The influence of biological DMARDs on aseptic arthroplasty loosening: a retrospective cohort study

OBJECTIVE

To investigate whether biological DMARDs affect the risk of aseptic loosening after total hip/knee arthroplasty (THA/TKA) in patients with RA.

METHODS

We retrospectively identified all patients suffering from RA who underwent THA/TKA at our academic centre between 2002 and 2015 and linked them with an existing prospective observational RA database at our institution. The risk of aseptic loosening was estimated using radiological signs of component loosening (RCL). A time-dependent Cox regression analysis was used to compare the risk of implant loosening between patients treated with traditional DMARDS and biological DMARDs, or alternately both over time.

RESULTS

A total of 155 consecutive total joint arthroplasties (TJAs) (103 TKA vs 52 THA) was retrospectively included in the study. Mean age at implantation was 59 ± 13 years. Mean follow-up time was 69 ± 43 months. Overall, 48 (31%) TJAs showed signs of RCL, with 28 (27.2%) RCLs occurring after TKA compared with 20 after THA (38.5%). A significant difference regarding the incidence of RCL between the traditional DMARDs group (39 cases of RCL, 35%) and the biological DMARDs group (nine cases of RCL, 21%) (P = 0.026) was observed using the log-rank test. This was also true when using a time-dependent Cox regression with therapy as well as arthroplasty location (hip vs knee) as variables (P = 0.0447).

CONCLUSION

Biological DMARDs may reduce the incidence of aseptic loosening after TJA in patients with RA compared with traditional DMARDs. This effect seems to be more pronounced after TKA than THA.

Two-stage revision for periprosthetic joint infection after hip and knee arthroplasty

Aims

Histology is widely used for diagnosis of persistent infection during reimplantation in two-stage revision hip and knee arthroplasty, although data on its utility remain scarce. Therefore, this study aims to assess the predictive value of permanent sections at reimplantation in relation to reinfection risk, and to compare results of permanent and frozen sections.

Methods

We retrospectively collected data from 226 patients (90 hips, 136 knees) with periprosthetic joint infection who underwent two-stage revision between August 2011 and September 2021, with a minimum follow-up of one year. Histology was assessed via the SLIM classification. First, we analyzed whether patients with positive permanent sections at reimplantation had higher reinfection rates than patients with negative histology. Further, we compared permanent and frozen section results, and assessed the influence of anatomical regions (knee versus hip), low- versus high-grade infections, as well as first revision versus multiple prior revisions on the histological result at reimplantation. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), chi-squared tests, and Kaplan-Meier estimates were calculated.

Results

Overall, the reinfection rate was 18%. A total of 14 out of 82 patients (17%) with positive permanent sections at reimplantation experienced reinfection, compared to 26 of 144 patients (18%) with negative results (p = 0.996). Neither permanent sections nor fresh frozen sections were significantly associated with reinfection, with a sensitivity of 0.35, specificity of 0.63, PPV of 0.17, NPV of 0.81, and accuracy of 58%. Histology was not significantly associated with reinfection or survival time for any of the analyzed sub-groups. Permanent and frozen section results were in agreement for 91% of cases.

Conclusion

Permanent and fresh frozen sections at reimplantation in two-stage revision do not serve as a reliable predictor for reinfection.

Early postoperative laboratory parameters are predictive of initial treatment failure in acute septic arthritis of the knee and shoulder joint

Septic arthritis is an orthopedic emergency potentially causing irreversible joint damage. However, the predictive value of potential risk factors such as early postoperative laboratory parameters remains uncertain. We investigated risk factors for initial surgical treatment failure using data from 249 patients (194 knees, 55 shoulders) treated for acute septic arthritis between 2003 and 2018. Necessity for further surgical intervention was defined as primary outcome. Demographic data, medical history, initial and postoperative laboratory parameters, Charlson Comorbidity Index (CCI), and Kellgren and Lawrence classification were collected. Two scoring systems were developed as tools for failure risk estimation after initial surgical irrigation and debridement. More than one intervention was necessary in 26.1% of cases. Treatment failure occurred significantly more often for those with longer symptom duration (p = 0.003), higher CCI grades (p = 0.027), Kellgren-Lawrence grade IV (p = 0.013), shoulder arthroscopy (p = 0.010), positive bacterial culture results (p < 0.001), slow postoperative CRP decline until day three (p = 0.032) and five (p = 0.015), reduced WBC-decline (p = 0.008), and lower hemoglobin (p < 0.001). Scores for third and fifth postoperative day achieved AUCs of 0.80 and 0.85, respectively. This study identified risk factors for treatment failure in patients with septic arthritis, suggesting that early postoperative laboratory parameters can guide further treatment.

