Perioperative immunomodulation with interferon-alpha in patients with renal cell carcinoma: Early results of a controlled phase II trial

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Background: Complex perioperative immunodysfunction occurs in patients with renal cell carcinoma undergoing surgery. Earlier, we presented evidence of a survival benefit in patients, who received perioperative immunomodulation with interleukin-2 (JCO 23 (16S):4601, 2005). Here, we report on the effect of interferon-alpha (IFN-α). Methods: Fifty-four consecutive patients, who underwent tumor nephrectomy, were enrolled into this prospective one stage phase II trial from June 2003 to May 2005. Patients were alternately assigned to the two study groups: 27 received immunomodulation with IFN-α (4 doses 9 million IU s.c a week before operation, followed by a daily dose of 3 million IU until a day before the operation), 27 did not. Parameters of immunity (differential blood count, CD3, CD4, CD8, CD16, CD19, CD28, CD56, HLA-DR, VEGF, IL-10) were measured in venous blood before and during IFN-α, one day before and immediately after the operation, and on the 1., 3., 5., and 10. postoperative day. The primary endpoint was tumor-specific survival. T-test, χ2-test and the log-rank test were used for statistical analysis. Results: The study groups did not differ with respect to age, sex, tumor stage and grade, histological type, operation time and technique. IFN-α related toxicity was WHO grade 0 (11%), 1 (59%), 2 (26%), and 3 (4%). During IFN-α administration leukocytes, CD19, HLA-DR and VEGF dropped significantly, while no difference was observed in T-cell and NK-cell markers, and IL-10. All patients showed postoperatively elevated leukocyte counts. T-cell and activation markers decreased, but CD3, CD4 and CD28 alterations were significantly less accentuated in patients who had been treated with IFN-α. Median follow-up was 14 months. The 1- and 2-year rates (±SE) of tumor-specific survival were 96% (±4%) and 83% (±12%) in the IFN-α group and 85% (±7%) and 85% (±7%) in the control group, respectively (p = 0.52). Also, no difference was seen in progression-free survival (p = 0.32). Conclusions: In this study with limited follow-up, perioperative IFN-α medication was not associated with a survival benefit, but was well tolerated. Interestingly, the decline in VEGF during administration suggests a role of IFN-α in the inhibition of angiogenesis.

No significant financial relationships to disclose.

Soliton-radiation beat analysis

A technique is introduced which allows us to extract information on the solitonic content from a nonlinear wave. Its applicability is not as narrowly restricted as that of inverse scattering theory; therefore, it works in situations that could not be studied before. As an example we identify and demonstrate a higher order dispersion-managed soliton.

Non-pigmentary actions of alpha-melanocyte-stimulating hormone--lessons from the cutaneous melanocortin system

In the last years the neuropeptide a-melanocyte-stimulating hormone has emerged as a regulator of various biological processes far beyond the initially described pigment-inducing action. Expression of melanocortin-receptors (MC-Rs), mainly MC-1R, has been identified in several non-pigmentary human skin cell types. Moreover, expression of MC-5R has been detected in sebocytes and skin mast cells while MC-4R has been reported in dermal papilla cells, a specialized myofibroblast cell type regulating hair follicle activity. In accordance with early observations in the rat preputial gland alpha-melanocyte-stimulating and related peptides have lipogenic activity in the human system. The immunomodulatory actions of alpha-melanocyte-stimulating include regulation of expression and secretion of chemokines, downregulation of proinflammatory signal-induced NF-kappaB activation and adhesion molecule expression, prostaglandin E2 synthesis, as well as induction of interleukin-10. Depending on the cell type studied and the experimental conditions alpha-melanocyte-stimulating however may also have weak proinflammatory actions. In dermal fibroblasts alpha-melanocyte-stimulating was further reported to modulate collagen metabolism via upregulating interstitial collagenase as well as by attenuating the inductive effect of transforming growth factor B on 1 collagen synthesis and fibrosis, the latter pointing towards a potential role of a-melanocyte-stimulating during chronic inflammatory skin responses. The immunomudulatory effects, the established melanotropic action and the recently identified cytoprotective activity of a-melanocyte-stimulating on UVB-induced apoptosis and DNA damage may be part of the body's host defence in which this neuropeptide--typically induced by proinflammatory signals--maintains tissue homeostasis and prevents genotoxicity during inflammatory responses.

