Facilitators and barriers to implementation of suicide prevention interventions: Scoping review

We know that suicide is preventable, yet hundreds of thousands of people still die due to suicide every year. Many interventions were proven to be effective, and dozens of others showed promising results. However, translating these interventions into new settings brings several challenges. One of the crucial obstacles to success is not anticipating possible barriers to implementation nor enhancing possible benefits of factors facilitating the implementation. While we witnessed great support for suicide prevention activities globally in the past years, implementation barriers and facilitating factors are yet to be comprehensively mapped to help implementation activities worldwide. This scoping review maps current knowledge on facilitators and barriers to the implementation of suicide prevention interventions while using the Consolidated Framework for Implementation Research (CFIR) for classification. We included 64 studies. Barriers and facilitators were most commonly identified in the outer setting CFIR domain, namely in the sub-domain of patient needs and resources, which refers to the way in which these needs and resources are reflected by the reviewed interventions. The second most saturated CFIR domain for facilitators was intervention characteristics, where relative advantage, adaptability and cost of intervention sub-domains were equally represented. These sub-domains refer mostly to how the intervention is perceived by key stakeholders, to what extent it can be tailored to the implementation context and how much it costs. While intervention characteristics domain was the second most common also for barriers, the complexity sub-domain referring to high perceived difficulty of implementation was the most frequently represented. With reference to the results, we recommend adapting interventions to the needs of the target groups. Furthermore, carefully selecting the intervention to suit the target context concerning their adaptability, costs and complexity is vital for a successful implementation. Further implications for practice and research are discussed.

Real-world effectiveness of anti-interleukin-23 antibodies in chronic plaque-type psoriasis of patients from the Austrian Psoriasis Registry (PsoRA)

With the introduction of the latest class of biologic drugs targeting interleukin (IL)-23p19, three new, highly effective drugs can be used for the treatment of chronic plaque psoriasis. However, poorer skin improvement as well as higher rates of serious adverse events have been reported for patients under real-world conditions (outside clinical trials). This accounts especially for patients who have already been treated with biologic drugs. We therefore aimed to determine effectiveness and safety of IL-23p19 inhibitors in real-world patients by analysing data from the Psoriasis Registry Austria (PsoRA) in this observational, retrospective, multicentre cohort study. Data for 197 patients (52.3% biologic-non-naïve), who were treated with anti-IL-23p19 antibodies (127 guselkumab, 55 risankizumab and 15 tildrakizumab) for at least 3 months, were eligible for analysis. In general, biologic-non-naïve patients displayed a less favourable response to anti-IL-23 treatment as compared to biologic-naïve patients. However, after correction for previous biologic exposure, few differences in PASI improvement were detected among biologic-naïve and -non-naïve patients treated with different IL-23p19 inhibitors. This indicates that treatment effectiveness is not related to the class of the previously administered therapy in biologic-non-naïve patients. Therefore, IL-23p19 inhibitors represent a promising treatment alternative for patients who have not responded to previous biologics. However, as with other biologic agents (including IL-17 inhibitors), we did not observe an entirely satisfactory treatment response (i.e. PASI < 3 and/or PASI 75) to anti-IL-23 treatment in one out of four to five patients. Adverse events (mainly non-severe infections) were observed in 23 (11.7%) patients with no major differences regarding the administered IL-23 inhibitor or previous biologic exposure.

Biologic drug survival rates in the era of anti-interleukin-17 antibodies: a time-period-adjusted registry analysis

Background

Drug survival rates reflect efficacy and safety and may be influenced by the availability of alternative treatment options. Little is known about time‐dependent drug survival in psoriasis and the effect of increasing numbers of biologic treatment options.

Objectives

To determine whether drug survival is influenced by the availability of treatment options and by factors such as gender, psoriatic arthritis or previous biologic treatment.

Methods

This observational, retrospective, multicentre cohort study analysed data from patients registered in the Austrian Psoriasis Registry (PsoRA) who were treated with biologics between 1 January 2015 and 30 November 2019.

Results

A total of 1572 patients who received 1848 treatment cycles were included in this analysis. The highest long‐term Psoriasis Area and Severity Index improvement was observed after treatment with ixekizumab, followed by ustekinumab and secukinumab, adalimumab and etanercept. Overall, ustekinumab surpassed all other biologics in drug survival up to 48 months. However, when adjusted for biologic naïvety, its superiority vanished and drug survival rates were similar for ixekizumab (91·6%), secukinumab (90·2%) and ustekinumab (92·8%), all of them superior to adalimumab (76·5%) and etanercept (71·9%) at 12 months and beyond. Besides biologic non‐naïvety (2·10, P < 0·001), the introduction of a new drug such as secukinumab or ixekizumab (relative hazard ratio 1·6, P = 0·001) and female gender (1·50, P = 0·019) increased the risk of treatment discontinuation overall, whereas psoriatic arthritis did not (1·12, P = 0·21).

Conclusions

The time‐dependent availability of drugs should be considered when analysing and comparing drug survival. Previous biologic exposure significantly influences drug survival. Women are more likely to stop treatment.

