The influence of anastomotic techniques on postoperative anastomotic complications: Results of the Oesophago-Gastric Anastomosis Audit

BACKGROUND

The optimal anastomotic techniques in esophagectomy to minimize rates of anastomotic leakage and conduit necrosis are not known. The aim of this study was to assess whether the anastomotic technique was associated with anastomotic failure after esophagectomy in the international Oesophago-Gastric Anastomosis Audit cohort.

METHODS

This prospective observational multicenter cohort study included patients undergoing esophagectomy for esophageal cancer over 9 months during 2018. The primary exposure was the anastomotic technique, classified as handsewn, linear stapled, or circular stapled. The primary outcome was anastomotic failure, namely a composite of anastomotic leakage and conduit necrosis, as defined by the Esophageal Complications Consensus Group. Multivariable logistic regression modeling was used to identify the association between anastomotic techniques and anastomotic failure, after adjustment for confounders.

RESULTS

Of the 2238 esophagectomies, the anastomosis was handsewn in 27.1%, linear stapled in 21.0%, and circular stapled in 51.9%. Anastomotic techniques differed significantly by the anastomosis sites (P < .001), with the majority of neck anastomoses being handsewn (69.9%), whereas most chest anastomoses were stapled (66.3% circular stapled and 19.3% linear stapled). Rates of anastomotic failure differed significantly among the anastomotic techniques (P < .001), from 19.3% in handsewn anastomoses, to 14.0% in linear stapled anastomoses, and 12.1% in circular stapled anastomoses. This effect remained significant after adjustment for confounding factors on multivariable analysis, with an odds ratio of 0.63 (95% CI, 0.46-0.86; P = .004) for circular stapled versus handsewn anastomosis. However, subgroup analysis by anastomosis site suggested that this effect was predominantly present in neck anastomoses, with anastomotic failure rates of 23.2% versus 14.6% versus 5.9% for handsewn versus linear stapled anastomoses versus circular stapled neck anastomoses, compared with 13.7% versus 13.8% versus 12.2% for chest anastomoses.

CONCLUSIONS

Handsewn anastomoses appear to be independently associated with higher rates of anastomotic failure compared with stapled anastomoses. However, this effect seems to be largely confined to neck anastomoses, with minimal differences between techniques observed for chest anastomoses. Further research into standardization of anastomotic approach and techniques may further improve outcomes.

Textbook outcome following oesophagectomy for cancer: international cohort study

Background

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

Methods

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

Results

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter ‘no major postoperative complication’ had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P &lt; 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P &lt; 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

Conclusion

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.

Textbook outcome following oesophagectomy for cancer: international cohort study

BACKGROUND

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

METHODS

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

RESULTS

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter 'no major postoperative complication' had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P < 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P < 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

CONCLUSION

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.

Postoperative outcomes in oesophagectomy with trainee involvement

BACKGROUND

The complexity of oesophageal surgery and the significant risk of morbidity necessitates that oesophagectomy is predominantly performed by a consultant surgeon, or a senior trainee under their supervision. The aim of this study was to determine the impact of trainee involvement in oesophagectomy on postoperative outcomes in an international multicentre setting.

METHODS

Data from the multicentre Oesophago-Gastric Anastomosis Study Group (OGAA) cohort study were analysed, which comprised prospectively collected data from patients undergoing oesophagectomy for oesophageal cancer between April 2018 and December 2018. Procedures were grouped by the level of trainee involvement, and univariable and multivariable analyses were performed to compare patient outcomes across groups.

RESULTS

Of 2232 oesophagectomies from 137 centres in 41 countries, trainees were involved in 29.1 per cent of them (n = 650), performing only the abdominal phase in 230, only the chest and/or neck phases in 130, and all phases in 315 procedures. For procedures with a chest anastomosis, those with trainee involvement had similar 90-day mortality, complication and reoperation rates to consultant-performed oesophagectomies (P = 0.451, P = 0.318, and P = 0.382, respectively), while anastomotic leak rates were significantly lower in the trainee groups (P = 0.030). Procedures with a neck anastomosis had equivalent complication, anastomotic leak, and reoperation rates (P = 0.150, P = 0.430, and P = 0.632, respectively) in trainee-involved versus consultant-performed oesophagectomies, with significantly lower 90-day mortality in the trainee groups (P = 0.005).

CONCLUSION

Trainee involvement was not found to be associated with significantly inferior postoperative outcomes for selected patients undergoing oesophagectomy. The results support continued supervised trainee involvement in oesophageal cancer surgery.

