Application frequency - key indicator for the efficiency of severe dry eye disease treatment - evidence for the importance of molecular weight of hyaluronan in lubricating agents

PURPOSE

Lubricant eye drops are the main therapeutic resource for dry eye disease (DED), with each drop representing the equivalent of ocular surface disease treatment. Thus, any reduction in the frequency of eye drop application reflects a degree of therapeutic success. Considering also the socioeconomic burden of DED, we investigated eye drop application frequency (DF) as a parameter to potentially track the success of therapy in severe DED. Hyaluronan (HA)-containing eye drops have become the first choice for tear substitution in many countries, and recent data indicate that the average molecular weight (Mw) of HA determines the therapeutic efficacy of such eye drops. This post-hoc subgroup analysis of a previously published multicentre prospective randomized open-label study, HYLAN M, is set out to compare the effects of very high Mw HA (hylan A) eye drops to comparator eye drops, containing lower Mw HA (control).

METHODS

Patients with severe DED (n = 47), recruited as part of the larger HYLAN M prospective, multicentre, open-label study, were randomized into two groups: hylan A and control group. In the hylan A group, 24 patients replaced their HA-containing eye drops with eye drops containing 0.15% hylan A, whereas the 23 control patients continued to use comparator HA eye drops. The DF was recorded daily by all participants over 8 weeks, and other subjective and objective parameters of DED were assessed at the time of inclusion (baseline), as well as at week 4 and 8.

RESULTS

There was a significant decrease in DF in the hylan A users between the baseline and week 4 (p = 0.004), remaining stable until week 8. Indeed, in contrast to the baseline, the hylan A group had a significantly lower DF than the control group at weeks 4 (p = 0.018) and 8 (p = 0.008). Likewise, the ocular surface disease index (OSDI) improved significantly between the time of inclusion and week 4 (p < 0.001) in hylan A users, remaining stable until week 8. The OSDI was similar in both groups at the baseline but it was significantly lower in the hylan A group than in the control group at week 4 (p = 0.002), remaining lower at week 8. Such a decrease in the DF and OSDI was not witnessed in the control group at any time point. The objective parameters assessed did not differ significantly within or between the two groups.

CONCLUSION

When treating severe DED, the DF can be significantly reduced by using very high Mw HA (3 MDa) lubricant eye drops, which better alleviate DED symptoms and decrease the OSDI scores. These drops not only provide an attractive and comfortable alternative for patients with severe DED but also offer the possibility of reducing the disease's socioeconomic burden, both for affected individuals and society as a whole.

The systemic impact of different COVID-19 vaccines in 2-[18F] FDG-PET/CT

Austria started its COVID-19-vaccination program in December 2020 with three different vaccines. As the vaccination program continues, we encountered increased 2-[18F] FDG-activity not only in axillary lymph nodes ipsilateral to the injection site but also in other organs. The aim of this retrospective study is to present results of the metabolic activity of ipsilateral axillary lymph nodes, liver, blood pool, spleen, and bone marrow after three different vaccines. To our knowledge, this is the first study to examine systemic response changes in relation to time after COVID-19 vaccination using three different vaccines. The collected data of 220 eligible vaccinated patients (127 with BioNTech/Pfizer BNT162b2, 61 with Moderna, and 32 with AstraZeneca) examined with 2-[18F] FDG-PET/CT were enrolled. The PET/CT examinations were evaluated from day 1 to day 135 (SD: 23.2, median: 26) after different vaccinations. Seventy-one out of these 220 patients underwent a pre-vaccination 2-[18F] FDG -PET/CT. SUVmax of axillary node(s), and blood pool, liver, spleen, and bone marrow as reference organs were calculated. The ratio of SUVmax activity of axillary lymph node to reference organs was also compared in all patients. The tracer activity dynamics were investigated in three different vaccines. After BioNTech/Pfizer vaccination 2-[18F] FDG activity in axillary lymph nodes shows a steady decrease in all patients. Ten days after vaccination the 2-[18F] FDG uptake was at its highest activity. Seventy days after vaccination, tracer activity is not different from the background activity of 2-[18F] FDG in the axillary region. This result also applies to other two vaccines; however, in the 4th week after Moderna vaccination SUVmax in lymph nodes showed the highest peak of tracer activity. With AstraZeneca the highest activity was at the earlier days. There was no significant statistical difference of SUVmax of lymph nodes or its ratios to other reference organs between three groups of vaccines. SUVmax in lymph nodes was statistically significant lower than SUVmax in the liver, spleen, and bone marrow with p-values of < 0.001, 0.044, and 0.001, respectively. In the group of 71 patients with a pre-vaccination PET/CT examination, the median SUVmax of lymph nodes increased significantly after vaccination from 0.82 (IQR 0.59-1.38) to 1.80 (IQR 1.07-3.89)(p < 0.001). In contrast median tracer activity in the liver decreased from 3.37 (IQR 2.83-3.91) to 3.11 (2.56-3.70) (p = 0.032). There was no significant change of tracer activity after vaccination in other reference regions (mediastinum, spleen, and bone marrow). In this group of 71 patients, there was also no significant difference in tracer activity in different types of vaccines. Local site and ipsilateral axillary lymph node activity in 2-[18F] FDG PET/CT after COVID19-vaccination is suggested in many studies. The main challenge is recognizing the changes in lymph nodes during time after vaccination to minimize false interpretation, foremost in patients with oncological diagnoses. Moreover, different vaccines cause different system metabolic changes. The knowledge of vaccine type, the time interval between vaccination and PET/CT scan is essential, especially in therapy evaluation.

Periodontal disease and its association to endothelial dysfunction and clinical changes in limited systemic sclerosis: A case-control study

OBJECTIVES

Periodontal disease occurs frequently in patients with limited cutaneous systemic sclerosis (lcSSc) while data about underlying pathways contributing to periodontal changes are scarce. The aim of this study was to evaluate periodontal disease and to investigate its association with endothelial dysfunction and clinical changes in patients with lcSSc.

METHODS

In 38 lcSSc patients and 38 controls, periodontal status was evaluated by disease-specific questionnaire, dental examination including bleeding on probing (BOP), pocket depth, and plaque index, and dental panoramic radiograph. Periodontopathogen bacteria were collected subgingivally using paper points and interleukin-1 (IL-1) gene polymorphisms were evaluated using buccal swabs. Endothelial dysfunction was measured by flow-mediated dilatation, pulse-wave velocity and biochemical analysis, including arginine metabolites and endothelial microparticles. Additionally, lcSSc-specific clinical changes and parameters were recorded.

RESULTS

Periodontitis was present in 31 patients with lcSSc (81.6%) and in 27 controls (71.1%) (p = .280). LcSSc patients had a lower teeth number (p = .039) and Eikenella corrodens was to a higher degree detectable in patients with lcSSc (p = .041) while the remaining periodontal parameters revealed no differences between both cohorts. Significant correlations between parameters of arterial stiffness, EUSTAR index, number of teeth and BOP were observed (all p < .05). Detection of Prevotella intermedia was associated with selected IL-1 gene polymorphisms (p = .032) and Porphyromonas gingivalis was associated with severe periodontitis (p = .041).

CONCLUSION

Periodontal disease may occur frequently in patients with lcSSc and may be associated with arterial stiffness and with SSc activity.

