Successful treatment of a newborn with acute myocardial infarction on the first day of life

Cardiogenic shock occurring after acute neonatal myocardial infarction (MI) due to coronary artery thrombosis is very rarely encountered. Acute neonatal MI typically presents suddenly with usually a fatal outcome. Treatment options in patients with this condition are limited. There are previous case reports in the literature advocating the use of extracorporeal membrane oxygenation for hemodynamic support. In this report, we present a newborn with severe MI secondary to thrombus formation within the left anterior descending coronary artery. There also proved to be a Factor V Leiden heterozygotic mutation. The patient initially presented with cardiogenic shock. After resuscitation and thrombolytic therapy were administered, coronary artery patency was restored resulting in myocardial revitalization and recovery of left-ventricular function within 4 weeks.

Comparison of emergency department and hospital admissions data for air pollution time-series studies

BACKGROUND

Emergency department (ED) visit and hospital admissions (HA) data have been an indispensible resource for assessing acute morbidity impacts of air pollution. ED visits and HAs are types of health care visits with similarities, but also potentially important differences. Little previous information is available regarding the impact of health care visit type on observed acute air pollution-health associations from studies conducted for the same location, time period, outcome definitions and model specifications.

METHODS

As part of a broader study of air pollution and health in St. Louis, individual-level ED and HA data were obtained for a 6.5 year period for acute care hospitals in the eight Missouri counties of the St. Louis metropolitan area. Patient demographic characteristics and diagnostic code distributions were compared for four visit types including ED visits, HAs, HAs that came through the ED, and non-elective HAs. Time-series analyses of the relationship between daily ambient ozone and PM₂.₅ and selected cardiorespiratory outcomes were conducted for each visit type.

RESULTS

Our results indicate that, compared with ED patients, HA patients tended to be older, had evidence of greater severity for some outcomes, and had a different mix of specific outcomes. Consideration of 'HA through ED' appeared to more effectively select acute visits than consideration of 'non-elective HA'. While outcomes with the strongest observed temporal associations with air pollutants tended to show strong associations for all visit types, we found some differences in observed associations for ED visits and HAs. For example, risk ratios for the respiratory disease-ozone association were 1.020 for ED visits and 1.004 for 'HA through ED'; risk ratios for the asthma/wheeze-ozone association were 1.069 for ED visits and 1.106 for 'HA through ED'. Several factors (e.g. age) were identified that may be responsible, in part, for the differences in observed associations.

CONCLUSIONS

Demographic and diagnostic differences between visit types may lead to preference for one visit type over another for some questions and populations. The strengths of observed associations with air pollutants sometimes varied between different health care visit types, but the relative strengths of association generally were specific to the pollutant-outcome combination.

[Urothelial carcinoma of the bladder: evaluation by combined endoscopy and urine cytology: is incontrovertible assessment possible?]

BACKGROUND

Transurethral resection of transitional cell carcinoma of the bladder provides a definitive surgical treatment and supplies tissue for histological evaluation. Superficial low-grade carcinomas with a small risk of progression are treated properly with fulguration alone. To justify fulguration as a definitive treatment of papillary bladder tumours, one must be able to safely distinguish low-grade, noninvasive tumours from those that are high grade and potentially invasive.

MATERIAL AND METHODS

A total of 160 patients with a transitional cell carcinoma at cystoscopy underwent transurethral resection of the tumour. The macroscopic appearance of the tumour, the aspect with bimanual palpation and the perioperative urine cytology were compared with the histological report.

RESULTS

In our study we were able to safely distinguish low-grade tumours from high-grade tumours. All noninvasive tumours could be identified visually as such.

CONCLUSION

Urologists skilled in the evaluation of urine cytology can distinguish low-grade noninvasive tumours of the bladder from high-grade and potentially invasive tumours by means of appearance at cystoscopy and perioperative urine cytology.

3-Dimensional sonographic volumetry of fetal brain, liver and myocardial mass--interdisciplinary clinical validation of the method and application in fetuses with and without structural heart disease

BACKGROUND

Prenatal 3-dimensional (3D) ultrasound allows volumetry of the fetal brain, liver and measurement of myocardial mass (MM). We studied the reliability of this method in an interdisciplinary approach, defined the relation of the values throughout gestation, and evaluated the results in fetuses with congenital heart disease (CHD).

