Einleitung: Die Implantation kryokonservierter allogener Aortenklappen stellt heutzutage eine effektive operative Technik dar, um in schweren Fällen einer floriden Aortenklappenendokarditis exzellente postoperative Ergebnisse zu erzielen. Diese Studie demonstriert die Langzeitergebnisse im Deutschen Herzzentrum Berlin über einen Zeitraum von 17 Jahren. Material und Methoden: Zwischen dem 1.Januar 1987 und 31.Dezember 2003 wurden bei 203 Patienten mit florider Aortenklappenendokarditis kryokonservierte Aortenklappenallografts implantiert (in subkoronarer Implantationstechnik n=107 und durch totalen Aortenwurzelersatz n=96). Das mittlere Alter der Patienten betrug 51,3 Jahre (2-82 Jahre). Darunter waren 42 Frauen und 161 Männer. 161 Patienten zeigten präoperativ eine anuläre Aortenwurzelabszeßbildung. Ergebnisse: Die 30-Tage-Mortalität (mit Anulusabszeß) betrug insgesamt 21,1% (23,6%): bei nativer Aortenklappenendokarditis 14,9% (17,5%) und bei Prothesen-endokarditis 29,2% (29,6%). Nach 17 Jahren waren 70,4+3,6% und 78,6+6,3% (p=0,24) der Patienten mit und ohne präoperativem Anulusabszeß am Leben. Bei 12 Patienten mit Anulusabszeß trat eine Allograft-Re-Infektion auf, die aktualisierte Freiheit von Reinfektion betrug 91,6+2,4% nach 17 Jahren. Insgesamt wurden 37 Patienten reoperiert, die aktualisierte Freiheit von Reoperation betrug 75,0+3,7% nach 17 Jahren. Die aktualisierte Freiheit von Explantation der Allografts wegen Strukturalteration betrug bei den Patienten mit Anulusabszeß nach 17 Jahren 96,0+2,0%. Thrombembolische Ereignisse traten nicht auf. Die Univarianzanalyse identifizierte die Allograft-Re-Infektion (p=0,0001) und zu klein bemessene Allografts (p=0,001) als Risikofaktoren für eine Reoperation sowohl bei nativer als auch Prothesenendokarditis. Schlußfolgerung: Aortenklappenallografts zeigen bei florider Aortenklappenendokarditis mit Anulusabszeß exzellente Langzeitresultate. Die 30-Tage–Mortalität wird hinsichtlich der Schwere der Erkrankung akzeptiert und Re-Infektionen sind selten. Zu klein bemessene Allografts und Re-Infektionen sind Risikofaktoren für Reoperationen. / Objective: Cryopreserved aortic valve homografts have become an accepted valve substitute in acute aortic valve endocarditis, but long-term studies of valve function are largely unavailable. This survey represents our observations over a period of 17 years. Material and methods: Between February 9, 1987 and October 30, 2003, 203 patients with infective aortic valve endocarditis underwent allograft replacement of the aortic valve (free-hand subcoronary technique, n=107 and root replacement, n=96). The patients’ age ranged between 2 and 82 years with a mean age of 51.3 years. The survey included 42 females and 161 males. 161 had infected aortic root with ring abscesses. Results: The hospital mortality of patients with native and prosthetic endocarditis complicated by periannular abscess was 14.9% (17.5%) and 29.2 % (29.6%) respectively making an overall hospital mortality of 21.2% (23.6%). 17 years patient survival in patients with and without periannular abscess was 70.4+3.6% and 78.6+6.3% (p=0,24) respectively. There were 12 events of recurrent endocarditis in patients with periannular abscess, giving an actuarial freedom of 91.6+2.4% at 17 years. Reoperation was performed in 37 patients for a variety of reasons, and overall freedom from reoperation was 75.0+3.7% at 17 years. Freedom from explantation for structural valve deterioration was 96.0+2.0% at 17 years for patients with periannular abcess. No thrombembolic event was evident. Univariable analysis identified recurrent endocarditis (p=0.0001) and undersized allograft (p=0.001) as risk factors for reoperation for both native and prosthetic aortic valve endocarditis. No risk factors for hospital mortality were found. Conclusion: Aortic allograft offers an excellent long-term clinical result in patients with infective aortic valve endocarditis with associated periannular abscess. Operative mortality is acceptable based on the severity of aortic pathology, with low evidence of recurrent endocarditis and no thrombembolic events. Undersized allograft and recurrent infection are risk factors for reoperation.

