[A birth cohort study on allergic diseases among toddlers in Northwest Germany]

In the late 1990s, a birth cohort study was conducted in the cities of Delmenhorst, Wilhelmshaven and Leer, where more than 3,000 newborn children were recruited in five hospitals. The baseline survey in the clinics was followed by three follow-up surveys 6, 12 and 24 months later. The prime concern of the study was to estimate prevalences and to conduct analyses concerning the association between breastfeeding as well as exposure to pets and the occurrence of allergy symptoms. Children living together with a dog in the same household were at higher risk of disease only if a familial predisposition of allergic diseases was present - without such a familial predisposition a dog in the same household seems to reduce the risk for atopic diseases during the first 2 years of life. A protective effect due to long breastfeeding could be observed in our study in particular in case of a paternal history of allergic diseases, whereas an exclusive maternal history of allergic diseases seems to increase the risk. The concept of the study has proved itself. Contacting mothers in obstetrical departments in hospitals as well as in medical offices of self-employed pediatricians has proven to be very practicable. With comparatively little effort a relatively large cohort was recruited, which allowed us to analyze longitudinal data, adequately taking into account several confounders as well as effect-modifying factors.

Curative embolization of brain arteriovenous malformations with onyx: patient selection, embolization technique, and results

BACKGROUND AND PURPOSE

A new curative embolization technique with Onyx for selected small and medium-sized superficially located brain AVMs was developed, which consists of obliteration of the nidus, including incremental occlusion of the draining veins. We report our first clinical results.

MATERIALS AND METHODS

Between June 2008 and July 2011, 24 patients (7 women, 17 men; mean age, 41 years; range, 6-74 years) with AVMs were selected for curative embolization with Onyx. Presentation was hemorrhage in 14 and seizures in 10 patients. AVM location was frontal in 11, occipital in 6, parietal in 4, and temporal in 3. AVM size was a mean of 2.2 cm (median, 2; range, 1-3 cm).

RESULTS

Complete angiographic obliteration of the AVM with Onyx in a single session was achieved in all 24 patients. There were no hemorrhagic or ischemic complications (0%; 95% CI, 0%-16.3%), and no new deficits induced by the treatment. Of 14 patients with ruptured AVMs, 1 patient who presented with a large frontal hematoma died shortly after surgical evacuation of the hematoma following complete embolization of a micro-AVM. Follow-up angiography at 3 months in 23 patients demonstrated a small AVM remnant in 1 that was treated with gamma knife radiosurgery. The other 22 AVMs remained completely occluded.

CONCLUSIONS

In selected patients with small and medium-sized superficial brain AVMs, as defined in our study, injection of Onyx by using a curative embolization technique in a single session seems to provide a safe and effective alternative to radiosurgery or surgery.

Endovascular treatment of ruptured brain AVMs in the acute phase of hemorrhage

BACKGROUND AND PURPOSE

Patients with ruptured brain AVMs are at considerable risk of repeat hemorrhage, particularly when associated intranidal or flow-related aneurysms are present. There is controversy about the timing of diagnosis and treatment of patients with hemorrhagic stroke. We present our results of endovascular treatment of ruptured AVMs in the acute phase.

MATERIALS AND METHODS

Between January 2008 and March 2011, 23 patients (16 men, 7 women; mean age 42 years) with AVM-related hemorrhagic stroke were treated with endovascular techniques within 10 days of the ictus. There were 10 micro-AVMs (< 1 cm) and 1 single-hole pial fistula. In 9 patients, an intranidal or flow-related aneurysm was the likely cause of hemorrhage.

RESULTS

Complete obliteration of the AVM with Onyx was achieved in 13 of 23 patients (57%). Eight of the 13 AVMs were micro-AVMs and 3 had an intranidal aneurysm. Partial obliteration of the AVM was achieved in 10 of 23 patients (43%). In 6 of these 10 patients, an intranidal (n = 1) or flow-related aneurysm (n = 5) was obliterated with Onyx or coils. There were no complications of treatment. During a mean follow-up of 21 months in 22 surviving patients, no repeat hemorrhage occurred.

CONCLUSIONS

Endovascular treatment with Onyx in the acute phase cured most ruptured AVMs. All 9 AVM-associated aneurysms that were considered the source of hemorrhage could be excluded from the circulation. In patients with AVM-related hemorrhagic stroke, prompt angiographic diagnosis and treatment may improve prognosis by reducing repeat hemorrhage rate.