Do Elevated Serum C-Reactive-Protein Levels Excuse Delayed Surgery for Femoral Neck Fractures?

In elderly patients with femoral neck fractures, preoperative serum C-reactive protein (CRP) values might be elevated due to active infections. Although there are limited data on CRP as a predictor of periprosthetic joint infection (PJI), out of concern, this could lead to delayed surgery. Therefore, we aim to investigate whether elevated serum-CRP levels justify delayed surgery for femoral neck fractures. A retrospective analysis was performed of the records of patients undergoing arthroplasty who were found to have an elevated CRP level of 5 mg/dL or more between January 2011 to December 2020. The patients were stratified to three groups, according to initial serum CRP levels at a cut off of 5 mg/dL and the time between admission and surgery (<48 vs. ≥48 h after admission). This study revealed that the patients with elevated serum CRP levels and delayed surgery showed a worse survival rate and significantly more postoperative complications than the patients on whom surgery was performed immediately. There were no significant differences in terms of PJI and prolonged wound healing in the inter-group comparison. Therefore, delays to surgery on the basis of elevated CRP values offer no benefits to patients with femoral neck fractures.

The accelerated waning of immunity and reduced effect of booster in patients treated with bDMARD and tsDMARD after SARS-CoV-2 mRNA vaccination

Objectives

This study aimed to assess the duration of humoral responses after two doses of SARS-CoV-2 mRNA vaccines in patients with inflammatory joint diseases and IBD and booster vaccination compared with healthy controls. It also aimed to analyze factors influencing the quantity and quality of the immune response.

Methods

We enrolled 41 patients with rheumatoid arthritis (RA), 35 with seronegative spondyloarthritis (SpA), and 41 suffering from inflammatory bowel disease (IBD), excluding those receiving B-cell-depleting therapies. We assessed total anti-SARS-CoV-2 spike antibodies (Abs) and neutralizing Ab titers 6 months after two and then after three doses of mRNA vaccines compared with healthy controls. We analyzed the influence of therapies on the humoral response.

Results

Patients receiving biological or targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs) showed reduced anti-SARS-CoV-2 S Abs and neutralizing Ab titers compared with HC or patients receiving conventional synthetic (cs)DMARDs 6 months after the first two vaccination doses. Anti-SARS-CoV-2 S titers of patients with b/tsDMARDs declined more rapidly, leading to a significant reduction in the duration of vaccination-induced immunity after two doses of SARS-CoV-2 mRNA vaccines. While 23% of HC and 19% of patients receiving csDMARDs were without detectable neutralizing Abs 6 months after the first two vaccination doses, this number was 62% in patients receiving b/tsDMARDs and 52% in patients receiving a combination of csDMARDs and b/tsDMARDs. Booster vaccination led to increased anti-SARS-CoV-2 S Abs in all HC and patients. However, anti-SARS-CoV-2 S Abs after booster vaccination was diminished in patients receiving b/tsDMARDs, either alone or in combination with csDMARDs compared to HC.

Conclusion

Patients receiving b/tsDMARDs have significantly reduced Abs and neutralizing Ab titers 6 months after mRNA vaccination against SARS-CoV-2. This was due to a faster decline in Ab levels, indicating a significantly reduced duration of vaccination-induced immunity compared with HC or patients receiving csDMARDs. In addition, they display a reduced response to a booster vaccination, warranting earlier booster vaccination strategies in patients under b/tsDMARD therapy, according to their specific Ab levels.

Neural correlates of script-driven imagery in adolescents with interpersonal traumatic experiences: A pilot study

In adults, trauma imagery has proven to be a useful tool to assess the neural mechanisms of psychological trauma processing. In adolescents, heterogeneous results could be found for other tasks, however, a trauma imagery paradigm has not been evaluated. For this purpose, we investigated a trauma imagery paradigm with control scripts to assess neural correlates of traumatic experiences in youth. 15 adolescents, who had experienced a traumatic interpersonal event in the past and have developed clinically relevant symptoms, underwent an fMRI scan while listening to their individual trauma- versus two control scripts (positive/negative). We analysed a parametric contrast of the imagery phases (trauma > negative > positive) which revealed activity in the thalamus, dorsal anterior cingulate cortex, cuneus, dorsomedial prefrontal cortex and amygdala. Additionally, amygdala-activity correlated positively with depression-symptom-severity. Our data provide evidence for the feasibility of fMRI during a trauma imagery task in adolescents to investigate networks previously related to hyperarousal in adults with PTSD. Further, we demonstrate the specificity of the activated networks for trauma imagery as compared to imagery of other emotional situations. The task might be particularly useful to evaluate neural correlates of treatment in adolescents when hyperarousal is a target symptom.