POS1390 ULTRASOUND BASED WITHDRAWAL OF BIOLOGICS IN RHEUMATOID ARTHRITIS (RA-BioStop)

Background

Discontinuation of biological (b)DMARDs may be considered in rheumatoid arthritis (RA) patients in persistent clinical remission [1]. Some earlier studies reported that baseline ultrasound may predict successful tapering or withdrawal of bDMARDs, while others found that ultrasound had little additional value over clinical parameters alone [2-4]. The majority of these studies, however, were limited by small sample size, inadequate remission criteria and variable tapering regimens.

Objectives

To test the hypothesis whether ultrasound-verified subclinical inflammation might predict a relapse in RA patients in stringent clinical remission who discontinue bDMARDs.

Methods

Prospective, phase IV clinical trial including RA patients in persistent clinical remission according to the ACR/EULAR criteria treated with a combination of conventional synthetic (cs)DMARD plus bDMARDs. Upon stopping the bDMARD, 9 study visits were conducted within 52 weeks. At each visit, patients underwent clinical examination and ultrasound of 14 joints. The primary hypothesis was that a Power Doppler (PD) score >0 predicted a relapse until week 16 after bDMARD cessation. Relapse was defined as change from remission to moderate/high disease activity according to the simplified disease activity index.

Results

Although 110 patients were required by the protocol, inclusion had to be stopped after reaching 38 (34.5%) due to insufficient recruitment. There were 9, 10 and 13 relapses between baseline and weeks 16, 24 and 52, respectively. Relapses till week 16 tended to be more common in patients with PD score >0 at baseline than in those without [9/30 (30.0%) vs. 0/7 (0%), p=0.160)]. Similar observations were made for weeks 24 [9/30 (30.0%) vs. 1/7 (14.3%), p=0.647)] and 52 [12/30 (40.0%) vs. 1/7 (14.3%), p=0.383)]. Kaplan-Meier plot indicates the relapse-free survival in patients with and without PD+ synovitis at baseline (Figure 1).

Figure 1.

Kaplan-Meier analysis of relapses according to presence or absence of Power Doppler (PD) synovitis at baseline.

PD scores were higher at the time of relapse as compared to the preceding visits [mean difference in the PD score 3.2 (±4.5) points, p=0.034]. PD scores were also higher at visits preceding a relapse [mean 5.6 (±3.9), n=13] as compared to the mean PD score across all visits of patients without a relapse [mean 2.0 (±1.5), n=24, p=0.003, respectively]. There were trends towards a higher mean baseline PD score in patients who had a relapse between baseline and week 16 as compared to those who remained in remission (5.2 ± 5.8 vs. 2.3 ± 3.0, p=0.079). Similar observations were made for relapses until weeks 24 and 52. No difference was observed comparing mean residual swollen or tender joint counts at baseline between patients with and without a relapse. There were 9 adverse events. All of them were mild to moderate.

Conclusion

In RA patients in strict clinical remission, PD assessment at baseline but not clinical joint count could help identify patients who will relapse after the cessation of a bDMARD. Due to insufficient recruitment and limited power of the present trial, however, no definitive conclusion can be made.

References

[1]Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2019 update. Ann Rheum Dis 2020;79:685-99.

[2]Naredo E, Valor L, De la Torre I, et al. Predictive value of Doppler ultrasound-detected synovitis in relation to failed tapering of biologic therapy in patients with rheumatoid arthritis. Rheumatology (Oxford) 2015;54:1408–14.

[3]Lamers-Karnebeek FB, Luime JJ, Cate DFT, et al. Limited value for ultrasonography in predicting flare in rheumatoid arthritis patients with low disease activity stopping TNF inhibitors. Rheumatology (Oxford) 2017;56:1560–5.

[4]Terslev L, Brahe CH, Hetland ML, et al. Doppler ultrasound predicts successful discontinuation of biological DMARDs in rheumatoid arthritis patients in clinical remission. Rheumatology (Oxford) 2021;60:5549–59.

Acknowledgements

This study was funded by a grant of the Austrian Research Fund (KLI514-B30)

Disclosure of Interests

Christian Dejaco Speakers bureau: Pfizer, AbbVie, MSD, Roche, BMS, UCB, Consultant of: Pfizer, AbbVie, MSD, Roche, BMS, UCB, Grant/research support from: Pfizer, Irina Gessl: None declared, Rusmir Husic Speakers bureau: MSD, Lilly und Abbvie, Thomas Deimel: None declared, Angelika Lackner: None declared, Gabriela Supp: None declared, Josef Hermann Speakers bureau: Novartis, Lilly, AbbVie, Janssen, Consultant of: GlaxoSmithKline, Otsuka Pharmaceutical Europe Ltd, Josef S. Smolen Speakers bureau: AbbVie, Amgen, AstraZeneca, Astro, Bristol-Myers Squibb, Celgene, Celltrion, Chugai, Gilead, ILTOO, Janssen, Lilly, Merck Sharp & Dohme, Novartis- Sandoz, Pfizer, Roche, Samsung, Sanofi, and UCB, Consultant of: AbbVie, Amgen, AstraZeneca, Astro, Bristol-Myers Squibb, Celgene, Celltrion, Chugai, Gilead, ILTOO, Janssen, Lilly, Merck Sharp & Dohme, Novartis- Sandoz, Pfizer, Roche, Samsung, Sanofi, and UCB, Grant/research support from: Abbvie, AstraZeneca, Lilly and Roche, Martin Stradner Speakers bureau: Eli Lilly, Pfizer, MSD, BMS, AbbVie, Janssen, Consultant of: Eli Lilly, AbbVie, Janssen, Daniel Aletaha Speakers bureau: Abbvie, Amgen, Lilly, Janssen, Merck, Novartis, Pfizer, Roche, Sandoz, Consultant of: Abbvie, Amgen, Lilly, Janssen, Merck, Novartis, Pfizer, Roche, Sandoz, Grant/research support from: Abbvie, Amgen, Lilly, Novartis, Roche, SoBi, Sanofi, Gerold Schwantzer: None declared, Peter Mandl Speakers bureau: AbbVie, Janssen and Novartis, Grant/research support from: AbbVie, BMS, Novartis, Janssen, MSD and UCB

Evaluation of endothelial dysfunction and clinical events in patients with early-stage vasculopathy in limited systemic sclerosis

OBJECTIVES

Limited cutaneous systemic sclerosis (lcSSc) is characterised by vasculopathy contributing to vascular apoptosis, structural and functional changes. The aim of this study was to investigate parameters of endothelial dysfunction and their association to clinical events in lcSSc patients with early-stage vasculopathy.

METHODS

Patients with lcSSc and early-stage vasculopathy defined as absent pre-existing pulmonary arterial hypertension (PAH), digital ulcers, and symptomatic cardiovascular diseases were recruited together with age-, race- and sex-matched controls with primary Raynaud's phenomenon. All subjects underwent measurements of flow-mediated (FMD) and nitroglycerine-mediated dilation (NMD), pulse-wave analysis, and biochemical analysis, including arginine, homoarginine, citrulline, ornithine, asymmetric dimethylarginine (ADMA), symmetric dimethylarginine (SDMA), and endothelial microparticles (EMP). Clinical events, including EUSTAR index, sicca symptoms, microvascular, skin, renal, gastrointestinal, and pulmonary involvement, were recorded by medical history, physical examination, laboratory parameters, disease-specific questionnaire, electrocardiogram, diagnostic imaging and spirometry.