What is already known about this topic?

Female gender and previous biologic exposure have been discussed as predictors for decreased drug survival in patients with psoriasis, but it remains unknown whether a time‐dependent increased availability of treatment options alters biologic drug survival.

What does this study add?

The increased availability of alternative biologic treatments over time leads to an elevated risk for treatment discontinuation overall; therefore, drug survival analysis has to be time adjusted.

Moreover, the study reveals that the impact of previous biologic treatment on drug survival is tremendous and confirms worse drug survival in female patients.

Linked Comment: Gniadecki. Br J Dermatol 2021; 184:996–997.

Low-threshold SARS-CoV-2 testing facility for hospital staff: Prevention of COVID-19 outbreaks?

BACKGROUND

The ongoing global SARS-CoV-2 pandemic has caused over 4.7 million infections greatly challenging healthcare workers (HCW) and medical institutions worldwide. The SARS-CoV-2 pandemic has shown to significantly impact mental and physical health of HCW. Thus, implementation of testing facilities supporting HCW are urgently needed.

METHODS

A low-threshold SARS-CoV-2 testing facility was introduced at the University Hospital Bonn, Germany, in March 2020. Irrespective of clinical symptoms employees were offered a voluntary and free SARS-CoV-2 test. Furthermore, employees returning from SARS-CoV-2 risk regions and employees after risk contact with SARS-CoV-2 infected patients or employees were tested for SARS-CoV-2 infection. Pharyngeal swabs were taken and reverse transcription polymerase chain reaction for detection of SARS-CoV-2 was performed, test results being available within 24 h. Profession, symptoms and reason for SARS-CoV-2 testing of employees were recorded.

RESULTS

Between 9th March and April 30, 2020, a total of 1510 employees were tested for SARS-CoV-2 infection. 1185 employees took advantage of the low-threshold testing facility. One percent (n = 11) were tested positive for SARS-CoV-2 infection, 18% being asymptomatic, 36% showing mild and 36% moderate/severe symptoms (missing 10%). Furthermore, of 56 employees returning from SARS-CoV-2 risk regions, 18% (10/56) were tested SARS-CoV-2 positive. After risk contact tracking by the hospital hygiene 6 patient-to-employee transmissions were identified in 163 employees with contact to 55 SARS-CoV-2 positive patients.

CONCLUSION

In the absence of easily accessible public SARS-CoV-2 testing facilities low-threshold SARS-CoV-2 testing facilities in hospitals with rapid testing resources help to identify SARS-CoV-2 infected employees with absent or mild symptoms, thus stopping the spread of infection in vulnerable hospital environments. High levels of professional infection prevention training and implementation of specialized wards as well as a perfectly working hospital hygiene network identifying and tracking risk contacts are of great importance in a pandemic setting.

Modified QuEChERS extraction for the analysis of young-of-year smallmouth bass using GC × GC-TOFMS

Signs of disease, such as external lesions, have been prevalent in smallmouth bass throughout the Susquehanna River Basin, USA. Previous targeted chemical studies in this system have identified known persistent organic pollutants, but a common explanatory link across multiple affected sites remains undetermined. A fast and robust extraction method that can be applied to young-of-year fish is needed to effectively screen for target and non-target compounds that may be impacting organism health. The quick, easy, cheap, effective, rugged, and safe (QuEChERS) extraction methodology was optimized to perform both targeted and non-targeted chemical analyses from a single extraction of whole young-of-year fish. Comprehensive two-dimensional gas chromatography coupled with time-of-flight mass spectrometry (GC × GC-TOFMS) was used for extract analysis. Sample extraction was performed using the solvent ethyl acetate, followed by a two-step cleanup in which samples were frozen for lipid removal and subjected to dispersive solid phase extraction using Florisil. A sample of 21 young-of-year smallmouth bass collected from areas with disease and exhibiting different types of external lesions were evaluated for 233 target compounds. A total of 34 organic contaminants, including polychlorinated biphenyls, brominated diphenyl ethers, organochlorinated pesticides, and personal care products, were detected. Data from this sample set was then analyzed for non-targets. Using the Fisher ratio method and multivariate analysis, an additional 10 significant features were identified specific to either fish with visible lesions or with no visible disease characteristics.

AB1303-HPR TIME UNTIL DIAGNOSIS IN RHEUMATOLOGICAL PRACTICE: RESULTS FROM A CROSS-SECTIONAL MIDDLE-EUROPEAN COHORT COMPARED TO DATA FROM A SYSTEMATIC LITERATURE REVIEW

Background:

The time from first symptom to diagnosis (= diagnostic delay) is considered as key factor for better outcome in many chronic inflammatory rheumatic diseases, especially for rheumatoid arthritis (RA) and vasculitides like giant cell arteritis (GCA). A longer diagnostic delay may cause pain, reduced functionality, reduced life-quality and increased morbidity, as well as structural damages of the organs linked with higher mortality. This retrospective study assessed the diagnostic delay in consecutive Middle-European outpatients and compared results with those of a systematic literature review (SLR).