B-51 Impact of Resilience on Symptoms and Mood during Recovery in Adolescents and Young Adults Following Sports-Related Concussion

Objective

It is unclear how resilience, the ability to “bounce back” from a stressful experience, is associated with recovery following a sport-related concussion (SRC). The aim of this project is to assess how resilience is related to symptoms following SRC.

Method

Participants (N = 353) aged 12-25 were evaluated within 30 days of injury at clinics in the ConTex Concussion Registry. The Sport Concussion Assessment Tool-5 symptom evaluation, Brief Resilience Scale (BRS), General Anxiety Disorder-7 Item (GAD-7), and Patient Health Questionnaire-8 Item (PHQ-8) were administered at initial visit and at three-months. BRS scores were used to place subjects into low (n = 40), average (n = 214), and high (n = 99) resilience groups, with a 2 (time) by 3 (group) repeated measures ANOVA to compare symptom scales.

Results

At initial visit subjects with low resilience reported higher GAD-7 [F (2,308) = 3.95, p = .02; 95% C.I. 5.19, 7.64] and PHQ-8 [F (2,311) = 4.40, p = .01; 95% C.I. 4.76, 7.47] scores compared to average and high resilience samples and demonstrated significant interaction effects with time. Subjects with low resilience also endorsed more initial SCAT5 symptoms [F (2,350) = 3.69, p = .026, 95% C.I. 10.99, 14.18] but showed no interaction with time.

Conclusion

Findings suggest that resilience may influence mood (anxiety & depression) initially and during SRC recovery. Consideration of resilience as a pre-injury factor may be important in SRC research.

Disruptive Mood Dysregulation Disorder

Disruptive Mood Dysregulation Disorder (DMDD), übersetzbar als disruptive Störung der Stimmungsregulation, findet sich als neues eigenständiges Krankheitsbild im DSM-5. Im Gegensatz zu anderen disruptiven Störungsbildern wurde DMDD in den Bereich der depressiven Störungen gelegt. Der vorliegende Beitrag soll sich mit den diagnostischen Kriterien, der Prävalenz sowie den Behandlungsoptionen dieses neuen Störungsbildes, basierend auf einer selektiven Literaturübersicht auseinandersetzen. Aus Deutschland liegen keine Studien vor, die aufbauend auf den neuen diagnostischen Kriterien erstellt wurden; eine Prävalenzschätzung ist daher schwierig. Aus den USA wurden Prävalenzraten von ca. 1% aus nicht klinischen Stichproben berichtet. Die spezifischen therapeutischen Optionen zur Behandlung dieses neu geschaffenen Störungsbildes sind in ihrer Evidenz kaum überprüft. Essenziell scheinen die Trennung des Störungsbildes von bipolaren Störungen und die Beachtung von DMDD als möglicher Vorläufer einer depressiven Entwicklung.

[Urinary tract infections in children]

Urinary tract infections (UTI) are the most common bacterial infections in children. The symptoms are not very specific and range from abdominal pain, poor feeding to nocturnal urinary incontinence. The technique of collecting urine plays an important role for securing the diagnosis. The best way to obtain urine in non-toilet-trained children is catheterization or suprapubic bladder aspiration. In toilet-trained children midstream urine is an acceptable alternative after cleaning the foreskin or labia. In the case of an infection a prompt empirical antibiotic therapy is necessary to reduce the risk of parenchymal scarring of the kidneys. There are different approaches to diagnose vesicoureteral reflux in different countries. The commonly used standard approach in Germany is voiding cystourethrography. In the case of reflux dimercaptosuccinic acid (DMSA) scintigraphy should be performed additionally to exclude renal scarring (bottom-up approach).

Successful group psychotherapy of depression in adolescents alters fronto-limbic resting-state connectivity

BACKGROUND

Current resting state imaging findings support suggestions that the neural signature of depression and therefore also its therapy should be conceptualized as a network disorder rather than a dysfunction of specific brain regions. In this study, we compared neural connectivity of adolescent patients with depression (PAT) and matched healthy controls (HC) and analysed pre-to-post changes of seed-based network connectivities in PAT after participation in a cognitive behavioral group psychotherapy (CBT).

METHODS

38 adolescents (30 female; 19 patients; 13-18 years) underwent an eyes-closed resting-state scan. PAT were scanned before (pre) and after (post) five sessions of CBT. Resting-state functional connectivity was analysed in a seed-based approach for right-sided amygdala and subgenual anterior cingulate cortex (sgACC). Symptom severity was assessed using the Beck Depression Inventory Revision (BDI-II).

