[Medical liability and criminal law in emergency medicine]. / Arzthaftung und Strafrecht in der Akutmedizin.

Medical liability is booming. Malpractice can entail both civil and criminal consequences. Besides financial and custodial penalties, at worst the license to practice medicine can be withdrawn. Physicians owe their patients a treatment according to current standards. Furthermore, physicians are obliged to fulfill their duty of care. Nevertheless, the patient's right of self-determination must not be violated. Especially in emergency situations, physicians have to focus on taking protective measures in order to avert further dangers to the health of patients. This article analyses common pitfalls in emergency medical treatment with respect to the legal aspects.

[Medical liability and criminal law in emergency medicine]. / Arzthaftung und Strafrecht in der Akutmedizin.

Medical liability is booming. Malpractice can entail both civil and criminal consequences. Besides financial and custodial penalties, at worst the license to practice medicine can be withdrawn. Physicians owe their patients a treatment according to current standards. Furthermore, physicians are obliged to fulfill their duty of care. Nevertheless, the patient's right of self-determination must not be violated. Especially in emergency situations, physicians have to focus on taking protective measures in order to avert further dangers to the health of patients. This article analyses common pitfalls in emergency medical treatment with respect to the legal aspects.

[Indications, consent and treatment limitation in emergency medicine]. / Indikation, Einwilligung und Therapielimitierung in der Akutmedizin.

Physicians in acute and emergency medicine are increasingly confronted by geriatric, multimorbid or oncology patients with advanced stages of disease. Lacking further information or specification about the patient's will may result in overtreatment. An increasing part of the German population has advance directives; however, there is still uncertainty among physicians when dealing with advance directives and health care proxies. Misinterpretation may entail civil and criminal consequences or may lead to a withdrawal of the license to practice. Advance directives for instance are not equivalent to a general waiving of treatment and therapy. Besides life support, terminal care and its legal aspects must also be considered in acute medicine.

New generation CPPs show distinct selectivity for cancer and noncancer cells.

In the last three decades, many new cell-penetrating peptides (CPPs) were developed that exhibited enhanced cell selectivity. Thus, we aimed to validate the tumor cell selectivity of peptides from this new generation, namely fragments mini-crotamine and mini-maurocalcine. Both of these peptides are derived from venoms. Furthermore, we studied an analog of the classical CPP HIV-TAT(47-57) with alternating chirality of Arg residues. To allow covalent coupling of cargoes or fluorophores, a cysteine residue was introduced to the N-terminus of the synthesized peptides. The therapeutic antibody trastuzumab conjugated to different fluorescent dyes was used for internalization studies. Comparison of uptake efficiencies revealed that CPPs of the new generation are in contrast to MPG-peptides, nearly unable to internalize the noncovalently formed complexes with trastuzumab. Interestingly, the fluorescent derivative of the crotamine fragment was mainly observed in a subpopulation of breast cancer cells, whereas it was homogenously distributed in fibrosarcoma, colon cancer, and noncancerous endothelia cells. Thus, the fluorescent crotamine fragment reported herein is a potent theranostic tool for image-guided applications. This peptide can be used to pinpoint the level of heterogeneity present within tumors and aid in the generation of therapeutics that target heterogenic subpopulations.

Hydrophobic alkyl chains substituted to the 8-position of cyclic nucleotides enhance activation of CNG and HCN channels by an intricate enthalpy - entropy compensation.

