Update "Systemic treatment of atopic dermatitis" of the S2k-guideline on atopic dermatitis

This guideline is an update from August 2020 the S2k-guideline "Atopic dermatitis" published in 2015. The reason for updating this chapter of the guideline were the current developments in the field of systemic therapy of atopic dermatitis. The agreed recommendations for systemic treatment in atopic dermatitis of the present guideline are based on current scientific data. Due to the approval of dupilumab for the treatment of moderate to severe atopic dermatitis, which cannot be treated sufficiently with topical drugs alone, this part of the guideline has now been adapted and newly consented. The indication for systemic therapy and the therapeutic response to topical and systemic treatment should be recorded and documented in a suitable form in clinic and practice. A standardized documentation of the indication for system therapy in atopic dermatitis can be recommended and is also part of the updated chapter of this guideline.

Paired EMI-HIMU hotspots in the South Atlantic-Starting plume heads trigger compositionally distinct secondary plumes?

Age-progressive volcanism is generally accepted as the surface expression of deep-rooted mantle plumes, which are enigmatically linked with the African and Pacific large low-shear velocity provinces (LLSVPs). We present geochemical and geochronological data collected from the oldest portions of the age-progressive enriched mantle one (EMI)-type Tristan-Gough track. They are part of a 30- to 40-million year younger age-progressive hotspot track with St. Helena HIMU (high time-integrated 238U/204Pb) composition, which is also observed at the EMI-type Shona hotspot track in the southernmost Atlantic. Whereas the primary EMI-type hotspots overlie the margin of the African LLSVP, the HIMU-type hotspots are located above a central portion of the African LLSVP, reflecting a large-scale geochemical zonation. We propose that extraction of large volumes of EMI-type mantle from the margin of the LLSVP by primary plume heads triggered upwelling of HIMU material from a more internal domain of the LLSVP, forming secondary plumes.

Methylation of L1RE1, RARB, and RASSF1 function as possible biomarkers for the differential diagnosis of lung cancer

Background

Lung cancer is the major cause of cancer-related deaths worldwide. Differential diagnosis can be difficult, especially when only small samples are available. Epigenetic changes are frequently tissue-specific events in carcinogenesis and hence may serve as diagnostic biomarkers.

Material and methods

138 representative formalin-fixed, paraffin-embedded (FFPE) tissues (116 lung cancer cases and 22 benign controls) were used for targeted DNA methylation analysis via pyrosequencing of ten literature-derived methylation markers (APC, CDH1, CDKN2A, EFEMP1, FHIT, L1RE1, MGMT, PTEN, RARB, and RASSF1). Methylation levels were analyzed with the Classification and Regression Tree Algorithm (CART), Conditional Interference Trees (ctree) and ROC. Validation was performed with additional 27 lung cancer cases and 38 benign controls. TCGA data for 282 lung cancer cases was included in the analysis.

Results

CART and ctree analysis identified the combination of L1RE1 and RARB as well as L1RE1 and RASSF1 as independent methylation markers with high discriminative power between tumor and benign tissue (for each combination, 91% specificity and 100% sensitivity). L1RE1 methylation associated significantly with tumor type and grade (p<0.001) with highest methylation in the control group. The opposite was found for RARB (p<0.001). RASSF1 methylation increased with tumor type and grade (p<0.001) with strongest methylation in neuroendocrine tumors (NET).

Conclusion

Hypomethylation of L1RE1 is frequent in tumors compared to benign controls and associates with higher grade, whereas increasing methylation of RARB is an independent marker for tumors and higher grade. RASSF1 hypermethylation was frequent in tumors and most prominent in NET making it an auxiliary marker for separation of NSCLC and NET. L1RE1 in combination with either RARB or RASSF1 could function as biomarkers for separating lung cancer and non-cancerous tissue and could be useful for samples of limited size such as biopsies.

