Extracorporeal pumpless interventional lung assist in clinical practice: determinants of efficacy

Respiratory acidosis can become a serious problem during protective ventilation of severe lung failure. A pumpless arteriovenous interventional lung assist (iLA) for extracorporeal carbon dioxide removal has been used increasingly to control critical respiratory situations. The present study sought to evaluate the factors determining the efficacy of iLA and calculate its contribution to gas exchange. In a cohort of 96 patients with severe acute respiratory distress syndrome, haemodynamic parameters, oxygen consumption and carbon dioxide production as well as gas transfer through the iLA were analysed. The measurements demonstrated a significant dependency of blood flow via the iLA device on cannula size (mean+/-sd 1.59+/-0.52 L x min(-1) for 15 French (Fr), 1.94+/-0.35 L x min(-1) for 17 Fr, and 2.22 +/-0.45 L x min(-1) for 19 Fr) and on mean arterial pressure. Oxygen transfer capacity averaged 41.7+/-20.8 mL x min(-1), carbon dioxide removal was 148.0+/-63.4 mL x min(-1). Within two hours of iLA treatment, arterial oxygen partial pressure/inspired oxygen fraction ratio increased significantly and a fast improvement in arterial carbon dioxide partial pressure and pH was observed. Interventional lung assist eliminates approximately 50% of calculated total carbon dioxide production with rapid normalisation of respiratory acidosis. Despite limited contribution to oxygen transfer it may allow a more protective ventilation in severe respiratory failure.

Distinct regulation of IgE, IgG4 and IgA by T regulatory cells and toll-like receptors

BACKGROUND

Allergic diseases are characterized by the activation of the immune system and formation of immunoglobulin (Ig)E antibodies against normally innocuous environmental antigens, whereas IgG4 and IgA represent noninflammatory and blocking antibody isotypes. The T helper 2 (Th2) cells induce and T regulatory (Treg) cells suppress several features of allergic inflammation. Our aim was to investigate the role of allergen-specific T regulatory type 1 (Tr1) cells and CD4(+)CD25(+) Treg cells and toll-like receptors (TLRs) on IgE, IgG4 and IgA production.

METHODS

Germline or productive Ig-transcripts are determined by real-time reverse transcriptase-polymerase chain reaction, secreted Igs are measured by enzyme-linked immunosorbent assay and the frequency of Ig-producing plasma cells is investigated by enzyme-linked immunosorbent spot. Circulating CD4(+)CD25(+) Treg cells and allergen-specific Tr1 cells are used.

RESULTS

Both allergen-specific, interleukin-10-secreting Tr1 cells and CD4(+)CD25(+) Treg cells from healthy individuals induced IgG4 and suppressed IgE production in peripheral blood mononuclear cells and purified B-cell cultures. In contrast, induction of IgA production is independent of T-cell help and the role of Tr1 or Treg cells is very limited, whereas it was highly induced by direct B-cell activation via TLR7 and 9.

CONCLUSIONS

These data suggest that T regulatory cells may contribute to the suppression of allergic diseases by suppression of IgE and induction of IgG4, whereas IgA production is enhanced by B-cell activation via TLR7 and TLR9.

From particle self-assembly to functionalized sub-micron protein patterns

Biologically relevant nanopatterns are useful platforms to address fundamental questions, for example, regarding protein-protein and cell-protein interactions. For the creation of nanopatterns, complex and expensive instrumentation is often needed. We present a simple but versatile patterning method using a combination of particle and subsequent molecular self-assembly to produce ordered structures in the micron and sub-micron range. Polystyrene particles were, in a first step, assembled via dip-coating or dried in a drying cell. Silicon wafers and glass slides coated with SiO(2) and a top layer of 11 nm of TiO(2) were used as substrates. Large hexagonally ordered particle monolayers were formed with high reproducibility. These were subsequently shrunk in a controlled manner by exposure to a O(2)/N(2) plasma and subsequently used as etching masks to transfer the particle pattern onto the substrate, creating TiO(2) features in an SiO(2) background. After removing the mask the oxide contrast was translated in three simple dip-and-rinse steps into a biochemical contrast of protein-coated features in an inert background. In short, alkane phosphates were first selectively adsorbed to the TiO(2) features. Then the SiO(2) background was backfilled using poly(L-lysine)-graft-poly(ethylene glycol) and finally streptavidin was adsorbed to the hydrophobic alkane phosphate SAMs, allowing subsequent binding and hybridization of biotinylated DNA.

