Pre-operative Assessment of Shoulder Pathologies on MRI by a Radiologist and an Orthopaedic Surgeon.

Introduction: Pathologies of the shoulder, i.e. rotator cuff tears and labral injuries are very common. Most patients receive MRI examination prior to surgery. A correct assessment of pathologies is significant for a detailed patient education and planning of surgery. Materials and methods: Sixty-nine patients were identified, who underwent both, a standardised shoulder MRI and following arthroscopic shoulder surgery in our hospital. For this retrospective comparative study, the MRIs were pseudonymised and evaluated separately by an orthopaedic surgeon and a radiologist. A third rater evaluated images and reports of shoulder surgery, which served as positive control. Results of all raters were then compared. The aim was an analysis of agreement rates of diagnostic accuracy of preoperative MRI by a radiologist and an orthopaedic surgeon. Results: The overall agreement with positive control of detecting transmural cuff tears was high (84% and 89%) and lower for partial tears (70-80%). Subscapularis tears were assessed with moderate rates of agreement (60 - 70%) compared to intra-operative findings. Labral pathologies were detected mostly correctly. SLAP lesions and pulley lesions of the LHB were identified with only moderate agreement (66.4% and 57.2%) and had a high inter-rater disagreement. Conclusion: This study demonstrated that tears of the rotator cuff (supraspinatus, infraspinatus) and labral pathologies can be assessed in non-contrast pre-operative shoulder MRI images with a high accuracy. This allows a detailed planning of surgery and aftercare. Pathologies of the subscapularis tendon, SLAP lesions and biceps instabilities are more challenging to detect correctly. There were only small differences between a radiologic and orthopaedic interpretation of the images.

Attitudes and perceptions towards oral hygiene tasks among geriatric nursing home staff.

OBJECTIVES: To assess attitudes and perceptions towards oral hygiene tasks among geriatric nursing home staff, before and after a dental hygiene education. METHODOLOGY: A survey questionnaire was distributed to the nursing staff (n = 105), at a geriatric nursing home in Stockholm, Sweden. RESULTS: The response rate to the questionnaire was 83%. A vast majority (87%) of the nursing staff considered oral hygiene tasks unpleasant. The main reason for considering oral care unpleasant was a perceived unwillingness from the residents. The perceived unwillingness from the residents among the nursing staff was reduced after the dental hygiene education (chi-square test, P = 0.02). A vast majority of the nursing staff experienced, always or sometimes, resistance from the residents towards oral care. CONCLUSIONS: Nursing home staff members consider oral care tasks unpleasant, and frequently experience resistance from the nursing home residents towards oral care. The perceived unwillingness from the residents is reduced after an advanced dental hygiene education. Further studies are needed to evaluate the effects of education on nursing staff's attitudes and perceptions towards oral care tasks, with the overall aim of improving the oral health among older people in hospitals and nursing homes.

Scintigraphy with 99mTc-labeled heat-altered erythrocytes in diagnosing hyposplenia: prospective comparison to 99mTc-labeled colloids and colour-coded duplex ultrasonography.

AIM: Ultrasound may be a cheap alternative to scintigraphic determination of splenic function. We directly compared nanocolloid scintigraphy (NS), scintigraphy with heat-altered erythrocytes (ES), and colour-coded Doppler sonography (DS) in patients with chronic inflammatory bowel disease (CIBD). PATIENTS, METHODS: 35 patients were included into the study. Clearance rates were determined in ES, spleen/liver ratios (SLR) were measured scintigraphically in ES/NS. In DS, spleen size, echogenicity, and vascular resistance indices (RI) were determined. The results were compared to each other, to the clinical activity scores for CIBD, and to the course of the disease. RESULTS: Based on the blood erythrocyte clearance serving as standard, patients had a good (19 patients), impaired (5), or missing splenic function (11). There was a good correlation of the clearance to SLR in ES (0.63, p < 0.01). The 10 min / 45 min ES clearance showed a high correlation (Spearman-Rho 0.87, p < 0.01). The SLR in ES at 2, 5, 10 and 45 min also correlated well with each other (Spearman-Rho > 0.9, p < 0.01; SLR > 3.45 normal splenic function, SLR < 1.22 indicated hyposplenia). There were no correlations between the results of NS, DS, Howell-Jolly-bodies, or clinical parameters. Only ES and the erythrocyte clearance correlated well. Howell-Jolly-Bodies detected 1 of 11 patients with hyposplenia while false-positive in 4. CONCLUSION: Ultrasound and colloid scintigraphy show a low correlation with clearance of heat-altered erythrocytes. Only ES shows a good correlation in patients with CIBD. The clearance at 10 min already reliably determines splenic function. SLR may be determined after 10 minutes and is predictive of normal function if above 3.45 while SLR < 1.2 indicated hyposplenia.

