[Lesions of the triceps tendon : Diagnostics, management, treatment]. / Läsionen der Trizepssehne : Diagnostik, Management, Therapie.

The triceps brachii muscle is the main extender of the elbow joint. Triceps tendon rupture or tearing presents a rare injury pattern in general. Distal tendon ruptures occur most commonly in the area of the insertion of the olecranon. Fractures of the radial head are reported as the most common concomitant injury. In many cases, pre-existing degenerative damage predisposes for tendon injury. These include local steroid injections, anabolic steroid abuse, renal insufficiency requiring dialysis, hyperparathyroidism, lupus erythematosus and Marfan's syndrome. However, the most frequent trauma mechanism is a direct fall onto the extended forearm or a blow to the elbow. Beside clinical examination and sonography, magnetic resonance imaging is the diagnostic gold standard. The treatment of triceps tendon injuries includes conservative as well as operative approaches, whereby the indications for surgical treatment must be generously considered depending on the patient's age, functional demands of the patient, involvement of the dominant extremity as well as on the extent of the tendon rupture.

Frequently assessed and used prognostic factors for outcome after macular hole surgery: which is better?

BACKGROUND: The aim of this retrospective study was to evaluate commonly used clinical and OCT-morphological parameters, including perifoveal pseudocysts, as prognostic factors for postoperative outcome after macular hole surgery in a retinal referral clinic in North Rhine-Westphalia, Germany. METHODS AND MATERIAL: This was a retrospective analysis of all patients who underwent surgery because of idiopathic MH between 2011 and 2017 in Augenklinik Tausendfensterhaus, Duisburg, Germany. Statistical evaluation of clinical and OCT-based parameters, including the areas of intraretinal pseudocysts, was conducted. The main statistical outcomes were surgical success and visual acuity. Only parameters with a highly significant correlation to the outcome parameters (postoperative visual acuity (VA); surgical success) in univariate analysis were entered in linear and logistic regression analyses. RESULTS: A total of 189 eyes of 178 patients (71.4% female; mean age 67.5 ± 8.2 a) who underwent surgery because of MH were included. The overall closure rate was 86.8%. The mean best corrected VA increased from 0.7 ± 0.3 logMAR before surgery to 0.5 ± 0.3 logMAR (p < 0.0001). While several clinical and OCT-based parameters as well as calculated indices showed a significant correlation with the outcome measures, the regression analysis showed that the minimum linear diameter was the only parameter that both predicted surgical success (p = 0.015) and was correlated with postoperative VA (p < 0.001). CONCLUSION: The minimum linear diameter serves as an easily assessed prognostic factor with the best predictive properties. This result is of great importance for clinical practice, as it simplifies the postsurgical prognosis.

[Patellar fractures]. / Patellafrakturen.

Patellar fractures are a relatively rare entity with an prevalence of 1%. Preoperative computed tomography has gained a significant role as a diagnostic tool for patellar fractures in recent years. It enables an exact assessment of the fracture and helps in the decision making for the correct treatment procedure. Therapeutically, the armamentarium was supplemented by angle stable plate fixation, which potentially enables a better reconstruction of the patella than the conventional tension band fixation. In this context, the results of angle stable plate fixation are promising in terms of functional outcome and lower complication rates. The proven tension band fixation using K­wires or cannulated screws continues to be widespread in clinical practice and retains significance for simple patellar fractures. The use of polyethylene thread material instead of steel wire has shown advantages in biomechanical studies but the clinical application is more restrained.

CeO2-x nanorods with intrinsic urease-like activity.

The large-scale production and ecotoxicity of urea make its removal from wastewater a health and environmental challenge. Whereas the industrial removal of urea relies on hydrolysis at elevated temperatures and high pressure, nature solves the urea disposal problem with the enzyme urease under ambient conditions. We show that CeO2-x nanorods (NRs) act as the first and efficient green urease mimic that catalyzes the hydrolysis of urea under ambient conditions with an activity (kcat = 9.58 × 101 s-1) about one order of magnitude lower than that of the native jack bean urease. The surface properties of CeO2-x NRs were probed by varying the Ce4+/Ce3+ ratio through La doping. Although La substitution increased the number of surface defects, the reduced number of Ce4+ sites with higher Lewis acidity led to a slight decrease of their catalytic activity. CeO2-x NRs are stable against pH changes and even to the presence of transition metal ions like Cu2+, one of the strongest urease inhibitors. The low costs and environmental compatibility make CeO2-x NRs a green urease substitute that may be applied in polymer membranes for water processing or filters for the waste water reclamation. The biomimicry approach allows the application of CeO2-x NRs as functional enzyme mimics where the use of native or recombinant enzyme is hampered because of its costs or operational stability.