Cooperative Problem Solving with Personal Mobile Information Tools in Hospitals

Health-care professionals have a broad range of needs for information and cooperation while working at different points of care (e.g., outpatient departments, wards, and functional units such as operating theaters). Patient-related data and medical knowledge have to be widely available to support high-quality patient care. Furthermore, due to the increased specialization of health-care professionals, efficient collaboration is required. Personal mobile information tools have a considerable potential to realize almost ubiquitous information and collaborative support. They enable to unite the functionality of conventional tools such as paper forms, dictating machines, and pagers into one tool. Moreover, they can extend the support already provided by clinical workstations. An approach is described for the integration of mobile information tools with heterogeneous hospital information systems. This approach includes identification of functions which should be provided on mobile tools. Major functions are the presentation of medical records and reports, electronic mailing to support interpersonal communication, and the provision of editors for structured clinical documentation. To realize those functions on mobile tools, we propose a document-based client-server architecture that enables mobile information tools to interoperate with existing computer-based application systems. Open application systems and powerful, partially wireless, hospital-wide networks are the prerequisites for the introduction of mobile information tools.

Motion Artifact Reducing Reconstruction of 4D CT Image Data for the Analysis of Respiratory Dynamics

Objectives: Respiratory motion represents a major problem in radiotherapy of thoracic and abdominal tumors. Methods for compensation require comprehensive knowledge of underlying dynamics. Therefore, 4D (= 3D + t) CT data can be helpful. But modern CT scanners cannot scan a large region of interest simultaneously. So patients have to be scanned in segments. Commonly used approaches for reconstructing the data segments into 4D CT images cause motion artifacts. In orderto reduce the artifacts, a new method for 4D CT reconstruction is presented. The resulting data sets are used to analyze respiratory motion.

Methods: Spatiotemporal CT image sequences of lung cancer patients were acquired using a multi-slice CT in cine mode during free breathing. 4D CT reconstruction was done by optical flow based temporal interpolation. The resulting 4D image data were compared with data generated bythe commonly used nearest neighbor reconstruction. Subsequent motion analysis is mainly concerned with tumor mobility.

Results: The presented optical flow-based method enables the reconstruction of 3D CT images at arbitrarily chosen points of the patient’s breathing cycle. A considerable reduction of motion artifacts has been proven in eight patient data sets. Motion analysis showed that tumor mobility differs strongly between the patients.

Conclusions: Due to the proved reduction of motion artifacts, the optical flow-based 4D CT reconstruction offers the possibility of high-quality motion analysis. Because the method is based on an interpolation scheme, it additionally has the potential to enable the reconstruction of 4D CT data from a lesser number of scans.

Herpes Zoster – Empfehlungen der konsensbasierten Europäischen Leitlinie

Diagnosestellung Bei diagnostischer Unsicherheit wird die Anwendung molekulargenetischer Untersuchungen oder alternativ Antigen-basierter Tests empfohlen.

Weiterführende Diagnostik Risikofaktoren und klinische Zeichen für komplizierte Verläufe sollten erfasst werden und erfordern ggf. weiterführende diagnostische Maßnahmen.

Therapieziele und Indikationen zur systemischen antiviralen Behandlung Insbesondere Patienten mit Risikofaktoren für eine kompliziert verlaufende Erkrankung sollten eine systemische antivirale Therapie erhalten. Für junge Patienten ohne Risikofaktoren wurde eine relative Therapieindikation ausgesprochen.

Wie sollte behandelt werden? Die Auswahl der antiviralen Medikation sollte gemeinsam mit dem Patienten unter Berücksichtigung der Praktikabilität, Therapiekosten, Kontraindikationen und Komorbiditäten erfolgen. Patienten mit Risikofaktoren für komplizierte Verläufe sollten bevorzugt mit parenteralem Aciclovir behandelt werden.

Spezifische Situationen Die ergänzende systemische Verabreichung von Kortikosteroiden wird nur in spezifischen Situationen (z. B. akute Retinanekrose, Ramsay-Hunt-Syndrom) und in Konsultation mit den entsprechenden Fachdisziplinen empfohlen.

Schmerztherapie Eine suffiziente Schmerztherapie unter Berücksichtigung des WHO-Stufenschemas und Einbezug von Komedikation soll frühzeitig erfolgen.

Lokalbehandlung Die Studienlage für spezifische Ansätze der Lokaltherapie ist unzureichend und es konnte innerhalb des Expertengremiums keine Einigung für eine spezifische Empfehlung erzielt werden.

