[Laparoscopy in the management of endometrial cancer]

Recent advance in laparoscopy have changed the surgical approach of endometrial cancer patients. The Swissendos Center, Fribourg, in collaboration with AGO (Groupe de travail pour la gynécologie oncologique) and AGE (groupe de travail pour la gynécologie endoscopique) have established a consensus based on the available evidence for the use of laparoscopy in the management of patients with endometrial cancer The main objective was to define Swiss clinical practice guidelines appropriate to the country and consistent with the needs of the physicians.

The sheep as a knee osteoarthritis model: early cartilage changes after meniscus injury and repair

The purpose of this study was to analyse cartilage changes after traumatic meniscal lesions and to provide a detailed description of the model used with a view to reducing the number of animals used in future studies. The sheep's knee was chosen, as ovine biomechanics are similar to that of humans. In two groups of 10 animals each, a radial tear in the medial meniscus was either sutured with polydioxanone (PDS) or left untreated (sham-operated). Half of the animals in each group were sacrificed after six months, the other half after one year. The time periods to achieve weight bearing, meniscus healing, joint effusion (magnetic resonance imaging scan) and knee cartilage in the medial, lateral and patellofemoral compartments were evaluated in comparison to the opposite knee (control). Osteoarthritis (OA) was assessed by a modified Outerbridge classification and confirmed by scanning electron microscopy. Only one sutured meniscus remained completely adapted. In all other meniscus lesions, the rupture healed with a scar. In the PDS and sham-operated groups, OA was significantly higher in the medial knee compartment than in the lateral compartment and in controls (P < 0.001). In the operated groups, joint effusion was higher in the right hindlimb knee than in the normal left hindlimb knee (control) after six and 12 months (P < 0.001). Non-treated, displaced and even adapted sutured radial ovine meniscus tears produced intense OA within less than six months. Therefore, this animal model is suitable for assessment of new therapeutic regimens in meniscal surgery.

pH nanoenvironment at the surface of single melanoma cells

Extracellular pH and the Na(+)/H(+) exchanger (NHE1) modulate tumor cell migration. Yet, the pH nanoenvironment at the outer surface of the cell membrane (pH(em)) where cell/matrix interaction occurs and matrix metalloproteinases work was never measured. We present a method to measure this pH nanoenvironment using proton-sensitive dyes to label the outer leaflet of the plasma membrane or the glycocalyx of human melanoma cells. Polarized cells generate an extracellular proton gradient at their surface that increases from the rear end to the leading edge of the lamellipodium along the direction of movement. This gradient collapses upon NHE1 inhibition by HOE642. NHE1 stimulation by intracellular acidification increases the difference in pH(em) between the tips of lamellipodia and the cell body in a Na(+) dependent way. Thus, cells create a pH nanoenvironment that promotes cell migration by facilitating cell adhesion at their front and the release of cell/matrix contacts at their rear part.

Increased brain oxygenation during intubation-related stress

BACKGROUND AND OBJECTIVES

The purpose of this study was to determine whether brain oxyhaemoglobin-deoxyhaemoglobin coupling was altered by anaesthesia or intubation-induced stress.

METHODS

This was a prospective observational study in the operating room. Thirteen patients (ASA I and II) undergoing spinal or peripheral nerve procedures were recruited. They were stabilized before surgery with mask ventilation of 100% oxygen. Anaesthesia was induced with 2 microg kg(-1) fentanyl and 3 mg kg(-1) thiopental. Laryngoscopy and intubation were performed 4 min later. After intubation, desflurane anaesthesia (FiO2=1.0) was adjusted to maintain response entropy of the electroencephalogram at 40-45 for 20 min. Prefrontal cortex oxyhaemoglobin and deoxyhaemoglobin were determined every 2 s using frequency domain near-infrared spectroscopy. Blood pressure, heart rate and response entropy were collected every 10 s.

RESULTS

Awake oxyhaemoglobin and deoxyhaemoglobin were 18.9 +/- 2.3 micromol (mean +/- SD) and 12.7 +/- 0.8 micromol, respectively, and neither changed significantly during induction. Intubation increased oxyhaemoglobin by 37% (P < 0.05) and decreased deoxyhaemoglobin by 16% (P < 0.05), and both measures returned to baseline within 20 min of desflurane anaesthesia. Blood pressure, heart rate and electroencephalogram response entropy increased during intubation, and the increase in heart rate correlated with the increase in brain oxygen saturation (r = 0.48, P < 0.05).

CONCLUSIONS

Intubation-related stress increased oxyhaemoglobin related to electroencephalogram and autonomic activation. Stress-induced brain stimulation may be monitored during anaesthesia using frequency domain near-infrared spectroscopy.

