Julian Marschalek

Glutamate Decarboxylase67 is Expressed in Hippocampal Mossy Fibers of Temporal Lobe Epilepsy Patients

Recently, expression of glutamate decarboxylase‐67 (GAD67), a key enzyme of GABA synthesis, was detected in the otherwise glutamatergic mossy fibers of the rat hippocampus. Synthesis of the enzyme was markedly enhanced after experimentally induced status epilepticus. Here, we investigated the expression of GAD67 protein and mRNA in 44 hippocampal specimens from patients with mesial temporal lobe epilepsy (TLE) using double immunofluorescence histochemistry, immunoblotting, and in situ hybridization. Both in specimens with (n = 37) and without (n = 7) hippocampal sclerosis, GAD67 was highly coexpressed with dynorphin in terminal areas of mossy fibers, including the dentate hilus and the stratum lucidum of sector CA3. In the cases with Ammons horn sclerosis, also the inner molecular layer of the dentate gyrus contained strong staining for GAD67 immunoreactivity, indicating labeling of mossy fiber terminals that specifically sprout into this area. Double immunofluorescence revealed the colocalization of GAD67 immunoreactivity with the mossy fiber marker dynorphin. The extent of colabeling correlated with the number of seizures experienced by the patients. Furthermore, GAD67 mRNA was found in granule cells of the dentate gyrus. Levels, both of GAD67 mRNA and of GAD67 immunoreactivity were similar in sclerotic and nonsclerotic specimens and appeared to be increased compared to post mortem controls. Provided that the strong expression of GAD67 results in synthesis of GABA in hippocampal mossy fibers this may represent a self‐protecting mechanism in TLE. In addition GAD67 expression also may result in conversion of excessive intracellular glutamate to nontoxic GABA within mossy fiber terminals.

Effect of intraportal infusion of tacrolimus on ischaemic reperfusion injury in orthotopic liver transplantation: a randomized controlled trial

The increased use of older and/or marginal donor organs in liver transplantation over the last decade calls for strategies to minimize ischaemic reperfusion (I/R) injury to prevent early graft failure. Tacrolimus, a very potent and effective calcineurin inhibitor, was selected because of its ability to ameliorate I/R injury. A randomized, blinded, controlled single‐centre trial of 26 liver transplant recipients was performed between February 2008 and December 2009. Donor organs were randomized to be perfused intraportally during liver transplantation with 1.5 l 5% albumin infusion containing either 20 ng/ml tacrolimus or placebo. The primary end point was liver function as assessed by aspartate transaminase (AST) or alanine transaminase (ALT) levels 6 days after transplantation. Treatment effectiveness was tested by transcriptome‐wide analysis of biopsies. There was no difference in the primary end point, i.e. AST (IU/l) and ALT (IU/l) at day 6 after transplantation between groups. Furthermore, choleastatic parameters as well as parameters of liver synthesis were not different between groups. However, tacrolimus treatment suppressed inflammation and immune response in the transplanted liver on a genome‐wide basis. Intrahepatic administration of tacrolimus did not result in a reduction of AST and ALT within the first week after transplantation. (ClinicalTrials.gov number: NCT00609388)

Anatomic outcomes after pelvic-organ-prolapse surgery—comparing uterine preservation with hysterectomy

OBJECTIVE Pelvic organ prolapse (POP) is of growing importance to gynecologists, as the estimated lifetime risk of surgical interventions due to prolapse or incontinence amounts to 11-19%. Conflicting data exist regarding the effectiveness of POP surgery with and without uterine preservation. We aimed to compare anatomic outcomes in patients with and without hysterectomy at the time of POP-surgery and identify independent risk factors for symptomatic recurrent prolapses. STUDY DESIGN In this single-centre retrospective analysis we analyzed 96 patients after primary surgical treatment for POP. These patients were followed up with clinical and vaginal examination six months postoperatively. For comparison of the groups, the chi-squares test were used for categorical data and the u-test for metric data. A logistic regression model was calculated to identify independent risk factors for recurrent prolapse. RESULTS Of 96 patients, 21 underwent uterus preserving surgery (UP), 75 vaginal hysterectomy (HE). Median operating time was significantly shorter in the UP group (55 vs. 90min; p=0.000). There was no significant difference concerning postoperative urinary incontinence or asymptomatic relapse (p>0.05), whereas symptomatic recurrent prolapses were significantly more common in the UP group (23.8% vs. 6.7%; p=0.023). However, in multivariate analysis, only vaginal parity and sacrospinous ligament fixation were identified as independent risk factors for recurrent prolapse after POP surgery. CONCLUSION Uterus-preservation at time of POP-surgery is a safe and effective alternative for women who wish to preserve their uterus but is associated with more recurrent symptomatic prolapses.