Minimal residual disease-directed risk stratification using real-time quantitative PCR analysis of immunoglobulin and T-cell receptor gene rearrangements in the international multicenter trial AIEOP-BFM ALL 2000 for childhood acute lymphoblastic leukemia

Detection of minimal residual disease (MRD) is the most sensitive method to evaluate treatment response and one of the strongest predictors of outcome in childhood acute lymphoblastic leukemia (ALL). The 10-year update on the I-BFM-SG MRD study 91 demonstrates stable results (event-free survival), that is, standard risk group (MRD-SR) 93%, intermediate risk group (MRD-IR) 74%, and high risk group (MRD-HR) 16%. In multicenter trial AIEOP-BFM ALL 2000, patients were stratified by MRD detection using quantitative PCR after induction (TP1) and consolidation treatment (TP2). From 1 July 2000 to 31 October 2004, PCR target identification was performed in 3341 patients: 2365 (71%) patients had two or more sensitive targets (< or =10(-4)), 671 (20%) patients revealed only one sensitive target, 217 (6%) patients had targets with lower sensitivity, and 88 (3%) patients had no targets. MRD-based risk group assignment was feasible in 2594 (78%) patients: 40% were classified as MRD-SR (two sensitive targets, MRD negativity at both time points), 8% as MRD-HR (MRD > or =10(-3) at TP2), and 52% as MRD-IR. The remaining 823 patients were stratified according to clinical risk features: HR (n=108) and IR (n=715). In conclusion, MRD-PCR-based stratification using stringent criteria is feasible in almost 80% of patients in an international multicenter trial.

[Positive tests for serum anti-endomysium antibodies (AEA) and anti-jejunal antibodies (JAB) and histopathological diagnosis of celiac disease in children]

Non-invasive examination methods are increasingly important in diagnosing celiac disease. New options for diagnosing celiac disease have been discovered in addition to the established biochemical, hematological and other methods as a result expansive progress ofclinical genetics and immunology. At the same time, detection of circulating auto-antibodies is becoming ever more frequent in clinical practice. As a result, many new, clinically highly heterogeneous cases of the disease have been diagnosed and consequently the prevalence of the disease in both child and adult population has grown. Detection of anti-endomysial antibodies (AEA), characteristic for their high sensitivity and specificity, plays an important role in diagnosing and monitoring celiac disease in pediatric practice. Nevertheless, histopathological diagnosis remains the critical tool for definitive diagnosis of the disease. The article refers to relations between the degree of positivity of AEA and JAB antibodies in the IgA class and the respective grade in the Marsh grading system. The objective of the study was to examine AEA and JAB antibodies and the histological picture of the duodenal mucosa in 20 children and adolescents with celiac disease aged from 2 to 18 years. The authors developed a semiquantitative scale of positivity of both the antibodies, which they compared trying to find a correlation between these and the histopathological picture of the duodenal mucosa. The authors point out the need of timely determination of AEA and t-TG (tissue transglutaminase) in patients whose anamnesis, clinical picture or laboratory results may be indicative of celiac disease.

[Histopathological diagnosis of celiac disease in adults with functional dyspeptic syndrome]

Celiac disease is associated with permanent intolerance to gluten, which is found in some cereals. The symptoms of the disease are often nonconspicuous and the course of the disease is atypical. With the introduction of serological markers as a sensitive method of testing new cases of the disease were identified. Despite of the increased screening intensity among children and adults celiac disease in our region is still underdiagnosed. The article deals with the diagnostics of celiac disease in adults with functional dyspeptic syndrome. It is based on the laboratory and pathological correlation of 25 patients. Our aim was to identify the group at risk with functional dyspeptic syndrome and celiac disease. This disease can show symptoms from the onset all the way to relapse. Each person was examined by a gastroenterologist while hospitalized in the relevant department. In addition to the routine serological testing, blood samples were taken and sent for antiendomyzial antibody testing for positive reaction verification. A subsequent gastrointestinal examination was done and samples taken from the duodenum were sent for histology. Light microscopy analysis showed mucous damage typical for celiac disease, which is expressed with the levels of the Marsh histological grading. In closing, we recommend a three-step approach to goal-oriented screening of celiac disease. Determination of autoantibody against tissue transglutaminase, if positive, then biopsy from the aboral duodenum, and consequently follow-up by testing for antiendomyzial antibody.