Disseminated Mycobacterium marinum infection in a hematopoietic stem cell transplant recipient

Mycobacterium marinum is a photochromogenic mycobacterium that is ubiquitous in the aquatic environment. In the general population, exposure to aquaria is the most common cause of M. marinum infection. Known as "swimmer's granuloma" or "fish tank granuloma," M. marinum is an occupational hazard for aquarium cleaners and fishermen. There are several reports in the literature of M. marinum infection in immunocompromised hosts, including those with solid organ transplants, but none in patients who have received stem cell transplants (SCTs). To our knowledge, this is a first report of disseminated M. marinum infection in an SCT recipient who continued to develop new skin lesions even after months of targeted therapy. The implications are that elderly patients who receive T-cell-depleted SCTs may be at prolonged risk for pathogens dependent on cellular immunity, and the presentation of illness with such pathogens may be more severe and widely disseminated than might otherwise be expected.

Active or passive bio-coating: does it matters in extracorporeal circulation?

Background: Two types of surface coating for cardiopulmonary bypass (CPB) are used: bioactive (heparin, nitric oxide) and biopassive (albumin, polyethyleneoxide (PEO), phosphorylcholine). When haemocompatible coatings are combined with the separation of pleuro-pericardial aspiration, attenuation of both the coagulation and complement cascades, as well as better platelet preservation, has been demonstrated. This study wants to investigate if the combination of a bioactive with a biopassive coating (unfractionated heparin embedded in a phosphorylcholine matrix) combines the beneficial effects of both approaches.

Materials and methods: Thirty patients undergoing elective CABG were prospectively randomized into two groups of 15 patients. The sole exclusion criterion was an ejection fraction of less than 40%. In the control group (PC), the whole CPB circuit was coated with phosphorylcholine (PC). In the study group (XPC), unfractionated heparin was embedded in the PC matrix of the oxygenator and arterial line filter.

Results: No differences were found for haemolytic index, thrombin-anti-thrombin complex (TAT), IL-6, IL-10 and blood loss. PF4 plasma concentration increased from 27.6±22.0 IU/mL to 165.7±43.9 IU/mL (p<0.001) at 15 minutes of CPB in the PC and from 16.0±9.7 IU/mL to 150.9 ± 61.3 IU/mL (p<0.001) in the XPC group. Terminal complement complex (TCC) increased over time in both groups until the end of CPB (Figure 2A). Within each group, TCC generation was statistically significantly higher after the release of the aortic cross-clamp (p<0.001) and at the end of CPB (p<0.001). Total TCC generation was statistically significantly higher in the XPC group compared to the PC group (p=0.026). The difference was statistically significant after the release of the aortic cross-clamp (p=0.005) and at the end of CPB (p=0.001).

Conclusions: Based on our results, there is no additional benefit in combining phosphorylcholine with unfractionated heparin in elective patients undergoing coronary artery bypass grafting (CABG). Massive haemodilution leads to enhanced complement activation.

Prediction of the annuloplasty ring size in patients undergoing mitral valve repair using real-time three-dimensional transoesophageal echocardiography

Aims

We sought to investigate the additional value of real-time three-dimensional transoesophageal echocardiography (RT 3D TOE)-guided sizing for predicting annuloplasty ring size during mitral valve repair.

Methods and results

In 53 patients undergoing elective mitral valve repair, an RT 3D TOE was performed pre- and post-operatively. The digitally stored loops were imported into a software for mitral valve assessment. The annuloplasty ring size was predicted by superimposing computer-aided design (CAD) models of annuloplasty rings onto Live 3D zoom loops, measurement of the intercommissural distance, or the height of the anterior mitral leaflet. The surgeon implanted the annuloplasty ring according to the usual surgical technique and was blinded to the echocardiographic measurement results. Pre-operative correlation between the selected ring size with mitral valve assessment and the actual implanted annuloplasty ring size was 0.91. The correlation for measurement of the intercommissural distance was 0.55 and for measurement of the height of the anterior mitral leaflet 0.75. The post-operative correlation with the actual implanted ring size was 0.96 for mitral valve assessment, 0.92 for intercommissural distance, and 0.79 for the anterior mitral leaflet height.

Conclusion

Superimposition of annuloplasty ring CAD models on the Live 3D zoom loops of the mitral valve using mitral valve assessment is superior to two-dimensional measurements of the intercommissural distance or the height of the anterior mitral leaflet in predicting correct annuloplasty ring size.

Frequency of allergic diseases in 2-year-old children in relationship to parental history of allergy and breastfeeding

BACKGROUND

The association between breastfeeding and the risk of atopic diseases in children is controversial. While some studies support the theory of a decreased risk of asthma and allergic diseases due to breastfeeding, others have failed to confirm such a protective effect, and even suggest increased risk. The aim of this longitudinal study was to investigate the association between breastfeeding and the prevalence of atopic diseases in 2-year-old children.

METHODS

Data on 1685 children from a birth cohort were collected from questionnaires completed by parents at birth and at 6, 12, and 24 months. By means of logistic regression and considering confounders such as family history and socioeconomic status, we analyzed the association between exclusive breastfeeding and the development of allergic reactions in 2-year-old children.

