A genome-wide RNAi screen identifies proteins modulating aberrant FLT3-ITD signaling

Fms-like tyrosine kinase-3 is a commonly mutated gene in acute myeloid leukemia, with about one-third of patients carrying an internal-tandem duplication of the juxtamembrane domain in the receptor (FLT3-ITD). FLT3-ITD exhibits altered signaling quality, including aberrant activation of STAT5. To identify genes affecting FLT3-ITD-mediated STAT5 signaling, we performed an esiRNA-based RNAi screen utilizing a STAT5-driven reporter assay. Knockdowns that caused reduced FLT3-ITD-mediated STAT5 signaling were enriched for genes encoding proteins involved in protein secretion and intracellular protein transport, indicating that modulation of protein transport processes could potentially be used to reduce constitutive STAT5 signaling in FLT3-ITD-positive cells. The relevance of KDELR1, a component involved in the Golgi-ER retrograde transport, was further analyzed. In FLT3-ITD-expressing leukemic MV4-11 cells, downregulation of KDELR1 resulted in reduced STAT5 activation, proliferation and colony-forming capacity. Stable shRNA-mediated depletion of KDELR1 in FLT3-ITD-expressing 32D cells likewise resulted in reduced STAT5 signaling and cell proliferation. Importantly, these cells also showed a reduced capacity to generate a leukemia-like disease in syngeneic C3H/HeJ mice. Together our data suggest intracellular protein transport as a potential target for FLT3-ITD driven leukemias, with KDELR1 emerging as a positive modulator of oncogenic FLT3-ITD activity.

A pragmatic guide on how physicians can take over financial control of their clinical practice

Control of clinical cost is becoming increasingly important in health care worldwide. Physicians should accept the limitation of resources and take responsibility to improve their clinical cost-reimbursement ratio. To achieve this, they will need basic education in clinic management to control and adjust costs and reimbursement, without impacting professional quality of care. Rational use of diagnostics and therapy should be implemented and frequently verified. Physicians are the only professionals that are able to integrate economics with health care. This is in the best interest of patients and will improve a physician's position, influence, and professional freedom levels within our hospitals.

[Detection of prostate cancer by real-time MR/ultrasound fusion-guided biopsy: 3T MRI and state of the art sonography]

PURPOSE

Multiparametric MRI of the prostate is a noninvasive diagnostic method with high sensitivity and specificity for prostate cancer. The aim of this study is to evaluate whether prostate cancer detection rates of transrectal ultrasound (TRUS)-guided biopsy may be improved by an image fusion of state-of-the-art ultrasound (CEUS, elastography) and MR (T2w, DWI) imaging.

MATERIALS AND METHODS

32 consecutive patients with a history of elevated PSA levels and at least one negative TRUS-guided biopsy with clinical indication for a systematic re-biopsy underwent multiparametric 3 T MRI without endorectal coil. MR data (T2w) were uploaded to a modern sonography system and image fusion was performed in real-time mode during biopsy. B-mode, Doppler, elastography and CEUS imaging were applied to characterize suspicious lesions detected by MRI. Targeted biopsies were performed in MR/US fusion mode followed by a systematic standard TRUS-guided biopsy. Detection rates for both methods were calculated and compared using the Chi²-test.

RESULTS

Patient age was not significantly different in patients with and without histologically confirmed prostate cancer (65.2 ± 8.0 and 64.1 ± 7.3 age [p = 0.93]). The PSA value was significantly higher in patients with prostate cancer (15.5 ± 9.3 ng/ml) compared to patients without cancer (PSA 10.4 ± 9.6 ng/ml; p = 0.02). The proportion of histologically confirmed cancers in the study group (n = 32) of the MR/US fusion biopsy (11/12; 34.4 %) was significantly higher (p = 0.01) in comparison to the TRUS systematic biopsy (6/12; 18.8 %).

CONCLUSION

Real-time MR/US image fusion may enhance cancer detection rates of TRUS-guided biopsies and should therefore be studied in further larger studies.

Hypertensive Disorders of Pregnancy - A Life-Long Risk?!

