Walking exercise in patients with intermittent claudication. Experience in routine clinical practice.

BACKGROUND: In patients with intermittent claudication, exercise in the form of walking is effective in reducing pain and maximising achievable walking distance. However, data are lacking on the implementation of walking exercise in these patients. AIMS: To explore the current behaviour and views of patients with intermittent claudication towards taking walking exercise. DESIGN OF STUDY: Postal questionnaire and focus group meetings. SETTING: Two academic general practice networks (Utrecht and Maastricht Universities) in The Netherlands. METHOD: Three hundred and seventy-five patients with intermittent claudication, selected from the files of general practitioners participating in two academic general practice networks, were sent a postal questionnaire; 216 (58%) were returned. Nine of these responders also attended a focus group meeting. RESULTS: Seventy per cent (151/216) of the patients reported having received advice about walking exercise. If specified, the advice given most often recommended walking in the local neighbourhood (56%, 84/151). Fifty-two per cent (113/216) of all patients actually performed walking exercise and only 32%of them received any kind of supervision. Among the barriers for taking walking exercise, 'comorbidity', 'lack of (specific) advice' and 'lack of supervision' were often mentioned. Among the stimuli to start and continue walking, 'following the doctor's advice', 'relief of complaints' and 'a better general condition' were often mentioned by patients. CONCLUSIONS: Walking exercise was not carried out by almost half of patients with intermittent claudication in this study. Lack of specific advice and supervision were found to be important barriers to taking walking exercise.     

Der Nachweis des frischen Herzinfarktes beim Menschen durch Bestimmung der Wasserstoffionenkonzentration im Herzmuskel mit Indicatorpapier

Zusammenfassung Bei 3 Patienten, die unmittelbar nach herzchirurgischen Eingriffen verstarben, konnte durch Bestimmung der Wasserstoffionenkonzentration [H⁺] mit Indicatorpapier am Gefrierschnitt des Herzens 1–2 Std nach dem Tod jeweils eine umschriebene ischämische Schädigung nachgewiesen und das Alter des frischen Herzinfarktes anhand der veränderten [H⁺] festgestellt werden. Innerhalb der ersten 1–2 Std nach Beginn der Herzmuskelischämie war die [H⁺] in dem ischämisch geschädigten Bereich erhöht (pH<6.0). Anschließend wies der Infarktbereich, im Randbereich beginnend, eine erniedrigte Wasserstoffionenkonzentration (pH 7.4–7.5) auf.Im Zusammenhang mit der erniedrigten [H⁺] ließ sich mit der Perjodsäure Schiff-(PAS-) Reaktion sogenanntes PAS-positives diastaseresistentes Material im Myokard nachweisen. Beim enzymhistochemischen Succinodehydrogenasenachweis fand sich in einem 7–8 Std alten Infarkt eine verstärkte Enzymreaktion.

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The demonstration of acute human cardiac infarction by determining the hydrogen ion concentration of the myocardium with indicator paper

Summary In three patients who died immediately after surgical procedures on the heart it was possible one—two hours after death to demonstrate with indicator paper on frozen sections of myocardium a circumscribed ischemic lesion and to determine the age of the infarction from the changed hydrogen ion concentration. Within the first one—two hours after the onset of ischemia the hydrogen ion concentration in the area of ischemic damage is increased (pH<6.0). Subsequently the infarcted area, beginning in the border zone, shows a decreased hydrogen ion concentration (pH appr. 7.4–7.5).As to the decreased hydrogen ion concentration, it was possible with the periodic-acid-Schiff (PAS) reaction to demonstrate so-called PAS-positive diastase-resistant material in the myocardium. The enzymhistochemical succinodehydrogenase test showed an increased enzyme reaction in an infarction which was 7–8 hours old.

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Mit Unterstützung der Deutschen Forschungsgemeinschaft.

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Vorgetragen auf der Thoraxchirurgischen Arbeitstagung, Februar 1970 in Bad Nauheim.     

