The role of intracardiac echocardiography in interventional electrophysiology

Visualization of the cardiac anatomy becomes more and more important as the complexity of interventions increases. Intracardiac echocardiography (ICE) provides good depiction of cardiac soft tissue structures and has become an important tool in today's cardiology. It has been shown to be valuable during many ablation procedures for supraventricular and ventricular arrhythmias. ICE has been used for monitoring catheter placement, observing catheter-tissue contact and lesion formation as well as titrating ablation energy. The rate of complications could be reduced, outcome of procedures improved and radiation exposure decreased. Even more, new therapy strategies have been evaluated based on ICE and it has also been used in the setting of three- dimensional imaging and image integration.

Low-Temperature Rapid-Scan Detection of Reactive Intermediates in Epoxidation Reactions Catalyzed by a New Enzyme Mimic of Cytochrome P450

The use of synthetic iron(III) porphyrins as models for heme-type catalysts in biomimetic cytochrome P450 research has provided valuable information on the nature and reactivity of intermediates produced in the "peroxide shunt" pathway. This article reports spectroscopic detection of reactive intermediates formed in the epoxidation reaction of cis-stilbene with m-chloroperoxybenzoic acid catalyzed by a new mimic of cytochrome P450 with a substituted RSO3- group (1). The application of low-temperature rapid-scan stopped-flow techniques enabled the determination of equilibrium and rate constants for the formation and decay of all intermediates in the catalytic cycle of 1, including the rate constant for the formation (1*+)FeIV=O and for oxygen transfer to the substrate. Noteworthy, the reaction of (1*+)FeIV=O with cis-stilbene leads to an almost complete re-formation (95%) of the starting complex 1. The results show that complex 1 is a valuable catalyst with promising properties for further applications in a biomimetic approach toward mimicking oxygenation reactions of cytochrome P450.

A pragmatic randomized controlled trial on the effectiveness of low concentrated saline spa water baths followed by ultraviolet B (UVB) compared to UVB only in moderate to severe psoriasis

OBJECTIVE

To evaluate whether low concentrated saline spa water baths followed by ultraviolet B (LC-SSW-UVB) are superior to UVB alone in moderate to severe psoriasis.

BACKGROUND

There is a lack of sufficiently large randomized controlled clinical trial evaluating the additional benefit of saltwater baths followed by UVB compared to UVB only in psoriasis.

STUDY DESIGN

Partly evaluator blind, multicentre, pragmatic, randomized controlled trial.

SETTING

Five German spa centres.

SUBJECTS

One hundred and forty-three adults with stable psoriasis during the last month and a Psoriasis Area and Severity Index (PASI) of > 10 and/or an affected body surface area of > 15%.

INTERVENTIONS

LC-SSW-UVB or UVB thrice a week until remission (PASI < 5) or for a maximum of 6 weeks. Sodium chloride concentrations of natural springs varied between 4.5% and 12%. Conventional UVB (broadband UVB or selective UVB phototherapy) was used as irradiation source.

MAIN OUTCOME

Reduction of PASI and/or affected body surface area of 50% at the end of the intervention period (PASI-50). Only participants receiving at least one intervention were included in the primary analysis.

RESULTS

Patients allocated to LC-SSP-UVB attained a statistically significantly higher rate of PASI-50 at the end of the intervention period than patients allocated to UVB [58/79 (73%) vs. 32/64 (50%); P = 0.01; NNT, 4.3, 95% CI, 2.4-18.1]. Benefit persisted until 3 months only for one of two secondary outcomes considered.

CONCLUSIONS

In routine clinical practice balneophototherapy using conventional UVB is superior to conventional UVB only at the end of a 6-week treatment course.

Empfehlungen zur Anorektalen Manometrie im Erwachsenenalter

This document contains the guidelines of the German Societies of Neurogastroenterology and Motility, Gastroenterology (committee for proctology), Abdominal Surgery (coloproctology working group), and Coloproctology for anorectal manometry in adults. Recommendations are given about technical notes, study preparation (equipment; patient), technique for performing manometry and data analysis, reproducibility, and indications. Minimum standards for anorectal manometry are measurement of resting and squeeze pressure, testing of rectoanal inhibitory reflex, determination of rectal sensation (first perception and urge), and calculation of rectal compliance. Anorectal manometry is indicated in patients with fecal incontinence and constipation in the context of a structured programme.

