Cost-effectiveness of adding a non-invasive acoustic rule-out test in the evaluation of patients with suspected stable angina pectoris. Design of the randomized multicenter FILTER-SCAD trial

Background

Patients with suspected stable coronary artery disease (CAD) are selected for further non-invasive or invasive diagnostic tests depending on their pre-test probability (PTP) of obstructive CAD. However, the PTP, based on age, sex, and type of angina, has shown to grossly overestimate the likelihood of obstructive CAD. Consequently, the use of diagnostic tests has increased over the last decades despite a low diagnostic yield (6–7%). The CAD-score is a risk stratification score for obstructive CAD measured using a novel non-invasive acoustic device, and when added to PTP has shown excellent rule-out capabilities.

Purpose

To investigate if the addition of the CAD-score to a standard diagnostic examination is superior in terms of reducing overall number of diagnostic procedures and non-inferior in terms of safety as compared to a standard PTP-guided strategy when evaluating patients with suspected stable CAD.

Methods

The FILTER-SCAD trial is a randomized, controlled, multicenter trial expected to include 2000 subjects ≥30 years of age without known CAD referred for outpatient assessment for suspected CAD at 5 hospitals in Denmark and Sweden. First subject was randomized on October 22, 2019.

Subjects will be randomized 1:1 to either 1) a control group undergoing standard diagnostic examination (SDE) according to current guidelines, or 2) an intervention group undergoing SDE plus a CAD-score measurement, using permuted block randomization stratified by study site and PTP (very low vs. low-intermediate). Follow-up will be 12 months for a primary endpoint of cumulative number of diagnostic tests and a combined secondary safety endpoint of all-cause death, non-fatal myocardial infarction, unstable angina pectoris, heart failure, and ischemic stroke. Questionnaires assessing symptom severity, quality of life, life style measures, and medical treatment will be collected at baseline, 3 months, and 12 months after randomization.

The study is powered to detect superiority in terms of cumulative number of diagnostic tests with a power of 80% and a significance level of 0.05, and non-inferiority on the safety endpoint with a power of 90% and a significance level of 0.05. The study is conducted in compliance to the principles of the Declaration of Helsinki of the World Medical Association. ClinicalTrials.gov ID: NCT04121949.

Results

One study site is currently enrolling. Preliminary baseline data is available on the first 77 (44% males) enrolled patients (median age 61 years IQR (51–72) and PTP 22% IQR (13–38)) showing successful randomization with even distribution of baseline characteristic between the two groups including sex, age, and PTP.

Perspectives

The FILTER-SCAD trial will investigate whether it is feasible to reduce resource consumption without compromising safety in the outpatient assessment of patients with suspected CAD using a simple, non-invasive acoustic device. Enrollment and follow-up are expected to be completed spring 2022.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): The company Acarix A/S har provided an unrestricted grant for the study. The Foundation “Fonden for Faglig Udvikling i Speciallægepraksis” has provided a grant for the study.

P706Treatment of hypercholesterolaemia with PCSK-9 Inhibitors in Denmark. Assessment of real-life data; safety an extent of adverse effects after the first years of clinical use

Introduction

PCSK9 Inhibitors (PCSK9 I) are a new group of drugs for treatment of hyperlipidaemia. These drugs have been available in Denmark since October 2015. From the two existing major outcome studies (FOURIER and ODYSSEY OUTCOMES) it has been shown that there was no significant difference in the risk of serious adverse events, discontinuation due to adverse events, neurocognitive events, diabetes-related events, muscle-related events, or myalgia in the treatment group, compared with the control group. In FOUIRER 12.5% came of treatment; In ODYSSEY the rate was 10.2–14.8%. Although this highlights the efficacy and safety in patients with cardiovascular disease, we have little knowledge of the use, efficacy and safety with these drugs in real-life populations

Purpose

We aim to describe the demography, the treatment efficacy and the extent of adverse effects among patients treated in Danish lipid clinics.

Methods

Data on all patients treated with PCSK9 I between October 1st, 2015 and May 1st, 2018 were obtained from lipid clinics in Denmark. A database containing information on medications before treatment, adverse effects, plasma lipids (LDL-C, Triglyceride, High density lipoprotein cholesterol (HDL-C)) and supplementary blood tests was created. Levels of plasma lipids and organ markers (Creatinine, Hba1c or Alanine aminotransferase (ALAT)) at baseline and at follow up visits were analysed.