Acanthosis nigricans, Papillomatosis mucosae und „tripe palms” bei einem Patienten mit metastasiertem Magenkarzinom

HISTORY AND CLINICAL FINDINGS

A 48-year-old obese man presented with thickening, coarseness and hyperpigmentation of the skin, especially of the intertriginous areas, papillomatous to verrucous lesions of the lips and buccal oral mucosa, and hyperkeratosis of the palms ("tripe palms") and soles. He was obese, reported sleep apnea and had a history of hyperuricemia, mixed hyperlipidemia and previous myocardial infarction. He was on a maintenance dose of a proton pump inhibitor for chronic gastro-esophageal reflux.

EXAMINATIONS

Immunohistochemical studies of the skin lesion revealed increased epidermal immunoreactivity for the melanocortin-1-receptor. Increased levels of tumor markers CA 19-9 (141100 U/ml), CA 72-4 (755 U/ml) and CEA (189 ng/ml) were found in the serum. Gastroscopic findings were suspicious of adenocarcinoma of the stomach: it was classified histologically as a signet-ring cell, non-mucinous adenocarcinoma. At the time of diagnosis the tumor had already metastasized to perigastric and peripancreatic lymph nodes with peritoneal carcinosis.

TREATMENT AND COURSE

Since a curative resection was impossible a gastrojejunostomy was carried out. After this the patient received several courses of chemotherapy according to different schemes. Serum tumor marker levels and cutaneous signs regressed several times.

CONCLUSIONS

Marked acanthosis nigricans -- especially when associated with further cutaneous markers of malignancy, e.g. mucocutaneous papillomatosis or so-called tripe palms -- calls for thorough search for malignant tumor, also if metabolic or endocrinological abnormalities co-exist. A pathogenetic role of a-melanocyte-stimulating hormone in the development of the skin changes is suggested.

ESPEN Guidelines on Enteral Nutrition: Cardiology and Pulmonology

These guidelines are intended to give evidence-based recommendations for the use of enteral nutrition (EN) in patients with chronic heart failure (CHF) and chronic obstructive pulmonary disease (COPD). They were developed by an interdisciplinary expert group in accordance with officially accepted standards and are based on all relevant publications since 1985. They have been discussed and accepted in a consensus conference. EN by means of oral nutritional supplements (ONS) or tube feeding (TF) enables nutritional intake to be maintained or increased when normal oral intake is inadequate. No data are yet available concerning the effects of EN on cachexia in CHF patients. However, EN is recommended to stop or reverse weight loss on the basis of physiological plausibility. In COPD patients, EN in combination with exercise and anabolic pharmacotherapy has the potential to improve nutritional status and function. Frequent small amounts of ONS are preferred in order to avoid postprandial dyspnoea and satiety as well as to improve compliance.

Specific Properties of Heavy Fraction of Mitochondria from Human-term Placenta – Glycerophosphate-dependent Hydrogen Peroxide Production

Mitochondrial respiratory chain enzyme Complexes are present in placenta at proportion similar to other tissues with exception of glycerophosphate dehydrogenase (mGPDH) which is expressed at a very high rate. As shown by Western blot quantification and respiratory chain enzyme activity measurements, the specific content of mGPDH is similar to that of succinate dehydrogenase or NADH dehydrogenase. Using fluorometric probe dichlorodihydrofluorescein diacetate we found that placental mitochondria display high rate of glycerophosphate-dependent hydrogen peroxide production. This was confirmed by oxygraphic detection of glycerophosphate-induced, KCN- or antimycin A-insensitive oxygen uptake. Hydrogen peroxide production by mGPDH was highly activated by one-electron acceptor, potassium ferricyanide and it was depressed by inhibitors of mGPDH and by cytochrome c. Our results indicate that mGPDH should be considered as an additional source of reactive oxygen species participating in induction of oxidative stress in placenta.