Good manufacturing practice-compliant validation and preparation of BM cells for the therapy of acute myocardial infarction

BACKGROUND

Intracoronary application of BM-derived cells for the treatment of acute myocardial infarction (AMI) is currently being studied intensively. Simultaneously, strict legal requirements surround the production of cells for clinical studies. Thus good manufacturing practice (GMP)-compliant collection and preparation of BM for patients with AMI was established by the Cytonet group.

METHODS

As well as fulfillment of standard GMP requirements, including a manufacturing license, validation of the preparation process and the final product was performed. Whole blood (n=6) and BM (n=3) validation samples were processed under GMP conditions by gelafundin or hydroxyethylstarch sedimentation in order to reduce erythrocytes/platelets and volume and to achieve specifications defined in advance. Special attention was paid to the free potassium (<6 mmol/L), some rheologically relevant cellular characteristics (hematocrit <0.45, platelets <450 x 10(6)/mL) and the sterility of the final product.

RESULTS

The data were reviewed and GMP compliance was confirmed by the German authorities (Paul-Ehrlich Institute). Forty-five BM cell preparations for clinical use were carried out following the validated methodology and standards. Additionally three selections of CD34+ BM cells for infusion were performed. All specification limits were met. Discussion In conclusion, preparation of BM cells for intracoronary application is feasible under GMP conditions. As the results of sterility testing may not be available at the time of intracoronary application, the highest possible standards to avoid bacterial and other contaminations have to be applied. The increased expense of the GMP-compliant process can be justified by higher safety for patients and better control of the final product.

Thermodynamic and Kinetic Studies on the Binding of Nitric Oxide to a New Enzyme Mimic of Cytochrome P450

A new model for the P450 enzyme carrying a SO(3)(-) ligand coordinated to iron(III) (complex 2) reversibly binds NO to yield the nitrosyl adduct. The rate constant for NO binding to 2 in toluene is of the same order of magnitude as that found for the nitrosylation of the native, substrate-bound form of P450(cam) (E.S-P450(cam)). Large and negative activation entropy and activation volume values for the binding of NO to complex 2 support a mechanism that is dominated by bond formation with concomitant iron spin change from S = (5)/(2) to S = 0, as proposed for the reaction between NO and E.S-P450(cam). In contrast, the dissociation of NO from 2(NO) was found to be several orders of magnitude faster than the corresponding reaction for the E.S-P450(cam)/NO system. In a coordinating solvent such as methanol, the alcohol coordinates to iron(III) of 2 at the distal position, generating a six-coordinate, high-spin species 5. The reaction of NO with 5 in methanol was found to be much slower in comparison to the nitrosylation reaction of 2 in toluene. This behavior can be explained in terms of a mechanism in which methanol must be displaced during Fe-NO bond formation. The thermodynamic and kinetic data for NO binding to the new model complexes of P450 (2 and 5) are discussed in reference to earlier results obtained for closely related nitrosylation reactions of cytochrome P450(cam) (in the presence and in the absence of the substrate) and a thiolate-ligated iron(III) model complex.

Bi-weekly dosing preserves the efficacy of rituximab in elderly patients with poor-prognosis DLBCL: Results from the RICOVER-60 trial of the German High-Grade Non-Hodgkin Lymphoma Study group (DSHNHL)

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Background: The addition of rituximab (R) to 3-weekly CHOP-21 improved overall results in elderly patients with DLBCL, but was more effective in good-prognosis (g-p: IPI = 1,2) than poor-prognosis (p-p: IPI = 3,4,5) patients (JCO 23:4117, 2005). Similarly, addition of R to bi-weekly CHOP-14 in the RICOVER-60 trial resulted in improved time to treatment failure (TTF) in 828 elderly (61–80 years) DLBCL patients (Blood 106:9a, 2005). To study the effects of R when combined with CHOP-14 in different subgroups of elderly DLBCL patients. Methods: Intention-to-treat-analysis of the primary endpoint time-to-treatment-failure (TTF) and the secondary endpoint overall survival (OS) in the subgroup of g-p and p-p patients treated within the RICOVER trial which compared 6 and 8 cycles of CHOP-14, both with and without R. Results: Of 828 evaluable patients (61–80 years, stage I-IV), 503 had g-p (CHOP-14 = 252; R-CHOP-14 = 251) and 325 p-p (CHOP-14 = 161; R-CHOP-14 = 163). After a median observation of 26 months, there was no difference between 6 and 8 cycles in either subgroup. In contrast, addition of R resulted in a similar improvement of TTF in both g-p (67% vs. 81%, p = 0.001) and p-p (36% vs. 52%, p = 0.004) patients. The improvement of survival is not yet different in either group: g-p: 82% (CHOP-14) vs. 88% (R-CHOP-14), p = 0.458; p-p: 58% (CHOP-14) vs. 64% (R-CHOP-14), p = 0.146. Pharmacokinetic studies show a pronounced nadir of R levels after the first R-CHOP-14, with R levels increasing after each subsequent cycle. The R nadir after the first R-CHOP is expected to be even more pronounced in a 3-weekly schedule and might explain the small improvement reproted for 3-weekly R in elderly patients with p-p DLBCL. Conclusions: Our subgroup and pharmacokinetic analysis indicate that not only dose-dense chemotherapy, but also dose-dense rituximab contribute to the excellent results of the RICOVER-60 trial. Supported by Deutsche Krebshilfe.

