Tumor-derived GDF-15 blocks LFA-1 dependent T cell recruitment and suppresses responses to anti-PD-1 treatment

Immune checkpoint blockade therapy is beneficial and even curative for some cancer patients. However, the majority don't respond to immune therapy. Across different tumor types, pre-existing T cell infiltrates predict response to checkpoint-based immunotherapy. Based on in vitro pharmacological studies, mouse models and analyses of human melanoma patients, we show that the cytokine GDF-15 impairs LFA-1/β2-integrin-mediated adhesion of T cells to activated endothelial cells, which is a pre-requisite of T cell extravasation. In melanoma patients, GDF-15 serum levels strongly correlate with failure of PD-1-based immune checkpoint blockade therapy. Neutralization of GDF-15 improves both T cell trafficking and therapy efficiency in murine tumor models. Thus GDF-15, beside its known role in cancer-related anorexia and cachexia, emerges as a regulator of T cell extravasation into the tumor microenvironment, which provides an even stronger rationale for therapeutic anti-GDF-15 antibody development.

Abstract 6118: Tumor-derived GDF-15 promotes immune escape of tumors by functional alteration of the myeloid compartment

Background: Growth and differentiation factor 15 (GDF-15), a divergent member of the TGF-β protein superfamily, shows low physiological baseline expression. GDF-15 is, however, strongly upregulated during pregnancy. It is further induced in stressed and damaged tissues, where it limits immune infiltration and inflammation. In solid tumors, GDF-15 was shown to be a key inhibitor of T-cell infiltration. While this might already explain the strong correlation between GDF-15 overexpression and poor survival with or without checkpoint-based immunotherapy, effects of GDF-15 on dendritic cells and monocytes may further shape the tumor microenvironment.

Methods: To analyze the impact of GDF-15 in murine tumor models, GDF-15 was either deleted by CRISPR/CAS9 gene editing or neutralized by administration of a blocking antibody. Effects on tumor growth were recorded and the composition of the tumor microenvironment was characterized by flow cytometry. More detailed insight into tumor-immune interactions was obtained via the CrownBio Mouse I/O RNA-Seq Panel. Specific effects on polarization of innate and on antigen-specific priming of adaptive immune cells were confirmed in cellular assays in vitro.

Results: Tumor-derived GDF-15 modulates the tumor microenvironment by inhibiting infiltration and activation of myeloid cells. GDF-15 thereby impairs the induction of antitumoral immune responses. Deletion of GDF-15 enhances infiltration of innate cells into immune-excluded tumors, supports the priming of naïve T cells by dendritic cells and generates a pro-inflammatory tumor microenvironment. In vitro, GDF-15 inhibits DC maturation and synapse formation, thus preventing successful T-cell activation. Moreover, GDF-15 interferes with M1 polarization of macrophages.

Conclusion: GDF-15 secretion helps tumors to generate a microenvironment that is poorly infiltrated by immune cells. GDF-15 further polarizes myeloid cells towards a tumor-promoting, anti-inflammatory phenotype. By inducing a more pro-inflammatory tumor phenotype, anti-GDF-15 antibodies may synergize with other immunotherapeutic agents. A clinical trial combining anti-GDF-15 (CTL002) with anti-PD-1 (NCT04725474) is ongoing.

Citation Format: Markus Haake, Beatrice Haack, Sabrina Genßler, Julia Weigandt, Marlene Auer, Vincent Thiemann, Wahid M. Haq, Melanie Haag, Florian Wedekink, Birgitt Fischer, Kathrin Klar, Matthias Wölfl, Christine Schuberth-Wagner, Jorg Wischhusen. Tumor-derived GDF-15 promotes immune escape of tumors by functional alteration of the myeloid compartment [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 6118.

Abstract P06-01: A phase I, first-in-human clinical trial of the GDF-15 neutralizing antibody CTL-002 in subjects with advanced stage solid tumors (Acronym: GDFATHER)

Background: Growth and differentiation factor 15 (GDF-15) is a TGF-β superfamily member physiologically expressed mainly in placenta and linked to feto-maternal tolerance. Under pathophysiologic conditions, prevention of excessive immune cell infiltration during tissue damage and cachexia induction have been ascribed to GDF-15. A recent study [Haake et al. AACR2020; Abstract #5597] elucidated a mechanism by which GDF-15 inhibits LFA-1 activation on CD8+ T cells, thus interfering with effector T cell recruitment to tissues. Importantly, several cancer entities secrete high levels of GDF-15, correlating with poor prognosis and reduced overall survival [reviewed in Front Immunol 2020 May 19;11:951]. To block this effect the GDF-15 neutralizing antibody CTL-002 was generated. In preclinical models CTL-002 demonstrated potent effector T cell shifting into tumor tissue by neutralizing GDF-15 and enhancing response to checkpoint inhibitor therapy. Methods: This is a phase 1, first-in-human (FIH), two-part, open-label clinical trial of intravenous (IV) administration of CTL-002 given as monotherapy and in combination with an anti-PD-1 antibody in subjects with advanced-stage, relapsed/refractory solid tumors who relapsed on or were refractory to a prior anti-PD-1/PD-L1 therapy. Eligible subjects have exhausted all available approved standard treatments, including prior anti-PD1/-PD-L1 treatment, and present with a biopsy-accessible tumor for serial biopsy taking. The trial is termed GDFATHER, for “GDF-15 Antibody-mediaTed Effector cell Relocation”. Main endpoints are safety of CTL-002 monotherapy and CTL-002 combination with an anti-PD-1 antibody, pharmacokinetics, pharmacodynamics (e.g., degree of GDF-15 neutralization achieved and change in immune-cell number and composition in the tumor tissue) as well as preliminary clinical efficacy (tumor mass reduction; anticachexia effect). In part A of the trial (dose escalation) up to 24 subjects will receive escalating doses of CTL-002 IV (0.3 – 20 mg/kg) in a „mono-followed-by-combination“-design with CTL-002 given as monotherapy and followed by combination with an anti-PD-1 checkpoint inhibitor. In part B (expansion) up to 5 cohorts with up to 25 subjects per cohort with defined tumor entities expected to be GDF-15 dependent will be treated to determine the recommended phase 2 dose (RP2D) and further evaluate safety and preliminary efficacy of CTL-002 monotherapy and the combination. The study was initiated in December 2020 and enrolled the first patient on Dec 09, 2020. Cohort 4 is ongoing at time of submission (07/2021) and so far no DLT has occurred. Updated safety, biomarker and response assessments will be reported. The ClinicalTrials.gov Identifier is NCT04725474.

Citation Format: Ignacio Melero, Emiliano Calvo, Maria-Elisabeth Goebeler, Elena Garralda, Reinhard Dummer, María Rodríguez-Ruiz, María De Miguel, Cyrus Sayehli, Guzman Alonso Casal, Egle Ramelyte, Martin Schuler, Tanja Gromke, Miguel Sanmamed, Irene Moreno, Ralf Bargou, Maria Lostes, Julia-Tatjana Maul, Heike Richly, Petra Fettes, Kathrin Klar, Christine Schuberth-Wagner, Markus Haake, Joerg Wischhusen, Eugen Leo. A phase I, first-in-human clinical trial of the GDF-15 neutralizing antibody CTL-002 in subjects with advanced stage solid tumors (Acronym: GDFATHER) [abstract]. In: Proceedings of the AACR-NCI-EORTC Virtual International Conference on Molecular Targets and Cancer Therapeutics; 2021 Oct 7-10. Philadelphia (PA): AACR; Mol Cancer Ther 2021;20(12 Suppl):Abstract nr P06-01.

