[The S2k guideline: Indications for knee endoprosthesis : Evidence and consent-based indications for total knee arthroplasty]. / S2k-Leitlinie: Indikation Knieendoprothese : Evidenz- und konsensbasierte Indikationsstellung in der Knie-Endoprothetik (EKIT-Knie).

Total knee arthroplasty (TKA) is one of the most frequent surgical procedures in orthopaedic surgery. Until now there have not been any standardized indication criteria, which might contribute to the large geographical differences in the frequency of TKA. This guideline aims to consent minimal requirements (main criteria), additional important aspects (minor criteria), as well as relative and absolute contraindications for TKA. The following main criteria have been consented: knee pain, radiological confirmation of osteoarthritis or osteonecrosis, inadequate response to conservative treatment, adverse impact of knee disease on the patient's quality of life and the burden of suffering due to the knee disease. Relative contraindications have been consented as severe general disease with reduced life expectancy and a BMI ≥40; absolute contraindications are an active infection and if the patient is not able to undergo major surgery.

[Echocardiography and right heart catheterization in pulmonal hypertension]. / Echokardiographie und Rechtsherzkatheterisierung bei pulmonaler Hypertonie.

BACKGROUND AND OBJECTIVE: Since pulmonary hypertension is defined haemodynamically with a mean pulmonary artery pressure (mPAP) of at least 25 mmHg, right heart catheterization is mandatory for diagnosis of PH. However, it remains unclear if echocardiography can always detect a PH and to what extent echocardiographic and invasive parameters correlate. We aimed to determine the frequency of right heart valve insufficiencies, the correlation of mPAP measured invasively and estimated by echocardiography and the correlation of other echocardiographic parameters with invasively measured cardiac output (CO) and pulmonary vascular resistance (PVR) in patients who presented at our center for pulmonary hypertension. METHODS: Retrospective analysis of echocardiographic and invasively measured parameters in consecutive patients who presented with dyspnea and suspected PH. RESULTS: 10% of the patients with invasively confirmed PH had no tricuspid valve insufficiency, 61.3% had no pulmonary valve insufficiency. The highest correlation of invasively measured mPAP was found for mPAP estimated non-invasively via RVSP (R = 0.80; < 0.0001). Correlation of non-invasively estimated mPAP by the pulmonary valve regurgitation (R = 0,72, p < 0,004) and mPAP measured by the right ventricular outflow tract flow acceleration time (R = 0,54, p < 0.0001) with invasively measured mPAP were inferior. Left ventricular eccentricity index and systolic tissue Doppler velocity of tricuspid annulus correlated highly significant with PVR, TAPSE correlated with PVR and CO. Right ventricular myocardial performance index correlated with CO. CONCLUSION: In 10% of invasively proven PH, the diagnosis can be missed by estimation of RVSP by echocardiography alone, due to a lack of tricuspid valve insufficiency. Echocardiographic assessment of mPAP remains difficult. Echocardiography can deliver qualitative information about CO and PVR. Right heart catheterization remains mandatory to confirm or to rule out PH.

Social isolation-induced epigenetic changes in midbrain of adult mice.

Social isolation and loneliness increase the risk of death as much as well-established risk factors for mortality such as cigarette smoking and alcohol consumption. The underlying molecular mechanisms are poorly understood. In the present study, 3 months old male C57BL/6 mice were socially isolated by individual housing for another 3 months. At the age of 6 months, epigenetic changes were analyzed in midbrain. Social isolation of male adult mice led to an increased global DNA methylation, which was associated with enhanced activity of DNA methyltransferase. Di- and trimethylation of global histone H3 lysine 4 (H3K4) were increased in midbrain of socially isolated mice, accompanied by enhanced H3K4 histone methyltransferase activity. In addition, social isolation of adult mice led to activation of histone acetyltransferases as well as of histone deacetylases (HDAC) resulting in a net enhancement of histone H3 lysine 9 (H3K9) acetylation. Gene-specific effects were observed for Hdac1, Hdac3 and the serotonin transporter Slc6a4. Social isolation led to an up-regulation of Hdac1 and Hdac3, associated with decreased DNA methylation in the CpG island of the respective genes. On the contrary, the Slc6a4 gene was down-regulated, which was associated with enhanced DNA methylation. Collectively, the results from the present study demonstrate for the first time that social isolation of adult mice leads to a wide range of global epigenetic changes and these effects may have profound impact on gene expression pattern and phenotype of the socially isolated animals.

The impact of ovarian stimulation on the expression of candidate reprogramming genes in mouse preimplantation embryos.