Cyclic nucleotide-gated (CNG) and hyperpolarization-activated cyclic nucleotide-gated (HCN) channels are tetrameric non-specific cation channels in the plasma membrane that are activated by either cAMP or cGMP binding to specific binding domains incorporated in each subunit. Typical apparent affinities of these channels for these cyclic nucleotides range from several hundred nanomolar to tens of micromolar. Here we synthesized and characterized novel cAMP and cGMP derivatives by substituting either hydrophobic alkyl chains or similar-sized more hydrophilic heteroalkyl chains to the 8-position of the purine ring with the aim to obtain full agonists of higher potency. The compounds were tested in homotetrameric CNGA2, heterotetrameric CNGA2:CNGA4:CNGB1b and homotetrameric HCN2 channels. We show that nearly all compounds are full agonists and that longer alkyl chains systematically increase the apparent affinity, at the best more than 30 times. The effects are stronger in CNG than HCN2 channels which, however, are constitutively more sensitive to cAMP. Kinetic analyses reveal that the off-rate is significantly slowed by the hydrophobic alkyl chains. Molecular dynamics simulations and free energy calculations suggest that an intricate enthalpy - entropy compensation underlies the higher apparent affinity of the derivatives with the longer alkyl chains, which is shown to result from a reduced loss of configurational entropy upon binding.

[Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic State]. / Diabetologische Notfälle: Ketoazidose und hyperglykämes Koma.

BACKGROUND: Diabetic ketoacidosis and the hyperosmolar hyperglycemic state are the most serious diabetic emergencies. Before the discovery of insulin in 1921 by Banting and Best the diagnosis of type 1 diabetes was fatal ending in diabetic ketoacidosis equivalent to a torturous death. Today, mortality from diabetic ketoacidosis is low at approximately 2 %. But each death from these two acute metabolic complications of diabetes is potentially avoidable by improved patient and healthcare professional education. Therefore, there is a need to raise awareness of hyperglycemic crisis and its management amongst physicians. PATHOGENESIS: Insulin deficiency or resistence and increased concentrations of counterreulatory hormones (glucagon, catecholamines, cortisol and growth hormone) are responsible for the development of diabetic ketoacidosis and the hyperosmolar hyperglycemic state. Hyperglycemia develops as a result of increased gluconeogenesis and accelerated glyconeogenesis. In DKA, the absolute insulin deficiency additionally leads to increased lipolysis and production of ketone bodies and resulting metabolic acidosis. DIAGNOSIS: Both DKA and HHS require prompt recognition and management. The diagnosis can be suspected by clinical features and confirmed by laboratory findings. TREATMENT: The treatment of DKA and HHS is similar, including correction of fluid and electrolyte abnormalities and the administration of insulin.

Mediators and Moderators of the Effectiveness of a Community Health Worker Intervention That Improved Dietary Outcomes in Pregnant Latino Women.

BACKGROUND: Pregnancy is an opportune time to initiate diabetes prevention strategies for minority and underserved women, using culturally tailored interventions delivered by community health workers. A community-partnered randomized controlled trial (RCT) with pregnant Latino women resulted in significantly improved vegetable, fiber, added sugar, and total fat consumption compared to a minimal intervention group. However, studying RCT intervention effects alone does not explain the mechanisms by which the intervention was successful or help identify which participants may have benefitted most. PURPOSE: To improve the development and targeting of future community health worker interventions for high-risk pregnant women, we examined baseline characteristics (moderators) and potential mechanisms (mediators) associated with these dietary changes. METHOD: Secondary analysis of data for 220 Latina RCT participants was conducted. A linear regression with effects for intervention group, moderator, and interaction between intervention group and moderator was used to test each hypothesized moderator of dietary changes. Sobel-Goodman mediation test was used to assess mediating effects on dietary outcomes. RESULTS: Results varied by dietary outcome. Improvements in vegetable consumption were greatest for women who reported high spousal support at baseline. Women younger than age 30 were more likely to reduce added sugar consumption than older women. Participants who reported higher baseline perceived control were more likely to reduce fat consumption. No examined mediators were significantly associated with intervention effects. CONCLUSION: Future interventions with pregnant Latinas may benefit from tailoring dietary goals to consider age, level of spousal support, and perceived control to eat healthy.

Internalization of Near-Infrared Fluorescently Labeled Activatable Cell-Penetrating Peptide and of Proteins into Human Fibrosarcoma Cell Line HT-1080.

