Correction: Longitudinal microbiome profiling reveals impermanence of probiotic bacteria in domestic pigeons.

[This corrects the article DOI: 10.1371/journal.pone.0217804.].

Successful treatment of a recurrent post-dural puncture headache with an epidural blood patch 18 months after the initial dural puncture.

Inadvertent dural puncture is a recognised complication of epidural insertion. Parturients are at increased risk of developing a post-dural puncture headache, which can be debilitating for a mother caring for a newborn infant. Epidural blood patch is an effective treatment in patients presenting acutely with post-dural puncture headaches but its efficacy in those with delayed presentation or with late recurrent post-dural puncture headache is less clear. We present the case of a woman with a recurrent post-dural puncture headache who was successfully treated with an epidural blood patch 18 months after the initial dural puncture. Patients who develop post-dural puncture headaches may remain symptomatic for some time and an epidural blood patch may be beneficial, following appropriate investigation.

An Under-Recognised Cause of Iatrogenic, Severe Metabolic Acidosis

Case Pyroglutamic acidosis is an uncommonly diagnosed but important cause of a high anion gap metabolic acidosis. Our case report concerns an elderly male admitted to the Intensive Care Unit (ICU) following the acute onset of coma which developed during treatment of a prosthetic joint infection. A diagnosis of pyroglutamic acidosis was ultimately made and later confirmed with laboratory testing. Blood gas analysis revealed a profound high anion gap metabolic acidosis. Treatment Treatment included withdrawal of the precipitating medications, N-acetylcysteine and sodium bicarbonate. Discussion This case highlights an unusual cause of severe metabolic acidosis caused by commonly used medications and readily reversible if recognised. This is of particular relevance in elderly, frail patients as incorrect alternate diagnoses may result in decisions which incorrectly limit critical care therapies.

Longitudinal microbiome profiling reveals impermanence of probiotic bacteria in domestic pigeons.

Probiotics are bacterial species or assemblages that are applied to animals and plants with the intention of altering the microbiome in a beneficial way. Probiotics have been linked to positive health effects such as faster disease recovery times in humans and increased weight gain in poultry. Pigeon fanciers often feed their show pigeons probiotics with the intention of increasing flight performance. The objective of our study was to determine the effect of two different probiotics, alone and in combination, on the fecal microbiome of Birmingham Roller pigeons. We sequenced fecal samples from 20 pigeons divided into three probiotic treatments, including prior to, during, and after treatment. Pre-treatment and control group samples were dominated by Actinobacteria, Firmicutes, Proteobacteria, and Cyanobacteria. Administration of a probiotic pellet containing Enterococcus faecium and Lactobacillus acidophilus resulted in increase in average relative abundance of Lactobacillus spp. from 4.7 ± 2.0% to 93.0 ± 5.3%. No significant effects of Enterococcus spp. were detected. Probiotic-induced shifts in the microbiome composition were temporary and disappeared within 2 days of probiotic cessation. Administration of a probiotic powder in drinking water that contained Enterococcus faecium and three Lactobacillus species had minimal effect on the microbiome. We conclude that supplementing Birmingham roller pigeons with the probiotic pellets, but not the probiotic powder, temporarily changed the microbiome composition. A next step is to experimentally test the effect of these changes in microbiome composition on host health and physical performance.

A randomised controlled trial of the effect of a head-elevation pillow on intrathecal local anaesthetic spread in caesarean section.