Abscessos e granulomas periapicais são considerados lesões inflamatórias relacionadas a elementos dentários, com origem em infecções do tecido pulpar e periapical. É pouco conhecido o papel da interleucina 17 (IL-17) nessas lesões, uma citocina que participa ativamente de uma classe de resposta imunológica recentemente descrita, denominada Th17. A resposta Th17 tem sido caracterizada pela produção de IL-17 por linfócitos CD4+ e tem sido associada à instalação e perpetuação do processo inflamatório, bem como a intenso recrutamento de neutrófilos. Este estudo tem como foco investigar a expressão dessa citocina em lesões de abscesso e granuloma periapicais, com a intenção de verificar se há diferenças de expressão entre essas duas lesões, já que a presença de infiltrado neutrofílico difere bastante entre elas. Testes imuno-histoquímicos para IL-17, CD4 (para identificação de linfócitos T CD4+), CD8 (para identificação de linfócitos T CD8+) e elastase (para identificação de células inflamatórias polimorfonucleadas) foram realizados em casos de abscesso (n=25) e granuloma (n=25) periapicais, selecionados do acervo do Serviço de Patologia Cirúrgica da Disciplina de Patologia Bucal da FOUSP. Foi obtida a porcentagem da área de células com expressão positiva para os marcadores citados. Também foi realizada a quantificação de células CD4+/IL-17+ e CD8+/IL-17+ detectadas por imunofluorescência nessas mesmas biópsias. Foram realizados testes estatísticos de Friedman e Mann-Whitney, para se verificarem as diferenças entre as porcentagens de marcação imuno-histoquímica obtidas para o abscesso e o granuloma, bem como teste de correlação de Spearman, para se verificar se havia correlação entre a expressão de IL-17 e os demais marcadores. Nos casos de abscesso periapical, houve expressão intensa de elastase, seguida de IL-17 e CD8, cujas respectivas porcentagens de expressão não diferiram estatisticamente entre si, mas foram significativamente maiores do que a da expressão do CD4 (p<0,0001). No teste de correlação de Spearman, houve correlação positiva significante entre IL-17 e CD8 (rs = 0,5944, p=0,0415), mas não entre IL-17 e elastase e IL-17 e CD4. Na quantificação de células duplamente positivas pela técnica da imunofluorescência houve significantemente mais células CD4+/IL-17+ do que CD8+/IL-17+ (p=0,0250). Nos casos de granuloma periapical, observou-se que a porcentagem de área de marcação do CD4 foi significativamente maior em relação a da elastase (p=0,0055), do CD8 (p=0,0200) e da IL-17 (p=0,0210). Houve correlação positiva significativa entre IL-17 e elastase (rs = 0,5604, p=0,0463), mas não entre IL-17 e os demais marcadores. Na quantificação de células duplamente positivas pela técnica da imunofluorescência houve significância maior para células CD4+/IL-17 do que de células CD8+/IL-17+ (p=0,0470). Na comparação da porcentagem de área de marcação entre abscesso e granuloma, a porcentagem de IL-17 foi significativamente maior nos abscessos (p=0,0114). Concluiu-se que há maior expressão da IL-17 em abscessos do que em granulomas e que, nesses últimos, essa citocina é mais expressa quando há maior expressão de células polimorfonucleadas. Isso parece evidenciar a participação da resposta Th17 em fases agudas do processo inflamatório. Apesar de haver diferenças significativas entre as lesões quanto ao predomínio das subpopulações de linfócitos T, em ambas as lesões há maior co-expressão da IL-17 em linfócitos CD4+, indicando que provavelmente essa população linfocitária seja a principal responsável pela secreção dessa citocina nas lesões estudadas. / Periapical abscess and periapical granulomas are considered inflammatory lesions related to dental infections originated from pulpal and periodontal tissues. There is little information about the role of interleukin 17 (IL-17) on these lesions. IL-17 is a cytokine pertaining to a new class of immunological response termed Th17. Th17 response has been characterized by the IL-17 release by CD4+ lymphocytes and has been associated to stabilization and perpetuation of the inflammatory process, as well as to neutrophil recruitment. The present study focused on the investigation of the IL-17 expression in periapical abscess and periapical granuloma, in order to verify if there are differences between the lesions that could be related to level of neutrophil infiltrate. Immunohistochemical tests to IL-17, CD4 and CD8 (to identify different lymphocyte population) and elastase (to detect neutrophils) were performed in the periapical abscess (n=25) and granuloma (n=25) biopsies, selected from the collection of Surgical Pathology Service of the Department of Oral Pathology FOUSP. Percentage of the labeling area showing positive expression was obtained for the all cited markers. Counting of CD4+/IL17+ and CD8+/IL7+ cells detected by immunofluorescence was also performed. Friedman´s and Mann-Whitney non-parametric statistical tests were applied for the labeling area percentages in order to detect the significant differences between abscess and granuloma. Spearman´s correlation test was adopted to verify whether there was a correlation between IL-17 and the other markers. In the periapical abscess biopsies, elastase, IL-17, and CD8 were intensively labeled, with area percentage significantly higher than that observed for CD4 (p<0.0001). By the Spearman correlation test, there was significant positive correlation between IL-17 and CD8 (rs = 0.5944, p=0.0415), but not between IL-17 and elastase, and IL-17 and CD4. In the double staining by immunofluorescence there was significantly more CD4+/IL17+ cells than CD8+/IL17+ cells (p=0.0250). In the periapical granulomas, CD4 labeling area percentage was significantly higher than those for elastase (p=0.0055), CD8 (p=0.0200), and IL-17 (p=0.0210). There was significant positive correlation between IL-17 and elastase (rs = 0.5604, p=0.0463), but not between IL-17 and the other markers. The most frequent double staining cells were CD4+/IL17+ cells in the comparison with CD8+/IL17+ cells (p=0.0114). In conclusion, IL-17 labeling area percentage is higher in the abscess than in the granuloma; in the granulomatous lesions the IL-17 expression is directly proportional to the neutrophil infiltration. These results may indicate that the Th17 response participates to the acute phase of the apical inflammatory process. Although there were significant differences regarding the predominant T lymphocytes types, the co-expression of IL-17 and CD4 in the both inflammatory processes may suggest that this CD4+ lymphocytes are the main responsible for IL-17 release in the analyzed periapical lesions.