Results

Nationwide, 383 patients were included, an estimated 90% of all patients undergoing treatment with PCSK9 I in Denmark. A large proportion (n=243 - 63.4%) were described as statin intolerant and only 94 patients were receiving statins at baseline. Adverse effects (AE) were reported by 71 patients (18.5%) on PCSK9 I therapy and 50 patients (13.1%) stopped treatment. Most common AE were flu like symptoms and musculoskeletal aches. In two cases an increase in serum creatinine kinase was detected. One case of angioedema and three cases of local reactions to injections had been documented. No case of anaphylaxis was reported. Of the 71 patients with AEs 55 (77.5%) were statin intolerant. Of the 50, who came off treatment, 43 (86.0%) were statin intolerant. When treatment was stopped 15 patients (30.0%) tried the alternative PCSK9 Inhibitor (cross over). Of those, nine patients were able to tolerate the alternative PCSK9 I treatment.

Conclusion

Many patients (18.3%) reported AEs on a wide range of symptoms, but the rate of patients terminating PCSK9 I treatment was the same as found in the outcome studies (13.1% vs. 12.2 and 10.2–14.8%). Most of the patients who stopped treatment were statin intolerant and produced the same symptoms, as they had experienced with statins. Interestingly, nine of the 15 patients that were switched to the alternate PCSK9 I seems to tolerate this treatment.

2981Treatment of Hypercholesterolaemia with PCSK9 Inhibitors in Denmark. Assessment of real-life data; Extent and Efficacy after the first years of clinical use

Introduction

Proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9 I) are a new group of drugs for treatment of hypercholesterolaemia. At present there are two available drugs evolocumab and alirocumab, which lowers low-density lipoprotein cholesterol (LDL-C) by inhibiting the enzyme proprotein convertase subtilisin/kexin type 9. Both evolocumab and alirocumab outcome data (FOURIER and ODYSSEY OUTCOMES respectively) have shown a reduced risk of myocardial infarction, stroke, and coronary revascularization without adverse effects. Patients included in these trials had existing atherosclerotic cardiovascular disease and all patients received maximum-tolerated statin. In the FOURIER trail 100% of the patients received statin and 69% high intensity statin, in the ODYSSEY trial is was 98% and 89%, respectively

Purpose

In collaboration with lipid clinics in Denmark we aimed to describe the clinical characteristics of patients treated, along with the efficacy of LDL-C reduction of such treatment in a real-life population.

Methods

We contacted lipid and cardiological clinics throughout Denmark and obtained clinical data on the majority of patients treated with PCSK9 I in Denmark between October 1st, 2015 and May 1st, 2018. A database containing information on medical history, medications used prior to PCSK9 I initiation, adverse events and plasma lipids including LDL-C was created. Records of baseline LDL-C and at follow up visits were analysed.

Results

From October 1st 2015 to may 1st2018, 383 patients were enrolled; an estimated 90% of all patients in Denmark. The distribution of clinical indications for PCSK9 I initiation is shown in figure 1. A total 243 of these patients (63.4%) were characterised as statin intolerant and 225 (58.7%) had familial hypercholesterolaemia. More than two thirds (69.5%) of the patients were given PCSK9 Inhibitors as secondary prophylaxis. Overall LDL was significantly reduced from 5.11 mmol/L (CI [4.95; 5.28]) to 2.46 mmol/L (CI [2.33–2.68]) after the first month of treatment, corresponding to a 48.9% decrease in LDL-C, which persisted without significant changes throughout the two years of observation. Even with this reduction, only about half of the population of both primary and secondary prevention reached their treatment target. This remained unchanged in patients with familial hypercholesterolaemia an those with statin intolerance (Table 1). A subgroup analysis showed a significantly lower LDL in the first 12 months when PCSK9 I were combined with statins versus PCSK9 I as monotherapy (p<0.05) (results not shown).

Conclusion

Patients treated with PCSK9 I in this real-life do not resemble the populations in the major endpoint studies, as the majority in this real-life population are statin intolerant. Nevertheless, we see an overall reduction of LDL of approx. 50%, even though the number of patients reaching their treatment target remains low (approx. 50% at best).