Mortality from esophagectomy for esophageal cancer across low, middle, and high-income countries: An international cohort study

BACKGROUND

No evidence currently exists characterising global outcomes following major cancer surgery, including esophageal cancer. Therefore, this study aimed to characterise impact of high income countries (HIC) versus low and middle income countries (LMIC) on the outcomes following esophagectomy for esophageal cancer.

METHOD

This international multi-center prospective study across 137 hospitals in 41 countries included patients who underwent an esophagectomy for esophageal cancer, with 90-day follow-up. The main explanatory variable was country income, defined according to the World Bank Data classification. The primary outcome was 90-day postoperative mortality, and secondary outcomes were composite leaks (anastomotic leak or conduit necrosis) and major complications (Clavien-Dindo Grade III - V). Multivariable generalized estimating equation models were used to produce adjusted odds ratios (ORs) and 95% confidence intervals (CI95%).

RESULTS

Between April 2018 to December 2018, 2247 patients were included. Patients from HIC were more significantly older, with higher ASA grade, and more advanced tumors. Patients from LMIC had almost three-fold increase in 90-day mortality, compared to HIC (9.4% vs 3.7%, p < 0.001). On adjusted analysis, LMIC were independently associated with higher 90-day mortality (OR: 2.31, CI95%: 1.17-4.55, p = 0.015). However, LMIC were not independently associated with higher rates of anastomotic leaks (OR: 1.06, CI95%: 0.57-1.99, p = 0.9) or major complications (OR: 0.85, CI95%: 0.54-1.32, p = 0.5), compared to HIC.

CONCLUSION

Resections in LMIC were independently associated with higher 90-day postoperative mortality, likely reflecting a failure to rescue of these patients following esophagectomy, despite similar composite anastomotic leaks and major complication rates to HIC. These findings warrant further research, to identify potential issues and solutions to improve global outcomes following esophagectomy for cancer.

Comparison of short-term outcomes from the International Oesophago-Gastric Anastomosis Audit (OGAA), the Esophagectomy Complications Consensus Group (ECCG), and the Dutch Upper Gastrointestinal Cancer Audit (DUCA)

BACKGROUND

The Esophagectomy Complications Consensus Group (ECCG) and the Dutch Upper Gastrointestinal Cancer Audit (DUCA) have set standards in reporting outcomes after oesophagectomy. Reporting outcomes from selected high-volume centres or centralized national cancer programmes may not, however, be reflective of the true global prevalence of complications. This study aimed to compare complication rates after oesophagectomy from these existing sources with those of an unselected international cohort from the Oesophago-Gastric Anastomosis Audit (OGAA).

METHODS

The OGAA was a prospective multicentre cohort study coordinated by the West Midlands Research Collaborative, and included patients undergoing oesophagectomy for oesophageal cancer between April and December 2018, with 90 days of follow-up.

RESULTS

The OGAA study included 2247 oesophagectomies across 137 hospitals in 41 countries. Comparisons with the ECCG and DUCA found differences in baseline demographics between the three cohorts, including age, ASA grade, and rates of chronic pulmonary disease. The OGAA had the lowest rates of neoadjuvant treatment (OGAA 75.1 per cent, ECCG 78.9 per cent, DUCA 93.5 per cent; P < 0.001). DUCA exhibited the highest rates of minimally invasive surgery (OGAA 57.2 per cent, ECCG 47.9 per cent, DUCA 85.8 per cent; P < 0.001). Overall complication rates were similar in the three cohorts (OGAA 63.6 per cent, ECCG 59.0 per cent, DUCA 62.2 per cent), with no statistically significant difference in Clavien-Dindo grades (P = 0.752). However, a significant difference in 30-day mortality was observed, with DUCA reporting the lowest rate (OGAA 3.2 per cent, ECCG 2.4 per cent, DUCA 1.7 per cent; P = 0.013).

CONCLUSION

Despite differences in rates of co-morbidities, oncological treatment strategies, and access to minimal-access surgery, overall complication rates were similar in the three cohorts.

Disturbed glutathione antioxidative defense is associated with structural brain changes in neuroleptic-naïve first-episode psychosis patients

BACKGROUND

Oxidative stress and impaired antioxidant defense are reported in schizophrenia and are thought to be associated with disturbed neurodevelopment, brain structural alterations, glutamatergic imbalance, negative symptomatology, and cognitive impairment. To test some of these assumptions we investigated the glutathione (GSH) antioxidant defense system (AODS) and brain structural abnormalities in drug-naïve individuals with first acute episode of psychosis (FEP).