Abscessos e granulomas periapicais são considerados lesões inflamatórias relacionadas a elementos dentários, com origem em infecções do tecido pulpar e periapical. É pouco conhecido o papel da interleucina 17 (IL-17) nessas lesões, uma citocina que participa ativamente de uma classe de resposta imunológica recentemente descrita, denominada Th17. A resposta Th17 tem sido caracterizada pela produção de IL-17 por linfócitos CD4+ e tem sido associada à instalação e perpetuação do processo inflamatório, bem como a intenso recrutamento de neutrófilos. Este estudo tem como foco investigar a expressão dessa citocina em lesões de abscesso e granuloma periapicais, com a intenção de verificar se há diferenças de expressão entre essas duas lesões, já que a presença de infiltrado neutrofílico difere bastante entre elas. Testes imuno-histoquímicos para IL-17, CD4 (para identificação de linfócitos T CD4+), CD8 (para identificação de linfócitos T CD8+) e elastase (para identificação de células inflamatórias polimorfonucleadas) foram realizados em casos de abscesso (n=25) e granuloma (n=25) periapicais, selecionados do acervo do Serviço de Patologia Cirúrgica da Disciplina de Patologia Bucal da FOUSP. Foi obtida a porcentagem da área de células com expressão positiva para os marcadores citados. Também foi realizada a quantificação de células CD4+/IL-17+ e CD8+/IL-17+ detectadas por imunofluorescência nessas mesmas biópsias. Foram realizados testes estatísticos de Friedman e Mann-Whitney, para se verificarem as diferenças entre as porcentagens de marcação imuno-histoquímica obtidas para o abscesso e o granuloma, bem como teste de correlação de Spearman, para se verificar se havia correlação entre a expressão de IL-17 e os demais marcadores. Nos casos de abscesso periapical, houve expressão intensa de elastase, seguida de IL-17 e CD8, cujas respectivas porcentagens de expressão não diferiram estatisticamente entre si, mas foram significativamente maiores do que a da expressão do CD4 (p<0,0001). No teste de correlação de Spearman, houve correlação positiva significante entre IL-17 e CD8 (rs = 0,5944, p=0,0415), mas não entre IL-17 e elastase e IL-17 e CD4. Na quantificação de células duplamente positivas pela técnica da imunofluorescência houve significantemente mais células CD4+/IL-17+ do que CD8+/IL-17+ (p=0,0250). Nos casos de granuloma periapical, observou-se que a porcentagem de área de marcação do CD4 foi significativamente maior em relação a da elastase (p=0,0055), do CD8 (p=0,0200) e da IL-17 (p=0,0210). Houve correlação positiva significativa entre IL-17 e elastase (rs = 0,5604, p=0,0463), mas não entre IL-17 e os demais marcadores. Na quantificação de células duplamente positivas pela técnica da imunofluorescência houve significância maior para células CD4+/IL-17 do que de células CD8+/IL-17+ (p=0,0470). Na comparação da porcentagem de área de marcação entre abscesso e granuloma, a porcentagem de IL-17 foi significativamente maior nos abscessos (p=0,0114). Concluiu-se que há maior expressão da IL-17 em abscessos do que em granulomas e que, nesses últimos, essa citocina é mais expressa quando há maior expressão de células polimorfonucleadas. Isso parece evidenciar a participação da resposta Th17 em fases agudas do processo inflamatório. Apesar de haver diferenças significativas entre as lesões quanto ao predomínio das subpopulações de linfócitos T, em ambas as lesões há maior co-expressão da IL-17 em linfócitos CD4+, indicando que provavelmente essa população linfocitária seja a principal responsável pela secreção dessa citocina nas lesões estudadas. / Periapical abscess and periapical granulomas are considered inflammatory lesions related to dental infections originated from pulpal and periodontal tissues. There is little information about the role of interleukin 17 (IL-17) on these lesions. IL-17 is a cytokine pertaining to a new class of immunological response termed Th17. Th17 response has been characterized by the IL-17 release by CD4+ lymphocytes and has been associated to stabilization and perpetuation of the inflammatory process, as well as to neutrophil recruitment. The present study focused on the investigation of the IL-17 expression in periapical abscess and periapical granuloma, in order to verify if there are differences between the lesions that could be related to level of neutrophil infiltrate. Immunohistochemical tests to IL-17, CD4 and CD8 (to identify different lymphocyte population) and elastase (to detect neutrophils) were performed in the periapical abscess (n=25) and granuloma (n=25) biopsies, selected from the collection of Surgical Pathology Service of the Department of Oral Pathology FOUSP. Percentage of the labeling area showing positive expression was obtained for the all cited markers. Counting of CD4+/IL17+ and CD8+/IL7+ cells detected by immunofluorescence was also performed. Friedman´s and Mann-Whitney non-parametric statistical tests were applied for the labeling area percentages in order to detect the significant differences between abscess and granuloma. Spearman´s correlation test was adopted to verify whether there was a correlation between IL-17 and the other markers. In the periapical abscess biopsies, elastase, IL-17, and CD8 were intensively labeled, with area percentage significantly higher than that observed for CD4 (p<0.0001). By the Spearman correlation test, there was significant positive correlation between IL-17 and CD8 (rs = 0.5944, p=0.0415), but not between IL-17 and elastase, and IL-17 and CD4. In the double staining by immunofluorescence there was significantly more CD4+/IL17+ cells than CD8+/IL17+ cells (p=0.0250). In the periapical granulomas, CD4 labeling area percentage was significantly higher than those for elastase (p=0.0055), CD8 (p=0.0200), and IL-17 (p=0.0210). There was significant positive correlation between IL-17 and elastase (rs = 0.5604, p=0.0463), but not between IL-17 and the other markers. The most frequent double staining cells were CD4+/IL17+ cells in the comparison with CD8+/IL17+ cells (p=0.0114). In conclusion, IL-17 labeling area percentage is higher in the abscess than in the granuloma; in the granulomatous lesions the IL-17 expression is directly proportional to the neutrophil infiltration. These results may indicate that the Th17 response participates to the acute phase of the apical inflammatory process. Although there were significant differences regarding the predominant T lymphocytes types, the co-expression of IL-17 and CD4 in the both inflammatory processes may suggest that this CD4+ lymphocytes are the main responsible for IL-17 release in the analyzed periapical lesions.

