[Inhibitor development after changing FVIII/IX products in patients with haemophilia]

The retrospective observational study surveys the relationship between development of inhibitors in the treatment of haemophilia patients and risk factors such as changing FVIII products. A total of 119 patients were included in this study, 198 changes of FVIII products were evaluated.

RESULTS

During the observation period of 12 months none of the patients developed an inhibitor, which was temporally associated with a change of FVIII products. A frequent change of FVIII products didn't lead to an increase in inhibitor risk. The change between plasmatic and recombinant preparations could not be confirmed as a risk factor. Furthermore, no correlation between treatment regimens, severity, patient age and comorbidities of the patients could be found.

Assay-Abhängigkeit der Calcitonin- Zielbereiche für „biochemisch geheilte“ Patienten mit medullärem Schilddrüsenkarzinom

Aim: Calcitonin (hCT) is an important diagnostic parameter in medullary thyroid carcinoma (MTC). We determined the variability of the reference ranges of several currently available immunometric assays for „biochemically cured“ MTC patients. Patients, methods: We compared six assays [Nichols ICMA, Biomerica IEMA, Immulite 2000 (Siemens), Calcitonin-IRMA magnum (Medipan), SELco-IRMA (Medipan) and Calcitonin IRMA (Medgenix)] in subgroups of 198 patients with differentiated thyroid cancer (DTC) after total thyroidectomy as a model for curatively treated MTC patients. In addition, hCT was measured after pentagastrin stimulation in 13 DTC patients and 13 patients with MTC. Results: The basal hCT concentrations were below the detection limit of the respective assay in 100% of all thyroidectomized DTC patients for Nichols ICMA (n = 138) and Immulite 2000 (n = 60), in 97% for Biomerica IEMA (n = 57), and in 85% for IRMA magnum (n = 20). However, basal hCT was mostly within the reference range in Selco-IRMA (n = 20) and Medgenix IRMA (n = 76). In all DTC patients and 9/13 MTC patients the pentagastrin stimulated hCT was below the detection limit for the Nichols ICMA and Immulite 2000, all four MTC patients with elevated stimulated hCT developed a recurrence during follow-up. Conclusions: For assays with high monomer specificity (Nichols ICMA, Biomerica IEMA, Immulite 2000, to a lesser degree IRMA magnum) biochemical cure is defined by basal and stimulated calcitonin levels below the detection limit. For assays with low monomer specificity (SELco-IRMA, IRMA Medgenix) calcitonin levels in the reference range of patients without thyroid diseases are consistent with “biochemical cure”.

[Computer assistance to improve therapy planning for head neck oncology]

The ongoing development in therapies of head and neck malignomas has led to a further differentiation of treatment options. Complex surgical procedures, a wide variety of multi modal therapy options, changing radiation technologies (IMRT - Intensity-modulated radiation therapy) and numerous "targeted therapies" emphasize the need for a precise treatment plan. Beside this, imaging has seen significant improvements beyond the technical ones, e. g. with the implementation of PET/CT scanners. This increase in pre-therapeutic data volume, together with a diversification of treatment options calls for a further discussion of the basics of therapeutic decisions. Planning relevant data processing by computer assisted systems can aid in these decisions. This work describes the current status of relevant computer assisted systems undergoing first testing for head and neck cancer therapy planning. Here, the integration of 3-dimensional patient data plays a central role. This planning tool forms the integrated base for a further development in the areas of radiation planning, documentation and study management.

[Does FVIII-activity increase with age in patients with haemophilia A and carriers of haemophilia A?]

The retrospective cohort study surveys the influence of age, co-morbidity and laboratory values on FVIII-activity (FVIII:C) in patients with haemophilia A with (mild n = 48, moderate n = 10, severe n = 7 and carriers n = 23). Median observation was 19 years for patients with haemophilia A and 9,5 years for carriers.