METHOD

The study involved 27 drug-naïve FEP patients and 31 healthy controls (HC). GSH AODS markers and TBARS (thiobarbituric acid reactive substances) were measured in blood plasma and erythrocytes. High-resolution T₁-weighted 3T MRI were acquired from all subjects. To investigate brain structural abnormalities and effects of illness on interactions between GSH metabolites or enzyme activities and local grey matter density, voxel-based morphometry (VBM) with the computational anatomy toolbox (CAT12) was used. Symptomatology was assessed using the Positive and Negative Syndrome Scale (PANSS) and the Symptom Checklist 1990 revised (SCL-90-R).

RESULTS

(i) In FEP patients, glutathione reductase activity (GSR) was lower than in the HC group. GSR activity in plasma was inversely correlated with SCL-90-R scores of depression and PANSS scores of the negative symptom subscale. (ii) A reduction of GM was observed in left inferior frontal, bilateral temporal, as well as parietal cortices of FEP patients. (iii) Interaction analyses revealed an influence of illness on GSR/GM associations in the left orbitofrontal cortex (BA 47).

CONCLUSION

Our findings support the notion of altered GSH antioxidative defense in untreated acute psychosis as a potential pathomechanism for localized brain structural abnormalities. This pathology relates to a key brain region of social cognition, affective motivation control and decision making, and is clinically accompanied by depressive and negative symptoms.

Aufbau des Deutschen Hämophilieregisters

Seit Dezember 2004 wird die Entwicklung des Deutschen Hämophilieregisters (DHR) vom Paul-Ehrlich-Institut (PEI) vorangetrieben. Auf dem Jahreskongress der GTH (Gesellschaft für Thrombose und Hämostaseforschung e. V.) im Februar 2007 wurde der Kooperationsvertrag zum Aufbau und Betrieb des DHR als gemeinschaftliches Projekt der Patientenorganisationen DHG (Deutsche Hämophiliegesellschaft zur Bekämpfung von Blutungskrankheiten e. V.) und IGH (Interessengemeinschaft Hämophiler e. V.) sowie der GTH und des PEI unterschrieben. Das PEI wurde von den beteiligten Parteien mit der Federführung zum Aufbau des DHR betraut. Im Oktober 2007 haben sich je zwei Vertreter der vier beteiligten Parteien zum DHR-Ausschuss formiert. Da das DHR personenbeziehbare Gesundheitsdaten sammeln wird, wurde dem Schutz der Persönlichkeitsrechte der Patienten und damit der Datensicherheit eine besondere Stellung eingeräumt. Das PEI hat sich deshalb an die Datenschutzbeauftragten des Bundes und der Länder gewendet mit dem Ziel, ein von allen akzeptiertes Datenschutzkonzept zu erstellen. Mit der positiven Stellungnahme aller Datenschutzbeauftragten im Mai 2007 konnte die Programmierung der Datenbank begonnen und im Februar 2008 abgenommen werden. Erweiterungen und Anpassungen, die im Testbetrieb erkennbar wurden, wurden projektiert und implementiert. Eine zusätzlich von den Datenschutzbeauftragten geforderte Sicherheitsmaßnahme wird zurzeit umgesetzt, so dass sich der offizielle Beginn um einige Monate verzögert.

Neue Daten aus dem Deutschen Hämophilieregister

The German Haemophilia Registry records online data from patients with haemophilia A, haemophilia B, von Willebrand`s disease and other coagulation factor deficiency disorders since 2009. Patient´s pseudonymised data will only be enrolled in the German Haemophilia Registry if the patient signs an informed consent. Without the informed consent, only aggregated data according to §21 German Transfusion Law are reported. These data include the number of persons with congenital haemostasis disorders classified to type of disease and severity as well as patients’ age, and the consumption of clotting factor according to each group. Results: The highest number of patients with haemophilia was reported in 2010: 3375 patients with haemophilia A and 614 with haemophilia B respectively; the highest number of patients with von Willebrand`s disease was 1473, reported in 2011. Conclusion: In comparison to data from registries in Austria and Switzerland it can be assumed that most of the patients with severe haemophilia are registered in the German Haemophilia Registry whereas patients with moderate and mild forms are still missing.

