ARDS und schweres Schädelhirntrauma Therapiestrategien im Konflikt

The development of adult respiratory distress syndrome (ARDS) complicates the treatment of patients with severe head injury, since special therapeutic strategies for both conditions might lead to a "conflict of interest". We report on the intensive care treatment of a young man who suffered severe brain injury (Glasgow Coma Scale = 3) due to a traffic accident and simultaneously developed ARDS from the aspiration of gastric content. We performed extensive monitoring of cerebral hemodynamics and metabolism (intracranial pressure measurement, jugular bulb oxymetry, estimation of arterial-jugular bulb lactate concentration difference) to prevent cerebral hypoxia and to control cerebral hyperemia. The application of a "lung protective strategy" with "permissive hypercapnia" led to a conflict, since the development of cranial hyperemia combined with cranial hypertension a few days after trauma, warranted the concept of controlled, temporary hyperventilation. Therefore, we applied a pumpless extracorporeal lung assist to improve carbon dioxide elimination. Furthermore, we started the ventilation in the prone position, since arterial oxygenation continued to deteriorate, although there is a lack of data describing the effect of a prone position on acute cerebral injury. Positioning the patient prone, we observed a prompt increase in intracranial pressure, which resulted in pharmacological intervention (mannitol). Treating the patient by intermittent prone position, by continuous extracorporeal lung assist and aerosolized prostacyclin administration in the following period, lung function improved and ARDS was treated successfully. After withdrawing the analgo-sedation the patient's vigilance rose continuously. The patient was transferred to a rehabilitation ward 33 days after admission to the intensive care unit. The combination of ARDS and severe brain injury needs special treatment, which includes extensive monitoring techniques to find a solution for therapeutic conflicts.

Abstract P4-12-30: A bivalent Her2 targeting DARPin with high efficacy against Her2-low and Her2-positive tumors

The approval of Herceptin, Perjeta and Kadcyla has dramatically improved the outcome of the 15% of breast cancer patients with high expression of Her2 (Her2-positive, IHC3+). In contrast, up to 50% of women with breast cancer express low levels of Her2 (Her2-low, IHC+2 or +1) at diagnosis, and these patients do not derive benefit from approved Her2 targeted therapies. It is estimated that 5-10% of Her2-positive patients will also develop Her2-low metastases refractory to treatment. Therefore, new therapeutic strategies are needed to alleviate the high tumor burden of Her2-low patients.

We generated a bivalent Designed Ankyrin Repeat Protein (DARPin) containing two anti-Her2 moieties that target unique non-overlapping epitopes on Her2 (biparatopic). The biparatopic DARPin exerts a strong pro-apoptotic response on a panel of breast and gastric cancer cell lines, which cannot be fully recapitulated by treatment with Herceptin, Perjeta or both combined. DARPin treatment of Her2-positive breast cancer BT474 cells induces apoptosis (IC50 < 1nM) in virtually all cells within 24 hours, whereas single or combined treatment with Herceptin and/or Perjeta reduces proliferation by 50% (IC50 = 2-4nM). The biparatopic DARPin inhibits as well the viability (via apoptosis) of Her2-low MDAMB175 cells with a 100-fold higher potency than Herceptin. Mechanistically, treatment with the anti-Her2 biparatopic DARPin inhibits both Her2 and Her3 signaling, which in turn results in the induction of apoptosis. Interestingly, cell treatment with the mix of the two individual anti-Her2 DARPin moieties does not recapitulate the apoptotic effect of the biparatopic molecule, indicating that both moieties must be linked for maximum efficacy. In vivo, the biparatopic DARPin shows efficient anti-tumor activity in established breast cancer Her2-positive xenografts and Her2-low PDX tumor models. DARPin treatment of Her2-positive BT474 xenograft in BALB/c mice results in rapid tumor regression (50% tumor shrinkage after one dose) that is sustained at least during one month after the last dose. The biparatopic DARPin strongly inhibits tumor growth as well in a Her2-low breast cancer PDX in NMRI mice, where it demonstrates superior efficacy compared to Herceptin (DARPin/Herceptin tumor volume ratio < 30%).