<p>Care and treatment of women with inflammatory symptoms of the breast during lactation</p><p>Inflammation of the breast during lactation causes considerable discomfort to mothers and carries a risk of early abandonment of breastfeeding. Little is known about the effects of care interventions, including acupuncture, used for these mothers or about mothers’ experiences of the complaint. Aim: to study care and treatment given at a midwife-led breastfeeding clinic to mothers with inflammatory symptoms of the breast during lactation, to gain knowledge of mothers’ experiences of being afflicted by breast inflammation and to investigate factors which may be associated with the development of breast abscess. Methods: method triangulation was used to study different aspects of the phenomenon of inflammatory symptoms of the breast during lactation; two randomised controlled trials I (n = 88) and II (n = 210), a descriptive study III (n = 210), an interview study with a Grounded Theory approach IV (n = 14), and a population-based register study V (n = 1,454,068 singleton deliveries). Results: mothers’ symptoms were more effectively relieved when acupuncture was used but acupuncture treatment did not shorten contact with health services. Nine percent (I) and 15 % (II) respectively, of mothers were prescribed antibiotics. Twelve percent experienced renewed symptoms requiring health care contact within 6 weeks (III). Seven mothers (0.1% of breastfeeding mothers) developed breast abscess, which was comparable to the figure in the population-based study (V). The presence of Group B streptococci in the breast milk was related to longer contact with health care (II). Mothers’ “will to breastfeed” may make it possible for them to withstand physical and emotional difficulties caused by the illness. Mothers considered access to clinical expertise to be an important factor in their care (IV). Primiparous mothers, those over the age of 30 years and those who give birth after 41 weeks gestation appear to be at a significantly increased risk for the development of breast abscess (V).</p><p>Conclusions: mothers’ symptoms were more effectively dissipated when acupuncture treatment was used. However, acupuncture treatment did not shorten mothers’ contact with health care services. Interventions, including acupuncture treatment for relief of symptoms may help mothers to withstand their discomfort and await the body’s own anti-inflammatory response and therefore make it possible to substantially reduce the use of antibiotic therapy for this group. The results indicate a need for a better understanding of the influence on breastfeeding of hormones administered to birthing and breastfeeding women. The availability of immediate clinical expertise is an important factor for these mothers, which health care planners should be aware of. Information on potential breastfeeding problems should be improved.</p><p>Key words: acupuncture, antibiotics, breast abscess, breastfeeding, care interventions, inflammatory symptoms, lactation mastitis</p> / <p>Vård och behandling av kvinnor med inflammation i brösten under amningsperioden</p><p>Bröstinflammation orsakar stort obehag för ammande mödrar och innebär en risk för att amning avslutas i förtid. Det finns ringa kunskap om effekterna av interventioner, inkluderande akupunktur, som används vid vård av dessa kvinnor. Det saknas även kunskap om mödrarnas upplevelser av bröstinflammation. Syfte: att studera vård och behandling av kvinnor med bröstinflammation vid en amningsmottagning ledd av barnmorskor, att utveckla kunskap om mödrars upplevelser av att vara drabbad av bröst inflammation samt att undersöka faktorer som kan ha betydelse för utvecklandet av bröstabscess. Metoder: metodtriangulering användes för att studera olika aspekter av fenomenet bröstinflammation under amningsperioden; två randomiserade kontrollerade studier I (n = 88) and II (n = 210), en deskriptiv studie III (n = 210), en intervjustudie med en grounded theory ansats IV (n = 14) och en populationsbaserat registerstudie V (n = 1 454 068 enkelbörds förlossningar). Resultat: mödrarnas symptom lindrades mer effektivt med akupunktur akupunkturbehandling men förkortade inte deras kontakt med vården. Nio procent (I) respektive 15 % (II) av mödrarna fick antibiotika. Tolv procent fick recidiv vilket föranledde kontakt med vården inom 6 veckor (III). Sju mödrar (0,1 % av ammande mödrar) utvecklade bröstabscess (II), vilket överensstämde med resultat i den populationsbaserade studien (V). Förekomsten av Grupp B streptococcer i bröstmjölken var relaterad till längre vårdkontakt (II). Mödrarnas viljan att amma kan göra det möjligt för dem att uthärda fysiska och emotionella svårigheter som sjukdomen innebär (IV). Tillgång till klinisk expertis var en viktig del av vården för dessa kvinnor. Att vara förstföderska kan innebära en något större risk för utveckling av bröstabscess. Mödrar över 30 år samt de som föder efter graviditetsvecka 41 har också en ökad risk för abscess (V).</p><p>Slutsatser: mödrarnas symptom lindrades mer effektivt när akupunktur användes. Kontakten med vården blev dock inte förkortad av akupunkturbehandling. Interventioner som inkluderar akupunkturbehandling kan tillåta mödrar att invänta kroppens anti-inflammatoriska respons och kan därför möjliggöra en avsevärd minskning av antibiotika terapi för dessa mödrar. Resultaten visar behov av att bättre förstå hur amning påverkas av hormoner administrerade till kvinnor under förlossningsarbete och amningen. Tillgång till omedelbar klinisk expertis är en viktig faktor för dessa mödrar vilket hälso- och sjukvårdsplanerare bör vara medvetna om. Förbättrad information angående potentiella amningsproblem bör eftersträvas.</p><p>Nyckelord: akupunktur, amning, antibiotika, bröstabscess, bröstinflammation, interventioner, mastit, mjölkstockning</p>

