire developed at the Bethanien Hospital, Heidelberg) and objective measurements of 408 hospitalized patients aged over 70 years (139 men, 269 women, average age 82.2 years). Body mass index (BMI) was calculated for each patient and in those in whom it was over 25, concentrations of albumin, calcium, vitamin D and lymphocyte count as well as triceps skin fold thickness were also obtained. RESULTS: 22 of the 408 patients (5.4%) had a BMI of < or = 18.5 (step 1). 191 patients (46.8%) answered affirmatively four or more of the questions, placing them in the group of "in danger of malnutrition". The "objective" parameters were present in all patients wih a BMI < 25. Abnormal levels were found only in patients who had already been identified through their questionnaire (four or more positive answers). 310 answered positively to question 8 and 11 (step 2). When additionally answers to questions 1, 2, 6, 7 and 10 were included (at least four additional positive answers in the Bethanian questionnaire, step 3) 175 patients in danger of malnutrition (91.6%) were identified. CONCLUSION: The 3-step assessment (BMI and questions answered positively) correctly identified 90% of elderly patients in danger of malnutrition. This assessment thus ensured effective provision of nutritional care in an acute-admissions hospital.

[Malnutrition in elderly patients of an acute care clinic]. / Mangelernährung kranker Senioren in der Akutklinik.

Malnutrition is associated with a higher complication rate, a higher morbidity and mortality. In-hospital patients consume up to 75% fewer calories than they would need, according to studies in international literature. For German general hospitals data are not yet available on this topic, especially for elderly people. Here we publish a prospective study of 166 persons, aged at least 70 years. According to international data in German general hospitals, elderly people consume only 50% of calories they need. There is evidence that malnutrition causes longer hospital stays, which not only adversely affects the patients themselves but also involves a considerable cost factor.

The Brucella suis homologue of the Agrobacterium tumefaciens chromosomal virulence operon chvE is essential for sugar utilization but not for survival in macrophages.

Brucella strains possess an operon encoding type IV secretion machinery very similar to that coded by the Agrobacterium tumefaciens virB operon. Here we describe cloning of the Brucella suis homologue of the chvE-gguA-gguB operon of A. tumefaciens and characterize the sugar binding protein ChvE (78% identity), which in A. tumefaciens is involved in virulence gene expression. B. suis chvE is upstream of the putative sugar transporter-encoding genes gguA and gguB, also present in A. tumefaciens, but not adjacent to that of a LysR-type transcription regulator. Although results of Southern hybridization experiments suggested that the gene is present in all Brucella strains, the ChvE protein was detected only in B. suis and Brucella canis with A. tumefaciens ChvE-specific antisera, suggesting that chvE genes are differently expressed in different Brucella species. Analysis of cell growth of B. suis and of its chvE or gguA mutants in different media revealed that ChvE exhibited a sugar specificity similar to that of its A. tumefaciens homologue and that both ChvE and GguA were necessary for utilization of these sugars. Murine or human macrophage infections with B. suis chvE and gguA mutants resulted in multiplication similar to that of the wild-type strain, suggesting that virB expression was unaffected. These data indicate that the ChvE and GguA homologous proteins of B. suis are essential for the utilization of certain sugars but are not necessary for survival and replication inside macrophages.

Biomonitoring of pJP4-carrying Pseudomonas chlororaphis with Trb protein-specific antisera.

The transfer of catabolic genes on conjugative plasmids to indigenous organisms from which they may spread further into the community allows the introduction of new biodegradative pathways for metabolic conversion of pollutants to the community. Biomonitoring of IncP plasmid pJP4-carrying Pseudomonas chlororaphis from the rhizosphere of Arabidopsis thaliana was achieved using antisera specific for proteins from the plasmid transfer machinery. Antisera were generated that recognized TrbC and TrbF, the putative major and minor components of pJP4-determined pili, respectively, and the putative lipoprotein TrbH. Cell fractionation studies showed association of TrbC, TrbF and TrbH with the cells and suggested that TrbC and TrbF are part of extracellular pJP4-determined pili. TrbF and TrbH antisera allowed specific detection of IncP compared with IncN or IncW plasmid-carrying cells and even permitted differentiation between bacteria carrying IncPalpha plasmid RP4 and IncPbeta plasmid pJP4. Immunofluorescence microscopy was applied to detect TrbF and TrbH signal at the cell periphery, allowing distinction from autofluorescing cells and soil debris. In situ experiments showed specific recognition of pJP4-carrying cells from laboratory cultures, as well as from the rhizosphere of A. thaliana grown in natural soil. After co-inoculation of donor P. chlororaphis pJP4 and recipient Ralstonia eutropha, a combination of immunofluorescence and oligonucleotide hybridization techniques permitted the detection of plasmid transfer between both organisms in the A. thaliana rhizosphere. This strategy may be generally applicable for the analysis of plasmid transfer in natural ecosystems.