The internalization of near-infrared fluorescently labeled cargos into living cells and tissues allows a highly sensitive detection without interference from skin, porphins or other fluorescent cell and tissue compounds. In this study, the uptake of labeled bovine serum albumin and an antibody, into fibrosarcoma (HT-1080) cells was triggered by the formation of non-covalent complexes with different cell-penetrating peptides; uptake efficiency and intracellular localization were determined. To improve selectivity of internalization into tumor cells, a fluorescent activatable cell-penetrating peptide (ACPP) was synthesized and functionally characterized. This 25-mer peptide was designed to be activatable by Matrix-Metallo-Proteases (MMPs). Its uptake selectivity was estimated using cells with different MMP activities.

Dietary outcomes in a Spanish-language randomized controlled diabetes prevention trial with pregnant Latinas.

OBJECTIVES: We evaluated the effectiveness of a community-based healthy lifestyle intervention in improving dietary behaviors of pregnant Latinas from 2004 to 2006 in Detroit, Michigan. METHODS: The 11-week, culturally tailored, Spanish-language Healthy Mothers on the Move (MOMs) intervention offered home visits, group classes, related activities, and social support from trained community health workers (CHWs) and peers. Dietary behaviors were measured by food frequency questionnaire. Linear mixed models estimated pre- and post-intervention changes, within and between MOMs intervention and minimal intervention (MI) groups. RESULTS: MOMs (n = 139) and MI (n = 139) participants had similar baseline characteristics and dietary intake. Post-intervention, MOMs participants showed significant improvement in all dietary behaviors, except fruit and fiber consumption. Compared with MI participants, MOMs participants had significantly decreased consumption of added sugar (P = .05), total fat (P < .05), saturated fat (P < .01), percentage of daily calories from saturated fat (P < .001), solid fats and added sugars (P < .001), and had increased vegetable consumption (P < .001). Their increase in fiber consumption (P < .05) was significant relative to MI participants' decrease in fiber intake. CONCLUSIONS: We confirmed the hypothesis that a community-planned, CHW-led healthy lifestyle intervention could improve dietary behaviors of low-income Latina women during pregnancy.

Periconception diet does not vary by duration of US residence for Mexican immigrant women.

This cross-sectional study assessed the influence of duration of residence in the United States on periconception dietary intake of pregnant Mexican immigrant women, using baseline data from Healthy Mothers on the Move, a randomized control trial conducted with 234 women from 2004 to 2006 in Detroit, MI. Average maternal age was 27.3±5.2 years (range=18 to 41 years) with 5.99±4.76 years of US residence (range=0 to 36 years). Women's usual dietary intake during the past 12 months was recorded on a validated food frequency questionnaire (17.3 weeks average gestation). Intakes of selected micronutrients, macronutrients, and food groups were compared by US residence categories (≤5, 6 to 10, or ≥11 years) using analysis of covariance. The percent of women with intakes below the Estimated Average Requirement and the percent not meeting US dietary guidelines were calculated. There was no association between dietary intake and duration of US residence in this population. Percentages of women with dietary intake below the Estimated Average Requirement were: 12.0% for folate, 7.7% for vitamin C, 23.9% for calcium, 11.2% for protein, and 5.1% for carbohydrates. US dietary guidelines were not met for fruit by 17.5% and for vegetables by 74.8% of women. Typical diets were high in saturated fat and cholesterol. Of the 2,195 kcal average daily energy intake, >25% came from saturated fats, trans fats, and added sugars that may replace nutrients important for healthy fetal growth and development and women's health. Interventions to improve intake before, during, and after pregnancy are important in this population, regardless of duration of US residence.

Malolactic enzyme from Oenococcus oeni: heterologous expression in Escherichia coli and biochemical characterization.