M. Quadriceps femoris of Man,a muscle with an unusual enzyme activity pattern of energy supplying metabolism in mammals

1. The following enzyme activities were estimated in needle-biopsy samples of the lateral part of the human quadriceps femoris muscle: triosephosphate dehydrogenase (TPDH), lactate dehydrogenase (LDH), NAD : glycerol-3-phosphate dehydrogenase (GPDH), hexokinase (HK), NAD: malate dehydrogenase (MDH), citrate synthase (CS) and hydroxyacyl-CoA dehydrogenase. 2. Although the enzyme activities in muscles of women were lesser than in those of men, no difference was found in the calculated enzyme activity ratios. There is thus no sex-dependent metabolic type-differentiation in this muscle. 3. The human quadriceps femoris is a low-activity muscle, in comparison with muscles of homoiotherm laboratory animals. The enzyme activity ratio of TPDH to CS, characterizing the glycolytic pyruvate formation to aerobic oxidative capacities, shows this muscle to be of an intermediate type in this respect, similarly as the extensor digitorum longus of the rat. The relatively very high capacity of glucose phosphorylation (HK), the high aerobic regeneration of cytoplasmic dehydrogenated NAD (GPDH) and the very low anaerobic regeneration (LDH), show the unusually high proportion of carbohydrates (glucose) which can be broken down aerobically.     

Stress as a precipitating factor in subjects with recurrent herpes labialis

The model of recurrent herpes labialis was selected to evaluate the role played by stress in increasing susceptibility to illness. Initially, 35 paid volunteers with recurrent herpes were enrolled in the project. Compared with 35 age- and sex-matched controls, this group demonstrated a familial predisposition for recurrent herpes labialis. Eighteen subjects without confounding variables known to precipitate recurrent herpes infections completed a pretested "stress" questionnaire during a dormant and again during an active stage of infection. In the week prior to the appearance of a recurrence, this group experienced increased daily hassles, increased stressful life events, and higher state anxiety. These findings are discussed in the broader context of stress-associated disease with some speculations concerning a possible biologic mechanism, which involves modulations of T-lymphocyte function.     

Biomechanical comparison of semirigid junctional fixation techniques to prevent proximal junctional failure after thoracolumbar adult spinal deformity correction

BACKGROUND CONTEXTAdult spinal deformity patients treated operatively by long-segment instrumented spinal fusion are prone to develop proximal junctional kyphosis (PJK) and failure (PJF). A gradual transition in range of motion (ROM) at the proximal end of spinal instrumentation may reduce the incidence of PJK and PJF, however, previously evaluated techniques have not directly been compared.PURPOSETo determine the biomechanical characteristics of five different posterior spinal instrumentation techniques to achieve semirigid junctional fixation, or “topping-off,” between the rigid pedicle screw fixation (PSF) and the proximal uninstrumented spine.STUDY DESIGNBiomechanical cadaveric study.METHODSSeven fresh-frozen human cadaveric spine segments (T8–L3) were subjected to ex vivo pure moment loading in flexion-extension, lateral bending and axial rotation up to 5 Nm. The native condition, three-level PSF (T11–L2), PSF with supplemental transverse process hooks at T10 (TPH), and two sublaminar taping techniques (knotted and clamped) as one- (T10) or two-level (T9, T10) semirigid junctional fixation techniques were compared. The ROM and neutral zone (NZ) of the segments were normalized to the native condition. The linearity of the transition zones over three or four segments was determined through linear regression analysis.RESULTSAll techniques achieved a significantly reduced ROM at T10-T11 in flexion-extension and axial rotation relative to the PSF condition. Additionally, both two-level sublaminar taping techniques (CT2, KT2) had a significantly reduced ROM at T9-T10. One-level clamped sublaminar tape (CT1) had a significantly lower ROM and NZ compared with one-level knotted sublaminar tape (KT1) at T10-T11. Linear regression analysis showed the highest linear correlation between ROM and vertebral level for TPH and the lowest linear correlation for CT2.CONCLUSIONSAll studied semirigid junctional fixation techniques significantly reduced the ROM at the junctional levels and thus provide a more gradual transition than pedicle screws. TPH achieves the most linear transition over three vertebrae, whereas KT2 achieves that over four vertebrae. In contrast, CT2 effectively is a one-level semirigid junctional fixation technique with a shift in the upper rigid fixation level. Clamped sublaminar tape reduces the NZ greatly, whereas knotted sublaminar tape and TPH maintain a more physiologic NZ. Clinical validation is ultimately required to translate the biomechanics of various semirigid junctional fixation techniques into the clinical goal of reducing the incidence of proximal junctional kyphosis and failure.CLINICAL SIGNIFICANCEThe direct biomechanical comparison of multiple instrumentation techniques that aim to reduce the incidence of PJK after thoracolumbar spinal fusion surgery provides a basis upon which clinical studies could be designed. Furthermore, the data provided in this study can be used to further analyze the biomechanical effects of the studied techniques using finite element models to better predict their post-operative effectiveness.     