Objectives:

To compare disease-specific diagnostic delays of consecutive rheumatic patients with international data from a systematic literature review.

Methods:

Charts of a single-centre cohort with consecutively recruited patients were retrospectively reviewed for patients’ and diseases’ characteristics at a Middle-European university outpatient clinic for rheumatology. A SLR was performed according to PRISMA guidelines.

Results:

The average mean ± SD time from first symptom to established diagnosis was 7.9 ± 11.7 (0.02-56.7) years. Spondyloarthritis patients showed the longest diagnostic delay with 13.1 ± 14.2 (0.1-56.7) years, whereas polymyalgia rheumatica-patients had the shortest diagnostic delay with 1.5 ± 0.4 (0.3-18.0) months. In the SLR, most data for diagnostic delays are comparable to the Innsbruck cohort, but the diagnostic delay for psoriatic arthritis in Innsbruck is longer than in the Danish DANBIO registry (p<0.001). Independent risk factors for prolonged diagnostic delays could not be identified.

Conclusion:

For this Middle-European area, initiatives are justified especially to shorten diagnostic delays of SpA and PsA.

References:

[1]O’Dell JR. Treating rheumatoid arthritis early: A window of opportunity? Arthritis Rheum. 2002;46:283–5.

[2]Seo MR, Baek HL, Yoon HH, Ryu HJ, Choi HJ, Baek HJ, et al. Delayed diagnosis is linked to worse outcomes and unfavourable treatment responses in patients with axial spondyloarthritis. Clin Rheumatol. 2015;34:1397–405.

[3]Diagnostic delay of more than 6 months contributes to poor radiographic and functional outcome in psoriatic arthritis. Ann Rheum Dis. 2015;74:1045–50.

[4]Dejaco C, Brouwer E, Mason JC, Buttgereit F, Matteson EL, Dasgupta B. Giant cell arteritis and polymyalgia rheumatica: current challenges and opportunities. Nat Rev Rheumatol. Nature Publishing Group; 2017;13:578–92.

Acknowledgments:

We acknowledge and thank all patients who could be recruited to the SolutionX project. Ethical vote was obtained by the local ethics committee of the Medical University of Innsbruck (AN2017-0041 370/4.18).

Disclosure of Interests:

Rick Mc-Cutchan: None declared, Sarah Maier: None declared, Valentin Winkler: None declared, Bernhard Gruber: None declared, Michael Schirmer Grant/research support from: total <3000.- €, Speakers bureau: total <3000.- €

Evaluation and application of gas chromatography - vacuum ultraviolet spectroscopy for drug- and explosive precursors and examination of non-negative matrix factorization for deconvolution

Since the introduction of a benchtop vacuum ultraviolet (VUV) absorption spectroscope with an increased wavelength range towards to the high energetic ultraviolet radiation, gas chromatography coupled to VUV has been proven a powerful tool in several fields of application such as petroleomics, permanent gas analytic, pesticide analytic and many more. In this study, the potential of GC-VUV for investigations was examined, focusing on drug- and explosive precursors as well as chemical warfare simulants. The ability of VUV absorption spectra to differentiate isomers is presented, among others for nitroaromatics. In addition, the limit of detection for target compounds was determined to 0.7 ng absolute on column. Furthermore, non-negative matrix factorization (NMF) was successfully implemented as alternative deconvolution approach and evaluated for the deconvolution of unknown substances. In comparison, the spectral library-based deconvolution was applied to a standard mixture and a simulated case study. The results reveal that the NMF is a useful additional tool for deconvolution because, unlike library-based deconvolution, it allows to investigate unknown substances as well.

Vacuum ultraviolet absorption spectroscopy in combination with comprehensive two-dimensional gas chromatography for the monitoring of volatile organic compounds in breath gas: A feasibility study

Vacuum ultraviolet (VUV) absorption spectroscopy was recently introduced as a new detection system for one, as well as comprehensive two-dimensional gas chromatography (GC×GC) and successfully applied to the analysis of various analytes in several matrices. In this study, its suitability for the analysis of breath metabolites was investigated and the impact of a finite volume of the absorption cell and makeup gas pressure was evaluated for volatile analytes in terms of sensitivity and chromatographic resolution. A commercial available VUV absorption spectrometer was coupled to GC×GC and applied to the analysis of highly polar volatile organic compounds (VOCs). Breath gas samples were acquired by needle trap micro extraction (NTME) during a glucose challenge and analysed by the applied technique. Regarding qualitative and quantitative information, the VGA-100 is compatible with common GC×GC detection systems like FID and even TOFMS. Average peak widths of 300ms and LODs in the lower ng range were achieved using GC×GC-VUV. Especially small oxygenated breath metabolites show intense and characteristic absorption patterns in the VUV region. Challenge responsive VOCs could be identified and monitored during a glucose challenge. The new VUV detection technology might especially be of benefit for applications in clinical research.

A novel flow-based assay reveals discrepancies in ADAMTS-13 inhibitor assessment as compared with a conventional clinical static assay

BACKGROUND

Several static Bethesda-type assays are routinely used to determine ADAMTS-13-neutralizing autoantibodies in acquired thrombotic thrombocytopenic purpura (TTP), but the inhibitory activity of these antibodies has not been thoroughly evaluated under the more physiologic condition of flow.