568 Tumor-derived GDF-15 prevents therapy success of checkpoint inhibitors by blocking T-lymphocyte recruitment

Background

Immune checkpoint blockade (ICB) can achieve durable responses in a subgroup of patients with metastatic cancer, only. Poor immune effector cell infiltration into the tumor microenvironment is a major obstacle to successful therapy. Growth and differentiation factor 15 (GDF-15) is a divergent member of the TGF-β superfamily and has been linked to feto-maternal tolerance, anorexia but recently also to potent local immunosuppression under physiologic and pathophysiologic conditions. GDF-15 is overexpressed in a wide variety of tumors and may be key factor produced by tumors to prevent effective immune cell infiltration into the tumor and to potently block checkpoint inhibitor activity.

Methods

Effects of recombinant GDF-15 and a proprietary GDF-15 neutralizing antibody (CTL-002) on immune cell trafficking and activation were analyzed by adhesion and interaction assays and in melanoma-bearing humanized mouse models. The impact of GDF-15 overexpression was tested in subcutaneously implanted, GDF-15-transgenic MC38 cells. Additionally, patient GDF-15 serum levels were correlated with immune infiltration and OS in cutaneous melanoma. Associations between GDF-15 serum levels, response to PD-1-based ICB and corresponding OS were assessed in two independent cohorts of melanoma patients.

Results

GDF-15 impairs adhesion of T and NK cells on activated endothelia. In HV18-MK bearing humanized mice, inhibition of GDF-15 strongly enhances infiltration of activated myeloid and lymphoid cells. In MC38 tumors, GDF-15 overexpression can abrogate tumor rejection upon anti-PD-1 therapy. 50% of the mice with GDF-15 overexpressing tumors were, however, rescued when anti-PD-1 was combined with anti-GDF-15 (CTL-002). Likewise, anti-GDF-15 improved responses to anti-CD40 + poly(I:C) in the same tumor model. Clinically, inverse correlations of GDF-15 levels with CD8+ T cell infiltration were shown for melanoma brain metastases. In two independent melanoma patient cohorts, low baseline serum GDF-15 levels predicted clinical response to anti-PD1 treatment and superior OS. Bivariate analysis including LDH indicates that GDF-15 is an independently predictor for poor survival in anti-PD-1 treated melanoma patients.

Conclusions

Tumor-derived GDF-15 blocks the infiltration of immune effector cells into tumor tissues. Neutralizing GDF-15 with CTL-002 restores the ability of immune cells to extravasate blood vessels and enter the tumor microenvironment in vivo. GDF-15 thus represents a promising target for cancer immunotherapy. Antibodies against GDF-15 may support treatments with anti-PD-1 and other immunotherapeutic agents. A clinical trial combining anti-GDF-15 (CTL002) with anti-PD-1 (NCT04725474, submitted Abstract ID 15073) is ongoing.

Ethics Approval

Use of patient samples for this study had been approved by the institutional ethics committee Tübingen (ethic vote 125/2015BO2). Use of surplus sera collected in the University of Zurich Hospital (USZ) Biobank during routine blood draws from consenting metastatic melanoma patients was performed according to IRB approval (KEK.Zh- 647/800) and followed the Declaration of Helsinki on Human Rights.

Consent

All patients had given written informed consent to have clinical data recorded by the Central Malignant Melanoma Registry (CMMR) database.

504 A phase I, first-in-human clinical trial of the GDF-15 neutralizing antibody CTL-002 in subjects with advanced stage solid tumors (Acronym: GDFATHER)

Background

Growth and differentiation factor 15 (GDF-15) is a TGF-β superfamily member physiologically expressed mainly in placenta and linked to feto-maternal tolerance. Under pathophysiologic conditions, prevention of excessive immune cell infiltration during tissue damage and cachexia induction have been ascribed to GDF-15. Recent research has though indicated a prominant role in modulation of the tumor microenvironment and the immune synapse, too1 2 indicating that GDF-15 may be a major tumor-derived immunosuppressant. Importantly, several cancer entities secrete high levels of GDF-15, correlating with poor prognosis and reduced overall survival [Front Immunol 2020 May 19;11:951]. To block this effect the GDF-15 neutralizing antibody CTL-002 was generated. In preclinical models CTL-002 demonstrated potent effector T cell shifting into tumor tissue by neutralizing GDF-15.

Methods

This is a phase 1, first-in-human (FIH), two-part, open-label clinical trial of intravenous (IV) administration of CTL-002 given as monotherapy and in combination with an anti-PD-1 antibody in subjects with advanced-stage, relapsed/refractory solid tumors who relapsed or were refractory to a prior anti-PD-1/PD-L1 therapy. Eligible subjects have exhausted all available approved standard treatments, including prior anti-PD1/-PD-L1 treatment, and present with a biopsy-accessible tumor for serial biopsy taking. The trial is termed GDFATHER, for ”GDF-15 Antibody-mediaTed Effector cell Relocation”.Main endpoints are safety of CTL-002 monotherapy and CTL-002 combination with an anti-PD-1 antibody, pharmacokinetics, pharmacodynamics (e.g. degree of GDF-15 neutralization achieved and change in immune-cell number and composition in the tumor tissue) as well as preliminary clinical efficacy (tumor mass reduction; anticachexia effect)In part A of the trial (dose escalation) up to 24 subjects will receive escalating doses of CTL-002 IV (0.3 – 20 mg/kg) in a ”mono-followed-by-combination”-design with CTL-002 given as monotherapy and followed by combination with an anti-PD-1 checkpoint inhibitor. In part B (expansion) up to 5 cohorts with up to 25 subjects per cohort with defined tumor entities expected to be GDF-15 dependent will be treated to determine the recommended phase 2 dose (RP2D) and further evaluate safety and preliminary efficacy of CTL-002 monotherapy and the combination.The study was initiated in December 2020 and enrolled the first patient on Dec 09, 2020. Cohort 4 is ongoing at time of submission (07/2021) and so far no DLT has occurred. Updated safety, biomarker and response assessments will be reported at the meeting. The ClinicalTrials.gov Identifier is NCT04725474. For more information please contact info@catalym.com.

Trial Registration

NCT04725474

References

Wischhusen J, Wistuba-Hamprecht K, Harter PN, Cheng P, Martens A, Gogolla F, Nonomura Y, Romer P, Koch SD, Haake M, Schuberth-Wagner C, Rudiger M, Leo E, Mittelbronn M, Levesque MP, Hackl H, Dummer R, Weide B. Identifying GDF-15 as potential novel immunotherapeutic target linked to immune cell exclusion in tumors and resistance to anti-PD-1 treatment [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27–28 and Jun 22–24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl): Abstract nr 2161.

Hurt E, Thomas S, Mulgrew K, Blackmore S, Moynihan J, Cusdin F, Dodd R, Cariuk P, Sigurdardottir A, Brannigan E, Dobson C, Kumar R, Cobbold M. AZD8853: A novel antibody targeting GDF15 for immunotherapy refractory tumors [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10–15 and May 17–21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl): Abstract nr 1828.

Ethics Approval

All participants gave informed consent prior to participation. EC approval by Gobierno de Navarra, Departamento de Salud, EC_2020/30, Dated: Oct 13, 2020 in Pamplona, Spain. Respective additional national lead EC approvals for Germany (Ethikkommission der Universität Würzburg, 203–20ff of Oct 26, 2020) and Switzerland (Kantonale Ethikkommission Zürich, 2020–02308 of Nov 24, 2020).