Vir proteins stabilize VirB5 and mediate its association with the T pilus of Agrobacterium tumefaciens.

Three VirB proteins (VirB1*, VirB2, and VirB5) have been implicated as putative components of the T pilus from Agrobacterium tumefaciens, which likely mediates binding to plant cells followed by transfer of genetic material. Recently, VirB2 was indeed shown to be its major component (E.-M. Lai and C. I. Kado, J. Bacteriol. 180:2711-2717, 1998). Here, the influence of other Vir proteins on the stability and cellular localization of VirB1*, VirB2, and VirB5 was analyzed. Solubility of VirB1* and membrane association of VirB2 proved to be inherent features of these proteins, independent of virulence gene induction. In contrast, cellular levels of VirB5 were strongly reduced in the absence of other Vir proteins, indicating its stabilization by protein-protein interactions. The assembly and composition of the T pilus were analyzed in nopaline strain C58(pTiC58), its flagellum-free derivative NT1REB(pJK270), and octopine strain A348(pTiA6) following optimized virulence gene induction on solid agar medium. In all strains VirB2 was the major pilus component and VirB5 cofractionated during several purification steps, such as ultracentrifugation, gel filtration, and sucrose gradient centrifugation. VirB5 may therefore be directly involved in pilus assembly, possibly as minor component. In contrast, secreted VirB1* showed no association with the T pilus. In-frame deletions in genes virB1, virB2, virB5, and virB6 blocked the formation of virulence gene-dependent extracellular high-molecular-weight structures. Thus, an intact VirB machinery as well as VirB2 and VirB5 are required for T-pilus formation.

TraC of IncN plasmid pKM101 associates with membranes and extracellular high-molecular-weight structures in Escherichia coli.

Conjugative transfer of IncN plasmid pKM101 is mediated by the TraI-TraII region-encoded transfer machinery components. Similar to the case for the related Agrobacterium tumefaciens T-complex transfer apparatus, this machinery is needed for assembly of pili to initiate cell-to-cell contact preceding DNA transfer. Biochemical and cell biological experiments presented here show extracellular localization of TraC, as suggested by extracellular complementation of TraC-deficient bacteria by helper cells expressing a functional plasmid transfer machinery (S. C. Winans, and G. C. Walker, J. Bacteriol. 161:402-410, 1985). Overexpression of TraC and its export in large amounts into the periplasm of Escherichia coli allowed purification by periplasmic extraction, ammonium sulfate precipitation, and column chromatography. Whereas TraC was soluble in overexpressing strains, it partly associated with the membranes in pKM101-carrying cells, possibly due to protein-protein interactions with other components of the TraI-TraII region-encoded transfer machinery. Membrane association of TraC was reduced in strains carrying pKM101 derivatives with transposon insertions in genes coding for other essential components of the transfer machinery, traM, traB, traD, and traE but not eex, coding for an entry exclusion protein not required for DNA transfer. Cross-linking identified protein-protein interactions of TraC in E. coli carrying pKM101 but not derivatives with transposon insertions in essential tra genes. Interactions with membrane-bound Tra proteins may incorporate TraC into a surface structure, suggested by its removal from the cell by shearing as part of a high-molecular-weight complex. Heterologous expression of TraC in A. tumefaciens partly compensated for the pilus assembly defect in strains deficient for its homolog VirB5, which further supported its role in assembly of conjugative pili. In addition to its association with high-molecular-weight structures, TraC was secreted into the extracellular milieu. Conjugation experiments showed that secreted TraC does not compensate transfer deficiency of TraC-deficient cells, suggesting that extracellular complementation may rely on cell-to-cell transfer of TraC only as part of a bona fide transfer apparatus.

[Myocardial involvement in carrier states for Duchenne muscular dystrophy. A rare cause of supraventricular arrhythmia]. / Myokardbeteiligung bei Uberträgerstatus für die Muskeldystrophie Typ Duchenne. Eine seltene Ursache für supraventrikuläre Rhythmusstörungen.

HISTORY AND CLINICAL FINDINGS: Two women, both aged 54 years, were admitted because of supraventricular arrhythmias of recent onset. Patient 2 was also in heart failure. Male family members of both patients were known to have Duchenne's muscular dystrophy, of which one had died. INVESTIGATIONS: The electrocardiogram of patient 1 demonstrated atrial fibrillation. Patient 2 had a raised serum creatine kinase concentration and increased pulmonary marking in the chest radiogram. Patient 1 had normal findings on left heart catheterization, but immunohistochemical analysis of a myocardial biopsy revealed dystrophin mosaic with 20% dystrophin-negative fibres. Patient 2 had a reduced ejection fraction and 80% dystrophin-negative fibres. DIAGNOSIS, TREATMENT AND COURSE: Myocardial involvement in the carrier state for Duchenne's muscular dystrophy having been demonstrated in both women, patient 1 received antihypertensive treatment while patient 2, who was in cardiac failure, was given diuretics, ACE-inhibitor and beta-receptor blockers. CONCLUSION: Cardiomyopathy in carriers of Duchenne's muscular dystrophy is a rare cause of supraventricular arrhythmias. The cause can be confirmed by immunochemical analysis of an endomyocardial biopsy.