The a angle: a quantitative measurement of patella alignment and realignment

This case study introduces a clinical measurement of patellar glide, tin, and rotation, and defines a quantitative measurement called the A angle. An 11-year-old female with patellofemoral pain is treated using a protocol that includes a technique to align the patella through taping, stretching the lateral structures, and strengthening using functional training and isokinetics, with emphasis on the vastus medialis obliquus. The A angle may be a sensitive clinical indicator of patellofemoral pathomechanics. J Orthop Sports Phys Ther 1990;12(6):237-242.     

The pharmacokinetics of high-dose medroxyprogesterone acetate (MPA) in the therapy of advanced breast cancer

Summary Oral MPA 1.5 g/day leads to plasma concentrations between 1 and 12 g/ml, with a broad intra-and interindividual variance. The plateau state is reached in between 4 and 16 days. Plasma concentrations in the plateau state are very sensitive to dose modifications. After cessation of administration, the decline in plasma levels seems to proceed in two phases, with half-times of about 20 h and 4 days. Extraction procedures reveal no benefit in discriminating between MPA and its metabolites.     

Die Veränderungen der physikalischen Eigenschaften von Polyacetalharz (Hostaform,C®), Polyester (Hostadur®), Polyäthylen (Hostalen®) und Teflon (Hostaflon®) nach tierischer Implantation und mehrfachem Autoklavieren

Zusammenfassung Nach 4- und 12wöchiger Implantation in der Rückenmuskulatur von 6 Monate alten gleichgewichtigen männlichen Kaninchen sowie nach ein- bis viermaligem Autoklavieren erfolgte die Untersuchung von standardisierten Probekörpern aus Polyacetalharz (Polyoxymethylen-Copolymer), Polyester (Polyäthylenterephthalat), Polyäthylen und Teflon (Polytetrafluoräthylen) im Rahmen eines Zugversuches. Dabei zeigte es sich, daß Polyester durch Implantation und Autoklavieren eine starke Verminderung der viscoelastischen Eigenschaften erfährt. Während Polyäthylen und Teflon nach beiden Behandlungen im wesentlichen unveränderte Eigenschaften aufweisen, läßt sich bei Polyacetalharz nach 12wöchiger Implantation und viermaligem Autoklavieren nur eine leichte Verminderung der viscoelastischen Eigenschaften im Sinne einer Versprödung von 10 bis 15% nachweisen.Die histologisch-qualitative Beurteilung des umliegenden Gewebes ergibt eine überragende Gewebsverträglichkeit von Polyäthylen, während bei den drei übrigen Kunststoffen Polyacetalharz, Polyester und Teflon eine vergleichbare Fremdkörperreaktion nach 4 Wochen erkennbar ist, die nach 12 Wochen jedoch deutlich abgenommen hat.