Background: Arterial hypertension is one of the most important causes of cardiovascular diseases, and the latter are responsible for almost half of the deaths in the industrialised nations. Hypertensive disorders of pregnancy constitute one of the most frequent causes of feto-maternal morbidity and mortality; on the other hand the occurrence of a hypertensive disorder of pregnancy represents a risk for the later development of hypertension and the cardiovascular risks resulting therefrom. The aim of this article is to demonstrate the association of hypertensive disorders of pregnancy with consecutive cardiovascular diseases. Materials and Methods: Specific selective literature research. Results: After the occurrence of a hypertensive disorder of pregnancy the relative risks for hypertension are 3.7 (2.70-5.05), for ischaemic heart disease 2.2 (1.86-2.52), for cerebral insult 1.8 (1.45-2.27) and for mortality resulting from cardiovascular causes 1.5 (1.05-2.14) and are thus significant. According to a recent study 56 % of internal specialists and 23 % of gynecologists do not know about the association of preeclampsia with ischemic heart disease, 48 % and 38 % respectively are not aware of the link with stroke and 79 % and 77 % respectively are not aware of the association with a reduced life expectancy after preeclampsia. The presence of hypertension is not known by many of the patients, merely 28-38 % receive an appropriate therapy. Conclusion: Adequate follow-up after hypertensive disorders of pregnancy and the early recognition of and therapy for hypertension represent the cornerstones in the prevention of late cardiovascular sequelae. General practitioners, specialist for internal medicine and gynaecologists have a special responsibility with regard to the reduction of later complications.

[Magnetic resonance elastography of the liver]

CLINICAL/METHODICAL ISSUE

The early detection of liver fibrosis remains a major challenge in medical imaging.

STANDARD RADIOLOGICAL METHODS

Nowadays staging of liver fibrosis is not a task for radiological examinations and the gold standard is liver puncture.

METHODICAL INNOVATIONS

Elastography is sensitive to the mechanical properties of soft tissues and in the liver stiffness is highly correlated to the degree of fibrosis. In magnetic resonance imaging elastography (MRE) time-harmonic vibrations are induced in the liver and encoded by motion-sensitive phase-contrast sequences. Viscoelastic constants are recovered from the obtained wave images and displayed by so-called elastograms.

PERFORMANCE

The MRE procedure is able to discriminate low grades of fibrosis (F0-F1) from medium and severe fibrosis (F2-F4) with a diagnostic accuracy (AUROC) of 0.92.

ACHIEVEMENTS

Currently, MRE is the most sensitive imaging modality for the noninvasive staging of liver fibrosis.

PRACTICAL RECOMMENDATIONS

Current technical developments of MRE may further improve the accuracy of the method towards a new gold standard for noninvasive staging of fibrosis by radiologists.

Charged-current weak interaction processes in hot and dense matter and its impact on the spectra of neutrinos emitted from protoneutron star cooling

We perform three-flavor Boltzmann neutrino transport radiation hydrodynamics simulations covering a period of 3 s after the formation of a protoneutron star in a core-collapse supernova explosion. Our results show that a treatment of charged-current neutrino interactions in hot and dense matter as suggested by Reddy et al. [Phys. Rev. D 58, 013009 (1998)] has a strong impact on the luminosities and spectra of the emitted neutrinos. When compared with simulations that neglect mean-field effects on the neutrino opacities, we find that the luminosities of all neutrino flavors are reduced while the spectral differences between electron neutrinos and antineutrinos are increased. Their magnitude depends on the equation of state and in particular on the symmetry energy at subnuclear densities. These modifications reduce the proton-to-nucleon ratio of the outflow, increasing slightly their entropy. They are expected to have a substantial impact on nucleosynthesis in neutrino-driven winds, even though they do not result in conditions that favor an r process. Contrary to previous findings, our results show that the spectra of electron neutrinos remain substantially different from those of other (anti)neutrino flavors during the entire deleptonization phase of the protoneutron star. The obtained luminosity and spectral changes are also expected to have important consequences for neutrino flavor oscillations and neutrino detection on Earth.

Efficacy and safety of methantheline bromide (Vagantin(®) ) in axillary and palmar hyperhidrosis: results from a multicenter, randomized, placebo-controlled trial

BACKGROUND

Focal hyperhidrosis can severely affect quality of life. So far, knowledge on the effect of systemic therapy of focal hyperhidrosis is limited.

OBJECTIVE

To assess the efficacy and safety of methantheline bromide (MB) in the treatment of axillary and palmar-axillary hyperhidrosis.

METHODS

A multicenter controlled randomized double-blind clinical trial was conducted in patients with axillary or palmar-axillary hyperhidrosis defined by a sweat production >50 mg/5 min. Patients received 3 × 50 mg MB daily or placebo over a period of 28 ± 1 days. Main outcome criterion was the reduction of sweat as measured by gravimetry on day 28 ± 1. Quality of life was assessed by Dermatology Life Quality Index (DLQI) and Hyperhidrosis Disease Severity Score (HDSS).