RESULTS

FVIII:C levels collected from patients with mild haemophilia A displayed a significant median increase of 6.5% with proceeding age (p = 0.0013). Patients with moderate haemophilia A (and carriers of haemophilia A) showed a non significant median increase of 1.05% (carriers 8%). Eight patients showed FVIII:C levels at last blood withdrawal that indicated a change of severity from moderate to mild haemophilia A. A significant correlation was found between FVIII:C and VWF:RCo (p = 0.0203) and AFP (p < 0.0005). The correlation between FVIII:C and triglycerides and LDH was significant negative (p < 0.0005). No significant correlation could be found for FVIII:C and co-morbidity, fibrinogen, cholesterol and VWF:Ag.

Locoregional therapy for hepatocellular carcinoma: radioembolization with yttrium-90 microspheres

Compared with other malignant tumours, hepatocellular carcinoma (HCC) exhibits particular characteristics regarding its supplying vessels and tumour biology. If a potentially curative surgical approach, such as resection or liver transplantation, is due to technical or prognostical reasons no option, these characteristics are a fundamental prerequisite for the possibility to effectively treat this tumour by local ablation methods. Microsphere and particle technology with selective transport of tumoricidal substances or radiation represents a new generation of therapeutics in interventional oncology. With the intrahepatic application of radioactive microspheres via the hepatic artery (radioembolization) local ablation can be performed even of diffuse and multifocal liver tumours, which hitherto, could only be approached with systemic therapy. The present standard for radioembolization, is the use of yttrium-90 glass or resin microspheres. The indications, technique and current results of radioembolization with yttrium-90 microspheres for the treatment of HCC are discussed in this review.

[Special training therapy to reduce inflammation in Anti-Jo-1 syndrome]

A 46-year-old patient was frequently seen with a medically treated Anti-Jo-1 syndrome. The patient had already been treated with azathioprine and oral corticosteroids on account of decreasing lung function, dyspnoea, fatigue, and beginning signs of myositis. Although high doses of steroids and azathioprine were administered, the muscleskeletal syndromes increased steadily. The patient used to be an active long-distance runner (20 km), but now was unable to perform that kind of physical exercise. It was decided to start a treatment with the GalileoTM training device for active muscle training of the lower extremities. Before and after three months of training the following assessment was performed: measurement of health-related quality of life (St. Georges respiratory questionnaire, SGRQ), ultrasound measurement of the cross-sectional area of the quadriceps muscle, 6 minute walk test (6 MWT), lung function testing, and assessment of serum markers of inflammation (TNF-alpha, interleukin-8, CRP, CK, myoglobin). After only two months, training with the GalileoTM five times a week has improved the patient's conditions dramatically. The training will be continued.

Comparative chromosome maps of neotropical rodents Necromys lasiurus and Thaptomys nigrita (Cricetidae) established by ZOO-FISH

This work presents chromosome homology maps between Mus musculus (MMU) and 2 South American rodent species from the Cricetidae group: Necromys lasiurus (NLA, 2n = 34) and Thaptomys nigrita (TNI, 2n = 52), established by ZOO-FISH using mouse chromosome-specific painting probes. Extending previous molecular cytogenetic studies in Neotropical rodents, the purpose of this work was to delineate evolutionary chromosomal rearrangements in Cricetidae rodents and to reconstruct the phylogenetic relationships among the Akodontini species. Our phylogenetic reconstruction by maximum parsimony analysis of chromosomal characters confirmed one consistent clade of all Neotropical rodents studied so far. In both species analyzed here, we observed the syntenic association of chromosome segments homologous to MMU 8/13, suggesting that this chromosome form is a synapomorphic trait exclusive to Neotropical rodents. Further, the previously described Akodontini-specific syntenic associations MMU 3/18 and MMU 6/12 were observed in N.lasiurus but not in T. nigrita, although the latter species is considered a member of the Akodontini tribe by some authors. Finally, and in agreement with this finding, N.lasiurus and Akodon serrensis share the derived fission of MMU 13, which places them as basal sister clades within Akodontini.

White blood cell SPECT during active period of cluster headache and in remission

BACKGROUND AND PURPOSE

Cluster headache (CH) is an episodic headache disorder characterized by recurrent, unilateral attacks of excruciating pain in the temporal/orbital region. The pathophysiology of CH is largely unknown although involvement of immunological mechanisms has been suggested. The aim of our study was to investigate whether patients with CH show signs of intracranial inflammation, when using white blood cell single-photon emission computer tomography (WBC-SPECT).