The upregulation of hypoxia-related miRNA 210 in primary tumor of lymphogenic metastatic prostate cancer

Aim: To show the association between the expression level of hsa-miR-210 (miR-210) and tumor progression in prostate cancer (PCa). Methods: Quantitative PCR was performed to measure miR-210 on 55 subjects with different tumor stages; our results were then validated using three external datasets. ANOVA and Tukey's post hoc analysis were performed for comparative analyses between different tumor stages. Using the transcriptome data from The Cancer Genome Atlas for CaP, the gene expression analyses were performed on experimentally validated target genes of miR-210 identified in Tarbase and miRWalk datasets. Results & conclusion: miR-210 was significantly higher in N1 PCa compared with nonmetastatic PCa, whereas the metastatic tumor revealed a lower expression level of miR-210 than the primary tumor.

The expression profiles of miRNAs in the progression of prostate cancer from high-grade prostatic intraepithelial neoplasia to metastatic diseases

221

Background: The epigenetic regulation by miRNA plays an important role in tumor progression of prostate cancer (PCa). Methods: The expression data of 1054 miRNAs from TCGA were applied to identify relevant miRNAs associated with tumor progression (i.e. miR-210, miR-375, miR-378, miR-345, miR-143 miR-183 and miR-98). miRNA were isolated by miRNeasy FFPE kit (Qiagen, Hilden, Germany) from paraffin-embedded tissues of prostate specimens with PCa, HGPIN and normal tissues. Early-stage PCa was defined as PCa with pT2 tumor stage, Gleason score < = 7a (3+4) and PSA level < 10 ng/ml. PCa with pT3/4 or Gleason > 7a was defined as advanced PCa. PCa with pN1 were considered as metastatic diseases. Additionally, 3 cases with castration-resistant prostate cancer (CRPC) were considered. Quantitative miRNA expression data were acquired and analyzed using a real-time TaqMan-based PCR. ANOVA analyses were performed to evaluate the expression of miRNAs between HGPIN, Normal and PCa tissues. The small nuclear U6 RNA was used as an endogenous control Results: ANOVA analysis revealed a significant variation in expression of all miRNAs among groups. The expression level of miR-183 and miR-375 increased with the tumor progression. miR-143, miR-375-3p were inversely correlated with the tumor progression. miR-210 and miR-183 were significantly overexpressed in metastatic diseases compared to non-metastatic diseases (FDR < 0.01), whereas the expression level of miR-378-3p was lower in metastatic diseases than in organ-confined PCa. The expression of miR-98 was lower in PCa compared to normal tissues. In silico analysis, the down-regulation of miR-98 and miR-345-5p seems to activate the HIF-1 signaling pathway initiating the up-regulation of miR-210 that interact with genes related to cell cycle, RNA transcription, homologous recombination and non-homologous end-joining. Conclusions: Our data reveal epigenetic regulations of miRNA, which are associated with transition from normal tissues to HGIPN, from HGPIN to early-stage PCa, and early-stage PCa to advanced PCa. Advanced PCa represents the first stage of metastatic diseases.

Enhanced overexpression of hypoxia-related miRNA-210 in primary tumor of metastatic prostate cancer

166

Background: miR-210 is a known transcriptional target of the hypoxia-responsive HIF-1α signaling pathway. However, the association between the expression of miR-210 and the tumor progression in prostate cancer (PCa) remains unclear. Methods: We isolated miRNA by miRNeasy FFPE kit (Qiagen, Hilden, Germany) from paraffin-embedded tissues of 87 prostate specimens with adenocarcinoma of the prostate cancer in different tumor stages, with high-grade prostatic intraepithelial neoplasia (HGPIN) and normal tissues. Organ-confined PCa was defined as PCa with pT2 tumor stage, Gleason score ≤ 7a and PSA level < 10 ng/ml. PCa with pT3/4 or Gleason > 7a was defined as advanced PCa. PCa with pN1 were considered as metastatic diseases. Additionally, 3 cases with castration-resistant prostate cancer (CRPC) were considered. Quantitative miR-210 expression data were acquired and analyzed using a real-time TaqMan-based PCR with the ABI Prism 7900HT (Life Technologies, Darmstadt, Germany). ANOVA and post hoc analysis according to Turkey were performed using SPSS 22 (IBM, Armonk, USA). For silico analysis, Diana tools were applied to determine target genes of miR-210 and related functions and pathways. All the statistical tests were two-sided, and the level of statistical significance was set at P < 0.05. The small nuclear U6 RNA was used as an endogenous control. Results: ANOVA revealed significant differences in expression levels of miR-210 according to the tumor progression. Interestingly, organ-confined PCa showed the lowest expression level of miR-210 in our analysis. No sig. differences in miR-210 expression between normal tissues, HGPIN and organ-confined PCa and between advanced PCa, metastatic diseases and CRPC were observed. However, miR-210 expression was significantly higher in metastatic diseases and CRPC in comparison to organ-confined PCa. The silico analysis showed that genes regulated by miR-210 were associated with homologous recombination, non-homologous end-joining, the cell cycle regulation and synthesis of DNA. Conclusions: We observed an enhanced overexpression of hypoxia-related miRNA-210 in primary tumor of metastatic prostate cancer and CRPC in comparison to organ-confined PCa.