Evolutionary bottlenecks in brackish water habitats drive the colonization of fresh water by stingrays.

Species richness in freshwater bony fishes depends on two main processes: the transition into and the diversification within freshwater habitats. In contrast to bony fishes, only few cartilaginous fishes, mostly stingrays (Myliobatoidei), were able to colonize fresh water. Respective transition processes have been mainly assessed from a physiological and morphological perspective, indicating that the freshwater lifestyle is strongly limited by the ability to perform osmoregulatory adaptations. However, the transition history and the effect of physiological constraints on the diversification in stingrays remain poorly understood. Herein, we estimated the geographic pathways of freshwater colonization and inferred the mode of habitat transitions. Further, we assessed habitat-related speciation rates in a time-calibrated phylogenetic framework to understand factors driving the transition of stingrays into and the diversification within fresh water. Using South American and Southeast Asian freshwater taxa as model organisms, we found one independent freshwater colonization event by stingrays in South America and at least three in Southeast Asia. We revealed that vicariant processes most likely caused freshwater transition during the time of major marine incursions. The habitat transition rates indicate that brackish water species switch preferably back into marine than forth into freshwater habitats. Moreover, our results showed significantly lower diversification rates in brackish water lineages, whereas freshwater and marine lineages exhibit similar rates. Thus, brackish water habitats may have functioned as evolutionary bottlenecks for the colonization of fresh water by stingrays, probably because of the higher variability of environmental conditions in brackish water.

Effect of dietary vitamin E and selenium supplementation on semen quality in Cairn Terriers with normospermia.

Among others, selenium (Se) and vitamin E (VitE) have been provided to dogs to improve semen quality. However, scientific evidence documenting an effect in dogs is lacking. The aim of this study was to investigate the effect of supplementation of these antioxidants on various ejaculate parameters in a randomized, double-blinded trial using Cairn Terrier males exhibiting normal seminal quality parameters. Three dogs each were fed a standardized diet and supplemented with 0.1 mg Se, 100 mg VitE or 0.1 mg Se + 100 mg VitE/dog for 3 months. Ejaculate analyses (volume, progressive motility, vitality, morphology, concentration) were performed before inclusion (D0) and after 1, 2 and 3 months (+1, +2, +3). At the same time, glutathione peroxidase (GSH-PX) and VitE in seminal plasma (SP) and GSH-PX in blood samples were determined. Vitamin E levels in SP were below the detection limit (1.0 mg/L) in all samples. GSH-PX in blood (164.0-2794.4 IU/L) and SP (18.4-4326.0 IU/L) was highly variable. Supplementation only significantly affected the total percentage of sperm head abnormalities (p = .011). Time significantly affected the percentage of morphologically abnormal sperm (p = .025), sperm head abnormalities (p = .007), proximal droplets (p = .001) and GSH-PX in SP (p = .015). Additionally, a significant interaction between time and group was identified for the percentage of membrane-intact sperm (p = .048), head abnormalities (p = .018), acrosomal defects (p = .043) and proximal droplets (p = .002). Although some effects could be identified for selected parameters, we failed to identify a clear trend about how a 3 months VitE and/or Se supplementation affects semen parameters in normospermic Cairn Terriers.

Changes in serum progesterone concentrations in Bernese mountain dogs and Cavalier King Charles Spaniels during pregnancy.