Ovarian stimulation with gonadotrophins is an integral part of assisted reproductive technologies in human subfertility/infertility treatment. Recent findings have associated ovarian stimulation with the increased incidence of imprinting disorders in humans as well as defects in genome-wide methylation reprogramming and, in particular, imprinting in mice. Here, we present the first study that determined the impact of ovarian stimulation on the expression of developmentally important reprogramming genes (Apex1, Lig1, Lig3, Mbd2, Mbd3, Mbd4, and Polb) in single early mouse morula embryos (16-cell stage). Using absolute quantification of mRNA by quantitative real-time PCR, we observed an association of ovarian stimulation with a downregulation of mRNAs encoding the base excision repair proteins APEX1 and POLB as well as the 5-methyl-CpG-binding domain protein MBD3 in individual morula embryos. Whole mount immunofluorescence staining of early and late morula embryos with an antibody against APEX1 revealed individual embryos with lower protein expression levels after ovarian stimulation and a correlation of mRNA expression with protein abundance. Our data argue for a negative impact of ovarian stimulation during female gametogenesis and/or early embryo development affecting the expression of candidate reprogramming factors.

Leaf surface structures enable the endemic Namib desert grass Stipagrostis sabulicola to irrigate itself with fog water.

The Namib grass Stipagrostis sabulicola relies, to a large degree, upon fog for its water supply and is able to guide collected water towards the plant base. This directed irrigation of the plant base allows an efficient and rapid uptake of the fog water by the shallow roots. In this contribution, the mechanisms for this directed water flow are analysed. Stipagrostis sabulicola has a highly irregular surface. Advancing contact angle is 98° ± 5° and the receding angle is 56° ± 9°, with a mean of both values of approximately 77°. The surface is thus not hydrophobic, shows a substantial contact angle hysteresis and therefore, allows the development of pinned drops of a substantial size. The key factor for the water conduction is the presence of grooves within the leaf surface that run parallel to the long axis of the plant. These grooves provide a guided downslide of drops that have exceeded the maximum size for attachment. It also leads to a minimum of inefficient drop scattering around the plant. The combination of these surface traits together with the tall and upright stature of S. sabulicola contributes to a highly efficient natural fog-collecting system that enables this species to thrive in a hyperarid environment.

United States (US) multi-center study to assess the validity and reliability of the Spinal Cord Independence Measure (SCIM III).

STUDY DESIGN: Multi-center, prospective, cohort study. OBJECTIVES: To assess the validity and reliability of the Spinal Cord Independence Measure (SCIM III) in measuring functional ability in persons with spinal cord injury (SCI). SETTING: Inpatient rehabilitation hospitals in the United States (US). METHODS: Functional ability was measured with the SCIM III during the first week of admittance into inpatient acute rehabilitation and within one week of discharge from the same rehabilitation program. Motor and sensory neurologic impairment was measured with the American Spinal Injury Association Impairment Scale. The Functional Independence Measure (FIM), the default functional measure currently used in most US hospitals, was used as a comparison standard for the SCIM III. Statistical analyses were used to test the validity and reliability of the SCIM III. RESULTS: Total agreement between raters was above 70% on most SCIM III tasks and all κ-coefficients were statistically significant (P<0.001). The coefficients of Pearson correlation between the paired raters were above 0.81 and intraclass correlation coefficients were above 0.81. Cronbach's-α was above 0.7, with the exception of the respiration task. The coefficient of Pearson correlation between the FIM and SCIM III was 0.8 (P<0.001). For the respiration and sphincter management subscale, the SCIM III was more responsive to change, than the FIM (P<0.0001). CONCLUSION: Overall, the SCIM III is a reliable and valid measure of functional change in SCI. However, improved scoring instructions and a few modifications to the scoring categories may reduce variability between raters and enhance clinical utility.

[Exulcerated, nodular tumor on the occiput of a 29-year-old patient]. / Exulzerierter, nodulärer Tumor am Hinterkopf eines 29-jährigen Patienten.

Cranial fasciitis is a rare variation of nodular fasciitis that occurs in the region of the capillitium. We report on a 29-year-old patient who presented with a 2-month history of a tumor progressively increasing in size located on the occiput. Histological examination revealed a tumor, consisting of tightly packed spindle-shaped cells with underlying myxoid stroma, which extended from the dermis to the subcutis. Actin and vimentin were detected by immunohistochemistry. We established a diagnosis of cranial fasciitis and excised the tumor. Especially when a child or young adult presents with a tumor in the skull area, consideration should be given to cranial fasciitis in the differential diagnosis to avoid unnecessary and possibly very invasive treatment approaches.

Evaluation of portal venous gas detected by ultrasound examination for diagnosis of necrotising enterocolitis.