OBJECTIVES

We investigated whether ADAMTS-13 inhibitor assessment with the FRETS-VWF73 assay is predictive for evaluation under flow.

METHODS

Anti-ADAMTS-13 autoantibodies were purified from patients with acquired TTP by chromatography involving an ADAMTS-13 affinity matrix and/or protein G. ADAMTS-13 activity was measured with the FRETS-VWF73 assay and a novel flow assay determining the ADAMTS-13-mediated decrease in platelet aggregate surface coverage, caused by perfusion of a suspension containing platelets, erythrocytes and von Willebrand factor (VWF) over a surface coated with extracellular matrix components. The neutralizing activities of ADAMTS-13 inhibitors were compared under static conditions and under flow by use of the two assays.

RESULTS

The suitability of the flow-based ADAMTS-13 activity assay for quantification of ADAMTS-13 inhibitors could be demonstrated by reversibility of the ADAMTS-13-dependent decrease in surface coverage upon addition of goat ADAMTS-13 antiserum. Testing the neutralizing activity of purified autoantibodies from six patients in the flow assay according to their FRETS-VWF73-based inhibitor titers gave rise to vastly different inhibitory effects, indicating a discrepancy in inhibitor assessment between static and flow conditions.

CONCLUSIONS

Anti-ADAMTS-13 autoantibodies may show inhibitory properties in vivo that are not consistent with the ADAMTS-13 inhibitor levels determined in routine static assays, possibly because certain epitopes are selectively exposed under shear. Consequently, the course of disease and treatment efficacy may vary among TTP patients, despite common inhibitor titers.

Metal mobilization from soils by phytosiderophores - experiment and equilibrium modeling

AIMS

To test if multi-surface models can provide a soil-specific prediction of metal mobilization by phytosiderophores (PS) based on the characteristics of individual soils.

METHODS

Mechanistic multi-surface chemical equilibrium modeling was applied for obtaining soil-specific predictions of metal and PS speciation upon interaction of the PS 2'-deoxymugineic acid (DMA) with 6 soils differing in availability of Fe and other metals. Results from multi-surface modeling were compared with empirical data from soil interaction experiments.

RESULTS

For soils in which equilibrium was reached during the interaction experiment, multi-surface models could well predict PS equilibrium speciation. However, in uncontaminated calcareous soils, equilibrium was not reached within a week, and experimental and modeled DMA speciation differed considerably. In soils with circum-neutral pH, on which Fe deficiency is likely to occur, no substantial Fe mobilization by DMA was predicted. However, in all but the contaminated soils, Fe mobilization by DMA was observed experimentally. Cu and Ni were the quantitatively most important metals competing with Fe for complexation and mobilization by DMA.

CONCLUSION

Thermodynamics are unable to explain the role of PS as Fe carrier in calcareous soils, and the kinetic aspects of metal mobilization by PS need to be closer examined in order to understand the mechanisms underlying strategy II Fe acquisition.

Blastomycosis of the skull base

Blastomycosis is usually considered a pulmonary or cutaneous disease. A patient with blastomycosis of the infratemporal fossa temporal bone and sinuses without pulmonary disease is presented. Extensive skull base involvement required surgical debridement for relief of pain, and long-term systemic antifungal therapy. The literature is reviewed and discussed.

Malignant vestibular schwannoma

A 61-year-old woman underwent a translabyrinthine resection of a right intracanulicular acoustic neuroma, which had been detected in the work-up of sudden hearing loss. At the time of surgery, the tumor was roughly twice as large as indicated by the magnetic resonance scan taken only 2 months previously. The tumor eroded the vertical and transverse crests and extended well into the cerebellopontine angle. It was impossible to distinguish the facial nerve proximal to the geniculate ganglion. All visible tumor was resected, along with the facial nerve. Histological evaluation showed a highly cellular tumor, with many mitoses and areas of necrosis, meeting the criteria for malignant schwannoma. The patient has no stigmata of neurofibromatosis, and has no known relatives with that condition. This case is only the fourth reported of a malignant vestibular schwannoma. The relationships between vestibular schwannoma, neurofibromatosis, and malignancy are discussed.

Sevelamer decreases systemic inflammation in parallel to a reduction in endotoxemia

INTRODUCTION

Uremic toxins play a pivotal role in the development of systemic complications of chronic kidney disease (CKD), which are largely mediated by the activation of the immune system. Triggers of inflammation in CKD are largely unknown and strategies aiming to reduce circulating ligands that could start the inflammatory response are potentially important. In the present study, we investigated the impact of sevelamer hydrochloride treatment in reducing endotoxemia and inflammation in a group of hemodialysis (HD) patients.

MATERIAL AND METHODS

HD patients, who were converted from calcium carbonate treatment to sevelamer according to KDOQI guidelines, were included and prospectively followed for 6 months. Systemic inflammation was evaluated by serum ultra-high-sensitivity C-reactive protein (hsCRP) using an automated immunoturbidimetric assay. Endotoxin was measured using Limulus amebocyte lysate chromogenic endpoint assay. All the analyses were performed immediately before conversion and after 6 months of treatment.