Three cases of malignant neoplasm, pneumonitis, and pancytopenia during treatment with low-dose methotrexate.

A 77-year-old man with chronic obstructive pulmonary disease was treated with low-dose methotrexate (7.5-15 mg per week). After 15 months a diagnosis of urothelial carcinoma of the bladder was made; after a further 6 months pneumonitis and pancytopenia developed. The patient died due to massive pulmonary hemorrhage. A malignant teratoma was diagnosed in a 65-year-old asthmatic man 16 months after initiation of methotrexate therapy (15 mg per week). The patient died 4 months later due to fulminant progression of the neoplasm. A third malignant neoplasm (dermal squamous cell carcinoma) was seen in a 64-year-old woman with rheumatoid arthritis after 13 months treatment with 7.5 mg methotrexate per week. These three cases, while obviously not proving a causal relationship between long-term treatment with low-dose methotrexate and development of malignant neoplasm, do call for stringent treatment criteria, close surveillance, and prospective studies.

Media hypertrophy in hypertensive coronary resistance vessels.

Coronary reserve is reduced in human hypertensive hypertrophy and in the model of spontaneously hypertensive rats (SHRs). In isolated coronary resistance vessels, the role of structural and functional changes was evaluated. Furthermore, the effect of long-term antihypertensive therapy was also studied. At the age of 20 weeks, SHR and Wistar-Kyoto (WKY) rats were examined. Distal segments of the left anterior descending coronary artery were dissected and mounted on a myograph developed by Mulvany and Halpern. After recording of radius-wall tension curves, the vessels were set up to a wall tension equal to two-thirds of the systolic blood pressure. In SHRs, the vessel diameters were reduced. After equilibration with Ringer's solution, vessel dilatation was decreased in calcium-free solution (10 +/- 3 vs. 34 +/- 7%, p less than 0.05), but contraction increased after 123 mM of potassium stimulation (78 +/- 19 vs. 33 +/- 9%). There was no difference in calcium sensitivity during methoxamine or potassium activation. In the coronary resistance vessels of SHRs, electron microscopy revealed media hypertrophy (15.6 +/- 2.9 vs. 9.5 +/- 2.1 microns, p less than 0.05) and media hyperplasia (4.5 +/- 3 vs. 3.7 +/- 6 muscle layers, p less than 0.05). Media hypertrophy and a decrease in the vasodilatating capacity of resistance vessels contribute to the reduction of coronary reserve in hypertensive hypertrophy. The minimal coronary vascular resistance, a parameter of the vasodilatating capacity, was significantly increased in SHRs. Antihypertensive therapy with metoprolol and hydralazine or nifedipine resulted in an improvement of coronary reserve.

IAEA/WHO 60Co teletherapy dosimetry service using mailed LiF dosimeters. A survey of results obtained during 1975-1982.

During 1975-1982 the International Atomic Energy Agency (IAEA) in co-operation with the World Health Organization (WHO) carried out 603 absorbed dose determinations for 60Co gamma-ray beams for 278 radiotherapy institutes in 60 countries. The participants were asked to irradiate capsules containing LiF powder to 2 Gy in 5 cm of water. The percentage of the determinations in which the deviation between the institutes quoted dose and the IAEA measured dose was within +/- 5% was 62%. In 17% of the determinations, the deviation was more than +/- 10%. For around 70% of the institutes the deviation decreased when further measurements were carried out.

IAEA-WHO cobalt-60 teletherapy dosimetry service using mailed LiF dosemeters. A survey of results obtaining during 1970-75.

The IAEA-WHO postal dose comparison service for cobalt-60 teletherapy dosimetry is an ongoing programme aimed at improving dosimetric accuracy in IAEA-WHO Member States. LiF dosemeters were irradiated under specified conditions in a water phantom at the participating radiotherapy centres and returned to the IAEA's Dosimetry Labotatory for evaluation. The participants filled in a data sheet giving numerical values of physical factors (such as per cent depth dose, tissue-air ratio, etc.) that they employed. Nearly 65% of the comparisons showed deviations within +/- 5%, a figure which is believed to represent the overall uncertainty of the method itself. Almost 10% of the measurements deviated more than +/- 15%. It appears that participants applying 'in phantom' output measurements have better control over the dose they administer. Many of the errors observed are due to the use of faulty values for the various physical factors employed, and to the fact that often a check of the output just before the irradiation of the LiF dosemeters was not carried out.