Identification of an AR Mutation-Negative Class of Androgen Insensitivity by Determining Endogenous AR Activity

CONTEXT

Only approximately 85% of patients with a clinical diagnosis complete androgen insensitivity syndrome and less than 30% with partial androgen insensitivity syndrome can be explained by inactivating mutations in the androgen receptor (AR) gene.

OBJECTIVE

The objective of the study was to clarify this discrepancy by in vitro determination of AR transcriptional activity in individuals with disorders of sex development (DSD) and male controls.

DESIGN

Quantification of DHT-dependent transcriptional induction of the AR target gene apolipoprotein D (APOD) in cultured genital fibroblasts (GFs) (APOD assay) and next-generation sequencing of the complete coding and noncoding AR locus.

SETTING

The study was conducted at a university hospital endocrine research laboratory.

PATIENTS

GFs from 169 individuals were studied encompassing control males (n = 68), molecular defined DSD other than androgen insensitivity syndrome (AIS; n = 18), AR mutation-positive AIS (n = 37), and previously undiagnosed DSD including patients with a clinical suspicion of AIS (n = 46).

INTERVENTION(S)

There were no interventions.

MAIN OUTCOME MEASURE(S)

DHT-dependent APOD expression in cultured GF and AR mutation status in 169 individuals was measured.

RESULTS

The APOD assay clearly separated control individuals (healthy males and molecular defined DSD patients other than AIS) from genetically proven AIS (cutoff < 2.3-fold APOD-induction; 100% sensitivity, 93.3% specificity, P < .0001). Of 46 DSD individuals with no AR mutation, 17 (37%) fell below the cutoff, indicating disrupted androgen signaling.

CONCLUSIONS

AR mutation-positive AIS can be reliably identified by the APOD assay. Its combination with next-generation sequencing of the AR locus uncovered an AR mutation-negative, new class of androgen resistance, which we propose to name AIS type II. Our data support the existence of cellular components outside the AR affecting androgen signaling during sexual differentiation with high clinical relevance.

Real time tracking in liver SBRT: comparison of CyberKnife and Vero by planning structure-based γ-evaluation and dose-area-histograms

The purpose of this study was to evaluate and compare two clinical tracking systems for radiosurgery with regard to their dosimetric and geometrical accuracy in liver SBRT: the robot-based CyberKnife and the gimbal-based Vero. Both systems perform real-time tumour tracking by correlating internal tumour and external surrogate motion. CyberKnife treatment plans were delivered to a high resolution 2D detector array mounted on a 4D motion platform, with the platform simulating (a) tumour motion trajectories extracted from the corresponding CyberKnife predictor log files and (b) the tumour motion trajectories with superimposed baseline-drift. Static reference and tracked dose measurements were compared and dosimetric as well as geometrical uncertainties analyzed by a planning structure-based evaluation. For (a), γ-passing rates inside the CTV (γ-criteria of 1% / 1 mm) ranged from 95% to 100% (CyberKnife) and 98% to 100% (Vero). However, dosimetric accuracy decreases in the presence of the baseline-drift. γ-passing rates for (b) ranged from 26% to 92% and 94% to 99%, respectively; i.e. the effect was more pronounced for CyberKnife. In contrast, the Vero system led to maximum dose deviations in the OAR between  +1.5 Gy to +6.0 Gy (CyberKnife: +0.5 Gy to +3.5 Gy). Potential dose shifts were interpreted as motion-induced geometrical tracking errors. Maximum observed shift ranges were  -1.0 mm to  +0.7 mm (lateral) /-0.6 mm to +0.1 mm (superior-inferior) for CyberKnife and  -0.8 mm to +0.2 mm /-0.8 mm to +0.4 mm for Vero. These values illustrate that CyberKnife and Vero provide high precision tracking of regular breathing patterns. Even for the modified motion trajectory, the obtained dose distributions appear to be clinical acceptable with regard to literature QA γ-criteria of 3% / 3 mm.