A phase I, first-in-human clinical trial of the GDF-15 neutralizing antibody CTL-002 in subjects with advanced-stage solid tumors (ACRONYM: GDFATHER)

TPS2658

Background: Growth and differentiation factor 15 (GDF-15) is a TGF-β superfamily member physiologically expressed mainly in placenta and linked to feto-maternal tolerance. Under pathophysiologic conditions, prevention of excessive immune cell infiltration during tissue damage and cachexia induction have been ascribed to GDF-15. A recent study [Haake et al. AACR2020; Abstract #5597] elucidated a mechanism by which GDF-15 inhibits LFA-1 activation on CD8+ T cells, thus interfering with effector T cell recruitment to tissues. Importantly, several cancer entities secrete high levels of GDF-15, correlating with poor prognosis and reduced overall survival [reviewed in Front Immunol 2020 May 19;11:951]. To block this effect the GDF-15 neutralizing antibody CTL-002 was generated. In preclinical models CTL-002 demonstrated potent effector T cell shifting into tumor tissue by neutralizing GDF-15. Methods: This is a phase 1, first-in-human (FIH), two-part, open-label clinical trial of intravenous (IV) administration of CTL-002 given as monotherapy and in combination with an anti-PD-1 antibody in subjects with advanced-stage, relapsed/refractory solid tumors who relapsed post or were refractory to a prior anti-PD-1/PD-L1 therapy. Eligible subjects have exhausted all available approved standard treatments. Further key eligibility criteria include having received at least one prior anti-PD1/-PD-L1 treatment and having relapsed on or after it or having been refractory to it, and presenting with a biopsy-accessible tumor for serial biopsy taking. The trial is termed GDFATHER, for “GDF-15 Antibody-mediaTed Effector cell Relocation”. Main endpoints are safety of CTL-002 monotherapy and CTL-002 combination with an anti-PD-1 antibody, pharmacokinetics, pharmacodynamics (e.g. degree of GDF-15 neutralization achieved and change in immune-cell number and composition in the tumor tissue) as well as preliminary clinical efficacy (tumor mass reduction; anticachexia effect) In part A of the trial (dose escalation) up to 24 subjects will receive escalating doses of CTL-002 IV (0.3 – 20 mg/kg) in a „mono-followed-by-combination“-design with CTL-002 given as monotherapy and followed by combination with an anti-PD-1 checkpoint inhibitor. In part B (expansion) up to 5 cohorts with up to 25 subjects per cohort with defined tumor entities expected to be GDF-15 dependent will be treated to determine the recommended phase 2 dose (RP2D) and further evaluate safety and preliminary efficacy of CTL-002 monotherapy and the combination. The study was initiated in December 2020 and enrolled the first patient on Dec 09, 2020. Cohort 1 has been completed without DLT and enrollment for cohort 2 began in February 2021. Clinical trial information: NCT04725474.

Tumor-derived GDF-15 to suppress t-lymphocyte recruitment to the tumor microenvironment resulting in resistance to ANTI-PD-1 treatment

e14532

Background: Growth and differentiation factor 15 (GDF-15) is a divergent member of the TGF-β superfamily with low to absent expression in healthy tissue. GDF-15 has been linked to feto-maternal immune tolerance, to prevention of excessive immune cell infiltration during tissue damage, and to anorexia. Various major tumor types secrete high levels of GDF-15. In cancer patients, elevated GDF-15 serum levels correlate with poor prognosis and reduced overall survival (OS). Methods: Impact of a proprietary GDF-15 neutralizing antibody (CTL-002) regarding T cell trafficking was analyzed by whole blood adhesion assays, a HV18-MK melanoma-bearing humanized mouse model and a GDF-15-transgenic MC38 model. Additionally, patient GDF-15 serum levels were correlated with clinical response and overall survival in oropharyngeal squamous cell carcinoma (OPSCC) and melanoma brain metastases. Results: In whole blood cell adhesion assays GDF-15 impairs adhesion of T and NK cells to activated endothelial cells. Neutralization of GDF-15 by CTL-002 rescued T cell adhesion. In HV18-MK-bearing humanized mice CTL-002 induced a strong increase in TIL numbers. Subset analysis revealed an overproportional enrichment of T cells, in particular CD8+ T cells. As immune cell exclusion is detrimental for checkpoint inhibitor (CPI) therapy, a GDF-15-transgenic MC38 model was tested for anti-PD-1 therapy efficacy. In GDF-15 overexpressing MC38 tumors response to anti PD-1 therapy was reduced by 90% compared to wtMC38 tumors. Combining aPD-1 with CTL-002 resulted in 50% of the mice rejecting their GDF-15 overexpressing tumors. Clinically, inverse correlations of GDF-15 levels with CD8+ T cell infiltration were shown for HPV+ OPSCC and for melanoma brain metastases. GDF-15 serum levels were significantly higher in HPV- than in HPV+ OPSCC patient (p < 0.0001). Low GDF-15 levels corresponded to longer OS in both HPV- and HPV+ OPSCC. In two independent melanoma patient cohorts treated with nivolumab or pembrolizumab low baseline serum GDF-15 levels were predictive for clinical response to anti-PD1 treatment and superior OS. Bivariate analysis including LDH indicates that GDF-15 independently predicts poor survival in aPD-1 treated melanoma patients. Conclusions: Taken together our in vitro and in vivo data show that elevated GDF-15 levels block T-cell infiltration into tumor tissues. Neutralizing GDF-15 with CTL-002 restores the ability of T cells to extravasate blood vessels and enter tumor tissue both in vitro and in vivo. In melanoma, patients with higher GDF-15 levels have significantly shorter survival and are less likely to respond to anti-PD1 therapy. GDF-15 may thus serve as a new predictive biomarker for anti-PD1 response, but most importantly also represents a novel target for cancer immunotherapy to improve tumor immune cell infiltration and response to anti-PD1 therapy.

Abstract 2161: Identifying GDF-15 as potential novel immunotherapeutic target linked to immune cell exclusion in tumors and resistance to anti-PD-1 treatment

Introduction:

Growth and differentiation factor 15 (GDF-15) is a TGF-β superfamily member mainly expressed in placenta and prostate of healthy individuals. GDF-15 has been linked to feto-maternal tolerance, prevention of excessive immune cell infiltration during tissue damage and to anorexia. In cancer patients, GDF-15 serum levels are frequently elevated and associated with poor prognosis, via so far mostly unknown mechanism(s). A recent study elucidated a mechanism by which GDF-15 inhibits LFA-1 activation on CD8+ T cells, thus interfering with T cell recruitment to tissues [Haake et al. AACR 2020; submitted]. To further delineate the role of GDF-15 in cancer in this study GDF-15 serum and tissue levels were analyzed and correlated with tumoral immune-cell infiltration and clinical anti-PD1 response.

Methods:

In-silico, TCGA-derived mRNA levels of GDF-15 were compared in cancer vs. normal tissue. Two independent melanoma patient cohorts (88 and 34 patients) treated with nivolumab or pembrolizumab were analyzed regarding baseline GDF-15 serum levels, correlation with clinical response and overall survival. Melanoma brain metastases from 80 patients were collected to assess and compare intratumoral GDF-15 levels vs. CD3+, CD8+ and Foxp3+ cell numbers by immunohistochemistry (IHC).

Results:

TCGA-based analyses demonstrated significantly elevated GDF-15 mRNA levels in tumor vs. surrounding normal tissue in various major cancer types such as e.g. colorectal, prostate, head & neck and melanoma. In the two independent, anti-PD1 treated melanoma patient cohorts baseline serum GDF-15 levels were predictive for superior overall survival and clinical response to anti-PD1 treatment (p&lt;0.0001 and p=0.0382, respectively). In melanoma biopsies an inverse correlation of GDF-15 levels (histoscore) with CD3+ (R=-0.26; p=0.016) and CD8+ T cells (R=-0.21; p=0.05), but no correlation with Foxp3+ T cells was shown.

Conclusion:

GDF-15 is elevated in serum and tumor tissue of various major cancer types. In melanoma, patients with higher GDF-15 levels have significantly shorter survival and are less likely to respond to anti-PD1 therapy. In addition, intratumoral GDF-15 levels in melanoma brain metastasis correlate inversely with CD3+ and CD8+ T cell infiltration. Consequently, GDF-15 may serve as a predictive biomarker for anti-PD1 response and potentially represent a novel target in the immunotherapy of cancer to improve tumor immune cell infiltration and anti-PD1 response.