Care and treatment of women with inflammatory symptoms of the breast during lactation Inflammation of the breast during lactation causes considerable discomfort to mothers and carries a risk of early abandonment of breastfeeding. Little is known about the effects of care interventions, including acupuncture, used for these mothers or about mothers’ experiences of the complaint. Aim: to study care and treatment given at a midwife-led breastfeeding clinic to mothers with inflammatory symptoms of the breast during lactation, to gain knowledge of mothers’ experiences of being afflicted by breast inflammation and to investigate factors which may be associated with the development of breast abscess. Methods: method triangulation was used to study different aspects of the phenomenon of inflammatory symptoms of the breast during lactation; two randomised controlled trials I (n = 88) and II (n = 210), a descriptive study III (n = 210), an interview study with a Grounded Theory approach IV (n = 14), and a population-based register study V (n = 1,454,068 singleton deliveries). Results: mothers’ symptoms were more effectively relieved when acupuncture was used but acupuncture treatment did not shorten contact with health services. Nine percent (I) and 15 % (II) respectively, of mothers were prescribed antibiotics. Twelve percent experienced renewed symptoms requiring health care contact within 6 weeks (III). Seven mothers (0.1% of breastfeeding mothers) developed breast abscess, which was comparable to the figure in the population-based study (V). The presence of Group B streptococci in the breast milk was related to longer contact with health care (II). Mothers’ “will to breastfeed” may make it possible for them to withstand physical and emotional difficulties caused by the illness. Mothers considered access to clinical expertise to be an important factor in their care (IV). Primiparous mothers, those over the age of 30 years and those who give birth after 41 weeks gestation appear to be at a significantly increased risk for the development of breast abscess (V). Conclusions: mothers’ symptoms were more effectively dissipated when acupuncture treatment was used. However, acupuncture treatment did not shorten mothers’ contact with health care services. Interventions, including acupuncture treatment for relief of symptoms may help mothers to withstand their discomfort and await the body’s own anti-inflammatory response and therefore make it possible to substantially reduce the use of antibiotic therapy for this group. The results indicate a need for a better understanding of the influence on breastfeeding of hormones administered to birthing and breastfeeding women. The availability of immediate clinical expertise is an important factor for these mothers, which health care planners should be aware of. Information on potential breastfeeding problems should be improved. Key words: acupuncture, antibiotics, breast abscess, breastfeeding, care interventions, inflammatory symptoms, lactation mastitis / Vård och behandling av kvinnor med inflammation i brösten under amningsperioden Bröstinflammation orsakar stort obehag för ammande mödrar och innebär en risk för att amning avslutas i förtid. Det finns ringa kunskap om effekterna av interventioner, inkluderande akupunktur, som används vid vård av dessa kvinnor. Det saknas även kunskap om mödrarnas upplevelser av bröstinflammation. Syfte: att studera vård och behandling av kvinnor med bröstinflammation vid en amningsmottagning ledd av barnmorskor, att utveckla kunskap om mödrars upplevelser av att vara drabbad av bröst inflammation samt att undersöka faktorer som kan ha betydelse för utvecklandet av bröstabscess. Metoder: metodtriangulering användes för att studera olika aspekter av fenomenet bröstinflammation under amningsperioden; två randomiserade kontrollerade studier I (n = 88) and II (n = 210), en deskriptiv studie III (n = 210), en intervjustudie med en grounded theory ansats IV (n = 14) och en populationsbaserat registerstudie V (n = 1 454 068 enkelbörds förlossningar). Resultat: mödrarnas symptom lindrades mer effektivt med akupunktur akupunkturbehandling men förkortade inte deras kontakt med vården. Nio procent (I) respektive 15 % (II) av mödrarna fick antibiotika. Tolv procent fick recidiv vilket föranledde kontakt med vården inom 6 veckor (III). Sju mödrar (0,1 % av ammande mödrar) utvecklade bröstabscess (II), vilket överensstämde med resultat i den populationsbaserade studien (V). Förekomsten av Grupp B streptococcer i bröstmjölken var relaterad till längre vårdkontakt (II). Mödrarnas viljan att amma kan göra det möjligt för dem att uthärda fysiska och emotionella svårigheter som sjukdomen innebär (IV). Tillgång till klinisk expertis var en viktig del av vården för dessa kvinnor. Att vara förstföderska kan innebära en något större risk för utveckling av bröstabscess. Mödrar över 30 år samt de som föder efter graviditetsvecka 41 har också en ökad risk för abscess (V). Slutsatser: mödrarnas symptom lindrades mer effektivt när akupunktur användes. Kontakten med vården blev dock inte förkortad av akupunkturbehandling. Interventioner som inkluderar akupunkturbehandling kan tillåta mödrar att invänta kroppens anti-inflammatoriska respons och kan därför möjliggöra en avsevärd minskning av antibiotika terapi för dessa mödrar. Resultaten visar behov av att bättre förstå hur amning påverkas av hormoner administrerade till kvinnor under förlossningsarbete och amningen. Tillgång till omedelbar klinisk expertis är en viktig faktor för dessa mödrar vilket hälso- och sjukvårdsplanerare bör vara medvetna om. Förbättrad information angående potentiella amningsproblem bör eftersträvas. Nyckelord: akupunktur, amning, antibiotika, bröstabscess, bröstinflammation, interventioner, mastit, mjölkstockning