Rapid freeze-substitution preserves membranes in high-pressure frozen tissue culture cells

We describe a method for high-pressure freezing and rapid freeze-substitution of cells in tissue culture which provides excellent preservation of membrane detail with negligible ice segregation artefacts. Cells grown on sapphire discs were placed 'face to face' without removal of tissue culture medium and frozen without the protection of aluminium planchettes. This reduction in thermal load of the sample/holder combination resulted in freezing of cells without visible ice-crystal artefact. Freeze-substitution at -90 degrees C for 60 min in acetone containing 2% uranyl acetate, followed by warming to -50 degrees C and embedding in Lowicryl HM20 gave consistent and clear membrane detail even when imaged without section contrasting. Preliminary data indicates that the high intrinsic contrast of samples prepared in this way will be valuable for tomographic studies. Immunolabelling sensitivity of sections of samples prepared by this rapid substitution technique was poor; however, reducing the uranyl acetate concentration in the substitution medium to 0.2% resulted in improved labelling. Samples substituted in this lower concentration of uranyl acetate also gave good membrane detail when imaged after section contrasting.

Effects of radial shockwave therapy on the limb function of dogs with hip osteoarthritis

The objective of this study was to evaluate the effects of extracorporeal radial shock wave therapy on the hindlimb function of dogs suffering from hip osteoarthritis. Twenty-four client-owned dogs with hip osteoarthritis were investigated; 18 of them received radial shockwave therapy and six were left untreated as controls. Force plate analysis on a treadmill was used to assess the dogs' hindlimb function before treatment and four weeks after the last treatment, and the treated dogs were re-evaluated three and six months after the treatment. The parameters chosen for evaluation were peak vertical force and vertical impulse, and the calculated symmetry indices. In the treated dogs, differences between the ground reaction forces exerted by the right and left hindlegs disappeared four weeks after the treatment, whereas in the control dogs only the peak vertical force distribution changed significantly. The significant improvement in the treated dogs was confirmed by changes in the symmetry indices. Significant improvements in vertical impulse and peak vertical force were observed three months after the treatment.

Low-dose Tacrolimus/Sirolimus and Steroid Withdrawal in Heart Recipients Is Highly Efficacious

Heart transplant recipients treated with long-term calcineurin inhibitors (CNIs) experience significant nephrotoxicity and transplant vasculopathy. Signal proliferation inhibitors might prevent the development of transplant vasculopathy. In an open, prospective pilot study, 33 primary heart transplant recipients received tacrolimus (Tac) and sirolimus (rapamycin, Rapa) with steroids. To reduce both nephrotoxicity and transplant vasculopathy at the same time, both Tac and Rapa exposure was kept low (6 to 8 ng/ml). Steroids were withdrawn successfully from all patients within 6 months. Just one acute rejection occurred at 54 days post-transplant, resulting in 0.03 acute rejection episode per patient at 1-year (primary end-point) and 2-year follow-up. Transplant vasculopathy assessed by angiogram was absent at 2 years. Graft and patient survival were 100% at 1 and 2 years. Accordingly, the survival estimate for freedom from first acute rejection, transplant vasculopathy, graft loss or death was 0.97 at 1 and 2 years. The regimen was well tolerated with only 3 patients requiring a change of study medication. Mean serum creatinine increased during the first year but returned to baseline at 2 years.

Prognostic relevance of increased Rac GTPase expression in prostate carcinomas

Rac proteins of the Rho-like GTPase family, including the ubiquitous Rac1, the hematopoiesis-specific Rac2, and the least-characterized Rac3 play a major role in oncogenic transformation, tumor invasion and metastasis. However, the prognostic relevance of Rac expression in human tumors has not been investigated yet. In the present study, Rac protein expression was analyzed in benign secretory epithelium, high-grade prostatic intraepithelium neoplasia (HG-PIN), and prostate carcinomas of 60 R0-resected radical prostatectomy specimens by semiquantitative immunohistochemistry. Thus, Rac proteins were significantly strongly expressed in HG-PIN (P < 0.001) and prostate carcinomas (P < 0.001) when compared with benign secretory epithelium. Accordingly, all tumor tissues analyzed by isoform-specific real-time PCR (n = 7) exhibited significantly higher RNA expression levels of Rac (i.e. sum of Rac1 and Rac3 expression levels) than the respective benign counterparts (P = 0.018) and this appeared to result mainly from increased expression of the Rac3 isoform as verified by immunoblotting. Univariate analyses showed statistically significant associations of increased Rac protein expression in prostate cancer (P = 0.045), preoperative prostate-specific antigen levels (P = 0.044), pT stage (P = 0.002), and Gleason score (P = 0.001) with decreased disease-free survival (DFS). This prognostic effect of increased protein expression of Rac remained significant even in a multivariate analysis including all these four factors (relative risk = 3.22, 95% confidence interval = 1.04-10.00; P = 0.043). In conclusion, our data suggest that increased Rac protein expression in prostate cancer relative to the corresponding benign secretory epithelium is an independent predictor of decreased DFS and appears to result mainly from increased expression of the Rac3 isoform.