Progesterone (P4) concentrations during canine pregnancy follow a specific pattern. Although the general pattern is similar, it is likely that breed-specific differences exist. Detailed knowledge about the physiological range of P4 concentrations may be helpful in cases of suspected hypoluteoidism. The aim of this study was to investigate P4 changes during pregnancy in a small and a large breed, to obtain reference values for specific intervals during pregnancy and to test for breed- or body weight-specific differences. We studied P4 concentrations in pregnancies from healthy Bernese mountain dogs (BMDs, n = 6) and Cavalier King Charles Spaniels (CKCSs, n = 6) with a normal reproductive history. Blood samples for P4 were taken to determine the day of ovulation and after confirmation of pregnancy in regular intervals from Days 23 to 29 to Days 60 to 64. Bernese mountain dogs delivered 6.2 ± 2.6 puppies (range: 3-9) 63.4 ± 1.5 (range: 61-65) days after ovulation (excluding data from one BMD with elective c-section) and CKCS delivered 3.3 ± 1.9 puppies (range: 1-5) 63.5 ± 1.1 (range: 62-65) days after ovulation. In general, the P4 concentrations of individual dogs continuously decreased from the first to the last sampling during pregnancy. Respective mean concentrations were Days 23 to 29: 19.2 ± 4.3/22.2 ± 3.9 ng/mL (BMD/CKCS), Days 30 to 34: 15.6 ± 2.3/17.7 ± 5.8 ng/mL, Days 35 to 39: 12.5 ± 2.8/14.1 ± 3.4 ng/mL, Days 40 to 44: 8.9 ± 1.4/11.8 ± 3.7 ng/mL, Days 45 to 49: 7.7 ± 1.6/8.9 ± 1.9 ng/mL, Days 50 to 54: 6.0 ± 1.3/8.7 ± 7.1 ng/mL, Days 55 to 59: 4.7 ± 1.2/5.3 ± 2.8 ng/mL, and Days 60 to 64: 3.69 ± 1.86/2.62 ± 0.42 ng/mL. ANOVA indicated significant differences over time within each breed when considered individually (P < 0.0001 each), but not between breeds although mean P4 was slightly lower in BMD until Days 55 to 59. The present data clearly confirm the previously described P4 pattern during canine pregnancy with highest P4 concentrations obtained in the first interval (Days 23-29) and a subsequent decrease of P4. The lack of a significant rapid prepartal P4 drop might be related to methodological issues (time of last collection in regards to parturition). Other than expected, we failed to proof significant differences in P4 between CKCS and BMD. Further studies are required to confirm the results on a larger population of both breeds, but also other large-sized breeds to test for the hypothesis if BMD might have lower P4 concentrations and smaller litter size compared to other large breeds with larger litter size.

Medical clerkships do not reduce common prescription errors among medical students.

Prescribing correctly represents one of the most essential skills of a doctor when it comes to patient safety. Unfortunately, prescribing errors still account for a large proportion of avoidable drug-related problems (DRP). Despite this shortcoming, many medical schools do not provide specific prescribing training and assume that students acquire sufficient prescribing skills during regular medical clerkships. We therefore investigated whether there is an association between the individual time spent by students in internal-medicine clerkships and the number of prescription errors committed in a standardized prescribing test for common drug-related problems in a medical inpatient setting. Seventy-four fifth-year medical students (25 +/- 3 yrs, 24 m, 50 f) who had completed their formal pharmacology training filled in prescription charts for two standardized patient paper cases. The charts were rated by two blinded consultants from the field of internal medicine using a checklist for common prescription errors. Students were divided into three groups according to the number of weeks previously spent in internal-medicine clerkships. Group differences in the number of prescription errors made were subsequently examined. Students committed 69% +/- 12% of all possible prescription mistakes. There was no significant difference between the group without clerkships in internal medicine (G1) (71 +/- 9%), the group with one to four weeks (G2) (67 +/- 15%), and the group with more than five weeks of clerkships (G3) (71 +/- 10%), p = .76. Medical students do not seem to acquire the necessary skills to avoid common prescription errors during regular clerkships in internal medicine. This study provides evidence to suggest that specific prescription training within medical education is warranted in order to prevent DRP.

[Normokalaemic primary aldosteronism due to an aldosterone-producing adrenal adenoma--Case 06/2009]. / Normokaliämischer primärer Hyperaldosteronismus infolge eines Aldosteron-produzierenden Nebennierenadenoms--Fall 06/2009.