RESULTS

38 patients with lcSSc and 38 controls were included after screening for eligibility. There was no difference in FMD (p=0.775), NMD (p=0.303), aortic pulse-wave velocity (p=0.662) or in augmentation index (p=0.600) between patients with lcSSc and controls. Higher values of ADMA (p=0.030), SDMA (p=0.025) and borderline significantly higher values for CD31+/CD42b- EMP (p=0.062) were observed in lcSSc patients, also with positive correlations between those parameters. ADMA, SDMA and CD31+/CD42b- were correlated with subclinical PAH, nephropathy and capillary changes.

CONCLUSIONS

Selected parameters of endothelial dysfunction contribute to clinical events in lcSSc patients with early-stage vasculopathy and endothelial dysfunction seems to be primarily present in microvasculature, while its impact on macrovascular changes in lcSSc is still indistinct.

Successful Two-Stage Exchange Arthroplasty for Periprosthetic Infection Following Total Knee Arthroplasty: The Impact of Timing on Eradication of Infection

Background: Periprosthetic joint infection (PJI) represents a serious complication following total knee arthroplasty. In the setting of chronic infections, the two-staged approach has traditionally been the preferred treatment method. The aim of this study was to determine the optimal period of rest between the first and second stage. Furthermore, we analyzed potentially outcome-relevant parameters, such as general and local conditions and the presence of difficult-to-treat or unidentified microorganisms, with regard to their impact on successful treatment of PJI. Patients and Methods: We performed a retrospective analysis of prospectively collected data for all patients treated for PJI at our institution. Seventy-seven patients who had undergone two-stage revision arthroplasty for PJI of the knee were included into the study. Antibiotic-loaded cement spacers were used for all patients. Results: After a median follow-up time of 24.5 months, infection had reoccurred in 14 (18.7%) patients. A prolonged spacer-retention period of more than 83 days was related to a significantly higher proportion of reinfections. Furthermore, significant compromising local conditions of the prosthetic tissue and surrounding skin, as well as repeated spacer-exchanges between first- and second-stage surgery, negatively influenced the outcome. Neither the patients' age nor gender exerted a significant influence on the outcome regarding reinfection rates for patients' age or gender. Conclusions: We observed the best outcome regarding infection control in patients who had undergone second-stage surgery within 12 weeks after first-stage surgery. Nearly 90% of these patients stayed free from infection until the final follow-up. An increased number of performed spacer-exchanges and a bad local extremity grade also had a negative impact on the outcome.

Concordance of tumor infiltrating lymphocytes, PD-L1 and p16 expression in small biopsies, resection and lymph node metastases of oropharyngeal squamous cell carcinoma

OBJECTIVE

The incidence of oropharyngeal squamous cell carcinoma (OPSCC), especially human papillomavirus (HPV)-associated, is increasing worldwide. Immunotherapy become available for patients with carcinomas in the head and neck region, however without ideal biomarker. Markers like PD-L1 vary in the clone of the antibody used, and the method of evaluation. Adequate and reliable immune cells characterization and evaluation is still not found. Furthermore, studies analyzing representativeness of different tissue samples are scarce. We analyzed small biopsy, lymph node (LN) metastasis and resected OPSCC, in regards of tumor infiltrating lymphocyte (TIL) density, PD-L1 and p16 expression.

MATERIAL AND METHODS

Patients with OPSCC diagnosed from 2000 to 2016, with small biopsy, resection specimen and LN metastasis samples were selected. We analyzed TILs on hematoxylin-eosin stain, and PD-L1 and p16 expression in tumor cells. Concordance between different tumor locations was evaluated.

RESULTS

93 patients, with 65 small biopsies, 72 resection specimens, and 70 LN metastases were included. TILs, p16 and PD-L1 demonstrated very high concordance. Additionally, PD-L1 expression in the small biopsies was more representative of the PD-L1 expression in the resection specimens, than the LN samples.

CONCLUSION

TILs density can be reliably assessed using hematoxylin-eosin stain with high concordance between the small biopsy, resection specimen and LN metastasis. Evaluation of concordance of p16 expression is very high, nevertheless some cases might be misdiagnosed on a small biopsy or lymph node metastasis. Evaluation of PD-L1 expression is very reliable on the biopsy specimen. Different PD-L1 clones and methods of evaluation still remain to be addressed.

Demodex Mite Infestation and its Associations with Tear Film and Ocular Surface Parameters in Patients with Ocular Discomfort

PURPOSE

The presence of Demodex species can be associated with blepharitis. Their pathogenic potential in meibomian gland dysfunction is discussed herein. The purpose of this study was to determine the prevalence of Demodex mites in eyelashes of Austrian patients with ocular discomfort and to evaluate associated changes of the lid margins and meibomian glands.

DESIGN

This is a case-control study.

METHODS

Two hundred twenty-nine consecutive patients with ocular discomfort from an Austrian dry eye clinic were investigated for the presence of Demodex mites on sampled eyelashes. Associations of a mite infestation with individual dry eye and lid parameters were assessed. Lid margins were evaluated for scales, vascularization, Marx line, expressibility and quality of meibum, and drop-out of meibomian glands.

RESULTS

Demodex mites were identified in 40.2% of patients suffering from ocular discomfort (mean mite count 3.3 ± 2.9 per patient). Infestation with mites was associated with the presence of significantly more cylindrical scales (sleeves), a higher Marx line score, and a lower quality of meibum compared with mite-free patients. There were no significant associations with the expressibility and the drop-out of meibomian glands.

CONCLUSION

The prevalence of Demodex mites in patients with ocular discomfort is high. The mean mite count per patient in this Austrian dry eye unit population is lower compared with previously published data from Asian regions. The infestation of the eyelids with Demodex species is associated with changes of the anterior and posterior lid margin, suggesting a pathogenic role in blepharitis and meibomian gland dysfunction.

Limiting factors for wearing personal protective equipment (PPE) in a health care environment evaluated in a randomised study

Pandemics and re-emerging diseases put pressure on the health care system to prepare for patient care and sample logistics requiring enhanced personnel protective equipment (PPE) for health care workers. We generated quantifiable data on ergonomics of PPE applicable in a health care setting by defining error rates and physically limiting factors due to PPE-induced restrictions. Nineteen study volunteers tested randomly allocated head- or full body-ventilated PPE suits equipped with powered-air-purifying-respirators and performed four different tasks (two laboratory tutorials, a timed test of selective attention and a test investigating reaction time, mobility, speed and physical exercise) during 6 working hours at 22°C on one day and 4 working hours at 28°C on another day. Error rates and physical parameters (fluid loss, body temperature, heart rate) were determined and ergonomic-related parameters were assessed hourly using assessment sheets. Depending on the PPE system the most restrictive factors, which however had no negative impact on performance (speed and error rate), were: reduced dexterity due to multiple glove layers, impaired visibility by flexible face shields and back pain related to the respirator of the fully ventilated suit. Heat stress and liquid loss were perceived as restrictive at a working temperature of 28°C but not 22°C.

Extracts of different pollen species and their effect on human tear fluid and an epithelial cell line

PURPOSE

Hazelnut and birch pollen are known to destroy tear film components and attack ocular surface cells. We investigated further pollen species from different plant families, whether they show similar effects on human tear fluid and an epithelial cell line in vitro, to provide a broad basis for further research on pollen reactions affecting the tear film and ocular surface.