Approach to Detection in Laser-Induced Breakdown Spectroscopy

Gated detection with intensified detectors, e.g., ICCDs, is today the accepted approach for detection of plasma emission in laser-induced breakdown spectroscopy (LIBS). However, these systems are more cost-intensive and less robust than nonintensified CCDs. The objective of this paper is to compare, both theoretically and experimentally, the performance of an intensified (ICCD) and nonintensified (CCD) detectors for detection of plasma emission in LIBS. The CCD is used in combination with a mechanical chopper, which blocks the early continuum radiation from the plasma. The detectors are attached sequentially to an echelle spectrometer under the same experimental conditions. The laser plasma is induced on a series of steel samples under atmospheric conditions. Our results indicate that there is no substantial difference in the performance of the CCD and ICCD. Signal-to-noise ratios and limits of detection achieved with the CCD for Si, Ni, Cr, Mo, Cu, and V in steel are comparable or even better than those obtained with the ICCD. This result is further confirmed by simulation of the plasma emission signal and the corresponding response of the detectors in the limit of quantum (photon) noise.

Reproducible isolation of distinct, overlapping segments of the phosphoproteome

The ability to routinely analyze and quantitatively measure changes in protein phosphorylation on a proteome-wide scale is essential for biological and clinical research. We assessed the ability of three common phosphopeptide isolation methods (phosphoramidate chemistry (PAC), immobilized metal affinity chromatography (IMAC) and titanium dioxide) to reproducibly, specifically and comprehensively isolate phosphopeptides from complex mixtures. Phosphopeptides were isolated from aliquots of a tryptic digest of the cytosolic fraction of Drosophila melanogaster Kc167 cells and analyzed by liquid chromatography-electrospray ionization tandem mass spectrometry. Each method reproducibly isolated phosphopeptides. The methods, however, differed in their specificity of isolation and, notably, in the set of phosphopeptides isolated. The results suggest that the three methods detect different, partially overlapping segments of the phosphoproteome and that, at present, no single method is sufficient for a comprehensive phosphoproteome analysis.

Identification of Borrelia burgdorferi ribosomal protein L25 by the phage surface display method and evaluation of the protein's value for serodiagnosis

The phage surface display technique was used to identify Borrelia burgdorferi antigens. By affinity selection with immunoglobulin G from pooled sera of six Lyme borreliosis (LB) patients, the ribosomal protein L25 was identified. The diagnostic value of L25 was investigated by an enzyme-linked immunosorbent assay, using sera from 80 LB patients and 75 controls, and the use of the protein resulted in a specificity of 99% and a 23% sensitivity, which qualify L25 as a useful antigen when combined with others.

Prognostic relevance of Tiam1 protein expression in prostate carcinomas

The Rac-specific guanine nucleotide exchange factor, Tiam1, plays a major role in oncogenicity, tumour invasion and metastasis but its usefulness as a prognostic marker in human cancer has not been tested yet. In the present study, Tiam1 expression was analysed in benign secretory epithelium, pre-neoplastic high-grade prostatic intraepithelium neoplasia (HG-PIN) and prostate carcinomas of 60 R0-resected radical prostatectomy specimens by semiquantitative immunohistochemistry. Tiam1 proved significantly overexpressed in both HG-PIN (P<0.001) and prostate carcinomas (P<0.001) when compared to benign secretory epithelium. Strong Tiam1 overexpression (i.e. ⩾3.5-fold) in prostate carcinomas relative to the respective benign prostatic epithelium was statistically significantly associated with disease recurrence (P=0.016), the presence of lymph vessel invasion (P=0.031) and high Gleason scores (GS) (i.e. ⩾7) (P=0.044). Univariate analysis showed a statistically significant association of strong Tiam1 overexpression with decreased disease-free survival (DFS) (P=0.03). This prognostic effect of strong Tiam1 overexpression remained significant in multivariate analysis including preoperative prostate-specific antigen levels, pT stage, and GS (relative risk= 3.75, 95% confidence interval=1.06–13.16; P=0.04). Together, our data suggest that strong Tiam1 overexpression relative to the corresponding benign epithelial cells is a new and independent predictor of decreased DFS for patients with prostate cancer.

Retropatellar chondromalacia associated with medial osteoarthritis after meniscus injury. One year of observations in sheep

BACKGROUND/AIMS

In an ovine meniscal repair model, the patellofemoral (PF) osteoarthritis due to a non-sutured tear or failed repair was investigated.