RESULTS

Prior to group CBT, between groups amygdala and sgACC connectivity with regions of the default mode network was stronger in the patients group relative to controls. Within the PAT group, a similar pattern significantly decreased after successful CBT. Conversely, seed-based connectivity with affective regions and regions processing cognition and salient stimuli was stronger in HC relative to PAT before CBT. Within the PAT group, a similar pattern changed with CBT. Changes in connectivity correlated with the significant pre-to-post symptom improvement, and pre-treatment amygdala connectivity predicted treatment response in depressed adolescents.

LIMITATIONS

Sample size and missing long-term follow-up limit the interpretability.

CONCLUSIONS

Successful group psychotherapy of depression in adolescents involved connectivity changes in resting state networks to that of healthy controls.

[Vesico-ureteral reflux: Diagnosis and treatment recommendations]

BACKGROUND

Vesico-ureteral reflux (VUR) is one of the most common urologic diseases in childhood. About every third child that presents with a urinary tract infection (UTI) has urinary reflux to the ureter or kidney. Demonstration of a backflow of urine into the ureters or kidneys proves vesicoureteral reflux. In unclear cases, a positioned instillation of contrast agent (PIC) cystogram might be performed and is able to prove vesico-ureteral reflux.

OBJECTIVES

Since low-grade VUR has a high probability of maturation and self-limitation, infants with VUR should be given prophylactic antibiotics during their first year of life, reevaluating the status of VUR after 12 months. The aim of any treatment is to prevent renal damage.

THERAPY

The individual risk of renal scarring is decisive for the choice of adequate therapy. This risk is mainly dependent on reflux grade, age, and gender of the child as well as parental therapy adherence. In principle, therapeutic options include conservative as well as endoscopic or open surgical antireflux therapies.

CONCLUSION

Decisions on treatment should be made individually with parents taking into account all the findings available.

[Imaging in pediatric urology]

BACKGROUND

For many years, sonography and the intravenous pyelogram (IVP) were the most important examination methods for the evaluation of the urinary tract in children. Both methods have their pros and cons: sonography provides ideal visualization of normal kidneys and the evaluation of the pelvicalyceal system. For detection or exclusion of renal scarring, however, this method is not well suited. It provides no information regarding kidney function.

METHODS

With an IVP, it is possible to evaluate urinary excretion and, thus, indirectly assess kidney function. As this examination method involves radiation exposure and the necessity of a contrast agent, it should be avoided in the examination of children. The CT is an excellent examination method that can diagnose nearly all urological diseases in children or answer urological questions; however, a CT scan applies the highest radiation dose of all discussed methods. For this reason, examination via MRI is of increasing importance in uroradiology. Initially only the T2 sequences for the visualization of the urinary tract in children were applied.

CONCLUSION

The current technical developments as well as the use of the contrast agent gadolinium and the antidiuretic agent furosemide allow an all-in-one evaluation of the kidneys and urinary tract.

Cilengitide combined with cetuximab and platinum-based chemotherapy as first-line treatment in advanced non-small-cell lung cancer (NSCLC) patients: results of an open-label, randomized, controlled phase II study (CERTO)

BACKGROUND

This multicentre, open-label, randomized, controlled phase II study evaluated cilengitide in combination with cetuximab and platinum-based chemotherapy, compared with cetuximab and chemotherapy alone, as first-line treatment of patients with advanced non-small-cell lung cancer (NSCLC).

PATIENTS AND METHODS

Patients were randomized 1:1:1 to receive cetuximab plus platinum-based chemotherapy alone (control), or combined with cilengitide 2000 mg 1×/week i.v. (CIL-once) or 2×/week i.v. (CIL-twice). A protocol amendment limited enrolment to patients with epidermal growth factor receptor (EGFR) histoscore ≥200 and closed the CIL-twice arm for practical feasibility issues. Primary end point was progression-free survival (PFS; independent read); secondary end points included overall survival (OS), safety, and biomarker analyses. A comparison between the CIL-once and control arms is reported, both for the total cohorts, as well as for patients with EGFR histoscore ≥200.

RESULTS

There were 85 patients in the CIL-once group and 84 in the control group. The PFS (independent read) was 6.2 versus 5.0 months for CIL-once versus control [hazard ratio (HR) 0.72; P = 0.085]; for patients with EGFR histoscore ≥200, PFS was 6.8 versus 5.6 months, respectively (HR 0.57; P = 0.0446). Median OS was 13.6 for CIL-once versus 9.7 months for control (HR 0.81; P = 0.265). In patients with EGFR ≥200, OS was 13.2 versus 11.8 months, respectively (HR 0.95; P = 0.855). No major differences in adverse events between CIL-once and control were reported; nausea (59% versus 56%, respectively) and neutropenia (54% versus 46%, respectively) were the most frequent. There was no increased incidence of thromboembolic events or haemorrhage in cilengitide-treated patients. αvβ3 and αvβ5 expression was neither a predictive nor a prognostic indicator.