Mitogen- and stress-activated protein kinase 1 is critical for interleukin-1-induced, CREB-mediated, c-fos gene expression in keratinocytes

c-fos, which encodes a transcription factor of the AP-1 family, is a prototypical immediate-early gene induced by a number of proinflammatory cytokines including interleukin-1 (IL-1), the latter being an important regulator of skin homeostasis. Using the human keratinocyte cell line HaCaT as an in vitro model, we dissected the molecular pathways leading to IL-1-induced c-fos gene induction. Phosphorylation of the transcription factor cAMP response element binding protein (CREB) at Ser133 was found to be essential for IL-1-induced c-fos gene induction and was closely paralleled by protein kinase A (PKA) activation. In contrast to other cell types, the cyclooxygenase/prostaglandin pathway, known to activate the cAMP/PKA cascade, plays little, if any, role in c-fos expression downstream of the IL-1 receptor in keratinocytes. Simultaneous activation of several of the mitogen-activated protein kinase (MAPK) cascades occurred in response to IL-1, but each differentially contributed to c-fos induction by IL-1, with the p38/MAPK being the most crucial of all, the extracellular signal-regulated kinase pathway contributing in an additive manner and the Jun N-terminal kinase pathway playing little, if any, role. We also demonstrate that p38-dependent activation of mitogen- and stress-activated kinase 1 (MSK1), a CREB kinase, is a key step for c-fos gene activation by IL-1. Finally, we identify MSK1 as playing a positive role in the control of cell proliferation of both HaCaT keratinocytes and the A431 human epidermoid carcinoma line.

[Characteristics of patients with coronary ectasias with and without stenotic coronary artery disease]

BACKGROUND AND OBJECTIVE

The term "coronary ectasia" describes the dilatation of one or more coronary artery segments with the signs of an impaired coronary blood flow. The prevalence, clinical significance and necessity of treatment of such a lesion is unclear.

PATIENTS AND METHODS

Diagnostic coronary angiographies of 7101 patients (2131 women and 4970 men) were retrospectively evaluated for the presence of dilated coronary segments. Prevalence, age- and gender distribution, cardiovascular risk factors, clinical symptoms, CRP-concentrations, prevalence of myocardial infarction as well as the coronary morphology of patients with coronary ectasia were studied. The occurrence of myocardial infarction in this group was compared to that in a control group consisting of patients with stenotic coronary artery disease.

RESULTS

The prevalence of coronary ecstasy was 1.4 % (women: 0.56 %; men: 1.79 %), mean age of patients was 63.5 +/- 10.5 years. The right coronary artery was most frequently involved (RCA: 97 %, LAD: 30 %, RCX: 23 %, LCA: 35 %). In patients with one-vessel disease the right coronary artery was exclusively affected. In 85.1 % the dilatation of coronary segments was associated with stenotic coronary artery disease. 73.3 % of the patients with coronary ectasias suffered from angina, 33.7 % CCS (Canadian Cardiovascular Society) class III and IV. Angina in patients with coronary ecstasy did not differ from that of patients with stenotic coronary artery disease only. Patients with coronary ectasias had a higher incidence of myocardial infarction than patients with stenotic coronary heart disease (p < 0.001).

CONCLUSION

Coronary ectasia is a relatively rare entity and often associated with stenosis. Angina is a common symptom. Patients with coronary ectasias seem to suffer more frequently from myocardial infarctions than patients with only stenotic coronary heart disease.

Cardiovascular dysphagia

A 72-year-old patient was admitted to our clinic following posterior wall myocardial infarction. Furthermore, he had suffered from dysphagia and intermittent regurgitation for a time period of two months. Radiological diagnostics revealed an esophageal impingement by the left atrium and the descending aorta due to severe thoracic scoliosis. This represents an infrequent form of cardiovascular esophageal compression.