Ability of an orally administered lactobacilli preparation to improve the quality of the neovaginal microflora in male to female transsexual women

OBJECTIVE Lactobacilli have been found in the neovagina of very low numbers of transsexual women. We undertook this study to determine whether an orally administered preparation of four lactobacilli strains exerts some measurable effect on the neovaginal microflora of female transsexuals. STUDY DESIGN 60 male to female transsexual women with penile linked neovagina were randomised into two groups. Women in the intervention group (n=33) received oral probiotic capsules and women in the control group (n=27) placebo in for 7 days. Swabs of the neovagina were taken before and after the therapy. RESULTS Comparing the first and second swabs, we observed a significant improvement of the Nugent score in the intervention group 16 (48.5%) vs. low improvement in control group 4 (14.8%) (p<0.006). The neovaginal microflora was significantly enriched with lactobacilli after oral supplementation compared to placebo. In the intervention group, an increase by 10,000±600 colony forming units (CFU) of presumptive lactobacilli was observed, compared with an increase by 1600±100CFU in the control group (p<0.0001). When measured by real-time PCR (c/ml), lactobacilli increased by 1400±100c/ml in the intervention group and 300±100c/ml in the control group (p<0.0001). CONCLUSION There was an improvement of vaginal lactobacilli microflora after of oral supplementation with lactobacilli strains in transsexual women.

Molecular detection of Lactobacillus species in the neovagina of male-to-female transsexual women

There is a general opinion that penile skin lined neovagina of transsexual women is not able to support the growth of lactobacilli. This study was undertaken to prove if lactobacilli strains could survive in neovagina and to characterise the most dominant Lactobacillus species. Sixty three male-to-female transsexual women without abnormal vaginal discharge, clinical signs of infection were recruited on an ongoing basis from among transsexual outpatients in an academic research institution and tertiary care centre. Neovaginal smears were taken for molecular Lactobacillus spp. profiling by denaturing gradient gel electrophoresis (PCR–DGGE). Lactobacillus species were detected from 47/63 transsexual women (75%). The 279 Lactobacillus signals detected by PCR-DGGE technique belonged to 13 different species. Lactobacilli of the L. delbrueckii group (L. gasseri, L. crispatus, L. johnsonii, L. iners, L. jensenii) were predominant. More than 90% of women harboured a combination of two or more neovaginal Lactobacillus species. In this study we report the frequent occurrence of lactobacilli from neovagina of transsexual women. Both, frequency and composition were similar to the normal lactic acid bacterial microflora in both women of reproductive age and postmenopausal women.

Maternal smoking and fetal lung volume—an in utero MRI investigation

To investigate whether fetal lung volume and fetal lung volume growth over gestation are different in mothers who reported smoking during pregnancy compared to non‐smoking controls.

Non‐persistent effect of short‐term bisphosphonate treatment in preventing fractures after liver transplantation

Bone disease is one of the most common complications after transplantation, affecting many transplant patients; some of them have recurrent fractures. We recently showed that high-dose zoledronic acid (ZOL) prevents bone fractures after orthotopic liver transplantation (OLT) [1]. The anti-re-absorptive action of ZOL became evident after 6 months, resulting in a beneficial outcome on bone matrix mineralization [2]. Renal function was not affected by bisphosphonate therapy. This study was carried out to determine whether a high-dose bisphosphonate treatment within the first 12 months exerted long-term beneficial effects on bone mineralization and turnover, preventing fractures. For this purpose, all subjects received conventional X-ray, bone mineral density (BMD) measurements and determination of serologic markers of bone turnover 3 years after transplantation. The long-term consequence of this treatment is yet to be investigated. Baseline characteristics, cumulative steroid dose, creatinine values and liver function parameters did not differ significantly. A total of 96 patients underwent randomization (49 patients in the control (CON) group and 47 in the ZOL group) at the beginning of the trial and 29 patients were analysed in the CON and 28 in the ZOL group after 36 months of engraftment. The ZOL and CON groups did not differ significantly in major baseline characteristics (Table 1). Three new fractures at 12 months after OLT occurred in the ZOL group (total numbers over 36 months: n = 7), these ‘late’ fractures were asymptomatic and detected by X-ray: no further fractures could be seen after 12 months in the CON group (total numbers over 36 months: n = 11). Two patients with ‘late’ fractures had a normal BMD after 12 months. The third patient had osteopenia at the lumbar spine after 1 year of transplantation. All fractures were vertebral fractures. No clinical sign or biochemical parameter could be detected to predict these late fractures. The preventive effect of bisphosphonate treatment after engraftment for fractures was not sustained from 12 months to 3 years (P = 0.076) (Fig. 1). BMD of the femoral neck and lumbar spine increased significantly in both groups (P < 0.001) from the time of transplantation until the third year after OLT. The increase in BMD t-scores of the lumbar spine in the same time interval also reached statistical significance in both groups (P = 0.006). No statistically significant differences could be detected in BMD t-scores of the femoral neck in both groups 36 months after OLT (P = 0.125). Osteoprotegerin, C-telopeptide, calcitonin, iPTH, osteocalcin and bone specific alkaline phosphatase were not significantly different at 12 and 36 months after OLT between both groups. Accordingly, adequate conversion of 25OHVitD to bioactive 1,25 (OH)-VitD occurred within 12 months in both groups and continued to be sufficient in the following years. Serum calcium and phosphate levels were similar in both groups at every time point (Table 2). One patient suffered from osteonecrosis of the jaw 25 months after OLT and 13 months after the last ZOL infusion. CON-, but not ZOL, -treated patients lost bone mineral density at femoral neck in the first 6 months. From the sixth month onwards, femoral neck BMD increased in both groups, being statistically higher at 3 years than at 12 months. The BMD of the lumbar spine increased in the ZOL the CON group in the first 12 months without a statistically significant difference between the groups. After 1 year, the BMD of lumbar spine increased and was statistically higher at 3 years than that at 12 months. This effect is most likely driven by the fact that the corticosteroid doses are significantly higher early after transplantation than doses used for the maintenance of immunosuppression after the first year. Millonig et al. [3] used a study protocol involving alendronate in combination with calcium/VitD to prevent bone loss after OLT. The study was not powered to assess fractures. In this trial, patients were stratified by BMD before transplantation and patients with osteopenia or osteoporosis received alendronate after OLT. Similar to like their results, we found that patients who received bisphosphonate did not experience significant bone loss in the lumbar spine in the early phase after OLT. We could even demonstrate a significant increase of BMD in femo-