In summary, biparatopic targeting of Her2 enables inhibition of both Her2 and Her3, and blocks a tumor driver and its resistance mechanism. As a result, the DARPin interferes with both the proliferation and survival of tumor cells and triggers durable anti-tumor responses in vivo. DARPin treatment of Her2 positive tumors in mice show equivalent efficacy to Herceptin with faster kinetics; an effect that is magnified in Her2-low PDX tumors where the DARPin provides superior tumor control to Herceptin. Altogether, our data demonstrate the potential for the biparatopic DARPin to surpass some of the limitations of approved Her2 targeted agents, and warrants clinical investigation.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P4-12-30.

Autoantibodies against galectin-8: their specificity, association with lymphopenia in systemic lupus erythematosus and detection in rheumatoid arthritis and acute inflammation

The role of autoantibodies in the pathogenesis of systemic lupus erythematosus (SLE) has not been completely defined. From more than a hundred autoantibodies described in SLE, relatively few have been associated with clinical manifestations. The glycan-binding proteins of the galectin family can modulate the immune system. Anti-galectin autoantibodies thus could have functional and/or pathogenic implications in inflammatory processes and autoimmunity. We previously reported function-blocking autoantibodies against galectin-8 (Gal-8) in SLE. Here we tested these autoantibodies against a series of other human galectins and demonstrated their specificity for Gal-8, being detectable in 23% of 78 SLE patients. Remarkably, they associated with lymphopenia (50% of 18 anti-Gal-8-positive versus 18% of 60 anti-Gal-8-negative cases, Fisher’s Exact test two-tailed: P < 0.012). Lymphopenia is a common clinical manifestation in SLE, yet of unknown mechanism. In addition, six of eight patients with both lymphopenia and malar rash had anti-Gal-8 in their sera. Occurrence of these autoantibodies was not confined to SLE as we also found them in sera of patients with rheumatoid arthritis (16%) and septicemia (20%). This study thus establishes occurrence of specific anti-Gal-8 autoantibodies in autoimmune rheumatic diseases and in acute inflammation, with an apparent association to a clinical subset in SLE.

Epidemiological studies of leukaemia in children and young adults around nuclear facilities: a critical review

The existence of an increased risk of childhood leukaemia near nuclear installations is a recurrent issue. A review of the related epidemiological literature is presented here. Results for 198 nuclear sites throughout 10 countries were included in the review. In addition to local studies, 25 multi-site studies have been published for eight countries. A large variability was noticed in the quality of the data as well as in the definition of the study population and in the methods of analysis. Many studies present important limits that make the results difficult to interpret. The review confirms that some clusters of childhood leukaemia cases exist locally. However, results based on multi-site studies around nuclear installations do not indicate an increased risk globally. Many studies were launched to investigate possible origins of the observed clusters around specific sites, but up to now, none of the proposed hypotheses have explained them.

[Possibilities for process optimization in orthopedic surgery]

It is mandatory to include all professions involved in the operating room (OR) in any attempt to improve the process. Early and detailed planning, short interruptions to change OR patients and a variable end of the day combined with transparent decision hierarchies help to ensure that things run smoothly. Parallel processes are essential for accelerating the change of patients. The different duties and responsibilities have to be documented. This can be done either in the records of quality management or in a special OR statutes. The evaluation and analysis of process critical parameters, including surgery as well as anesthesiology, are essential for maintaining the continuous process of improvement.

Problemfeld der Notfallverlegungen beim Schlaganfall

BACKGROUND

Specific stroke subtypes like subarachnoid hemorrhages or malignant brain infarcts require immediate interventions, but treatment options are offered mainly in specialized centers. For this reason, interhospital transfers from primary hospitals need to be done without delay.