[ESPEN guidelines on enteral nutrition--summary]. / ESPEN-Leitlinien Enterale Ernährung--Zusammenfassung.

Under the auspices of the European Society for Clinical Nutrition and Metabolism (ESPEN) clinical practice guidelines were systematically developed by 88 experts from 20 different countries between spring 2004 and winter 2005 in a predefined evidence and consensus based process. Evidence was gathered by a structured literature search, and the quality and strength of the evidence was graded according to published standards. On this basis recommendations were formulated which were then finalised in a consensus conference. The recommendations and their grades were summarized in table form. The German translation of these tables is now published for the following chapters: Intensive care, surgery including organ transplantation, non-surgical oncology, gastroenterology, pancreas, liver disease, adult renal failure, cardiology and pulmonology, wasting in HIV and chronic infectious diseases, geriatrics. The full text and the comments are available in ,,Clinical Nutrition" as well as on the internet under www.espen.org and www.dgem.de. The ESPEN guidelines enteral nutrition reflect the current medical knowledge in the field of enteral nutrition therapy and may help to decide when enteral nutrition is indicated and which therapeutic goals can be reached.

ESPEN Guidelines on Enteral Nutrition: Geriatrics.

Nutritional intake is often compromised in elderly, multimorbid patients. Enteral nutrition (EN) by means of oral nutritional supplements (ONS) and tube feeding (TF) offers the possibility to increase or to insure nutrient intake in case of insufficient oral food intake. The present guideline is intended to give evidence-based recommendations for the use of ONS and TF in geriatric patients. It was developed by an interdisciplinary expert group in accordance with officially accepted standards and is based on all relevant publications since 1985. The guideline was discussed and accepted in a consensus conference. EN by means of ONS is recommended for geriatric patients at nutritional risk, in case of multimorbidity and frailty, and following orthopaedic-surgical procedures. In elderly people at risk of undernutrition ONS improve nutritional status and reduce mortality. After orthopaedic-surgery ONS reduce unfavourable outcome. TF is clearly indicated in patients with neurologic dysphagia. In contrast, TF is not indicated in final disease states, including final dementia, and in order to facilitate patient care. Altogether, it is strongly recommended not to wait until severe undernutrition has developed, but to start EN therapy early, as soon as a nutritional risk becomes apparent.

Methodology for the development of the ESPEN Guidelines on Enteral Nutrition.

Under the auspices of the European Society for Clinical Nutrition and Metabolism (ESPEN) clinical practice guidelines on enteral nutrition were systematically developed between spring 2004 and winter 2005 in a both evidence and consensus based process. A steering committee implemented 13 disease-specific working groups with a total of 88 experts in clinical nutrition from 20 countries. Evidence was gathered by conducting a structured literature search applying a defined search strategy, inclusion criteria and specified keywords. The quality and strength of the supporting evidence was then graded according to published standards. On this basis recommendations were spelled out which were not only based on the evidence levels of the studies but also on the judgement of the working groups concerning the consistency, clinical relevance and validity of the evidence. Preparation of the drafts was accomplished in interactive small group work processes. The voting of statements took place in a consensus conference and final refinements and voting were done using the Delphi technique. The ESPEN guidelines enteral nutrition reflect the current medical knowledge in the field of enteral nutrition therapy and summarize the evidence when enteral nutrition is indicated and which goals can be reached in regard to nutritional state, quality of life and outcome.

Estimating the pen trajectories of static signatures using hidden Markov models.

Static signatures originate as handwritten images on documents and by definition do not contain any dynamic information. This lack of information makes static signature verification systems significantly less reliable than their dynamic counterparts. This study involves extracting dynamic information from static images, specifically the pen trajectory while the signature was created. We assume that a dynamic version of the static image is available (typically obtained during an earlier registration process). We then derive a hidden Markov model from the static image and match it to the dynamic version of the image. This match results in the estimated pen trajectory of the static image.

Sewage sludge treatment with lime.