New insight into immunosuppression and treatment of autoimmune diseases

The achievements in photoimmunology over the last years have not only broadened our knowledge how ultraviolet (UV) light compromises the immune system but have also yielded important insights into general immunology and photobiology. Therefore, studies will not only increase our understanding how UV acts as a pathogen but will also support the development of new therapeutic strategies, e.g. suppressing (auto)immune reactions via administration of antigen-specific regulatory T cells. Major advances in biotechnology have already resulted in the development of several novel agents for the treatment of inflammatory and autoimmune diseases. Some of these new immunomodulating drugs, such as mycophenolate mofetile and rituximab, are actually evaluated in controlled clinical trials to confirm the efficacy and safety profile in patients with autoimmune diseases. However, there is urgent need for specific immunointervention and further therapeutic options, especially for patients with autoimmune diseases in life-threatening situations and for non-responders to standard immunosuppression.

[Recurrent miscarriage or failed in-vitro fertilization: antibodies against annexin V, cardiolipin, beta-2-glycoprotein-1 and APC-resistance]

Antibodies against annexin-V, a potent anticoagulant abundant in placental tissues, were recently controversially reported to be associated with recurrent miscarriages or failures of in-vitro-fertilization (IVF) attempts.

PATIENTS, MATERIAL, METHODS

We screened 56 women (34.7 +/- 4.3 years of age: mean +/- 1 SD) with recurrent IVF failures and/or early pregnancy losses for resistance against activated protein C, lupus anticoagulant and antibodies against annexin V, cardiolipin or beta(2)-glycoprotein-1. Among them the prevalence of APC-R (8/56, 14%) and elevated levels of IgG- or IgM-anti-cardiolipin antibodies (7/56, 12%) were more common than elevated levels of (IgG or IgM) antibodies against beta(2)-glycoprotein-1 (3/56, 5%) or annexin-V (1/56, 2%). 42 (75%) of the women had another IVF-attempt after this haemostaseological evaluation and received low molecular weight heparin and/ or acetylsalicylic acid in the case of positivity for APC-resistance, lupus anticoagulant or antibodies against annexin V, cardiolipin or beta(2)-glycoprotein-1.

RESULTS

The outcome of these IVF-attempts were 19 pregnancies (34%): 4 early miscarriages (7%) and 15 so far uncomplicated pregnancies (27%). The only woman with an elevated anti-annexin V (IgG) level had had 7 IVF before and received 40 mg Enoxaparin (Lovenox) subcutaneously once daily during the 8(th) IVF, which resulted in a healthy pregnancy.

DISCUSSION, CONCLUSION

Our findings suggest that among women with recurrent IVF failures anti-annexin V antibody positivity is less prevalent than APC-resistance, lupus anticoagulant (LA) or elevated levels of antibodies against cardiolipin, beta(2)-glycoprotein-1 and that the IVF-result of women with APC-R, LA or with elevated levels of antibodies against annexin V, cardiolipin or beta(2)-glycoprotein might be positively influenced by low molecular weight heparin.

Comparative study of tacrolimus and paclitaxel stent coating in the porcine coronary model

BACKGROUND

Tacrolimus is a potent antiproliferative and immunosuppressive agent allowing for improved endothelial regeneration. The aim of our study was the preclinical evaluation of tacrolimus in a drug eluting nonerodable polymer stent system and its comparison with paclitaxel.

METHODS AND RESULTS

A total of 40 domestic pigs and 10 mini-pigs underwent coronary stenting with a follow-up time between 6 hours and 3 months. Stents were implanted in coronary arteries with an overstretch ratio of 1.2. After 3 days, a 1.73 microg/mm(2) coating produced tacrolimus tissue levels of 20 mumol/l in the coronary artery wall. Effective tissue concentrations were sustained for 28 days. Based on histomorphometric analysis, tacrolimus stent treated vessels had a reduced extent of neointima formation compared with controls at 28 days (-51% compared to control) but not at 3 months. High dose paclitaxel stent coating (1.44 microg/mm(2)) was complicated by unexpected deaths of pigs and thrombotic stent occlusion at control angiography. Long-term porcine data showed no persistent inhibition of neointimal growth by paclitaxel and tacrolimus stent coating.

