Improvement of functional outcome for patients with newly diagnosed grade 2 or 3 gliomas with co-deletion of 1p/19q - IMPROVE CODEL: the NOA-18 trial

Background

Given the young age of patients with CNS WHO grade 2 and 3 oligodendrogliomas and the relevant risk of neurocognitive, functional, and quality-of-life impairment with the current aggressive standard of care treatment, chemoradiation with PCV, of the tumour located in the brain optimizing care is the major challenge.

Methods

NOA-18 aims at improving qualified overall survival (qOS) for adult patients with CNS WHO grade 2 and 3 oligodendrogliomas by randomizing between standard chemoradiation with up to six six-weekly cycles with PCV and six six-weekly cycles with lomustine and temozolomide (CETEG) (n = 182 patients per group accrued over 4 years) thereby delaying radiotherapy and adding the chemoradiotherapy concept at progression after initial radiation-free chemotherapy, allowing for effective salvage treatment and delaying potentially deleterious side effects. QOS represents a new concept and is defined as OS without functional and/or cognitive and/or quality of life deterioration regardless of whether tumour progression or toxicity is the main cause. The primary objective is to show superiority of an initial CETEG treatment followed by partial brain radiotherapy (RT) plus PCV (RT-PCV) at progression over partial brain radiotherapy (RT) followed by procarbazine, lomustine, and vincristine (PCV) chemotherapy (RT-PCV) and best investigators choice (BIC) at progression for sustained qOS. An event concerning a sustained qOS is then defined as a functional and/or cognitive and/or quality of life deterioration after completion of primary therapy on two consecutive study visits with an interval of 3 months, tolerating a deviation of at most 1 month. Assessments are done with a 3-monthly MRI, assessment of the NANO scale, HRQoL, and KPS, and annual cognitive testing. Secondary objectives are evaluation and comparison of the two groups regarding secondary endpoints (short-term qOS, PFS, OS, complete and partial response rate). The trial is planned to be conducted at a minimum of 18 NOA study sites in Germany.

Discussion

qOS represents a new concept. The present NOA trial aims at showing the superiority of CETEG plus RT-PCV over RT-PCV plus BIC as determined at the level of OS without sustained functional deterioration for all patients with oligodendroglioma diagnosed according to the most recent WHO classification.

Trial registration

Clinicaltrials.govNCT05331521. EudraCT 2018–005027-16.

The influence of the SARS-CoV-2 lockdown on patients with inflammatory rheumatic diseases on their adherence to immunomodulatory medication: a cross sectional study over 3 months in Germany

Objectives

To evaluate the influence of the SARS-CoV-2 pandemic on the adherence of patients with inflammatory rheumatic diseases (IRD) to their immunomodulatory medication during the three-months lockdown in Germany.

Methods

From March 16^th until June 15^th 2020, IRD patients from private practices and rheumatology departments were asked to answer a questionnaire addressing their behaviour with respect to their immunomodulating therapy. Eight private practices and nine rheumatology departments which included rheumatology primary care centres and university hospitals participated. 4252 questionnaires were collected and evaluated.

Results

The majority of patients (54%) were diagnosed with rheumatoid arthritis, followed by psoriatic arthritis (14%), ankylosing spondylitis (10%), connective tissue diseases (12%) and vasculitides (6%). The majority of patients (84%) reported to continue their immunomodulatory therapy. Termination of therapy was reported by only 3% of the patients. The results were independent from the type of IRD, the respective immunomodulatory therapy and by whom the patients were treated (private practices vs rheumatology departments). Younger patients (<60 years) reported just as often as older patients to discontinue their therapy.

Conclusion

The data show that most of the patients continued their therapy in spite of the pandemic. A significant change in behavior with regard to their immunomodulatory therapy was not observed during the three months of observation. The results support the idea that the immediate release of recommendation of the German Society of Rheumatology were well received, supporting the well-established physician-patient-relationship in times of a crisis.