Les abcès cérébraux sont des infections potentiellement mortelles, entraînant souvent des séquelles graves. La prise en charge médicale en reste empirique en raison d’un manque de connaissance approfondie des microorganismes responsables de cette condition. Dans la plupart des laboratoires microbiologiques, le diagnostic d’abcès cérébral est basé sur la culture du pus recueilli chirurgicalement. Malheureusement, cette procédure a de nombreuses limites et ne permet l’identification que d’une petite partie de la population microbienne en cause. L’amplification par PCR et le séquençage du gène codant la fraction 16S de l’ADN ribosomal ont récemment été utilisées pour surmonter les limites de la culture, et ont été démontré leur efficacité dans la documentation des infections bactériennes. Malheureusement, cette procédure présente un degré de discrimination limité en cas d’infection polymicrobienne. Des études métagénomiques de flores complexes de l’homme, basées sur une combinaison de PCR, clonage et séquençage des produits de PCR se sont avérées utiles pour évaluer la diversité bactérienne des flores dentaires, vaginales et intestinales. Nous avons appliqué cette technique à des échantillons d’abcès cérébral pour étudier la flore associée à cette maladie. Dans une première étape, nous avons réalisé une enquête en utilisant la culture et les techniques moléculaires. Le but de cette étude était d’analyser et d’évaluer les bactéries de la flore responsable des abcès cérébraux, en comparant la culture à trois techniques moléculaires basées sur le gène 16S rDNA, incluant le séquençage direct, le clonage suivi de séquençage par méthode de Sanger, et le séquençage direct des produits de PCR par pyroséquençage. Cette enquête a déterminé que la variété des espèces bactériennes associée aux abcès cérébraux est beaucoup plus grande que précédemment décrite, et inclut de nombreuses bactéries anaérobies et des bactéries incultivables de la flore buccale. Cette étude préliminaire a identifié 49 agents bactériens différents, et a permis l’identification de 27 bactéries jamais détectées auparavant dans des abcès du cérébraux, dont 15 n’avaient jamais été cultivées. Un tel nombre d’espèces bactériennes impliquées dans les abcès cérébraux a motivé l’étude de 51 nouveaux spécimens dans le but de décrire plus en détail la flore associée aux abcès cérébraux en fonction de leurs étiologies. Ainsi, nous avons effectué une analyse métagénomique, basé sur le gène 16S rDNA, de 51 patients ayant développé un abcès cérébral. Notre stratégie a été beaucoup plus discriminatoire et a permis à l’identification d’un plus grand nombre de bactéries que la culture et l’amplification et le séquençage direct de l’ANRr 16S. La combinaison des données de 71 patients (20 de la première étude et 51 de la deuxième étude) a permis l’identification de plusieurs associations à l’aide de la méthode de data mining.En outre, notre étude a permis l’identification de deux nouvelles bactéries, la première étant une nouvelle espèce de genre Staphylococcus (Staphylococcus massiliensis) et la seconde étant une bactérie anaérobie qui représente une nouvelle espèce dans un nouveau genre au sein du phylum des Bacteroidetes (Phocaeicola abscesses). En outre, nous avons décrit deux cas inhabituels d’abcès du cerveau, à Mycoplasma hominis après curetage utérin, et à Nocardia carnea chez un greffé rénal. Malgré les limites inhérentes à la procédure de clonage, nos résultats suggèrent que le clonage et le séquençage de gène DNAr 16S est une méthode très performante pour identifier les agents bactériens associés aux abcès cérébraux. / Brain abscess is a life-threatening infection with frequent serious sequelae. The medical management remains empirical due to a lack of comprehensive knowledge of the microorganisms responsible for this condition. In most microbiology laboratories the diagnosis of brain abscess is based on culture from pus collected surgically. Unfortunately, this procedure has many limitations and reveals only a small portion of the true microbial population. PCR-amplified 16S rDNA sequencing has recently been used to overcome the limitations of culture-based bacterial detection in brain abscess pus, and it was demonstrated to be effective in the documentation of monomicrobial infections. Unfortunately, this procedure failed to discriminate among polymicrobial floras.Metagenomic studies of complex human floras using a combination of 16S rDNA PCR and cloning-sequencing of PCR products proved useful to evaluate the bacterial diversity of dental, vaginal and intestinal floras. Thus, we applied this technique to brain abscess samples to study the flora associated with this condition. In a first step, we performed an investigation using culture and molecular techniques. The purpose of this investigation was to analyze and evaluate the bacterial flora responsible for brain abscess by comparing standard culture technique to three techniques using 16S rDNA amplification, that is, direct sequencing, multiple sequencing following cloning, and multiple sequencing via high throughput pyrosequencing. This investigation has determined that the variety of brain abscess-associated bacterial species is much larger than previously reported, and it includes many anaerobes and uncultured bacteria from the oral cavity flora. This preliminary study identified 49 distinct brain abscess bacterial agents, and enabled the identification of 27 bacteria never detected before in brain abscess, 15 of which were uncultured.Such a high number of bacterial species involved in brain abscess prompted the study of 51 new specimens in an effort to describe further the flora associated with brain abscesses and their etiologies. Thus, we performed a 16S rDNA-based metagenomic analysis of cerebral abscesses from 51 patients. Our strategy was significantly more discriminatory and enabled the identification of greater number of bacterial taxa, than culture and conventional 16S rDNA PCR/sequencing, respectively. The combination of data from 71 patients (20 from the first study and 51 from the second study) enabled the identification of several associations using the data mining analysis. Also, these studies permitted the identification of two novel bacteria, the first being a novel Staphylococcus species (Staphylococcus massiliensis) and the second being a novel anaerobic bacterium that represents a novel species in a new genus within the phylum Bacteroidetes (Phocaeicola abscesses). In addition, we reported tow unusual cases of brain abscess, the first case was a Mycoplasma hominis brain abscess following uterus curettage and the second case was a Nocardia carnea infection in a kidney transplant recipient patient.Despite limitations inherent to the cloning procedure, our results suggest that cloning and sequencing of PCR-amplified 16S rDNA is a highly valuable method to identify bacterial agents of brain abscesses.