CONCLUSIONS

Similar to paclitaxel, tacrolimus stent coating reduces neointimal proliferation in the porcine coronary model. However, dosing and long-term efficacy remains a critical issue in stent-based local drug delivery.

Splenic rupture complicating periinterventional glycoprotein IIb/IIIa antagonist therapy for myocardial infarction in polycythemia vera

Polycythemia vera is a myeloproliferative disorder predisposing to thromboembolic and bleeding complications. We report the case of a patient with polyglobuly, leukocytosis, and thrombocytosis, who suffered from acute ST-segment elevation myocardial infarction due to thrombotic high-grade pre-stent stenosis two months after percutaneous coronary intervention for complex coronary one vessel disease. Following re-PTCA and stent implantation in conjunction with periinterventional GP IIb/IIIa antagonist treatment, the patient was initially symptom free for about two hours before rapidly developing signs of a hemorrhagic shock. An abdominal CT scan showed splenic rupture with massive intraabdominal hemorrhage as a consequence of secondary bleeding into multiple pre-existing splenic infarctions. The patient's condition stabilized after emergency splenectomy. Subsequent bone marrow biopsy revealed the presence of polycythemia vera. Post-operatively, the patient was treated with the anti-platelet agents aspirin and clopidogrel to prevent subacute stent thrombosis. Additionally, cyto-reductive therapy with hydroxyurea was initiated because of a further increase in the platelet count. In patients with polycythemia vera, the indication for treatment with GP IIb/IIIa antagonists should be carefully weighed against the potentially serious bleeding complications. Should treatment be established, a risk stratification using abdominal sonography and bleeding time testing is recommended, while during treatment red blood count, platelet count, coagulation tests, and hemodynamic parameters should be closely monitored.

Development of ulcerative colitis after heart transplantation during immunosuppressive therapy

BACKGROUND

Cardiac transplantation has become an accepted treatment modality for end-stage heart failure. Immunosuppressive agents, which are used after transplantation, are considered as therapeutic options for inflammatory bowel disease.

CASE REPORT

We report on a 53-year-old patient who was treated for 2 years with cyclosporine A, azathioprine and prednisolone after heart transplantation. He developed a distal colitis with all features of ulcerative colitis. An infectious or ischemic etiology was carefully excluded. In spite of high-dose treatment with prednisolone the patient's abdominal symptoms worsened and he developed a progression of the inflammation in the entire colon and a colectomy with ileostomy was necessary. The histology was consistent with ulcerative colitis. After colectomy he recovered and remained in a good state of health.

CONCLUSIONS

This report supports the concept that new onset inflammatory bowel disease can develop in a heart transplantation recipient in spite of immunosuppression.

Confetti-like lesions with hyperkeratosis: a novel ultraviolet-induced hypomelanotic disorder?

Confetti leucoderma can occur in a variety of unrelated skin disorders and is often a diagnostic challenge. We describe a 33-year-old man with a history of mycosis fungoides and vitiligo. He developed disseminated 1-2-mm round-shaped leucodermic lesions 6 months after psoralen photochemotherapy and 12 months after systemic therapy with interferon. The skin lesions had a discrete hyperkeratotic scale. Multiple skin biopsies and immunohistochemical studies showed lamellar orthohyperkeratosis, papillomatosis, hypomelanotic keratinocytes but a normal number of melanocytes. Langerhans cells, in contrast, were reduced in lesional skin. Electron microscopy disclosed only a few type I and II melanosomes in lesional melanocytes, while keratinocytes were largely devoid of any melanosomes. This constellation of clinical, immunohistochemical and ultrastructural findings has not been reported before and distinguishes our case from leucoderma punctatum, idiopathic guttate hypomelanosis and disseminated hypopigmented keratoses. We suggest that the skin lesions observed in our patient represent an unusual response to ultraviolet damage to melanocytes followed by reactive epidermal hyperkeratosis.