Citation Format: Jorg Wischhusen, Kilian Wistuba-Hamprecht, Patrick N. Harter, Phil Cheng, Alexander Martens, Falk Gogolla, Yumi Nonomura, Paula Romer, Sven D. Koch, Markus Haake, Christine Schuberth-Wagner, Manfred Rudiger, Eugen Leo, Michael Mittelbronn, Mitchell P. Levesque, Hubert Hackl, Reinhard Dummer, Benjamin Weide. Identifying GDF-15 as potential novel immunotherapeutic target linked to immune cell exclusion in tumors and resistance to anti-PD-1 treatment [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 2161.

IL-10 reduces apoptosis and extracellular matrix degradation after injurious compression of mature articular cartilage

OBJECTIVE

The aim of this study was to examine whether anti-inflammatory interleukin-10 (IL-10) exerts chondroprotective effects in an in vitro model of a single mechanical injury of mature articular cartilage.

METHOD

Articular cartilage was harvested from the femoro-patellar groove of adult cows (Bos taurus) and cultured w/o bovine IL-10. After 24 h of equilibration explants were subjected to an axial unconfined compression (50% strain, velocity 2 mm/s, held for 10 s). After 96 h cell death was measured histomorphometrically (nuclear blebbing, NB) and the release of glycosaminoglycans (GAG, DMMB assay) and nitric oxide (NO, Griess-reagent) were analyzed. mRNA levels of matrix degrading enzymes and nitric oxide synthetase were measured by quantitative real time PCR. Differences between groups were calculated using a one-way ANOVA with a Bonferroni post hoc test.

RESULTS

Injurious compression significantly increased the number of cells with NB, release of GAG and nitric oxide and expression of MMP-3, -13, ADAMTS-4 and NOS2. Administration of IL-10 significantly reduced the injury related cell death and release of GAG and NO, respectively. Expression of MMP-3, -13, ADAMTS-4 and NOS2 were significantly reduced.

CONCLUSION

Joint injury is a complex process involving specific mechanical effects on cartilage as well as induction of an inflammatory environment. IL-10 prevented crucial mechanisms of chondrodegeneration induced by an injurious single compression. IL-10 might be a multipurpose drug candidate for the treatment of cartilage-related sports injuries or osteoarthritis (OA).

Characterization of the biological anti-staphylococcal functionality of hUK-66 IgG1, a humanized monoclonal antibody as substantial component for an immunotherapeutic approach

Multi-antigen immunotherapy approaches against Staphylococcus aureus are expected to have the best chance of clinical success when used in combinatorial therapy, potentially incorporating opsonic killing of bacteria and toxin neutralization. We recently reported the development of a murine monoclonal antibody specific for the immunodominant staphylococcal antigen A (IsaA), which showed highly efficient staphylococcal killing in experimental infection models of S. aureus. If IsaA-specific antibodies are to be used as a component of combination therapy in humans, the binding specificity and biological activity of the humanized variant must be preserved. Here, we describe the functional characterization of a humanized monoclonal IgG1 variant designated, hUK-66. The humanized antibody showed comparable binding kinetics to those of its murine parent, and recognized the target antigen IsaA on the surface of clinically relevant S. aureus lineages. Furthermore, hUK-66 enhances the killing of S. aureus in whole blood (a physiological environment) samples from healthy subjects and patients prone to staphylococcal infections such as diabetes and dialysis patients, and patients with generalized artery occlusive disease indicating no interference with already present natural antibodies. Taken together, these data indicate that hUK-66 mediates bacterial killing even in high risk patients and thus, could play a role for immunotherapy strategies to combat severe S. aureus infections.

[Update on rheuma-orthopedics - role and therapeutic options]

Orthopaedic treatment options for rheumatological patients have been further developed over recent years. For orthopaedic treatment, a range of different interventions are offered: orthoses and special technical aids as well as injections for joints and tendons, or surgery. Surgical interventions cover joint preservation, restitution and arthrodeses. Improvements in equipment and surgical procedures also make minimally invasive interactions possible for rheumatoid diseases. Thus, postoperative morbidity has been reduced significantly. Improvement in function, reduction of pain and prevention of recurrent local inflammation are primary. Considering these aims, arthrodeses are restricted to special indications. Joint preservation and restitution are the predominant measures used. The various procedures are discussed.

Zur Problematik von Akupunkturstudien am Beispiel der Methodik von gerac

OBJECTIVE

Conflicting or ambivalent findings on the effectiveness of body acupuncture in pain treatment are often attributed to flaws in study methodology. The paper describes the methodology used for the German Acupuncture Trials (gerac), which demonstrates that it is possible to design acupuncture studies in accordance with the standards of good clinical practice.

METHOD

Approximately 1000 chronic pain sufferers per indication (migraine, tension-type headache, low back pain (cLBP), or gonarthrosis) are randomly allocated to one of three treatment groups (verum acupuncture, sham acupuncture, or established conservative therapy). Patients are blind to the type of acupuncture. All patients receive ten sessions of treatment (two per week) with an option of adding five more treatments in cases of slight but insufficient improvement (number of headache days or von Korff pain score). Participating physicians are in private practice, representing a variety of specialties. All have completed at least a 140-hour training course in acupuncture. Mandatory and optional verum and sham points are predefined. The point selection is individualized according to the criteria of traditional Chinese medicine (TCM). Primary outcome measures are number of headache days per month, von Korff Graded Chronic Pain Scale or Hannover Functional Ability Questionnaire (cLBP), or WOMAC scores (gonarthrosis). Data are assessed by trained telephone interviewers not involved in treatment and blind to types of acupuncture.

PRESENT STATUS

Over 500 participating physicians in ten urban areas of Germany. Patient recruitment for cLBP and gonarthrosis was completed in November 2003 and March 2004 respectively. Recruitment for chronic headaches will be completed in autumn 2004.

CONCLUSIONS

The gerac trials prove that it is possible to design and carry out acupuncture studies in accordance to stringent standards of methodology and clinical practice. The results will form a basis for the assessment of acupuncture effectiveness in Germany and abroad.

[Impact of the quality of clinical trials in orthopedics and traumatology on the status of evidence]

Medical decisions have to be founded on the current scientific state of the art. To evaluate the efficacy of any therapeutical measure, controlled clinical trials are necessary. Firstly, we describe important principles for the design and conduct of controlled clinical trials. Secondly, we list examples from the topical literature and discuss these regarding adherence to the described principles. The accepted quality criteria for clinical trials have insufficiently been transferred to the area of clinical orthopedic and traumatologic research. As a consequence, the evidence for many therapeutical measures is low. We point out frequently occurring flaws in the design and conduct of controlled clinical trials. A brief introduction to the interpretation of clinical trials and meta analyses is given. In orthopedics and traumatology, well designed controlled clinical trials have to be enforced. This is a prerequisite for evaluating therapeutical measures on a scientific basis.

The diesel exhaust component pyrene induces expression of IL-8 but not of eotaxin

Environmental pollutants can influence the expression of immunoregulatory molecules and, in this way, promote allergies. The local synthesis of proinflammatory chemokines is an important aspect in the development of allergic airway inflammation. We have characterized the influence of pyrene, a polycyclic aromatic hydrocarbon (PAH) contained, for example, in diesel exhaust particles (DEP), on transcription and secretion of the chemokines interleukin-8 (IL-8) and eotaxin. Reporter genes under control of the respective promoters were tested in the human cell lines A549 and HeLa, mRNA production was assayed in A549 cells and protein production was measured by ELISA in cell supernatants from primary human fibroblasts. Pyrene content of cell supernatants was measured by analytical HPLC. Promoter activity, mRNA production and protein expression of IL-8 were increased by pyrene. The activating effect in reporter gene studies was abolished by mutating either an NF-kappaB or an AP-1 binding site in the IL-8 promoter. In contrast, pyrene showed no effect on transcription from the eotaxin promoter, despite the important role of this chemokine in asthma. Our data show that pyrene has specific effects on chemokine synthesis, which are not restricted to mediators primarily associated with atopic diseases. Pyrene also affected cells not derived from lung tissue, which suggests a broader immunoregulatory influence for this pollutant.