CONCLUSIONS

The addition of cilengitide to cetuximab/chemotherapy indicated potential clinical activity, with a trend for PFS difference in the independent-read analysis. However, the observed inconsistencies across end points suggest additional investigations are required to substantiate a potential role of other integrin inhibitors in NSCLC treatment.

CLINICAL TRIAL REGISTRATION ID NUMBER

NCT00842712.

Abituzumab combined with cetuximab plus irinotecan versus cetuximab plus irinotecan alone for patients with KRAS wild-type metastatic colorectal cancer: the randomised phase I/II POSEIDON trial

BACKGROUND

Integrins are involved in tumour progression and metastasis, and differentially expressed on colorectal cancer (CRC) cells. Abituzumab (EMD 525797), a humanised monoclonal antibody targeting integrin αν heterodimers, has demonstrated preclinical activity. This trial was designed to assess the tolerability of different doses of abituzumab in combination with cetuximab and irinotecan (phase I) and explore the efficacy and tolerability of the combination versus that of cetuximab and irinotecan in patients with metastatic CRC (mCRC) (phase II part).

METHODS

Eligible patients had KRAS (exon 2) wild-type mCRC and had received prior oxaliplatin-containing therapy. The trial comprised an initial safety run-in using abituzumab doses up to 1000 mg combined with a standard of care (SoC: cetuximab plus irinotecan) and a phase II part in which patients were randomised 1 : 1 : 1 to receive abituzumab 500 mg (arm A) or 1000 mg (arm B) every 2 weeks combined with SoC, or SoC alone (arm C). The primary end point was investigator-assessed progression-free survival (PFS). Secondary end points included overall survival (OS), response rate (RR) and tolerability. Associations between tumour integrin expression and outcomes were also assessed.

RESULTS

Phase I showed that abituzumab doses up to 1000 mg were well tolerated in combination with SoC. Seventy-three (arm A), 71 (arm B) and 72 (arm C) patients were randomised to the phase II part. Baseline characteristics were balanced. PFS was similar in the three arms: arm A versus SoC, hazard ratio (HR) 1.13 [95% confidence interval (CI) 0.78-1.64]; arm B versus SoC, HR 1.11 (95% CI 0.77-1.61). RRs were also similar. A trend toward improved OS was observed: arm A versus SoC, HR 0.83 (95% CI 0.54-1.28); arm B versus SoC, HR 0.80 (95% CI 0.52-1.25). Grade ≥3 treatment-emergent adverse events were observed in 72%, 78% and 67% of patients. High tumour integrin αvβ6 expression was associated with longer OS in arms A [HR 0.55 (0.30-1.00)] and B [HR 0.41 (0.21-0.81)] than in arm C.

CONCLUSION

The primary PFS end point was not met, although predefined exploratory biomarker analyses identified subgroups of patients in whom abituzumab may have benefit. The tolerability of abituzumab combined with cetuximab and irinotecan was acceptable. Further study is warranted. CLINICALTRIALS.GOV IDENTIFIER: NCT01008475.

All-atom empirical potential for molecular modeling and dynamics studies of proteins

New protein parameters are reported for the all-atom empirical energy function in the CHARMM program. The parameter evaluation was based on a self-consistent approach designed to achieve a balance between the internal (bonding) and interaction (nonbonding) terms of the force field and among the solvent-solvent, solvent-solute, and solute-solute interactions. Optimization of the internal parameters used experimental gas-phase geometries, vibrational spectra, and torsional energy surfaces supplemented with ab initio results. The peptide backbone bonding parameters were optimized with respect to data for N-methylacetamide and the alanine dipeptide. The interaction parameters, particularly the atomic charges, were determined by fitting ab initio interaction energies and geometries of complexes between water and model compounds that represented the backbone and the various side chains. In addition, dipole moments, experimental heats and free energies of vaporization, solvation and sublimation, molecular volumes, and crystal pressures and structures were used in the optimization. The resulting protein parameters were tested by applying them to noncyclic tripeptide crystals, cyclic peptide crystals, and the proteins crambin, bovine pancreatic trypsin inhibitor, and carbonmonoxy myoglobin in vacuo and in crystals. A detailed analysis of the relationship between the alanine dipeptide potential energy surface and calculated protein φ, χ angles was made and used in optimizing the peptide group torsional parameters. The results demonstrate that use of ab initio structural and energetic data by themselves are not sufficient to obtain an adequate backbone representation for peptides and proteins in solution and in crystals. Extensive comparisons between molecular dynamics simulations and experimental data for polypeptides and proteins were performed for both structural and dynamic properties. Energy minimization and dynamics simulations for crystals demonstrate that the latter are needed to obtain meaningful comparisons with experimental crystal structures. The presented parameters, in combination with the previously published CHARMM all-atom parameters for nucleic acids and lipids, provide a consistent set for condensed-phase simulations of a wide variety of molecules of biological interest.