[Prevention of iodine deficiency diseases: solved and unsolved problems]

This article was prepared on the basis of the presentations of the co-authors at the plenary and breakout sessions of the V Congress of Endocrinologists in Moscow. These reports provided up-to-date information on the state of the problem of eliminating iodine deficiency diseases (IDD), and also discussed a number of controversial scientific aspects of the control and prevention of IDD.

[Acute intermittent porphyria. A clinical chameleon: case study of a 40-year-old female patient]

Acute porphyrias are rare, but often misdiagnosed and may take a dramatic clinical course. The combination of various internal, psychiatric and neurological symptoms can mimic different other diseases. We report a 40-year-old female patient who was admitted with a subacute tetraparesis. During the last 2 months the patient was treated several times because of abdominal pain and just before admission to our clinic in a psychiatric hospital because of acute mental changes and hallucinations. The typical combination of abdominal pain, motor neuropathy and psychiatric symptoms confirmed by increased amounts of porphyrins and their precursors, led us to promptly diagnose acute intermittent porphyria. Better knowledge about the pathogenesis has clearly improved the prognosis of acute porphyria. In remission, measurement of enzyme activities or mutation screening can be the only diagnostic verification. A mutation screening for family members should be conducted to identify symptom-free carriers, especially in cases of a positive family history.

[Company centredness in the rehabilitation system of the German Democratic Republic, GDR]

This article describes major aspects of the rehabilitation system of the former German Democratic Republic, GDR. Based on presentation of the actors in the medical and occupational rehabilitation system, differences are pointed out in comparison to the notion of rehabilitation in the former Federal Republic of Germany, FRG. The article focuses on the system of rehabilitation after stroke, which is outlined with relevant scientific literature. The health and rehabilitation system of the GDR was company-centred. Patients in rehabilitation received comprehensive care and guidance, and especially the companies played an integrative part and adjusted the occupational activity of the patients in rehabilitation to their physical and mental abilities in order to avoid early retirement. On account of the political and social transformation process as well as transfer of the health and rehabilitation legislation of the old FRG, the company-centred rehabilitation system of the GDR was replaced, implementing West German rehabilitation structures in East Germany as well.

[Modified platelet aggregation test in patients on ASA and/or clopidogrel]

Therapy with acetylsalicylic acid (ASA) and/or clopidogrel is used to achieve prophylactic inhibition of platelet aggregation in patients with arterial thrombosis. We examined if aggregometry can be used to see the effect of antiplatelet drugs (ASA 30, 50, 100, 300 mg/d, clopidogrel 75 mg/d or ASA 100 + clopidogrel 75 mg/d). A modified platelet aggregation test was used to investigate maximum aggregation in response to ADP, collagen, adrenalin and arachidonic acid. Reference values were established based on healthy individuals. We devised a simple scoring system for detection of inadequate platelet inhibition. Compared with the control group, we detected a significant delay of maximum aggregation in response to all agonists in patients on ASA and combination therapy ASA + clopidogrel. Patients on clopidogrel alone were found to have prolonged aggregation when induced with ADP, collagen and arachidonic acid. The failure rate to achieve adequate platelet inhibition on 100 mg/d ASA, 75 mg/d clopidogrel or combination therapy was 27%, 26% and 7%, respectively. Our results demonstrate that platelet inhibition in aggregometry is inadequate in many patients with arterial thrombosis.

