[Interventional, intramyocardial stem cell therapy in ischemic cardiomyopathy: update 2010]

BACKGROUND

The intracoronary application of autologous bone marrow cells has proven hitherto to be safe but not sufficiently effective in patients with ischemic cardiomyopathy. The interventional application of cells injected directly into the myocardium represents one possible approach to improve effectiveness.

TECHNIQUES

The NOGA method is based on the CARTO technique, which has been evaluated extensively for safety and feasibility in patients with heart failure. In a first step, an electrically and anatomically exact map of the left ventricle is obtained. Guided by this three-dimensional map direct injection of the cells into the ischemic area can be easily performed.

CLINICAL STUDIES

Since its introduction in 2002 many studies have proven the safety, feasibility and effectiveness of NOGA-guided regenerative therapy to the left ventricle. While several studies also suggest effectiveness regarding various parameters of left ventricular function, no larger multicenter study is available to date. Such studies with also clinical endpoints are currently ongoing.

CONCLUSION

The currently available data support, but do not yet prove, the hypothesis that intramyocardial stem cell therapy using NOGA-guided injection into the myocardium is safe and feasible in both acute and chronic ischemic cardiomyopathy. Ongoing trials will reveal whether this approach will become the standard form for applying cell therapy to the heart.

[Therapeutic alternatives for antihistamine-refractory urticaria]

Patients with chronic spontaneous urticaria, the most frequent non-acute form of urticaria, generally exhibit a clinical picture of persistent disease, a high degree of disease activity, considerable impairment of quality of life, and poor response to treatment. More than half of the patients continue to develop symptoms despite standard therapy with non-sedating antihistamines. In these cases, the antihistamine dose should be increased (up to four times the daily dose). If this approach also does not result in symptom control, the high-dose antihistamine should be combined with a leukotriene antagonist and if necessary an H2 blocker. If the patient does not respond to this combination therapy, cyclosporin A, dapsone, or omalizumab should be administered.

[Chronic urticaria. Prevalence, course, prognostic factors and impact]

Chronic urticaria (CU) is one of the most frequent diseases in the field of dermatology. Recent studies have shown a point prevalence between 0.5 and 1% in the total population with a predominance of females. In general, all age groups and all classes of the population can be affected. An incidence peak has been found in the third and fourth decades. According to the current guidelines, CU is characterized by the spontaneous occurrence of wheals and/or angioedema for more than 6 weeks. However, epidemiological studies have revealed that the majority of patients suffer for several months, or frequently years. Disease duration is likely to be longer in case of angioedema, a combination with physical urticaria, positivity in the autologous serum skin test (autoreactivity) and a high disease severity. Studies on the impairment of quality of life have been shown that many CU patients suffer as strong from their disease as patients with coronary artery disease. Apart from pure physical symptoms, patients experience restrictions in daily life activities and social life. In addition, sleep disturbances are common and CU patients frequently exhibit psychiatric comorbidities. To avoid frustration in care, it is important to perceive all different dimensions of CU that impact the patient's life and to take the patients and their disease seriously. The aim of therapy should be to obtain total symptom control.

Laparoscopic inguinal herniorrhaphy in premature infants

INTRODUCTION

We report the clinical, operative, and outcome results in 58 premature infants (with maximum weight of 5,000 g at time of surgery) undergoing laparoscopic herniorrhaphy.

PATIENTS AND METHODS

This study was designed as a prospective, non-randomized single center feasibility study. The inclusion criteria were: symptomatic inguinal hernia, gestational age up to 37 weeks and maximum weight of 5,000 g at the time of surgery. Out of 58 premature infants (42 boys and 16 girls), 24 had bilateral, 20 had right-sided and 14 had left-sided hernias. 14 (24.1%) infants were operated on for an irreducible hernia.