Low molecular weight heparins for thromboprophylaxis during induction chemotherapy in patients with multiple myeloma

BACKGROUNDS

Patients with multiple myeloma have a high risk of venous thromboembolism (VTE), especially during the induction chemotherapy. The aim of our observational study was to determine the impact of prophylaxis with low molecular weight heparin (LMWH) on the incidence of thromboembolic complications.

PATIENTS AND METHODS

We analyzed the incidence of thromboembolic events in 258 patients treated with induction chemotherapy containing vincristin, doxorubicin or idarubicin, and dexamethasone, followed by stimulation chemotherapy with cyclophosphamide and G-CSF, and high-dose chemotherapy with melphalan. Two groups of these patients were compared based on the practice of thromboprophylaxis. Patients in the first group (Control, n = 140) were either not treated or treated with a short duration of anticoagulation therapy while the patients in the second group (Prophylactic, n = 118) underwent standard prophylaxis with LMWH throughout the entire period of induction chemotherapy. A total of 102 patients were selected for a close monitoring of the prophylactic effect of different LMWH doses and to be compared to patients without treatment.

RESULTS

Standard prophylaxis with LMWH significantly (p < 0.007) lowered a risk of VTE when compared to patients without such prophylaxis (3.4% versus 12.9%, respectively). Furthermore, analysis of the subgroup of 102 patients revealed that higher LMWH doses (> 70 IU/kg per day) achieved full prophylaxis in 28 patients while lower doses were less effective leading to DVT in 3 (7.7%) out of 39 patients. In contrast, VTE was diagnosed in 5 (14.3%) out of 35 patients without any LMWH prophylaxis.

CONCLUSION

Prophylaxis with LMWH leads to a significant reduction of the risk of thromboembolic complications during the induction chemotherapy in patients suffering from MM. The prophylactic effect of LMWH is dose-dependent.

Retrospective analysis of the results of high-dose chemotherapy with the support of autologous blood stem cells in patients with multiple myeloma. The experience of a single centre

Despite new medical products introduced in multiple myeloma therapy, autologous stem cell transplant (ASCT) remains a standard procedure in younger patients with symptomatic disease. We analyzed a group of 190 patients who underwent ASCT at our clinic for multiple myeloma as primary therapy in years 1995-2008. The total number of transplants performed in this group was 291. 110 patients underwent one ASCT, 59 patients had double transplant, out of which 51 patients underwent tandem transplant, 21 patients underwent triple ASCT, out of which 15 patients were transplanted front-line throughout a clinical trial and 6 patients underwent follow-up transplants due to disease progression. The assessment of the best therapeutic effect of ASCT showed the total rates of patients with complete remission--22%, very good partial remission (VGPR)--8%, partial remission--63%, stabilized disease--6% and progression--1%. The transplant related mortality (TRM) was 4.1%. With the median follow-up of surviving patients 2.6 years, the median progression-free survival (PFS) and overall survival (OS) were 21 and 54 months, respectively; the likelihood of a 7-year overall survival was 28%. Comparing tandem versus single transplants, there was a significant increase in the median PFS (25.8 versus 20.8 months, respectively); however, there was no difference in overall survivals. The IVE mobilization regimen was found to be more efficacious for PBPC collection than high-dosed cyclophosphamide.

[Lenalidomid (Revlimid) in the treatment of multiple myeloma--first experience in the Czech Republic]

The prognosis of multiple myeloma (MM) has substantially improved during last decades due to new, so-called targeted drugs--proteasome inhibitor bortezomib and immunomodulatory drugs (ImiDs), thalidomide and lenalidomide. They could be used in various combinations and/or sequentially thanks to different mechanism of action and toxicity. Both bortezomib and thalidomide are widely used in Czech republic, however, lenalidomide was approved for the treatment of MM (and MDS) at the very latest and its usage is limited due to high costs, as well. According to the results of clinical trials lenalidomide is effective in myeloma refractory to various therapy including other new drugs. First time in the Czech republic the combination of lenalidomide and dexamethasone was given in our center to 2 patients with relapsed myeloma as 7th and 10th line of therapy. Acceptable results of treatment with improved clinical status in the first patient enabled to suspend his therapeutic plasmaferesis. Disease stabilization lasting three months was observed also in the second patient.