miRNA expression profiles in high-grade prostatic intraepithelial neoplasia

45

Background: High-grade prostatic intraepithelial neoplasia (HGPIN) is widely believed to be a precursor of prostate cancer (PCa). However, little is known about the expression of miRNAs variations in HGPIN compared to normal tissues and PCa. Methods: The expression data of 1054 miRNAs from TCGA were applied to identify relevant miRNAs associated with tumor progression (i.e., miR-98-5p, miR-183-5p, 345-5p, miR-143 miR-210-3p and miR-378-3p). miRNA were isolated by miRNeasy FFPE kit (Qiagen, Hilden, Germany) from paraffin-embedded tissues (FFPE) of prostate specimens with PCa, HGPIN and normal tissues. Early-stage PCa was defined as PCa with pT2 tumor stage, Gleason score <=7a (3+4) and PSA level <10 ng/ml. Quantitative miRNA expression data were acquired and analyzed using a real-time TaqMan-based PCR with the ABI Prism 7900HT (Life Technologies, Darmstadt, Germany). ANOVA analysis were performed to evaluate the expression of miRNAs between HGPIN, Normal and PCa tissues. All statistical analysis was performed using SPSS (IBM, Armonk, USA). P values were adjusted using the false discovery rate for multiple comparisons. The small nuclear U6 RNA was used as an endogenous control. Results: The expression of miR-143-3p, miR-210-3p and miR-345-5p and miR-98-5-p were varied between normal tissue, HGPIN and early-stage PCa. Interestingly, decrease in expression of miR-143.-3p, miR-98-5p and miR-210-3p was associated with tumor development (Normal tissues > HGPIN > early-stage PCa) (FDR<0.001). Furthermore, overexpression of miR-345-5p was observed in normal tissues compared to HGPIN and early-stage PCa, which both showed similar expression level of miR-345-5p. No significant differences in expression of miR-375, miR-183-5p and miR-378-3p were observed between HGPIN and PCa. These miRNAs were interacted with genes related to HIF-1 signaling pathway, p53 signaling pathway, androgen receptor signaling pathway, intrinsic apoptotic signaling pathway, RNA transcription, homologous recombination and non-homologous end-joining. Conclusions: HGPIN shows an altered expression of miRNAs interact with genes related to hypoxia, androgen receptor signaling pathway, cell cycle and epigenetic regulation.

Arthroscopic popliteus bypass graft for posterolateral instabilities of the knee : A new surgical technique

Objective

An arthroscopic technique for the reconstruction of the posterolateral corner combined with posterior cruciate ligament (PCL) reconstruction was developed.

Indications

Posterolateral rotational instabilities of the knee. Combined lesions of the PCL, the popliteus complex (PLT) and the posterolateral corner. Isolated PLT lesions lacking static stabilizing function.

Contraindications

Neuromuscular disorders; knee deformities or fractures; severe posterolateral soft tissue damage.

Surgical technique

Six arthroscopic portals are necessary. Using the posteromedial portal, resect dorsal septum with a shaver. Visualize the PCL, the lateral femoral condyle and the posterolateral recessus with the PLT. Dissect the popliteomeniscal fibers; retract PLT until sulcus popliteus is visualized. Drill a 6-mm tunnel anteriorly into the distal third of the sulcus popliteus. Visualize femoral footprint of the PLT and place an anatomical drill tunnel. Pull the popliteus bypass graft into the knee and fix with bioscrews. Fix the reconstructed PCL. In cases of additional LCL injury, reconstruct LCL with autologous graft.