BACKGROUND: A head-elevation pillow places a patient in a ramped posture, which maximises the view of the larynx during laryngoscopy, particularly in obese parturients. In our institution an elevation pillow is used pre-emptively for neuraxial anaesthesia. We hypothesised that head-elevation may impair cephalad spread of local anaesthetic before caesarean section resulting in a lower block or longer time to achieve a T6 level. We aimed to investigate the effect of head-elevation on spread of intrathecal local anaesthetics during anaesthesia for caesarean section. METHODS: One-hundred parturients presenting for caesarean section under combined spinal-epidural anaesthesia were randomised to either the standard supine position with lateral displacement or in the supine position with lateral displacement on an head-elevation pillow. Each patient received intrathecal hyperbaric bupivacaine 11 mg, morphine 100 µg and fentanyl 15 µg. Patients were assessed for adequacy of sensory block (T6 or higher) at 10 min. RESULTS: Sensory block to T6 was achieved within 10 min in 65.9% of parturients in the Elevation Pillow Group compared to 95.7% in the Control Group (P<0.05). Compared to the Control Group, patients in the Elevation Pillow Group had greater requirements for epidural supplementation (43.5% vs 2.1%, P<0.001) or conversion to general anaesthesia (9.3% vs 0%, P<0.04). CONCLUSIONS: Use of a ramped position with an head-elevation pillow following injection of the intrathecal component of a combined spinal-epidural anaesthetic for scheduled caesarean section was associated with a significantly lower block height at 10min.

XIAP impairs Smac release from the mitochondria during apoptosis.

X-linked inhibitor of apoptosis protein (XIAP) is a potent inhibitor of caspases 3, 7 and 9, and mitochondrial Smac (second mitochondria-derived activator of caspase) release during apoptosis inhibits the activity of XIAP. In this study we show that cytosolic XIAP also feeds back to mitochondria to impair Smac release. We constructed a fluorescent XIAP-fusion protein by labelling NH(2)- and COOH-termini with Cerulean fluorescent protein (C-XIAP-C). Immunoprecipitation confirmed that C-XIAP-C retained the ability to interact with Smac and impaired extrinsically and intrinsically activated apoptosis in response to tumour necrosis factor-related apoptosis-inducing ligand/cycloheximide and staurosporine. In C-XIAP-C-expressing cells, cytochrome c release from mitochondria proceeded normally, whereas Smac release was significantly prolonged and incomplete. In addition, physiological expression of native XIAP prolonged or limited Smac release in HCT-116 colon cancer cells and primary mouse cortical neurons. The Smac-binding capacity of XIAP, but not caspase inhibition, was central for mitochondrial Smac retention, as evidenced in experiments using XIAP mutants that cannot bind to Smac or effector caspases. Similarly, the release of a Smac mutant that cannot bind to XIAP was not impaired by C-XIAP-C expression. Full Smac release could however be provoked by rapid cytosolic C-XIAP-C depletion upon digitonin-induced plasma membrane permeabilization. Our findings suggest that although mitochondria may already contain pores sufficient for cytochrome c release, elevated amounts of XIAP can selectively impair and limit the release of Smac.

[Sports after surgical treatment of a herniated lumbar disc: a prospective observational study]. / Sport nach lumbaler Bandscheibenoperation: Eine prospektive Beobachtungsstudie.

AIM: Lumbar discectomy is the most frequent spinal surgical procedure in Germany. Surgeons vary widely in their preferences with regard to patients' return to sports after spinal surgery. The self-reported sporting activity before and after microdiscectomy was evaluated in a prospective observational study with 5 year follow-up. METHOD: One hundred and five patients (mean age 45.4 years) with self-reported sporting activity before lumbar single-level discectomy were re-evaluated after 5 years. The clinical outcome was graded using a modified Prolo scale (pain and medication). RESULTS: Based on the Prolo scale, an excellent (n = 80) or good (n = 17) outcome was achieved in 92.4% of patients. Altogether, 91.4% of patients (n = 96) resumed sporting activities: 87 patients returned to their previous sport. Only 8.6% of the patients (n = 9) were unable to return to sports, for various reasons (e.g., poor general health, lumbar pain, or lack of time). The mean time until return to sports after operation was 5.8 months (range 6 weeks to 24 months).The recurrence rate was 5.7% (n = 6), with 3 of the herniations occurring before the return to sporting activities (after 1, 2 and 7 months). CONCLUSIONS: The success rate of single-level microdiscectomy in athletes was frequently good or excellent, with over 90% of patients able to return to sports. The reherniation rate after postoperative athletic activity was comparable with results reported in the literature.

An investigation of the interaction of iminosulfurane transdermal penetration enhancers with model skin preparations using NMR spectroscopy.