[Detection of free light chains--a new method of diagnostics of haematological diseases]

BACKGROUND

To diagnose monoclonal gamopathy, one of the most frequent haematological diseases, we use immunochemical assays, which are based on the detection of paraprotein in serum and/or urine.

METHODS AND RESULTS

The most common laboratory assays we use are SPE (serum protein electrophoresis) and IFE (immunofixation electrophoresis). New method represents the detection of free light chain (FLC) in serum. In our study we compared those three methods (SPE, IFE and FLC) from the point of sensitivity of paraprotein detection. For FLC detection was used Freelite system analyzer (Immunotech Beckman Coulter). We examined 51 patients with diagnosis of multiple myeloma, nonHodgkin's lymphoma, primary amyloidosis and monoclonal gammopathy of undetermined significance.

CONCLUSIONS

Detection of FLC is a valuable method which sometimes could specify diagnosis of MG and make the treatment more accurate.

[Recommendations for early identification of damage to the skeleton by malignant processes, and for early diagnosis of multiple myeloma]

The number of newly diagnosed cases of multiple myeloma in the Czech Republic is about 3-4 per 100 000 persons per year. In the higher age groups, the incidence increases. Multiple myeloma is an illness that reacts well to treatment which can result in periods of remission lasting for years. Some of the patients are even able to return to work. A pre-requisite for successful treatment is early diagnosis and this is usually in the hands of first line physicians. This is the reason why the Czech Myeloma Group, in conjunction with neurologists, orthopedicians and radio diagnosticians has issued the following recommendations for first line physicians containing a more detailed description of the symptoms and the diagnostic pitfalls of the disease. This disease reminds a chameleon for the variety of its symptoms. For the sake of clarification, we shall divide multiple myeloma symptoms into five points, each of which is reason enough to warrant an examination to confirm or rule out a malignant cause of health problems (a negative result does not automatically mean exclusion). If any of the recommended examinations results positive, the diagnostic process must be continued, in which case a general practitioner refers the patient to a specialist health centre. Observing these recommendations should minimize the number of cases of late diagnosis. 1. Bone destruction symptoms. - Unexplained backache for more than one month in any part of spine even without nerve root irritability or without pain in other part of skeleton (ribs, hips, or long bones). - Pain at the beginning of myeloma disease is very similar to benigne common discopathy, however the intensity of backache is decreasing within one months in benigne disease. In the case of malignant process the intensity of bone pain is steadily increasing. - Immediate imaging and laboratory investigation are indicated by resting and night pain in spinal column or in any part of skeleton. - Backache with the sign of spinal cord or nerve compression should be sent for immediate X Ray, and focussed CT/MRI followed by acute surgery if needed. - Osteoporosis especially in men and premenopausal women. 2. Features of changed immunity or bone marrow function. Persistent and recurrent infection, typical is normochromic anaemia, with leucopenia and trombocytopenia. 3. Raised erythrocyte sedimentation rate even increase concentration of total plasma protein. 4. Impaired renal function. Increased level of creatinin or proteinuria, nephrotic syndrome with bilateral legs oedema. 5. Hypercalcemia with typical clinical symptoms (polyuria with dehydratation, constipation, nausea, low level conscience, coma). Every one from these points has to be reason for general medical doctor to start battery of tests: -X-ray of bones focused to painful area (mandatory before physiotherapy, local anaesthesia or other empiric therapy). If plain X-ray does not elucidate pain and symptoms are lasting more than one month, please consider all circumstances and results from laboratory investigation. This patient needs referral to the centre with MRI/CT facilities (CT or MRI is necessary investigation in case of nerve root or spine compression). -Investigation of erythrocyte sedimantion rate (high level of sedimentation of erythrocyte can indicate multiple myeloma). -Full blood count. -Basic biochemical investigation serum and urine: serum urea, creatinin, ionts including calcium, total protein, and albumin CRP (high concentration of total protein indicates myeloma, low level of albumin indicates general pathological process, similary increased concentration of fibrinogen, impaired renal function indicates myeloma kidney, however hypercalcemia is typical for highly aggressive myeloma). -Quantitative screening for IgG, IgM and IgA in serum (isolated raised level one of immunoglobulin with decreased level of the others indicates myeloma). -Common electrophoresis of serum is able to detect monoclonal immunoglobulin level at few gramm concentration. If all the laboratory investigation are in normal level the possibility that the current problems are multiple myeloma origine is smaller, but it does not exclude one of rare variant--non secretory myeloma (undifferentiated plasmocyt lost characteristic feature to produce monoclonal immunoglobulin). If any of tests indicate the possibility of myeloma, patient require urgent specialist referral to department with possibility to make diagnosis of malignant myeloma.