Geschichte der Schmerztherapie 1500 bis 1900

The history of pain treatment likely started in the cradle of mankind, as the experience of pain from many causes presumably had an aversive dimension comparable in its ranking to elementary sensations and motivations such as hunger, thirst, maintenance of body temperature, and sexuality-all vital for individual and genetic survival. Thus, pain certainly was among the drives to create social behavior and medicine-these functions still are inherent in pain. The period of history from 1500, as considered here, is dominated by the emergence of science. The exploration of the inside of the human body found the brain to be the seat of sensations, emotions, and behavior, and this progress included pain as well, slowly disabusing it from the magic elements and demons still inherent from early times. The rational phase of medicine began and also included new concepts of pain as first conceived by Descartes. The treatment and prevention of pain became a strong motive of medicine, with new approaches in drug treatment, physical applications such as electricity, and discoveries of psychosocial implementations. During the nineteenth century the most important breakthroughs in pain treatment included general and local anesthesia as well as analgesic drugs from morphine to anti-inflammatory agents. They succeeded in taking the terror out of the agonizing pain of surgery and dramatic courses of diseases. Today's natural extension of the medical success in controlling acute pain may be seen in the period of pain medicine aimed at understanding and preventing chronic pain.

Prognostic significance of circulating tumor cells in bone marrow or peripheral blood detected by qualitative and quantitative PCR in pediatric NPM-ALK positive anaplastic large cell lymphoma

9559

Background: Clinical and histopathological characteristics have limited prognostic value for children with anaplastic large cell lymphoma (ALCL). We evaluated the presence, extent and prognostic impact of circulating tumor cells in bone marrow (BM) and peripheral blood (PB) of children and adolescents with NPM-ALK positive ALCL by real-time quantitative PCR for NPM-ALK. Methods: Qualitative and TaqMan-based quantitative PCR assays targeting NPM-ALK were developed with a sensitivity to detect 1 NPM-ALK positive cell among 105 cells. Numbers of NPM-ALK transcripts were normalized to 104 copies ABL (NCN). BM was analyzed from 80 and PB from 52 German patients registered into the subsequent protocols NHL-BFM95 and ALCL99. Results: BM was positive for NPM-ALK in 47.5% of patients, and positivity was significantly correlated with clinical stage, mediastinal or visceral involvement, microscopic BM involvement, and histological subtype, but not with skin or CNS involvement. Qualitative and quantitative PCR results in BM and PB strongly correlated. BM PCR was associated with the cumulative incidence of relapses (CI-R): CI-R was 50±10% for 38 PCR-positive and 15±7% for 42 PCR-negative patients (p10 NCN NPM-ALK in BM had a CI-R of 71±14% compared to a CI-R of 18±6% for 59 patients with =10 NCN (p10 NCN NPM-ALK in BM, clinical risk factors (skin, mediastinal or visceral involvement) and atypical histological subtype, only >10 NCN NPM-ALK remained a significant poor prognostic factor with a risk ratio of 4.74 (1.57–14.3; p<0.006). Conclusions: The detection of NPM-ALK positive cells by PCR in BM is associated with advanced stage disease, visceral involvement and atypical histology. Quantitative PCR in BM or PB allows identification of 20% of patients experiencing 60% of all relapses with an event-free survival of 20%.

No significant financial relationships to disclose.

The Faces Symbol Test, a newly developed screening instrument to assess cognitive decline related to multiple sclerosis: first results of the Berlin Multi-Centre FST Validation Study

Reliable, language-independent, short screening instruments to test for cognitive function in patients with multiple sclerosis (MS) remain rare, despite the high number of patients affected by cognitive decline. We developed a new, short screening instrument, the Faces Symbol Test (FST), and compared its diagnostic test characteristics with a composite of the Digit Symbol Substitution Test (DSST) and the Paced Auditory Serial Addition Test (PASAT), in 108 MS patients and 33 healthy controls. An Informant-Report Questionnaire, a Self-Report Questionnaire, and a neurologist's estimation of the Every Day Life Cognitive Status were also applied to the MS patients. The statistical analyses comprised of a receiver operating characteristic analysis for test accuracy and for confounding variables. The PASAT and DSST composite score estimated that 36.5% of the MS patients had cognitive impairment. The FST estimated that 40.7% of the MS patients were cognitively impaired (sensitivity 84%; specificity 85%). The FST, DSST and PASAT results were significantly correlated with the patients' physical impairment, as measured by the Expanded Disability Status Scale (EDSS). The results suggest that the FST might be a culture-free, sensitive, and practical short screening instrument for the detection of cognitive decline in patients with MS, including those in the early stages. Multiple Sclerosis 2007; 13: 402-411. http://msj.sagepub.com

[Primary and secondary malabsorption in the veterinary theory and praxis]

