Regenerative Therapien in der Kardiologie

During acute myocardial infarction, ischemia causes progressive loss of contractile tissue. Subsequently, structural changes lead to left ventricular remodeling finally resulting in the development of heart failure. In addition to an optimal reperfusion and pharmacologinal post-infarction therapy, increased neovascularization and regeneration of cardiomyocytes could reduce or even abolish the ongoing left ventricular remodeling processes within the infarct area. Experimental studies have demonstrated that transplantation of adult progenitor cells leads to increased neovascularization, reduced fibrosis and, therefore, increased left ventricular function after acute myocardial infarction. In contrast to current treatment strategies, progenitor cell therapy offers a new regenerative approach for myocardial tissue. Initial clinical studies have demonstrated, apart from safety and feasibility of intracoronary infusion of adult autologous progenitor cells, a significant improvement of left ventricular function, geometry and vascularization in patients with acute myocardial infarction receiving intracoronary infusion of progenitor cells. However, in patients with chronic ischemic cardiomyopathy, the improvement in contractility is less pronounced. Finally, whether intracoronary infusion of adult progenitor cells can also reduce morbidity and mortality due to heart failure, remains to be investigated.

[Bronchial asthma. Update 2006]

Bronchial asthma, with a prevalence in Germany of 5% among adults and 10% among children, remains a frequent disease. Newer cell biological data show a separate regulation of the allergy (interleukin 4, IL-4, pathway) and of the eosinophilic inflammation in asthma (IL-5 pathway). Both conditions require a therapeutic approach. To prevent irreversible bronchial remodeling, early diagnosis and targeted therapy are decisive. Bronchial asthma is regarded as evident when the paroxysmal character of the disease is confirmed and an-at least intermittent-obstructive ventilation disorder is apparent which responds well to short-acting beta2-adrenergic agents. Current asthma treatment has been assured in many studies (evidence level A) and is based on therapy in stages which classifies therapeutic measures depending on four grades of severity. Accordingly, most patients are largely without complaints, and nocturnal attacks are now rare. New medications are intended to overcome any remaining therapeutic weak points. Antileukotrienes and anti-IgE antibodies can contribute to reducing the necessary corticosteroids. Pharmaceutical agents that intervene in the IL-4 or IL-5 regulation or prevent remodeling are being developed.

Nerve growth factor in treatment and pathogenesis of Alzheimer's disease

The etiology of Alzheimer's disease (AD) is still unknown. In addition, this terrible neurodegenerative disease will increase exponentially over the next two decades due to longer lifespan and an aging "baby-boomer" generation. All treatments currently approved for AD have moderate efficacy in slowing the rate of cognitive decline in patients, and no efficacy in halting progression of the disease. Hence, there is an urgent need for new drug targets and delivery methods to slow or reverse the progression of AD. One molecule that has received much attention in its potential therapeutic role in AD is nerve growth factor (NGF). This review will demonstrate data from humans and animals which promote NGF as a potential therapeutic target by (1) outlining the hypothesis behind using NGF for the treatment of AD, (2) reviewing both the normal and AD altered signaling pathways and effects of NGF in the central nervous system (CNS), and (3) examining the results of NGF treatment obtained from animal models of AD and AD patients.

Cluster-Immuntherapie bei allergischer Rhinokonjunktivitis

Apart from allergen avoidance, specific immunotherapy (SIT) represents the only potentially curative treatment available to patients with allergic rhinoconjunctivitis. Evidence for its clinical efficacy has been clearly demonstrated in several controlled clinical trials and depends on the allergen to which the patient is sensitive, the quality and total amount of allergen administered, and the SIT schedule. In classic SIT, gradually ascending dosages of the allergen extract are injected subcutaneously (dose-increase period) until the individual maximum dose is reached (dose-maintenance period). Several dosage schedules have been worked out. In cluster immunotherapy, 2-3 injections per day of treatment are given once a week to rapidly reach the maintenance dose. Several cluster schedules have been described. Recent data demonstrate that the frequency and severity of adverse effects in cluster immunotherapy correspond to those in other dosage schedules. As far as safety goes, cluster immunotherapy is an interesting alternative for the dose-increase period. In addition, recent studies reveal that clinical benefits appear sooner with cluster immunotherapy.