Expanding the clinical spectrum of the 'HDAC8-phenotype' - implications for molecular diagnostics, counseling and risk prediction

Cornelia de Lange syndrome (CdLS) is a clinically heterogeneous disorder characterized by typical facial dysmorphism, cognitive impairment and multiple congenital anomalies. Approximately 75% of patients carry a variant in one of the five cohesin-related genes NIPBL, SMC1A, SMC3, RAD21 and HDAC8. Herein we report on the clinical and molecular characterization of 11 patients carrying 10 distinct variants in HDAC8. Given the high number of variants identified so far, we advise sequencing of HDAC8 as an indispensable part of the routine molecular diagnostic for patients with CdLS or CdLS-overlapping features. The phenotype of our patients is very broad, whereas males tend to be more severely affected than females, who instead often present with less canonical CdLS features. The extensive clinical variability observed in the heterozygous females might be at least partially associated with a completely skewed X-inactivation, observed in seven out of eight female patients. Our cohort also includes two affected siblings whose unaffected mother was found to be mosaic for the causative mutation inherited to both affected children. This further supports the urgent need for an integration of highly sensitive sequencing technology to allow an appropriate molecular diagnostic, genetic counseling and risk prediction.

Respiratory surface motion measurement by Microsoft Kinect

In radiotherapy of abdominal and thoracic tumors, respiratory motion is a problem for an accurate treatment. Most current motion compensation techniques rely on externally acquired breathing signals of the patient. The systems in clinical use usually work with 1D surface motion signals to describe internal structure respiratory motion patterns. As a 1D signal is not able to describe complex motion patterns and breathing variations, in this work the Microsoft Kinect, which can record multidimensional respiratory surface motion signals, is proposed to be used instead. For the Kinect, a clinically acceptable measurement setup is designed and Kinect measurements are compared to the Varian RPM system (clinical standard). The results show that the signals are well aligned. An additional comparison of Kinect signals from different regions of interest on the chest further reveals variations between them. This illustrates that the use of a system that provides multidimensional signals is worthwhile; the knowledge about breathing variations could be applied for optimization of current clinical workflows.

Conductivity and magnetoresistance of La0.7Ce0.3MnO(3-δ) thin films under photoexcitation

La0.7Ce0.3MnO3 thin films of different thicknesses, degrees of CeO2-phase segregation and oxygen deficiency, grown on SrTiO3 single crystal substrates, were comparatively investigated with respect to both their spectral and temperature-dependent photoconductivity (PC) and their magnetoresistance (MR) behaviour under photoexcitation. While as-grown films were insensitive to optical excitation, oxygen reduction appeared to be an effective way to decrease the film resistance, but the film thickness was found to play a minor role. However, from the evaluation of the spectral behaviour of the PC and the comparison of the MR of the LCeMO/substrate-samples with a bare substrate under illumination we find that the photoconductivity data reflects not only contributions from (i) photogenerated charge carriers in the film and (ii) carriers injected from the photoconductive substrate (as concluded from earlier works), but also (iii) a decisive parallel photoconduction in the SrTiO3 substrate. Furthermore--also by analyzing the MR characteristics--the unexpected occurence of a strong electroresistive effect in the sample with the highest degree of CeO2 segregation and oxygen deficiency could be attributed to the electroresistance of the SrTiO3 substrate as well. The results suggest a critical reconsideration and possibly a reinterpretation of several previous photoconductivity and electroresistance investigations of manganite thin films on SrTiO3.

Simulation of range imaging-based estimation of respiratory lung motion. Influence of noise, signal dimensionality and sampling patterns

OBJECTIVES

A major problem associated with the irradiation of thoracic and abdominal tumors is respiratory motion. In clinical practice, motion compensation approaches are frequently steered by low-dimensional breathing signals (e.g., spirometry) and patient-specific correspondence models, which are used to estimate the sought internal motion given a signal measurement. Recently, the use of multidimensional signals derived from range images of the moving skin surface has been proposed to better account for complex motion patterns. In this work, a simulation study is carried out to investigate the motion estimation accuracy of such multidimensional signals and the influence of noise, the signal dimensionality, and different sampling patterns (points, lines, regions).

METHODS

A diffeomorphic correspondence modeling framework is employed to relate multidimensional breathing signals derived from simulated range images to internal motion patterns represented by diffeomorphic non-linear transformations. Furthermore, an automatic approach for the selection of optimal signal combinations/patterns within this framework is presented.