Pathological conditions, which are the reason of indigestive and resorption in small intestine are linked with nutrition and are so-called malabsorptions. The reason of these conditions is on one hand decreasing of production abilities and on the other hand bad prosperity of farm husbandry eventually domestic animals. Malabsorptions are classified from pathological point of view to secondary and primary. To the first category belong the postsurgical state of digestive organs, malfunction of digestive organs from the various reasons such as decreasing of bile activity, decreasing of pancreas activity or for the reason of the malignant changes in the digestive organs or as the consequence of antibiotic treatment or cytostatics. The second category represents endogenous malfunction of intestine enzymes, which are linking with hypersensitivity to some kinds of feed. However the secondary malabsorptions are epiphenomenon several diseases, are in text also cure method mentioned, respectively mark of cure in some stadium diagnosed malabsorption. This present study is particulary oriented to pathogenesis and characterisation of the primary and secondary malabsorptions in the veterinary theory and praxis.

[The need for autonomy in the process of care-conceptual framework and research perspectives]

The article reflects the difference between independence and self-determination or autonomy in care relations. We consider that independence is only a fiction even for people with no functional limitations. Compared with this are people in need of care always confronted with professional interventions in their daily life which limit their self-determination. Even if participation and therefore also autonomy are part of the goal setting process in care a hierarchy in the relation of professional nurses and client is hardly to neglect. Quality of care with methods of evidence based nursing has must always take into account the client's implicit knowledge and experience which we call the "internal" evidence. Only the respect of the internal evidence can reduce the structural hierarchy between nurse and client. The article exemplifies these general conditions in care with nurse-client communication and the challenges of quality of care and quality of life.

Low efficacy of methotrexate in childhood acute myeloid leukemia (AML): single-agent therapeutic window study in relapsed AML

BACKGROUND

The efficacy in pediatric acute myeloid leukemia (AML) of single-agent methotrexate (MTX) at a higher dose than previously applied, 1,000 mg/m2, given as a theoretically beneficial 36-hr continuous infusion, is unknown, but may be beneficial based on preclinical data.

PROCEDURE

We performed a therapeutic window study in children with first relapsed AML treated in four different countries.

RESULTS

Based on a comparison between the percentage of leukemic blasts in the bone marrow shortly before and 7-10 days after the MTX infusion, none of the first cohort of nine patients showed a good response, defined as a reduction of blasts of at least 50%. Therefore, the study was closed, concluding that the probability of a good response in this patient-group was most likely to be less than 30%. By that time, another four patients had been enrolled, of which one patient with a late relapsed AML FAB type M7 showed a good response. Toxicity of MTX was limited and tolerable.

CONCLUSIONS

This study shows that single-agent MTX in the applied regimen in pediatric relapsed AML has limited efficacy. However, it also demonstrates the feasibility of an international and therapeutic window phase II study in pediatric relapsed AML.

Dendritic cell deficiencies in pediatric acute lymphoblastic leukemia patients

Acute lymphoblastic leukemia (ALL) cells are particularly poor at generating anti-leukemia immunity, despite residing in lymphoid organs. To assess a potential role of dendritic cells (DC) in poor anti-leukemia immunity, we analyzed peripheral blood DC in 55 pediatric ALL patients at the time of initial diagnosis and 19 age-matched healthy controls. Dendritic cells were identified by their expression of HLA-DR, lack of B, T, NK, and monocyte markers, and expression of CD11c (myeloid DC(mDC)) or BDCA-2 (plasmacytoid DC(pDC)) using flow cytometry. We found that in children with B-lineage ALL, numbers of both mDC and pDC were significantly reduced (P = 0.0001). In contrast, T-lineage ALL patients showed normal pDC and significantly elevated mDC (P = 0.003) levels, with normal expression of HLA-DR and co-stimulatory molecules. A decrease in DC could not be explained by general impairment of myelopoiesis, as we could not demonstrate a correlation of DC numbers with granulocyte/monocyte numbers in patients with B-lineage ALL. However, aberrant expression of myeloid surface markers on leukemic blasts was frequent in patients lacking myeloid DC indicating a potential block of DC differentiation. Thus, depletion of DC in B-lineage ALL patients may contribute to poor anti-leukemia immune responses.