MATERIALS AND METHODS

Regional pollen species from different plant families (Adoxaceae, Betulaceae, Fagaceae, Juglandaceae, Malvaceae, Oleaceae, Pinaceae, Plantaginaceae, Poaceae, Salicaceae, Sapindaceae) were collected. Their proteolytic activity was evaluated by Zymography. Human tear fluid and cells of an epithelial cell line were incubated with pollen extracts. Tear fluid was analyzed by Polyacrylamide gel electrophoresis (PAGE). Cytomorphology was assessed microscopically and cell viability by proliferation (MTS), water-soluble tetrazolium (WST-1) assay and the impedance-based xCELLigence real-time analysis (RTCA).

RESULTS

Zymography revealed significant protease activity and PAGE showed the degradation of tear proteins by different pollen species. Cells incubated with pollen extracts presented dose- and time-dependent cytomorphological changes. MTS, WST-1, and RTCA revealed cytostatic as well as cytotoxic effects of pollen extracts.

CONCLUSIONS

Pollen species from different plant families exert proteolytic activity and degrade human tear fluid as well as epithelial cells, which may play a crucial role in the pathogenesis of allergic and non-allergic reactions affecting the ocular surface.

The prevalence of meibomian gland dysfunction, tear film and ocular surface parameters in an Austrian dry eye clinic population

PURPOSE

The purpose of this study was to assess the prevalence of meibomian gland dysfunction (MGD) and its association with tear film and ocular surface parameters in an Austrian clinical population of dry eye patients.

METHODS

The records of 1372 consecutive patients from a dry eye unit were analysed retrospectively. Symptoms and objective tear film and ocular surface parameters were evaluated. Patients were classified into pure MGD, pure aqueous tear deficiency (ATD), MGD combined with ATD, pure anterior blepharitis (AB), Sjogren's syndrome (SS) without MGD and SS together with MGD.

RESULTS

Nine-hundred and sixty-five patients, that is 70.3% of the investigated population, mean age 55.4 ± 16.6 years, had signs of MGD. Of these, 684 (70.9%) were female. The intensity of symptoms did not differ between subgroups. Four hundred and ninety (50.8%) MGD patients had Schirmer test values ≤10 mm/5 min. The fluorescein break-up time and Schirmer test values were significantly higher in the pure AB and MGD group. The pure MGD group showed a significantly lower fluorescein staining of the cornea compared to the other groups, except for pure AB. Lissamine green staining of the ocular surface was present in all groups, but was at least pronounced in the pure MGD and AB group.

CONCLUSION

Meibomian gland dysfunction is a major cause of ocular discomfort and could often be found in combination with a reduced aqueous tear secretion. Although the intensity of subjective complaints was similar to all other subgroups, pure MGD exhibited the lowest severity of signs of ocular surface damage and also affected younger people.

Istaroxime, a potential anticancer drug in prostate cancer, exerts beneficial functional effects in healthy and diseased human myocardium

The current gold standard for prostate cancer treatment is androgen deprivation therapy and antiandrogenic agents. However, adverse cardiovascular events including heart failure can limit therapeutic use. Istaroxime, which combines Na⁺-K⁺-ATPase (NKA) inhibition with sarco/endoplasmic reticulum Ca²⁺-ATPase 2a (SERCA2a) stimulation, has recently shown promising anti-neoplastic effects in prostate cancer (PC) models and may also improve cardiac function. Considering the promising anticancer effects of istaroxime, we aimed to assess its functional effects on human myocardium.

Small airway function before and after cold dry air challenge in pediatric asthma patients during remission

BACKGROUND

We wanted to compare cold dry air challenge (CACh) induced changes in spirometric parameters with changes in nitrogen multiple breath washout (N₂ MBW) parameters in pediatric asthma patients during clinical remission over the past year (ie, with "inactive asthma"). As N₂ MBW assesses ventilation heterogeneity we expected to gain detailed information about peripheral airways contribution.

METHODS

In subjects with normal spirometry N₂ MBW, spirometry and body plethysmography were performed at baseline, after CACh, and after salbutamol inhalation. An initial measurement of the fraction of exhaled nitric oxide (FeNO) was conducted.

RESULTS

Forty-three (20 female) subjects, mean age 13.7 years (range 6.5-18.6) performed reproducible N₂ MBW measurements. Ten were tested hyperresponsive (23.3%) and 33 normoresponsive (76.7%). Baseline spirometry and body plethysmography as well as FRC (N₂ MBW) were similar in both groups. Scond (0.031 vs 0.022), Sacin (0.057 vs 0.067), and FeNO (92.0 vs 28.5 ppb) were not statistically different between hyperresponsive and nomoresponsive subjects at baseline. Subjects with airway hyperresponsiveness (AHR) showed significant increases in lung clearance index (LCI, P = 0.011) and Scond (P = 0.008) after CACh, and significant decreases after salbutamol (LCI: P = 0.005; Scond: P = 0.005). In contrast, normoresponsive subjects showed no relevant changes after CACh, and only a decrease of Scond after salbutamol (P = 0.007). There were significant correlations between the CACh induced changes in FEV1 and changes in LCI (r = -0.45, P = 0.003), Scond (r = -0.30, P = 0.047), and Sacin (r = -0.47, P = 0.008), respectively.

CONCLUSION

Our study provides evidence of small airway involvement in children and adolescents with inactive asthma and airway hyperresponsiveness.

Superficial Vancomycin Coating of Bone Cement in Orthopedic Revision Surgery: A Safe Technique to Enhance Local Antibiotic Concentrations

BACKGROUND

The use of antibiotic-loaded cement has become a well-accepted method to develop high local antibiotic concentrations in revision surgery of infected arthroplasty. A new surgical technique has been established to further increase the local antibiotic concentration and thereby minimizes the risk of reinfection. Our study aim was to investigate the safety of additional superficial vancomycin coating (SVC) by analyzing postoperative joint and serum vancomycin concentrations, as well as the creatinine levels of patients with orthopedic revision surgery.

METHODS

A longitudinal case series was performed by reviewing collected data of patients who were treated by SVC during revision surgery (1- or 2-stage exchange) because of prosthetic joint infections. Vancomycin levels were obtained, local from drains and systemic from blood samples, on postoperative days 1 to 5. Furthermore, preoperative and postoperative serum creatinine levels were analyzed.

RESULTS

Highest median local vancomycin levels were documented on postoperative day 1 with 546.8 μg/mL (range, 44.4-1485 μg/mL) in the reimplantation group and 408.7 μg/mL (range, 24.7-1650 μg/mL) in the spacer group. Median serum vancomycin level was 4.4 μg/mL (range, <2.0-11.7 μg/mL) on the first postoperative day in the reimplantation group and <2.0 μg/mL (range, <2.0-3.9 μg/mL) in the spacer group, and lower than 2.0 μg/mL (range, <2.0-7.5 μg/mL) from postoperative day 2 to 5 in both groups. Neither an anaphylactic reaction nor other side effects to SVC were observed.

CONCLUSION

Our data showed that SVC of bone cement is an effective technique to enhance local concentrations of vancomycin without leading to systemic side effects.