Heart failure and statins—Why do we need a clinical trial?

The effect of statins to reduce mortality and morbidity in primary and secondary prevention as well as in acute coronary syndrome is well established. Recent data show that pleiotropic effects might also have direct effects on the myocardial cell. However, in chronic heart failure the outcome is inversely related to LDL-plasma concentrations and other pleiotropic effects might impair mitochondrial function. Since there are no safety data on the use of statins in chronic heart failure, a controlled randomized and placebo-controlled trial is urgently needed.

[Systolic heart failure in the elderly]

Aging is associated with changes in cardiac and vascular structure, promoting the development of heart failure. An increase in vascular stiffness leads to an increase of systolic arterial pressure and pulse wave velocity. This augments the afterload of the heart, which contributes to cardiac hypertrophy and neuroendocrine activation in the elderly. On the molecular level the age-associated changes in the sympathetic nervous system are similar to alterations that can be found in congestive heart failure. Therapy of systolic heart failure does not differ between the elderly and younger patients. All drugs which have shown to improve the prognosis of younger patients are indicated in the elderly as well. This holds true for ACE-inhibitors or angiotensin receptor antagonists, betablockers and aldosterone antagonists. However, comorbidities as well as changes in the pharmacokinetics and pharmacodynamics might require a cautious initiation of the therapy, an individual adjustment of the dosage and a thoroughly monitoring of the elderly patients.

[Hypertensive emergencies]

Critical cases of high blood pressure are common clinical occurrences that may account for as many as 25% of all medical emergencies. About 75% of these increases in blood pressure can be judged as hypertensive urgencies, 25% are even hypertensive emergency situations. Nevertheless, only less than 1% of the hypertensive population experiences hypertensive urgency or emergency situations. Hypertensive emergencies are defined as acute cardiac, vascular or cerebral target organ damages. In these cases an acute lowering of blood pressure is inevitable. The rate and intensity of blood pressure depression is dependent on the localization of organ damages. For cardiac and vascular damages it is absolutely necessary to lower the blood pressure rapidly to near normal values. On the contrary, cerebral organ damages are better treated by a moderate lowering of blood pressure peaks to slightly increased blood pressure levels. In hypertensive urgencies no target organ damages occur. For these patients a slow lowering of blood pressure values to normal levels is adequate.

Carnitine concentrations in term and preterm newborns at birth and during the first days of life

Carnitine plays an important role in energetic metabolism. The aim of the study was to characterize the carnitine status in term and preterm newborns with respect to gestational age, birth weight, haematocrit and red blood cell count (RBC). The effect of nutrition on carnitine levels in the first week of life was also studied. Total blood pool of free carnitine (FC), acylcarnitines (AC) and total carnitine (TC) were analysed in whole cord blood and postnatally in capillary blood obtained at the day 4-6 in 33 term newborns and at the day 7-10 in 27 preterm newborns using tandem mass spectrometry. Plasma level of carnitine in the cord blood was measured using radioenzymatic method. Cord plasma levels of FC, AC and TC were higher in preterm newborns in comparison with term newborns (p < 0.01), but the total blood pool of FC and TC in whole cord blood was lower in preterm newborns than in term newborns (p < 0.01) and positive correlation was found between FC and gestational age or birth weight (p < 0.05). In addition, positive correlation was found between AC and red blood cell count or haematocrit (p < 0.05). During the first week of life, blood pool of FC and TC in term newborns and AC and TC in preterm newborns decreased regardless of the type of enteral or parenteral nutrition. Our results indicate that preterm newborns are born with limited carnitine store. Interpretation of carnitine analyses in whole blood relies in addition to gestational age and birth weight on the haematocrit, especially in newborns with anaemia or blood hyperviscosity.