Loss of heterozygosity on chromosome 6q14-q24 is associated with poor outcome in children and adolescents with T-cell lymphoblastic lymphoma

Deletions of chromosome 6q have been reported in several hematological malignancies, but data are not conclusive regarding their biological and prognostic impact. Therefore, we focused on pediatric patients diagnosed with T-cell lymphoblastic lymphoma (T-LBL) treated uniformly according to the NHL-BFM95 protocol. We used loss-of-heterozygosity (LOH) analysis of 25 microsatellite markers located on chromosome 6q14-q24. Fragment-length analysis was performed on ABI-PRISM3100 Genetic-Analyzer. Eligibility criterion was > or =3 informative markers. Between April 1995 and March 2003, 185 T-LBL patients were treated according to the NHL-BFM95 protocol. Five-year event-free (EFS) and disease-free survival (DFS) were 79+/-3 and 87+/-3% (median follow-up 4.7 [1.2-10.1] years). Sixty-one patients were evaluable for LOH analysis, including 18 out of 23 patients with relapse. EFS and DFS were 67+/-6 and 69+/-6% for these 61 patients. Testing of 853 markers in the 61 patients identified the presence of LOH in 19 patients (31%): 13 of the 18 relapse patients and five of the 41 in complete remission (odds ratio 18.7, 95% confidence interval 4.7-75.3). One LOH-positive patient died from treatment-related toxicity. We conclude that LOH on chromosome 6q14-q24 may have conferred a high risk of relapse on our group of children with T-LBL treated according to the NHL-BFM95 protocol.

[Medico-legal aspects of the use of fentanyl patches]

The use of fentanyl patches has become accepted as standard in Germany for the treatment of chronic and cancer pain. Recently generic fentanyl patches were launched but in contrast to the original patches the new patches are without labels concerning the concentration. There is not only a difference of ca 30% in the fentanyl concentration among the different generic patches, there is also a variation in the size. Especially in hospitals, nursing homes or in emergency cases the dose of the patches cannot be distinguished by doctors, nurses or other healthcare providers which can lead to overdoses or to withdrawal reactions with one of the strongest opioids available. In cases where problems occur the prescribing doctor will be held responsible.

[Anterior cervical fusion with tantalum interbody implants. Clinical and radiological results in a prospective study]

Anterior cervical discectomy and interbody fusion (ACDF) is a widely accepted surgical technique in the treatment of cervical disc disease. Tantalum cages have been recently introduced in spine surgery for interbody fusion because of the advantages of their mechanical properties. We present the results of a prospective clinical and radiological study on 24 consecutive patients who underwent an ACDF with tantalum cages. Clinical evaluation was assessed preoperatively and after surgery by a questionnaire that included a Visual Analogic Scale (VAS) of neck and arm pain, the Oswestry Disability Index and the Zung Depression Scale. Results were classified by Odom's criteria. Radiological evaluation included flexion-extension X-rays, and changes in distance between spinous processes and Cobb angle were measured. Postoperatively patients were reviewed 3 and 12 months after surgery. A statistical significative improvement in all clinical data was reported. According to Odom's criteria in 75% of patients the results were considered like excellent or good. Only one case of radiological and clinical pseudoarthrosis was confirmed. No significative differences were reported 3 and 12 months after surgery. Tantalum cages are a very promising and usefull alternative among implants available for ACDF. Compatibility with MRI postoperative studies and the unnecessariness of autograft are some of their advantages.

Prognostic impact of age in children and adolescents with acute lymphoblastic leukemia: data from the trials ALL-BFM 86, 90, and 95

