Definition of treatment goals for moderate to severe psoriasis: a European consensus

Patients with moderate to severe psoriasis are undertreated. To solve this persistent problem, the consensus programme was performed to define goals for treatment of plaque psoriasis with systemic therapy and to improve patient care. An expert consensus meeting and a collaborative Delphi procedure were carried out. Nineteen dermatologists from different European countries met for a face-to-face discussion and defined items through a four-round Delphi process. Severity of plaque psoriasis was graded into mild and moderate to severe disease. Mild disease was defined as body surface area (BSA) ≤10 and psoriasis area and severity index (PASI) ≤10 and dermatology life quality index (DLQI) ≤10 and moderate to severe psoriasis as (BSA > 10 or PASI > 10) and DLQI > 10. Special clinical situations may change mild psoriasis to moderate to severe including involvement of visible areas or severe nail involvement. For systemic therapy of plaque psoriasis two treatment phases were defined: (1) induction phase as the treatment period until week 16; however, depending on the type of drug and dose regimen used, this phase may be extended until week 24 and (2) maintenance phase for all drugs was defined as the treatment period after the induction phase. For the definition of treatment goals in plaque psoriasis, the change of PASI from baseline until the time of evaluation (ΔPASI) and the absolute DLQI were used. After induction and during maintenance therapy, treatment can be continued if reduction in PASI is ≥75%. The treatment regimen should be modified if improvement of PASI is <50%. In a situation where the therapeutic response improved ≥50% but <75%, as assessed by PASI, therapy should be modified if the DLQI is >5 but can be continued if the DLQI is ≤5. This programme defines the severity of plaque psoriasis for the first time using a formal consensus of 19 European experts. In addition, treatment goals for moderate to severe disease were established. Implementation of treatment goals in the daily management of psoriasis will improve patient care and mitigate the problem of undertreatment. It is planned to evaluate the implementation of these treatment goals in a subsequent programme involving patients and physicians.

Left Main Stenosis – Where Do We Stand?

The presence of significant left main coronary disease is associated with increased mortality. Limited data examining the role of surgery in patients with a left main stenosis suggest a significant improvement in longevity. With the advent of coronary stenting, particularly the use of drug-eluting stents and improvements in percutaneous technology, left main coronary intervention has become more commonplace. However, despite important advances in the understanding of left main disease, management can be challenging. Many aspects, including the assessment of significance and the need for and choice of intervention (surgical or percutaneous revascularisation), remain unclear. This article serves to facilitate the management of patients with left main coronary disease with a focus on the assessment of lesion significance and the role of percutaneous intervention.

Voxel-based morphometry reveals an association between aerobic capacity and grey matter density in the right anterior insula

This study investigated the effects of aerobic capacity on brain structure and memory performance. A sample of 33 healthy young subjects completed (i) assessment of aerobic capacity based on blood-lactate concentration, (ii) structural magnetic resonance imaging (MRI) scanning and analysis of grey matter density using voxel-based morphometry (VBM) and (iii) a range of memory tests. Memory performance was not significantly associated with aerobic capacity. After adjusting for effects of age, gender and total intracranial volume, cortical grey matter density in the right anterior insula was strongly correlated with aerobic capacity. These findings are in line with studies implicating the insula in the cortical control of cardiovascular processes during both exercise and autonomic arousal. Interindividual differences in aerobic capacity are thus reflected in structural differences in brain regions involved in cardiovascular control, resembling structural changes associated with certain cognitive or motor skills.

An Update on Carotid Stent Trials and Perspectives

The presence of carotid artery stenosis is associated with an increased risk of stroke. Carotid endartectomy (CEA) has been demonstrated to reduce the stroke risk in standard-risk patients with symptomatic carotid stenosis as well as in asymptomatic patients, provided that the operative risk is low. The role of percutaneous carotid intervention is less clear. There are no trials that compare percutaneous carotid intervention with medical management. Although trial results comparing CEA with carotid artery stenting (CAS) are variable and/or controversial, some trials have demonstrated promising results and have fostered enthusiasm for the performance of ongoing trials comparing CAS with CEA. This article focuses on the results of completed trials and outlines ongoing and planned trials that aim to clarify the role of CAS in patients with carotid stenosis. In addition, potential unresolved problems associated with CAS, such as CAS in the elderly, in-stent restenosis and distal embolisation, are discussed.

Manipulating surface diffusion ability of single molecules by scanning tunneling microscopy

The bonding of single diferrocene [Fc(CH(2))(14)Fc, Fc = ferrocenyl] molecules on a metal surface can be enhanced by partial decomposition of Fc groups induced by the tunneling current in scanning tunneling microscopy. Although the isolated intact molecule is mobile on the terrace of Cu(110) at 78 K, the modified molecule is immobilized on the terrace. Calculations based on density functional theory indicate that the hollow site of the Cu(110) surface is the energetically favorable adsorption site for both ferrocene and the Fe-cyclopentadienyl complex, but the latter one possesses a much higher binding energy with the substrate.