RESULTS

The median gestational age at birth was 33 weeks (range 23-37) and the median gestational age at operation was 41 weeks (range 33-52). The body weight at surgery ranged from 1,450 g to 5,000 g (median 3 900 g); 11 infants (19%) weighed less than 2 500 g. No intraoperative surgical complications occurred. Anesthesia complications were noted in 7 cases. At median follow-up of 25 months (range 6-51 months), there were 3 hernia recurrences in 2 infants (3.6%). In 5 boys, we observed high testes requiring subsequent orchiopexy. Regression analysis showed that the risk of undescended testes increased by 65.5% for every 1 kilo lower weight at surgery.

CONCLUSION

Based on our early results, it seems that laparoscopic hernia repair in preterm infants and very low birth weight babies is a safe and feasible procedure and has some procedural benefits compared to the standard open technique.

High-efficient nonviral transfection of the rat thyroid cell line FRTL-5

FRTL-5 cells are used in many laboratories as an in vitro system of thyroid follicular cells since they share many properties of human thyrocytes. However, the use of FRTL-5 cells for experimental modifications is limited by low transfection efficiencies of lipid-based transfections and the need for cumbersome viral transduction protocols. A new technology - nucleofection - has become available for cell lines that are difficult to transfect. Here, we report the application and optimization of this method in FRTL-5 cells. Using the green fluorescent protein (GFP) as a reporter gene, FRTL-5 cells were easily transfectable with efficiencies over 60%. In addition, the simultaneous transfer of siRNA against GFP was feasible and allowed suppression of GFP over at least 4 days. Furthermore nucleofection was successful for establishing stable FRTL-5 cell clones. In conclusion, this optimized fast and efficient nucleofection protocol offers new properties for the experimental use of FRTL-5 cells.

Distinct regulation of intrinsic apoptosis in benign and malignant thyroid tumours

Aberrations in the control of apoptosis represent a central feature of thyroid carcinogenesis. However, little is known about the regulation of components of the intrinsic apoptosis pathway in the thyroid. Using a real-time PCR approach we investigated the mRNA expression levels of Caspase3, Caspase3 s, xIAP, Bad, and beta-actin in a panel of 79 thyroid tumours. Additionally, we assessed the activation status of Caspase3 by immunohistochemistry. In the present study, we provide first evidence for a deregulation of the intrinsic apoptosis pathway on the transcriptional and post-transcriptional level. Thus, malignant thyroid tumours revealed a significant downregulation of the proapoptotic Bad. In contrast Caspase3 s, an alternative splice variant of Caspase3 with anti-apoptotic characteristics, was upregulated in follicular and anaplastic cancers. Moreover, papillary thyroid tumours revealed a significant upregulation of Caspase3 mRNA. On the post-translational level, thyroid malignancies featured an impairment in the activation of Caspase3, since activated Caspase3 accumulated exclusively in the cytoplasm of thyroid cancer cells, whereas follicular adenoma and normal thyroid tissues showed no cytoplasmatic but nuclear Caspase3 distribution. Further knowledge on apoptosis-deregulation during thyroid carcinogenesis might confer diagnostic and therapeutic benefits in the management of thyroid cancer.

Anatomic changes in multiple brainstem nuclei after incremental, near-complete neurotoxic destruction of the pre-Bötzinger Complex in adult goats

Abrupt, bilateral destruction of the pre-Bötzinger Complex (preBötC) leads to terminal apnea in unanesthetized goats and rats. In contrast, respiratory rhythm and pattern and arterial blood gases in goats during wakefulness and sleep are normal after incremental (over a month) destruction of > 90% of the preBötC. Here, we tested the hypothesis that the difference in effects between abrupt and incremental destruction of the preBötC are a result of time-dependent plasticity, which manifests as anatomic changes at sites within the respiratory network. Accordingly, we report data from histological analyses comparing the brainstems of control goats, and goats that had undergone bilateral, incremental, ibotenic acid (IA)-induced preBötC lesioning. A major focus was on the parafacial respiratory group/retrotrapezoid nucleus (pFRG/RTN) and the pontine respiratory group (PRG), which are sites thought to contribute to respiratory rhythmogenesis. We also studied the facial (FN), rostral nucleus ambiguus (NA), medullary raphé (MRN), hypoglossal (HN), and the dorsal motor vagal (DMV) nuclei. Neuronal counts, count region area (mm²), and neuronal densities were calculated using computer-assisted analyses and/or manual microscopy to compare control and preBötC-lesioned animals. We found that within the ventral and lateral medulla 2mm rostral to the caudal pole of the FN (presumed pFRG/RTN), there were 25% and 65% more (P < 0.001) neurons, respectively, in preBötC-lesioned compared to control goats. Lesioned goats also showed 14% and 13% more (P < 0.001) neurons in the HN and medial parabrachialis nucleus, but 46%, 28%, 7%, and 17% fewer (P < 0.001) neurons in the FN, NA, DMV, and Kölliker-Fuse nuclei, respectively. In the remaining sites analyzed, there were no differences between groups. We conclude that anatomic changes at multiple sites within the respiratory network may contribute to the time-dependent plasticity in breathing following incremental and near-complete destruction of the preBötC.