Mapping arrhythmias in the failing heart: from Langendorff to patient

Sudden cardiac death due to ventricular arrhythmias is a major cause of mortality in patients with heart failure (HF). As HF develops, a host of changes occur at multiple levels, spanning the spectrum from subcellular/molecular to organ-system levels. These changes, collectively referred to as "cardiac remodeling," predispose to electrical disturbances via multiple mechanisms. In humans, most arrhythmias are reentrant by nature, involving circulatory wavefront(s) that excite the heart in rapid, irregular succession. Hence, by definition, reentrant excitation occurs at the multicellular intact tissue level, and therefore, a complete understanding of its dynamics and underlying mechanisms requires investigation of electrophysiological properties (such as action potentials and calcium transients) in intact tissue preparations where cells are electrically coupled to one another. While molecular and cellular studies are critical for identifying changes in individual myocytes, only recently have we begun to understand how these complex changes can create an environment ripe for arrhythmias. In particular, the integrative technique of optical action potential mapping was used in recent years to address key questions regarding changes in network electrical properties of the failing myocardium. In the present manuscript, we review recent findings from mapping studies in the experimental laboratory as they relate to the characterization of the arrhythmic substrate of the failing heart, followed by a discussion of clinical mapping approaches used to identify key characteristics of atrial and ventricular arrhythmias in patients with HF.

Metabolomics-based systems biology and personalized medicine: moving towards n = 1 clinical trials?

Personalized medicine – defined as customized medical care for each patient’s unique condition – in the broader context of personalized health, will make significant strides forward when a systems approach is implemented to achieve the ultimate in disease phenotyping and to create novel therapeutics that address system-wide molecular perturbations caused by disease processes. Combination drug therapies with individualized optimization are likely to become a major focus. Metabolomics incorporates the most advanced approaches to molecular phenotype system readout and provides the ideal theranostic technology platform for the discovery of biomarker patterns associated with healthy and diseased states, for use in personalized health monitoring programs and for the design of individualized interventions.

Airway smooth muscle as a target of asthma therapy: history and new directions

Ultimately, asthma is a disease characterized by constriction of airway smooth muscle (ASM). The earliest approach to the treatment of asthma comprised the use of xanthines and anti-cholinergics with the later introduction of anti-histamines and anti-leukotrienes. Agents directed at ion channels on the smooth muscle membrane (Ca2+ channel blockers, K+ channel openers) have been tried and found to be ineffective. Functional antagonists, which modulate intracellular signalling pathways within the smooth muscle (beta-agonists and phosphodiesterase inhibitors), have been used for decades with success, but are not universally effective and patients continue to suffer with exacerbations of asthma using these drugs. During the past several decades, research energies have been directed into developing therapies to treat airway inflammation, but there have been no substantial advances in asthma therapies targeting the ASM. In this manuscript, excitation-contraction coupling in ASM is addressed, highlighting the current treatment of asthma while proposing several new directions that may prove helpful in the management of this disease.

[Autologous transfusion--from enthusiasm to reason: clinical practice based on scientific knowledge]

This symposium (Nottwil/Lucerne, Switzerland, January 20./21. 2006,) gives you the latest review / clinical results / experimental data on autologous transfusion: Routine leucodepletion of preoperative autologous deposit, immunological perspectives, special processing of bacterially contaminated autologous blood, pro and con concerning autologous blood supply as a reasonable alternative, autologous platelet gel, the Austrian benchmark study on RBC-transfusion. The report on this symposium is published in 'AINS' (Thieme); papers will be published in detail in English in "Transfusion Medicine and Hemotherapy" (Karger Inc.) and in German in "Anästhesiologie und Intensivmedizin" (DIOmed Inc.).

Treatment of mantle cell lymphoma: current approach and future directions

Although mantle cell lymphoma has been described as "moderately aggressive" it has become clear that it carries a worse long-term prognosis than other subtypes of non-Hodgkin's lymphoma. In recent years, this has prompted numerous clinical trials of novel and more aggressive therapies in hopes of impacting these poor outcomes. These include more intensive combination chemotherapy regimens, monoclonal antibody therapy in conjunction with other treatments or conjugated to radioactive isotopes, high-dose chemotherapy followed by autologous or allogeneic stem cell transplantation, and newer targeted therapies based on increasing understanding of the molecular pathways of this malignancy.

[The attractive position of France in international clinical research: 2006 survey assessed by Leem (French pharmaceutical companies)]

In order to evaluate the attractiveness of France for conducting international clinical trials, a survey is performed every two years among pharmaceutical companies that are based in France or have affiliates in France. Initiated in 2006, the current survey was much more representative than the previous ones with 20 companies accounting for 61% of the French market. This survey included 352 international phase II and III clinical studies carried out in 2004 and 2005, 74 countries, 17 345 centres and 137 989 patients. France has participated to half of the overall number of international clinical trials. France ranked among the best European recruiters (0,19 patient/1000 inhabitants) at the second position behind Scandinavian countries, taking in account numbers of inhabitants. Protocols are now to be given the go-ahead by Ethics Committee (CCPPRB) within 60 days. With a high productivity in phase IIb and in oncology, France is still an attractive place to locate clinical research.