International Staging System required standardization of biochemical laboratory testing in multiple myeloma

The standardization of biochemical measurement procedures in multiple myeloma is necessary for reliable prognostic stratification of patients in multicentric trials. The new prognostic index International Staging System for multiple myeloma uses only two laboratory markers, albumin and beta-2 microglobulin. Our study compared results of albumin, beta-2 microglobulin and monoclonal immunoglobulin measurements from six centers which provide treatment for multiple myeloma in the Czech Republic and attempted to standardize the analytic procedures. We have found that the measurement of albumin is well standardized and the results from all laboratories were comparable. The measurement of beta-2 microglobulin achieved comparability only after a partial unification of analytical methods. The determination of monoclonal immunoglobulin concentration provided comparable results for concentrations higher than 20 g/l with higher variability for lower values.

Schistosomiasis in einem uterinen Leiomyom

This case report deals with an, in our regions, unusual diagnosis of coincidence of a genital schistosomiasis of a 30-year-old woman, coming from Africa. The female patient presented herself by a specialist because of longer lasting hypermenorrhoe. After clinical examination the patient underwent an operation because of an uterus myomatosus. The histopathological evaluation showed beside a leimyoma an expanded infestation with schistosomiasis haematobium. After pathological diagnosis the patient underwent the standard therapy with a single injection of praziquantel. We report about the clinic, epidemiology, morphology and diagnostic.

[Pilot study of echocardiographic studies using color- and pulsed-wave spectral Doppler methods in blue-crowned amazons (Amazona ventralis) and blue-fronted amazons (Amazona a. aestiva)]

Colour-flow and pulsed-wave spectral Doppler echocardiography was performed on 6 healthy, adult Hispaniolan amazon parrots (Amazona ventralis) and 6 blue-fronted amazon parrots (Amazona a. aestiva) to establish normal reference values. Birds were anesthetized with isoflurane in oxygen and placed in dorsal recumbency. An electrocardiogram was recorded continuously and birds were imaged with a micro-phased-array scanner with a frequency of 7.0 MHz. After assessment of cardiac function in 2-D-echocardiography, blood flow across the left and the right atrioventricular valve and across the aortic valve was determined using color-flow and pulsed-wave spectral Doppler echocardiography. Diastolic inflow (mean value +/- standard deviation) into the left ventricle was 0.17 +/- 0.02 m/s (Hispaniolan amazons) and 0.18 +/- 0.03 m/s (Blue fronted amazons). Diastolic inflow into the right ventricle was 0.22 +/- 0.05 m/s (Hispaniolan amazons) and 0.22 +/- 0.04 m/s (Blue fronted amazons). Velocity across the aortic valve was 0.84 +/- 0.07 m/s (Hispaniolan amazons) and 0.83 +/- 0.08 m/s (Blue fronted amazons). Systolic pulmonary flow could not be detected in any of the birds in this study. No significant differences were evident between the two species examined. Results of this study indicate that Doppler echocardiography is a promising technique to determine blood flow in the avian heart. Further studies in other avian species are needed to establish reference values for assessment of cardiac function in diseased birds.

[Bortezomib (Velcade) in relapsed/refractory multiple myeloma--the first experience in the Czech Republic]

BACKGROUND

Multiple myeloma is the second most prevalent and mostly fatal hematologic cancer. Further advances have been made in understanding the mechanisms involved in the myeloma pathogenesis and elucidation of critical signalling pathways as therapeutical targets. Proteasome inhibitors are the example of this new approach and bortezomib is the first agent in this class to enter clinical trials.

METHODS AND RESULTS

In 6 hematological centers in Czech Republic 29 patients with refractory/relapsed myeloma had been treated with bortezomib (Velcade, Millennium Pharmaceuticals) in 2004. The initial dose 1.3 mg/m2 of Velcade was given, in 1 case the dose was adjusted due to pre-existing renal failure to 1 mg/m2. The response was achieved in 17 patients (59%). Four patients had complete, 11 partial and two minor responses. In 5 cases stabilization of disease was observed and 6 patients progressed during the therapy.

CONCLUSIONS

Unfortunately, one patient died immediately after the start of therapy due to sepsis. The most common adverse events were thrombocytopenia, anaemia, neuropathy, gastrointestinal complication, renal failure and fatigue. Grade 4 adverse events occurred in 37.9% of patients (4x thrombocytopenia, 2x gastrointestinal, 2x renal failure, 1x sepsis, leucopenia, hepatopathy and anaemia, respectively). Peripheral neuropathic pain of grade 3 was reported in 4 cases, in one patient therapy had to be interrupted due to this complication. We confirmed promising results of phase II trials.