[A cross sectional study on patients with inflammatory rheumatic diseases in terms of their compliance to their immunsuppressive medication during COVID-19 pandemic]

The current COVID-19 pandemic inherits an unprecedented challenge for the treating rheumatologists. On the one hand, antirheumatic drugs can increase the risk of infection and potentially deteriorate the course of an infection. On the other hand, an active inflammatory rheumatic disease can also increase the risk for an infection. In the recommendations of the German Society for Rheumatology (www.dgrh.de), it is recommended that our patients continue the antirheumatic therapy to maintain remission or low state of activity despite the pandemic. In this study, patients with inflammatory rheumatic disease were asked in the first weeks of the pandemic on their opinion of their immunomodulating therapy. The result shows that over 90% of the patients followed the recommendation of the rheumatologist to continue the antirheumatic therapy, and only a small percentage of the patients terminated the therapy on their own. This result was independent of the individual anti-rheumatic therapy. Taken together, the results of this study illustrate not only the trustful patient-physician partnership in a threatening situation but also the high impact of state-of-the art recommendations by the respective scientific society.

Electrically conductive 2D-PAN-containing surfaces as a culturing substrate for neurons

In the present contribution we report on a novel route to synthesize 2D-polyaniline (2D-PAN) on sulfonated-poly(styrene) (SPS) templates by allowing first monomer assembly followed by chemical oxidation to achieve polymerization. We show that Aplysia neurons grown on 2D-PAN exhibit an unusual growth pattern and adhesion to this conducting substrate that is manifested by the formation of giant lamellipodia. The lamellipodial domains are characterized by small gap between the plasma membrane and the 2D-PAN substrate (ca. 30 nm) and actin rich skeleton resembling the skeleton of growth cones. This behavior is characteristic to uniform substrates containing only 2D-PAN. However, in patterned substrates containing additionally poly(L-lysine) Aplysia neurons prefer to extend new neurites on the poly(L-lysine) domains.

[Gastrointestinal stromal tumours (GIST) of the jejunum in a patient with neurofibromatosis type 1 (von Recklingshausen's disease)]

CASE REPORT

A 72-year-old female patient with known neurofibromatosis type 1 was admitted to the hospital with symptomatic anaemia and a history of melaena. Upper and lower endoscopy did not show any signs of bleeding. Ultrasound and computed tomography revealed an abdominal mass. The histological analysis of a US-guided puncture showed a mesenchymal tumour with spindle-shaped appearance. Laparotomy revealed two jejunal tumours which could be classified as gastrointestinal stromal tumours (GIST) by immunohistochemistry.

CONCLUSION

Patients with neurofibromatosis type 1 have an increased risk of developing gastrointestinal tumours including rare types such as GIST. Because the localisation in the small intestine by conventional endoscopy can be difficult, further diagnostic means such as ultrasound, computed tomography or possibly capsule endoscopy should be considered.

[Multiple focal liver lesions of a 33 year-old female. Presentation of an unexpected differential diagnosis]

We report the case of a 33 year-old female with a history of 16 years of oral contraception who had been admitted to hospital for further diagnosis of multiple focal liver lesions; laboratory findings showed elevated levels of gamma-GT und AP. Diagnostic procedures showed no primary malignancy as possible reason for metastasis. All further imaging procedures compared with doppler-enhanced ultrasound did not help in diagnosis and lead to inconsistent results. Transcutaneous liver-biopsy showed normal liver histology. In laparoscopic biopsy the result was multifocal adenoma. Because of the rupture risk and potential malignant transformation and no change of sonomorphologic appearance within 12 months a liver-segment resection has been undertaken. Pathology revealed the diagnosis of a multifocal hyperplastic-adenomateous focal-nodular hyperplasia. This case shows that there is no need to use different methods of medical imaging redundantly. We favor a fine-needle double-puncture (lesion and extra-lesion) and tissue examination through an experienced pathologist. A total resection of the lesion is necessary in case of resting uncertainty to characterize its tissue characteristics.

[Biliary ascariasis after cholecystectomy and papillotomy in a non-endemic area]

HISTORY AND ADMISSION FINDINGS

A 61-year-old woman was admitted to hospital with nausea and vomiting. Four years earlier she had undergone cholecystectomy and papillotomy.