The article describes the application of lime as a method for treatment and hygienisation of sewage sludges with lime products such as quicklime, slake lime and dolomitic lime. As a result of the increase in temperature and pH-value during sludge and lime mixing most pathogenic vectors of disease (i.e. bacteria, worms, viruses and parasites) are reduced in concentration and viability to manufacture a safe product for further application on agricultural land.

Phase I study in melanoma patients of a vaccine with peptide-pulsed dendritic cells generated in vitro from CD34(+) hematopoietic progenitor cells.

Dendritic cells (DCs) are professional antigen-presenting cells (APCs) that can be used for vaccination purposes, to induce a specific T-cell response in vivo against melanoma-associated antigens. We have shown that the sequential use of early-acting hematopoietic growth factors, stem cell factor, IL-3 and IL-6, followed by differentiation with IL-4 and granulocyte-macrophage colony-stimulating factor allows the in vitro generation of large numbers of immature DCs from CD34(+) peripheral blood progenitor cells. Maturation to interdigitating DCs could specifically be induced within 24 hr by addition of TNF-alpha. Here, we report on a phase I clinical vaccination trial in melanoma patients using peptide-pulsed DCs. Fourteen HLA-A1(+) or HLA-A2(+) patients received at least 4 i.v. infusions of 5 x 10(6) to 5 x 10(7) DCs pulsed with a pool of peptides including either MAGE-1, MAGE-3 (HLA-A1) or Melan-A, gp100, tyrosinase (HLA-A2), depending on the HLA haplotype. A total of 83 vaccinations were performed. Clinical side effects were mild and consisted of low-grade fever (WHO grade I-II). Clinical and immunological responses consisted of anti-tumor responses in 2 patients, increased melanoma peptide-specific delayed-type hypersensitivity reactions in 4 patients, significant expansion of Melan-A- and gp100-specific cytotoxic T lymphocytes in the peripheral blood lymphocytes of 1 patient after vaccination and development of vitiligo in another HLA-A2(+) patient. Our data indicate that the vaccination of peptide-pulsed DCs is capable of inducing clinical and systemic tumor-specific immune responses without provoking major side effects.

Studies of vehicular padding materials.

The Federal Motor Vehicle Safety Standard 571.201 discusses occupant protection with interior impacts of vehicles. Rule making by the National Highway Traffic Safety Administration (NHTSA) has identified padding for potential injury reduction in vehicles. In these studies, head injury mitigation with padding on vehicular roll bars and brush bars was evaluated. Studies were conducted with free falling Hybrid 50% male head form drops on the forehead and side of the head and a 5% female head. Marked reductions in angular acceleration, as well as Head Injury Criterions (HIC), were observed when compared to unpadded roll bars and brush bars.

De novo expression of MHC class II molecules by microglial cells during acute rat renal allograft rejection.

The expression of MHC class I and class II molecules in the cerebral cortex of rats was investigated at daily intervals from day 3 to day 6 after fully allogeneic (DA-->LEW) and isogeneic (LEW-->LEW) kidney transplantation. MHC class II molecules were temporarily induced on the previously negative microglial cells and on the endothelia of arterioles and venules during acute rejection. On the endothelia of all brain vessels MHC class I expression was enhanced. MHC class I+ cells with microglial cell morphology were discernible within the diffusely MHC class I+ brain parenchyma. In contrast, the brain parenchyma of isograft recipients and untreated control animals did not express detectable levels of MHC molecules. In conclusion, we demonstrate that a strong immune reaction in the periphery is able to activate microglial cells in the central nervous system.

GM-CSF promotes differentiation of a precursor cell of monocytes and Langerhans-type dendritic cells from CD34+ haemopoietic progenitor cells.