RESULTS

A total of 339 patients were randomly assigned to receive MB or placebo. On day 28 ± 1, the mean axillary sweat production was 99 mg for MB and 130 mg for placebo compared with 168 mg and 161 mg respectively at baseline (P = 0.004). Patient's HDSS score decreased in the MB group from 3.2 to 2.4 compared with 3.2 to 2.7 for placebo (P = 0.002). Similar results could be obtained for the DLQI with 9.7 for MB and 12.2 for placebo, which decreased from 16.4 or 17 respectively (P = 0.003). Tolerability was good for both groups. The most frequent adverse event was dry mouth.

CONCLUSION

Fifty milligrams methantheline bromide three times a day is an effective and safe treatment of axillary hyperhidrosis.

Prognostic impact of meningeal dissemination in primary CNS lymphoma (PCNSL): experience from the G-PCNSL-SG1 trial

BACKGROUND

We evaluated the frequency and prognostic impact of meningeal dissemination (MD) in immunocompetent adult patients with primary central nervous system lymphoma treated in a randomized phase III trial.

PATIENTS AND METHODS

MD was evaluated at study entry and defined by lymphoma proof in the meningeal compartment detected by at least one of the following methods: cerebrospinal fluid (CSF) cytomorphology, detection of clonal B cells by IgH PCR in CSF or contrast enhancement of the leptomeninges on magnetic resonance imaging (MRI).

RESULTS

Data on MD were available in 415 patients, of those, MD was detected in 65 (15.7%): in 44/361 (12.2%) by CSF cytomorphology, in 16/152 (10.5%) by PCR and in 17/415 (4.1%) by MRI. Major patients' characteristics and therapy did not significantly differ between patients with MD (MD+) versus those without MD (MD-). There was a significant correlation of MD with CSF pleocytosis (>5/μl; P < 0.0001), but no correlation with CSF protein elevation (>45 mg/dl). Median progression-free survival was 6.7 months [95% confidence interval (CI) 0-14.5] in MD+ and 8.3 months (5.7-10.8) in MD- patients (P = 0.95); median overall survival was 21.5 months (95% CI 16.8-26.1) and 24.9 months (17.5-32.3), respectively (P = 0.98).

CONCLUSION

MD was detected infrequently and had no impact on outcome in this trial.

Significant differentiation of focal breast lesions: raw data-based calculation of strain ratio

PURPOSE

We compared elastography, B-mode ultrasound and mammography to determine whether raw data calculation of strain ratios (SRs) can further improve the differentiation of focal breast lesions.

MATERIALS AND METHODS

201 women with histologically proven focal breast lesions (85 benign, 116 malignant) were included at two German breast centers. Patients underwent a standardized ultrasound procedure using high-end ultrasound system with a 9-MHz broadband linear transducer. Two experienced readers analyzed the B-mode scans and mammograms using the BI-RADS criteria, while elastograms were analyzed using the Tsukuba score. SRs were calculated from a tumor-adjusted ROI and a comparable ROI placed in the lateral fatty tissue. The sensitivity, specificity, and cutoff values were calculated for SRs (ROC analysis).

RESULTS

The median age was 53 years. The sensitivity and specificity were 85 %/ 60 % for B-mode scanning, 85 %/ 68 % for elastography, 78 %/ 62 % for mammography, and 95 %/ 74 % for SRs. An SR cutoff value of 2.27 (AUC 0.907) allowed significant differentiation (p < 0.001) between malignant and benign lesions. The quantitative SR calculation was superior to subjective interpretation of B-mode scans and sonoelastograms with a positive predictive value of 83 % versus 78 % and 74 %, and equal to mammograms.

CONCLUSION

Strain ratio calculation contributes to the standardization of sonoelastography with high sensitivity and allows significant differentiation between benign and malignant breast lesions with a higher specificity compared to B-mode, subjective evaluation of elastography and mammography.

[Sonographic detection of microcalcifications - potential of new method]

PURPOSE

Does the easier microcalcification detection (EMD) method enable sonographic visualization of microcalcifications in breast core biopsy specimens compared with mammography?

MATERIALS AND METHODS

In a prospective randomized study, 105 core biopsy specimens obtained with stereotactic guidance were examined by mammography and ultrasound. EMD is integrated in a high-end ultrasound system and uses three level settings (0 - 2 blue, 3 - 5 violet, and 6 - 8 black-and-white; 14 MHz). Detection of microcalcifications per core specimen was determined for ultrasound and mammography. EMD image quality was rated on a scale of 1 - 9. ANOVA and Sidak post-hoc testing, Pearson regression analysis (r), and Spearman rank correlation (rho) were performed. The intraclass correlation coefficient (ICC) was calculated, and an ROC analysis was conducted.