Higher psychological and psychovegetative strain in adolescents with atypical pigment naevi

An observational, exploratory, cross-sectional study was performed to assess whether the presence of atypical naevi (AN) in adolescents is associated with psychological and psychovegetative stress parameters. Fifty-one students of a secondary school in Graz, Austria, completed a defined test procedure consisting of an initial period of rest, a standardised mental stress task, another period rest and a questionnaire, the change-sensitive symptom list (ASS-SYM). Electrocardiogram and blood pressure were recorded continuously. The study population was divided in two groups: probands without AN (NAN, n = 33), and probands with at least one AN (n = 18). We found higher values for the AN group in all scales of ASS-SYM, reaching statistical significance in the dimensions "nervousness and mental tension" (p = 0.025), "psychophysiological dysregulation" (p = 0.020), burden of pain" (p = 0.023) and "general symptoms and problems" (p = 0.031). Regarding physiological parameters, the AN group showed higher vegetative strain reflected in heart rate and heart rate varibility during the periods of rest as well as a reduced baroreceptor sensitivity. On the basis of our results, the presence of AN in adolescents seems to be associated with a higher vegetative arousal. Additionally, participants with AN complained significantly more often about stress-associated general psychological symptoms and problems.

Short-term intravenous fish-oil emulsions in pediatric oncologic patients--effect on liver parameters

Pediatric oncologic patients often need parenteral nutrition (PN) during chemotherapy. Long-term use of soybean-based lipid emulsions is associated with progressive liver disease and cholestasis, whereas fish-oil based emulsions have anticholestatic effects. We studied the potentially hepato-protective effects of short-term use of SMOF lipids in children undergoing chemotherapy. Fifteen pediatric oncologic patients treated with SMOF lipids were retrospectively analyzed in respect to bilirubin and liver parameters and compared to matched-controls who had received soybean-based fat emulsions. For statistics the time-points baseline, Day 14 of PN (PN14), and post (Day+7) were chosen. None of the study patients developed cholestasis. Within the SMOF-lipid group there were no differences in the laboratory parameters between baseline, PN14, and post. In the control group, gamma glutamyltransferase (γGT) levels increased during PN (baseline vs. PN14, 26.43 vs. 63.00 U/l, P < 0.05). Lactate dehydrogenase (LDH) levels showed a significantly different behavior in the 2 groups: In the SMOF lipids group, LDH decreased whereas it increased in the controls (-32.75 U/l vs. + 29.57 U/l, P < 0.05). An advantage of fish oil-based fat emulsions can be shown even after short-term PN. In children undergoing chemotherapy the use of soybean-based fat emulsions but not SMOF lipids led to increased γGT levels.

Prosthetic joint infection following total hip replacement: results of one-stage versus two-stage exchange

PURPOSE

Prosthetic hip joint infection remains a challenging socio-economic problem. Curative treatment is usually a one- or two-stage revision surgery, but neither of these options has yet emerged as the treatment of choice. The aim of this study was to evaluate which of these methods produced superior outcomes.

METHODS

A retrospective study was performed including 92 patients with deep infections after implantation of primary total hip arthroplasty (THA) who had undergone either one-stage or two-stage revision surgery at a single centre. Infections were classified according to McPherson and we evaluated the rate of persisting infection or reinfection after surgical intervention.

RESULTS

The two-stage revision surgery revealed superior outcomes for the analysed infection categories compared to the one-stage procedure except for the least serious category of infections (i.e. McPherson Stage I/A/1, early postoperative infection, no systemic comorbidities, local status uncompromised). Eradication of prosthetic infection was achieved in 94.5 % (n = 52) within the group of two-stage exchange, and 56.8 % (n = 21) of patients treated with a one-stage procedure. Outcome of patients following a one-stage or a two-stage exchange was overall significantly different with p < 0.001. Further deviations between the described two procedures were noted in the subgroups following the classification described by McPherson.

CONCLUSIONS

Our results indicate superiority of two-stage revision surgery in case of serious infections. The authors believe that decisions on the surgical approach for the treatment of deep prosthesis infections should be made on the basis of standardized staging systems.

Influence of prereferral surgery in soft tissue sarcoma: 10 years' experience in a single institution

Soft tissue sarcomas are a group of rare mesenchymal neoplasms comprising 0.8% of all malignant tumors. Workup should include medical history, physical examination, magnetic resonance imaging, biopsy, and thoracoabdominal computed tomography scan, in that order. Centralized multimodality treatment in a cross-disciplinary setting is mandatory. Treatment not according to current clinical practice guidelines is a common problem before referral to a specialized institution. The purpose of this 10-year, single-institution review was to investigate the influence of curative surgery on outcome, with a special emphasis on surgery before referral. A cohort of 266 patients who underwent curative surgery for soft tissue sarcoma between 1998 and 2008 was analyzed. One hundred thirty-one (49%) patients underwent surgery contrary to current clinical guidelines before referral, most (73%) at primary care units. One hundred thirteen (86%) of these patients underwent surgery without previous biopsy with a higher rate of intralesional margins (P<.001), a smaller mean diameter of primary lesion (P<.001), a higher rate of subcutaneous situs (P<.001), a lower mean American Joint Committee on Cancer score (P=.008), a higher rate of additional plastic surgery after re-resection (eg, flap surgery) (P<.001), and a longer period before referral (P<.001). No influence on survival, local recurrence, or metastasis existed. Prereferral surgery necessitating re-resection has no influence on survival but leads to an unfavorable clinical course. More effort should be made to improve awareness and referral modalities for general practitioners and physicians at community hospitals.

Course of Antibody Response in Lyme Borreliosis Patients before and after Therapy

The early immune response (IR) in European Lyme borreliosis patients has not yet been studied in detail. The aim of the study was to analyse retrospectively the antibody development in 61 erythema migrans (EMs) patients depending on the duration of infection from tick bite by using a whole-cell lysate B. garinii immunoblot. The evolution of antibodies proved to be undulatory in untreated patients with two peaks for IgM at weeks 5 and 9 and for IgG at weeks 4 and 8. The analysis of IR courses after therapy identified patients constantly seropositive or seronegative and patients with repeated seroconversions with a switch, disappearance, or reappearance of anti-23 kD or anti-39 kD antibodies during the one-year period. We suggest that the antibody production in EM patients may be missed due to an undulatory IR. This phenomenon might be an as yet insufficiently researched aspect in Lyme borreliosis.

Pilot study on the acceptance of mobile teledermatology for the home monitoring of high-need patients with psoriasis

BACKGROUND/OBJECTIVES

The willingness to be educated is one of the highest desires among patients with psoriasis. Therefore, a collaborative model of management would appear to be essential in enhancing patient satisfaction in this challenging condition. The present study aimed at examining the applicability of a mobile teledermatology service in this regard and assessing the association between patient acceptance and perceived health-related quality of life.

METHODS

High-need patients with psoriasis performed visits over 12 weeks transmitting clinical images together with some relevant clinical information via mobile phones to teledermatologists, who provided treatment instructions. Ten patients and two teledermatologists completed 20-item patient (weeks 6 and 12) and 10-item physician (at week 12) acceptance questionnaires. In addition, patients answered the dermatology life quality index (DLQI) at weeks 0, 6 and 12.

RESULTS

Both patients and teledermatologists were pleased with the service with high acceptance rates (patients: 81.0% at week 6 and 82.9% at week 12; teledermatologists: 74.0%). In addition, 80% of the patients considered the service an alternative to in-person consultation and 90% felt they were in good hands but had achieved a more flexible and empowered lifestyle. No significant correlations were found between patient acceptance and DLQI. Both teledermatologists found the service a convenient and reliable tool for patient monitoring. Neither patients nor teledermatologists thought further in-person consultations necessary.

CONCLUSION

Mobile teledermatology is a valuable tool for the home monitoring of patients with psoriasis that makes a meaningful difference in their lives. It is well accepted by both patients and the physicians involved.