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Diabetes insipidus due to herpes encephalitis in a patient with diffuse large cell lymphoma. A case report

The major causes of central diabetes insipidus are neoplastic or infiltrative lesions of the hypothalamus or pituitary, severe head injuries and pituitary or hypothalamic surgery. Central diabetes insipidus caused by viral infections has been rarely reported in immunosuppressed patients, such as those with acquired immunodeficiency syndrome or Cushing's syndrome. We report the case of a 48-year-old woman suffering from diffuse large cell lymphoma, who developed hypotonic polyuria, hypernatriaemia and somnolence after the first course of chemotherapy with CHOEP and rituximab. Diabetes insipidus was diagnosed by low urine osmolarity and an undetectable vasopressin concentration. MRI revealed no pituitary abnormalities but encephalitis, and lumbar punction confirmed herpes zoster infection. To the best of our knowledge this is the first description of central diabetes insipidus in a lymphoma patient caused by an opportunistic CNS-infection.

Increased risk of venous thromboembolism in patients with acute leukaemia

Patients with malignancies have an increased risk for venous thromboembolisms (VTE), but data on patients with acute leukaemia are very limited so far. We found VTE in 12% of 455 patients with acute leukaemia, half of which occurred in association with central venous catheters, with equal risk of ALL and AML.

Analysis of myocardial deformation based on pixel tracking in two dimensional echocardiographic images enables quantitative assessment of regional left ventricular function

OBJECTIVE

To evaluate whether myocardial strain and strain rate calculated from two dimensional echocardiography by automatic frame-by-frame tracking of natural acoustic markers enables objective description of regional left ventricular (LV) function.

METHODS

In 64 patients parasternal two dimensional echocardiographic views at the apical, mid-ventricular and basal levels were obtained. An automatic frame-by-frame tracking system of natural acoustic echocardiographic markers was used to calculate radial strain, circumferential strain, radial strain rate and circumferential strain rate for each LV segment in a 16 segment model. Cardiac magnetic resonance imaging (cMRI) was performed to define segmental LV function as normokinetic, hypokinetic or akinetic.

RESULTS

Image quality was sufficient for adequate strain and strain-rate analysis from two dimensional echocardiographic images obtained from parasternal views in 88% of segments. Obtained radial strain data were highly reproducible and analysis was affected by only small intraobserver (mean 4.4 (SD 1.6)%) and interobserver variabilities (7.3 (2.5)%). Each of the analysed strain and strain-rate parameters was significantly different between segments defined as normokinetic, hypokinetic or akinetic by cMRI (radial strain 36.8 (10.5)%, 24.1 (7.5)% and 13.4 (4.8)%, respectively, p < 0.001). Peak systolic radial strain enabled detection of hypokinesis or akinesis with a sensitivity of 83.5% and a specificity of 83.5% (cut off value 29.1%, receiver operating characteristic (ROC) curve area 0.905, 95% CI 0.883 to 0.923). Peak systolic radial strain analysis also enabled detection of akinesis versus hypokinesis with a sensitivity of 82.7% and a specificity of 94.5% (cut off value 21.0%, ROC curve area 0.946). Peak systolic radial strain-rate analysis was less accurate than peak systolic radial strain analysis to detect cMRI-defined segmental function abnormalities. The accuracy of peak systolic circumferential strain and strain rate was similar to that of corresponding radial parameters.

CONCLUSIONS

Frame-by-frame tracking of acoustic markers in two dimensional echocardiographic images enables accurate analysis of regional systolic LV function.