Somatostatin receptor subtype expression in human thyroid tumours

Somatostatin receptors (SSTR) are expressed in various endocrine tumours. The expression of SSTR at the tumour cell surface confers the possibility for diagnostic imaging and therapy of tumours using radiolabeled somatostatin analogues. The majority of currently available somatostatin analogues show a higher binding affinity for the SSTR2 subtype. To date, the precise expression pattern of the SSTR subtypes 1-5 in thyroid epithelial tumours remains to be determined. We investigated the mRNA expression of SSTR1-5 in benign and malignant epithelial thyroid tumours [20 cold thyroid nodules (CTNs), 20 toxic thyroid nodules (TTNs), 20 papillary, 20 follicular, and 5 anaplastic carcinomas (PTCs, FTCs, ATCs, respectively)] and compared them to normal surrounding thyroid tissues. Four out of five SSTR subtypes were detected in malignant thyroid tumours, benign neoplasia, and normal surrounding tissue with a predominant expression of SSTR2 and SSTR5, and a weak expression of SSTR1 and SSTR3. Weak SSTR4 mRNA expression was detected in some PTCs. Compared to normal thyroid tissue, SSTR2 was significantly upregulated in PTC and ATC. In addition significant upregulation of SSTR3 was found in PTC. SSTR5 mRNA expression was increased in PTC and FTC and significantly decreased in CTN and TTN compared to normal thyroid tissue. SSTR2 is the predominant subtype in thyroid epithelial tumours with a high expression pattern, in particular, in PTC . Perspectively, the expression of distinct SSTR in thyroid epithelial tumours might represent a promising avenue for diagnostics and therapy of advanced thyroid cancer with somatostatin analogues.

[Influence of mydriatic eye drops on the aberrometer predicted phoropter refraction]

BACKGROUND AND PURPOSE

Wavefront-guided ablations are based on wavefront sensing in a pupil dilated under mesopic conditions, or in patients with insufficient natural pupil dilation, after the application of mydriatic eye drops. The aim of this study was to investigate a potential influence of mydriatic eye drops on wavefront-sensing in terms of the predicted phoropter refraction (PPR).

METHOD

In this prospective study 70 myopic eyes were measured in miosis and pharmacologically induced mydriasis with the Zywave aberrometer and automated refraction (Canon R-F10). 52 eyes were dilated with eye drops containing tropicamide 0.5 % and phenylephrine 2.5 %, in the remaining 18 eyes tropicamide 0.5 % was used. The PPR for a pupil diameter of 3.5 mm in miosis and in mydriasis, respectively, were compared and correlated to the corresponding values of the automated refraction.

RESULTS

PPR values obtained in mydriasis were less myopic than in miosis. The sphere of PPR differed by an average of + 0.19 +/- 0.3 diopters (range: -1.07 to + 0.37 diopters) when using tropicamide 0.5 % and phenylephrine 2.5 %. With tropicamide 0.5 % eye drops the difference was + 0.25 +/- 0.4 diopters (range: -1.12 diopters to + 0.27 diopters). Cylinder values were not affected. Automated refraction yielded a smaller difference of + 0.16 +/- 0.33 diopters (tropicamide 0.5 % and phenylephrine 2.5 %) and + 0.1 +/- 0.19 diopters (tropicamide 0.5 %). Cylinder values changed significantly.