BACKGROUND: Early diagnosis of necrotising enterocolitis (NEC) is difficult but essential for timely therapy. The diagnostic hallmarks and specific radiological signs for NEC are pneumatosis intestinalis (PI) and portal venous gas (PVG), but PVG in abdominal ultrasound (PVG-US) has been proposed as an effective tool in the diagnosis of NEC as well. OBJECTIVE: To prospectively assess the value of PVG-US for the diagnosis of NEC. METHODS: The study screened 352 neonates for PVG-US (n = 796 routine examinations) and performed 48 additional screenings in 34/352 neonates with suspected (stage I, n = 28) or definite NEC (stage > or =II, n = 20). Sensitivity and specificity of PVG-US for detection of NEC were computed by using NEC stage > or =II as the reference standard. RESULTS: PVG-US was only present in cases of suspected or definite NEC. The study observed PVG-US in 4/28 NEC stage I and in 9/20 NEC stage > or =II episodes corresponding to a 86% specificity and a 45% sensitivity for diagnosis of NEC stage > or =II. However, 7/20 patients with NEC stage > or =II showed intraoperative findings other than NEC and another 3/20 infants presented with radiologically unspecific intestinal dilatation. None of these 10 infants had detectable PVG-US. Thus, with application of specific radiological signs the sensitivity of PVG-US for diagnosis of NEC stage > or =II increased to 90%. CONCLUSION: Screening for PVG-US is a useful, easy and quick bedside test with a high specificity for NEC. Moreover, these results question the value of the Walsh criteria in the diagnosis of NEC.

[Does mental training improve learning to walk with an above-knee prosthesis?]. / Verbessert mentales Training das Erlernen der Gehbewegung mit Oberschenkelprothese?

BACKGROUND: Mental training is a method for optimizing movement patterns, which has become well established through its application in high performance sport and is also adopted in therapeutic contexts. The question arises as to whether the process of learning to walk following the fitting of a femoral prosthesis can be enhanced by means of mental training. METHODS: In the framework of a prospective randomized study, healthy subjects (36 students) were required to learn to walk with a femoral prosthesis: the control group (n=18) exclusively with the aid of practical training and the experimental group (n=18) with practical and mental training. Dependent variables were specified as the gait parameters of a computer-supported and an observational gait analysis. RESULTS: In comparison to the control group, the experimental group made significantly faster learning progress in all parameters of the computer-supported and observational gait analysis. CONCLUSIONS: Mental training seems to be an effective gait training method following the fitting of a femoral prosthesis. Transferring this method to rehabilitation, particularly in young patients, would most certainly appear feasible.

Delayed profound local brain hypothermia markedly reduces interleukin-1beta gene expression and vasogenic edema development in a porcine model of intracerebral hemorrhage.

White matter (lobar) intracerebral hemorrhage (ICH) can cause edema-related deaths and life-long morbidity. In our porcine model, ICH induces oxidative stress, acute interstitial and delayed vasogenic edema, and up-regulates interleukin-1beta (IL-1beta), a proinflammatory cytokine-linked to blood-brain barrier (BBB) opening. In brain injury models, hypothermia reduces inflammatory cytokine production and protects the BBB. Clinically, however, hypothermia for stroke treatment using surface and systemic approaches can be challenging. We tested the hypothesis that an alternative approach, i.e., local brain cooling using the ChillerPad System, would reduce IL-1beta gene expression and vasogenic edema development even if initiated several hours after ICH. We infused autologous whole blood (3.0 mL) into the frontal hemispheric white matter of 20 kg pentobarbital-anesthetized pigs. At 3 hours post-ICH, we performed a craniotomy for epidural placement of the ChillerPad. Chilled saline was then circulated through the pad for 12 hours to induce profound local hypothermia (14 degrees C brain surface temperature). We froze brains in situ at 16 hours after ICH induction, sampled perihematomal white matter, extracted RNA, and performed real-time RT-PCR. Local brain cooling markedly reduced both IL-1beta RNA levels and vasogenic edema. These robust results support the potential for local brain cooling to protect the BBB and reduce injury after ICH.

Cysteine proteinases mediate extracellular prohormone processing in the thyroid.