METHODS

A radial meniscus tear was either sutured with polydioxanone (PDS), with a slow degrading polylactide long-term suture(LTS) or left without treatment. Knee joint cartilage in the PF and medial compartment was evaluated compared to normal knees (healthy controls).

RESULTS

Retropatellar osteoarthritis in the non-sutured and sutured animals was intense in contrast to the control knees after 6 months in all groups (p < 0.001), and after 12 months in the PDS group (p < 0.001), LTS group and non-sutured animals (p < 0.05).

CONCLUSION

Non-sutured meniscus tears and failed repair lead fast to intense PF osteoarthritis corresponding with tibial damage of the injured compartment.

A Bioequivalence Study of Two Oral Desmopressin Tablet Formulations

The present study was carried out to test bioequivalence between two different oral desmopressin formulations. Sixty healthy volunteers were enrolled in the study and were randomly assigned to receive the test (T) and reference (R) drug in a two-period two-sequence, crossover, analyst-blinded study design. Subjects received an oral dose of 400 mug of desmopressin acetate separated by a wash-out period of at least 7 days. The area under the concentration-time curve (AUC) over 12 h in plasma and the maximum concentration (C(max)) were compared by analysis of variance (ANOVA) after log transformation. The mean ratios of the T to R drug were within the bioequivalence boundaries with mean values of 1.00 (90% CI: 0.87-1.14) and 1.03 (90% CI: 0.92-1.15) for AUC(0-t) and AUC(0-inf), respectively. For the C(max), the mean ratio of the T to R drug was 0.97 (90% CI: 0.87-1.08). The rate and the extent of oral desmopressin absorption were identical for both formulations. Hence, the desmopressin test tablet met all bioequivalence criteria of the marketed reference desmopressin tablet.

Influence of immunisation with Mycobacterium bovis bacillus Calmette-Guérin on the sensitisation to inhaled allergens after infection with respiratory syncytial virus

Respiratory syncytial virus (RSV) may play an important role in allergic diathesis by creating a Th2-type immune response. Mycobacterium bovis bacillus Calmette-Guérin (BCG) is known to induce a Th1-type immune response, but the association of BCG vaccination and the suppression of allergy development remain controversial. We investigated the influence of BCG vaccination on the immune response to RSV in a mouse model. Balb/c mice were BCG vaccinated, RSV infected and ovalbumin (OVA) challenged. Mice were sacrificed one, two and four weeks after allergen exposure. Bronchoalveolar lavage was performed. Alveolar macrophages and lymphocytes from spleens and lung-associated lymph nodes were investigated for cytokine production and cell proliferation. Serum was tested for allergen-specific immunoglobulin-E (IgE). Lung eosinophilia was diminished by BCG immunisation. OVA-specific serum IgE was increased regardless of prior BCG vaccination. Interleukin-4 secretion of spleen lymphocytes increased in BCG-vaccinated mice only one week after allergen exposure but was comparable to non-vaccinated mice at four weeks. The reactivity of spleen lymphocytes towards concanavalin-A to secrete interferon-gamma was increased in the vaccinated group at the end of the observation period. Interleukin-6 and tumour necrosis factor-alpha secretion of alveolar macrophages as well as proliferation of stimulated thoracic lymph node cells were increased and prolonged in vaccinated mice. BCG immunisation led to a local suppression of the allergic reaction within the lung. No reduction of systemic IgE production was observed. Further studies are necessary to determine a possible time dependence of BCG immunisation.

Enhanced acetylcholine-induced dilation in afferent arterioles in simvastatin-fed rats

OBJECTIVE

3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors have been shown to increase renal blood flow and glomerular filtration rate independent of their lipid lowering effects. The purpose of this study was to determine the effect of simvastatin on acetylcholine-induced vasodilation in the renal microcirculation. The hypothesis of the study was that simvastatin would increase acetylcholine-induced vasodilation in the renal microcirculation.

METHODS

The hydronephrotic kidney preparation was used. On the day of the experiment the kidney was prepared for videomicroscopy and dose-response curves were done with acetylcholine and sodium nitroprusside (10(-10) M to 10(-5) M) in simvastatin-fed rats ??(n=8) and control rats (n=13). The vasodilator responses of afferent and efferent arterioles were directly quantitated using videomicroscopy. L-NAME; (N(omega)-nitro-L-arginine methyl ester) was also given in a group of simvastatin-fed rats (10(-5) M) to determine if it would block the acetylcholine (Ach)-induced vasodilation.