METHODS

In 104 fetuses (39 with CHD) between 14 and 38 weeks of gestation 3D ultrasound was prospectively performed. Data sets of brain, abdomen and heart were stored for off-line analysis of volumes and MM. Descriptive statistics, coefficients of correlation and of variation (CV) were performed.

RESULTS

Volumetric data set acquirement was feasible in all pregnancies, lasted approximately 10 min, but off-line analysis was feasible in only 66% lasting about 45 min. MM increased in a linear fashion during gestation. CV were 11.0 and 10.8 for the left, 14.39 and 12.66, respectively, for the right MM. Median ratio between right and left MM was 0.88 in normal fetuses, and 8.25 in fetuses with hypoplastic left heart syndrome. Intra- and interobserver variabilities revealed CVs of 2.46 and 11.80, respectively, for brain volumetry, and CVs of 3.16 and 29.2, respectively, for liver volumetry. Both brain and liver volumes were positively associated with gestational age, and did not show different growth patterns in fetuses with CHD.

CONCLUSIONS

Prenatal volumetry is time-consuming, but reliable especially for left MM and brain volume. Linear growth of brain and liver volume is present in utero irrespective of CHD. Application of our reference graphs of MM growth allows early differentiation in CHD.

[Treatment of vesico-enteric fistulae in men. Pedicled bladder flap]

Genitourinary fistulae represent a rare condition for patients submitted to salvage radiotherapy due to local tumour relapse after radical prostatectomy. Nevertheless, it is associated with great morbidity and in many cases with repetitive surgeries limiting their quality of life. Many techniques have been proposed to reduce the incidence of early and late postsurgical complications, but up to now a safe and unique method to treat this disease has not been reported in the literature. Here we report on three cases of male patients who developed a vesicoenteric fistula after radiation salvage therapy following radical prostatectomy. A rotation bladder flap was used to cover the pelvic floor attempting to reduce the common complications. All of the patients underwent a urinary diversion and a protective colostomy. The 1-year follow-up showed good postsurgical outcomes with minor early complications and no signs of intestinal obstruction or recurrent fistula. Furthermore, perineal and pelvic pain improvement was also achieved.The small number of cases is a limiting factor in defining standard techniques for the treatment of actinic vesicoenteric fistulae. Nevertheless, the use of a rotational bladder flap for repair of the pelvic floor defect has shown promising results and should be indicated in special situations.

[An update on the management of chronic hepatitis C]

Treatment of chronic hepatitis C with pegylated interferon-a and ribavirin is now adapted individually based on the virological response on treatment. This approach should improve the tolerability while maintaining or even improving in some patients the efficacy of antiviral therapy. Several new antiviral drugs are currently being evaluated in advanced clinical trials, with very promising results. These new drugs should greatly broaden treatment options for chronic hepatitis C in the near future.

[Congenital heart disease. Transition from adolescence to adulthood]

There is a increasing clinical and scientific interest in adults with congenital heart disease. Germany is among, if not the first country worldwide, with a structured care of adults with congenital heart disease. Due to the advances in cardiology and in heart surgery, the primarily high mortality rate of relevant congenital heart disease has declined from 80% to less than 20% during the recent decades. Currently, in Europe the estimated number of adults with congenital heart disease is between 1.2 and 2.7 Mio., and the number in Germany exceeds 180,000. Almost all congenital heart defects, either native or interventionally or surgically treated, need regular control, since even after successful primary treatment significant residua or sequels have to be expected. Optimal care of these patients begins in the childhood and must be continued down to the high adulthood. The complexity of congenital heart defects makes a multidisciplinary approach necessary. A specialized, interdisciplinary cooperation between cardiologists, pediatric cardiologists, cardiac surgeons and other specialists is mandatory.