The (31)P NMR resonance from the inner and outer leaflets of DMPC in unilamellar vesicle bilayers has been split by use of the slowly penetrating paramagnetic shift reagent, Pr(3+). The perturbing effect of subsequently added iminosulfurane transdermal penetration enhancers (TPEs) is to accelerate the collapse of this splitting, especially in the case of the bromo derivative 3. The aforementioned acceleration of the splitting is enhanced by the addition of 16 mol% cholesterol. Conversely, 33 mol% cholesterol appears to seal the bilayer to the effect of the TPEs--even when present at 20 mol%. These observations are consistent with the deep penetration of the TPEs into the DMPC bilayer, i.e., the perturbation of the bilayer is transmembrane and supports a model in which a subset of the bromo TPE derivative 3 is kinetically trapped in the bilayer. This feature leads to an enhanced residence time of 3 in the bilayer, and by extension to the skin, and therefore to an explanation for the markedly enhanced activity of the bromo TPE derivative relative to that of other halogenated derivatives in the series of iminosulfuranes studied.

Morphometric analysis of untreated adult skulls in syndromic and nonsyndromic craniosynostosis.

The aim of this study was to perform a morphometric analysis of untreated adult skulls displaying syndromic and nonsyndromic craniosynostosis. We analyzed, in detail, 42 adult craniosynostoses (18 scaphocephaly, 11 anterior plagiocephaly, 2 trigonocephaly, 9 oxycephaly, and 2 brachycephaly) from archeological (three skulls) and pathoanatomical samples (39 skulls). The univariate and bivariate measurements from the pathological skulls were compared with 40 anatomical skulls with normal cranial vault morphology. Bony signs of chronic elevated intracranial pressure (ICP) are (1) diffuse beaten copper pattern, (2) dorsum sellae erosion, (3) suture diastasis, and (4) abnormalities of venous drainage that particularly affect the sigmoid-jugular sinus complex. The mean cranial length was significantly greater in scaphocephaly than in anatomical skulls (20.3 vs 18.0 cm), and the sagittal suture was also longer (14.3 vs 11.8 cm). There were three types of suture course in the bregma region in scaphocephaly: anterior spur (28%), normal configuration (61%), and posterior spur (11%). The plagiocephaly measurements showed nonsignificant differences, and there was no correlation between the length of the anterior and middle skull base (ipsilateral anterior-posterior shortening of the skull) and incomplete or complete suture synostosis. Bony signs of chronic elevated ICP were found in 82% of cases of oxycephaly and brachycephaly. In three such cases of oxycephaly, we found a marked (1.8-2.1 cm) elevation of bregma region. One skull (Saethre-Chotzen syndrome) yielded human DNA sufficient for polymerase chain reaction (PCR)-based amplification procedures. Mutation analyses in the FGFR3 gene revealed nucleotide alterations located in the mutational hot spot at amino acid residue 250 (g.C749). The mean cranial length in adult scaphocephaly was 12% greater than anatomical skulls. A unilateral complete or incomplete coronal synostosis can be found with or without plagiocephalic deformation. Elevation of the bregma region is a bony sign of chronic elevated ICP. These data on adult craniosynostosis could be of interest for physicians dealing with craniosynostotic children.

[Analysis of quality of life in patients with a facial prosthesis]. / Untersuchung zur Lebensqualität bei Patienten mit Gesichtsepithesen.

OBJECTIVE: This clinical study examined the quality of life of face-disabled patients who had received a facial prosthesis. PATIENTS AND METHODS: The examination of the 58 patients was performed using different questionnaires. For the evaluation of the subjective health-related quality of life an instrument constructed by the WHO was used (WHOQOQL-Bref). The Frankfurter Scales of Body Concepts (FKKS) was chosen to measure the self-assessment of the patient's own body perception. For the assessment of the present general quality of life a visual analogue scale was used (Anamnestic Comparative Self-Assessment, ACSA). Additionally an ad hoc questionnaire was used, which registers the post-therapeutic epithetic rehabilitation. The health-related quality of life of this sample was compared to a healthy one of the normal population. RESULTS: The examinations showed that the quality of life of the patients is reduced in contrast to the healthy group when the acquired defects were located in the region of the eye and the nose. The evaluation of the scales of body concepts showed that the patient's own body image was significantly altered. Body contact with other persons and their own sexual attraction was perceived as remarkably diminished. The patients believed that they spread an unpleasant odor. It is surprising that the wearers of a facial prosthesis indicated that they did not notice a restriction in the acceptance of their body by others. The influence of the application of camouflage did not have an impact on the quality of life. CONCLUSION: To improve the restricted quality of life, to the raise the reduced well-being and to strengthen the altered body experience, psychological care should be provided besides further optimization of the surgical-epithetic therapy and the camouflage technique.

