Development of the independent function of fetal thyroid glands in the dog in connection with iodothyronine concentrations in pregnant bitches, fetal fluids, and fetal serum

Thyroxine (T₄) and triiodothyronine (T₃) concentrations in pregnant and nonpregnant bitches were measured. The allantoic and amniotic fluid samples were collected separately in the third week of pregnancy, and fetal blood samples were collected in the fourth week of pregnancy. There was no difference between T₄ results in the pregnant and nonpregnant animals, but the measured serum concentrations exceeded the healthy range for normal adults. Serum T₄ concentrations were lower in the fetus than those in adults (P < 0.01). Fetal T₄ concentrations continuously increased and reached 13.38 ± 6.19 nmol/L before birth. The fetal serum T₄ concentrations were lower than the T₄ concentrations in allantoic and amniotic fluid until the seventh week, and the fetal serum T₃ concentrations were lower than those in fetal fluids throughout the pregnancy (P < 0.01). Maximum T₃ concentrations in allantoic and amniotic fluid exceeded the concentrations in the fetal and maternal serum. It is conceivable that the considerable differences between maternal and fetal serum T₄ concentrations in healthy animals are explained by the T₄ impermeability of the placenta. Extremely high maternal T₄ (193.5 nmol/L) in 1 bitch was associated with T₄ concentrations under the detection limit in the fetal fluids and serum suggesting an inhibitory effect. The T₄ concentrations in all the fetal fluids and serum were under the detectable concentration that can be defined by 3.0 nmol/L in that bitch. We have demonstrated that fetal thyroid glands start functioning independently at the same time as thyroid cell formation in the dog, but the overproduction of maternal T₄ may have a suppressive effect on fetal iodothyronine production.

[3D-Navigated Implantation of Pedicle Screws in the Cervical Spine - Experience and Analysis of Complications]

Background: Placing transpedicular screws in the cervical spine is a special challenge for spine surgeons, due to the anatomical features of this part of the spine. During the last 15 years, computer-aided navigation systems have been developed to facilitate this procedure and to make it safer for patients. One option is navigation by intraoperatively acquired data sets with the use of an 3D C-arm. Patients/Material and methods: Our retrospective study evaluates transpedicular screws in the cervical spine placed by 3D C-arm navigation, within a 6 year period in a level 1 trauma centre. We recorded epidemiological data, operation time and especially general adverse events, as well as revision surgery, including reasons for revision. We used a C-arm Arcardis Orbic 3D (Siemens, Munich), connected to a navigation system (VectorVision, Brainlab, Munich). Results: Between July 2007 and July 2013, 207 transpedicular screws were placed in 58 patients. The main indications were trauma (69 %), rheumatic diseases (20.7 %) and tumour (8.6 %). The most commonly instrumented cervical spine segments were C2 (53.5 %)%), C7 (10.3 %) and C5 (8.6 %). In nearly 95 % of the cases, we performed an intraoperative 3D scan after screw or k-wire placement to control the screw position. We found unacceptable malposition in 7.2 % of patients. This was corrected at once. Ten patients had to be revised: seven times due to wound problems, twice because of implant failure and once for treatment of CSF leakage. Three screws (1.5 %) led to injuries of the vertebral artery, once with a lethal outcome. Analysis of these cases showed that the 3D scan gave reduced data quality, due to reduced bone density or anatomical factors. Conclusion: Intraoperative 3D C-arm navigation seems to be a reliable option for transpedicular screw placement in the cervical spine. Complication rates were comparable to published values. 7.2 % of all screws were corrected intraoperatively after a control scan. Therefore possible revisions could be avoided during primary surgery. Analysis of problematic cases led to a change in our treatment strategy: in patients with poor bone quality and/or anatomical problems which lead to 3D scans of poor quality, we avoid transpedicular screw placement in C6 or higher, in order to prevent injuries of the vertebral artery.

Acute Angioedema Triggered by Daptomycin

INTRODUCTION

Daptomycin is a cyclic lipopeptide antibiotic, frequently administered for Staphylococcus aureus bloodstream infections. Numerous studies have shown that daptomycin is relatively safe and well tolerated. Serious adverse events possibly related to this antimicrobial compound are rare. We report a case of acute angioedema triggered by daptomycin.

CASE REPORT

A 60-year-old woman with S. aureus bacteremia without identified source was treated intravenously with high-dose beta-lactams at our institution. Because S. aureus bacteremia persisted on day 6, and in parallel, acute kidney injury developed, antimicrobial treatment was switched to a combination therapy with daptomycin and ceftriaxone. Shortly after completion of the first daptomycin administration, the patient developed lip and tongue swelling and dyspnea. Acute angioedema was clinically evident. Antibiotic therapy was switched to vancomycin, and the further clinical course was favorable. An intradermal test showed a significant wheal diameter for daptomycin, but negative results for ceftriaxone.

CONCLUSION

The association with daptomycin in this case is either probable or certain. Clinicians should be aware that daptomycin can cause immediate-type hypersensitivity reactions, including acute angioedema, even upon first administration.