Large progress has been made in the treatment of acute lymphoblastic leukemia (ALL) of childhood and adolescence over the past 30 years. Eighty percent of the patients can be cured, but clinical subgroups with a dismal outcome can still be identified. In this study, we investigated the association of age with prognosis in 5 181 patients with ALL under 18 years (y) of age enrolled in the three consecutive treatment trials ALL-BFM 86, 90 and 95 in more than 80 centers. Event-free survival (pEFS) of the total group was significantly associated with age. The most unfavorable outcome was found in infancy and the best results were achieved at toddler and pre-school age. Beyond 5 y of age, survival probability decreased (pEFS at 8 y: < 1 y = 0.45; 1-5 y = 0.82; 6-9 y = 0.75; 10-14 y = 0.63; > or = 15 y = 0.59). The proportion of T-ALL as compared to precursor B-cell ALL (pB-ALL) was lower in younger children, due to an incidence peak of pB-ALL in toddlers and at pre-school age compared to a constant incidence of T-ALL. Within the T-ALL group, no correlation of age with sex, initial white blood cell count, CNS disease, or early treatment response was found. Children under 10 y of age had a slightly lower relapse rate compared to older patients. Within pB-ALL patients, the proportion as well as the absolute incidence of TEL/AML1 rearrangement and DNA index of > or = 1.16 was higher in the younger children. A lower proportion of BCR/ABL-positive ALL was observed in the age group of < 6 y when compared to patients aged > or = 6 y, but the absolute incidence was constant across the age groups after the first year of life. More than half of the infants had a CD10-negative pB-ALL. The incidence was constant after a peak in the first year of life, yet the percentage of CD10 negativity increased with rising age in this subgroup. Adolescents with pB-ALL had a significantly higher proportion of prednisone poor-responders. Accordingly, outcome was worse in older patients. This pattern was also evident in the biologically heterogeneous group of patients with a DNA index of > or = 1.16. In contrast, no significant age-related outcome differences could be shown within TEL/AML1- or BCR/ABL-positive patients, as well as within CD10-negative pB-ALL beyond infant age. Analysis of the pB-ALL group in a Cox's regression model including age and the above-listed biological factors revealed age < 1 year and > or = 10 years as independent risk factors. This is in line with the poorer prognosis of these age groups in the pB-ALL subgroup without specific biological characteristics. This subgroup also had an incidence peak at toddler age, presumably containing other favorable biological subsets. An independent prognostic impact of age in pediatric ALL cannot be excluded by this study. However, our analyses show that the age-associated different prognosis in childhood ALL is at least partly related to the different distribution of relevant prognostic subgroups between the age groups.

Retroperitoneoscopic Pyeloplasty for Ureteropelvic Junction Obstruction (UPJO): Solving the Technical Difficulties

OBJECTIVES

To evaluate our current practice in retroperitoneoscopic pyeloplasty in patients with ureteropelvic junction obstruction (UPJO). Special interest was paid to technical difficulties associated with the retroperitoneoscopic approach.

METHODS

Our retroperitoneoscopic approach for pyeloplasty is explained step for step including the most technically challenging part: the ureteropelvic anastomosis.

RESULTS

Within 49 months a total of 47 retroperitoneoscopic pyeloplasties we performed at our institution. Before pyeloplasty an endopyelotomy had failed in five patients (11%). We did not necessarily perform a ventral transposition of the anastomosis in cases with a crossing vessel. Two (4%) conversions to open surgery were required because of scarring after previous endopyelotomy and massive obesity resulting in a limited working space. There were no intraoperative complications. A recurrence of UPJO was observed in 2% (n = 1).

CONCLUSION

Functional results after retroperitoneoscopic pyeloplasty are excellent and comparable to those of open surgery. However, special knowledge of retroperitoneoscopy is necessary to provide the patient with a safe and effective minimally invasive alternative to open pyeloplasty.

Treatment strategies and long-term results in paediatric patients treated in four consecutive AML-BFM trials

A total of 1111 children with acute myeloblastic leukaemia (AML) were treated in four consecutive Berlin-Frankfurt-Münster (BFM) studies from 1978 to 1998. The first cooperative trial AML-BFM 78 established intensive chemotherapy with seven drugs, CNS irradiation and 2-year maintenance, achieving a long-term survival (overall survival (OS)) of 40%. Induction intensification in AML-BFM 83 resulted in significant improvement of disease-free survival (DFS). The risk of haemorrhage, especially in children with hyperleukocytosis, proved the high relevance of supportive care. In AML-BFM 87, the benefit of CNS irradiation in preventing CNS/systemic relapses was demonstrated. In AML-BFM 93, the introduction of idarubicin during first induction followed by intensification with HAM increased the 5-year EFS, DFS and OS to 50+/-2, 61+/-3 and 57+/-2%, respectively. Stem cell transplantation (SCT), as applied in high-risk patients with a matched related donor, did not significantly improve the outcome compared to chemotherapy alone. In spite of treatment intensification, the therapy-related death rate decreased from trial to trial, mainly during induction. The future aim is to reduce long-term sequelae, especially cardiotoxicity, by administration of less cardiotoxic drugs, and toxicity of SCT by risk-adapted indications. The AML-BFM studies performed in three European countries with >70 cooperating centres have significantly improved the outcome in AML children; nevertheless, increasing experience with these intensive treatment regimens is of fundamental importance to reduce fatal complications.