RESULTS

This simulation study focuses on lung motion estimation and is based on 28 4D CT data sets. The results show that the use of multidimensional signals instead of one-dimensional signals significantly improves the motion estimation accuracy, which is, however, highly affected by noise. Only small differences exist between different multidimensional sampling patterns (lines and regions). Automatically determined optimal combinations of points and lines do not lead to accuracy improvements compared to results obtained by using all points or lines.

CONCLUSIONS

Our results show the potential of multidimensional breathing signals derived from range images for the model-based estimation of respiratory motion in radiation therapy.

Lung registration using automatically detected landmarks

OBJECTIVES

Accurate registration of lung CT images is inevitable for numerous clinical applications. Usually, nonlinear intensity-based methods are used. Their accuracy is typically evaluated using corresponding anatomical points (landmarks; e.g. bifurcations of bronchial and vessel trees) annotated by medical experts in the images to register. As image registration can be interpreted as correspondence finding problem, these corresponding landmarks can also be used in feature-based registration techniques. Recently, approaches for automated identification of such landmark correspondences in lung CT images have been presented. In this work, a novel combination of variational nonlinear intensity-based registration with an approach for automated landmark correspondence detection in lung CT pairs is presented and evaluated.

METHODS

The main blocks of the proposed hybrid intensity- and feature-based registration scheme are a two-step landmark correspondence detection and the so-called CoLD (Combining Landmarks and Distance Measures) framework. The landmark correspondence identification starts with feature detection in one image followed by a blockmatching-based transfer of the features to the other image. The established correspondences are used to compute a thin-plate spline (TPS) transformation. Within CoLD, the TPS transformation is improved by minimization of an objective function consisting of a Normalized Gradient Field distance measure and a curvature regularizer; the landmark correspondences are guaranteed to be preserved by optimization on the kernel of the discretized landmark constraints.

RESULTS

Based on ten publicly available end-inspiration/expiration CT scan pairs with anatomical landmark sets annotated by medical experts from the DIR-Lab database, it is shown that the hybrid registration approach is superior in terms of accuracy: The mean distance of expert landmarks is decreased from 8.46 mm before to 1.15 mm after registration, outperforming both the TPS transformation (1.68 mm) and a nonlinear registration without usage of automatically detected landmarks (2.44 mm). The improvement is statistically significant in eight of ten datasets in comparison to TPS and in nine of ten datasets in comparison to the intensity-based registration. Furthermore, CoLD globally estimates the breathing-induced lung volume change well and results in smooth and physiologically plausible motion fields of the lungs.

CONCLUSIONS

We demonstrated that our novel landmark-based registration pipeline outperforms both TPS and the underlying nonlinear intensity-based registration without landmark usage. This highlights the potential of automatic landmark correspondence detection for improvement of lung CT registration accuracy.

Crystal Structure and Magnetic Properties of a Linear Trinuclear Ni(II) Complex

Linear Trinuclear Nickel(II) Complex, Super-Exchange Interactions, Antiferromagnetic Coupling [Ni3(C2H32(CH3O)2L2] [L = 13-bis(5-chlorosalicylideneamino)propan-2-ol dianion, (C2H3O2)- = acetate, (CH3OH) = methanol] was synthesized and its crystal structure was determined. It crystallizes in the monoclinic spaceeroup P21 /n with a = 12.694(2), b = 13.281 (4), c = 15.420(3) Å, β = 111.25(2)°, V = 2422.9(9) Å3 ,Z = 2 . The molecule is a "linear" trinuclear complex with nearly octahedral coordination of each nickel ion. Adjacent nickel(II) ions are bridged by the phenolic oxygen atoms of the ligands and the oxygen atoms of the acetato ligands. The coordination sphere of the terminal nickel(II) ions is completed by the oxygen atom of the methanol. Adjacent nickel(II) centers are separated by 3.043(1) Å and weakly antiferromagnetically coupled (J1 = -3 .4 cm-1). The terminal nickel(II) centers are separated by 6.086(1) Å and very weakly antiferromagnetically coupled (J2 = -0 .3 cm-1) which follows from temperature-dependent magnetic susceptibility measurements in the temperature range 4.5 to 318 K. The magnetic moment rises from 2.99 μB at 4.5 K to 5.42 μB at 318 K. In the X(T) curve no characteristic maximum was observed.