Thyroglobulin, the precursor of thyroid hormones, is extracellularly stored in a highly condensed and covalently cross-linked form. Solublization of thyroglobulin is facilitated by cysteine proteinases like cathepsins B and K which are proteolytically active at the surface of thyroid epithelial cells. The cysteine proteinases mediate the processing of thyroglobulin by limited extracellular proteolysis at the apical plasma membrane, thereby rapidly liberating thyroxine. The trafficking of cysteine proteinases in thyroid epithelial cells includes their targeting to lysosomes where they become maturated before being transported to the apical plasma membrane and, thus, into the extracellular follicle lumen. We propose that thyroid stimulating hormone regulates extracellular proteolysis of thyroglobulin in that it enhances the rate of exocytosis of lysosomal proteins at the apical plasma membrane. Later, thyroid stimulating hormone upregulates thyroglobulin synthesis and its secretion into the follicle lumen for subsequent compaction by covalent cross-linking. Hence, cycles of thyroglobulin proteolysis and thyroglobulin deposition might result in the regulation of the size of the luminal content of thyroid follicles. We conclude that the biological significance of extracellularly acting cysteine proteinases of the thyroid is the rapid utilization of thyroglobulin for the maintenance of constant thyroid hormone levels in vertebrate organisms.

Immunosuppressed surfactant protein A-deficient mice have increased susceptibility to Pneumocystis carinii infection.

Immunosuppressed Swiss Black mice deficient in surfactant protein A (SP-A(-/-)) and wild-type control mice (SP-A(+/+)) were exposed to Pneumocystis carinii by environmental exposure, intratracheal inoculation, and direct exposure to other infected animals. The frequency and intensity of P. carinii infection were significantly greater in the SP-A(-/-) mice by all 3 methods of exposure. P. carinii free of SP-A and alveolar macrophages were isolated from SP-A(-/-) mice and were tested in an in vitro attachment assay. Pretreatment of P. carinii with human SP-A resulted in a significant dose-dependent increase of the adherence of P. carinii to the macrophages. Thus, SP-A plays a role in host defense against P. carinii in vivo, perhaps by functioning as a nonimmune opsonin.

Adhesion of trophoblast to uterine epithelium as related to the state of trophoblast differentiation: in vitro studies using cell lines.

At the initial phase of embryo implantation, the trophoblast must have acquired competence for adhesion to the uterine epithelium, a condition whose cell biological basis is far from understood. In the present study, trophoblast-type cells (BeWo, JAr, and Jeg-3 choriocarcinoma cell lines) were treated with retinoic acid, methotrexate, dibutyryl-cAMP, or phorbol-12-myristate-13-acetate in order to modulate their ability to adhere to uterine epithelial cells (RL95-2). In an established model, multicellular spheroids of choriocarcinoma cells were transferred onto the surface of monolayer cultures of RL95-2 cells followed by a centrifugal force-based adhesion assay. In controls, about 45% of BeWo and JAr cell spheroids and 75% of Jeg-3 spheroids adhered to uterine monolayers within 30 min. Pretreatment of spheroids with either of the agents stimulated differentiation as indicated by the rate of chorionic gonadotropin secretion, but consistently reduced the adhesion to the endometrial monolayer in all three choriocarcinoma cell lines. While previous investigations had shown that invasiveness of trophoblast cells (into extracellular matrix) does not seem to be linked to the differentiation program in a simple manner, the present data suggest that such an (inverse) link may indeed exist with respect to the ability to initiate an adhesive interaction with the uterine epithelium. These observations support the view that epithelial cell interactions as typical for the initial phase of embryo implantation are regulated in a way that is clearly different from cell-matrix interactions governing later phases of trophoblast invasion into the endometrial stroma.

Latent Pneumocystis carinii infection in commercial rat colonies: comparison of inductive immunosuppressants plus histopathology, PCR, and serology as detection methods.

Histopathologic evaluation combined with a period of immunosuppression has been the standard procedure for detection of Pneumocystis carinii in commercial rat colonies. Variation in induction regimens and in the sensitivity of detection methods may result in underreporting of the presence of P. carinii in breeding colonies or delay its detection. In the present study, methylprednisolone and cyclophosphamide were evaluated for the ability to induce P. carinii infection in rats from an enzootically infected commercial barrier colony. The presence of P. carinii was detected by histopathologic methods and by amplification of a targeted region of the P. carinii thymidylate synthase gene by PCR over the 8-week study period. Sera taken from rats prior to either induction regimen were evaluated for the presence of P. carinii-specific antibodies by the immunoblotting technique. Few significant differences in ability to induce organism burden or in histopathology were observed between the two immunosuppressive regimens. However, a dramatic loss of weight over the study period was observed in rats treated with methylprednisolone but not in rats treated with cyclophosphamide. Although histopathologic changes attributable to P. carinii did not appear before 2 weeks with either immunosuppressant, the presence of the organism in these animals was detected by immunoblotting and PCR. Cyst scores and the intensities of the histopathologic lesions increased during the study period, but the number of rats exhibiting evidence of P. carinii infection did not change after week 3. These results suggest that use of the PCR method on postmortem lung tissue of rats without prior induction regimens or identification of anti-P. carinii antibodies in antemortem serum samples is a sufficiently sensitive method for detection of the presence of a P. carinii carrier state in rodent breeding colonies.