[The "quality house pediatric oncology" as an instrument for improving the performance of the trial centers]

The project group "Central Trial Support" of the German Competence Network Pediatric Oncology and Haematology supports the members of the Society of Pediatric Oncology and Haematology in their effort to cope with the growing statutory, ethical and administrative requirements for therapy optimization studies (investigator-initiated, non-profit clinical trials). By these quality improvement measures the studies will become more revisable and reliable, but at the same time their processing will become more and more complex. The basic instrument of the project group "Central Trial Support" will be the so-called "Quality House" which has been built up in order to improve the performance of the associated study centres and to help put a systematic quality management system into practice. The "Quality House Pediatric Oncology" comprises detailed descriptions of the activities of all trial center co-workers. Its process map details all operational sequences which constitute an efficiently performing trial center. The so-called value adding processes are explained step by step, and the associated specific tasks are assigned to each respective co-worker. At each process step, the person in charge will have explanatory descriptions at her/his disposal and - if necessary - further problem solving means as well as references to possible optimization measures (e. g. Standard Operating Procedures and other documents). The German Competence Network Pediatric Oncology and Haematology will be implementing this electronic quality management system in trial centers which will convince both sponsors and authorities of the compliance with requirements and standards.

Interhospital transportation of patients with severe lung failure on pumpless extracorporeal lung assist

BACKGROUND

To describe the use of pumpless extracorporeal interventional lung assist (iLA) for transportation of patients with severe life-threatening acute lung failure from tertiary hospitals to a specialized centre.

METHODS

Retrospective analysis in eight patients with severe lung failure requiring interhospital transport, in whom implementation of an iLA system at a tertiary hospital for air/ground transportation was performed.

RESULTS

After implementation of iLA, a rapid increase in CO2-elimination (Pa(CO2) before iLA: 8.92+/-2.9 kPa, immediately after implementation: 5.06+/-0.93 kPa, 24 h after implementation: 4.53+/-1.20 kPa [mean+/-SD], P<0.05) was observed and a significant improvement in oxygenation (Pa(O2) before iLA: 6.66+/-2.26 kPa, immediately after implementation: 10.39+/-3.33 kPa, 24 h after implementation: 10.25+/-5.46 kPa, P<0.05) was noted. During transport, no severe complications occurred. Four patients died during further treatment due to multiple trauma or multiple organ failure.

CONCLUSIONS

Due to ease of handling, high effectiveness and relatively low costs, iLA seems to be a useful system for treatment and transportation of patients with severe acute lung injury or ARDS suffering from life-threatening hypoxia and/or hypercapnia.

Mutations in KIT and RAS are frequent events in pediatric core-binding factor acute myeloid leukemia

Activating mutations in RAS and receptor tyrosine kinases such as KIT and FLT3 are hypothesized to cooperate with chimeric transcription factors in the pathogenesis of acute myeloid leukemia (AML). To test this hypothesis, we genotyped 150 pediatric AML samples for mutations in KIT (exons 8, 17), NRAS and KRAS (exons 1, 2) and FLT3/ITD. This is the largest cohort of pediatric AML patients reported thus far screened for all four mutations. Of the children with AML, 40% had a mutation in KIT (11.3%), RAS (18%) or FLT3/ITD (11.1%), and 70% of cases of core-binding factor (CBF) leukemia were associated with a mutation of KIT or RAS. Mutations in RAS or FLT3/ITD were frequently found in association with a normal karyotype. Patients with a FLT3/ITD mutation had a significantly worse clinical outcome. However, the presence of a KIT or RAS mutation did not significantly influence clinical outcome. We demonstrate that KIT exon 8 mutations result in constitutive ligand-independent kinase activation that can be inhibited by clinically relevant concentrations of imatinib. Our results demonstrate that abnormalities of signal transduction pathways are frequent in pediatric AML. Future clinical studies are needed to determine whether selective targeting of these abnormalities will improve treatment results.