Malolactic enzymes (MLE) are known to directly convert L-malic acid into L-lactic acid with a catalytical requirement of nicotinamide adenine dinucleotide (NAD (+) ) and Mn ( 2+) ; however, the reaction mechanism is still unclear. To study a MLE, the structural gene from Oenococcus oeni strain DSM 20255 was heterologously expressed in Escherichia coli, yielding 22.9 kU l (-1) fermentation broth. After affinity chromatography and removal of apparently inactive protein by precipitation, purified recombinant MLE had a specific activity of 280 U mg (-1) protein with a recovery of approximately 61%. The enzyme appears to be a homodimer with a molecular mass of 128 kDa consisting of two 64 kDa subunits. Characterization of the recombinant enzyme showed optimum activity at pH 6.0 and 45°C, and Km, Vmax and kcat values of 4.9 mM, 427 U mg (-1) and 456 sec (-1) for L-malic acid, 91.4 µM, 295 U mg (-1) and 315 sec (-1) for NAD (+) and 4.6 µM, 229 U mg (-1) and 244 sec (-1) for Mn ( 2+) , respectively. The recombinant MLE retained 95% of its activity after 3 mo at room temperature and 7 mo at 4°C. When using pyruvic acid as substrate, the enzyme showed the conversion of pyruvic acid with detectable L-lactate dehydrogenase (L-LDH) activity and oxidation of NADH. This interesting observation might explain that MLE catalyzes a redox reaction and hence, the requirements for NAD (+) and Mn ( 2+) during the conversion of L-malic to L-lactic acid.

Heterologous expression of Oenococcus oeni malolactic enzyme in Lactobacillus plantarum for improved malolactic fermentation.

Lactobacillus plantarum is involved in a multitude of food related industrial fermentation processes including the malolactic fermentation (MLF) of wine. This work is the first report on a recombinant L. plantarum strain successfully conducting MLF. The malolactic enzyme (MLE) from Oenococcus oeni was cloned into the lactobacillal expression vector pSIP409 which is based on the sakacin P operon of Lactobacillus sakei and expressed in the host strain L. plantarum WCFS1. Both recombinant and wild-type L. plantarum strains were tested for MLF using a buffered malic acid solution in absence of glucose. Under the conditions with L-malic acid as the only energy source and in presence of Mn2+ and NAD+, the recombinant L. plantarum and the wild-type strain converted 85% (2.5 g/l) and 51% (1.5 g/l), respectively, of L-malic acid in 3.5 days. Furthermore, the recombinant L. plantarum cells converted in a modified wine 15% (0.4 g/l) of initial L-malic acid concentration in 2 days. In conclusion, recombinant L. plantarum cells expressing MLE accelerate the malolactic fermentation.

"I'm attached, and I'm a good guy/gal!": how character attachment influences pro- and anti-social motivations to play massively multiplayer online role-playing games.

One's feelings of intimacy and connectedness with distal, fictional media characters are referred to as parasocial interactions. Video games have challenged this concept, as the distance between game players and characters is greatly reduced, if not completely removed, in virtual environments. Games encourage the internalization and psychological merging of a player's and a character's mind, a multidimensional concept known as character attachment (CA). Data from our study suggest that dimensions of CA are useful in understanding both pro- and anti-social gaming motivations. Pro-social gamers feel a greater sense of control over their characters, while anti-social gamers are more likely to suspend their disbelief of the game environment and not take responsibility for their virtual actions. Pro-social gaming was more prevalent in older gamers, and younger male game characters were motivated by anti-social reasons.

Characterization of two distinct glycosyl hydrolase family 78 alpha-L-rhamnosidases from Pediococcus acidilactici.