The growing number of hemophilia registries: Quantity vs. quality

Registries for rare diseases provide a tool for obtaining an overview of the clinical situation and can be used to discover points of improvement and to monitor long-term safety. Registries could also become a powerful tool to provide supporting information for marketing authorization. There is an urgent need for a pan-European or global strategy that supports consistent data. Therefore, transparency in data collection, harmonization of the database structures, and the convergence of scientific approaches are required.

Experimentelle Untersuchungen über den Einfluß der Wand-Raumladungsschicht bei der Extraktion positiver Ionen

The mechanism of ion extraction from a weakly ionized plasma has been investigated using a quadrupole mass spectrometer. The plasma was generated in a flow system by means of a high frequency discharge.

It could be shown that the picture given by PAHL has to be extended by considering a space charge sheath spread over several mean free ion paths in front of the plane extraction probe, used. Two effects, resulting from the space charge, have been found observing the behaviour of nitrogen ions. First, the directional distribution of the extracted ions may be different for different ions. Second, ion-molecule reactions may be caused by the field strength within the sheath varying with both ion number density and probe voltage. In the case of N4 + ions the Varney reaction seems already to start in the static sheath. In order to minimize influences from the space charge, it is suitable to apply a slightly positive potential with respect to the container wall.

[New data from the German Haemophilia Registry]

The German Haemophilia Registry records online data from patients with haemophilia A, haemophilia B, von Willebrand`s disease and other coagulation factor deficiency disorders since 2009. Patient's pseudonymised data will only be enrolled in the German Haemophilia Registry if the patient signs an informed consent. Without the informed consent, only aggregated data according to §21 German Transfusion Law are reported. These data include the number of persons with congenital haemostasis disorders classified to type of disease and severity as well as patients' age, and the consumption of clotting factor according to each group.

RESULTS

The highest number of patients with haemophilia was reported in 2010: 3375 patients with haemophilia A and 614 with haemophilia B respectively; the highest number of patients with von Willebrand's disease was 1473, reported in 2011.

CONCLUSION

In comparison to data from registries in Austria and Switzerland it can be assumed that most of the patients with severe haemophilia are registered in the German Haemophilia Registry whereas patients with moderate and mild forms are still missing.

[Documentation of haemophilia treatment supported by the German Hemophilia Registry]

The DHR (Deutsches Hämophilieregister, German Haemophilia Register) records patient data on haemophilia A, haemophilia B, von Willebrand disease, and other coagulation factor deficiency disorders. The DHR has been online since 2009. The participation in the DHR leads to additional administrative workload for the hospitals and physicians, but provides many advantages as well: A standard of documentation will be developed to give evidence for the hospitals. They may use their own data as well as with new possibilities for data processing at any time. Reports in accordance with Section21 TFG (Transfusionsgesetz, German Transfusion Act) are compiled automatically and transmitted to the Paul-Ehrlich-Institut. The DHR may support the searching for patients fulfilling the requirements for participation in a study.

Dokumentation in der Hämophilietherapie mit Unterstützung des Deutschen Hämophilieregisters

The DHR (Deutsches Hämophilieregister, German Haemophilia Register) records patient data on haemophilia A, haemophilia B, von Willebrand disease, and other coagulation factor deficiency disorders. The DHR has been online since 2009. The participation in the DHR leads to additional administrative workload for the hospitals and physicians, but provides many advantages as well: A standard of documentation will be developed to give evidence for the hospitals. They may use their own data as well as with new possibilities for data processing at any time. Reports in accordance with Section 21 TFG (Transfusionsgesetz, German Transfusion Act) are compiled automatically and transmitted to the Paul-Ehrlich-Institut. The DHR may support the searching for patients fulfilling the requirements for participation in a study.

[DHR--ready for take-off]

The collaboration between the Paul-Ehrlich-Institute (PEI) and the GTH as well as the two patient organisations, DHG and IGH has been official since February 2007 with the signing of the collaboration contract. In December 2008, the University of Munich started data enrollment. The DHR is a new software development which includes matters and modules of epidemiological as well as clinical cancer registries. Instead of collaborating with a trustee for personal data the DHR is using a so called "Intermediate". Intermediate is an independent software module installed on a separate server without hard disk and with solely random access memory. It receives personal data from the treaters over the internet, calculates the pseudonyms, which are then forwarded to the database. The Intermediate needs to be protected from data access by the PEI and its operating system and software has to be started afresh with each start. These facts require the involvement of a trustworthy third party. It shuts Intermediate off from the PEI without itself coming into the possession of personal data.