METHODS

We have examined 14 patients with CH, both in active period and in remission, and five control subjects at one occasion, with WBC-SPECT. To be able to precisely define regions of interest (ROI:s) in the brain, all patients with CH and control subjects underwent magnetic resonance imaging (MRI) of the brain.

RESULTS

We found no significant difference in (99m)Tc-labeled WBC uptake between patients with CH in active period and controls. Furthermore, patients with CH in active period were not significantly different in uptake compared with patients with CH in remission.

CONCLUSIONS

These results did not provide conclusive support for a hypothesis of a pathophysiological role of inflammation intracranially. Our conclusions are restricted to the advantages and limitations of the chosen method.

Contact dermatitis induced by glatiramer acetate

Glatiramer acetate (Copaxone(®)) is an immunomodulatory polypeptide used in patients with relapsing-remitting multiple sclerosis. It represents a safe treatment option with mild side effects. In this study, we look at a 39-year-old woman who received glatiramer acetate as subcutaneous injections for two months and developed contact dermatitis. The drug had to be stopped, and treatment with topical prednisone was initiated. Prick/scratch testing was negative but the lymphocyte transformation test was highly positive for glatiramer acetate. This is the first report on contact dermatitis induced by glatiramer acetate injections. The treatment consisted of local topical steroids and cessation of the drug.

Malignancies after heart transplantation: incidence, risk factors, and effects of calcineurin inhibitor withdrawal

The objectives of the present study were to evaluate the incidence of malignancies and to describe the effects of immunosuppression on survival and recurrence of malignancies after heart transplantation (HTX). Data were analyzed in 211 cardiac allograft recipients, in whom HTX was performed between 1989 and 2005. All of these patients survived for more than 2 years after HTX and received induction therapy with antithymocyte globulin (RATG) guided by T-cell monitoring since 1994. An immunosuppressive regimen consisting of cyclosporine A (CsA) combined with azathioprine was followed by CsA and mycophenolate mofetil (MMF) in 2001; mammalian target of rapamycin (mTOR) inhibitors (everolimus/sirolimus) were used since 2003. Mean patient age at HTX was 51.4 ± 10.5 years; mean follow-up time after HTX 9.2 ± 4.7 years. Overall incidence of neoplasias was 30.8%. Individual risk factors associated with a higher risk of malignancy after HTX were higher age at transplantation (P = .003), male gender (P = .005) and ischemic cardiomyopathy before HTX (P = .04). Administration of azathioprine (P < .0001) or a calcineurin inhibitor (CNI) (P = .02) for more than 1 year was associated with development of malignancy, whereas significantly fewer malignancies were noticed in patients receiving an mTOR-inhibitor (P < .0001). Kaplan-Meier analysis demonstrated a strong statistical trend toward an improved survival in patients with a noncutaneous neoplasia switched to a CNI-free protocol (P = .05). This study demonstrated the impact of a variety of individual risk factors and immunosuppressive drugs on development of malignancy after HTX. Markedly fewer patients with noncutaneous malignancies died after switch to a CNI-free regimen, not quite reaching statistical significance by Kaplan-Meier analysis, however.

[Patient pathways in thrombosis prophylaxis after hip and knee replacement surgery : results of a survey]

A key element of patient care after hip and knee replacement is medication-based thrombosis prophylaxis. Due to decreasing lengths of acute hospital stays the question arises to what extent outpatients are taking responsibility thrombosis prophylaxis (patient pathway analysis).To analyze patient pathways a telephone survey of 668 patients was conducted. On average patients were interviewed 38 days following surgery with a focus on low molecular weight heparins. The analysis showed that nearly 90% of patients need to carry out thrombosis prophylaxis in an outpatient or home environment for at least 1 day and for 47.2% of patients a linking period between acute and rehabilitation stay is relevant. The obviously existing quantitative importance of outpatient thrombosis prophylaxis is also reflected by its duration and 45.7% of interviewed patients needed at least 5 days of outpatient prophylaxis.Outpatient thrombosis prophylaxis clearly makes high demands on the patients, in particular when combined with the task of administering complex forms of injections. Those involved in inpatient and outpatient provision of care should not assume that all patients carry out the necessary prophylaxis at the required level of reliability. On the contrary initial evidence shows that the non-adherence of patients during ambulatory thrombosis prophylaxis presents a genuine challenge to care providers.