Elimination of cancer stem cells (CD133+/EpCAM+) from malignant ascites by the trifunctional antibody catumaxomab: Results from a pivotal phase II/III study

3014

Background: Putative cancer stems cells (CSCs) are defined as “tumor-initiating cells” that have the capacity to self-renew and to give rise to the variety of differentiated cells found in the malignancy. The CD133 membrane glycoprotein represents a CSC marker that has been previously demonstrated to be capable of identifying a cancer-initiating subpopulation in brain tumors, melanoma, and EpCAM+ solid tumors. The trifunctional anti-EpCAM x anti-CD3 antibody catumaxomab efficiently eliminates tumor cells from the peritoneal fluid of malignant ascites (MA) patients as demonstrated in a pivotal phase II/III trial (Parsons et al., ASCO 2008). Here we report on the presence of CD133+/EpCAM+ putative CSCs in MA and, more importantly, on the elimination of this cell population from the peritoneal fluid of MA patients by means of catumaxomab therapy. Methods: 18 CTX-refractory patients with MA caused by a variety of primary carcinoma diseases (i.e., ovarian, pancreas, and gastric cancer) were analyzed for the presence CD133+/EpCAM+ cells in peritoneal fluids by means of CD133+/EpCAM+ double staining on cytospin preparations. Analyses were performed before, 2 days after the first, and 1 day after the last catumaxomab infusion, respectively. Double-stained cytospin preparations were evaluated with a computerized image analysis system. Results: Before therapeutic intervention, CD133+/EpCAM+ cells were detected in the peritoneal fluids of 14 from 18 patients suffering from MA. After the 1st infusion of catumaxomab (10μg), 9 of these 14 patients showed complete elimination of the CD133+/EpCAM+ cells. After 4 i.p. catumaxomab infusions (10μg day 0, 20μg day 3, 50μg day 7 and 150μg day 10) the CD133+/EpCAM+ cells were completely eliminated from the peritoneal fluids of all 14 MA patients. Conclusions: In a preliminary monitoring study, putative CSCs (CD133+/EpCAM+) were present in peritoneal fluids of 78 % of analyzed MA patients with different underlying primary tumor entities. Catumaxomab efficiently destroyed CD133+/EpCAM+ cells within peritoneal fluids of MA patients. Consequently, catumaxomab-based therapeutic measures may offer an additional treatment opportunity to eliminate CSCs in EpCAM+ malignancies.

[Table: see text]

Decrease of VEGF within malignant ascites during catumaxomab treatment: Results from a pivotal phase II/III study

3029

Background: Treatment with the trifunctional anti-EpCAM x anti-CD3 antibody catumaxomab efficiently eliminates tumor cells from the peritoneal cavity (Jäger et al., ASCO 2007) and led to clinically relevant prolongation of puncture-free survival (PuFS) in patients with malignant ascites (MA) in a pivotal phase II/III trial (Parsons et al., ASCO 2008). As vascular endothelial growth factor (VEGF) levels are markedly elevated in MA in comparison to cirrhotic ascites the question was addressed whether catumaxomab treatment impacts the expression or accumulation of VEGF within MA. Here we report that in addition to tumor cell depletion, VEGF protein levels in MA significantly decreased upon catumaxomab therapy. We propose that the strongly correlated tumor cell elimination and reduced VEGF protein levels are causative for the prolonged PuFS of patients suffering from MA. Methods: VEGF and total protein levels were measured by ELISA and BCA from MA supernatants before catumaxomab therapy, after the 1st infusion (10μg; day 3) and after the 4th infusion (150μg; day 11). Data were statistically analysed for the ratio of the VEGF protein concentration versus the total protein concentration for the MA treatment groups with ovarian (OC) or nonovarian cancer (NC) as underlying disease and the corresponding control groups that received paracentesis only. Results: One day after the last catumaxomab infusion 46 or 47 patients analysed in the OC or NC treatment group showed a statistically significant decrease in VEGF to total protein ratio when compared to the measurement before catumaxomab therapy (ANOVA p=0.034 for OC and p<0.001 for NC). These results are consistent with the tumor cell elimination previously assessed in these patients. In contrast, the OC control group showed a statistically significant increase of VEGF to total protein ratio (p=0.009), which is accompanied by an increase in tumor cell numbers. In the NC control group VEGF to total protein ratio remained unaffected (p=0.096). Conclusions: Catumaxomab therapy significantly reduced VEGF protein levels correlating with tumor cell elimination in MA, which in turn led to the prevention of fluid accumulation in the peritoneal cavity and finally to prolonged PuFS of patients suffering from MA.