An Update on Patent Foramen Ovale Closure

The patent foramen ovale is an intra-cardiac right-to-left shunt that is thought to have an important role in a number of disease processes, including stroke, peripheral embolism, systemic oxygen desaturation (i.e. hypoxaemia) and migraine. A wide variety of percutaneous devices to close congenital heart defects are currently commercially available or in clinical trials. The trend in percutaneous closure of patent foramen ovales is shifting towards defect-tailored devices and new strategies that minimise the amount of foreign material left in the atria. This article focuses on the latest technologies available for closure of patent foramen ovales and on experimental devices currently under investigation.

3D Echo Guidance for Structural Heart Interventions

With the increase of minimally invasive catheter-based cardiac interventions, multiplane 2D transoesophagal echocardiography (2D TEE) and intracardiac echocardiography (ICE) have evolved to become the most important guiding tools. However, 2D imaging modalities have limitations due to the fact that there are only two spatial dimensions. A novel realtime 3D technology (RT3D TEE) has been merged with TEE to provide realtime volume imaging with high resolution, resulting in unique views of cardiac structures. Despite limited clinical experience to date, high-quality realtime 3D TEE imaging with good spatial and temporal resolution has great potential for guiding interventional procedures by adding additional morphological information not available before. This may lead to safer and shorter procedures with higher technical success, a diminished amount of radiation exposure and, therefore, better outcomes for patients.

Detailed analysis concerning the biodistribution and metabolism of human calcitonin-derived cell-penetrating peptides

The interest in using small peptides for therapeutic and diagnostic in vivo applications is based on several advantageous features such as good penetration into tissues and rapid clearance from the body. Because of their size, they can easily be synthesized chemically. The recently discovered cell-penetrating peptides (CPP) and among them CPP derived from the native peptide hormone human calcitonin (hCT) could meet these requirements. Therefore, they are nowadays widely used as delivery vectors for a variety of bioactive molecules. However, the knowledge about the distribution and metabolism of CPP in vivo is very limited. Hence, evaluation of the pharmacological features of any promising peptide is a crucial challenge in its development process. Herein, we studied the in vivo radiopharmacology of (68)Ga radiolabeled DOTA-modified, hCT-derived CPP in rats using small animal PET. Furthermore, the arterial blood at different time points and urine were analyzed for radio-metabolites. It was shown that d-amino acid modifications of the sequence hCT(9-32) resulted in an increased in vivo stability and lower retention in the kidney cortex of this peptide.

[Acute carpal tunnel syndrome in a patient with Marfan syndrome]

Acute carpal tunnel syndrome (ACTS) is rare and is mostly the result of fractures of the distal radius or the carpal bones. This paper gives the first report of an ACTS following contusion of the wrist as the result of an extensive haematoma of the flexor tendon sheath, which did not appear until 50 hours after the injury was sustained but then developed rapidly. The patient suffers from Marfan syndrome. This disease is associated with pathologic changes to the major vessels, and especially the aorta, and of the smaller peripheral vessels. It is assumed that the haematoma arose from an aneurysm of such a small vessel. The treatment of choice in ACTS is emergency incision of the carpal tunnel.

[Initial experiences with subcutaneous Harrington distraction without spondylodesis in scoliosis]

We report on a special method in the treatment of scoliosis using subcutaneous Harrington-distraction without spondylodesis. We operated 14 patients in all who were between 7 and 12 years old, in average 10 2/12 years Indication is made if scoliosis is extremely progressive, if Cobb's measure is above 50 degrees, after unsuccessful conservative treatment also including orthosis and physiotherapy, or if patients appeared to late in our department. In this technique only two incisions to make are necessary to place the Harrington roots to the cranial and caudal end of the scoliosis curve. The Harrington root can be 'needled' in subcutaneously. When in times of further growth the amount of correction gets noticeably lost the cranial hook could be tightened or the Harrington root could be changed easily. We need an orthosis (Cheneau or Milwaukee) for after treatment until in a final operation with spinal fusion is made. This method has showed good results although we had to cope with a bad prognostic starting position.

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[Health-economic considerations for the use of BMP-2 for spinal surgery in Germany]

INTRODUCTION

BMP-2 can replace autogenous bone grafting in lumbar one-level anterior lumbar interbody fusions (ALIF). The current G-DRG system does not reimburse the upfront price of 2,970 euro per BMP-2 application for hospitals in Germany. The purpose of the current study was to create a health economic model to evaluate the financial savings for health care providers (hospitals) and health care payers (health care insurance) that can be achieved by the use of BMP-2 in spine surgery.

METHODS

A previously published pooled data analysis was used in which BMP-2 showed significant improvements in the treatment after ALIF surgery compared to autogenous bone grafting, including earlier return to work time and reduced revision rates. These medical findings were transformed into economic data based on the regulations of the German health system of 2005.

RESULTS

The significantly shorter return to work time under BMP-2 treatment generates important financial savings for health care insurances offsetting the upfront prize of 2,970 euro for BMP-2. Savings for hospitals are mainly related to shorter surgery time due to the absence of the bone grafting procedure and faster discharge of the patient.

CONCLUSIONS

The combination of improved medical outcome by BMP-2 treatment for the patient and net savings for the entire health care system in Germany represents a "dominant" strategy from a health economic perspective. This implicates that BMP-2 in ALIF procedures is to be recommended from a health economic point of view for the German health care system.