Prediction of steady-state occupancy of the serotonin transporter based on single-dose occupancy: A [11C]DASB pet study

Introduction

Clinical studies point toward a potential role of the serotonin transporter (SERT) binding as a predictor of clinical outcome in the treatment of depression. After long-term treatment with clinical doses of SSRIs the expected SERT occupancy is about 80%. Here, we were interested to investigate the relationship of SERT occupancy values between short- and longterm treatment.

Objectives

To test if the SERT occupancy at steady-state can be predicted based on the single dose occupancy by escitalopram (S-citalopram) or citalopram (racemate of S-citalopram and R-citalopram).

Methods

18 patients with major depressive disorder received either escitalpram (10 mg/d) or citalopram (20 mg/d) in a double-blind, randomized, longitudinal study. They underwent three PET scans using the radioligand [11C]DASB: PET1 baseline, PET2 6 hours after first drug intake and PET3 after three weeks of daily oral treatment. Occupancy of SERT was quantified in six subcortical regions: thalamus, N. caudatus, putamen, mibrain, dorsal raphe and median raphe nuclei. Data was analyzed by means of multiple linear regression models corrected for baseline SERT availability values using SPSS 15.0.

Results

Single dose occupancy of the SERT significantly predicted steady-state occupancy after three weeks in three regions: thalamus (r2 = 0.45, p = 0.009), N. caudatus (r2 = 0.4, p = 0.006) and putamen (r2 = 0.43, p = 0.005). Other regions did not show significant relationships.

Conclusions

In this study we demonstrated that single-dose occupancy in SERT rich regions such as thalamus, N. caudatus and the putamen could serve as reliable predictors for steady-state occupancy. However, a linear model failed to explain the relationship in regions known for serotonergic cell origin.

Evaluation of the VITEK 2 AST-N111 card for detection of extended-spectrum beta-lactamases (ESBLs) in Escherichia coli, Klebsiella pneumoniae, and Klebsiella oxytoca compared to ESBL Etests and combination disk methods

The VITEK 2 AST-N111 card was evaluated for detection of extended-spectrum beta-lactamases (ESBLs) by testing 51 ESBL positive and 50 ESBL negative isolates of E. coli, K. pneumoniae, and K. oxytoca. The occurrence of beta-lactamase genes was confirmed by PCR and sequencing. The advanced expert system (AES) of the VITEK 2 system achieved sensitivity and specificity values of 100% and 96.0%, respectively. The ESBL test of the VITEK 2 AST-N111 card showed a sensitivity of 92.1% and a specificity of 90.0%. Contradictory results obtained with the two VITEK 2 tools could be clarified by combination disk tests in nine of 11 isolates. The combined use of AES and ESBL tests of the AST-N111 card in association with combination disk tests in case of contradictory results seems to be a reliable method for ESBL detection.

Hämophilie-A-Patienten und Konduktorinnen für Hämophilie A

The retrospective cohort study surveys the influence of age, co-morbidity and laboratory values on FVIII-activity (FVIII : C) in patients with haemophilia A with (mild n = 48, moderate n = 10, severe n = 7 and carriers n = 23). Median observation was 19 years for patients with haemophilia A and 9,5 years for carriers.

Results FVIII : C levels collected from patients with mild haemophilia A displayed a significant median increase of 6.5% with proceeding age (p = 0.0013). Patients with moderate haemophilia A (and carriers of haemophilia A) showed a non significant median increase of 1.05% (carriers 8%). Eight patients showed FVIII : C levels at last blood withdrawal that indicated a change of severity from moderate to mild haemophilia A. A significant correlation was found between FVIII : C and VWF : RCo (p= 0.0203) and AFP (p < 0.0005). The correlation between FVIII : C and triglycerides and LDH was significant negative (p < 0.0005). No significant correlation could be found for FVIII : C and co-morbidity, fibrinogen, cholesterol and VWF : Ag.