Two-stage focus-hold system for rapid ultra-sensitive read-out of large-area biochips

We report here the development of a method for holding the focal plane in a fluorescence-based biochip scanner. The fast read-out of large (multiple cm(2)) glass slides as used in modern chip technology imposes severe constraints on the focal system. The limited focal depth of high-NA objectives together with the demand for single-molecule sensitivity challenges traditional focus-hold systems. Various long- and short-term effects disturb the often multiple hour-long data-acquisitioning process and cause blurred or unusable image data. Traditional focus-hold systems were often limited in terms of range, reaction time, sensitivity or demanded a large number of additional components. Our system uses the back-reflected illumination beam always present in total internal reflection fluorescence microscopy to generate an error proportional electrical signal, which in turn drives an actuator correcting the objective-sample distance. The latter consists of a fast but range-limited piezo drive attached to the objective and a slower motor coupled to the microscope's z-drive. With this combination, fast reaction times and virtually unlimited correction distances are possible. We show the applicability by scanning DNA microarrays on 27 x 18-mm(2) glass slides with single-molecule sensitivity over the whole array. Single-fluorescence dyes are imaged as diffraction-limited spots.

DHR – Ready for take-off

The collaboration between the Paul-Ehrlich-Institute (PEI) and the GTH as well as the two patient organisations, DHG and IGH has been official since February 2007 with the signing of the collaboration contract. In December 2008, the University of Munich started data enrollment. The DHR is a new software development which includes matters and modules of epidemiological as well as clinical cancer registries. Instead of collaborating with a trustee for personal data the DHR is using a so called “Intermediate”. Intermediate is an independent software module installed on a separate server without hard disk and with solely random access memory. It receives personal data from the treaters over the internet, calculates the pseudonyms, which are then forwarded to the database. The Intermediate needs to be protected from data access by the PEI and its operating system and software has to be started afresh with each start. These facts require the involvement of a trustworthy third party. It shuts Intermediate off from the PEI without itself coming into the possession of personal data.

[The German haemophilia register]

Since December 2004, the Paul-Ehrlich-Institut (PEI) has stepped up its efforts to develop the Deutsche Hämophilieregister (DHR, German Haemophilia Register). In February 2007, during the annual conference of the GTH, the collaboration contract for the establishment and operation of the German Haemophilia Register was signed as a joint project of the patient organisations DHG and IGH, the GTH, and the PEI. The parties involved conferred the responsibility for establishing the German Haemophilia Register to the PEI. They also decided that the German Haemophilia Register should be located at the PEI. Two representatives from each of the four parties involved formed as the steering committee. Since the DHR will collect personal health data, special importance must be attached to the protection of the patients' personal rights and data security. The PEI contacted the data protection representative of the Federal Republic of Germany and the federal states with the aim of a data protection concept acceptable to all parties involved. A favourable opinion from all data protection representatives was formulated in May 2007 so thus programming the database was accepted in February 2008. In the following testing period enlargements and adaptations were detected and projected. The security measures demanded by the data protection representatives will delay the official launching of the German Haemophilia Register as online register for some months.

[Report on notifications with respect to section sign 21 German Transfusion Act for 2003 and 2004]

Data with respect to the section sign 21 Transfusion Act concerning collection, manufacture, imports and exports show consolidation, but a non-plausible discrepancy due to the considerably lower figures of product consumption. Failure of numerous institutions to report their consumption precludes an interpretation as surplus supply. Homologous blood donations peaked in 2003 (6.8 million) with 2.4 million thereof being apheresis, which decreased to 1.6 million in 2004. Manufacture of red cells reached a peak of 4.52 million in 2004, with 74% attributable to the Red Cross. Reported consumption differs so significantly that the PEI considers utilising the legal possibility to compare the distribution lists of blood services with submitted user data. The 2.4 million litres plasma for fractionation in 2003 constitute the hitherto highest value, with a 62% share of apheresis; the latter decreased in 2004 to 50% of 1.9 million litres, paralleled by a decrease in commercial plasma centres. The new request (2004) for figures of fractionation in Germany revealed 734,224 litres, i.e. 45% of the calculated available amount on the German market. Isolated consideration of the German situation concerning plasma derivatives is impossible due to complex trade and manufacture in various federal states. Assessment of the supply situation is further impaired by missing data from users. Regarding haemophilia treatment, an improvement is intended by establishing a German Haemophilia Register.