RESULTS

After the exclusion of patients discontinuing the treatment, 20 patients (mean dialysis time 12 +/- 4 months on HD, age 52 +/- 2 years, 38% males, 11% diabetics) were included in the analysis. No significant changes were observed in Ca, P and PTH levels, while a reduction in cholesterol levels was seen. Plasma concentration of hsCRP and endotoxin significantly decreased after 6 months of conversion to sevelamer compared with baseline.

CONCLUSION

We conclude that sevelamer treatment leads to a decrease in hsCRP levels, which was accompanied by a parallel decrease in endotoxemia, suggesting that endotoxemia may contribute to the systemic inflammation in HD patients, which was partially reduced by the use of sevelamer.

On a minimum tetrahedron in a three-dimensional lattice. Part I. Lattices with a shortest basis fulfilling b x c > or = 0, a x c > or = 0, a x b > or = 0

The problem of a representative body of a three-dimensional lattice is considered. The cell fulfilling a + b + c = min is clearly not unique: even five mutually non-congruent such cells can exist in some lattices [Gruber (1973). Acta Cryst. A29, 433-440]. The idea that this number could be reduced by replacing the cell (i.e. a parallelepiped) by another, possibly more suitable, geometrical object is considered. For this object a lattice tetrahedron fulfilling the condition a + b + c + d + e + f = min is chosen, a to f being the lengths of its edges. It is called the minitetrahedron of the lattice. In this article, the problem is solved in detail for lattices that can be generated by a basis a, b, c fulfilling |a| + |b| + |c| = min, b x c > or = 0, a x c > or = 0, a x b > or = 0. It turns out that in this case not more than two mutually non-congruent minitetrahedra can exist. Necessary and sufficient conditions for the uniqueness are found. They have the form of inequalities between the lengths of the edges and diagonals of the parallelepiped formed by the vectors a, b, c. A procedure for determining all minitetrahedra of a given lattice is shown. Some results are illustrated graphically and all assertions are proved mathematically.

[Importance of the rearing period for laying hens in alternative systems]

Feather pecking and cannibalism are still major problems in alternative systems for laying hens. Literature and practical experience indicate that unfavourable rearing conditions might be important risk factors for the occurrence of these behavioural disturbances during the laying period. Typical rearing conditions of laying hens from 50 rearing units in Germany and Austria are presented. Obvious risk factors during rearing for feather pecking and cannibalism during the laying period were found. Most flocks were kept under high stocking density (mean: 15 pullets per m' useable area) and some flocks had access to litter only after the second week of life or access to raised perches after the fourth week of life. Plumage condition of pullets and laying hens varied widely in non-beak-trimmed as well as in beak-trimmed flocks. The percentage of pullets with damaged plumage was higher in beak-trimmed than in non-beak-trimmed flocks (medians: 53 % versus 30 %, p = 0,022). In laying hens there was a higher percentage of hens with plumage damage in non-beak-trimmed flocks compared to beak-trimmed flocks (medians: 23 % versus 50 %, p = 0,007). Data analysis will be continued, especially with regard to particular risk factors.

Homocysteine but not neopterin declines in demented patients on B vitamins

Inflammation and immune system activation seem to play an important role in the development and progression of dementia. Hyperhomocysteinemia is common in various forms of dementia, and a significant relationship was found between concentrations of homocysteine and immune activation marker neopterin. B vitamin supplementation is able to slow-down homocysteine formation in patients. In an open-label study, effects of B vitamin supplementation (Beneuran compositum ) on concentrations of homocysteine and neopterin were investigated in 58 patients with Alzheimer's disease (n=30), vascular dementia (n=12) and mild cognitive impairment (n=16). In all groups of patients, a significant percentage of patients presented with homocysteine concentrations >15 micromol/L and with elevated concentrations of immune activation marker neopterin. Decline of homocysteine concentrations was observed after one month of B vitamin supplementation (all p<0.01; paired Kruskal-Wallisn-test). By contrast, neopterin concentrations remained unchanged (all p>0.05). B vitamin supplementation in patients with various forms of dementia did not influence neopterin concentrations, which indicates that the degree of immune activation and inflammation remained unchanged. The question remains, if lowering of homocysteine by folate supplementation alone could have any beneficial effect to modulate the course of dementia development and if longer period of supplementation would also ameliorate immune system activation status.

[Intrapulmonary tumor cell embolism from cancer of the bladder as the cause of a subacute cor pulmonale]

HISTORY AND CLINICAL FINDINGS

A 61-year-old man had over 3 weeks experienced increasing dyspnoea on effort and loss of appetite. He reported previous chronic pain with a "stiffened hip" treated long-term with diclofenac, and three transurethral surgical interventions. It was only at the latest admission that bladder cancer (first diagnosed 2 years previously) became known as the reason for the interventions. On admission pallor, sinus tachycardia, fever of 38 degrees C and dyspnoea on light exertion were noted, but blood pressure was normal.

