Wartelistenführung und Organvermittlung zur Lungentransplantation 2018 – Aktuelles für den Pneumologen

Die gesetzliche Grundlage der Allokation und Wartelistenführung zur Lungentransplantation wurde 2017 novelliert. Durch die aktuelle Richtlinie ergeben sich für die Transplantationszentren wichtige Änderungen. Wesentliche Neuerungen der Richtlinie betreffen die Transplantationskonferenz, die Indikationen zum Verfahren und die Führung der Warteliste zur Organtransplantation. In bestimmten klinischen Konstellationen ist die Aufnahme von Patienten nun beschränkt, und es gibt neue Regeln zur Größenkompatibilität von Spenderlunge und Empfänger. Zudem wird im Detail beschrieben, wie die Parameter, die dem Lung Allocation Score (LAS) zugrunde liegen, definiert sind inkl. der Durchführung der hierfür notwendigen Untersuchungen. Darüber hinaus gibt der vorliegende Artikel einen Überblick über die Organzuteilung durch die Vermittlungsstelle.

Prognostic Factors for Local, Loco-regional and Systemic Recurrence in Early-stage Breast Cancer

Aim: The risk of recurrence in breast cancer depends on factors such as treatment but also on the intrinsic subtype. We analyzed the risk factors for local, loco-regional and systemic recurrence, evaluated the differences and analyzed the risk of recurrence for different molecular subtypes. Material and Methods: A total of 3054 breast cancer patients who underwent surgery followed by adjuvant treatment at HSK hospital or Essen Mitte Hospital between 1998 and 2011 were analyzed. Based on immunohistochemical parameters, cancers were divided into the following subgroups: luminal A, luminal B (HER2-), luminal B (HER2+), HER2+ and TNBC (triple negative breast cancer). Results: 67 % of tumors were classified as luminal A, 13 % as luminal B (HER2-), 6 % as luminal B (HER2+), 3 % as HER2+ and 11 % as TNBC. After a median follow-up time of 6.6 years there were 100 local (3.3 %), 32 loco-regional (1 %) and 248 distant recurrences (8 %). Five-year recurrence-free survival for the overall patient collective was 92 %. On multivariate analysis, positive nodal status, TNBC subtype and absence of radiation therapy were found to be independent risk factors for all forms of recurrence. Age < 50 years, tumor size, luminal B (HER2-) subtype and breast-conserving therapy were additional risk factors for local recurrence. Compared to the luminal A subtype, the risk of systemic recurrence was higher for all other subtypes; additional risk factors for systemic recurrence were lymphatic invasion, absence of systemic therapy and mastectomy. Conclusion: Overall, the risk of local and loco-regional recurrence was low. In addition to nodal status, subgroup classification was found to be an important factor affecting the risk of recurrence.

Twenty-two years of candidaemia surveillance: results from a Norwegian national study

Several studies have reported an increased incidence of candidaemia and a redistribution of species, with a decrease in the number of Candida albicans isolates. In Norway, a prospective, national surveillance study of candidaemia has been ongoing since 1991. Data from the period 1991-2003 have been published previously. The aim of this study was to follow up the incidence, species distribution and antifungal susceptibility of Candida species isolates from blood cultures in the period 2004-2012, and compare them with the corresponding findings from the period 1991-2003. Blood culture isolates of Candida species from all medical microbiological laboratories in Norway were identified and susceptibility tested at the Norwegian Mycological Reference Laboratory. A total of 1724 isolates were recovered from 1653 patients in the period 2004-2012. Comparison of the two periods showed that the average incidence of candidaemia episodes per 100 000 inhabitants increased from 2.4 (1991-2003) to 3.9 (2004-2012). The increase in incidence in the latter period was significantly higher in patients aged >40 years (p 0.001), and a marked increase was observed in patients aged >60 years (p < 0.001). In conclusion, the average incidence in Norway over a period of 22 years modestly increased from 2.4 to 3.9 per 100,000 inhabitants, this being mainly accounted for by candidaemia in the elderly. The species distribution was stable, and the rate of acquired resistance was low.

Additional prognostic value of lymph node ratio over pN staging in different breast cancer subtypes based on the results of 1,656 patients

PURPOSE

Although the impact of lymph node ratio (LNR: ratio of metastatic to resected LNs) in breast cancer (BC) has been investigated, its prognostic value in molecular subtypes remains unclear. Our aim was to evaluate the impact of LNR compared to pN-stage in BC subtypes.

PATIENTS/METHODS

We analyzed the impact of LNR and pN-stage on disease-free (DFS) and overall survival (OS) in 1,656 patients with primary BC who underwent primary axillary surgery (removal of ≥10 LNs) between 1998 and 2011. The cut-off points for LNR were previously published. Using immunohistochemical parameters tumors were grouped in luminalA, luminalB/HER2-, luminalB/HER2+, HER2+ and triple negative (TNBC).