INVESTIGATIONS

Laboratory examination showed a slight increase of aspartate and alanine aminotransferase, glutamyl transpeptidase, and moderate eosinophilia. Ultrasound revealed an elongated echogenic structure within the common bile duct. At endoscopic cholangiopancreaticography (ERCP) a 23 cm-long Ascaris lumbricoides was found.

TREATMENT AND COURSE

The worm was removed endoscopically with forceps. Antihelmintic therapy with mebendazole was given. After that the patient was well and laboratory findings were normal.

CONCLUSION

Biliary ascariasis should also be considered in a non-endemic area. Previous cholecystectomy and papillotomy are predisposing factors. In our case ERCP was the diagnostic and therapeutic method of choice.

Self-expanding metal stents for gastroduodenal malignancies: systematic review of their clinical effectiveness

BACKGROUND AND STUDY AIMS

The current standard approach to the management of malignant gastric outlet obstruction mainly involves bypass surgery, which is associated with significant rates of mortality and morbidity. Recently, metal stents have emerged as a new therapeutic option. The aim of the present study was to review the currently published evidence on the effectiveness and safety of this form of endoscopic treatment.

MATERIALS AND METHODS

A systematic review of the published data was carried out by searching medline, embase, and abstracts from the major gastroenterological conferences from January 1992 to September 2003. A total of 136 relevant publications were identified (case series, single case reports, letters and editorials, or reviews). The systematic review included 32 case series from a total of 46 publications identified as reporting primary clinical data. Abstracts and single case reports were not taken into account. Analysis of these 32 case series included data on technical success (successful stent placement and deployment), clinical success (relief of symptoms such as nausea and vomiting, and/or improvement of food intake), and complications. Pooled results were calculated from the 32 studies (10 of which were prospective).

RESULTS

Stent insertion was attempted in 606 patients with malignant symptomatic gastroduodenal obstruction; 94 % of the patients were unable to take food orally or were mainly ingesting liquids. Stent placement and deployment were successful in 589 of the patients (97 %). Clinical success was achieved in 526 patients in the group in which technical success was reported (89 %; 87 % of the entire group undergoing stenting). Disease-related factors accounted for the majority of clinical failures. Oral intake became possible in all of the patients in whom a successful procedure was carried out, with 87 % taking soft solids or a full diet, with final resolution of symptoms occurring after a mean of 4 days. There was no procedure-related mortality. Severe complications (bleeding and perforation) were observed in seven patients (1.2 %). Stent migration was reported in 31 patients (5 %). Stent obstruction occurred in 104 cases (18 %), mainly due to tumor infiltration. The mean survival period was 12.1 weeks.

CONCLUSIONS

Published evidence from case series suggests that gastroduodenal stenting offers good palliation and is a safe and effective treatment option in patients with a short remaining lifespan. However, patient selection for this intervention continues to be an issue requiring thorough consideration, and studies comparing the method with surgery are needed.

Structure and organisation of 47 nutrition support teams in Germany: a prospective investigation in 2000 German hospitals in 1999

OBJECTIVE

Evaluation. Contrary to the Anglo-American region, very little is known in Germany on the structure and organisation of nutrition support teams (NST).

DESIGN

Prospective investigation of the structure and organisation of German NST, using standardised interview questionnaires.

SETTINGS

Hospitals with more than 250 beds in Germany.

SUBJECTS

German NST (n=47).

INTERVENTIONS

Face-to-face interview in 1999, using a standardised questionnaire.

RESULTS

From a total of 2000 German hospitals, NST have been established at 47 hospitals (2.3%). Most NST are affiliated to a large university hospital or an academic teaching hospital. In general, the NST are not independently operating units but are affiliated to a special discipline, and were in operation for an average of 8 y. The NST cared for a median of 65 outpatients annually. At the university hospitals in average, 477 in-patients were treated per year, at the teaching hospitals 400 and at all other hospitals 179. The work of the NST centred on enteral nutrition. A total of 47% of the physicians, 19% of the nurses and 19% of the dietitians in the NST held a nutrition-specific additional qualification. A total of 2% of the physicians, 68% of the nurses and 77% of the dietitians are exclusively responsible for the NST. More than 70% of the financing of the personnel was secured through third-party funds.