INVESTIGATIONS

Chest X-ray was normal, but the patient had marked respiratory insufficiency (pO2 30.8 mmHg, pCO2 31.6 mmHg) on room air. Echocardiography showed a dilated right ventricle with paradoxical septal movement. There was no evidence of thrombosis in the leg veins on ultrasound. D-dimers were normal.

DIAGNOSIS, TREATMENT AND COURSE

Pulmonary artery embolism of unknown origin was suspected. Despite anticoagulation with low-molecular heparin the patient's condition deteriorated. Spiral computed tomography of the thorax did not show thrombi in the pulmonary arterial vessels. Perfusion scintigraphy demonstrated definite perfusion deficits bilaterally in the upper lobes of the lung, consistent with pulmonary embolism. As his condition gradually worsened rt-PA was started to achieve fibrinolysis, but failed to produce any change in haemodynamic and respiratory functions. He died a few hours later. Microscopic examination at autopsy revealed multiple tumour emboli with intimal fibrosis in the peripheral arteries. A poorly differentiated urothelial carcinoma of the bladder with extensive infiltration of blood vessels was found (carcinomatous haemangiosis).

CONCLUSION

A malignant tumour with micro-embolization of tumour cells should be considered as a possible diagnosis when the clinical picture indicates pulmonary embolism of unknown genesis.

The study on adriamycin induced DNA scissions in human cells with different activity of some antioxidant enzymes

Although the anthracycline antibiotic adriamycin has been widely used in treatment of variety of human malignances, the mechanism of its biological activity is still unknown. One of the proposed mechanisms of action assumes the generation of active oxygen species which may damage DNA of cells. In this study we investigated if the occurrence of DNA breaks induced by adriamycin depends on the intracellular level of antioxidant enzymes. The study was performed with two human cell lines (CRL2088 and CLV102) differing in activity of catalase and superoxide dismutase. The results indicated that the level of DNA breaks in both lines treated with adriamycin was similar despite of differences in the enzymes activity.

Mutational analysis of the tumor suppressor Smad2 in acute lymphoid and myeloid leukemia

Smad4 is a tumor suppressor that is inactivated in about 50% of pancreatic carcinomas. Mutations in this gene have also been found with variable, yet much lower frequency in other tumor types and were absent from a large number of samples from patients with hematological malignancies. Smad2 shows considerable sequence similarity with Smad4 and cooperates with it in the growth inhibitory TGF-beta pathway. Smad2 mutations have been found in a fraction of colon carcinomas and have been shown to impair the function of the corresponding proteins. However, only a few other tumor types have been screened for Smad2 mutations so far. Therefore, we analyzed 50 primary tumor samples from patients with acute lymphoid or myeloid leukemia (ALL or AML) and five cell lines of hematopoietic origin for alterations in the Smad2 gene. None of the specimens tested carried mutations in the conserved MH1 or MH2 domains of Smad2.

Sarcoidosis of the external nose mimicking rhinophyma. Case report and review of the literature

A 52-year-old man with a large external nasal mass is presented. Initially, the mass was thought to be rhinophyma, but biopsy of the mass revealed noncaseating granulomata consistent with sarcoidosis. The mass resolved following several steroid injections. The case is discussed in detail, along with a review of the literature pertaining to sarcoidosis of the nose and nasal cavity.

Oral iloprost treatment in patients with Raynaud's phenomenon secondary to systemic sclerosis: a multicenter, placebo-controlled, double-blind study

OBJECTIVE

To evaluate the efficacy and tolerability of an oral preparation of iloprost, a prostacyclin analog, in patients with Raynaud's phenomenon (RP) secondary to systemic sclerosis (scleroderma).

METHODS

A multicenter, randomized, parallel-group, placebo-controlled double-blind study was performed at university and community-based medical centers. Patients were randomly assigned to receive either 50 microg of iloprost orally twice daily or an identical gelatin-coated capsule containing placebo for 6 weeks. Outcome measures included average total daily duration of RP attacks, average number of RP attacks, and RP condition scored via a standardized daily diary.

RESULTS

Three hundred eight patients with scleroderma (272 women, 36 men, mean age 49 years [range 18-80]) were enrolled. One hundred fifty seven were assigned to receive iloprost and 151 to receive placebo. One hundred forty-three patients in the iloprost group (91.1%) and 144 in the placebo group (95.4%) completed the 6-week treatment phase. Fifteen of these treated patients (8 iloprost, 7 placebo) failed to complete all of the followup visits. The mean reduction in the average duration of attacks from baseline to week 5-6 was 24.32 minutes in the iloprost group and 34.34 minutes in the placebo group (P = 0.569). Likewise, the mean reduction from baseline to week 5-6 in the daily frequency of attacks was 1.02 in the iloprost group and 0.83 in the placebo group (P = 0.459). The Raynaud's condition score, a patient-completed assessment of the severity of RP attacks, was reduced by 1.32 in the iloprost group and 1.00 in the placebo group (P = 0.323). The lack of significant difference between treatment groups did not change when a variety of factors, including use of other vasodilators, duration of disease, classification of scleroderma (limited versus diffuse), or number of baseline digital ulcers were taken into account. Premature withdrawal from the study due to adverse events occurred in 10 patients (6.4%) in the iloprost group and 3 (2.0%) in the placebo group (P = 0.058).