HISTORY AND ADMISSION FINDINGS: A 39-year-old patient presented with normokalaemic therapy refractory arterial hypertension despite of four antihypertensive drugs for further diagnostics. INVESTIGATIONS: Ultrasound displayed no evidence of renal artery stenosis. Furthermore, the kidneys were normal sized and morphologically without pathological findings. Renal function was normal. Free cortisol and catecholamine levels in a 24-hr-urine sample were within the normal range. Plasma renin activity was reduced and both the plasma aldosterone concentration and the aldosterone to renin ratio were elevated. A saline infusion test showed no suppression of the plasma aldosterone concentration, nor did an orthostatic testing show an increase. MRI revealed an adenoma of the right adrenal gland. DIAGNOSIS, TREATMENT AND COURSE: The results were consistent with primary aldosteronism due to an aldosterone-producing adenoma of the adrenal gland. The patient underwent laparoscopic adrenalectomy. The histological findings confirmed an adenoma of the adrenal gland. Three months later, blood pressure was normal under a single treatment regimen with an AT(1) receptor blocker. CONCLUSIONS: Screening for endocrine causes of hypertension is recommended in young patients, therapy refractory hypertension, and in hypokalaemic hypertension. Normokalaemia does not exclude primary aldosteronism as the underlying cause of hypertension.

The risk allele load accelerates the age-dependent decline in beta cell function.

AIMS/HYPOTHESIS: Among the novel type 2 diabetes risk loci identified by genome-wide association studies, TCF7L2, HHEX, SLC30A8 and CDKAL1 appear to affect beta cell function. In the present study we examined the effect of these genes' risk alleles on the age-dependent decline in insulin secretion. METHODS: The SNPs rs7903146 (TCF7L2), rs7754840(CDKAL1), rs7923837 (HHEX) and rs13266634 (SLC30A8) were genotyped in 1,412 non-diabetic patients, who were subsequently grouped according to their number of risk alleles. All participants underwent an OGTT. Insulin secretion was assessed by validated indices and proinsulin conversion by calculating AUC(proinsulin)/AUC(insulin). RESULTS: The number of risk alleles revealed a Gaussian distribution, with most participants carrying four risk alleles. Stratification into groups with low (LAL, up to three alleles), median (MAL, four alleles) and high (HAL, five to eight alleles) allele load resulted in MAL and HAL participants displaying significantly lower insulin secretion and proinsulin conversion than LAL participants (p

Variation in the FTO gene influences food intake but not energy expenditure.

Polymorphisms in the FTO (fat mass- and obesity-associated) gene are associated with obesity. The mechanisms how genetic variation in this gene influences body weight are unknown. Body weight is determined by energy intake/storage and energy expenditure. In this study, we investigated whether genetic variation in FTO influences energy expenditure or food intake in carefully phenotyped subjects. In 380 German subjects, insulin sensitivity was measured by a hyperinsulinemic euglycemic clamp. Lean body mass and body fat were quantified using the bioimpedance method. Indirect calorimetry was used to estimate the metabolic rate. Food intake was assessed using food diaries (mean 11+/-1 d) in 151 subjects participating in a lifestyle intervention program to prevent diabetes. All subjects were genotyped for the FTO single nucleotide polymorphism (SNP) rs8050136. The risk allele of SNP rs8050136 was associated with higher body fat-related parameters (all p< or =0.04, additive inheritance model). Energy expenditure was not affected by the SNP. However, the risk allele of rs8050136 was significantly associated with higher energy intake (p=0.01, dominant inheritance model) during dietary restriction. Our data suggest that the increased body weight in carriers of the risk allele of FTO SNP rs8050136 is a consequence of increased food intake, but not of impaired energy expenditure.

Polymorphisms in the TCF7L2, CDKAL1 and SLC30A8 genes are associated with impaired proinsulin conversion.