CONCLUSION

In Germany, neither uniform nor comprehensive patient care by NST existed in 1999. More than 50% of all NST members do not hold a nutrition-specific additional qualification. Frequently, besides their tasks in the team, the NST staff also carries out other clinical functions. Contrary to the American NST, the German NST are not interdisciplinary operating units but are primarily financed through third-party funds of the industry.

[Anaphylactic shock caused by rupture of an echinococcal cyst in a 25-year-old asylum seeker from Georgia]

HISTORY AND ADMISSION FINDINGS

A 25-year-old asylum seeker from Georgia was admitted to hospital with acute right upper quadrant abdominal pain, vertigo, dyspnea, generalized urticaria and positive shock index (blood pressure 80/40 mmHg, pulse 120/min) several minutes after eating an instant soup.

INVESTIGATIONS

Laboratory investigations showed a slight increase of the eosinophilic cell count and GOT and GPT activities. Abdominal ultrasound scan (USS) and computed tomography (CT) revealed a multivesicular septated cystic space-occupying lesion of the right liver lobe (segment VII, 13 x 9 x 8 cm) and perihepatic fluid.

TREATMENT AND COURSE

Intravenous steroids, H 1 and H 2 antagonists and fluid were given. Emergency laparatomy with endocystectomy was performed. A 3-month course of antihelmintic therapy with albendazole was applied. During follow-up up to one year after surgery the patient did well. Ultrasonography and computed tomography showed only a small residual defect in the right liver lobe where the cyst had been removed.

CONCLUSION

In patients from echinococcosis-endemic regions who develop an anaphylactic reaction, a ruptured Echinococcus granulosus cyst should be considered in the differential diagnosis. Abdominal ultrasonography and serology (to be noted: substantial rate of false negative results!) should be performed.

Calcium, protease activation, and cytoskeleton remodeling underlie growth cone formation and neuronal regeneration

The cytoarchitecture, synaptic connectivity, and physiological properties of neurons are determined during their development by the interactions between the intrinsic properties of the neurons and signals provided by the microenvironment through which they grow. Many of these interactions are mediated and translated to specific growth patterns and connectivity by specialized compartments at the tips of the extending neurites: the growth cones (GCs). The mechanisms underlying GC formation at a specific time and location during development, regeneration, and some forms of learning processes, are therefore the subject of intense investigation. Using cultured Aplysia neurons we studied the cellular mechanisms that lead to the transformation of a differentiated axonal segment into a motile GC. We found that localized and transient elevation of the free intracellular calcium concentration ([Ca2+]i) to 200-300 microM induces GC formation in the form of a large lamellipodium that branches up into growing neurites. By using simultaneous on-line imaging of [Ca2+]i and of intraaxonal proteolytic activity, we found that the elevated [Ca2+]i activate proteases in the region in which a GC is formed. Inhibition of the calcium-activated proteases prior to the local elevation of the [Ca2+]i blocks the formation of GCs. Using retrospective immunofluorescent methods we imaged the proteolysis of the submembrane spectrin network, and the restructuring of the cytoskeleton at the site of GC formation. The restructuring of the actin and microtubule network leads to local accumulation of transported vesicles, which then fuse with the plasma membrane in support of the GC expansion.