Postoperative management

Partial weight-bearing for 6 weeks, range of motion exercises, quadriceps-strengthening exercises on postoperative day 1. Full extension allowed immediately with flexion limited to 20° for 2 weeks, to 45° for up to week 4, and to 60° up to week 6. Use a PCL brace for 3 months, running and squatting exercises allowed after 3 months.

Results

In the 35 patients treated, no technique-related complications. After 1 year, 12 patients had a mean Lysholm Score of 88.6 (± 8.7) points and a side-to-side difference in the posterior drawer test of 2.9 (± 2.2) mm (preoperative 13.3 [± 1.9] mm).

Conclusion

Low complication risk and good and excellent clinical results after arthroscopic posterolateral corner reconstruction.

[Ligament bracing--augmented primary suture repair in multiligamentous knee injuries]

OBJECTIVE

Reconstruction of knee stability by primary ligament sutures and additional augmentation after knee dislocation.

INDICATIONS

Acute knee dislocation Schenck type III and IV. Operative treatment should be performed within 7 days after injury.

CONTRAINDICATIONS

Chronic instability after knee dislocation, refixable bony avulsions, critical soft tissue, infection, lack of compliance.

SURGICAL TECHNIQUE

Supine position with electric leg holder. Short arthroscopic assessment of concomitant injuries. Schenck type III medial injuries and Schenck IV injuries: anteromedial parapatellar arthrotomy. Injuries type Schenck III lateral: anteromedian arthrotomy. Armoring of ligament stumps for transosseus sutures. Placement of anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) drill tunnels. Extracortical diversion of the suture armorings and insertion of augmentation systems. Fixation of the PCL augmentation in 70-90° flexion. Fixation of the ACL augmentation in 20-30° flexion. Knotting of the transosseus ligament sutures. If necessary (postero-)lateral and/or medial stabilization.

POSTOPERATIVE MANAGEMENT

Limited weight bearing with 20 kg for 6 weeks. Stabilizing brace (e.g., Hypex-Lite®, Albrecht) generally for 12 weeks. Mobilization under tension of the quadriceps muscle for 6 weeks.

RESULTS

In total, 20 patients have been treated using the principle of "ligament bracing". So far 8 patients (aged 18-60 years, median 33 years) have been assessed with a follow-up of 10-15 months (median 12 months) postoperatively. In all, 6 patients showed stable knees with good results. Recurrent instability of the ACL was observed in 2 patients; the collateral ligaments and PCL were stable. For the evaluation the following scores were used: IKDC score, Tegner score, and Lysholm score. To objectify the data, stress radiography and physical examination were performed. Using the operative technique mentioned above, no complications occurred. During follow-up 2 patients reported a deficiency of flexion.

COX-2 mRNA expression is significantly increased in acid-exposed compared to nonexposed squamous epithelium in gastroesophageal reflux disease

BACKGROUND

Little is known about the role of cyclooxygenase (COX)-2 in gastroesophageal reflux disease (GERD) and the development of Barrett's metaplasia. The objectives of this study were to further analyze COX-2 mRNA expression in patients with GERD compared to Barrett's esophagus (BE) and Barrett's cancer (BC).

METHODS

Tissue samples from 110 patients with GERD (n = 43), BE (n = 20), and BC (n = 47) were obtained in routine upper GI endoscopy. Expression levels of COX-2 were measured by quantitative real-time reverse trancriptase polymerase chain reaction (RT-PCR). Also, 24-h pH monitoring was performed in all patients of the GERD study group and the DeMeester composite score was used to match COX-2 mRNA expression with the severity of acid exposure in the lower esophagus.

RESULTS

COX-2 mRNA is progressively upregulated within the metaplasia-dysplasia-adenocarcinoma (MDA) sequence (p = 0.001). COX-2 levels of the squamous epithelium in the distal esophagus from patients with GERD and a pathologic mean DeMeester score (>14.72) were significantly higher than in patients with normal DeMeester scores (p = 0.01).