METHODS

The telemedic pilot project for integrative stroke care (TEMPiS) connects 2 stroke centers and 12 regional hospitals in Bavaria (Germany). Core elements are the implementation of stroke wards, telemedic consultation and improvement of emergency interhospital transfers. Organization of patient transports is offered by the central telemedic service. During the first 12 months of the continuing project all interhospital transfers initiated by the central telemedic service were prospectively documented. Emergency transports were analysed according to diagnosis, type of transport, distance and time delays.

RESULTS

A total of 252 interhospital transfers were recommended in teleconsultations; finally 221 transports took place. Median total duration of transfers (including the necessary arrangements) was 134 min (interquartile range: 105-219) for intracerebral hemorrhages (N = 58), 138 min (95-157) for subarachnoid hemorrhages (N = 31), 161 min (100-230) for malignant infarcts (N = 22) and 147 min (109-180) for suspected basilar artery occlusion (N = 28). Time from admission in the primary hospital to initiation of interhospital transfer was 135 min (median; interquartile range: 86-172), transport time was 81 min (60-116). Helicopter transport did not save time for transfer distances up to 50 kilometres, compared to transport via ambulance (including assistance of hospital physicians). Transport using a special intensive care vehicle was much more time consuming because of the longer transport preparation time.

CONCLUSION

Emergency transfers of stroke patients are time consuming. This may contribute to additional harm being done to severely ill patients. Faster organization and conduct of transports is required.

Detection of an unexpected subtelomeric 15q26.2 --> qter deletion in a little girl: clinical and cytogenetic studies

Unlike the small proximal 15q deletions causing Prader-Willi and/or Angelman syndrome, distal deletions of the terminal long arm of chromosome 15 have rarely been described. To the best of our knowledge, only four patients with a pure terminal 15q deletion have been documented in the literature. We report here on an unexpected abnormal hybridization pattern for the 15q specific subtelomeric control probe (clone 154P1) of the commercial SNRPN probe in a girl referred for suspicion of Angelman syndrome. Investigation by fluorescent in situ hybridization (FISH) using bacterial artificial chromosome (BAC) clones defined a partial monosomy 15q26.2 --> 15qter for a minimal critical region of approximately 5.7 Mb, which is the most distal de novo 15qter deletion reported to date. All the de novo 15qter deletion cases, including ours, presented with pre- and post-natal growth retardation related to the loss of one copy of the IGF1R gene. Based on the comparaison with the previous published cases and owing to the clinical phenotype of our patient, we define a new subtelomeric 15qter syndrome which would be characterized by intrauterine growth retardation and global post-natal growth failure, variable mental retardation, facial anomalies including relative micrognathia and triangular facies and minor malformations of the extremities including proximally placed thumbs, cubitus valgus, and brachydactyly with tappering of the digits.

Tumour necrosis factor-α up-regulates macrophage migration inhibitory factor expression in endometrial stromal cells via the nuclear transcription factor NF-κB

BACKGROUND

A series of controlled changes including proliferation, secretion and menstrual shedding occur in the human endometrium during every normal menstrual cycle. Macrophage migration inhibitory factor (MIF), a multifunctional cytokine with numerous proinflammatory, immunomodulatory and angiogenic properties, appears to be expressed in the human endometrium and to follow a regulated cycle phase-dependent expression, but the mechanisms underlying endometrial MIF expression remain to be fully elucidated.

METHODS AND RESULTS

Results from enzyme-linked immunosorbent assay (ELISA) demonstrated a significant dose- and time-dependent increase in MIF secretion by human endometrial cells in response to tumour necrosis factor-alpha (TNF-alpha) (0.1-100 ng/ml). This increase was also observed at the mRNA level as shown by reverse transcription (RT)-PCR. Curcumin (10(-8) mol/l), a known nuclear factor (NF)-kappaB inhibitor, inhibited the TNF-alpha-induced pIkappaB phosphorylation as shown by western blotting, NF-kappaB translocation into the nucleus as shown by electrophoretic mobility shift assay, and MIF synthesis and secretion as measured by ELISA and RT-PCR. The expression of a dominant-negative NF-kappaB inhibitor (IkappaB) significantly decreased the TNF-alpha-induced MIF promoter activity as analysed by transient cell transfection.