[Effect of extracorporeal shockwave therapy on vascular regulation. Infrared thermography in epicondylitis humeri radialis]

BACKGROUND

Extracorporeal shockwave therapy (ESWT) is recommended as an alternative treatment for lateral epicondylitis (LE). An influence on the blood perfusion is considered to be one possible effect. Infrared thermography is used in this trial to measure effects of ESWT on the thermal regulation in the target area.

METHODS

33 patients with chronic LE were examined in a prospective, placebo-controlled single blind study with an independent observer. 3 x 2000 impulses of an energy flux density ED+ 0.22 mJ/mm2 were applied under local anaesthesia as verum-ESWT. Placebo-ESWT was performed under the same conditions. One elbow was treated, the other served as control. Before and after each shockwave application and after 12 weeks skin temperature was measured on both elbows at three predefined points by infrared thermography.

RESULTS

While a significant decrease in the skin temperature was found on the treated and sham-treated sides opposed to the contralateral side, there was no difference between the real shockwave treatment and placebo therapy. Responder and Non-responder to the treatment could not be distinguished during the therapy.

DISCUSSION

Infrared thermography was proved to be a valuable additional technical instrument for diagnosis of LE, but is not an appropriate instrument to predict the clinical outcome in patients treated with ESWT. A noted reduction of skin temperature on the treated side is not due to specific effects of the shockwaves. It is unlikely that ESWT as applied has an influence on thermal regulation in the target area. These findings are supported by negative results of experimental and clinical trials.

Extracorporeal shock wave therapy in the treatment of lateral epicondylitis : a randomized multicenter trial

BACKGROUND

On the basis of observational trials, numerous investigators have recommended extracorporeal shock wave therapy as an alternative treatment for chronic lateral epicondylitis of the elbow. However, there has been no evidence of its efficacy from well-designed randomized clinical trials. The objective of this study was to find out whether extracorporeal shock wave therapy in combination with local anesthesia was superior to placebo therapy in combination with local anesthesia.

METHODS

A randomized multicenter trial with a parallel-group design was conducted. Following administration of local anesthesia, either extracorporeal shock wave therapy with three treatments of 2000 pulses each and a positive energy flux density (ED+) of 0.07 to 0.09 mJ/mm (2) or placebo therapy was applied on an outpatient basis. Treatment allocation was blinded for patients and for observers. The primary end point was based on the rate of success, as determined with the Roles and Maudsley score and whether additional treatment was required, twelve weeks after the intervention. Crossover was possible after assessment of the primary end point. Secondary end points were the Roles and Maudsley score, subjective pain rating, and grip strength after six and twelve weeks and after twelve months. The planned number of 272 patients was included in the study.

RESULTS

The primary end point could be assessed for 90.8% of the patients. The success rate was 25.8% in the group treated with extracorporeal shock wave therapy and 25.4% in the placebo group, a difference of 0.4% with a 95% confidence interval of -10.5% to 11.3%. Similarly, there was no relevant difference between groups with regard to the secondary end points. Improvement was observed in two-thirds of the patients from both groups twelve months after the intervention. Few side effects were reported.

CONCLUSIONS

Extracorporeal shock wave therapy as applied in the present study was ineffective in the treatment of lateral epicondylitis. The previously reported success of this therapy appears to be attributable to inappropriate study designs. Different application protocols might improve clinical outcome. We recommend that extracorporeal shock wave therapy be applied only in high-quality clinical trials until it is proved to be effective.

[Physical-technical principles of extracorporeal shockwave therapy (ESWT)]

Extracorporeal shock waves in orthopaedics are currently applied in the treatment of chronic enthesiopathies such as lateral epicondylitis, plantar heel spur, as well as in calcifying tendinitis of the shoulder or in bony nonunions. Detailed knowledge of physical parameters and properties of shock waves appear to be necessary to determine clinically relevant dose-effect relations and to make shock wave devices, clinical results, and basic science in shock wave therapy more comparable. This study gives an overview of physical parameters and properties in shock wave therapy. Measurement technologies, types of shock wave devices, and mechanisms of shock waves are also described.

[Extracorporeal shockwave therapy (ESWT) in epicondylitis humeri radialis. A review of the literature]

This review article evaluates therapeutic procedures and clinical findings of extracorporeal shock wave therapy (ESWT) when used for lateral epicondylitis (LE) based on systematic research of the literature. A total of 20 studies were identified, 2 of which had been carried out as prospective, randomized, and controlled studies; the biometric quality of the remaining is clearly inferior. The inclusion and exclusion criteria used in the studies tallied well. In the more recent literature, important ESWT parameters such as energy used, number of impulses and treatment sessions, and locating methods also tallied in part. The studies reported only occasional side effects that could be evaluated as harmless. When evaluating the clinical success of ESWT, it was stated that about 40-80% of the patients achieved a good or very good result at follow-up examinations after 3-12 months. However, in the single placebo-controlled and blinded study with an independent observer, the same therapy results were achieved in the control group where a local anesthetic was used as in the ESWT group. For this reason, it has been concluded that up to now no clinically relevant efficacy has been proven for the use of ESWT for LE. It should no longer be applied clinically as a matter of course, but only as part of high-quality studies with an adequate control group and blinding of patients and follow-up examiners. Due to the pain incurred when applying ESWT and the risk of uncovering the masking, the blinding of the patients must be checked in each further controlled ESWT study.

[Extracorporeal shockwave therapy (ESWT) as therapeutic option in supraspinatus tendon syndrome? One year results of a placebo controlled study]

Extracorporeal shock wave therapy (ESWT) is seen as a therapeutic option in the treatment of chronic supraspinatus tendinitis by some authors. To test whether ESWT comprising 3 x 2000 pulses with the positive energy flux density ED+ of 0.33 mJ/mm2 is clinically superior to a sham ESWT treatment, a prospective, randomized, single-blinded, placebo-controlled study with an independent observer was performed. Forty patients were treated either by verum ESWT or sham ESWT under local anesthesia. Target criteria were the age-corrected Constant score, pain at rest and during activity on a visual analogue scale, and subjective improvement. Patients who reported no subjective improvement after 12 weeks were deblinded and received verum ESWT if they had belonged to the placebo group (partial crossover). The results of the verum group lie within the range of results for ESWT published by other authors. Patients in the placebo group with local anesthetic showed equally good results. At 12 weeks, and 1 year after intervention, no difference could be found between the verum and placebo groups regarding Constant score, pain, shoulder function, or subjective improvement. The nonresponders to the placebo ESWT continued to show no improvement after receiving verum ESWT. This contradicts a specific ESWT effect. Based on the results of this placebo-controlled study, ESWT appears to have no clinically relevant effect on supraspinatus tendinitis. The study underlines the importance of a control group in evaluating new treatment methods for diseases with unknown natural history.

[Acupuncture in diseases of the locomotor system. Status of research and clinical applications]

Acupuncture has been used for over 2000 years for a wide variety of complaints with minimal side effects. Based on the experience in Chinese medicine and the anticipated positive effects, acupuncture has been widely accepted in Western medicine as well. Some clinical evidence supports the efficacy of acupuncture treatment, but randomized controlled trials have been conducted for only a few of all possible locomotive disorder indications, and the results have been equivocal. Other indications have not yet been systematically studied, and application is based on clinical experience and consensus among practitioners. One of the outcomes on which consensus appears to exist is that 10-20 sessions are generally necessary, and that initial improvement can be expected to occur by the 10th treatment. Rigorous trials should be conducted to improve clinical validity and provide scientific proof of the efficacy of acupuncture. Clinical trials like the German Acupuncture Trials (gerac), funded by the German health insurance companies, have been launched with the aim of furthering knowledge in this area.