Multivariate regression approaches for surrogate-based diffeomorphic estimation of respiratory motion in radiation therapy

Breathing-induced location uncertainties of internal structures are still a relevant issue in the radiation therapy of thoracic and abdominal tumours. Motion compensation approaches like gating or tumour tracking are usually driven by low-dimensional breathing signals, which are acquired in real-time during the treatment. These signals are only surrogates of the internal motion of target structures and organs at risk, and, consequently, appropriate models are needed to establish correspondence between the acquired signals and the sought internal motion patterns. In this work, we present a diffeomorphic framework for correspondence modelling based on the Log-Euclidean framework and multivariate regression. Within the framework, we systematically compare standard and subspace regression approaches (principal component regression, partial least squares, canonical correlation analysis) for different types of common breathing signals (1D: spirometry, abdominal belt, diaphragm tracking; multi-dimensional: skin surface tracking). Experiments are based on 4D CT and 4D MRI data sets and cover intra- and inter-cycle as well as intra- and inter-session motion variations. Only small differences in internal motion estimation accuracy are observed between the 1D surrogates. Increasing the surrogate dimensionality, however, improved the accuracy significantly; this is shown for both 2D signals, which consist of a common 1D signal and its time derivative, and high-dimensional signals containing the motion of many skin surface points. Eventually, comparing the standard and subspace regression variants when applied to the high-dimensional breathing signals, only small differences in terms of motion estimation accuracy are found.

The Mn(2+)/Mn(3+) state of La0.7Ce0.3MnO3 by oxygen reduction and photodoping

Films of cerium-doped LaMnO3, which has been intensively discussed as an electron-doped counterpart to hole-doped mixed-valence lanthanum manganites during the past decade, were analyzed by x-ray photoemission spectroscopy with respect to their manganese valence under photoexcitation. The comparative analysis of the Mn 3s exchange splitting of La0.7Ce0.3MnO3 (LCeMO) films in the dark and under illumination clearly shows that both oxygen reduction and illumination are able to decrease the Mn valence towards a mixed 2+/3+ state, independently of the film thickness and the degree of CeO2 segregation. Charge-injection from the photoconductive SrTiO3 substrate into the Mn eg band with carrier lifetimes in the range of tens of seconds and intrinsic generation of electron-hole pairs within the films are discussed as two possible sources of the Mn valence shift and the subsequent electron doping.

Cost comparison of axillary sentinel lymph node detection and axillary lymphadenectomy in early breast cancer. A national study based on a prospective multi-institutional series of 985 patients 'on behalf of the Group of Surgeons from the French Unicancer Federation'

BACKGROUND

Our objective was to assess the global cost of the sentinel lymph node detection [axillary sentinel lymph node detection (ASLND)] compared with standard axillary lymphadenectomy [axillary lymph node dissection (ALND)] for early breast cancer patients.

PATIENTS AND METHODS

We conducted a prospective, multi-institutional, observational, cost comparative analysis. Cost calculations were realized with the micro-costing method from the diagnosis until 1 month after the last surgery.

RESULTS

Eight hundred and thirty nine patients were included in the ASLND group and 146 in the ALND group. The cost generated for a patient with an ASLND, with one preoperative scintigraphy, a combined method for sentinel node detection, an intraoperative pathological analysis without lymphadenectomy, was lower than the cost generated for a patient with lymphadenectomy [€ 2947 (σ = 580) versus € 3331 (σ = 902); P = 0.0001].

CONCLUSION

ASLND, involving expensive techniques, was finally less expensive than ALND. The length of hospital stay was the cost driver of these procedures. The current observational study points the heterogeneous practices for this validated and largely diffused technique. Several technical choices have an impact on the cost of ASLND, as intraoperative analysis allowing to reduce rehospitalization rate for secondary lymphadenectomy or preoperative scintigraphy, suggesting possible savings on hospital resources.