Differentiation markers and invasiveness: discordant regulation in normal trophoblast and choriocarcinoma cells.

In tumor cells, malignant (invasive) behavior and differentiation tend to be correlated inversely, although it is not clear to what extent this can be generalized and whether it may also apply to normal invasive cell types. We have modulated differentiation of normal trophoblast cells from first trimester or term placenta as well as choriocarcinoma cells (BeWo, Jeg-3, and JAr) with retinoic acid (RA), methotrexate (MTX), dibutyryl-cAMP (dbcAMP), or phorbol-[12-myristoyl-13-acetyl]-diester (PMA). The secretion of the differentiation marker chorionic gonadotrophin was stimulated by nearly all substances in all cell types. The activity of cellular sterylsulfatase showed a tendency to be increased (decreased by RA and dbcAMP in normal trophoblast; not detected in JAr). Invasiveness was decreased by all effectors in normal trophoblast (both types) and in BeWo. In Jeg-3 and JAr, however, PMA treatment (in JAr also RA treatment) increased invasion rates. These results suggest that only in normal trophoblast and in BeWo (but not in other choriocarcinoma cells, i.e., Jeg-3 and JAr) invasiveness and differentiation tend to be correlated inversely. When extrapolating to the various subpopulations of cells within a tumor, induction of differentiation-as intended in certain strategies for tumor therapy ("differentiation therapy")-may have the unwanted effect of stimulating invasiveness in certain subpopulations of tumor cells.

Immunization with the major surface glycoprotein of Pneumocystis carinii elicits a protective response.

Pneumocystis carinii, a leading opportunistic pulmonary pathogen, contains a major surface glycoprotein (MSG) which plays a central role in its interaction with the host. Naive Lewis rats were immunized with varying concentrations of purified native MSG and a recombinant form of the protein (MSG-B), placed in a conventional rat colony with exposure to P. carinii, and immunosuppressed with corticosteroids for 10 weeks to induce the development of pneumocystosis. Immunization elicited humoral and cellular immune responses to MSG which persisted throughout the experiment. Compared with animals immunized with ovalbumin or adjuvant alone, the MSG-immunized rats had improved survival (29 vs 66%, p < 0.001), lowered organism burden (log10 9.03 +/- 0.33/lung vs 7.51 +/- 0.38/lung, p < 0.001), less alveolar involvement as assessed by lung histologic score (3.54 +/- 0.42 vs 2.50 +/- 0.42, p < 0.01) and lung weight:body weight ratio (18.2 +/- 1.4 vs 14.6 +/- 1.7, p < 0.01). Animals immunized with MSG-B also showed a significantly lower organism burden, lung histologic score and lung weight:body weight ratio than control rats. Thus, MSG is the first P. carinii antigen which can elicit a protective response in the immunosuppressed rat model of pneumocystosis and this finding supports the rationale of developing a P. carinii vaccine.

Identification of a putative precursor to the major surface glycoprotein of Pneumocystis carinii.

The major surface glycoprotein (MSG) of Pneumocystis carinii f. sp. carinii is a family of proteins encoded by a family of heterogeneous genes. Messenger RNAs encoding different MSGs each begin with the same 365-bp sequence, called the Upstream Conserved Sequence (UCS), which is in frame with the contiguous MSG sequence. The UCS contains several potential start sites for translation. To determine if translation of MSG mRNAs begins in the UCS, polyclonal antiserum was raised against the 123-amino-acid peptide encoded by the UCS. The anti-UCS serum reacted with a P. carinii protein that migrated at 170 kDa; however, it did not react with the mature MSG protein, which migrates at 116 kDa. A 170-kDa protein was immunoprecipitated with anti-UCS serum and shown to react with a monoclonal antibody against a conserved MSG epitope. To explore the functional role of the UCS in the trafficking of MSG, the nucleotide sequence encoding the UCS peptide was ligated to the 5' end of an MSG gene and incorporated into a recombinant baculovirus. Insect cells infected with the UCS-MSG hybrid gene expressed a 160-kDa protein which was N-glycosylated. By contrast, insect cells infected with a baculovirus carrying an MSG gene lacking the UCS expressed a nonglycosylated 130-kDa protein. These data suggest that in P. carinii, translation begins in the UCS to produce a pre-MSG protein, which is subsequently directed to the endoplasmic reticulum and processed to the mature form by proteolytic cleavage.