[Unilateral decompressive craniectomy in left transverse and sigmoid sinus thrombosis]. / Unilaterale dekompressive Kraniektomie bei Thrombose des linken Sinus transversus und sigmoideus.

Cerebral venous and dural sinus thrombosis is a rare cause of stroke. We explore the controversial issue of anticoagulation therapy and indication for decompressive craniectomy in association with severe sinus thrombosis. The 62-year-old female patient was admitted to hospital, because of first generalized seizure. A computed tomographic (CT) scan of the brain revealed a left occipital hemorrhage. Digital subtraction angiogram showing thrombosis of the left transverse and sigmoid sinus. An intravenously administered regimen of heparin was begun, because of a protein S deficiency. On the 6th day the patients level of consciousness deteriorated, necessitating intubation, hyperventilation, and mannitol. Repeat CT scan revealed increasing edema with midline shift and obliteration of the basal cisterns, although the hemorrhagic lesion was unchanged. The patient developed signs of diencephalic dysfunction. A large left temporoparietooccipital craniectomy was performed and the dura was opened. The multiloculated intraparenchymatous hemorrhage portion of the brain was not removed. In addition, the patient was treated postoperatively with heparin therapy for three months, than a regimen of phenprocoumon was begun. Twelve months later the hemianopsia had not improved and she had an incomplete Wernicke's dysphasia. When, despite adequate anticoagulation therapy and intensive care, neurological deterioration occurs in sigmoideus and/or transversus dural sinus thrombosis with unilateral edema, a decompressive craniectomy should be considered especially in young patients.

[Degenerative changes of the cervical facet joints in the medial and lateral atlantoaxial joint - a paleopathological study]. / Degenerative Veränderungen der zervikalen Facettengelenke sowie der medialen und lateralen atlantoaxialen Gelenke - eine paläopathologische Studie.

AIM: This article describes the prevalence of degenerative changes of the upper cervical spine (C1-C2) and cervical facet joints found during investigations of spinal column remains. MATERIALS AND METHODS: This study was conducted on a sample of 196 cervical spines from southwestern Germany which derive from the 6th to 8th centuries AD. The degenerative lesions were classified into grades 1 (marginal osteophytes), 2 (uneven joint surfaces), or 3 (osseous ankylosis). RESULTS: Of the skeletons examined, 19.4 % (n = 38) showed degenerative changes of the cervical facet joints and/or upper cervical spine (mean age at death was 44 years). The medial (6.1 %) and lateral (0.6 %) atlanto-axial joints were rarely involved in degenerative changes. The facet joints from C3-C4 to C6-C7 showed degenerative changes in 8.0-11.7 % of cases (usually grade 1 and 2). The C2-C3 facet joints were significantly involved in degenerative changes in 19.7 % of cases, one fourth of which were osseous ankylosis (grade 3). CONCLUSION: The C2-C3 facet joints showed a high rate of degenerative changes.

Concomitant renal cell carcinoma with pituitary adenoma.

Renal cell carcinoma has a complex and variable natural history. We report a case underlining this who presented concomitant renal cell carcinoma metastasis with pituitary and adrenocortical adenomas. A 62-year-old woman presented with visual loss. Imaging revealed a large sellar mass with suprasellar extension. Four years before, nephrectomy and adrenalectomy had been performed for a renal cell carcinoma with metastasis in a coexistent adrenocortical adenoma. Faced with progressive visual loss and the questionable pituitary pathology, the patient underwent trans-sphenoidal surgery. Due to profuse tumor bleeding, only a biopsy was possible. In a second operation, the patient underwent craniotomy with subtotal resection of the tumor. Histological examination of the specimen revealed a metastasis of the renal cell carcinoma and a pituitary adenoma. The case presented here and a review of the reports suggest that there are some differences between the clinical features and outcomes of metastases of renal cell carcinoma and those of pituitary gland metastases from other primary sites.