Impact of the nutritional risk score in fast-track colon surgery

BACKGROUND

Patients at nutritional risk reveal an increased morbidity. Fast-track (FT) programs in colonic surgery have shown reduced complications and hospital stay. We aimed to assess the effect of FT programs on patients at nutritional risk.

METHODS

In a randomized trial (NCT00556790), we compared complications after open colonic surgery with either a FT program or standard care (SC). A subgroup analysis was performed in 67 patients for whom a prospective nutritional risk score (NRS) was available.

RESULTS

The SC and FT groups did not differ regarding patient characteristics or prevalence of NRS ≥ 3 (SC 8/31, FT 7/36, p = 0.569). Patients with SC had more complications (14/31 vs. 8/36, p = 0.044) and a longer hospital stay (9 vs. 5 days, p < 0.0001). No major complication occurred in patients with an NRS <3. Patients at nutritional risk had a high complication rate regardless of SC or FT (6/8 and 5/7, respectively, p = 1.000). Median hospital stay was shorter in FT (7 (range 5-30) days) versus SC patients (14.5 (range 8-30) days, p = 0.164).

CONCLUSIONS

Patients with a NRS ≥ 3 have an increased postoperative morbidity even within a FT program. They should be identified by nutritional screening and might benefit from nutritional supplements.

Predicting the segregation profile of the Pt25Rh75(100) surface from first-principles

The segregation profile of the Pt(25)Rh(75)(100) surface is studied by the combination of density functional theory calculations with the cluster-expansion method and Monte Carlo simulations. We construct the stability diagram for the surface layers, which allows the prediction of the most stable atomic configuration for a given average concentration in those layers. On this basis, we apply the cluster-expansion Hamiltonian in grand-canonical Monte Carlo simulations for the prediction of the temperature-dependent concentration profile. The experimentally found enrichment of Pt in the top layer and depletion in the second layer is nicely confirmed by the calculations.

Attitude toward xenotransplantation of patients prior and after human organ transplantation

Xenotransplantation is a potential strategy to overcome the shortage of human donor organs. As this technique has a major medical and psychological impact on patients and their family and friends, the attitude of patients currently waiting for organ transplantation is important. Therefore, we conducted a survey on the attitude toward xenotransplantation of patients on the waiting list and already transplanted patients. Patients received detailed information before being asked to fill in the questionnaire. We found that 65% would accept xenotransplantation, irrespective of gender, education level or if the patients were on the waiting list or already transplanted. The most common concern was transmission of diseases or genetic material, followed by psychological concerns and ethical issues. More patients had a positive attitude toward accepting cell or tissue transplantation when compared to whole organs. Pig pancreas islet cell transplantation is generally well accepted, patients with diabetes mellitus show even higher acceptance rates than patients without diabetes. In conclusion, xenotransplantation seems to be well accepted in patients who are potential future candidates for organ transplantation. Informing patients about the current status of research tended to decrease acceptance rates slightly.

[Validation of telemedical fundus images from patients with retinopathy]

BACKGROUND

The degree of retinal microangiopathy is important foran estimation of the vascular risk and for the optimisation of therapy in hypertensive and diabetic patients. Retinal microangiopathy may be determined by examination of the retinal fundus. We examined the reliability of the ophthalmoscopic diagnosis and of the telemedical judgement of fundus images in relation to the presence and the degree of retinopathy.

PATIENTS AND METHODS

This comparative observational study included 47 inpatient hypertensive and/or diabetic subjects. The fundus was judged ophthalmoscopically and subsequently, a fundus image was generated by use of a KOWA camera. The images were sent to the Interdisciplinary Center of Ophthalmologic Preventive Medicine. The reliability of the two diagnostic methods was calculated for one of the two eyes, which was selected by a random generator.

RESULTS

The largest concordance of the two diagnosis methods was achieved, in descending order, for retinal bleeding, stage of diabetic retinopathy and the papilla findings. Additionally, there were no differences for the stage of hypertensive retinopathy und tortuosity. The reliability of arterio-venous nicking related to the right and the left eye was low or absent, respectively.

CONCLUSIONS

The teleophthalmologic diagnosis achieves good results as compared to the ophthalmoscopic judgement in relation to retinopathy assessment criteria.