Design and development of a mobile computer application to reengineer workflows in the hospital and the methodology to evaluate its effectiveness

This paper describes a new method of collecting additional data for the purpose of skin cancer research from the patients in the hospital using the system Mobile Computing in Medicine Graz (MoCoMed-Graz). This system departs from the traditional paper-based questionnaire data collection methods and implements a new composition of evaluation methods to demonstrate its effectiveness. The patients fill out a questionnaire on a Tablet-PC (or iPad Device) and the resulting medical data is integrated into the electronic patient record for display when the patient enters the doctor's examination room. Since the data is now part of the electronic patient record, the doctor can discuss the data together with the patient making corrections or completions where necessary, thus enhancing data quality and patient empowerment. A further advantage is that all questionnaires are in the system at the end of the day - and manual entry is no longer necessary - consequently raising data completeness. The front end was developed using a User Centered Design Process for touch tablet computers and transfers the data in XML to the SAP based enterprise hospital information system. The system was evaluated at the Graz University Hospital - where about 30 outpatients consult the pigmented lesion clinic each day - following Bronfenbrenner's three level perspective: The microlevel, the mesolevel and the macrolevel: On the microlevel, the questions answered by 194 outpatients, evaluated with the System Usability Scale (SUS) resulted in a median of 97.5 (min: 50, max: 100) which showed that it is easy to use. On the mesolevel, the time spent by medical doctors was measured before and after the implementation of the system; the medical task performance time of 20 doctors (age median 43 (min: 29; max: 50)) showed a reduction of 90%. On the macrolevel, a cost model was developed to show how much money can be saved by the hospital management. This showed that, for an average of 30 patients per day, on a 250 day basis per year in this single clinic, the hospital management can save up to 40,000 EUR per annum, proving that mobile computers can successfully contribute to workflow optimization.

Discontinuing long-term Iloprost treatment for Raynaud's Phenomenon and systemic sclerosis: a single-center, randomized, placebo-controlled, double-blind study

BACKGROUND

Iloprost has been reported to reduce Raynaud`s phenomenon (RP) and to inhibit progression of systemic sclerosis (SSc).

OBJECTIVE

The aim of our study was to compare monthly iloprost infusions with placebo in patients treated long-term.

METHODS

Seventeen patients, six with RP and 11 with SSc on monthly treatment with iloprost, received either a 3-hour intravenous infusion of iloprost or an equal volume of placebo once per month for 4 months in a monocentric, randomized, placebo-controlled, double-blind study. Raynaud attacks as measured by diary entries, skin temperature, skin sclerosis, fist closure, mouth opening, and digital ulcers were recorded during the observation period.

RESULTS

Whereas mouth opening improved significantly (p = 0.043) in the iloprost-treated group, RS improved in both patient groups. However, no significant differences were found in the outcome measures.

CONCLUSION

Although iloprost influences the inflammatory cascade in SSc, no statistical differences were seen in our study, indicating that treatment strategies with iloprost should be modified.

Peripheral blood stem cell mobilization with pegfilgrastim compared to filgrastim in children and young adults with malignancies

BACKGROUND

Pegfilgrastim, the long acting agent of rh-GCSF, has been shown to be as effective as Filgrastim in children undergoing cytotoxic chemotherapy by reducing the duration of neutropenia. Recent studies in adults have also shown that Pegfilgrastim is effective to mobilize CD34+ stem cells, resulting in earlier peripheral stem cell collections (PSCC). The aim of the study was to compare the efficacy of Pegfilgrastim with Filgrastim for CD34+ stem cell mobilization in children.

PROCEDURE

Three groups of patients were compared: Group 1: six patients with Ewing Sarcoma stimulated with Filgrastim; Group 2: five patients with Ewing Sarcoma, Ependymoma, and Neuroblastoma; Group 3: four patients with relapsed neoplasm. Patients of Group 2 and 3 were stimulated with Pegfilgrastim followed by peripheral stem cell collection. Two patients in Group 3 needed further cytokine stimulation with Filgrastim combined with stem cell factor, Ancestim.

RESULTS

In Groups 1-3, a median of 4, 3, and 3 PSCC between day 12-24, 6-13, and 8-30 were performed, yielding a median of 14.2, 24.0, and 10.3 x 10(6) CD34+ stem cells/kg BW, respectively.

CONCLUSIONS

Group 2 data show that stem cell mobilization with Pegfilgrastim in children when performed during primary or without previous long lasting chemotherapy seems to produce earlier CD34+ peaks and better CD34+ yields than in Group 1. CD34+ cell mobilization with Pegfilgrastim in Group 3-patients with previous long lasting chemotherapy was possible.

Assessment of risk factors for survival of neonates born after second-trimester PPROM

OBJECTIVE

Assess fetal risk factors which impact survival of infants delivered after second-trimester PPROM.

STUDY DESIGN

Clinical records of 87 patients, who all had second-trimester rupture of membranes between 14+0 and 24+6 weeks of gestation treated January 1998 to July 2005 were reviewed regarding perinatal outcome. This study is based on 25 surviving infants.

RESULTS

13 of these 25 infants died in the hospital. Survivors had a higher birth weight (p=0.008) and higher Apgar scores after 5 min (p=0.005) than those infants dying. No differences in UA pH, the need of catecholamines and no association between histological verified chorioamnionitis and early onset sepsis were seen between survivors and nonsurvivors.

CONCLUSION

Higher gestational age at birth, higher birth weight, the absence of histologically verified chorioamnionitis and 5 min Apgar scores of >or= than 6 have positive prognostic value for survival of neonates delivered preterm after second-trimester PPROM.

Combination of different noninvasive measuring techniques: a new approach to increase accuracy of peripheral near infrared spectroscopy

One of the problems of near-infrared-spectroscopy (NIRS) measurements is low reproducibility. The aim of the present study was to introduce quality criteria to increase reproducibility of peripheral NIRS measurements. In a prospective cohort study in 40 neonates, repeated NIRS measurements were performed on the calf. During five "reapplication" periods (of NIRS optodes), five "measurements" (venous occlusions) were performed. Tissue oxygenation index (TOI), mixed venous oxygenation (SvO2), fractional oxygen extraction (FOE), hemoglobin flow (Hbflow), oxygen delivery (DO2), and oxygen consumption (VO2) were assessed. Measurements with linear changes during venous occlusions were included for further analysis (first quality criterion: R(2)>0.95). The second quality criterion was the equation 0 < or = TOI-SvO2 < or = (SaO2-SvO2)x0.2. Variance components and mean standard deviations were analyzed after introduction of the quality criteria. Variance components of reapplication and measurement decreased after introduction of the second quality criterion (TOI: 46.6-35.0%, SvO2: 76.8-38.2%, FOE: 73.1-37.5%, Hbflow: 70.3-51.9%, DO2: 71.5-52.7%, and VO2: 70.9-63.8%). Mean standard deviations of TOI (6.6+/-3.0 to 4.7+/-3.2%), SvO2 (11.1+/-4.8 to 5.7+/-3.9%), FOE (11.3+/-4.8 to 5.9+/-4.0%), Hbflow (4.3+/-2.0 to 2.9+/-1.6 micromol100 mLmin), and DO2 (17.8+/-7.6 to 11.4+/-6.2 micromol100 mLmin) decreased significantly, too. Only 12% of measurements fulfilled both quality criteria. With the introduction of two quality criteria, test-retest variability of peripheral NIRS measurements decreased significantly and reproducibility increased significantly.