Prevalence of genital dysplasia after kidney transplantation--a retrospective, non-interventional study from two centers.

Renal transplant patients are at increased risk for human papillomavirus‐related malignancies of the lower genital tract. Our aim was to describe the incidence of genital dysplasia, assess the most common cervical cancer screening intervals and identify independent risk factors for the development of genital dysplasia in renal transplant patients.

Rectal Lactobacillus Species and Their Influence on the Vaginal Microflora: A Model of Male‐to‐Female Transsexual Women

INTRODUCTION Based on Lactobacillus species co-colonizing the vagina and rectum, it has been hypothesized that the rectum may be an important reservoir for vaginal colonization by lactobacilli. There are no data on this issue in male-to-female transsexual women. AIM We undertook this observational study to characterize the Lactobacillus species present in the neovagina and rectum of male-to-female transsexual women and to determine the degree of neovaginal-rectal co-colonization in order to gain a better understanding of the potential role of the gut as a reservoir for genital lactobacilli. METHODS Sixty-one male-to-female transsexual women with penile skin lined neovagina without clinical signs of infection were recruited on an ongoing basis from among male-to-female transsexual outpatients. Neovaginal and rectal smears were taken for molecular Lactobacillus species profiling by denaturing gradient gel electrophoresis (PCR-DGGE). MAIN OUTCOME MEASURES Matching Lactobacillus species between neovagina and rectum. RESULTS Forty-three of the 61 male-to-female transsexual women (70.5%) simultaneously harbored the same lactobacilli in both the neovagina and rectum. We found 276 neovaginal and 258 rectal DGGE bands representing 11 Lactobacillus species, with 201 matches of the same Lactobacillus species in neovagina and rectum. 37 of the 61 women (61%) had two or more matching Lactobacillus species. CONCLUSION These data support the hypothesis that the rectum may play an important role as source of Lactobacillus species that colonies neovagina of male-to-female transsexual women. In view of the specific anatomical circumstances of the study population, these findings may be extended to the general population of women.

Pelvic floor symptoms in female cyclists and possible remedies: a narrative review

Introduction and hypothesisCycling has become a popular athletic activity worldwide and can lead to genital and pelvic floor dysfunction. This review summarizes the current body of evidence about the epidemiology of genital and pelvic floor symptoms in female cyclists, the therapy, and preventive interventions.MethodsTwo electronic meta-databases, OvidSP™ and Deutsches Institut für Medizinische Dokumentation und Information (DIMDI), comprising 40 individual databases, were searched for studies that described genital and pelvic floor symptoms in association with cycling and studies that tested possible therapies and prophylactic measures. For the literature search we explored the search terms “female”, “bicycling”, “pelvic floor”, “lower urinary tract symptoms”, and “vulvar diseases”.ResultsThe search retrieved 1,219 articles, leaving 763 articles after removal of duplicates, and finally 12 articles eligible for review. We assessed 10 observational and 2 experimental studies. Genital and pelvic floor symptoms related to bicycling were pain, tenderness, neuropathy, urological dysfunction and skin lesions. Broader and conventionally shaped saddles were associated with fewer symptoms compared with cut-out saddle designs.ConclusionThe quality of existing studies is generally low, but there is evidence that female cyclists suffer from similar problems to male cyclists, ranging from minor skin lesions to severe sequelae such as pain and neurological deficiencies.