RESULTS

Exclusive breastfeeding for >4 months was associated with an increased risk of asthma and atopic dermatitis in children without a parental history of allergic diseases (odds ratio [OR] = 1.62; 95% confidence interval [Cl], 1.02-2.56). Children whose fathers only had a history of allergic disease strongly benefited from exclusive breastfeeding for >4 months (OR = 0.39; 95%-CI: 0.18-0.83) whereas those whose mothers only had such a history had an increased risk of asthma and atopic dermatitis (OR: 2.31; 95%-CI: 1.16-4.60).

CONCLUSION

In children with a family history of allergy, it seems to be important to distinguish between maternal and paternal predisposition as children whose fathers have a history of atopic disease seem to benefit most from breastfeeding for >4 months.

Bevacizumab beginning concurrently with a sequential regimen of doxorubicin and cyclophosphamide followed by docetaxel and capecitabine as neoadjuvant therapy followed by postoperative bevacizumab alone for women with HER2-negative locally advanced breast cancer (LABC): A phase II trial of the NSABP Foundation Research Group

584

Background: Bevacizumab with chemotherapy improves outcomes in patients with metastatic breast cancer. The purpose of this trial was to determine the activity and safety profile of bevacizumab with chemotherapy in women with LABC. Methods: Between November 2006 and August 2007, 45 women with HER-2 negative LABC initiated preoperative standard AC x 4 followed by docetaxel 75 mg/m2 IV and capecitabine 825 mg/m2 BID days 1–14 (TX) every 21 days for 4 cycles. Bevacizumab 15 mg/kg IV was given concurrently with chemotherapy every 21 days for a total of 6 preoperative doses. Postoperatively, bevacizumab was resumed for a total of 10 doses. Primary endpoint was pathologic complete response rate (pCR) in the breast. The secondary endpoints include clinical response rates and toxicity. Results: The median age was 50 yrs (range 30–78). 30 patients had stage IIIA (67%), 12 stage IIIB (27%), and 3 stage IIIC (7%) disease. Of these, 10 (22%) had inflammatory breast cancer. 27 patients (60%) had ER-positive disease. A pCR in the breast was documented in 4/44 (9%) patients, which included negative axillary nodes. A complete clinical response was noted in 14/45 (31%). One patient did not have surgery due to progression. Toxicities included hand-foot (grade 2/3–33%/22%), mucositis (grade 2/3–49%/27%), and febrile neutropenia (grade 3–24%). Conclusions: This regimen demonstrated only modest activity with substantial toxicity, and does not appear to warrant further evaluation. This clinical trial is being conducted through the support of Genentech and Roche.

[Table: see text]

Epirubicin plus cyclophosphamide followed by docetaxel plus trastuzumab and bevacizumab as neoadjuvant therapy for HER2-positive locally advanced breast cancer (LABC) or as adjuvant therapy for HER2-positive pathologic stage III breast cancer (PS3BC): A phase II trial of the NSABP Foundation Research Group

580

Background: A previous phase II study evaluating the combination of trastuzumab (tras) and bevacizumab (bev) as first-line therapy in HER2 + MBC showed a response rate of 54%. The purpose of this trial is to determine the cardiac safety profile of these agents with docetaxel (T) following epirubicin plus cyclophosphamide (EC) in women with LABC and PS3BC and the activity in those with LABC. Methods: Since June 2007, 75 women with HER-2 + LABC or PS3BC have begun epirubicin 90 mg/m2 IV plus cyclophosphamide 600 mg/m2 IV q3wks x 4 followed by docetaxel 100 mg/m2 IV q3wks x 4. Targeted therapy: Cohort A (neoadjuvant), bev 15 mg/kg IV with Cycle 4 of EC, continued with the first 3 cycles of T. Standard weekly tras with 4 cycles of T. Postop, bev 15 mg/kg IV and tras 6 mg/kg IV q3wks to complete 1 yr of targeted therapy. Cohort B (adjuvant), bev 15 mg/kg q3wks for 4 cycles and weekly tras with T. After chemotherapy, bev and tras q3wks to complete 1 yr of therapy. Primary endpoints were the rate of cardiac events in both cohorts and pCR rate in breast/axillary lymph nodes in Cohort A. Results: Median age was 50 yrs. In Cohort A, 28 (53%) patients (pts) were stage IIIA, 20 (38%) stage IIIB, and 5 (9%) stage IIIC. 13 (25%) had inflammatory BC. A pCR occurred in 19 of the first 36 pts (53%). Toxicity information on the first 73 pts in both cohorts showed that grade 2 LVEF dysfunction has developed in 5 pts and grade 3 LVEF dysfunction in 2, 1 with NYHA Class II and 1 with Class III symptoms. The latter met criteria for a cardiac event. Conclusions: The regimen is active with an acceptable preliminary rate of cardiac toxicity. Updated results will be presented. This trial is conducted with the support of Genentech.

[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).