CONCLUSION

The cycloplegic effect of mydriatic eye drops should be taken into account when interpreting aberration measurements and planning a wavefront-guided laser ablation.

Impact of maternal body mass index on neonatal outcome

Introduction

Maternal body mass index has an impact on maternal and fetal pregnancy outcome. An increased maternal BMI is known to be associated with admission of the newborn to a neonatal care unit. The reasons and impact of this admission on fetal outcome, however, are unknown so far.

Objective

The aim of our study was to investigate the impact of maternal BMI on maternal and fetal pregnancy outcome with special focus on the children admitted to a neonatal care unit.

Methods

A cohort of 2049 non-diabetic mothers giving birth in the Charite university hospital was prospectively studied. The impact of maternal BMI on maternal and fetal outcome parameters was tested using multivariate regression analysis. Outcome of children admitted to a neonatal ward (n = 505) was analysed.

Results

Increased maternal BMI was associated with an increased risk for hypertensive complications, peripheral edema, caesarean section, fetal macrosomia and admission of the newborn to a neonatal care unit, whereas decreased BMI was associated with preterm birth and lower birthweight. In the neonatal ward children from obese mothers are characterized by hypoglycaemia. They need less oxygen, and exhibit a shorter stay on the neonatal ward compared to children from normal weight mothers, whereas children from underweight mothers are characterized by lower umbilical blood pH and increased incidence of death corresponding to increased prevalence of preterm birth.

Conclusion

Pregnancy outcome is worst in babies from mothers with low body mass index as compared to healthy weight mothers with respect to increased incidence of preterm birth, lower birth weight and increased neonate mortality on the neonatal ward. We demonstrate that the increased risk for neonatal admission in children from obese mothers does not necessarily indicate severe fetal impairment.

Percutaneous intramyocardial stem cell injection in patients with acute myocardial infarction: first-in-man study

BACKGROUND

Clinical studies on intracoronary stem cell infusion in patients with acute myocardial infarction (AMI) have shown promising results for left ventricular ejection fraction (LVEF). However, preclinical studies have shown that intramyocardial cell injection is better than the intracoronary approach.

OBJECTIVE

To test safety and feasibility of intramyocardial cell injection and left ventricular electromechanical mapping (EMM) early after AMI.

DESIGN

On day 10.5 (5) (mean (SD)) after AMI and percutaneous coronary intervention with stent implantation (culprit lesion: 15 LAD, 3 circumflex and 2 right coronary arteries) 20 patients (mean (SD) 60.4 (11.4) years) received bone marrow derived mononuclear cells in the low-voltage area using EMM-guided percutaneous intramyocardial injection. EMM and coronary angiography were performed in 15 patients at 6-months' follow-up. Echocardiography, recording of laboratory data and clinical assessment (6-month and 12-month follow-up) were carried out in all 20 patients.

RESULTS

None of the patients showed periprocedural complications. Three patients received an implantable cardioverter-defibrillator for primary prevention of sudden cardiac death and 6 (30%) patients showed in-stent restenosis. One patient underwent bypass surgery owing to chronic stent occlusion after 6 months. 2.0 (0.6)x10(8) cells, including 1.0 (0.3)x10(6) CD45(dim)/CD34(hi) stem cells, were injected in each patient. EMM showed a mean (SD) improvement from a baseline unipolar voltage of 45.5 (14.3)% to 59.3 (19.8)% of normal voltage (p = 0.002) and reduction of the low-voltage area from 28.7 (12.1)% to 20.3 (13.5)%; (p = 0.016). During the 12-month follow-up, the left ventricular ejection fraction (LVEF) improved from 40.8 (6.9)% to 47.1 (10.6)%; (p = 0.037).

CONCLUSION

Left ventricular EMM and percutaneous intramyocardial cell injection in patients with AMI was shown to be a safe procedure. It is associated with improved LVEF and electromechanical parameters after 12-months' follow-up.

TRIAL REGISTRATION NUMBER

Eudra-CT-No 2005-003629-19.