CONCLUSIONS

These results indicate clearly that TNF-alpha up-regulates the expression of MIF in endometrial stromal cells. This took place possibly through NF-kappaB activation, and may play an important role in the physiology of the human endometrium.

Stimulation of Macrophage Migration Inhibitory Factor Expression in Endometrial Stromal Cells by Interleukin 1, beta Involving the Nuclear Transcription Factor NFκB1

Endometriosis, the ectopic development of endometrial tissue, is, particularly in peritoneal endometriosis, believed to result from tubal reflux of menstrual tissue. The release of cytokines and growth factors by refluxed endometrial cells in response to peritoneal inflammatory stimuli may enhance the capability of endometrial cells to implant and grow into the peritoneal host tissue. Herein we report that interleukin 1 (IL1), a major proinflammatory cytokine that is overproduced by endometriosis women-derived peritoneal macrophages and found in elevated concentrations in the peritoneal fluid of patients with endometriosis, stimulates the synthesis and the secretion of macrophage migration inhibitory factor (MIF) by human endometrial stromal cells. IL1B (0.1-100 ng/ml) exerted dose- and time-dependent effects of MIF protein secretion and mRNA synthesis, as shown by ELISA and reverse transcription-polymerase chain reaction, respectively. IL1B appeared to induce MIF gene transcription via the kappaB nuclear transcription factor (NFkappaB), as shown by electrophoretic mobility shift assay and Western blot analysis of IkappaB phosphorylation. Curcumin (10(-8) M), which is known for inhibiting NFkappaB activation, inhibited IL1B-induced MIF secretion as well as NFkappaB nuclear translocation and DNA binding. Taken together, these findings clearly show that IL1B up-regulates the expression of MIF in endometrial stromal cells in vitro and acts via NFkappaB. This may play an important role in the physiology of the human endometrium and the pathophysiology of endometriosis considering the immunomodulatory properties of MIF as well as its role in cell growth, angiogenesis and tissue remodeling.

Cycle-dependent expression of macrophage migration inhibitory factor in the human endometrium

BACKGROUND

Macrophage migration inhibitory factor (MIF) is a multifunctional cytokine that was shown to promote angiogenesis and tissue remodelling. Our previous studies identified MIF as one of the principal bioactive molecules involved in endothelial cell proliferation released by ectopic endometrial cells.

METHODS AND RESULTS

In the present study, we examined the expression of MIF in the human endometrium and found an interesting distribution and temporal pattern of expression throughout the menstrual cycle. Immunoreactive MIF was predominant in the glands and surface epithelium. Dual immunofluorescence analysis further identified endothelial cells, macrophages and T-lymphocytes as cells markedly expressing MIF in the stroma. Quantitative assessment of MIF protein showed a regulated cycle phase-dependent expression pattern. MIF expression increased in the late proliferative/early Secretory phase of the menstrual cycle was moderate during the receptive phase or what is commonly called the implantation window before increasing again at the end of the cycle. This pattern paralleled MIF mRNA expression determined by northern blot.

CONCLUSION

The cycle phase-specific expression of MIF suggests a tight regulation and perhaps different roles for this factor in the reparative, reproductive and inflammatory-like processes that occur in human endometrium during every menstrual cycle.

Congenital gonadotropin deficiency in boys: management during childhood

OBJECTIVE

To analyze the features of boys with congenital gonadotropin deficiency (CGD), and to determine the value of plasma inhibin B and anti-Müllerian hormone (AMH) for predicting testicular function and the effect of testosterone treatment.

PATIENTS

We followed 19 boys for CGD, including five with Kallmann syndrome.

RESULTS

The boys were seen before 14 years of age for micropenis (9 boys) or later for delayed puberty (10 boys). No testis was palpable in the scrotum in 13 patients, bilaterally in seven of them. Luteinizing hormone (LH) peak after a gonadotropin releasing hormone (GnRH) test was between 0.5 and 5.6 U/l. Plasma inhibin B was low in the four patients evaluated at less than 1 year old. AMH was low in one of them and normal in four others. Of the older patients, three lad low plasma inhibin B and four had normal concentrations; plasma AMH was low in three of them and increased in four. Testosterone treatment restored penis length to normal in all patients.