Effect of first-line treatment on second primary malignancies and Richter's transformation in patients with CLL

This study aimed to assess the frequency of and the contributing factors for second primary malignancies (SPMs) and Richter's transformations (RTs) following first-line treatment of chronic lymphocytic leukemia within four phase II/III trials of the GCLLSG evaluating fludarabine (F) vs F+cyclophosphamide (FC), chlorambucil vs F, FC without or with rituximab, and bendamustine+R (BR). Among 1458 patients, 239 (16.4%) experienced either an SPM (N=191) or a RT (N=75). Solid tumors (N=115; 43.2% of all second neoplasias) appeared most frequently, followed by RTs (N=75; 28.2%). Patients showed a 1.23-fold increased risk of solid tumors in comparison to the age-matched general population from the German cancer registry. Age>65 (hazard ratio (HR) 2.1; P<0.001), male sex (HR 1.7; P=0.01), co-morbidities (HR 1.6; P=0.01) and number of subsequent treatments⩾1 (HR 12.1; P<0.001) showed an independent adverse prognostic impact on SPM-free survival. Serum thymidine kinase>10 U/l at trial enrollment (HR 3.9; P=0.02), non-response to first-line treatment (HR 3.6; P<0.001) and number of subsequent treatments⩾1 (HR 30.2; P<0.001) were independently associated with increased risk for RT.

Mycoplasma-induced minimally conscious state

Mycoplasma pneumoniae (M. pneumoniae) frequently causes community-acquired respiratory tract infection and often presents as atypical pneumonia. Following airborne infection and a long incubation period, affected patients mostly suffer from mild or even asymptomatic and self-limiting disease. In particular in school-aged children, M. pneumoniae is associated with a wide range of extrapulmonary manifestations including central nervous system (CNS) disease. In contrast to children, severe CNS manifestations are rarely observed in adults. We report a case of a 37 year-old previously healthy immunocompetent adult with fulminant M. pneumoniae-induced progressive encephalomyelitis who was initially able to walk to the emergency department. A few hours later, she required controlled mechanical ventilation for ascending transverse spinal cord syndrome, including complete lower extremity paraplegia. Severe M. pneumoniae-induced encephalomyelitis was postulated, and antimicrobial, anti-inflammatory and immunosuppressive therapy was applied on the intensive care unit. Despite early and targeted therapy using four different immunosuppressive strategies, clinical success was limited. In our patient, locked-in syndrome developed followed by persistent minimally conscious state. The neurological status was unchanged until day 230 of follow-up. Our case underlines that severe M. pneumoniae- related encephalomyelitis must not only be considered in children, but also in adults. Moreover, it can be fulminant and fatal in adults. Our case enhances the debate for an optimal antimicrobial agent with activity beyond the blood–brain barrier. Furthermore, it may underline the difficulty in clinical decision making regarding early antimicrobial treatment in M. pneumoniae disease, which is commonly self-limited.

Abstract OT1-02-02: The DETECT study program – Personalized treatment in metastatic breast cancer based on circulating tumor cells

Circulating tumor cells (CTCs) are found in patients with primary and metastatic breast cancer (MBC), respectively, and discordance in HER2 and hormone-receptor status between primary tumor, metastases and CTCs is well described. Treatment decisions are still based on the expression profile of solid tumor samples whereas CTCs are thought to cause tumor progression by blood-derived metastases. Nevertheless, targeted therapy based on expression profile of CTCs is not established in clinical routine. Individualized treatment decisions based on presence and phenotype of CTCs will be analyzed within the DETECT study program.

Metastatic breast cancer patients with HER2-negative MBC are screened in DETECT III and IV for presence of CTCs by using the CellSearch System (Janssen Diagnostics) which is FDA approved for enumeration of CTCs. Patients are enrolled into the different cohorts according to HER2-phenotype of CTCs. Since February 2012, women with HER2-negative MBC and HER2-positive CTCs are treated in the multicenter randomized Phase III study DETECT III with standard therapy with or without additional HER2-targeted therapy with Lapatinib. For standard therapy, physicians can choose between exemestane, letrozole and anastrozole for endocrine therapy, or docetaxel, paclitaxel, capecitabine, vinorelbine and non-pegylated liposomal doxorubicin for chemotherapy. Efficacy of CTC-based anti-HER2 treatment is evaluated by analyzing CTC-clearance rate after treatment.

Patients with only HER2-negative CTCs are recruited for the multicenter open-label phase II study DETECT IV. Since December 2013, women with hormone-receptor positive MBC receive endocrine therapy (tamoxifen, exemestane, letrozole or anastrozole) plus everolimus in DETECT IVa. In February 2015, DETECT IV was extended by the eribulin-cohort which offers a cytotoxic treatment with eribulin for women with triple-negative or hormone-receptor positive, chemotherapy demanding MBC (DETECT IVb). Progression free survival is used for assessment of clinical efficacy with overall survival and disease control rate as secondary objectives.

DETECT V, a multicenter open-label phase III study starting in summer 2015, randomizes patients with hormone-receptor positive, HER2-positive MBC to a dual HER2 targeted therapy (Trastuzumab and Pertuzumab) combined with either endocrine therapy or cytotoxic treatment. Quality of life determined by occurrence of adverse events is compared between both treatment arms. For prediction of endocrine treatment response, an "Endocrine Responsiveness Score" is calculated based on expression of estrogen-receptor and HER2 on detected CTCs.