RESULTS

For the entire cohort 5/10-year DFS and OS rates were 88/77% and 88/75%, respectively. LNR and pN-stage were independent prognostic parameters for DFS/OS in multivariate analysis in the entire cohort and each molecular subgroup (p < 0.001). However, increasing LNR seemed to discriminated 10-year DFS slightly better than pN-stage in luminalA (intermediate/high LNR 65/44% versus pN2/pN3 71/53%), luminalB/HER2- (intermediate/high LNR 48/24% versus pN2/pN3 41/42%), and TNBC patients (intermediate/high LNR 49/24% versus pN2/pN3 56/33%).

CONCLUSIONS

LNR is an important prognostic parameter for DFS/OS and might provide potentially more information than pN-stage in different molecular subtypes.

[Infection of the CNS caused by Listeria monocytogenes]

This report examines two cases of infection of the central nervous system by Listeria monocytogenes (L.m.). Both cases show that listeriosis is not only a differential diagnosis of purulent meningitis, but can also be the cause of an isolated brain stem syndrome with normal cerebrospinal fluid cell count. The prognosis depends crucially on the early antibiotic therapy (ampicillin). The first patient was a chronic alcoholic. He died of fulminant septic shock and meningitis with brain stem encephalitis (cell count of cerebrospinal fluid: 10500/microliters). L.m. was isolated from blood cultures and from cerebrospinal fluid. The second patient had no indications of preexisting immunological disorder. Two days after perianal injections for haemorrhoids, symptoms of a progredient brain stem syndrome developed. The cell count of cerebrospinal fluid was only 10/mu, but L.m. was isolated from blood cultures. The patient died of circulatory failure. At autopsy, a brain stem encephalitis and cerebellitis with inflammation of the surrounding leptomeninx was identified.

Pharmacokinetics of vancomycin in serum and tissue of patients undergoing open-heart surgery

Penetration of vancomycin into serum, heart valves, subcutaneous tissue and muscle was determined in 33 adult patients undergoing open-heart surgery. Each patient received 15 mg/kg vancomycin as a 30-min intravenous infusion preoperatively. Within 6 h vancomycin plasma concentrations declined from 28.9 to 4.2 mg/l. Vancomycin concentrations decreased in subcutaneous tissue slowly and varied in muscle between 1.2 and 3.2 mg/kg, in subcutaneous tissue between 1.3 and 4.4 mg/kg and in heart valves between 2.3 and 4.2 mg/kg. Vancomycin concentrations in heart valves are high enough to inhibit most oxacillin-resistant Staphylococcus aureus, and coagulase-negative staphylococci causing postoperative wound infections and endocarditis.

Purification of L-glutamate-dependent citrate lyase from Clostridium sphenoides and electron microscopic analysis of citrate lyase isolated from Rhodopseudomonas gelatinosa, Streptococcus diacetilactis and C. sphenoides

Citrate lyase from Clostridium sphenoides was purified 72-fold with a yield of 11%. In contrast to citrate lyase from other sources the activity of this enzyme was strictly dependent on the presence of L-glutamate. The purified enzyme was only stable in the presence of 150 mM L-glutamate or 7 mM L-glutamate plus glycerol, sucrose or bovine serum albumin. Changes of the L-glutamate pool and of enzyme activity in growing cells of C. sphenoides indicated that citrate lyase activity in this organism was regulated by the intracellular L-glutamate concentration. Citrate lyase isolated from C. sphenoides, Rhodopseudomonas gelatinosa and Streptococcus diacetilactis was investigated by electron microscopy using the negative staining technique. Three different projections of enzyme molecules were observed: 'star' form, 'ring' form and 'triangle' form. In samples from R. gelatinosa and S. diacetilactis, star and ring forms occurred in a ratio of about 1:9. Using the enzyme from S. diacetilactis it was demonstrated that this ratio could be altered in favour of the star form by the addition of citrate or tricarballylate. The triangle form was observed in less than 1% of all evaluated molecules and may represent a transition form. In lyase samples from C. sphenoides there existed a correlation between enzyme activity and the proportion of stars and rings at varying concentrations of L-glutamate.

Citrate lyase from Streptococcus diacetilactis. Association with its acetylating enzyme

Citrate lyase (EC 4.1.3.6) was purified 38-fold from cell-free extracts of Streptococcus diacetilactis. The enzyme was homogeneous in analytical ultracentrifugation and polyacrylamide gel electrophoresis. The final enzyme preparation contained acetate: HS-citrate lyase ligase--an acetylating enzyme which converts inactive HS-citrate lyase into enzymatically active acetyl-S-citrate lyase. This enzyme activity was purified 25-fold over the crude extract and seemed to be associated with citrate lyase. Partially purified citrate lyase from Leuconostoc citrovorum contained also its acetylating enzyme. Purified citrate lyases from Klebsiella aerogenes and Rhodopseudomonas gelatinosa were devoid of acetylating enzyme activity. The HS-form of citrate lyase from S. diacetilactis was completely acetylated and hence activated by incubation with ATP and acetate for 25 min at 25 degrees C. The enzyme did not acetylate the HS-lyases from R. gelatinosa and K. aerogenes. In contrast to the citrate lyases from R. gelatinosa and K. aerogenes the enzymes from S. diacetilactis and L. citrovorum showed only a very weak reaction inactivation. It is assumed that this is due to the association of the acetylating enzymes with these lyases.