Differences in length and cross-section of semitendinosus and gracilis tendons and their effect on anterior cruciate ligament reconstruction

The purpose of this anatomical study was to explore the morphological variations of the semitendinosus and gracilis tendons in length and cross-section and the statistical relationship between length, cross-section, and body height.

We studied the legs of 93 humans in 136 cadavers. In 43 specimens (46.2%) it was possible to harvest the tendons from both legs.

We found considerable differences in the length and cross-section of the semitendinosus and the gracilis tendons with a significant correlation between the two. A correlation between the length of the femur, reflecting height, and the length of the tendons was only observed in specimens harvested from women. The reason for this gender difference was unclear. Additionally, there was a correlation between the cross-sectional area of the tendons and the length of the femur. Surgeons should be aware of the possibility of encountering insufficient length of tendon when undertaking reconstructive surgery as a result of anatomical variations between patients.

Clinical epidemiology of invasive cutaneous malignant melanoma in the Austrian province Styria in the years 2001-2003 and its relationship with local geographical, meteorological and economic data

BACKGROUND

Melanoma incidence rates vary within Europe. The highest incidences are reported in Scandinavia, the lowest in the southern parts, but incidences themselves also vary within the different countries.

OBJECTIVE

We investigated the incidence of invasive cutaneous melanoma in Styria, a province of Austria, in the years 2001-2003.

METHODS

Data from 1,082 patients, 511 males and 571 females (mean age 58.2 years) with primary melanoma were collected. For each patient, information regarding residence was available, and therefore the geographic distribution of melanoma on district level was investigated with particular reference to the mean number of sun hours, mean altitude, number of companies with more than 200 employees and median income.

RESULTS

The mean annual incidence (age-standardized rate) was 24.5 per 100,000 (95% CI: 22.4-26.6), lifetime risk 1 in 52. Districts with a higher number of sun hours and higher altitude showed lower melanoma incidences. Higher median income was associated with higher melanoma incidence (p<0.001).

CONCLUSION

The high incidence of invasive melanoma in Styria is unclear and a causal relationship between higher income and melanoma incidence remains speculative. Further investigations, especially concerning lifestyle and environmental factors, may unravel additional causative factors.

Natural history of invasive cutaneous melanoma in Styria, Austria 2001?2003

BACKGROUND

Rising melanoma incidences have created the need of assessment of epidemiological and clinical data.

PATIENTS AND METHODS

We investigated the natural history of invasive cutaneous melanoma in Styria, a province of Austria, in the years 2001-2003. 1082 patients, 511 men and 571 women, mean age 58.2 +/- 16.7 years, were collected. Besides basic melanoma data, special histologic features such as regression structures, ulceration, microsatellites and vascular invasion were investigated. Furthermore, lymph node pathology in case of sentinel node biopsy and/or lymph node dissection was recorded.

RESULTS

Mean annual incidence (crude rate) was 28.6 per 100,000 inhabitants, age standardized rate 24.5 per 100,000 (95 % CI 22.4-26.6). Cumulative risk (0- 74 years) was 1.92, lifetime risk 1 in 52. Superficial spreading melanoma was the most common type in both sexes, men on the trunk and women on the extremities. Only 11 % of all melanomas were in easily visible areas. Median tumor thickness was 0.75 mm, ranging between 0.2 and 50.0 mm. Sentinel node biopsy was performed in 158 melanomas (14.6 %),and was positive in 22 %.Primary therapeutic lymph node dissection was performed in 19 patients, showing metastases in 18 patients.

CONCLUSIONS

The investigation revealed an unclear high melanoma incidence for invasive melanomas in our province, requiring further investigation.

Endoluminal therapy in patients with peripheral arterial disease: prospective assessment of quality of life in 190 patients

OBJECTIVE

The objective of our study was to assess the impact of endoluminal treatment on health-related quality of life in patients with peripheral arterial disease.

SUBJECTS AND METHODS

Changes in quality of life were prospectively evaluated in 190 patients before and 1, 3, 6, and 12 months after treatment. Physical, emotional, and general health components were determined using the short-form (36 items) health survey (SF-36). Claudicant patients were compared with patients who had critical limb ischemia. The influence of the lesion location (iliac, femoropopliteal, or crural) restenosis, and additional interventions on quality of life were evaluated.

RESULTS

Six- and 12-month follow-up data were available for 136 and 103 patients, respectively. Significant improvements in quality of life were observed in most of the patients after the intervention. Many of the SF-36 scores decreased from the 6- to the 12-month follow-up but remained significantly higher than the score before the intervention. Reduction of bodily pain was the most evident effect of treatment. Claudicant patients seemed to benefit more from treatment than patients with critical limb ischemia. In terms of SF-36 scores, percutaneous transluminal angioplasty of the crural arteries was equally as effective as endoluminal revascularization of the iliac and femoropopliteal arteries and multilevel interventions were as effective as single-level interventions. The occurrence of a restenosis was significantly related to lower SF-36 scores, and restenosis not followed by a second intervention was associated with lower SF-36 scores.

CONCLUSION

Although there were several differences between the groups, significant improvements in quality of life up to 12 months after endoluminal therapy were observed in most patients.

Minor neurological dysfunction, cognitive development and somatic development at the age of 3 to 11 years in very-low-birthweight infants with transient periventricular echodensities

AIM

To determine, using strict exclusion criteria, whether transient periventricular echodensities (TPE) in very-low-birthweight infants lead to minor neurological dysfunction and problems in cognitive and somatic development in children without major neurological impairments.

METHODS

23 children with TPE were matched to 23 children without TPE. Exclusion criteria were small for gestational age, microcephaly at birth, diplegia, asphyxia, psychomotor retardation, intraventricular haemorrhage grade III/IV, major surgical interventions and malformations. The Kaufman Assessment Battery for Children, Draw-a-Man Test and neuropaediatric examination were used for evaluation.

RESULTS

There were no differences in demographic data, growth and socio-economic status. Significant differences with lower results in the TPE group were found in fine motor skills and in the Draw-a-Man Test. In the Kaufman Assessment Battery for Children, all subscales were below average in the TPE group, except the sequential processing scale. In the control group, all subscales were within the average range.

CONCLUSION

By using strict exclusion criteria to eliminate other risk factors for minimal neurological dysfunction and poor cognitive development, we were able to focus on the effect of TPE. TPE seem to affect cognitive development and cause minor neurological dysfunction.

Predicting neurologic recovery in cervical spinal cord injury with postoperative MR imaging

STUDY DESIGN

Prospective, nonrandomized, observational cohort study.

OBJECTIVES

To determine whether the presence of spinal cord hemorrhage and length of hematoma on magnetic resonance imaging (MRI) is predictive of recovery in cervical spinal cord injury (SCI).

SUMMARY OF BACKGROUND DATA

A clear picture of the location, extent, and severity of traumatic cervical cord injury can be obtained with MRI. Several prognostic studies looked for an association between the degree of SCI, as depicted by MRI, and neurologic outcome. Up to now, an association between the length of hemorrhage and the extent of SCI and motor recovery could not be demonstrated.

METHODS

Twenty-nine patients with acute traumatic cervical spinal cord injury underwent surgery within 2 to 9 hours. MRI was performed within 2 weeks of injury. Neurologic impairment was classified using the ASIA classification. The effects of hemorrhage and length of hematoma on changes in the neurologic impairment were assessed at time of MRI and at median follow-up in 35 months (range, 24-65 months).