Side-effects of extracorporeal shock wave therapy (ESWT) in the treatment of tennis elbow

Apart from a few observational reports, there are no studies on the side-effects of extracorporeal shock wave therapy (ESWT) in the treatment of insertion tendopathies. Within the framework of a randomised, placebo-controlled, single-blind, multicentre study to test the effectiveness of ESWT in the case of lateral epicondylitis (LE), side-effects were systematically recorded. A total of 272 patients from 15 centres was allocated at random to active ESWT (3 x 2000 pulses, energy flux density ED(+) 0.04 to 0.22 mJ/mm(2) under local anaesthesia) or placebo ESWT. In all, 399 ESWT and 402 placebo treatments were analysed. More side-effects were documented in the ESWT group (OR = 4.3, CI = [2.9; 6.3]) than in the placebo group. Most frequently, transitory reddening of the skin (21.1%), pain (4.8%) and small haematomas (3.0%) were found. Migraine was registered in four and syncopes in three instances after ESWT. ESWT for LE with an energy flux density of ED(+) 0.04 to 0.22 mJ/mm(2) is a treatment method which has very few side-effects. The possibility of migraine being triggered by ESWT and the risk of a syncope should be taken into account in the future. No physical shock wave parameters could be definitely identified as the cause of the side-effects observed.

[Musculoskeletal shock wave therapy--current database of clinical research]

During the past decade application of extracorporal shock waves became an established procedure for the treatment of various musculoskeletal diseases in Germany. Up to now the positive results of prospective randomised controlled trials have been published for the treatment of plantar fasciitis, lateral elbow epicondylitis (tennis elbow), and of calcifying tendinitis of the rotator cuff. Most recently, contradicting results of prospective randomised placebo-controlled trials with adequate sample size calculation have been reported. The goal of this review is to present information about the current clinical database on extracorporeal shock wave treatment (ESWT).

[Acupuncture in the treatment of locomotive disorders - status of research and situation regarding clinical application]

Acupuncture has been used for over 2000 years for a wide variety of complaints with minimal side effects. Based on the experience in Chinese medicine and the anticipated positive effects, acupuncture has been widely accepted in Western medicine as well. Some clinical evidence supports the efficacy of acupuncture treatment, but randomized controlled trials have been conducted for only a few of all possible locomotive disorder indications, and the results have been equivocal. Other indications have not yet been systematically studied, and application is based on clinical experience and consensus among practitioners. One of the outcomes on which consensus appears to exist is that 10-20 sessions are generally necessary, and that initial improvement can be expected to occur by the 10th treatment. Rigorous trials should be conducted to improve clinical validity and provide scientific proof of the efficacy of acupuncture. Clinical trials like the German Acupuncture Trials (gerac), funded by the German health insurance companies, have been launched with the aim of furthering knowledge in this area.

Extracorporeal shockwave therapy (ESWT) in the treatment of plantar fasciitis--a biometrical review

The application of extracorporeal shockwave therapy (ESWT) as a treatment for conservatively unsuccessfully treated plantar fasciitis has experienced a rapid increase over the last years. However, the efficacy of ESWT has not yet been established unequivocally, as published studies have led to inconsistent results. Furthermore, reviews on clinical trials on ESWT are either not up to date, incomplete, or methodologically inadequate. As a consequence, a systematic literature search was conducted which yielded 21 relevant articles on ESWT in the treatment of plantar fasciitis. These were rated according to biometrical criteria for the conduct of therapeutic trials based on international guidelines. None of the rated trials fulfilled all of the criteria, and it is concluded that at this point the efficacy of ESWT can be neither confirmed nor excluded. Randomised and controlled clinical trials are required to adequately estimate the value of ESWT as a treatment for plantar fasciitis.

Assessment of the treatment costs of extracorporeal shock wave therapy versus surgical treatment for shoulder diseases

OBJECTIVE

To determine the actual costs of extracorporeal shock wave therapy (ESWT) in patients with tendinitis of the supraspinatus muscle.

METHODS

A comparison of the costs of surgical treatment versus the costs for ESWT was made. The total accrued costs were determined 12 weeks after intervention, using a sample group of 60 patients with calcifying or noncalcifying tendinitis of the supraspinatus muscle.

RESULTS

The costs per case ranged from EUR 2,700 to EUR 4,300 per patient for ESWT and from EUR 13,400 to EUR 23,450 for surgical treatment, dependent on the method of calculation. Approximately 65% of the per-patient cost is attributable to productivity losses in the workplace.

CONCLUSIONS

In comparable short-term results, costs for operative treatment are 5-7 times higher than for ESWT. The greater trauma caused by an operative procedure leads to patients being off work for a longer period and thus a correspondingly higher social economic burden.

[Comparison of extracorporeal shockwave therapy (ESWT) with roentgen irradiation in supraspinatus tendon syndrome--a prospective randomized single-blind parallel group comparison]

AIM

Extracorporal shock wave therapy (FSWT) is applied in the case of supraspinatus tendinitis if conservative therapies have failed. So far there has been no controlled study comparing the effectiveness of ESWT with an established conservative method of therapy such as X-ray stimulation radiotherapy.

METHOD

Thirty patients with chronic supraspinatus tendinitis were admitted into the prospective randomised study. After randomisation, the patients were treated either three times with 2000 pulses (energy flux density ED+ 0.33 mJ/mm2) with a Storz Minilith SL1 after one week, or with X-ray stimulation radiotherapy with 6 x 0.5 Gy on the ICRU reference point (1 neutral fraction/day) with cobalt 60 gamma rays. Primary endpoint was the age-corrected constant score.

RESULTS

In the ESWT group the average age-corrected constant score rose from 50.1 points before ESWT to 91.5 points after 12 weeks and to 97.8 after 52 weeks. In the radiotherapy group it improved from 47.6 through 79.5 points to 87.4 points.

CONCLUSION

No statistically significant differences were proven between ESWT and radiotherapy. ESWT appears to be at least equivalent to radiotherapy in treating chronic supraspinatus tendinitis syndrome and can avoid a dose of radiation for patients and staff. A comprehensive randomised study is, however necessary to ensure the equivalence of ESWT.

Specific inhibition of interleukin-4-dependent Stat6 activation by an intracellularly delivered peptide

The transcription factor Stat6 (signal transducer and activator of transcription 6) is activated following stimulation with interleukin (IL)-4 or IL-13. Stat6 binds via a single SH2 domain first to tyrosine-phosphorylated motifs in the IL-4Ralpha chain, and then to another Stat6 molecule, which results in the formation of active dimers. We show here that a peptide derived from the Stat6-binding region of IL-4Ralpha (Stat6BP) is an effective inhibitor when it is delivered into cells by coupling with a membrane-permeable peptide. Stat6BP completely inhibited IL-4 dependent phosphorylation of Stat6, as well as basal and IL-4 stimulated transcription from a reporter gene construct with a Stat6-dependent promoter, while IL-3 and IL-4 dependent phosphorylation of Stat5 was not affected. The inhibitory effect of Stat6BP was transient, but could be prolonged by treating the cells with the phosphatase inhibitor pervanadate.