RESULTS

Simvastatin enhanced Ach-induced vasodilation in the afferent arteriole compared to control rat responses to Ach. At 10(-7) M, ACH caused a 31.6+/-7.2% increase from baseline diameter in the afferent arteriole in the simvastatin-fed rats compared to a 23+/-8.1% vasodilation in the control rats (p<0.05). There were no differences in the response to ACH in the efferent arteriole between the two groups. L-NAME completely abolished the ACH response in the simvastatin-fed rats.

CONCLUSIONS

The increase in renal blood flow and glomerular filtration rate observed with simvastatin may be due to its preglomerular vasodilator effects. This may be due to an increase in nitric oxide production.

Dendritic cell-based cancer immunotherapy targeting MUC-1

Vaccination therapy using dendritic cells (DC) as antigen presenting cells (APC) has shown significant promise in laboratory and animal studies as a potential treatment for malignant diseases. Pulsing of autologous DCs with tumor-associated antigens (TAA) is a method often used for antigen delivery and choice of suitable antigens plays an important role in designing an effective vaccine. We identified two HLA-A2 binding novel 9-mer peptides of the TAA MUC1, which is overexpressed on various hematological and epithelial malignancies. Cytotoxic T cells generated after pulsing DC with these peptides were able to induce lysis of tumor cells expressing MUC1 in an antigen-specific and HLA-restricted fashion. Within two clinical studies, we demonstrated that vaccination of patients with advanced cancer using DCs pulsed with MUC1 derived peptides is well tolerated without serious side effects and can induce immunological responses. Of 20 patients with metastatic renal cell carcinoma, 6 patients showed regression of metastases with 3 objective responses (1 CR, 2 PR). Furthermore, we found that in patients responding to treatment T cell responses for antigens not used for treatment occurred suggesting that antigen spreading in vivo might be a possible mechanism of mediating antitumor effects. These results demonstrate that immunotherapy in patients with advanced malignancies using autologous DCs pulsed with MUC1 derived peptides can induce immunological and clinical responses. However, further clinical studies are needed to identify the most potent treatment regimen that can consistently mediate an antitumor immune response in vivo.

Critical evaluation of urine-based PCR assay for diagnosis of Lyme borreliosis

Many approaches were made in recent years to establish urine PCR as a diagnostic tool for Lyme borreliosis, but results are contradictory. In the present study, a standardized protocol spiking urine from healthy donors with a defined amount of whole Borrelia or Borrelia DNA was established. The development of a nested real-time PCR targeting ospA enabled a highly sensitive and quantitative analysis of these samples. We show the following. (i) Storage of spiked urine samples for up to 6 months at--20 degrees C had no negative effect on spike recovery. (ii) Centrifugation of 10 ml of urine at 40,000 x g for 30 min resulted in a concentration of both spikes, i.e., whole Borrelia and DNA. (iii) The inhibition of DNA spike recovery in 48% (11 of 23 samples) of urine samples tested could be attributed to nuclease activity. This was abrogated by alkalizing the urine or by working with the samples on ice. Despite optimized conditions, analysis of urine samples of 12 patients with erythema migrans, the clinical stage considered to be associated with the highest bacterial load, revealed a positive result in only one sample. All 12 samples were negative by an alternative PCR targeting flagellin. The results of our study support doubts that urine is a suitable material for diagnosis of Lyme borreliosis.

Endotoxin: physical requirements for cell activation

Lipopolysaccharide (LPS) is the eminent lipid component of the outer leaflet of the outer membrane of Gram-negative bacteria and the major initiator of innate immune response to bacterial infection. Below the critical micellar concentration (CMC), LPS is exclusively present as a monomer. Above this concentration, aggregates are formed. Increasing the concentration beyond the CMC leads to an increase in aggregate concentration, whereas the concentration of monomers remains constant or even decreases. The question how LPS activates immune cells and whether the aggregate or the monomer is the biologically active unit has been and still is controversial. To prepare clearly defined monomeric solutions, we utilized a dialysis set-up consisting of a donor and an acceptor chamber, separated by a dialysis diaphragm with a cut-off of 5 kDa, thus allowing only monomers to pass. Human mononuclear cells (MNCs) were then stimulated with equal concentrations of aggregates and monomers, respectively, of deep rough mutant LPS from Escherichia coli strain F515 (Re LPS) and TNF-alpha release was determined. In contrast to earlier and very recent work of others, we started with a preparation of aggregate-suspensions and pure monomer-solutions and show that monomers are significantly less active than aggregates in the absence and presence of serum proteins at identical concentrations. In our model, we propose that LPS aggregates are detected by membrane-associated LBP and intercalated into the cell membrane to bring LPS into close proximity to signaling proteins in the membrane, thus finally leading to cell activation. To support this model, we present data showing that LBP is indeed present in or at the cell membrane of human macrophages.