CONCLUSION

In summary our findings suggest that alterations in COX-2 mRNA expression occur independently of endoscopic or histologic signs of GERD in the acid-exposed squamous epithelium of the distal esophagus. However, this early COX-2 increase in GERD is further upregulated within the MDA sequence for yet unknown reasons.

Survivin mRNA in peripheral blood is frequently detected and significantly decreased following resection of gastrointestinal cancers

BACKGROUND AND OBJECTIVES

We evaluated if mRNA expression of survivin, an inhibitor of apoptosis, can be used to detect circulating tumor cells in peripheral blood of patients with various gastrointestinal cancers and if they decrease following complete surgical resection.

METHODS

Blood samples from 40 gastrointestinal cancer patients were analyzed prior and following surgical resection by direct quantitative real-time reverse transcriptase-PCR (RT-PCR) assays.

RESULTS

Survivin mRNA expression was pre-operatively detected in 35 of 40 cancer patients (88%). Post-operative survivin levels were significantly lower than pre-operative levels in 59% of resected patients and were non-detectable in 38% (Wilcoxon rank test: P < 0.04).

CONCLUSIONS

This is the first report showing that direct quantitative real-time RT-PCR analysis of survivin mRNA expression in peripheral blood of patients with gastrointestinal cancers is technically feasible. Survivin mRNA levels fall significantly following complete resection and might become a molecular marker for the completeness of surgical resection.

Analysis of prevalence of presumed inherited eye diseases in Entlebucher Mountain Dogs

We analyzed the prevalence of the presumed inherited eye diseases (PIED) noncongenital cataract and progressive retinal atrophy in the Entlebucher Mountain Dog for systematic environmental influences and the additive genetic variation. Multivariate linear animal models using residual maximum likelihood methods and multivariate threshold animal models using Gibbs sampling in Bayesian analyses were used to estimate variance and covariance components. Data were obtained from the kennel club for Swiss Mountain Dog breeds in Germany. PIED were recorded using the standardized protocols of the Dortmunder Kreis, the German panel of the European Eye Scheme for Diagnosis of Inherited Eye Diseases in Animals (DOK). The material included 515 Entlebucher Mountain Dogs from 344 litters at 77 different kennels. Veterinary diagnoses for PIED were from the years 1981-2001. Pedigree information was available for up to nine generations. The multivariate animal model regarded the fixed effects of sex, birth year, experience of the veterinary ophthalmologist, litter size, percentage of examined dogs per litter, inbreeding coefficient and age at examination. The common environment of the litter and the additive genetic effect of the animal were taken into account as randomly distributed effects. The heritability estimates for PIED in the Entlebucher Mountain Dog were h2=0.15+/-0.06 (noncongenital cataract), and h2=0.34+/-0.08 (progressive retinal atrophy) in the linear model and h2=0.32+/-0.05 (noncongenital cataract) and h2=0.59+/-0.03 (progessive retinal atrophy) in the threshold model. The additive genetic correlation between noncongenital cataract and progressive retinal atrophy was moderately positive (r(g)=0.54+/-0.08) in the threshold model. The number of examinations performed by the veterinary ophthalmologists was associated with slightly higher heritabilities for noncongenital cataract and considerably higher heritabilities for progressive retinal atrophy. The investigated PIED in the Entlebucher Mountain Dog are genetically influenced and the size of the genetic parameters estimated may be sensitive to the accuracy of the diagnosis and how the data were collected.

Suppression of theTIG3 tumor suppressor gene in human ovarian carcinomas is mediatedvia mitogen-activated kinase-dependent and -independent mechanisms