Low-energy extracorporeal shock-wave treatment (ESWT) for tendinitis of the supraspinatus. A prospective, randomised study

We have performed a controlled, randomised study to analyse the effects of low-energy shock-wave therapy (ESWT) on function and pain in tendinitis of the supraspinatus without calcification. There were 20 patients in the treatment group and 20 in the control group. The former group received 6,000 impulses (energy flux density, 0.11 mJ/mm2) in three sessions after local anaesthesia. The control group had 6000 impulses of sham ESWT after local anaesthesia. The patients were examined at six and 12 weeks after treatment by an independent observer who evaluated the Constant score and level of pain. We found an increase in function and a reduction of pain in both groups (p < or = 0.001). Statistical analysis showed no difference between the groups for the Constant score and for pain. We therefore do not recommend ESWT for the treatment of tendinitis of supraspinatus.

Low-energy extracorporeal shock-wave treatment (ESWT) for tendinitis of the supraspinatus

We have performed a controlled, randomised study to analyse the effects of low-energy shock-wave therapy (ESWT) on function and pain in tendinitis of the supraspinatus without calcification. There were 20 patients in the treatment group and 20 in the control group. The former group received 6000 impulses (energy flux density, 0.11 mJ/mm2) in three sessions after local anaesthesia. The control group had 6000 impulses of sham ESWT after local anaesthesia.

The patients were examined at six and 12 weeks after treatment by an independent observer who evaluated the Constant score and level of pain. We found an increase in function and a reduction of pain in both groups (p ≤ 0.001). Statistical analysis showed no difference between the groups for the Constant score and for pain. We therefore do not recommend ESWT for the treatment of tendinitis of supraspinatus.

[Value of exact focusing of extracorporeal shock waves (ESWT) in therapy of tendinitis calcarea. A prospective randomized study]

A controlled randomized study was designed to analyse the effect of extracorporeal shockwave therapy (ESWT) focussed on either the calcified region or the insertion of the supraspinatus tendon. The study included 50 patients who were treated with a Storz Minilith SI-1 prototype shockwave generator. In the treated group, 4000 impulses (ED+ 0.78 ml/mm2) were applied, under local anaesthesia to the insertion of the supraspinatus in 2 treatment sessions. Control patients received ESWT focussed on the calcified region. Follow-up examinations were carried out 12 weeks after treatment by an independent observer. We found functional improvement and pain reduction in both groups. Statistical analyses showed significant superiority of ESWT focussed on the calcified region for the parameters constant-score (primary endpoint, p < 0.001) and pain intensity (p = 0.001). For the treatment of calcific tendinitis affecting the supraspinatus, we recommend accurate fluoroscopy-controlled focussing of ESWT on the calcification. Focussing on the calcification rather than on the insertion of the supraspinatus tendon is significantly more effective. On the basis of our results, ESWT requires the use of suitable shockwave generators that permit accurate focussing.

Absence of spinal response to extracorporeal shock waves on the endogenous opioid systems in the rat

Extracorporeal shock wave therapy (ESWT) seems to be a new therapeutic strategy for chronic pain due to tendopathies. Neurophysiological mechanisms of action for pain relief following ESWT are still unknown. The aim of this study was to investigate if the analgesic effect of ESWT is caused by modulation of the endogenous spinal opioid system. Rats were treated with two different energy flux densities (0.04 and 0.11mJ/mm(2)) and immunohistochemical analysis of met-enkephalin (MRGL) and dynorphin (Dyn) was performed at 4 or 72 h after ESWT. ESWT had no modulatory influence on the expression of the spinal opioid systems. Different energy doses or repetitive treatment did not alter MRGL or Dyn immunoreactivity in the spinal cord. Furthermore, a delayed effect of ESWT at 72 h after treatment was not detectable. We conclude from these findings that the analgesic effects of ESWT treatment are not supported by endogenous opioids.

The glucocorticoid receptor and STAT6 physically and functionally interact in T-lymphocytes

In lymphocytes, glucocorticoids (GC)- and interleukin-4-signaling pathways are known to interact, as evidenced by inhibition of IL-4-mediated proliferation by dexamethasone or suppression of GC-induced apoptosis by IL-4. In this study, we characterized the molecular basis for this reciprocal interference. We report that, in murine CTLL-2 cells, IL-4 inhibits GC-induced MMTV (mouse mammary tumor virus) promoter transactivation, and that GC suppress IL-4-induced transactivation of a STAT6 (signal transducers and activators of transcription 6)-responsive promoter without affecting IL-4-stimulated STAT6 DNA-binding. Moreover, we evidenced a physical association between GC receptor and STAT6, which proved to be functionally relevant, since STAT6 overexpression increased the IL-4 inhibitory effect on GC-induced MMTV transactivation.

[Extracorporeal shockwave therapy in treatment of epicondylitis humeri radialis. A current overview]

In the past, extracorporeal shock-wave therapy (ESWT) has been used increasingly as a treatment for conservatively unsuccessfully treated radiohumeral epicondylitis. However, published reviews of clinical trials on the efficacy of ESWT have led to inconsistent results and are outdated or methodologically inadequate. As a consequence, a systematic literature search was conducted which yielded 20 relevant papers that described trials on the efficacy of ESWT in the treatment of radiohumeral epicondylitis. These were rated according to biometrical criteria for the conduct of therapeutic trials. None of the rated trials fulfilled all of the criteria, and it is concluded that the efficacy of ESWT in the treatment of epidondylitis can presently be neither confirmed nor excluded.

[Design of a multicenter study for assessing the effectiveness of extracorporeal shockwave therapy in epicondylitis humeri radialis]

INTRODUCTION

Previously published studies concerning, extracorporeal shock-wave therapy (ESWT) in the treatment of lateral epicondylitis do not fulfil the biometric standards of modern clinical research. The objective of the trial is to show that ESWT is effective in the treatment of chronic LE.

METHOD

A prospective, randomized, placebo-controlled, single-blinded, multicenter trial with an independent blinded observer was designed. The effectiveness of ESWT is evaluated by comparison with a control group in which sham-ESWT is performed, both under local anaesthesia. Outcome is determined on the basis of the Roles/Maudsley-Score. Inclusion criteria are a history of at least 6 months of LE and failure of conventional treatment. The therapy includes 3 sessions of low energy ESWT with 2000 impulses (energy flux density 0.07-0.09 mJ/mm2). Sample size is 272 patients.

STATUS

Randomisation started in October 1998 and is planned over a period of two and a half years.

CONCLUSION

Only a randomised clinical trial with adequate control of placebo effects and observer bias can provide the required evidence for the efficiency of ESWT in the treatment of lateral epicondylitis of the elbow.

[Effects of extracorporeal shock waves (ESW) on human bone marrow cell cultures]

INTRODUCTION

Extracorporeal shockwave therapy (ESWT) is a new method of treating insertion tendopathy and pseudo-arthrosis, the clinical importance of which cannot yet be definitively assessed, and the underlying mechanisms of which are still unclear.

AIM

To develop an experimental set-up enabling the standardised application of ESWT to human bone marrow cell culture and the determination of the effect of ESWT.

MATERIAL AND METHODS

After 14 days incubation, human bone marrow cell cultures were subjected to ESWT using 200/500 pulses at an energy flux densities ED + of 0.03, 0.04, 0.07, 0.11 and 0.25 millijoule/mm2. Samples were obtained for LDH measurement 15 minutes, 4 h and 18 h after ESWT. Transmission light microscopy was carried out before and after ESWT to determine cell numbers and for morphological analysis.

RESULTS

Gaps in the cellular tissue first appear at an energy of 0.01 millijoule/mm2. At energies of 0.25 millijoule/mm2, morphologically altered cells, thinned out cellular tissue with a cell-free focal zone are found. At low energy levels, defects have been repaired ca. 1 week after ESWT. No significant increase in LDH was detected at any of the energy levels applied.

CONCLUSION

Increasing energy and higher pulse frequency is associated with an increase in the size and number of holes in cellular tissue and in cell separation. Regeneration capability (regrowth, sprouting, normal cell form) decreases as the energy level increases. Changes can be detected even at the lowest energy flux densities, which up until now had been assumed to have no effect on cell morphology or number. The standardised application of ESWT to human bone marrow cell cultures provides reproducible results that can be controlled by a placebo ESWT application.