[Table: see text]

Comprehensive cancer cachexia staging and its impact in the outpatient oncology setting: A phase II study

e20530

Background: Symptom management in advanced cancer is based on appropriate and feasible syndrome staging. To test whether 1. various factors predict involuntary weight loss [WL], 2. patients [pts] attending a cachexia clinic [CC] improve nutritional intake [NI], and 3. eating-related distress [ERD] is a consequence of cachexia or psychological issues. Methods: The multidisciplinary CC (nurse, nutritionist, psycho-oncologist, palliative cancer care physician) applies standardized assessments (Symptom Visual Analogue Scales [VAS, 0=none, 10=severe], 2-day NI diary [% of calculated needs: calories, protein], secondary causes for impaired NI, weight history (2 months WL), Body Mass Index [BMI], C-reactive Protein [mg/dl, normal 8), ERD-VAS, Hospital Anxiety Depression Scale, spirituality [FICA]). Interventions include nutritional counseling, palliative cancer care and psychosocial supportive measures. Descriptive analysis, Spearman‘s Rank correlation and Factor analysis (Eigenvalue >1) were performed. Results: 58 pts (age 65 years [mean; range: 38, 85]; 28F/30M; cancer types: 24 GI, 13 GU, 12 lung/ENT, 9 other; survival 151 days [7, 776]) had 6.9% WL (-6, 22; 21%<2%), 21 kg/m2 BMI (15, 26), 52 CRP (1, 272; 32% normal), 5.6 anorexia, 1.6 anxiety, 6 HADS-A, 1.3 depression, 9 HADS-D, 68% of NI needs (1466kcal [400, 2700], 47g protein [15, 108]). WL correlated with NI kcal (r=-.29, p=.038) and protein (-.3,.035), not anorexia (.16), BMI (.032) or CRP (-.08); a 2 factor model (NI/anorexia/WL [.83/.79/.70], CRP/BMI [.86/.75] explains 67% variability. At second visit (21 days; 13, 64) 15/19 pts increased kcal (400kcal) and 15/16 protein (32g) NI, 6/17 weight. ERD correlated with anorexia (r=.56, p=.001) and depression (.48,.002), not anxiety (.23), WL (.038) or survival (-.15). A 3 factor model (ERD/anxiety/depression [.71/.85/.92], anorexia/survival [.82/.65], WL [.84]) explains 75% variability. Conclusions: A combination of clinical variables seems needed to characterize patients with involuntary WL. Most patients attending 2 consecutive cachexia clinic visits respond to multidimensional interventions. ERD seems to be associated both with loss of appetite and depression, not by WL or survival. Further testing of this intervention seems justified.

[Table: see text]

Positive cross-match living donor kidney transplantation: longer-term outcomes

The long-term graft outcomes after positive cross-match (PXM) living donor kidney transplantation (LDKT) are unknown and the descriptive published data present short-medium term results. We conducted a retrospective cohort study of LDKT with PXM by flow cytometry performed at our center during February 1999 to October 2006, compared to a control group, matched 1:1 for age, sex, race, retransplantation and transplant year. The PXM group was treated with a course of plasmapheresis/low-dose intravenous immunoglobulin (IVIg) preoperatively, and OKT3 or thymoglobulin induction. Both groups (n = 41 each) were comparable except for duration of end-stage renal disease (ESRD), induction, HLA mismatch and panel-reactive antibody (PRA). During the period of up to 9 years, 14 PXM and 7 controls lost their grafts (p < 0.04). Graft survival rates at 1 and 5 years were 89.9% and 69.4% for PXM group and 97.6% and 80.6% for the controls, respectively. PXM was associated with higher risk of graft loss (HR 2.6, p = 0.04; 95%CI 1.03-6.4) (t(1/2)= 6.8 years), but not with patient survival (HR 1.96, p = 0.29; 95%CI 0.6-7.0) or 1-year serum creatinine (beta= 0.06, p = 0.59 for ln (SCr); 95% CI -0.16 to 0.28). These results suggest that despite the favorable short-term results of PXM LDKT after PP/IVIg conditioning, medium-long-term outcomes are notably worse than expected, perhaps comparable to non-ECD deceased donor kidney transplantation (KT).

[Main therapeutic advances in IBD in 2008]

A coimmunosuppression with azathioprine or methotrexate in addition to infliximab does not improve the therapeutic efficacy in Crohn's disease but increase the risks of infectious complications and neoplasia.