Perioperative hemodynamic measurements with an implantable monitoring system (Chronicle) in a patient with severe heart failure undergoing non-cardiac surgery

A 53-year-old male patient with severe chronic heart failure due to ischemic cardiomyopathy (LVEF 25%) awaiting heart transplantation was admitted for resection of a bladder tumor. The patient underwent implantation of a Chronicle implantable hemodynamic monitor (IHM) two years before. Thus, perioperative monitoring of heart rate, right ventricular systolic, diastolic and pulse pressure, dP/dt and estimated pulmonary artery diastolic pressure through a lead implanted in the right ventricle was performed. In the postoperative period the patient developed low-output syndrome requiring catecholamine treatment. The patient was weaned from mechanical ventilation uneventfully the same day. However, he developed symptomatic and hemodynamic worsening of heart failure shortly after reduction of inotropes and required prolonged medical treatment with catecholamines. Patients with cardiac disease are known to be at increased risk for cardiovascular complications after noncardiac surgery. Therefore, it has been suggested that such patients could potentially benefit from perioperative invasive hemodynamic monitoring. For the first time, we report a case of perioperative continuous hemodynamic monitoring with a long term-implanted device in a potential heart transplant patient.

[Diabetes mellitus needs unrestricted evaluation of patient data to yield treatment progress. The DUTY Register]

Patients with diabetes mellitus require consistent risk management that fulfills risk reduction guidelines for patients suffering from CHD (coronary heart disease). The aim of the DUTY Registry (diabetes mellitus needs unrestricted evaluation of patient data to yield treatment progress) was to show whether the guidelines of the Deutsche Diabetes-Gesellschaft (DDG) are incorporated consistently into daily practice. Therefore 59,035 patients suffering from diabetes mellitus type 1 and type 2 were examined by general practitioners. The physician was requested to enter 20 consecutive patients with existing or newly diagnosed diabetes mellitus into the registry. A total of 45,605 patients showed up for the final examination after 9 months. The results presented show that too many patients suffering from diabetes mellitus do not receive consistent therapy for cardiovascular risk factors according to guidelines and therefore the required target values were rarely reached.

Measurement of von Willebrand factor cleaving protease (ADAMTS-13): results of an international collaborative study involving 11 methods testing the same set of coded plasmas

BACKGROUND

ADAMTS-13 is a von Willebrand factor (VFW)-cleaving protease. Its congenital or acquired deficiency is associated with thrombotic thrombocytopenic purpura (TTP) and more rarely with the hemolytic uremic syndrome. We report on a survey evaluating 11 methods for ADAMTS-13 measurement performed in different labs.

DESIGN

Two plasmas, one normal and one from a patient with familial TTP, were mixed at the co-ordinating center to prepare 6 plasmas with 0%, 10%, 20%, 40%, 80% and 100% ADAMTS-13 levels. Each plasma was aliquoted and assembled into sets of 60 (coded from 1 to 60), each containing 10 copies of the original 6 plasmas. Plasmas were frozen and shipped in dry ice to 10 labs with a common frozen reference plasma. Laboratories were asked to measure ADAMTS-13 with their methods. Results were sent to the coordinating center for statistical analysis.

RESULTS

Of the 10 methods performed under static conditions 9 were quantitative and one was semiquantitative. One method performed under flow conditions evaluated the extent of cleavage of endothelial cell-derived ultralarge VWF string-like structures and expressed results as deficient, normal, or borderline. Linearity (expected-vs-observed levels), assessed as the squared correlation coefficient, ranged from 0.98 to 0.39. Reproducibility, expressed as the coefficient of variation for repeated measurements, ranged from < 10% to 83%. The majority of methods were able to discriminate between different ADAMTS-13 levels. The majority were able to detect the plasma with 0% level and some of them to discriminate between 0% and 10%. Overall the best performance was observed for three methods measuring cleaved VWF by ristocetin cofactor, collagen binding, and immunoblotting of degraded multimers of VWF substrate, respectively. The poor interlaboratory agreement of results was hardly affected by the use of the common standard. The method performed under flow conditions identified the plasmas with 0%, 10%, 20% and 40% activity as deficient in 7, 5, 1 and 3 of the 10 replicate measurements. The plasmas with 80% and 100% were identified as normal in all of the 10 replicate measurements.