Epithelia-associated dendritic cells (DC) including Langerhans cells in the skin (LC) are precursors of lymph node located interdigitating DC (iDC). CD1a+ LC are known to be derived from CD34+ haemopoietic progenitor cells (HPC); however, cells of an intermediate differentiation state that are CD34- and CD1a- have not been identified. Monitoring the differentiation pathway of HPC in the presence of GM-CSF+IL-4, we observed the emergence of a distinct LC precursor population that was CD33+ CD13+ CD4+ CD38+ CD44+ CD34- CD14- CD1a-. The cells could be separated by FACS due to a unique CD44/CD38 expression pattern or by CD44 expression in conjunction with the SSC profile. It was found that they were similarly generated in the presence of GM-CSF alone and were detectable in culture for at least a week. Irrespective of being generated in the presence of GM-CSF+IL-4 or GM-CSF alone, CD44/SSC-sorted precursor cells matured to MHC class II compartments (MIIC) and Birbeck granules (BG) expressing LC, when subsequently cultured in the presence of GM-CSF+IL-4. When IL-4 was omitted, however, the same cells matured to phagocytically active adherent macrophages (Mphi). These culture conditions were associated with a > 4-fold increase in the concentration of IL-6 when compared to those used for LC differentiation. The identification of a distinct oligopotent precursor cell population that can deliberately be induced to give rise to BG+ MIIC+ CD1a+ CD14- LC or to adherent CD14+ Mk further substantiates the close relationship of monocytes and DC and may help to identify its in vivo equivalent.

Dynamics of monocytes/macrophages and T lymphocytes in acutely rejecting rat renal allografts.

We examined the infiltration of acutely rejecting renal allografts (DA-->LEW) by ED1+ and ED2+ macrophages and T lymphocytes at intervals of 24 h after transplantation. Donor and recipient macrophages were differentiated by MHC class II antigen expression in double-staining experiments with ED1. Proliferation was assayed after pulse-labelling with BrdU. We subdivided allograft infiltration into three consecutive phases: 1) During phase I on days 1 to 2 after allogeneic kidney transplantation, perivascular infiltrates developed that contained numerous donor and recipient macrophages. Allograft rejection could already be diagnosed 24 h after transplantation by perivascular infiltration of T lymphocytes, whereas T cells were rarely found in isografts. 2) Phase II of allograft rejection from day 3 to 4 was characterized by massive propagation of the infiltrate. About equal numbers of interstitial donor and recipient macrophages were counted. Both macrophages and T lymphocytes proliferated in situ and macrophages outnumbered T cells until complete rejection. 3) During phase III the allograft was destroyed. Large intravascular monocytes surprisingly expressed the ED2 antigen. In the interstitium of viable graft regions, the population of recipient macrophages grew, whereas the population of donor macrophages and of T lymphocytes decreased.

[Detection of H-ras and K-ras in tumors of gastrointestinal-pancreatic system]. / Detektion von H-Ras und K-Ras in Tumoren des Gastro-Entero-Pankreatischen Systems (GEP).

The Gastro-Entero-Pancreatic System (GEP) defined a group of highly differentiated neuroendocrine tumors (Insulinomas, Gastrinomas, PP-omas, Somatostatinomas, Carcinoids). In this kind of tumors the multistage carcinogenesis is really unknown. Activated ras oncogenes could play an important role in initiation or process of carcinogenesis in different human cancers. The purpose of our study was to determe if H-ras or K-ras play a role in the carcinogenesis of GEP tumors. 20 paraffin embedded tumor tissues (1 Vipom, 1 Somatostatinom, 10 Carcinoids, 1 Gastrinoma, 4 livermetastasis of a Carcinoid, 3 Insulinomas) were analysed immunohistologic of H-ras and K-ras oncogene protein expression. Immunohistologic investigations showed a H-ras expression in 65% (13/20). K-ras protein could detected in 10% (2/20). On the basis of these data H-ras oncogene expression could play a role in the multistage carcinogenesis of GEP tumors.

CD34+ peripheral blood progenitor cell and monocyte derived dendritic cells: a comparative analysis.

Dendritic cells (DC) have been generated in vitro from either CD34+ haemopoietic progenitor cells (HPC) or peripheral blood monocytes (Mo) in the presence of specific cytokine combinations, including granulocyte-macrophage colony-stimulating factor (GM-CSF). Since differences between DC from either source may be important for the clinical use of these antigen-presenting cells (APC), a comparative analysis was performed. HPC were expanded in the presence of interleukin (IL)-3, IL-6 and stem cell factor (SCF) (days 1-7) and subsequently induced by IL-4+ GM-CSF (days 8-26) to differentiate to Langerhans-type cells (pLC). The latter cytokines were similarly used to generate Mo-derived LC (mLC). Maturation of both cell types, pLC and mLC, to interdigitating DC-type cells (iDC) was induced by tumour necrosis factor-alpha (TNF-alpha) or lipopolysaccharide (LPS). Analysis of mLC/pLC and miDC/piDC with respect to morphology, phenotype, antigen uptake and presentation revealed a high similarity of DC from either source. The majority of mLC, however, exhibited a more mature differentiation stage, compared to pLC, evidenced from lower numbers of multilaminar MHC class II compartments and less efficient APC function for extracellular protein antigens. Although macropinocytosis was performed by LC, neither LC nor iDC from either source were able to take up > or = 0.5 microm latex beads. However, phagocytosis of 0.5 microm and 1 microm beads was performed by Mo that could subsequently be induced to become iDC, thus providing the unique opportunity to present phagocytosed material in DC-type fashion. Mo may be the preferential source for clinical use of iDC-type cells since preparation and culture are easier to perform and are less costly while APC function is similar to HPC-derived iDC.