The TIG3 gene is a retinoic acid inducible class II tumor suppressor gene downregulated in several human tumors and malignant cell lines. Diminished TIG3 expression correlates with decreased differentiation whereas forced expression of TIG3 suppresses oncogenic signaling pathways and subsequently induces differentiation or apoptosis in tumor cells. Analysis of TIG3 mRNA expression in a large set of cDNA pools derived from matched tumor and normal human tissues showed a significant downregulation of TIG3 in 29% of the cDNA samples obtained from ovarian carcinomas. Using in situ hybridization, we demonstrated expression of TIG3 in the epithelial lining of 7 normal ovaries but loss of TIG3 expression in 15/19 of human ovarian carcinoma tissues. In SKOV-3, CAOV-3 and ES-2 ovarian carcinoma cell lines, downregulation of TIG3 mRNA was reversible and dependent on an activated MEK-ERK signaling pathway. Re-expression of TIG3 mRNA in these cells upon specific interference with the MEK-pathway was correlated with growth inhibition of the cells. In OVCAR-3 and A27/80 ovarian carcinoma cells, TIG3 suppression is MEK-ERK independent, but expression could be reconstituted upon interferon gamma (IFNgamma) induction. Overexpression of TIG3 in A27/80 ovarian carcinoma cells significantly impaired cell growth and despite increased mRNA levels, TIG3 protein was hardly detectable. These results suggest that TIG3 is negatively regulated by an activated MEK-ERK signaling pathway. Further mechanisms must interfere with TIG3 expression that are independent of MEK and partially include interferon-responsive components.

Renal and cardiac function during alpha1-beta-blockade in congestive heart failure

The kidney and the neurohormonal systems are essential in the pathogenesis of congestive heart failure (CHF) and the physiologic response. Routine treatment of moderate to severe CHF consists of diuretics, angiotensin-converting enzyme (ACE) inhibition and beta-blockade. The need for control of renal function during initiation of ACE-inhibition in patients with CHF is well known. The aim of this study was to investigate whether supplementation by a combined alpha1-beta-blockade to diuretics and ACE-inhibition might improve cardiac function without reducing renal function.

METHODS

Fourteen patients treated for moderate to severe CHF with diuretics and ACE inhibitors were investigated at baseline, after 4 months of maximum carvedilol treatment and after withdrawal of carvedilol.

RESULTS

Carvedilol lowered blood pressure and heart rate but increased left and right ventricular ejection fractions without changing cardiac output or pulmonary blood volume. At the same time, a minor fall was seen in glomerular filtration rate (GFR). but renal blood flow was unchanged and effective renal plasma flow slightly increased. Carvedilol also lowered the plasma levels of angiotensin II and aldosterone. All changes were reversed after withdrawal of carvedilol.

CONCLUSIONS

Carvedilol augments ACE-inhibitor-induced vasodilation by lowering blood pressure, and angiotensin II beside reducing heart rate. The heart adapts to the haemodynamic alterations without changes in cardiac output and pulmonary blood volume. GFR is slightly lowered despite no changes in renal blood flow and a slight increase in effective renal plasma flow. The study emphasizes the need for control of renal function during treatment with carvedilol in patients with CHF.

[Renal function during treatment of chronic renal failure with angiotensin converting enzyme inhibitors]

The effect on kidney function fo treatment of cardiac failure with ACE-inhibitors was examined retrospectively in a material of 87 consecutive patients. Furthermore, it was evaluated whether concomitant treatment with diuretics or existing generalised atherosclerosis as indicated by ongoing treatment with nitrates could be a risk factor concerning reduction of kidney function. In 11.9% of the patients an increase in S-creatinine of > 30% was observed during the first weeks of treatment. It was only necessary to stop treatment in two of these patients. In the remainder S-creatinine decreased again during ongoing treatment. In another 10.7% of patients an increase of 20-30% in S-creatinine was observed. Seventy-two point six percent of the patients had unchanged kidney function during treatment with an ACE-inhibitor. Ongoing treatment with diuretics did not seem to be a risk factor for developing reduced kidney function, whereas significantly more patients on treatment with nitrates, indicating generalised atherosclerosis, developed reduced kidney function during treatment with ACE-inhibitors. It is recommended to control kidney function before, one to two weeks and two to three months following initiation of treatment with ACE-inhibitors and to pay special attention to patients with generalised atherosclerosis.

[Renal function during treatment with angiotensin converting enzyme inhibitors]

The use of ACE-inhibitors has increased greatly during the last years. They were first used in treating hypertension, but nowadays cardiac diseases, mainly cardiac failure, are common indications. This means that the drugs are used in the treatment of more elderly patients who often have generalised atherosclerosis. This means that the patients must be controlled more often after initiation of treatment, especially concerning kidney function, since treatment with ACE-inhibitors can cause pronounced changes in renal haemodynamics and kidney function. This review focuses on the effects of ACE-inhibitors on renal haemodynamics and kidney function, which may be positive, with preservation of kidney function in diabetic and other chronic nephropathy, or negative, for example in cases with atherosclerotic stenosis of large or small renal arteries. It is concluded, that in cases of diabetic nephropathy an ACE-inhibitor is the "drug of choice" for treatment of hypertension. Furthermore the ACE-inhibitors seem to reduce the rate of deterioration of renal function and proteinuria in other kidney diseases. It is emphasized, that during treatment with ACE-inhibitors kidney function must be controlled before and following one to two weeks of treatment, if the dose is changed and in all cases following two to three months of treatment. Special attention should be given to patients with atherosclerotic manifestations e.g. angina.