CONCLUSIONS

Low plasma inhibin B and AMH concentrations may indicate testicular damage in boys with CGD.

Macrophage migration inhibitory factor expression is increased in pituitary adenoma cell nuclei

Macrophage migration inhibitory factor (MIF) is an essential regulator of the macrophage responses to endotoxin. MIF also has the ability to override the anti-inflammatory actions of glucocorticoids during an immune response, and is thus an important pro-inflammatory factor. The presence of MIF in cells of the anterior pituitary has been described, and high levels of MIF in other rapidly proliferating tIssues have also been demonstrated. It has been hypothesised that MIF release from these cells is influenced by the hypothalamo-pituitary-adrenal axis, and that ACTH and MIF are released simultaneously to exert counter-regulatory effects on cortisol. However, another intracellular role for MIF has also been suggested as it has been shown that MIF exerts an effect on the inhibitory cell cycle control protein p27 through an interaction with Jab1, a protein implicated in p27 degradation. We studied MIF expression in different normal and adenomatous human pituitary samples using immunohistochemistry and RT-PCR. There was evidence of co-immunoprecipitation of MIF with Jab1, suggesting an interaction of the two proteins. Our results showed that there is increased expression of MIF protein in the nuclei of all pituitary adenomas compared with normal tIssue (P=0.0067), but there was no statistically significant difference in nuclear MIF expression between the different adenoma types. Nuclear MIF expression correlated positively with p27 and its phosphorylated form in normal tIssue (P=0.0028 and P<0.0001); however, this relationship was not seen in the adenoma samples. Cytoplasmic expression of MIF was found to be variable both in normal and adenomatous samples, with no consistent pattern. MIF mRNA was demonstrated to be present in all tumour and normal samples studied. Somatotroph tumours showed higher MIF mRNA expression compared with normal pituitary or other types of adenomas. In conclusion, MIF is expressed in cell nuclei in pituitary adenomas to a greater extent than in normal pituitary tIssue. We speculate that it may play a role in the control of the cell cycle, but whether its higher level in adenomas is a cause or a consequence of the tumorigenic process remains to be clarified.

Macrophage migratory inhibitory factor (MIF) expression in acute graft-versus-host disease (GVHD) in allogeneic hemopoietic stem cell transplant recipients

Graft-versus-host disease (GVHD) is a major complication after hemopoietic stem cell transplantation (HSCT), but its pathogenesis remains uncertain. Macrophage migratory inhibitory factor (MIF) is an important mediator in the allo-immune reaction during renal transplantation, yet its role in hemopoietic stem cell transplantation (HSCT) remains unexplored. This study investigated the potential role of MIF in acute graft-versus-host disease (aGVHD) following allogeneic HSCT. Forty-six randomly selected patients undergoing autologous or allogeneic HSCT were studied. Immunohistochemistry and in situ hybridization were performed to examine tissue MIF mRNA and protein expression on skin and colonic biopsy specimens. The associated T cell and macrophage activation was also studied by immunohistochemical studies. A semi-quantitative method was used to assess MIF staining, as well as T cell and macrophage staining. Serial blood samples were analyzed by ELISA for serum MIF levels. Immunohistochemistry and in situ hybridization performed in 15 skin and 19 colonic biopsies from 17 patients who developed moderate to severe aGVHD showed a significant increase in MIF mRNA and protein expression compared with normal controls (seven skin and five colonic biopsies). MIF was localized within the epidermis and the vascular area of skin, but diffusely expressed in the entire thickness of colon. Macrophage and T lymphocyte infiltration was confined to areas of strong MIF expression. Serial analysis by ELISA showed that only patients who developed aGVHD (n = 19) exhibited an increase (two- to three-fold) in serum MIF during HSCT, but not in the allogeneic HSCT recipients without aGVHD (n = 7) or those who received autologous HSCT (n = 8). In 14 out of 19 patients, serum MIF peaked before the onset of aGVHD. Local and systemic up-regulation of MIF expression is associated with the occurrence of acute GVHD. Its pathogenetic role remains to be further determined.