Background: Psoas abscess is a rare clinical disease of various origins. Most common causes include hematogenous spread of bacteria from a different primary source, spondylodiscitis or perforated intestinal organs. But rarely some abscesses are related to malignant metastatic disease. Case presentation: In this case report we present the case of a patient with known squamous cell carcinoma of the cervix treated with radio-chemotherapy three years prior. She now presented with a psoas abscess and subsequent complete inferior vena cava thrombosis, as well as duodenal and vertebral infiltration. The abscess was drained over a prolonged period of time and later was found to be a complication caused by metastases of the cervical carcinoma. Due to the massive extent of the metastases a Whipple procedure was performed to successfully control the local progress of the metastasis. Conclusion: As psoas abscess is an unspecific disease which presents with non-specific symptoms adequate therapy may be delayed due to lack of early diagnostic results. This case report highlights the difficulties of managing a malignant abscess and demonstrates some diagnostic pitfalls that might be encountered. It stresses the necessity of adequate diagnostics to initiate successful therapy. Reports on psoas abscesses that are related to cervix carcinoma are scarce, probably due to the rarity of this event, and are limited to very few case reports. We are the first to report a case in which an extensive and complex abdominal procedure was needed for local control to improve quality of life.

Die pyogene Spondylodiszitis als bakterielle Osteomyelitis der Wirbelsäule ist eine seltene Entität der bakteriell-entzündlichen Pathologien des Stütz- und Bewegungsapparates. Trotz adäquater Behandlungsstrategien, wird auch heute noch eine Mortalitätsrate von 5% bis 20% beschrieben. Vor allem die in dem vorwiegend älteren Patientenkollektiv deutlich erhöhte Prävalenz an metabolischen oder kardiopulmonalen Komorbiditäten fordert moderne Therapiekonzepte, die eine risikoarme, jedoch effektive Eradifizierung des bakteriell-entzündlichen Fokus mit schneller Wiederherstellung der prämorbiden Mobilität ermöglichen. Ausgehend von zwei grundlagenwissenschaftlichen Studien, wurden in der vorliegenden Habilitationsschrift zunächst die komplexen Zusammenhänge von lokaler Gewebsveränderungen und systemischer Entzündung erörtert. Hierbei zeigten die Analysen humaner degenerativer und traumatischer Bandscheibenzellen, dass die Apoptose, insbesondere die Herabregulation anti-apoptotischer Schlüsselkomponenten wie das Bcl-2, als mögliche Schnittstelle im katabolen Stoffwechsel der extrazellulären Bandscheibenmatrix diskutiert werden kann. In der generalisierten bakteriellen Entzündung (Sepsis), ließ sich durch die gentherapeutisch gewebsständige Überexpression von antiapoptotischen und antiinflammatorischen Interleukin-10 (IL-10), auch im IL-10-defzienten Organismus, eine deutliche Reduktion der systemischen proinflammatorischen Immunantwort mit verbesserter Überlebensrate septischer Tiere erzielen. Jedoch birgt der substantielle Gewebeschaden bei pyogener Spondylodiszitis nicht selten die Gefahr der konsekutiven Instabilität mit neurologischen Komplikationen und stellt damit eine besondere chirurgische Herausforderung dar. Daher wurden in drei weiteren klinischen Studien unsere, in den letzten 10 Jahren etablierten, lösungsorientierten Strategien erläutert. Zur Überbrückung größerer knöcherner Defekte gelang mit der Implantation expandierbarer Titancages eine sichere knöcherne Durchbauung mit vollständiger Ausheilung des Infektes. Im Beobachtungszeitraum von mehr als 3 Jahren war bei keinem der Patienten ein Infektrezidiv zu verzeichnen. In komplexen Fällen von monosegmentaler Spondylodiszitis der LWS mit multisegmentaler epiduraler Abszedierung, führte die epidurale Katheterspülung über den dorsalen Zugang für die Spondylodese zu einer folgenlosen Ausheilung. Damit konnte ein zusätzliches, iatrogenes Trauma mit multisegmentalen Lamintomien über die Distanz des epiduralen Abszesses vermieden werden. In einer weiteren Studie mit einem Beobachtungszeitraum von bis zu 5 Jahren, erzielte die Implantation von Poly-Ether-Ether-Keton (PEEK) Cages zur dorsalen intersomatischen Fusion bei pyogener Spondylodiszitis eine sehr gute, stabile knöcherne Durchbauung des infizierten Segmentes, ebenfalls ohne Infektrezidiv. Diese Abweichung vom herkömmlichen Standard mit Titanimplantaten erwies sich somit als sichere Alternative mit den für PEEK charakteristischen, verbesserten Eigenschaften. Im Vergleich zu herkömmlichen Operationsverfahren, verspricht die Integration dieser Ergebnisse in die Weiterentwicklung minimal-invasiver Techniken, insbesondere im multimorbiden Patientenklientel, mindestens gleichwertig gute Ergebnisse bei deutlich reduziertem Operationstrauma.:1. EINFÜHRUNG IN DIE THEMATIK 1 1.1 Die pyogene Spondylodiszitis 1 1.1.1 Epidemiologie, Ätiologie und Pathophysiologie 2 1.1.2 Diagnostik und Therapie 6 1.1.2.1 Konservative Therapie 11 1.1.2.2 Operative Therapie 12 1.2 Biomechanische Aspekte 14 1.3 Wissenschaftliche Fragestellung 15 2. ORIGINALARBEITEN 20 2.1 Apoptosis of human intervertebral discs after trauma compares to degenerated discs involving both receptor-mediated and mitochondrial-dependent pathways 20 2.2 Endogenous IL-10 regulates sepsis-induced thymic apoptosis and improves survival in septic IL-10 null mice 30 2.3 Reconstruction of large defects in vertebral osteomyelitis with expandable titanium cages 39 2.4 Single-stage epidural catheter lavage with posterior spondylodesis in lumbar pyogenic spondylodiscitis with multilevel abscess formation 45 2.5 Single-stage debridement and spinal fusion using PEEK-cages through a posterior approach for eradication of lumbar pyogenic spondylodiscitis: A safe treatment strategy for a detrimental condition 52 3. ZUSAMMENFASSUNG UND AUSBLICK 62 4. LITERATURVERZEICHNIS 78 5. APPENDIX 98 5.1 Tabellen und Abbildungen 98 Tabelle 1 & 2 98 Tabelle 3 & 4 99 Abbildung 1 100 Abbildung 2 101 Abbildung 3 102 Abbildung 4 103 Abbildung 5 104 5.2 Selbständigkeitserklärung 105 5.3 Danksagung 106 5.4 Curriculum Vitae 108