Haploinsufficiency of the SERPINA6 gene is associated with severe muscle fatigue: A de novo mutation in corticosteroid-binding globulin deficiency

Corticosteroid-binding globulin (SERPINA6) deficiency is an extremely rare hereditary disorder characterized by reduced corticosteroid-binding capacity with normal or low plasma corticosteroid-binding globulin concentration, and normal or low basal cortisol levels associated with hypo-/hypertension and muscle fatigue. Here, we present a patient with severe muscle fatigue, normal blood pressure, and abnormal high saliva cortisol levels following a standardized stress test. This patient was found heterozygous for a de novo 367 asparagine-encoding variant of the corticosteroid-binding globulin gene, previously described as "transcortin Lyon". Both parents were homozygous for the ("wildtype") 367 aspartate-encoding allele. To the best of our knowledge, this case represents the first de novo mutation reported for corticosteroid-binding globulin deficiency, implicating a pathogenic role of variants of SERPINA6 in some cases of muscle fatigue.

[Working hours and job satisfaction among physicians in hospitals and general practice in Munich. Results of an anonymous questionnaire]

PURPOSE

In autumn 2004 the local association of physicians (Arztlicher Kreis- und Bezirksverband München) performed a survey among employed physicians in Munich on working hours and working conditions. The aim of the study was to assess the extent to which the German law on working hours is actually implemented in employed physicians, and to obtain information about their work satisfaction.

METHODS

A questionnaire was sent to all employed physicians in hospitals and medical practices. Participants were asked to give anonymous information and send it back per mail.

RESULTS

In total, 2450 out of 5461 physicians took part in the survey. 45% reported that their working hours do not meet the German law on working hours of 1994. 44.4% stated that overtime is not fully recognized by their employers. 43.5% think the job would become more attractive if the law was implemented. 63.3% expect an income loss with the implementation. 53.7% are thinking about quitting their job. For 59.9% the burden of long working hours is an important reason for this. Women are more likely to be given a limited employment contract than men, and their overtime is more rarely recognized in full.

CONCLUSION

Many employed physicians in Munich are dissatisfied with their job. The high burden of long working hours is a main reason for this.

Plasma quality after whole-blood filtration depends on storage temperature and filter type

The study evaluated the quality of plasma obtained after whole-blood filtration with four different polyester filters and one polyurethane filter. The activities of coagulation factors and proteinase inhibitors were not or only negligibly affected by filtration, in all experiments. Filtration did not increase markers of clotting and fibrinolysis. Only a strong neutrophil and complement activation was observed, which depended on the type of filter and whole-blood storage conditions. However, as neutrophil elastase-specific degradation products did not increase and the complement-derived anaphylatoxin C3a was found in its inactivated form, C3a-desArg, these filtration-dependent changes apparently have little impact on the therapeutic quality of whole-blood-filtered fresh frozen plasma for transfusion.

Simultaneous optical and electrical recording of single gramicidin channels

We report here an approach for simultaneous fluorescence imaging and electrical recording of single ion channels in planar bilayer membranes. As a test case, fluorescently labeled (Cy3 and Cy5) gramicidin derivatives were imaged at the single-molecule level using far-field illumination and cooled CCD camera detection. Gramicidin monomers were observed to diffuse in the plane of the membrane with a diffusion coefficient of 3.3 x 10(-8) cm(2)s(-1). Simultaneous electrical recording detected gramicidin homodimer (Cy3/Cy3, Cy5/Cy5) and heterodimer (Cy3/Cy5) channels. Heterodimer formation was observed optically by the appearance of a fluorescence resonance energy transfer (FRET) signal (irradiation of Cy3, detection of Cy5). The number of FRET signals was significantly smaller than the number of Cy3 signals (Cy3 monomers plus Cy3 homodimers) as expected. The number of FRET signals increased with increasing channel activity. In numerous cases the appearance of a FRET signal was observed to correlate with a channel opening event detected electrically. The heterodimers also diffused in the plane of the membrane with a diffusion coefficient of 3.0 x 10(-8) cm(2)s(-1). These experiments demonstrate the feasibility of simultaneous optical and electrical detection of structural changes in single ion channels as well as suggesting strategies for improving the reliability of such measurements.

Gestures maintain spatial imagery

Recent theories suggest alternatives to the commonly held belief that the sole role of gestures is to communicate meaning directly to listeners. Evidence suggests that gestures may serve a cognitive function for speakers, possibly acting as lexical primes. We observed that participants gestured more often when describing a picture from memory than when the picture was present and that gestures were not influenced by manipulating eye contact of a listener. We argue that spatial imagery serves a short-term memory function during lexical search and that gestures may help maintain spatial images. When spatial imagery is not necessary, as in conditions of direct visual stimulation, reliance on gestures is reduced or eliminated.