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The change of physical properties of plastics (polyoxymethylenecopolymer, polyethyleneterephthalate, polyethylene, polytetrafluorethylene) after animal implantation and autoclavation

Summary The change of physical properties of plastics (polyoxymethylene-copolymer, polyethyleneterephthalate, polyethylene, polytetrafluorethylene) and the bio-compatibility of these materials were examined by implantation in the backmuscle of 6-month-old male rabbits for 4 and 12 weeks and after autoclavation.We have found out, that after implantation and autoclavation polyethyleneterephthalate demonstrates a strong diminution of the visco-elastic qualities. Polyethylene and polytetrafluorethylene were not changed by these treatments. After an implantation of 12 weeks and an autoclavation of four times the visco-elastic properties of polyoxymethylene-copolymer were only slightly diminished by 10 to 15%.The histological investigation of the surrounding tissue demonstrated a very good bio-compatibility of polyethylene. After an implantation of 4 weeks polyoxymethylene-copolymer, polyethyleneterephthalate and polytetrafluorethylene produced a comparable foreign body reaction, which, however, was evidently diminished after an implantation of 12 weeks.

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Mit Unterstützung der DFG (Schwerpunkt Biopolymere und Biomechanik von Bindegewebssystemen).

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Für Beratung und Unterstützung danken wir Herrn Prof. Dr. H. Ueberberg, Biberach, Abteilung für Experimentelle Pathologie der Firma Dr. K. Thomae.     

SRS-FISH: A high-throughput platform linking microbiome metabolism to identity at the single-cell level

One of the biggest challenges in microbiome research in environmental and medical samples is to better understand functional properties of microbial community members at a single-cell level. Single-cell isotope probing has become a key tool for this purpose, but the current detection methods for determination of isotope incorporation into single cells do not allow high-throughput analyses. Here, we report on the development of an imaging-based approach termed stimulated Raman scattering–two-photon fluorescence in situ hybridization (SRS-FISH) for high-throughput metabolism and identity analyses of microbial communities with single-cell resolution. SRS-FISH offers an imaging speed of 10 to 100 ms per cell, which is two to three orders of magnitude faster than achievable by state-of-the-art methods. Using this technique, we delineated metabolic responses of 30,000 individual cells to various mucosal sugars in the human gut microbiome via incorporation of deuterium from heavy water as an activity marker. Application of SRS-FISH to investigate the utilization of host-derived nutrients by two major human gut microbiome taxa revealed that response to mucosal sugars tends to be dominated by Bacteroidales, with an unexpected finding that Clostridia can outperform Bacteroidales at foraging fucose. With high sensitivity and speed, SRS-FISH will enable researchers to probe the fine-scale temporal, spatial, and individual activity patterns of microbial cells in complex communities with unprecedented detail.