Gas flow MRI using circulating laser-polarized 129Xe

We describe an experimental approach that combines multidimensional NMR experiments with a steadily renewed source of laser-polarized 129Xe. Using a continuous flow system to circulate the gas mixture, gas phase NMR signals of laser-polarized 129Xe can be observed with an enhancement of three to four orders of magnitude compared to the equilibrium 129Xe NMR signal. Due to the fact that the gas flow recovers the nonequilibrium 129Xe nuclear spin polarization in 0.2 to 4 s, signal accumulation on the time scale of seconds is feasible, allowing previously inaccessible phase cycling and signal manipulation. Several possible applications of MRI of laser-polarized 129Xe under continuous flow conditions are presented here. The spin density images of capillary tubes demonstrate the feasibility of imaging under continuous flow. Dynamic displacement profiles, measured by a pulsed gradient spin echo experiment, show entry flow properties of the gas passing through a constriction under laminar flow conditions. Further, dynamic displacement profiles of 129Xe, flowing through polyurethane foams with different densities and pore sizes, are presented.

Xenon-131 surface sensitive imaging of aerogels in liquid xenon near the critical point

In recent years, optically pumped xenon-129 has received a great deal of attention as a contrast agent in gas-phase imaging. This report is about the other NMR active xenon isotope (i.e., xenon-131, S = 32) which exhibits distinctive features for imaging applications in material sciences that are not obtainable from xenon-129 (S = (1/2)). The spin dynamics of xenon-131 in gas and liquid phases is largely determined by quadrupolar interactions which depend strongly on the surface of the surrounding materials. This leads to a surface dependent dispersion of relaxation rates, which can be substantial for this isotope. The dephasing of the coherence due to quadrupolar interactions may be used to yield surface specific contrast for imaging. Although optical pumping is not practical for this isotope because of its fast quadrupolar relaxation, a high spin density of liquid xenon close to the critical point (289 K) overcomes the sensitivity problems of xenon-131. We report the first xenon-131 magnetic resonance images and have tested this technique on various meso-porous aerogels as host structures. Aerogels of different densities and changing levels of hydration can clearly be distinguished from the images obtained.

[Magnetic resonance tomography in diagnosis and therapy follow-up of patients with congenital hip dysplasia and hip dislocation]

AIM

In patients with congenital dislocation of the hip the assessment of the correct position of the hip joint after closed or open reduction is very difficult to make from the radiograph with the hips in plaster. As the delayed recognition of a recurrent hip dislocation has bad effects on the outcome of the affected hip a safe and reliable imaging method must be employed.

METHOD

From 1993 to 1996 6 patients with 8 congenital dislocations of the hip joint were examined by magnetic resonance imaging for evaluation of the position of the hip in plaster after reduction. Magnetic resonance imaging was performed immediately after closed or open reduction. 3 hips had to be treated by open surgery.

RESULTS

The investigation confirmed that magnetic resonance imaging allows perfect differentiation between the bony and cartilaginous parts of the hip joint in plaster as well. Interpositioning of soft tissues which prevent reduction could also be visualized clearly. The best sequence in order to differentiate bony from cartilaginous structures was a gradient echo sequence in flash-technique using a flip-angle of 60 degrees. In all cases the correct position of the hip joint after reduction could be demonstrated in plaster.

CONCLUSION

Therefore, magnetic resonance imaging is the imaging method of choice for confirmation and documentation of the reduced position of the hip joint in plaster. Radiographs are no longer needed.

Multinuclear NMR study of enzyme hydration in an organic solvent

Multinuclear NMR spectroscopy has been used to study water bound to subtilisin Carlsberg suspended in tetrahydrofuran (THF), with the water itself employed as a probe of the hydration layer's physicochemical and dynamic characteristics. The presence of the enzyme did not affect the intensity, chemical shift or linewidth of water (up to 8% v/v) added to THF, as measured by 17O- and 2H-NMR. This finding suggests that hydration of subtilisin can be described by a three-state model that includes tightly bound, loosely bound, and free water. Solid-state 2H-NMR spectra of enzyme-bound D2O support the existence of a non-exchanging population of tightly bound water. An important implication is that the loosely-bound water is the same as free water from an NMR viewpoint. This loosely bound water must also be the water responsible for the large increase in catalytic activity observed in previous hydration studies.

Surface NMR Using Laser-Polarized 129Xe under Magic Angle Spinning Conditions

NMR signals of surface nuclei of solids may be enhanced by the transfer of spin polarization from laser-polarized noble gases. Until now such experiments have not been feasible under conditions of magic angle spinning. In the present contribution it is shown that laser-polarized 129Xe can be inserted into a spinning rotor under continuous-flow conditions using helium as a carrier gas. Effective adsorption of xenon on the sample occurs at temperatures of about 163-173 K making possible the observation of a spin polarization induced nuclear Overhauser effect (SPINOE) from the laser-polarized 129Xe to surface 1H nuclei of SiO2 (AEROSIL300). This technique opens the way to selectively enhanced high-resolution multinuclear surface NMR experiments. Copyright 1998 Academic Press. Copyright 1998 Academic Press

Standardized evaluation of long-term results after anterior lumbar interbody fusion

A total of 113 patients, excluding those with tumor, spondylitis, and idiopathic scoliosis, underwent anterior lumbar interbody fusion (ALIF) with autologous iliac crest graft between 1984 and 1991 at our department. The proportion of these who were failed back patients was higher than that reported in the literature. Evaluation of functional outcome was feasible in 80 patients, utilizing Oswestry and Marburg scores, which were closely intercorrelated. The overall results yielded an improvement in the Oswestry score of 35.7 percentage points. A subset of 52 patients who were evaluated twice, showed the same results at an average of 6.6 years as they did at 2.3 years following surgery. Functional results showed a weak correlation with postoperative height loss of the intervertebral space. Influencing factors for the functional result were: postoperative compensation claim, age, and obesity. Of the professional people involved, 19.4% did not return to any occupation. Patients satisfied with the result had significantly greater functional improvement. Younger patients with additional dorsal distraction prior to ALIF for reduction of severe spondylolisthesis fared better than patients with ALIF alone. The rate of complications was low and did not contribute to the postoperative functional result. On the basis of these results further prospective studies have been designed and are currently underway.

False-positive sonographic hip examinations in newborns with congenital varus deformity of the proximal femur

In cases of congenital varus deformity of the proximal femur, the screening of hip dysplasia can lead to misinterpretations. The false-positive ultrasound result is caused by the superiorly displaced greater trochanter in hips with coxa vara, which narrows the scan window. In this paper three typical patients are presented to demonstrate that the use of additional non-standard views cannot exclude hip dysplasia in all cases. Hence, such patients with femoral abnormalities and doubtful sonographic findings should be further evaluated by arthrography or magnetic resonance imaging to rule out additional hip dysplasia.

[Experimental studies of the effect of surgical technical errors on primary stability of cementless hip endoprosthesis shafts]

For quantified evaluation of the primary stability of cementless femoral stem prostheses the operative faults: too low sized stem, distally short-lined anchoring with proximally surpassing stem and fissure or fracture of the femur shaft were simulated in autoptical test series. By inductive displacement transducers the micromotion between stem and proximal bone layer were measured in medio-lateral and ventro-dorsal direction under static load conditions before and after a dynamic loading of 50,000 cycles. The underdimensioned stem showed its instable anchoring by obviously increased micromotions in all measure plains. The proximally excelling only distally anchored prosthesis demonstrated immense amounts of motion. The fissure doesn't seem to decrease the primary stability of the stems too much. These results of the autoptical test series can only be directly transferred to the conditions of the first weeks after implantation, because the influence of later bone integration could not be considered.