[Diarrhea as the initial manifestation of medullary thyroid gland carcinoma]

BACKGROUND

With the differential diagnosis of a diarrhea a lot of causes has to be considered. In very rare cases diarrhea can be the first symptom of a medullary thyroid carcinoma (MTC).

CASE REPORT

A 28-year-old patient came to the admission department because of persisting diarrhea. A computerized tomography revealed multiple hepatic and pulmonary metastases. A medullary thyreoid carcinoma was found as the cause of it. The serum calcitonin values were highly increased, later the carcinoembryonal antigen (CEA), too. Sandostatin, a radioimmune therapy (131J-anti-CEA antibody) and adriamycin were therapeutically applied. The patient died 24 months after the occurrence of the first symptoms.

CONCLUSION

In case of persisting diarrhea the differential diagnosis of a medullary thyroid carcinoma must be taken into consideration and a calcitonin determination has to be arranged. Yet, typical symptoms like struma nodosa, swollen neck lymph nodes or a CEA increase can still be missing in the initial phase.

Corf, the Rev/Rex homologue of HTDV/HERV-K, encodes an arginine-rich nuclear localization signal that exerts a trans-dominant phenotype when mutated

Regulation of nucleo-cytoplasmic export of viral transcripts by a viral protein (Rev/Rex) is a characteristic feature in the replication cycle of complex retroviruses. We recently reported that the endogenous retrovirus family HTDV/HERV-K encodes a protein, Corf, that is a cellular Counterpart of Rev/Rex function and thus a new component of nucleo-cytoplasmic pathways. In HTDV/HERV-K-expressing cells, Corf is localized within the nucleoli. Here we describe the nuclear localization signal (NLS) of the Corf protein. Mutations in the NLS lead to cytoplasmic accumulation of the mutated protein and abrogate Corf function in a trans-dominant way.

Evaluation of scanners and CCD cameras for high-resolution TEM of protein crystals and single particles

The modulation transfer function (MTF) and the geometric errors of two flatbed scanners, a slow-scan CCD (SSC) camera and film, have been measured and compared. The geometric errors of the SSC camera and film have been measured using diffraction spots from a lipid crystal. The SSC camera was shown to have the smallest geometric errors while film had the best MTF. Even though film had the best MTF, this is significantly reduced when scanning the film, so that the MTF of the film and scanner combined are comparable to the MTF of the SSC camera.

Mitochondria-derived and extra-mitochondrial human type-1 porin are identical as revealed by amino acid sequencing and electrophysiological characterisation

In mammalian cells porin channels are localised in both mitochondrial outer membranes and extra-mitochondrial membranes. We isolated mitochondria-derived porin of a human lymphoblastoid B cell line, determined its amino acid sequence and characterised its channel properties. Interestingly, the amino acid sequence of this porin preparation and, correspondingly, its electrophysiological characteristics in a reconstituted system were identical to those of 'Porin 31HL', the human type-1 porin purified from a crude membrane preparation of the same cell line using a different purification protocol. The results raise questions about targeting, insertion and orientation of human type-1 porin in different membranes.

[Malaria--state of the art. 2: Therapy and prevention of malaria]

Suspected tropical malaria is an acute emergency. Immediate effective pharmacological treatment is of the essence. As in the case of prevention, various antimalarials are now available for treatment. Complicated tropical malaria requires treatment in hospital and intensive monitoring. The risk of infection and serious illness leading to a fatal outcome can be considerably reduced by suitable chemoprophylaxis or the use of stand-by medication for self-treatment, which, however, must be matched to resistance zones and the incidence of the four species of Plasmodium, in particular Plasmodium falciparum.

[Malaria--state of the art. I: Epidemiology, forms of malaria, diagnosis]

Year for year, some 2.1 million people die of malaria worldwide. In Germany, about 1,000 people go down with the disease after visiting malarious areas, and up to 3% will die--mostly of tropical malaria. Decisive factors for mortality are age over 60 and delays in effective pharmacological therapy. It is essential that, in the presence of an appropriate history, malaria be suspected early on. The diagnosis can still be established using the "thick drop", or a blood smear stained with Pappenheim's stain, or Diff-Quick. In the event of a strong suspicion, the two methods should be applied every 8 hours for three days.