AIMS/HYPOTHESIS: Variation within six novel genetic loci has been reported to confer risk of type 2 diabetes and may be associated with beta cell dysfunction. We investigated whether these polymorphisms are also associated with impaired proinsulin to insulin conversion. METHODS: We genotyped 1,065 German participants for single nucleotide polymorphisms rs7903146 in TCF7L2, rs7754840 in CDKAL1, rs7923837 and rs1111875 in HHEX, rs13266634 in SLC30A8, rs10811661 in CDKN2A/B and rs4402960 in IGF2BP2. All participants underwent an OGTT. Insulin, proinsulin and C-peptide concentrations were measured at 0, 30, 60, 90 and 120 min during the OGTT. Insulin secretion was estimated from C-peptide or insulin levels during the OGTT using validated indices. We used the ratio proinsulin/insulin during the OGTT as indicator of proinsulin conversion. RESULTS: In our cohort, we confirmed the significant association of variants in TCF7L2, CDKAL1 and HHEX with reduced insulin secretion during the OGTT (p<0.05 for all). Variation in SLC30A8, CDKN2A/B and IGF2BP2 was not associated with insulin secretion. The risk alleles of the variants in TCF7L2, CDKAL1 and SLC30A8 reduced proinsulin to insulin conversion (p<0.05 for all), whereas the risk alleles in HHEX, CDKN2A/B and IGF2BP2 were not associated with reduced proinsulin to insulin conversion (p>0.6). CONCLUSIONS/INTERPRETATION: Diabetes-associated variants in TCF7L2 and CDKAL1 impair insulin secretion and conversion of proinsulin to insulin. However, both aspects of beta cell function are not necessarily linked, as impaired insulin secretion is specifically present in variants of HHEX and impaired proinsulin conversion is specifically present in a variant of SLC30A8.

The laryngeal tube for difficult airway management: a prospective investigation in patients with pharyngeal and laryngeal tumours.

BACKGROUND AND OBJECTIVE: Since the introduction of the laryngeal mask into clinical practice, various additional supraglottic ventilatory devices have been developed. Although it has been demonstrated that the laryngeal tube is an effective airway device during positive pressure ventilation no clinical study has been performed thus far regarding its use in patients with predicted ventilation and intubation difficulties. METHODS: The aim of this study was to prospectively evaluate the use of the laryngeal tube for temporary oxygenation and ventilation in adult patients with supraglottic airway tumours scheduled to undergo a pharyngeal-laryngeal oesophagoscopy and bronchoscopy under general anaesthesia. In addition to our standard airway management with face mask ventilation and rigid bronchoscopy, all patients were temporarily ventilated with an laryngeal tube. Also, in patients requiring laryngeal biopsies, endotracheal intubation was performed with a 6.0 mm microlaryngeal tracheal tube. Minute ventilation volumes, tidal volumes, ventilation pressures, end-expiratory CO2 concentration, oxygen saturation and arterial blood gas samples were measured. RESULTS: From 54 enrolled patients only patients with relevant tumour masses were evaluated (n = 23). Mask ventilation was performed without difficulty in 15 of 23 patients. Mechanical ventilation with the laryngeal tube was possible in 22 of 23 patients with an audible leak present in three. Conventional endotracheal intubation was successfully performed in 19 of 23 patients. During face mask ventilation, minute volume, tidal volume, ventilation pressure, end-tidal CO2, oxygen saturation and arterial PO2 were significantly lower and PCO2 significantly higher (P < 0.05, paired t-test). No statistically significant differences were noted between the laryngeal tube and the microlaryngeal tracheal tube. CONCLUSIONS: The possibility of difficult ventilation and intubation must always be considered, in patients with supraglottic airway tumours. In these cases, the laryngeal tube can be considered for routine airway management and may be useful in the 'cannot-intubate' situation although difficulties should be anticipated in patients with previous irradiation, specifically of the throat area.

[Co-maintenance with propofol and midazolam: sympathoadrenergic reactions, hemodynamic effects, stress response, EEG and recovery]. / Die "Co-Maintenance" mit Propofol und Midazolam: Sympatho-adrenerge Reaktionen, Kreislaufeffekte, Stressreaktion, EEG und Aufwachverhalten.