With the rapid advances in both genotyping and phenotyping of single cells, bridging genotype and phenotype at the single-cell level is becoming a new frontier of science (1). Methods have been developed to shed light on the genotype–metabolism relationship of individual cells in a complex environment (2, 3), which is especially relevant for an in-depth understanding of complex microbial communities in the environment and host-associated microbiomes. For functional analyses of microbial communities, single-cell isotope probing is often performed in combination with nanoscale secondary ion mass spectrometry (NanoSIMS) (4–7), microautoradiography (MAR) (8, 9), or spontaneous Raman microspectroscopy (10–12) to visualize and quantify the incorporation of isotopes from labeled substrates. These methods can be combined with fluorescence in situ hybridization (FISH) using ribosomal ribonucleic acid (rRNA)-targeted probes (13), enabling a direct link between metabolism and identity of the organisms. In addition, Raman-activated cell sorting has been recently developed using either optical tweezers or cell ejection for downstream sequencing of the sorted cells (14–16). While these approaches have expanded the possibilities for functional analyses of microbiome members (17), all of the aforementioned methods suffer from extremely limited throughput. Consequently, only relatively few samples and cells per sample are typically analyzed in single-cell stable isotope probing studies, hampering a comprehensive understanding of the function of microbes in their natural environment.To overcome the limited throughput of Raman spectroscopy, coherent Raman scattering microscopy based on coherent anti-Stokes Raman scattering (CARS) or stimulated Raman scattering (SRS) has been developed (18, 19). Compared with CARS, the SRS signal is free of the electronic resonance response (20) and is linear to molecular concentration, thus permitting quantitative mapping of biomolecules (21, 22). Both CARS and SRS microscopy have successfully been applied for studying single-cell metabolism in eukaryotes (23–26). In a label-free manner, SRS imaging has led to the discovery of an aberrant cholesteryl ester storage in aggressive cancers (27, 28), lipid-rich protrusions in cancer cells under starvation (29), and fatty acid unsaturation in ovarian cancer stem cells (30) and more recently, in melanoma (31, 32). CARS and SRS have also been harnessed to explore lipid metabolism in live Caenorhabditis elegans (33–36). Combined with stable isotope probing, SRS microscopy has allowed the tracing of glucose metabolism in eukaryotic cells (37, 38) and the visualization of metabolic dynamics in living animals (25). Recently, SRS was successfully applied to infer antibiotic resistance patterns of bacterial pure cultures and heavy water (D2O) metabolism (39). Yet, SRS microscopy has not been adapted for studying functional properties of members of microbiomes as SRS itself lacks the capability of identifying cells in a complex community.Here, we present an integrative platform that exploits the advantages of SRS for single-cell stable isotope probing together with two-photon FISH for the identification of cells in a high-throughput manner. To deal with the challenges in detecting low concentrations of metabolites inside small cells with diameters around 1 µm, we have developed a protocol that maximizes the isotope label content in cells and exploits the intense SRS signal from the Raman band used for isotope detection.Conventionally, FISH is performed separately by one-photon excited fluorescence microscopy (40). To enhance efficiency, we developed a system that implements highly sensitive SRS metabolic imaging with two-photon FISH using the same laser source. These efforts collectively led to a high-throughput platform that enables correlative imaging of cell identity and metabolism at a speed of 10 to 100 ms per cell. In comparison, it takes about 20 s to record a Raman spectrum from a single cell in a conventional spontaneous Raman FISH experiment (41, 42).Our technology enabled high-throughput analysis of single-cell metabolism in the human gut microbiome. In the human body, microbes have been shown to modulate the host’s health (43, 44). Analytical techniques looking into their activities and specific physiologies (i.e., phenotype) as a result of both genotype and the environment provide key information on how microbes function, interact with, and shape their host. As a proof of principle, we used stimulated Raman scattering–two-photon fluorescence in situ hybridization (SRS-FISH) to track the incorporation of deuterium (D) from D2O into a mixture of two distinct gut microbiota taxa. Incorporation of D from D2O into newly synthesized cellular components of active cells, such as lipids and proteins, occurs analogously to incorporation of hydrogen from water during the reductive steps of biosynthesis of various cellular molecules (10, 45, 46). Importantly, D incorporation from D2O has been shown to be reliable to track metabolic activity of individual cells within complex microbial communities in response to the addition of external substrates (10, 17, 47). When microbial communities are incubated in the presence of D2O under nutrient-limiting conditions, individual cells display only minimal activity and only minor D incorporation (11, 17, 47). In contrary, when cells are stimulated by the addition of an external nutrient, cells that can metabolize this compound become active and incorporate D into macromolecules, which lead to the presence of C-D bonds into the cell’s biomass. Consequently, D incorporation from D2O can be combined with techniques able to detect C-D signals, such as Raman-based approaches, and to track metabolic activity at the single-cell level in response to a variety of compounds. Here, we show that SRS-FISH enables fast and sensitive determination of the D content of individual cells while simultaneously unveiling their phylogenetic identity. We applied this technique to complex microbial communities by tracking in situ the metabolic responses of two major phylogenetic groups of microbes in the human gut (Bacteroidales and Clostridia spp.) and of a particular species within each group to supplemented host-derived nutrients. Our study revealed that 1) Clostridia spp. can actually outperform Bacteroidales spp. at foraging on the mucosal sugar fucose and shows 2) a significant interindividual variability of responses of these major microbiome taxa toward mucosal sugars. Together, our results demonstrate the capability of SRS-FISH to unveil the metabolism of particular microbes in complex communities at a throughput that is two to three orders of magnitude higher than other metabolism identity bridging tools, therefore providing a valuable multimodal platform to the field of single-cell analysis.