[Parasagittal meningioma in a skull dated 32500 years before present from southwestern Germany]. / Parasagittales Meningeom bei einem 32500 Jahre alten Schädel aus dem Südwesten von Deutschland - Neue Erkenntnisse über den Umgang mit Krankheit in der Altsteinzeit.

Summary. During excavation in 1931 by Riek in the cave of Vogelherd close to Stetten in the Lone Valley in southwestern Germany there was found an anatomically modern human skull (called: "Stetten 2") dated 32500 years before present. The skull was excavated without postcranial skeleton in the cave and showed no signs of burial. Paleopathological examinations of the calvarium reveals skeletal abnormalities that indicate parasagittal meningioma next to the bregma. Paracentral Meningiomas cause seizures and focal weakness, followed by headache. These observations are discussed in the context of modern medical knowledge. Our theory integrated archaeological, anthropological and paleopathological knowledge and helped to create the understanding of Paleolithic and earliest modern man knew regarding the "brain" and illness.

[Spontaneous intraspinal epidural hematoma secondary to use of platelet aggregation inhibitors]. / Spontanes intraspinales epidurales Hämatom unter medikamentöser Hemmung der Thrombozytenaggregation.

HISTORY AND ADMISSION FINDINGS: A 64-year-old woman previously in good health experienced an acute onset of severe neck pain and weakness of the left arm that had developed within minutes. Neurological examination revealed paresis of the left arm. There was a previous history of cardiovascular disease and she had been treated with 100 mg of aspirin per day. INVESTIGATIONS: MRI revealed a left posterolateral intraspinal mass extending from C3 to C7. The hemostatic evaluation showed no abnormalities (platelet count, prothrombin time, partial thromboplastin time). TREATMENT AND COURSE: A laminectomy with evacuation of the epidural hematoma was performed. The postoperative course was uneventful, with complete disappearance of the neurological deficit. CONCLUSION: We report a rare condition of spontaneous spinal epidural hematoma that was associated with aspirin intake. A short time interval from onset of symptoms to diagnosis (MRI) and surgery is crucial for the outcome.

[Effects of thrombolysis on left and right ventricular diastolic function in patients after myocardial infraction. One-year follow-up]. / Wplyw leczenia trombolitycznego na czynnosc rozkurczowa lewej i prawej komory u pacjentów po zawale sciany przedniej. Obserwacja roczna.

UNLABELLED: It has been shown, that successful reperfusion of the infarctrelated artery by thrombolysis can prevent left ventricular (LV) dilatation and dysfunction. To date no study has shown the impact of thrombolytic therapy on LV and RV diastolic filling. The aim of the study was to assess the effects of thrombolysis on LV and RV diastolic inflow and systolic function of LV in patients (pts) after anterior myocardial infarction MI. METHODS: Echocardiographic and Doppler-derived measurements of LV systolic function, RV and LV diameters and diastolic function at rest and after treadmill exercise test (TET) were assessed prospectively in 21 patients (pts) after MI treated with streptokinase and 10 pts treated without thrombolysis during one-year follow-up. They were compared with 31 age-matched controls. RESULTS: LV and RV filling indices in both groups of pts after MI were impaired compared to controls but in pts without thrombolysis were more abnormal compared to pts treated with thrombolysis. Among several echocardiographic variables most consistent alteration was shortening of E-deceleration time of mitral as well as RV inflow, more abnormal in pts without thrombolysis. There was strong inverse relation between degree of impairment of diastolic variables and exercise capacity. CONCLUSIONS: These data indicates beneficial effect of thrombolysis on RV and LV diastolic function in patients after AMI. E-deceleration was the most sensitive marker of diastolic dysfunction.