[Prolonged non-convulsive status epilepticus as an early clinical manifestation of epilepsy in connection with HIV infection--case report with EEG and MRI follow-up]

The non-convulsive status epilepticus (NCSE) is a complication of petit mal epilepsy or epilepsy with temporal lobe seizures. Very rarely it is the primary manifestation of a symptomatic epilepsy. This report is on a 30-year old female inpatient with NCSE as the primary manifestation of symptomatic epilepsy, occurring four years after HIV infection (stage B3 according to the CDC classification) through heterosexual contact. After an initial tonic-clonic seizure, the patient suffered from NCSE for four weeks with diminished consciousness and major cognitive deficits. During this whole time period the EEG showed bilateral synchrone 1-2 Hz spike-wave complexes. After several failed treatment attempts, the NCSE was successfully and permanently treated with a combination of valproic acid and ethosuximide. The cerebrospinal fluid, cranial CT and cranial MRI were completely uneventful with regard to a CNS infection by the HI-virus or other infectious agents. 20 days after the initial symptoms, MRI showed bilateral cortical-subcortical and bilateral hippocampal lesions which stood out as focal edema zones, gradually disappeared completely and occurred in combination with the development of a discrete brain and right sided hippocampal atrophy. The EEG continued to show signs of right-temporal epileptic discharges with tendencies to generalise after 3 months but normalised after 6 months. Epileptic seizures are rarely an initial clinical sign of an infection with the HI-Virus even if no signs of encephalitis is detectable in the cerebrospinal fluid or in the cerebral MRI.

Acupuncture versus metoprolol in migraine prophylaxis: a randomized trial of trigger point inactivation

OBJECTIVES

To compare the effects of dry needling of myofascial trigger points in the neck region to metoprolol in migraine prophylaxis.

DESIGN

Randomized, group comparative study. patients, investigator and statistician were blinded as to treatment, the therapist was blinded as to results.

SETTING

Outpatient pain clinic in the northern Copenhagen area. Patients were referred by general practitioners or respondents to newspaper advertisements.

SUBJECTS

Included were patients with a history of migraine with or without aura for at least 2 years. Excluded were persons with contraindications against treatment with beta blockers, chronic pain syndromes, pregnancy or previous experience with acupuncture or beta-blocking agents. A total of 85 patients were included; 77 completed the study.

INTERVENTIONS

After a 4-week run-in period, patients were allocated to a 17-week regimen either with acupuncture and placebo tablets or to placebo stimulation and metoprolol 100 mg daily.

RESULTS

Both groups exhibited significant reduction in attack frequency (P < 0.01). No difference was found between the groups regarding frequency (P > 0.20) or duration (P > 0.10) of attacks, whereas we found a significant difference in global rating of attacks in favour of metoprolol (P < 0.05).

CONCLUSIONS

Trigger point inactivation by dry needling is a valuable supplement to the list of migraine prophylactic tools, being equipotent to metoprolol in the influence on frequency and duration (but not severity) of attacks, and superior in terms of negative side-effects.

Outcome of [131I]metaiodobenzylguanidine therapy of neuroblastoma: seven years after

Beginning in 1984 and based on a total of 40 treatments with [131I]metaiodobenzylguanidine (131I-MIBG) in most cases with a follow-up of 5 years or more, it seems to be worthwhile reevaluating our clinical data and draw some final conclusions: We treated 12 children with a neuroblastoma (NB) IV and 3 with a NB III. In no case 131I-MIBG was the primary therapy. The great majority suffered from recurrence. The mean treatment interval after chemotherapy was 6 months (range 0-54). We calculated a median cumulative tumor dose of 77 Gy (range 0-259) in patients with stage III and 30 Gy (range 4-267) in stage IV NB. The tumor half-life time of 131I-MIBG does not significantly differ between stage III (3 days) and IV (2-5 days). Although the median tumor dose of stage III NB exceeded that of stage IV, we found in NB IV a significant tumor remission in 7 out of 12 cases. On the other hand, a slight reduction of tumor size was seen in only 1 case of stage III NB. This indicates a lower radiation sensitivity of stage III NB. Despite this fact, the two patients with stage III NB who presented a sufficient 131I-MIBG-tumor uptake turned to become operable after 131I-MIBG. Stage IV patients improved, too, even if most of them suffered from recurrence with a very poor prognosis: 3 patients of stage IV lived longer than 48-60 month or are still alive. However, no one of this group remitted completely.(ABSTRACT TRUNCATED AT 250 WORDS)