Freedom From Graft Vessel Disease in Heart and Combined Heart- and Kidney-transplanted Patients Treated With Tacrolimus-based Immunosuppression

BACKGROUND

In end-stage cardiomyopathy where concomitant chronic renal failure is a contraindication for cardiac transplantation (HTx), simultaneous heart and kidney transplantation (HKTx) may be the only feasible therapeutic option. Due to the increased donor shortage, the clinical outcome of combined HKTx patients on tacrolimus-based immunosuppression was assessed and compared with a group of HTx patients.

METHODS

Three hundred forty-nine HTxs, including 13 (4%) combined HKTxs, were performed since 1995. Two hundred twenty-one HTx and all HKTx recipients received tacrolimus-based immunosuppression. Acute rejection episodes (AREs), infections, renal function and clinical outcome were evaluated. Pre-operative renal diagnoses for HKTx patients included cystic nephropathy (n = 4), glomerulonephritis (n = 4), cytostatica-induced nephropathy (n = 1), chronic rejection after renal transplant (n = 1), reflux nephropathy (n = 2) and chronic calcineurin-inhibitor -induced nephropathy after HTx (n = 1). Twelve patients (92%) were on hemodialysis pre-operatively, 1 underwent implantation of a left ventricular assist device (LVAD) before HKTx.

RESULTS

After 4.7 +/- 2 years, 92% of HKTx compared with 85% of HTx patients had survived (p = 0.42). Acute cardiac rejection episodes were more frequent in HTx than in HKTx patients (0.04 +/- 0.09 vs 0.02 +/- 0.04 ARE/100 patient-days; p = 0.07). Incidence of infection was comparable (0.3 +/- 0.2 vs 0.5 +/- 0.4 infection/100 patient-days). Freedom from transplant vasculopathy was 100% in the HKTx group compared with 71% in the HTx group after 4 years (p = 0.04).

CONCLUSIONS

Tacrolimus-based immunosuppression yields promising long-term results in HKTx and HTx. The incidence of transplant vasculopathy seems to be lower after HKTx than after HTx. If these results are secondary to a protective effect of tacrolimus-induced tolerance or of tolerance-associated co-transplantation they will need to be investigated in prospective multicenter trials.

Macro-FF: Improving AI Planning with Automatically Learned Macro-Operators

Despite recent progress in AI planning, many benchmarks remain challenging for current planners. In many domains, the performance of a planner can greatly be improved by discovering and exploiting information about the domain structure that is not explicitly encoded in the initial PDDL formulation. In this paper we present and compare two automated methods that learn relevant information from previous experience in a domain and use it to solve new problem instances. Our methods share a common four-step strategy. First, a domain is analyzed and structural information is extracted, then macro-operators are generated based on the previously discovered structure. A filtering and ranking procedure selects the most useful macro-operators. Finally, the selected macros are used to speed up future searches. We have successfully used such an approach in the fourth international planning competition IPC-4. Our system, Macro-FF, extends Hoffmann's state-of-the-art planner FF 2.3 with support for two kinds of macro-operators, and with engineering enhancements. We demonstrate the effectiveness of our ideas on benchmarks from international planning competitions. Our results indicate a large reduction in search effort in those complex domains where structural information can be inferred.

Insulin glargine in combination with oral antidiabetic drugs as a cost-equivalent alternative to conventional insulin therapy in type 2 diabetes mellitus

BACKGROUND AND RATIONALE

Recent data suggest that insulin glargine might be a cost-effective alternative to conventional insulin therapy in patients with type 2 diabetes mellitus (T2DM). The aim of this observational study was to evaluate the treatment costs of insulin glargine in combination with oral antidiabetic drugs (OADs) compared with conventional insulin therapy in T2DM in everyday clinical practice.

PATIENTS AND METHODS

Data were obtained from a cohort of 678 patients with T2DM not adequately controlled by OADs alone (HbA1c mean 9.1 +/- 1.7%). Patients received either insulin glargine in addition to oral therapy or were switched to conventional insulin therapy. Treatment and dosing decisions were made at the physician's discretion, reflecting everyday practice. Patients were followed for 2-4 months. Primary outcome parameters were total treatment costs and clinical efficacy.

RESULTS

The two therapeutic regimens were equally effective in decreasing HbA1c to 7.8% (p < 10(-9)). Patients in the insulin glargine plus OAD group controlled their blood glucose level at endpoint with a median of 60 test strips per month and those in the conventional insulin therapy group with a median of 80 strips per month (p = 0.000000739). Total daily costs of insulin, needles, glycemic control and OAD treatment per patient were similar in the two treatment groups (insulin glargine group 1.91 Euro vs conventional group 1.99 Euro).