RESULTS

The blue color map 1 was assigned the highest mean score of 1.5 ± 0.7 (p< 0.05 compared with black-and-white and violet). There was good correlation between the two modalities (r= 0.708 and rho= 0.694) with detection of 3.5 ± 3.1 microcalcifications per specimen by ultrasound versus 4.3 ± 4.8 by mammography (p> 0.05). The ICC of 0.773 indicates little disagreement between the two modalities. ROC analysis showed mammography to be superior to ultrasound compared with histological detection of microcalcifications (AUC= 0.837 vs. AUC= 0.728).

CONCLUSION

Sonographic detection of microcalcifications in stereotactic biopsy specimens using the EMD method correlates well with digital mammography. Mammography is slightly superior.

[Pneumothorax, what kind of therapy is necessary? A clinical overview]

Pneumothorax is defined as the accumulation of air in the pleural space. A distinction is made between a primary (idiopathic) spontaneous pneumothorax (PSP), secondary spontaneous pneumothorax (SSP) as well as between iatrogenic pneumothorax and traumatic pneumothorax. Primary spontaneous pneumothorax (PSP) occurs mainly in otherwise healthy people (mainly tall and thin young men) without any clinical sign of lung disease. In contrast, secondary pneumothorax (SSP) mostly occurs in patients with diagnosed and clinically manifested lung disease and is most frequent in older subjects (> 50 years). Smokers have a higher risk of developing pneumothorax. Most pneumothorax cases require a therapeutic intervention using thorax drainage. Observation alone is recommended for only those few patients suffering from pneumothorax without clinical symptoms. Although simple needle aspiration is often recommended as a first-line treatment, our clinical experience shows no advantage for most of the patients. All patients with symptomatic pneumothorax should be treated with immediate intercostal tube drainage. In the surgical therapy of pneumothorax, VATS (video-assisted thoracic surgery) is the current effective standard treatment. Open posterolateral thoracotomy is the recommend approach rather than the minimally invasive procedure in patient with serious illness or complications. The aim of both interventions is to reduce the recurrence rate of pneumothorax as much as possible.

Phase IB study of the FLT3 kinase inhibitor midostaurin with chemotherapy in younger newly diagnosed adult patients with acute myeloid leukemia

This phase 1b trial investigated several doses and schedules of midostaurin in combination with daunorubicin and cytarabine induction and high-dose cytarabine post-remission therapy in newly diagnosed patients with acute myeloid leukemia (AML). The discontinuation rate on the 50-mg twice-daily dose schedule was lower than 100 mg twice daily, and no grade 3/4 nausea or vomiting was seen. The complete remission rate for the midostaurin 50-mg twice-daily dose schedule was 80% (FMS-like tyrosine kinase 3 receptor (FLT3)-wild-type: 20 of 27 (74%), FLT3-mutant: 12 of 13 (92%)). Overall survival (OS) probabilities of patients with FLT3-mutant AML at 1 and 2 years (0.85 and 0.62, respectively) were similar to the FLT3-wild-type population (0.78 and 0.52, respectively). Midostaurin in combination with standard chemotherapy demonstrated high complete response and OS rates in newly diagnosed younger adults with AML, and was generally well tolerated at 50 mg twice daily for 14 days. A phase III prospective trial is ongoing (CALGB 10603, NCT00651261).

[Authorization procedure of clinical trials with medical devices. First practical analysis of the BfArM]

The 4th amendment of the Medical Device Law introduced the authorization procedure for clinical trials with medical devices. The Federal Institute for Drugs and Medical Devices ("Bundesinstitut für Arzneimittel und Medizinprodukte", BfArM) has now drawn the first substantial interim balance on the basis of daily practice in order to describe results achieved by applications of clinical trials with medical devices. Overall, realization of the new authorization procedure of clinical trials is well underway. This empirical practical analysis of the first 405 applications points out further possibilities for improvements for future applicants. Furthermore, initial figures demonstrate the cooperative relationship with national and international applicants. Because the by far largest percentage of the premarket clinical trials with medical devices in the European Community are conducted in Germany (28%), the analysis also provides a comparison with other European countries in order to detect differences in specific areas as the result of the implementation of Directive 2007/47/EC.