α-L-Rhamnosidases play an important role in the hydrolysis of glycosylated aroma compounds (especially terpenes) from wine. Although several authors have demonstrated the enological importance of fungal rhamnosidases, the information on bacterial enzymes in this context is still limited. In order to fill this important gap, two putative rhamnosidase genes (ram and ram2) from Pediococcus acidilactici DSM 20284 were heterologously expressed, and the respective gene products were characterized. In combination with a bacterial ß-glucosidase, both enzymes released the monoterpenes linalool and cis-linalool oxide from a muscat wine extract under ideal conditions. Additionally, Ram could release significant amounts of geraniol and citronellol/nerol. Nevertheless, the potential enological value of these enzymes is limited by the strong negative effects of acidity and ethanol on the activities of Ram and Ram2. Therefore, a direct application in winemaking seems unlikely. Although both enzymes are members of the same glycosyl hydrolase family (GH 78), our results clearly suggest the distinct functionalities of Ram and Ram2, probably representing two subclasses within GH 78: Ram could efficiently hydrolyze only the synthetic substrate p-nitrophenyl-α-L-rhamnopyranoside (V(max) = 243 U mg(-1)). In contrast, Ram2 displayed considerable specificity toward hesperidin (V(max) = 34 U mg(-1)) and, especially, rutinose (V(max) = 1,200 U mg(-1)), a disaccharide composed of glucose and rhamnose. Both enzymes were unable to hydrolyze the flavanone glycoside naringin. Interestingly, both enzymes displayed indications of positive substrate cooperativity. This study presents detailed kinetic data on two novel rhamnosidases, which could be relevant for the further study of bacterial glycosidases.

Heterologously expressed family 51 alpha-L-arabinofuranosidases from Oenococcus oeni and Lactobacillus brevis.

Putative α-L-arabinofuranosidases of Oenococcus oeni and Lactobacillus brevis were heterologously expressed and characterized. We report the basic functional properties of the recombinant enzymes in comparison to those of a commercial family 51 arabinosidase of Aspergillus niger.

A ß-glucosidase from Oenococcus oeni ATCC BAA-1163 with potential for aroma release in wine: Cloning and expression in E. coli.

Lactic acid bacteria (LAB) are responsible for olfactory changes in wine during malolactic fermentation (MLF). A side characteristic of MLF is the release of grape derived aroma compounds from their glycosylated precursors by ß-glycosidase activities of these bacteria. Apart from Oenococcus oeni, which is regarded as the most promising species for MLF, glycosidic activities have also been observed in wine related members of the genera Lactobacillus and Pediococcus. Nevertheless, information on the involved enzymes including their potential use in winemaking is limited. In this study we report that ß-glucosidases with similar protein sequences can be identified in the genomes of Lactobacillus brevis, O. oeni and Leuconostoc mesenteroides. TTG serves as start codon for the glucosidase gene of O. oeni. The ß-glucosidase of O. oeni ATCC BAA-1163 was expressed in E. coli and partially characterized. The enzyme displayed characteristics similar to ß-glucosidases isolated from L. brevis and L. mesenteroides. A pH optimum between 5.0 and 5.5, and a K(m) of 0.17 mmol L(-1 )pNP-ß-D-glucopyranoside were determined. A glycosyltransferase activity was observed in the presence of ethanol. The enzyme from O. oeni was capable to hydrolyze glycosides extracted from Muskat wine. This study also contains a report on glycosidase activities of several LAB species including Oenococcus kitaharae.

Timetable of effects of testosterone administration to hypogonadal men on variables of sex and mood.

INTRODUCTION: The effects of testosterone have been extensively characterized, but little attention has been given to the timetable of occurrence of the various effects of testosterone. METHODS: The timetables of effects on sexual and psychological variables in 40 hypogonadal men receiving treatment with either parenteral testosterone enanthate (TE) or undecanoate (TU). RESULTS: Sexual thoughts/fantasies and sexual interest/desire/spontaneous morning erections emerged quickly and plateaued after 3 weeks. Total erections rose to a maximum over 9 weeks and then plateaued. Ejaculations per week/satisfaction with sex life rose over the first 3 weeks, increasing steadily to a plateau at 12 weeks. Depression scores decreased to reach a plateau after 6 weeks. Aggressiveness did not change. Scores of concentration improved and reached a plateau after 3 weeks in the group treated with TE and after 9 weeks in the group treated with TU. Good mood improved after 6-9 weeks. Positive effects on self-confidence appeared between 3-6 weeks and on fatigue after 9-12 weeks. CONCLUSION: Insight into the emergence of effects may be useful information for the patient and for the attending physician in monitoring clinical effects of testosterone treatment of hypogonadal men.