CONCLUSION

The two treatment regimens were equally effective in improving glycemic control. These results were achieved with significantly lower insulin doses and fewer blood glucose test strips in the insulin glargine group, which therefore led to cost equivalence when compared with conventional insulin therapy.

Impact of Donor Serum Sodium Levels on Outcome After Heart Transplantation

We investigated the impact of elevated donor serum sodium levels on outcome after heart transplantation in 336 consecutive heart transplantations. Mean donor serum sodium was 148.2+/-10.2 mmol/liter (range 116 to 180 mmol/liter). Recipients were divided into 4 groups with serum sodium levels of 141, 147 and 155 mmol/liter, resulting in sodium levels of: 133+/-6.1 mmol/liter for Quartile A; 144+/-4.2 mmol/liter for Quartile B; 151+/-4.3 mmol/liter for Quartile C; and 162+/-6.6 mmol/liter for Quartile D, respectively (mean+/- standard deviation). Mean occurrence of primary graft failure (PGF) was 3.6% with the following quartile breakdown: A, 3.6%; B, 4.8%; C, 3.6%; and D, 2.4% (p=non-significant [NS]). Mean 5-year survival was 81.32% with: A, 83.51%; B, 76.03%; C, 80.47%; and D, 85.25% (p=NS). Coronary allograft vasculopathy (CAV) occurred in 19% of patients with a quartile breakdown of: A, 16.5%; B, 21%; C, 20%; and D, 14.5% (p=NS). No impact of donor serum sodium levels was seen on early post-operative results or on long-term outcome, indicating that cardiac allografts from donors with elevated sodium levels may be transplanted successfully with favorable results.

In vivo culture of IVM/IVF embryos in bovine oviducts by transvaginal endoscopy

This study was conducted to establish a new approach for in vivo culture of in vitro produced embryos in the bovine oviduct by transvaginal endoscopy. Embryos were in vitro matured, fertilized and cultured for 1-4 days and assigned to groups consisting of 10-30 embryos. Embryos were transferred unilaterally into oviducts of 24 heifers by the means of transvaginal endoscopy. After 3-6 days of in vivo incubation embryos were re-collected. Experiment I aimed to evaluate the capability of embryos to migrate to the uterus. The uterine horns of four animals were flushed first, followed by a combined flushing of both oviducts and uterine horns resulting in collection rates of 31 and 34%, respectively. In experiment II, the transfer of embryos into the oviduct close to ovulation (day 1-2--experiment IIA) or at a more advanced cyclic stage (day 3--experiment IIB) succeeded in the collection of 46 and 34% of the transferred complexes, of which 13 and 37% showed the blastocyst stage. This is the first report of successful recovery of transferable blastocysts by transvaginal endoscopy after tubal in vivo culture in the homologous species of originally in vitro produced embryos.

Toll-like receptors 2 and 4 do not contribute to clearance of Chlamydophila pneumoniae in mice, but are necessary for the release of monokines

Activation of immune cells by Chlamydophila pneumoniae in vitro has been shown to be toll-like receptor (TLR2)-dependent, but TLR4 is also involved to a minor extent. To investigate the role of TLR2 and TLR4 in vivo, a murine model of C. pneumoniae infection was established. Mice were infected intranasally with a low inoculum of 106 C. pneumoniae elementary bodies (EB) and spreading of bacteria was monitored by real-time PCR. The bronchoalveolar lavage (BAL) showed maximal bacterial load on the day of infection and the lung 2 days later. By day 95, C. pneumoniae were eradicated completely. In serum, anti-C. pneumoniae IgG became detectable on day 18 by microimmunofluorescence test. The course of infection was mild with no apparent symptoms, lack of acute phase response and no induction of tumor necrosis factor-alpha and interleukin-6 in BAL, lung supernatants or blood. Infection of TLR2-/- and C3H/HeJ mice revealed no differences in clearance of bacteria and serological responses compared to wild-type controls, even if a dose of 10(7) EB was used. Intracellular replication of C. pneumoniae in the lungs was proven by the efficacy of antibiotic treatment. These findings indicate that in vivo TLR2 and TLR4 are not important for the development of antibodies and elimination of C. pneumoniae.