More than 1200 patients are already screened in the DETECT study concept. Thus, it is the worldwide largest study concept with therapy decisions resulting from CTC-testing and CTC-phenotypization. The accompanying translational research programs evaluates further markers for molecular characterization of CTCs and prediction of therapy response.

Conclusion and Contact

The value of CTC phenotypes for making decisions on therapy interventions and predicting treatment responses in patients with MBC is tested in the DETECT study concept. The findings will help to move a step forward towards a more personalized anti-cancer therapy.

Citation Format: Schramm A, Friedl TWP, Huober J, Jäger B, Rack B, Trapp E, Fasching PA, Taran F-A, Hartkopf A, Schneeweiss A, Müller V, Aktas B, Pantel K, Meier-Stiegen F, Wimberger P, Kümmel S, Gebauer G, Müller L, Janni W, Fehm T. The DETECT study program – Personalized treatment in metastatic breast cancer based on circulating tumor cells. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr OT1-02-02.

ABC3 Consensus Commented from the Perspective of the German Guidelines: Third International Consensus Conference for Advanced Breast Cancer (ABC3), Lisbon, 07. 11. 2015

The Third International Consensus Conference for Advanced Breast Cancer ABC3 on the diagnosis and treatment of advanced breast cancer was held in Lisbon from 5 to 7 November 2015. This year the focus was the treatment of metastatic breast cancer (stage IV) - including the patient perspectives. Important topics were questions relating to quality of life, the care for long-term survivors as well as the management of disease-related symptoms and treatment-based side effects. The use of standardised tools to assess individual treatment success and the benefits of new substances were important points for discussion. The diagnosis and treatment of inoperable locally advanced breast cancer were discussed two years ago during the ABC2 consensus 1. A working group of German breast cancer experts commented on the results of the ABC panellists, paying particular attention to the German guidelines (AGO, S3, DGHO) on the diagnosis and treatment of breast cancer 2, 3, 4, 5 in Germany.

[Radial Head Replacement - Surgical Technique and Own Clinical Results]

BACKGROUND

Radial head arthroplasty is an established method to restore the anatomy and biomechanics of the elbow joint - especially for non-reconstructable radial head fractures.

AIMS

This video article aims to explain the indications, the surgical procedure and the postoperative rehabilitation protocol for radial head replacement. We also present our own results with this procedure.

MATERIAL AND METHODS

Since 2014, we have prospectively evaluated all patients undergoing surgery for radial head replacement (MoPyC, Tornier, France). A 6 month follow-up of 11 patients is now available. Moreover, 3 retrospective cases with rare complications are reported which were not part of our prospective evaluation.

RESULTS

8 of 11 procedures were performed due to acute, non-reconstructable radial head fractures. Secondary radial head replacement as a result of failed osteosynthesis was performed in the remaining 3 cases. 8 patients had clinically relevant concomitant injuries to the elbow joint. The mean Mayo Elbow Performance Score was 88 points (65 to 100 points). The arc of motion averaged 124° (± 18°). At 6 months, the mean extension lag was 8°. There were no complications requiring revision surgery at 6 months. Retrospective evaluation found one patient with extensive osteolysis due to oversizing of the shaft, one with disconnection of the prosthesis and one with a broken prosthesis shaft.

CONCLUSIONS

The clinical results with radial head arthroplasty are promising. Accurate implantation is crucial to minimise the risk of complications requiring revision surgery.

Online monitoring of stable carbon isotopes of methane in anaerobic digestion as a new tool for early warning of process instability

Effective control of anaerobic digestion in biogas plants requires the monitoring of process sensitive and rapid response parameters in order to ensure efficient biogas production and to prevent potential process failure. In this study, stable carbon isotopes of methane (δ(13)CCH4) produced in a full-scale continuous stirred-tank reactor were investigated as a potential new monitoring tool for this purpose. Over a six-month period with variable organic loading rates, δ(13)CCH4-values were measured online by a portable high-precision laser absorption spectrometer. During a stress period of consecutive high organic loading, δ(13)CCH4-values early indicated process changes in contrast to traditionally monitored parameters where a change was observed some five to ten days later. Comparison of the stable isotope values with data from microbial analyses showed a distinct relationship between the quantity of potentially acetoclastic methanogens and δ(13)CCH4-values. This finding indicates an association between dominant methanogenic pathways and carbon isotope values.

[Total Elbow Replacement - Implantation of the Latitude Prosthesis (Tornier)]

Due to technical progress, the indication for total elbow arthroplasty could be expanded in recent years. As a result, the demand regarding functionality and mobility of the replaced joint has risen as well. Elbow arthroplasty has to be considered as technically demanding. Only with detailed knowledge of this surgical procedure and its possible intraoperative pitfalls can one provide the best possible results. In this instructional video we explain the implantation of the Latitude elbow prosthesis (Tornier) putting emphasis on the correct approach as well as implantation of the prosthesis and subsequent wound closure.