Macrophage migration inhibitory factor in rheumatoid arthritis: clinical correlations

OBJECTIVE

Cytokines play an important role in the pathology of rheumatoid arthritis (RA). Macrophage migration inhibitory factor (MIF) is a cytokine with a broad spectrum of actions, including induction of monocyte tumour necrosis factor alpha (TNF-alpha). Evidence of the expression and proinflammatory activity of MIF has recently been demonstrated in RA synovium and in animal models of RA. We wished to assess the relationship between MIF expression in synovium and clinical disease.

METHODS

Computer-assisted analysis of the cytokine content of arthroscopically obtained biopsies of RA synovium, using paired samples from eight patients with active and inactive/treated disease, was compared with documented clinical parameters.

RESULTS

Synovial MIF immunostaining correlated strongly with disease activity as measured by CRP concentration. Reductions in clinical disease parameters, including CRP, tender and swollen joint counts, were accompanied by significant reductions in synovial MIF. Synovial TNF-alpha, transforming growth factor beta (TGF-beta) and interleukin (IL) 10 also showed a significant reduction in association with reduced disease activity, while IL-1 beta and IL-1 receptor agonist did not.

CONCLUSION

The correlation of synovial MIF with disease activity corroborates existing evidence of the role of this cytokine in RA. The demonstration that only MIF and TNF-alpha show significant variation in synovial cytokine content with clinical remission suggests that MIF is an important member of the cytokine hierarchy in RA.

Response of serum macrophage migration inhibitory factor levels to stimulation or suppression of the hypothalamo-pituitary-adrenal axis in normal subjects and patients with Cushing's disease

Macrophage migration inhibitory factor (MIF) is a proinflammatory pituitary and immune cell cytokine and a critical mediator of septic shock. It has been reported that MIF is secreted in parallel with ACTH from the pituitary in response to stress or inflammatory stimuli. MIF release from immune cells is also induced rather than inhibited by glucocorticoids. It has therefore been suggested that MIF may be a novel counterregulatory hormone of glucocorticoid action that acts both as a paracrine and endocrine modulator of host responses. We have measured circulating MIF levels, using a human MIF ELISA, in normal subjects and patients under numerous pathophysiological conditions. Serum MIF was measured in normal subjects who underwent stimulation of the hypothalamo-pituitary-adrenal axis with an insulin tolerance test (n = 8), a CRH-stimulation test (n = 5), a short synacthen test (n = 5), and following a low-dose dexamethasone suppression test (n = 6). We also sampled from a peripheral vein and both inferior petrosal sinuses before and after CRH stimulation in four patients with a histologically proven diagnosis of Cushing's disease. Immunostaining of the pituitary tumors for MIF was also performed. In normal subjects serum MIF levels did not rise in parallel with cortisol during the insulin tolerance or CRH test or after administration of synthetic ACTH. In all subjects cortisol levels became undetectable after the low-dose dexamethasone suppression test, and no consistent change was observed in serum MIF levels during the test. In patients with Cushing's disease, there was no basal central-to-peripheral gradient in MIF, and no consistent changes occurred in serum MIF levels in either the left or right inferior petrosal sinus after CRH stimulation; however, immunostaining of the surgically removed pituitary tumors from the same patients showed strong staining for both ACTH and MIF. These results show that in humans acute modulation of the hypothalamo-pituitary-adrenal axis does not significantly alter circulating MIF levels. In addition, ACTH-secreting pituitary tumors that express MIF do not release MIF either spontaneously or in response to CRH stimulation, and there is no gradient for MIF in the venous drainage of the pituitary. Our study suggests that the pituitary gland is not the major contributor to circulating MIF; an autocrine or paracrine role for pituitary-derived MIF is more likely.