OBJECTIVE: The study was undertaken to investigate the influence of TIVA with propofol, midazolam and fentanyl (comaintenance, COM-group) or TIVA with propofol and fentanyl (control-group) on sympathoadrenergic and hemodynamic reactions, stress response, EEG and recovery. METHODS: After ethical approval, 2 x 20 patients of ASA-risk I - III over 55 years of age undergoing visceral surgery were investigated in a prospective randomized design. For induction of anesthesia, patients of the COM-group received 0,05 mg/kg BW midazolam und 1,0 mg/kg BW propofol, and anesthesia was maintained with 0,05 mg/kg BW/h midazolam (until 15 - 30 min before the end of the operation) together with propofol in decreasing doses of 10 - 5 - 2 mg/kg BW/h. In the control-group, 2,0 mg/kg BW propofol were used for induction followed by decreasing doses of 10 - 5 - 2 mg/kg BW/h as well. Premedication (0,1 mg/kg BW midazolam orally) and weight-dependent doses of fentanyl (2,5 microgram/kg BW for induction, 1,25 microgram/kg BW 2 min before skin incision, further repetition doses of 1,25 - 2,5 microgram/kg/BW as required) and vecuronium were equal in both groups. Beyond consumption of anesthetics and recovery, sympathoadrenergic, other endocrine and hemodynamic reactions and SEF 90 were investigated at 7 time points before induction and postoperative recovery. alpha 70 years) and duration of anesthesia and operation were comparable in both groups. Consumption of midazolam was higher in the COM-Group (14,8 vs. 7,5 mg; p = 0,004), whereas doses of fentanyl and vecuronium were comparable in both collectives. Recovery was significantly (p = 0,004) delayed in the COM-group: observing of simple orders 12,6 vs. 5,8 min, orientation with respect to person 19,8 vs. 9,9 min, local orientation 23,1 vs. 11,3 min. Mean arterial pressure in the COM-group was throughout lower than in the control-group, whereas heart rate was higher during the course of operation. Endocrine stress parameters (adrenaline, noradrenaline, antidiuretic hormone, adrenocorticotropic hormone, cortisol) and spectral edge frequency (SEF 90; Dräger-pEEG) were comparable in group level and time course between both groups. Plasma-concentrations of midazolam were significantly higher in the COM-group. CONCLUSION: In elderly patients undergoing visceral surgery in TIVA and when compared with propofol alone, no benefit of coinduction and comaintenance with midazolam and propofol could be demonstrated with respect to hemodynamic reactions and sympathoadrenergic and other endocrine stress response as well. Recovery was significantly delayed after administration of midazolam.

Detection of anaphylatoxin receptors on CD83+ dendritic cells derived from human skin.

Dendritic cells (DC) are recruited to sites of inflammation for the initiation of immune responses. As the anaphylatoxins C5a and C3a are important mediators of inflammation, we investigated the expression of their receptors (C3aR and C5aR) on human DC. DC were isolated from human skin or generated from purified blood monocytes and were identified by their expression of CD1a or CD83. Freshly isolated or cultured dermal CD1a+ and CD83+ DC bound anti-C5aR and anti-C3aR monoclonal antibodies (mAbs), as detected by flow cytometry. C5a induced calcium fluxes in dermal CD1a+ and CD83+ DC, which could be inhibited by C17/5, an anti-C5a mAb. C3a did not induce calcium fluxes in these cells. Anaphylatoxin receptor expression was down-regulated on dermal DC by adding tumour necrosis factor-alpha (TNF-alpha) to the culture medium. On CD1a+ CD83- cells generated from isolated blood monocytes by culture with 6.25 ng/ml of granulocyte-macrophage colony-stimulating factor (GM-CSF) and 125 U/ml of interleukin-4 (IL-4), expression of both C5aR and C3aR was observed. In these cells, both C5a and C3a induced calcium fluxes. After addition of TNF-alpha to the culture medium, the majority of the CD1a+ cells expressed CD83+. These cells - expressing a phenotype of 'mature DC' - down-regulated the expression of the anaphylatoxin receptors and lost their reactivity to the respective ligands. Our results demonstrate the expression of the anaphylatoxin receptors C5aR and C3aR on human skin-derived DC and blood-derived cells expressing the DC-associated membrane molecule, CD1a. Furthermore, the expression of anaphylatoxin receptors on CD83+ dermal DC is indicative of an intermediate stage of maturation of these cells, which was not observed on in vitro-differentiated CD83+ cells.

Activated human T lymphocytes express a functional C3a receptor.

The C3a molecule is an anaphylatoxin of the C system with a wide spectrum of proinflammatory effects predominantly on cells of myeloid origin. In this study we investigated the expression of the high affinity receptor for C3a (C3aR) in human T lymphocytes using receptor-specific mAb. C3aR expression was detected in CD4(+) and CD8(+) blood- or skin-derived T cell clones (TCC) from birch pollen-sensitized patients with atopic dermatitis. No significant difference in C3aR expression in CD4(+) or CD8(+) TCCs could be observed. In contrast to C3a(desArg), C3a led to a transient calcium flux in TCCs expressing the C3aR, whereas C3aR-negative TCCs were unreactive. Circulating T cells from patients suffering from severe inflammatory skin diseases expressed the C3aR, whereas no expression of C3aR could be found in unstimulated T lymphocytes from patients with mild inflammatory skin diseases or from healthy individuals. Type I IFNs, which are potent stimulators of cellular immunity, were identified as up-regulators of C3aR expression in vitro in freshly isolated or cloned T lymphocytes. Moreover, C3aR(+) T cells were found at the sites of injection in IFN-beta-treated patients with multiple sclerosis. These data provide direct evidence for the expression of C3aR on activated human T lymphocytes; this may point to a biological function of C3a in T cell-dependent diseases.