[Impact of surgery for residual tumors after chemotherapy]

Metastases are a feature not only of local tumor manifestation but also of systemic disease. Thus, the question arises regarding the extent to which local therapy contributes to a systemic state of disease. With renal cell carcinoma, resection of pulmonary metastases is a common operation. Other sites should be considered individually. Only a well-defined subset of patients with metastasized urothelial carcinoma benefit from the resection of their metastases.

Participation in cervical cancer screening by age and region--a cohort study with a 3 1/2 year follow-up on 2,223,135 women in Bavaria

OBJECTIVE OF THE STUDY

Cervical cancer rates are higher in Germany than in comparable European countries. While other European countries have implemented invitation programs, Germany relied on annual free access only. Are sufficient screening participation rates achieved?

METHODS

We analyzed data from 2,223,135 Bavarian women between 2002/3 and 2005/4 in a retrospective cohort, to evaluate screening participation, frequency, age dependencies and regional differences.

RESULTS

The highest screening participation was amongst women between 20 and 29 (54.6% had at least one visit after one year, 84% within three years) and decreased progressively with increasing age. Participation was lowest for women above 70 in rural areas (in some regions less than 20% had at least one screening within three years).

CONCLUSION

Poor participation rates in general are unlikely to account for the high cervical cancer rates in Germany. Low participation rates in elderly women, particularly those in rural regions might contribute to the well-known peak of cervical cancer in elderly women.

Progressive intrapulmonary shunting in a child after bidirectional Glenn operation only resolved after total cavopulmonary completion

We report on a girl with progressive intrapulmonary shunting after bidirectional Glenn (BDG) operation and resolution of these microscopic fistulas after completion to total cavopulmonary connection (TCPC).

FRMD3, a novel putative tumour suppressor in NSCLC

Lung cancer including non-small cell lung carcinoma (NSCLC) represents a leading cause of cancer death in Western countries. Yet, understanding its pathobiology to improve early diagnosis and therapeutic strategies is still a major challenge of today's biomedical research. We analyzed a set of differentially regulated genes that were identified in skin cancer by a comprehensive microarray study, for their expression in NSCLC. We found that ferm domain containing protein 3 (FRMD3), a member of the protein 4.1 superfamily, is expressed in normal lung tissue but silenced in 54 out of 58 independent primary NSCLC tumours compared to patient-matched normal lung tissue. FRMD3 overexpression in different epithelial cell lines resulted in a decreased clonogenicity as measured by colony formation assay. Although cell attachment capabilities and cell proliferation rate remained unchanged, this phenotype was most likely owing to induced apoptosis. Our data identify FRMD3 as a novel putative tumour suppressor gene suggesting an important role in the origin and progression of lung cancer.

Cardiac index monitoring by pulse contour analysis and thermodilution after pediatric cardiac surgery

OBJECTIVES

To validate a new device (PiCCO system; Pulsion Medical Systems, Munich, Germany), we compared cardiac index derived from transpulmonary thermodilution and from pulse contour analysis in pediatric patients after surgery for congenital heart disease. We performed a prospective clinical study in a pediatric cardiac intensive care unit of a university hospital.

METHODS

Twenty-four patients who had had cardiac surgery for congenital heart disease (median age 4.2 years, range 1.4-15.2 years) were investigated in the first 24 hours after admission to the intensive care unit. A 3F thermodilution catheter was inserted in the femoral artery. Intracardiac shunts were excluded by echocardiography intraoperatively or postoperatively. Cardiac index derived from pulse contour analysis was documented in each patient 1, 4, 8, 12, 16, 20, and 24 hours after admission to the intensive care unit. Subsequently, a set of three measurements of thermodilution cardiac indices derived by injections into a central venous line was performed and calculated by the PiCCO system.

RESULTS

The mean bias between cardiac indices derived by thermodilution and those derived by pulse contour analysis over all data points was 0.05 (SD 0.4) L x min x m(-2) (95% confidence interval 0.01-0.10). A strong correlation between thermodilution and contour analysis cardiac indices was calculated (Pearson correlation coefficient r = 0.93; coefficient of determination r2 = 0.86).

CONCLUSIONS

Pulse contour analysis is a suitable method to monitor cardiac index over a wide range of indices after surgery for congenital heart disease in pediatric patients. Pulse contour analysis allows online monitoring of cardiac index. The PiCCO device can be recalibrated with the integrated transpulmonary thermodilution within a short time frame.