CONCLUSIONS

The survey shows varied performance, but supports an optimistic view about the reliability of current methods for ADAMTS-13.

[Alpha-melanocyte-stimulating hormone. Its current significance for dermatology]

Alpha-melanocyte-stimulating hormone (alpha-MSH) is a tridecapeptide that was originally characterized as a neuropeptide derived from the pituitary gland. alpha-MSH is synthesized from pro-opiomelanocortin (POMC) by the action of specific prohormone convertases which cleave POMC into alpha-MSH, adrenocorticotropin and beta-endorphin. The various effects of alpha-MSH are mediated via melanocortin receptors. The skin as well as the majority of cutaneous cell types express POMC. Proinflammatory stimuli such as ultraviolet (UV) light induce POMC expression and alpha-MSH secretion. Receptors for alpha-MSH are not only expressed by melanocytes, where they mediate melanogenesis and proliferation, but also by virtually every cutaneous cell type. Accordingly, alpha-MSH elicits a plethora of biological actions in these cell types including immunomodulation, protection from oxidative stress and UV-induced apoptosis, modulation of secretory epithelial function and regulation of extracellular matrix composition. These actions may be exploited in future by using super potent and truncated MSH peptides for the treatment of various skin disorders including inflammatory dermatoses.

Does statin therapy influence steroid hormone synthesis?

Statins reduce cholesterol and isoprenoid de novo biosynthesis as well as receptor mediated uptake of cholesterol for steroidogenesis. The present randomized placebo-controlled trial investigated whether pravastatin (40 mg/day) reduces the plasma concentrations of steroid hormones as well as of gonadotropins. Patients (n = 22; 15 males, 7 females) were treated with pravastatin (40 mg/day) or placebo. Levels of total and LDL cholesterol, the steroid hormones estradiol, testosterone, cortisol and dehydroepiandrosterone sulphate (DHEAS) as well as FSH and LH were studied. Pravastatin led to a significant reduction of total cholesterol and LDL cholesterol. There was no significant change in estradiol, testosterone, cortisol or DHEAS plasma concentrations. There was no compensatory change in FSH or LH. It is concluded that pravastatin does not alter steroid hormones or gonadotropins in a clinically applicable dose, which significantly reduces total and LDL cholesterol.

Lipid management with statins. The lower the better?

The primary and not yet accomplished goal remains to treat all patients with coronary heart disease to the LDL cholesterol target < 100 mg/dl. To date there is no conclusive evidence for a recommendation of a LDL cholesterol goal lower than 100 mg/dl for all patients. Patients with high vascular risk benefit from statin therapy irrespective of cholesterol levels, underlining the importance of the assessment of global vascular risk as the basis of modern lipid therapy.

Serum antibody titres to canine parvovirus, adenovirus and distemper virus in dogs in the UK which had not been vaccinated for at least three years

Antibody titres to canine distemper (CDV), canine parvovirus (CPV) and canine adenovirus (CAV) were measured in 144 adult dogs that had not been vaccinated for between three and 15 years. Protective antibodies to CPV were present in 95 per cent of the population, to CDV in 71.5 per cent and to CAV in 82 per cent. The prevalence of protective titres did not decrease with increasing time interval from the last vaccination for any of the three diseases studied. Booster vaccination increased the dogs CAV titres. For comparative purposes, 199 puppies were sampled at the time of their first and second vaccination. In the case of CPV and CAV a significantly higher proportion of the adult dogs were protected than of the puppies immediately after they were vaccinated. Natural CPV boosting was strongly suspected because the dogs had significantly higher titres three years after their primary vaccination than two weeks after it and three unvaccinated dogs had acquired protective antibody levels uneventfully. There was no evidence of natural exposure to CDV.