Orally administered lead chloride induces bias of mucosal immunity.

The hypothesis that lead disturbs gut immune functions upon oral ingestion was tested. Long-term exposure to oral PbCl(2)for 10 days caused persistent downregulation of TGF-beta mRNA levels in intestinal tissue. PbCl(2) also disturbed oral tolerance induction to the dietary antigen ovalbumin. Upon challenge with an immunizing dose of ovalbumin and rechallenge of draining lymph node cells in vitro, tolerance induction was partially suppressed in animals exposed to oral PbCl(2). This was shown by increased proliferation to antigenic stimulus, increased production of IFN-gamma and decreased secretion of TGF-beta. In conclusion, we show for the first time that oral exposure to PbCl(2)has a significant effect on the gut immune system, demonstrated by a bias of the cytokine pattern towards Th(1)and by disturbed oral tolerance mechanisms.

Comparing two methods of topical anesthesia used before intravenous cannulation in pediatric patients.

INTRODUCTION: The purpose of this study was to compare the efficacy of two methods of topical anesthesia before venipuncture or intravenous cannulation of pediatric patients to assess which type of topical anesthetic would better alleviate pain in the least amount of time with the greatest success rate of cannulation. METHODS: This study was a randomly controlled trial of 100 preoperative pediatric patients aged 5 to 21 years. The following methods of topical anesthesia were compared: (a) iontophoresis of a topical solution of 2% lidocaine with epinephrine 1:100,000 using a Phoresor Dose Controller (PDC) with Numby Stuff electrodes and a eutectic mixture of local anesthetic and (b) 2.5% lidocaine and 2.5% prilocaine (eutectic mixture of local anesthetics [EMLA] cream). RESULTS: Children reported less pain with iontophoresis (M = 0.08) compared with EMLA cream (M = 1.88, P < .001). Time to accomplish topical anesthesia was shorter with iontophoresis (13 minutes) compared with EMLA cream (60 minutes, P < .001). Failure to accomplish venipuncture occurred 5 times with the iontophoresis method and 8 times with the EMLA method (not significant). No dermal burns resulted from use of iontophoresis. DISCUSSION: We conclude that use of iontophoresis in pediatric patients is safe, rapid, and significantly more effective than is EMLA cream in reducing pain associated with venipuncture or intravenous cannulation.

Critical care nurses' perceptions of obstacles and helpful behaviors in providing end-of-life care to dying patients.

BACKGROUND: Little is known about nurses' perceptions of obstacles or helpful behaviors ("helps") in providing end-of-life care in the intensive care setting. OBJECTIVE: To determine the importance of various obstacles and helps in providing end-of-life care as perceived by critical care nurses. METHODS: A questionnaire was mailed to 300 members of the American Association of Critical-Care Nurses. Nurses were asked to rate obstacles and helps in giving end-of-life care, and additional obstacles and/or helps, and answer demographic questions. RESULTS: Six of the top 10 obstacles were related to issues with patients' families that make care at the end of life more difficult, such as the family's not fully understanding the meaning of life support, not accepting the patient's poor prognosis, requesting more technical treatment than the patient wished, and being angry. Added obstacles related mostly to problems with physicians' behavior. Most helps were ways to make dying easier for patients and patients' families, such as agreement among physicians about care, dying with dignity, and families' acceptance of the prognosis. Added helps included allowing music, pets, and so forth into the patient's room. CONCLUSIONS: Nurses have difficulties with patients' families and physicians concerning end-of-life issues, especially when the behaviors remove the nurses from caring for a patient or cause the patient pain or prolong suffering. Nurses do not acknowledge having difficulty providing care to dying patients aside from conflicts that arise because of patients' families and physicians.