Interferon-gamma treatment in mice experimentally infected with Trichinella spiralis

Interferon-tau (IFN-tau) treatment of Trichinella spiralis-infected BALB/c mice was investigated. The therapeutic regimen consisted of daily intraperitoneal injection of 10(4) U murine IFN-tau for 7 days, starting at 2 weeks post-infection. Striated muscle samples (diaphragm, thigh) were collected at 4, 8 and 12 weeks after infection. The muscle larval burden, the degree of encystation and the digestion of T. spiralis larvae were investigated. Furthermore, immunohistochemical studies of the inflammatory cell infiltrate around encysted larvae were performed. The results demonstrated an influence of IFN-tau treatment on the CD4+ and CD8+ subset distribution during the immune response but revealed no difference in the degree of encystation or digestion of encapsulated larvae as compared with control values.

[Lymphadenopathy and a lower T-helper/suppressor cell (Th/Ts) ratio in homosexual men in West Germany. Studies of 147 patients to evaluate the individual risk of acquiring AIDS]

Investigations on 147 homosexual men in Berlin-West (17-57 years old, kappa = 32 years) revealed the presence of lymphadenopathy in 90 cases (61.2%). In addition, the Th/Ts-ratio was significantly reduced in the entire homosexual group compared to a control group of heterosexual men (n = 13) of comparable age [2P(z) = 0.0001; Mann-Whitney-U-test]. In homosexual men with marked lymphadenopathy (n = 43) the ThlTs-ratio was found to be lower than in those without lymphadenopathy (n = 57); the difference was significant (P less than 0.01). The reduction of the Th/Ts-ratio in the entire group was mainly due to a significant increase of the number of Ts-lymphocytes (P less than 0.005); Th-lymphocytes showed a trend to decrease which only became significant values in the group of homosexual men with marked lymphadenopathy (P less than 0.05). Similarly, no statistical correlation was found between reduction of Th/Ts-ratio and the age of homosexual men in the entire group (n = 147) as compared to controls; whereas, in the group of homosexuals with marked lymphadenopathy (n = 43) the decrease of Th/Ts became significant with increasing age. No statistical correlation was found between lymphadenopathy, reduction of Th/Ts-ratio and promiscuity (lifetime number of partners, number of partners during the last 6 months). The high prevalence of lymphadenopathy and reduction of Th/Ts-ratio, regarded as parameters of the individual AIDS-risk, indicate that a considerable number of homosexual men in Germany may develop that syndrome.

[The lymphadenopathy syndrome. Immunologic studies of young homosexual men with and without lymphadenopathy]

Investigations on 147 young homosexual men living in Berlin (West) revealed lymphadenopathy in 61.2% (90 pat.). This finding was prominent in 43.4% of all cases. Evaluation of total T-, T-helper und T-suppressor lymphocytes by means of immunofluorescence with monoclonal antibodies showed an unchanged total number of T-lymphocytes; in contrast, the T-helper subpopulation was decreased and the T-suppressor subpopulation was increased in the peripheral blood, in comparison to a control group of heterosexual men. Therefore, a significantly reduced Th/Ts-ratio was supposed. These changes were more pronounced in the group with marked lymphadenopathy. Our investigations prove a high prevalence of lymphadenopathy and immune dysfunction among young homosexual men in Germany. Both are correlates of one syndrome characterized by persisting unexplained lymphadenopathy, immune dysfunction, and general clinical symptoms (including loss of weight, fever, diarrhoea, etc.). This so called lymphadenopathy syndrome (LAS) with the above mentioned clinical symptoms and reduction of the Th/Ts-ratio may represent a prodrome of AIDS. A long-term and careful follow-up of these patients is therefore necessary.