CONCLUSION

Oral iloprost at a dosage of 50 microg twice daily is no better than placebo for management of RP secondary to scleroderma, either during 6 weeks of treatment or during 6 weeks of posttreatment followup.

Induction of arachidonic acid metabolite release by human fibroblasts in proliferative vitreoretinopathy

Proliferative vitreoretinopathy is a severe ocular disorder characterized by unwanted proliferation of cells and excessive production of fibrous tissue, which leads to the formation of cellular membranes on the surface of the retina and in the vitreous. Proliferative vitreoretinopathy is the most common cause of failure in retinal reattachment surgery, approximately occurring in one out of ten operated eyes. Proliferation of retinal pigment epithelial cells and fibroblasts is a cornerstone in the pathogenesis of proliferative vitreoretinopathy. An in vitro-proliferation assay showed previously that intraocular fluid from patients with proliferative vitreoretinopathy is potently effective in stimulating proliferation of human fibroblasts. Here we show that exposure of human fibroblasts to vitreous fluids from patients with proliferative vitreoretinopathy causes a rapid and sustained increase in arachidonic acid metabolite release as measured by competitive enzyme-immunoassay. The findings implicate prostaglandin E2 as a contributor to enhanced intraocular fibrosis in proliferative vitreoretinopathy. As prostaglandin E2 is a mediator of continuous aqueous-blood retinal barrier breakdown in this severe disease, cycclooxygenase inhibitors such as acetylsalicylic acid, which was successfully used in this study for blocking the effect of intraocular fluid, may be useful agents in targeting the progression of intraocular fibrosis.

The in vitro study on genotoxic activity of adriamycin and bleomycin in cells of mice with different catalase and superoxide dismutase activity

Genotoxic activity of adriamycin and bleomycin in embryo cells from mice differing in anti-oxidant enzymes activity was investigated. The catalase activity in cultured in vitro embryo cells of C3H mice was 2.3-fold and superoxide dismutase 2.5-fold higher than of C57BL/10 mice. For genotoxicity evaluation, the micronucleus test in vitro was used. The results obtained indicated that the frequency of micronucleated cells in untreated C3H cultures was higher than in C57BL/10 cell cultures. The increase in micronuclei formation after treatment with adriamycin and bleomycin was higher in C57BL/10 than in C3H cells as compared with micronuclei in untreated cultures. The higher frequency of micronucleated cells in treated versus untreated C57BL/10 than C3H cell cultures may be caused by lower activity of anti-oxidant enzymes in C57BL/10 cells. It may suggest that DNA damage caused by adriamycin and bleomycin resulted from action of active oxygen species.

Among genes involved in the RB dependent cell cycle regulatory cascade, the p16 tumor suppressor gene is frequently lost in the Ewing family of tumors

The pRB cell cycle regulatory cascade is frequently perturbed in neoplasia by overexpression of a component of the pRB-phosphorylating cyclin D1/CDK4 complex or by inactivation of pRB or the CDK4 inhibitors p16 and p15. We investigated the status and expression of p16, p15, CCND1, CDK4 and RB genes in the Ewing family of tumors. P16 loss was observed in 8 of 27 tumors (30%) and in 12 of 23 (52%) tumor cell lines from unrelated patients. There were no discrepancies in the p16 status between primary tumors and the corresponding cell lines and between cell lines established from consecutive tumor samples. p15 was codeleted in most cases but p15 mRNA was absent also in cell lines retaining the gene. In addition, posttranscriptional p16 inactivation was observed in two cases. Although no evidence for CDK4 or CCND1 amplification was obtained, expression of these genes varied considerably in the cell lines in a case specific manner. In wild-type p16 cell lines, pRB expression was lost in one case. Our data indicate that, despite the absence of cytogenetically detectable 9p21 chromosomal aberrations, p16 deletions constitute the most frequent secondary molecular aberration in Ewing tumors so far. These results are discussed in the context of the stage of disease and the clinical outcome of the patients. The potential prognostic impact of these findings remains to be further evaluated.

Effect of sex and age on bone mass, body composition and fuel metabolism in humans