A preserved native kidney alters acute renal allograft rejection in the rat.

In this study the effect of a native recipient kidney on acute rat renal allograft rejection is analysed. The authors performed a sequential daily analysis of allograft morphology and infiltration by macrophages and T cells in the presence and the absence of a recipient kidney. Several differences among both experimental groups were observed. Infiltrating macrophages and T cells in the allograft interstitium were more numerous in the presence than in the absence of a recipient kidney. The ratio of macrophages to T cells was 2:1 in the presence and 1:1 in the absence of a recipient kidney. Interstitial allograft infiltration started 1 day earlier in the presence of a contralateral kidney than in its absence. Graft necrosis occurred on day 6 and was complete in the presence of a native kidney. After total nephrectomy a patchy pattern of necrotic and viable tubules was observed from day 5 until the death of the animal. The diameter of monocytes in graft vessels increased only moderately in the presence of a recipient kidney but duplicated in its absence. The authors propose that in experimental renal transplantation contralateral nephrectomy should be performed according to a standardized schedule.

Activation of microglial and endothelial cells in the rat brain after treatment with interferon-gamma in vivo.

Activation of microglial cells occurs during the pathogenesis of various neurologic diseases. However, the mechanisms of activation in vivo are still elusive. We infused adult rats intravenously with interferon-gamma and demonstrated microglial cell activation after three days of treatment. We show for the first time that microglial cells proliferate inside the brain in response to a circulating cytokine. Microglial cells were induced to express major histocompatibility (MHC) class I and class II antigens and small amounts of leukocyte function-associated molecule 1 (LFA-1, CD11a). On endothelial cells of the brain, MHC class I and class II antigens and intercellular adhesion molecule 1 (ICAM-1, CD54) were enhanced.

The species-specific structure of microanatomical compartments in the human spleen: strongly sialoadhesin-positive macrophages occur in the perifollicular zone, but not in the marginal zone.

The microanatomical structure of human and rat splenic white pulp is compared, with special emphasis on the localization of the marginal zone occupied by immunoglobulin M (IgM)+ IgD-/dull B lymphocytes and its specialized macrophages. Our study reveals that in contrast to rats, the marginal zone of humans primarily exists in the vicinity of primary and secondary splenic follicles and that it is almost absent around the periarteriolar T-cell zones. We demonstrate that in humans there is an additional compartment, the perifollicular zone, located between the marginal zone and the red pulp. The perifollicular zone is a dynamic region of variable cellular and phenotypic composition, which can be regarded either as a part of the red pulp or of the follicles. In most cases the perifollicular zone appears as a compartment of the red pulp containing erythrocyte-filled spaces which differ from the typical red pulp sinusoids. Similar to the splenic cords, the perifollicular zone mostly harbours scattered B and T lymphocytes. However, sometimes B lymphocytes clearly predominate in the perifollicular area. In addition, strongly sialoadhesin-positive macrophages form sheaths around capillaries in the perifollicular zone. Such capillary sheaths are not observed in rats. In humans weakly sialoadhesin-positive macrophages are also present in the perifollicular zone and in the red pulp. In some specimens sialoadhesin is, however, strongly expressed by a large number of dispersed perifollicular macrophages. Interestingly, in striking contrast to rats, the human marginal zone does not contain sialoadhesin-positive macrophages and marginal metallophilic macrophages are also absent in humans. Thus, sialoadhesin-positive macrophages and IgM+ IgD- memory B lymphocytes both share the marginal zone as a common compartment in rats, while they occupy different compartments in humans. We show that the human splenic marginal zone does not contain a marginal sinus and assume that in humans the perifollicular region is the compartment where antigen and recirculating lymphocytes enter the organ.