Ortho- and heterotopic bone grafts in bifocal transport osteogenesis for craniofacial reconstruction--an experimental study in sheep

Bifocal transport osteogenesis (BTO) is a promising technique for the reconstruction of extended osseous craniofacial defects. Aim of this study was to determine the potential of this technique related to various donor sites of the transport segment. In 10 adult sheep critical size defects of the calvaria were treated by gradual movement of a transport segment consisting either of autogenous regional free calvarial bone grafts (n=5) or autogenous illiac free bone grafts (n=5). Latency period was 5 days; the rate of distraction was 1mm per day and extended approximately 40 days. The consolidation period was 28 days. After harvesting, specimens were investigated by conventional radiography, CT-scans, histologically and by fluorescence. In both groups transport osteogenesis resulted in a complete closure of the critical size defect. Membranous bone formation and remodeling occurred during the entire period of distraction and consolidation. The volumes and thickness of newly formed bone at the defect site were increased significantly when calvarial bone grafts were used (P<0.05). Iliac bone grafts became progrediently smaller during distraction, while the volume of calvarial grafts remained relatively constant (P<0.05). In conclusion, transport segments consisting of calvarial and iliac bone resulted in a reliable closure of craniofacial critical size defects in adult organisms; the application of calvarial bone grafts resulted in an increased extend of bone formation.

Sirolimus impairs gonadal function in heart transplant recipients

The impact of sirolimus on hormone levels involved in the hypothalamus-pituitary-gonad axis in male heart transplant recipients was investigated. A pair-matched analysis with 132 male heart transplant recipients on either sirolimus based- or calcineurin inhibitor-based immunosuppression was performed. Matching criteria were age, years after transplantation and creatinine levels. Measured parameters were testosterone, luteinizing hormone (LH), follicle stimulating hormone (FSH), sexual hormone-binding globulin (SHBG) and free androgen index (FAI). Mean testosterone was 3.86 +/- 1.41 ng/mL in the sirolimus group and 4.55 +/- 1.94 ng/mL in the controls (p = 0.025). Serum LH was 12.82 +/- 11.19 mlU/mL in the sirolimus patients and 6.2 +/- 5.25 mlU/mL in the controls (p = 0.015). Follicle stimulating hormone levels were 13.31 +/- 18.4 mlU/mL vs. 7.32 +/- 5.53 mlU/mL, respectively (p = 0.015). The analysis revealed a significant decrease in testosterone and a significant increase in FSH and LH in the sirolimus group. The duration of sirolimus treatment correlated positively with SHBG (p < 0.01), LH (p < 0.05) and FSH (p < 0.05) and negative with the FAI (p < 0.05). Sirolimus trough levels correlated with LH and FSH levels (p < 0.01). Heart transplant recipients treated with sirolimus revealed significantly lower testosterone levels and a significant increase in gonadotropic hormones. These effects were trough-level dependent. All candidates awaiting organ transplantation should be informed about these adverse effects.

Renal recovery after conversion to a calcineurin inhibitor-free immunosuppression in late cardiac transplant recipients

OBJECTIVE

Calcineurin inhibitor (CNI)-related renal failure is a common problem after cardiac transplantation (HTx). The aim of this prospective study was to evaluate the safety and efficacy of a completely CNI-free immunosuppressive regimen [mycophenolate mofetil (MMF) and sirolimus (Sir)] in HTx-recipients with late post-transplant renal impairment.

METHODS

Since 2001, 30 HTx-patients (25 men, 6 women; 0.2-14.2 years after transplantation) with CNI-based immunosuppression and a serum creatinine >1.9 mg/dl were included in the study. Creatinine and cystatin levels were monitored to detect renal function. Conversion was started with 6 mg Sir or 500 mg MMF according to the pre-existing regimen and was continued with the dose adjusted to achieve target trough levels between 8 and 14 ng/ml (Sir) or 1.5 and 4 microg/ml (mycophenolate). Subsequently, the CNIs were tapered down and stopped. Clinical follow-up included endomyocardial biopsies, echocardiography and laboratory studies. Additionally, every HTx-patient treated at our centre between 1996 and 2001 due to chronic renal failure without immunosuppressive conversion and fulfilling the inclusion criteria were retrospectively analysed and acted as control group.

RESULTS

Patient demographics and 1-year survival [93 (conversion) vs 90% (control)] were compared. No acute rejection episode was detected in either group. Renal function improved significantly in the conversion group (creatinine: 3.18+/-0.71 vs 2.22+/-0.79 mg/dl, P=0.001; cystatin pre- vs post-conversion: 2.95+/-1.06 vs 2.02+/-1.1 mg/l, P=0.01). In three patients haemodialysis therapy was stopped completely after conversion. In the control group renal impairment was deteriorating, creatinine increased from 2.44+/-0.8 to 3.28+/-1 mg/dl (P=0.01). In 10 out of 33 patients chronic haemodialysis had to be initiated within 1 year. Although side effects of CNI-free immunosuppression were common (76%), no patient had to be excluded due to adverse effects.

CONCLUSIONS

Conversion from CNI-based immunosuppression to MMF and Sir in HTx-patients with chronic renal failure was safe, preserved graft function and improved renal function.