The mechanism(s) governing the gain of upper-body fat and its relationship to the decrease in bone mass with age is still unclear. Therefore, four groups of subjects matched for weight, height, and body mass index (n = 119; 60 women, 59 men), but differing in age (above and below 50 y) and sex were investigated using dual energy x-ray absorptiometry (DXA) to assess body composition (bone, lean, and fat mass as well as its distribution) and indirect calorimetry to determine resting fuel metabolism. Fat mass of trunk and arms (P < 0.01), but not legs, increased with advancing age in males, resulting in a continuous increase in the ratio of upper- to lower-body fat (r = 0.45, P < 0.001). In contrast, total fat mass remained stable in women, irrespective of menopause, but a redistribution of fat occurred with advancing age (r = 0.43, P < 0.001), resulting in a higher upper- to lower-body fat ratio (P < 0.05) in older than in younger women. Total lean soft-tissue mass of all segments of the body was greater in men than in women irrespective of age (P < 0.001), and lower in the older groups than in the younger ones irrespective of sex. In males, but not females, lean soft-tissue mass in arms and legs decreased (r = 0.57, P < 0.001), whereas the ratio of total fat to lean soft-tissue mass increased (r = 0.53, P < 0.001) with age. Bone mineral content correlated with total body fat in both groups of women and in young males (r > 0.5, P < 0.001), but not in older males. With advancing age, the proportion of lean soft-tissue mass occupied by total skeleton declined in women (n = 59, P < 0.001), but remained stable in males. Resting energy expenditure decreased with age in both sexes. Protein and carbohydrate oxidation were similar in all four groups of subjects. Total fat oxidation and fat oxidation per kilogram of lean soft-tissue mass decreased with age (r > 0.36, P < 0.01) in males, but not in females, whereas it increased with increasing fat mass in females (r > 0.32, P < 0.03), but not in males. In contrast, fat oxidation per kilogram of fat mass decreased with fat mass in males (r = 0.61, P < 0.001), but not in females. Our results suggest that aging affects body composition and fuel metabolism differently in each gender, leading to reduced fat oxidation and accumulation of upper-body fat with loss of striated muscle in men, and to an increased ratio of upper- to lower-body fat and bone loss in women, the latter depending on fat mass.

Staurosporine-dependent activation of human endothelial cell monolayers for neutrophil adherence by secretoneurin

Functions of secretoneurin include chemotaxis for monocytes and endothelial cells, and inhibition of endothelial cell proliferation. Inhibition of monocyte chemotaxis by staurosporine indicated involvement of specific signaling mechanisms. We have tested effects of kinase inhibitors on activation of endothelial cells for neutrophil adherence by secretoneurin. Pretreatment of endothelial cells by secretoneurin induced in endothelium increased adhesiveness to neutrophils. Addition of staurosporine, an inhibitor of protein kinase C, completely abolished endothelial cell activation, whereas tyrphostin-23, a tyrosin kinase inhibitor, had no effect. Results on activation of neutrophil-endothelial cell adherence by secretoneurin demonstrate that specific signaling mechanisms are involved in endothelial cell activation.

Stimulation of human skin fibroblast migration by the neuropeptide secretoneurin

Fibroblasts, besides other cells, are called upon when tissue sustains an immunological, mechanical or chemical injury. Fibroblasts migrate into the site of inflammation, proliferate and synthesize and remodel a new matrix. These cellular responses are mediated locally by the release of neuropeptides from sensory nerve endings. Secretoneurin is a newly discovered 33-amino acid neuropeptide derived from secretogranin II (chromogranin C), which is found in sensory afferent C-fibers. We show here that secretoneurin triggers the selective migration of human skin fibroblasts in vitro, but does not stimulate their proliferation. The attraction of human skin fibroblasts toward secretoneurin could be blocked by specific anti-secretoneurin antibodies and is mediated by the C-terminal fragment of the peptide. The observed activity of this sensory neuropeptide is the first description of a specific effect on human skin fibroblasts and suggests a role for secretoneurin in inflammation and wound healing.

Mobilization of tumour cells during biopsy in an infant with Ewing sarcoma

Ewing sarcoma and the closely related peripheral primitive neuroectodermal tumour, recently referred to as Ewing tumour (ET), are characterised by unique gene rearrangements on chromosome 22. The breakpoints have been cloned and shown to fuse the Ewing sarcoma gene to one of two closely related ETS proto-oncogens, FLI-1 or ERG, which reside on chromosomes 11 and 21, respectively. The rearrangement results in the expression of specific hybrid transcripts which can be detected with high sensitivity by the reverse transcriptase polymerase chain reaction technique (RT-PCR) in primary tumours, blood and bone marrow. We report on a 7-month-old boy with a pelvic Ewing sarcoma in whom circulating tumour cells were identified in the peripheral blood during open tumour biopsy by RT-PCR. However, before and 6 days after surgery no tumour cells could be detected in the peripheral blood.

CONCLUSION

The application of RT-PCR to monitor shedding of tumour cells during surgical intervention will help to evaluate if open biopsy potentially contributes to metastatic tumour cell spread.

Total tracheobronchial thrombosis due to extracorporeal membrane oxygenation

Extracorporeal membrane oxygenation (ECMO) is widely used for neonatal respiratory failure that is potentially reversible but unresponsive to conventional management. Because of the anticoagulation necessary for maintaining the extracorporeal circuit, hemorrhagic complications occur in up to one third of patients. We present an unusual and previously unreported complication of ECMO, total tracheobronchial thrombosis. The thrombus filled the entire lower respiratory tract and resulted in airway obstruction and inability to ventilate. The airway was successfully managed with repeated bronchoscopic pulmonary toilet. Our experience and review of the literature provide a summary of ECMO-related complications likely to present to the otolaryngologist, and management strategies are discussed.