Neuronal IGF-1 resistance reduces Abeta accumulation and protects against premature death in a model of Alzheimer's disease.

Alzheimer's disease (AD) is characterized by progressive neurodegeneration leading to loss of cognitive abilities and ultimately to death. Postmortem investigations revealed decreased expression of cerebral insulin-like growth factor (IGF)-1 receptor (IGF-1R) and insulin receptor substrate (IRS) proteins in patients with AD. To elucidate the role of insulin/IGF-1 signaling in AD, we crossed mice expressing the Swedish mutation of amyloid precursor protein (APP(SW), Tg2576 mice) as a model for AD with mice deficient for either IRS-2, neuronal IGF-1R (nIGF-1R(-/-)), or neuronal insulin receptor (nIR(-/-)), and analyzed survival, glucose, and APP metabolism. In the present study, we show that IRS-2 deficiency in Tg2576 mice completely reverses premature mortality in Tg2576 females and delays beta-amyloid (Abeta) accumulation. Analysis of APP metabolism suggested that delayed Abeta accumulation resulted from decreased APP processing. To delineate the upstream signal responsible for IRS-2-mediated disease protection, we analyzed mice with nIGF-1R or nIR deficiency predominantly in the hippocampus. Interestingly, both male and female nIGF-1R(-/-)Tg2576 mice were protected from premature death in the presence of decreased Abeta accumulation specifically in the hippocampus formation. However, neuronal IR deletion had no influence on lethality of Tg2576 mice. Thus, impaired IGF-1/IRS-2 signaling prevents premature death and delays amyloid accumulation in a model of AD.

Cloning, sequence analysis and heterologous expression in Pichia pastoris of a gene encoding a thermostable cellobiose dehydrogenase from Myriococcum thermophilum.

We cloned and expressed a gene encoding a thermostable cellobiose dehydrogenase (CDH) from the thermophilic ascomycete Myriococcum thermophilum. The 2904bp long open reading frame contained six introns located either close to the 5'- or 3'-end of the ORF. The corresponding cDNA of 2487bp was cloned into the expression vector pPICZalphaB to achieve inducible heterologous expression and secretion of the recombinant flavocytochrome in the methylotrophic yeast Pichia pastoris. Transformants were selected on media with normal and 10-fold increased zeocin concentration, and selected clones were tested for inducible extracellular production of the recombinant oxidoreductase. The maximally obtained volumetric activity was 0.25U/ml in YPM (rich) medium and 2.15U/ml in production stage (minimal) medium in a fed-batch fermentation. Recombinant CDH was purified in two consecutive chromatographic steps leading to a final specific activity of up to 7.4U/mg protein at 40 degrees C. Kinetic properties of the recombinant CDH were characterized and the temperature optimum for the recombinant CDH was determined at 63 degrees C. Certain properties of the sequence of MtCDH are discussed in context with thermal and proteolytic stability.

Gene expression of adrenomedullin in failing myocardium: comparison to atrial natriuretic peptide.

The expression of adrenomedullin (AM) and atrial natriuretic factor (ANF) were investigated in the myocardium of a rat model of chronic ischemic heart failure (CHF) compared with sham-operated controls. In addition, human myocardium of patients with end-stage heart failure due to idiopathic dilated cardiomyopathy compared with myocardium of normal subjects (NF) was studied. In CHF, similar AM levels but increased ANF expression were observed in left ventricular myocardium, as assessed by semiquantitative PCR. Functional experiments with freshly excised papillary muscles showed no influence of AM on myocardial contractility. In NF human myocardium, the expression of AM mRNA was threefold higher in atrial compared with ventricular tissue. In analogy, ANF mRNA was increased by approximately 15-fold in atrial tissue. In dilated cardiomyopathy, the expression of AM was significantly increased in right and left ventricles compared with NF. In parallel, ventricular ANF expression was enhanced.