RESULTS

Patients with hemorrhage were much more likely to have a complete injury at time of follow-up (odds ratio = 2.33, 95% confidence interval, 1.42-3.82). Patients admitted with complete SCI, ASIA A, showed a median length of hematoma of 10.5 mm and a median length of edema of 66.5 mm and no change at follow-up. Patients with incomplete SCI showed a median length of hematoma of 4 mm and small edema. Presence of hemorrhage less than 4 mm was associated with good prognosis.

CONCLUSION

This study indicates that presence of hemorrhage of less than 4 mm was not associated with complete SCI and showed good prognosis.

Radiofrequency tissue volume reduction of the soft palate and UPPP in the treatment of snoring

The purpose of this study was to evaluate the efficiency of radiofrequency tissue volume reduction (RFTVR) and uvulopalatopharyngoplasty (UPPP) in the treatment of snoring in a prospective clinical trial of 79 patients consecutively undergoing surgery for snoring. Seventy-nine patients with primary snoring or mild OSAS (obstructive sleep apnea syndrome) were enrolled in this clinical trial (66 males and 13 females). According to the anatomical findings (the size of the tonsils and uvula), the patients underwent UPPP/TE of the RFTVR of the soft palate. Forty-seven patients had UPPP/TE (age 45.81+/-12.11 years; median AHI: 8; range 1-29). Thirty-two patients were treated with RFTVR of the soft palate (age 48.10+/-10.92; median AHI: 5.0; range 0-26). The average number of treatments was 2.2. All patients underwent preoperative polysomnography to exclude severe OSAS. Pre- and postoperative snoring scores were evaluated from the patients with bed partners. Postoperative follow-up data were collected at a median of 4 months after treatment; 85.1% of the UPPP group and 53.1% of the RFTVR group underwent postoperative polysomnography. Subjective snoring scores of all study participants were evaluated. Preoperatively, there was no statistically significant difference of subjective symptoms, age and BMI between the two groups. The snoring scores improved statistically significantly in both groups (P <0.001 in the UPPP group; P =0.001 in the RFTVR group). After UPPP/TE snoring improved in 37 patients (78.7%), and 29 (61.7%) thereof were free of bothersome snoring; no change was found in 9 patients (19.2%), and 1 (2.1%) worsened. In the RFTVR group, snoring improved in 15 (46.9%), and 9 (28.1%) thereof were free of bothersome snoring; no change was found in 13 patients (50%), and 1 worsened (3.1%). Preoperative AHI was statistically higher (P =0.016) and mean minimal oxygen saturation significantly lower (P =0.002) in the UPPP group. In the UPPP group AHI and HI showed statistically significant improvement postoperatively (P =0.025 and P =0.034, respectively). After RFTVR, no statistically significant change of AHI, HI or oxygen saturation was found. Besides limited mucosal erosions (15%) after RFTVR and foreign body sensations (<10%) after UPPP/TE, no side effects were observed. The success rate of RFTVR of the soft palate is lower compared to the more invasive technique of UPPP. Due to its minimally invasive character, RFTVR is suitable as first-step treatment for snoring, but patients should be counseled about possible success rates and different treatment options.

Five-year results of prognostic value of tyrosinase in peripheral blood of uveal melanoma patients

Tyrosinase-based reverse transcriptase-polymerase chain reaction (RT-PCR) is a method for the detection of circulating melanoma cells in peripheral blood. To our knowledge, no long-term studies on the prognostic impact of tyrosinase PCR in uveal melanoma have yet been reported. In this prospective, non-randomized, observational cohort study, we included 41 patients with uveal malignant melanoma. RT-PCR for tyrosinase was performed in each patient before and after treatment. A clinical follow-up was performed for each patient for at least 5 years, including chest X-ray, serum liver enzyme determination, ultrasound of the liver and bone scintigraphy. The PCR results, age of the patients, tumour size, tumour location, tumour therapy, internal reflectivity, histology, development of distant metastasis and survival rate during follow-up were analysed. At the time of diagnosis, tyrosinase messenger RNA (mRNA) in peripheral blood, suggesting the presence of circulating melanoma cells, was detected in 16 of the 41 patients. Sixty-nine percent of the PCR samples with a positive result prior to therapy revealed a negative result after therapy. The internal reflectivity of the tumour (P=0.021) and the 5-year survival (P=0.023) showed a statistically significant association with positive PCR. It can be concluded that tyrosinase RT-PCR is a sensitive method for the detection of melanoma cells in peripheral blood. This study indicates that the presence of tumour cells in peripheral blood correlates with 5-year survival. Our results suggest a prognostic value of this method. Nevertheless, prospective analysis of a larger cohort is needed to determine the ultimate value of RT-PCR for tyrosinase in blood testing.

Evaluating an impression cytology grading system (IC score) in patients with dry eye syndrome

PURPOSE

To evaluate the IC score, a newly developed grading system for the morphological alterations of the ocular surface as a diagnostic tool in relation to type and severity of dry eye disease.

METHODS

Impression cytological specimens of 309 patients with simple dry eye (S-DE), 50 patients with Sjögren's syndrome and dry eye (SS-DE), and 39 patients with connective tissue disease and dry eye (CTD-DE) were examined. In all, 10 different morphological parameters were judged with points (IC subscores) and summarized to the IC score. IC score and subscores were correlated to tear function test results and with each other.

RESULTS

SS-DE patients had the highest IC scores and IC subscores. IC scores and IC subscores correlated significantly with the fluorescein staining of the cornea in all three patient groups. They were correlated to the rose bengal score in SS-DE and S-DE patients. The analysis of the IC subscores showed that there are significant correlations between most of the morphological alterations investigated. This underlines the importance of each parameter for the summarized IC score.

CONCLUSION

The IC score provides detailed information about the morphological alterations of the bulbar conjunctiva. It has proven to be useful for the differentiation of dry eye diseases and might help in the investigation of the pathogenesis of these diseases as well as for follow-up and therapy control.

Feasibility of high-dose interleukin-2 in heavily pretreated pediatric cancer patients

BACKGROUND

The administration of high-dose interleukin-2 (IL-2) seems to be a therapeutic option for children with refractory and metastatic solid malignancies.

METHODS

We prospectively studied treatment-related toxicities, quality of life and laboratory parameters in 10 children with progressive or metastatic solid tumors (metastatic osteosarcoma, n=4; neuroblastoma stage IV, n=3; metastatic Ewing's sarcoma, n=2; metastatic Wilms' tumor, n=1) during IL-2 therapy. Patients were scheduled to receive five cycles of high-dose IL-2 by continuous infusion for 5 days every 3 weeks.

RESULTS

All patients developed fever >39 degrees C and influenza-like symptoms, with a significant decrease in Karnofsky score. In two patients treatment had to be stopped after three cycles because of severe side-effects. During IL-2 therapy a statistical significant increase in white blood cells (WBC), creatinine, gamma-glutamyltransferase, C-reactive protein, glucose and body weight was observed. In contrast, red blood cells, platelets, protein, albumin and cholinesterase significantly decreased. When results from day 1 of the first and of the fifth cycle were compared, an increase of WBC and a decrease of alkaline phosphatase was shown. No constant quantitative changes in total lymphocytes and subsets were observed during IL-2 therapy.

CONCLUSIONS

IL-2 treatment in children with refractory and relapsed solid malignancies is associated with severe, but reversible, side-effects. However, five of the 10 patients with diseases of worst prognosis could be rescued by this treatment.