Swelling Phenomena in Sintered Silver Die Attach Structures at High Temperatures: Reliability Problems and Solutions for an Operation above 350°C

A very effective method to bond an electronic device to a substrate is the pressure assisted sintering of a sub-micron silver paste at temperatures between 150°C and 300°C. This technique-sometimes called “Silver-Sintering” or “Low Temperature Joining Technique (LTJT)” is already used in many power electronics industry applications. It provides die attach layers with excellent pull-strength of more than 100 MPa at room temperature and 30 MPa at 300°C. Additionally the electrical and thermal conductivity is nearly as good as it is in pure silver. Such sintered die attach layers are said to be stable up to temperatures above 500°C, but no detailed investigations in this temperature range are available up to now. Our recent investigations by shear- tests on monometallic chip/substrate-samples and dilatometer measurements showed a non-linear thermal expansion of the sintered structures above 350°C including a strong irreversible expansion of the whole sintered structure after long term heat treatments. Beyond the investigations on the swelling effect itself we present studies on the relationship between the expansion of the sintered layer and the resulting layer properties. Finally we discuss possibilities to take advantage out of this effect and additionally analyze options to reduce the swelling by adding SiC-particles to the silver paste. As a result, we demonstrate that swelling of the silver paste has to be taken into consideration when silver sintering is to be used for device operation temperatures above 350°C.

Ureterocystoplasty: an ideal method for vesical augmentation in children

BACKGROUND

Inadequate therapy endangers upper urinary tract function in children with low compliance bladders. We report our approach of increasing bladder compliance using the patients own (mega)-ureter for bladder augmentation.

PATIENTS

A total of 8 children underwent ureterocystoplasty. The etiology of bladder non-compliance and the need for augmentation was neurogenic in 5 children, posterior urethral valves in 2 children and in one child the situation after repeated antireflux surgery. In all patients the kidney of the used ureter was functionless. Surgery was done through a transperitoneal approach. After nephrectomy, the renal pelvis and the ureter were spatulated and sutured into the bladder incision. An additional MACE stoma was made in 3 patients, antireflux surgery for the contralateral kidney was necessary in 2 patients and one patient underwent stone removal in the remaining kidney. In 1 patient the ureter was used as a free transplant and was covered by an omental flap. In addition, a simultaneous living donor kidney transplant was performed (case 2).

RESULTS

Bladder capacity and compliance improved significantly in all patients. The function of the ureter which was used as a free transplant showed good clinical results. The longest follow-up is 8 years.

CONCLUSION

Ureterocystoplasty is a useful and metabolically neutral alternative to bowel segments. In patients with only one functioning kidney and a contralateral megaureter, ureterocystoplasty is the treatment of choice in our institution.

VEGF: a surrogate marker for peripheral vascular disease

This study aims to evaluate the value of VEGF as a surrogate marker for peripheral vascular disease (PVD). Prior to treatment, serum VEGF levels were evaluated by enzyme-linked immunosorbent assay (ELISA) in 293 PVD patients. Risk factors and clinical parameters of PVD were documented. Twenty-six age-matched healthy volunteers served as controls. Serum VEGF values strongly correlated with Fontaine stages (p<0.006, stage IV vs. controls). High VEGF values prior to treatment were associated with poor outcome. Serum VEGF appears to indicate the severity of PVD and might serve as a surrogate indicator of disease severity.

Alkali-helium snowball complexes formed on helium nanodroplets

We systematically investigate the formation and stability of snowballs formed by femtosecond photoionization of small alkali clusters bound to helium nanodroplets. For all studied alkali species Ak = (Na,K,Rb,Cs) we observe the formation of snowballs Ak(+)He(N) when multiply doping the droplets. Fragmentation of clusters Ak(N) upon ionization appears to enhance snowball formation. In the case of Na and Cs we also detect snowballs Ak(2) (+)He(N) formed around Ak dimer ions. While the snowball progression for Na and K is limited to less than 11 helium atoms, the heavier atoms Rb and Cs feature wide distributions at least up to Ak(+)He(41). Characteristic steps in the mass spectra of Cs-doped helium droplets are found at positions consistent with predictions on the closure of the first shell of helium atoms around the Ak(+) ion based on variational Monte Carlo simulations.