Uppsatsen har analyserat tandhälsan hos 20 vuxna individer med tandsten från medeltida S:t Hans, Visby, med fokus på: tandsten, karies, abscesser, parodontit, emaljhypoplasi och ante mortem tandförlust. I syfte att dra slutsatser om populationens tandhälsa och huruvida tandsten korrelerar med övrig tandhälsa. Resultatet påvisade en population med bristande tandhälsa, där 75 % av individerna hade minst ett kariesangrepp och 19 av 20 hade parodontit. Tandhälsan lär ha resulterat i tandvärk och komplikationer av allmänhälsan för S:t Hans populationen. Varken en negativ eller positiv korrelation mellan karies och tandsten kunde bevisas i materialet. Dock konstaterades att män hade en högre tandstensgrad, medan kvinnor påvisade grövre karies. Det leder till en tolkning om könsskillnader i diet i S:t Hans. Emaljhypoplasier är funna främst hos män. Det underbygger diettolkningen, samt tolkas som en indikation på könsbunden barndoms-mortalitet. Jämförelser med samtida befolkningar utfördes för att ge en vidare inblick i materialet; S:t Hans hade statistiskt fler individer med karies samt mer parodontit. Det kan innebära olika diet på fastlandet och Visby, eller indikera att tandsten leder till försämrad tand-hälsa då samtliga analyserade individer har tandsten. / The thesis focuses on the dental health of 20 adult individuals with dental calculus from medieval St. Hans, Visby. The dental health assessments were done with a focus on dental calculus, caries, dental abscesses, periodontitis, enamel hypoplasia and ante mortem tooth loss. The result of the thesis showed a lacking dental health due to a great amount of caries, 75 % of analysed individuals had at least one instance of caries, as well as periodontitis which was found in 19 out of 20 individuals. No clear negative nor positive correlation between dental calculus and caries could be seen in the material. However, men had a higher degree of dental calculus whilst women had more severe cases of caries. This leads to a possible conclusion of differing diets between the sexes. Enamel hypoplasia is found mainly in men, which supports the theory regarding diet and is posed as an indication of sex-bound childhood mortality. St. Hans popu-lation had a greater statistic of individuals with caries than contemporary Swedish populations as well as more periodontitis. This could indicate a bad dental hygiene and dental health amongst the individuals from St. Hans or it could indicate that dental calculus leads to worsened dental health since only individuals with dental calculus were analysed.

Les méthanogènes sont des Archaea anaérobies stricts, connus pour être les seuls êtres vivants capables de produire du méthane comme sous-produit de leur métabolisme. Notre revue de littérature a montré qu’outre les espèces environnementales, l’ordre des Methanomassiliicoccales ne comptait à ce jour qu’une seule espèce Methanomassiliicoccus luminyensis isolée et cultivée dans notre laboratoire. Aucours de notre thèse, nous avons développé une nouvelle méthode permettant la culture et l’isolement des méthanogènes en absence de source externe de dihydrogène (H2) d’une part et d’autre part une méthode de génotypage Multispacer Sequence Typing (MST) basée sur le séquençage d’espaces intergéniques pour typer Methanobrevibacter smithii et M. oralis. Par la suite, nous avons mis en évidence la présence de méthanogènes en situation pathologique chez l’homme. Nous avons détecté et isolé pour la première fois au sein de flores anaérobies, M. oralis à partir d’échantillons d’abcès cérébraux, et de sinusite d’une part, et d’autre part M. smithii à partir d’un échantillon de patient souffrant d’abcès para-vertébral. Enfin, dans la cinquième partie de notre thèse, nous avons testé in vitro la sensibilité de cinq méthanogènes associés aux flores humaines à la lovastatine qui est une pro-drogue utilisée pour abaisser la concentration de cholestérol chez l’homme dans le cadre de certaines pathologies. Les cinq méthanogènes se sont avérées sensibles à une concentration minimale inhibitrice de 1µg/mL, après activation par hydrolyse de la lovastatine par des bactéries anaérobies du microbiote digestif, via une l’inhibition de la croissance et de la production du méthane. / Methanogens are strict anaerobic Archaea, known to the only being able to producing methane gas as a byproduct. Methanogens which are not detected in clinical microbiology laboratories were present in oral, digestive, vaginal and cutaneous microbiota of human. Only five species on the thirteen known in human have been cultivated before the beginning of our thesis. In our thesis, we initially reviewed the state of knowledge about methanogens in human microbiota, particularly the new order Methanomassiliicoccales of methylotrophic methanogens, the as member of human microbiota. In the second part of this work, we performing new method for methanogens culture and isolation without any dihydrogen atmosphere, by co-cultured in tubes methanogens with Bacteroides thetaiotaomicron, which produces hydrogen. We also developed Multispacer Sequence Typing (MST), a genotyping method based on intergenic spacers sequencing, to genotype M. oralis and Methanobrevibacter. Smithii. We demonstrated that methanogens could be part of polymicrobial infection in the case of brain and sinusal abscesses, and also in skeletal muscle abscess, by isolating for the first time M. oralis and M. smithii in these pathologies, using culture-based and molecular-based approaches, and suggested that methanogens could be considered as human opportunistic or emerging pathogens. Finally, we tested the in vitro susceptibility of lovastatin which is a prodrug used as a powerful serum cholesterol-lowering drug in some human diseases and showed that it’s inhibits growth and methane production in human-associated methanogens without affecting intestinal bacteria.