Alternative Medizin in der Augenheilkunde?

In an overview new data from the literature regarding alternative/complementary medicine are presented. Naturopathy, acupuncture and homeopathy as well as new findings in placebo-research and their correlation to alternative medicine are discussed. In addition, as a synthesis a patient-orientated so-called anthropologic medicine is recommended to make alternative/complementary medicine unnecessary.

Design of a large cross-sectional study to facilitate future clinical trials in children with the Fontan palliation

BACKGROUND

Clinical trials in children with congenital heart disease are often limited by the absence of the following: (1) a primary outcome that can be observed in a reasonable period; (2) information regarding health-related quality of life; (3) knowledge of the correlation between health status and ventricular function and exercise performance; (4) a sufficient number of children at a single institution to provide adequate statistical power; and (5) procedural and management differences between and within institutions.

METHODS

The NHLBI-funded Pediatric Heart Network designed a cross-sectional study of children aged 6 to 18 years, from 7 pediatric clinical centers, who had undergone a Fontan procedure as treatment for congenital heart disease. Health-related quality of life was measured by the Child Health Questionnaire and the Congenital Heart Adolescent and Teenager Questionnaire. Ventricular function was assessed by maximal exercise testing, echocardiography, cardiac magnetic resonance imaging, and B-type natriuretic peptide. The study was designed to detect a correlation of R > or = 0.30 between health status scores and measures of ventricular function and performance in a subcohort with all study measures completed.

RESULTS

A total of 1078 children were screened by chart review; 644 (60%) were eligible. The consent rate was 85% and 546 children were enrolled. Acquisition of echocardiograms, B-type natriuretic peptide, and health status was > or = 94%; completion rates were lower for maximal exercise testing (76%) and cardiac magnetic resonance imaging (41%).

CONCLUSIONS

This large study provides unique information regarding the relationship between health status and clinical measures in post-Fontan patients that will facilitate the design of future randomized trials.

Clinical databases in nephrology: research and clinical practice goals and challenges

In clinical practice we formulate direct questions related to patient management that should be answered on the basis of results of valid studies. Bias problems are dealt with using different approaches in observational studies and in clinical trials. The clinical trial is the standard for assessing the efficacy of treatments while the efficiency of treatments at community level is better captured by observational studies. Electronic medical records have now emerged as a precious, matchless data source for clinical audits. The value of an audit cannot be taken for granted and should be tested in the specific health care setting where it is applied. Electronic medical records and high quality clinical databases offer a great opportunity for performing observational studies and for reducing the cost of clinical trials. Research on audit and feedback functionality is a new, useful and stimulating research area which may be of great interest to nephrologists.

Dronedarone: An Emerging Agent with Rhythm- and Rate-Controlling Effects

Of current antiarrhythmic agents, amiodarone is among the most effective with the additional advantage of having little proarrhythmic potential. However, it can cause potentially serious extracardiac side effects, stimulating the search for safer derivatives. Dronedarone, a new antiarrhythmic drug that is structurally related to amiodarone, lacks an iodine moiety and, thus, amiodarone's iodine-related organ toxicity, while its methane sulfonyl group decreases lipophilicity so shortening half-life and decreasing tissue accumulation. Electrophysiological studies show that dronedarone shares amiodarone's multichannel blocking effects, inhibiting transmembrane Na(+), K(+), Ca(2+), and slow L-type calcium channels, as well as its antiadrenergic effects. Unlike amiodarone, it has little effect at thyroid receptors. Possessing both rate- and rhythm-control properties, dronedarone has proved safe and effective in preventing recurrence of atrial fibrillation (AF) in patients with persistent AF in the Dronedarone Atrial Fibrillation Study After Electrical Cardioversion (DAFNE) trial, the first prospective randomized trial to evaluate its efficacy and safety. Dronedarone has since undergone further extensive evaluation in three pivotal phase III trials. In two sister studies, the European Trial in Atrial Fibrillation or Flutter Patients Receiving Dronedarone for the Maintenance of Sinus Rhythm (EURIDIS) and American-Australian-African Trial with Dronedarone in Atrial Fibrillation/Flutter Patients for the Maintenance of Sinus Rhythm (ADONIS), dronedarone 400 mg b.i.d. showed significant efficacy against placebo in prevention of AF recurrence. Additionally, in patients with permanent AF, dronedarone was highly effective at controlling ventricular rate on top of standard rate-controlling therapies in the Efficacy and Safety of Dronedarone for the Control of Ventricular Rate during Atrial Fibrillation (ERATO) study.