[Requirement for the structure and function of a nutritional support team]

Procedures in clinical nutrition have gained both invasiveness as well as the complexity. Thus improved education of professionals and their alliance in hospital based nutritional support teams (NST) is demanding. Two forms of collaboration, the "interdisciplinary nutritional committee" and the "department for nutritional therapy", are discussed. It is the goal of this contribution to present structure and tasks of an independently working department for nutritional support therapy. The pertinent areas of activity are composed as followed: clinical nutritional therapy, home nutrition, education, research, and quality management. The team members include the physician, the dietitian, the nurse, the nutritionist, and the pharmacist. The individual tasks as well as the areas of responsibility are presented. We discuss, whether nutritional support teams might be suitable to achieve cost reduction, provided adequate working conditions are available. Issues like "performance related reimbursement" and "NST certification" by health care organizations are discussed. We also elude to the option to merge services with other health care providers in order to built up an inter-disciplinary organization system. We conclude that nutritional support teams have to be prepared to meet hospital needs. Costs/benefit balances have to be assessable and must be documented. Although the effectiveness of selected nutritional support teams was clearly shown, it is the challenge of each individual team to produce proof of effectiveness for itself. Acceptable working conditions, however, should be provided as they have to be considered indispensable to achieve high quality performance.

Use of Aplysia neurons for the study of cellular alterations and the resealing of transected axons in vitro

The present report describes the experimental advantages offered by the combined use of Aplysia neurons and contemporary techniques to analyze the cellular events associated with nerve injury in the form of axotomy. The experiments were performed by transecting, under visual control, the main axon of identified Aplysia neurons in primary culture while monitoring several related parameters. We found that in cultured Aplysia neurons axotomy leads to the elevation of the [Ca2+]i in both the proximal and distal axonal segments from a resting level of 100 nM up to the millimolar range for a duration of 3-5 min. This increase in [Ca2+]i led to identical alterations in the cytoarchitecture of the proximal and distal segments. The formation of a membrane seal over the transected ends by their constriction and the subsequent fusion of the membrane is a [Ca2+]i-dependent process and is triggered by the elevation of [Ca2+]i to the microM level. Seal formation was followed by down-regulation of the [Ca2+]i to control levels. Following the formation of the membrane seal an increase in membrane retrieval was observed. We hypothesize that the retrieved membrane serves as an immediately available membrane reservoir for growth cone extension.

Successful treatment of AIDS-related pulmonary Kaposi's sarcoma with liposomal daunorubicin

We report a 35 year old male, human immunodeficiency virus (HIV)-infected patient with acquired immune deficiency syndrome (AIDS), who presented with rapidly progressive pulmonary Kaposi's sarcoma. The tumour regressed with treatment with liposomal daunorubicin and remained in partial remission until the patient died 12 months later from complications of HIV infection. Liposomal daunorubicin may be a safe and effective alternative to the treatment protocols in current use for pulmonary Kaposi's sarcoma.

Resealing of the proximal and distal cut ends of transected axons: electrophysiological and ultrastructural analysis

The fates of the proximal and distal segments of transected axons differ. Whereas the proximal segment usually recovers from injury and regenerates, the distal segment degenerates. In the present report we studied the kinetics of the recovery processes of both proximal and distal axonal segments following axotomy and its temporal relations to the alterations in the cytoarchitecture of the injured neuron. The experiments were performed on primary cultured metacerebral neurons (MCn) isolated from Aplysia. We transected axons while monitoring the changes in transmembrane potential and input resistance (Rn) by inserting intracellular microelectrodes into the soma and axon. Correlation between the electrophysiological status of the injured axon and its ultrastructure was provided by rapid fixation of the neuron at selected times postaxotomy. Axotomy leads to membrane depolarization from a mean of -55.7 S.D. 12.8 mV to -12.7 S.D. 3.3 mV and decreased Rn from tens of M omega to 1-3 M omega. The transected axons remained depolarized for a period of 10-260 s for as long as the axoplasm was in direct contact with the bathing solution. Rapid repolarization and partial recovery of Rn was associated with the formation of a membrane seal over the cut ends by the constriction and subsequent fusion of the axolema. Prior to the formation of a membraneous barrier, electron-dense deposits aggregate at the tip of the cut axon and appear to form an axoplasmic "plug." Electrophysiological analysis revealed that this "plug" does not provide resistance for current flow and that the axoplasmic resistance is homogenously distributed. The kinetics of injury and recovery processes as well as the ultrastructural changes of the proximal and distal segments are identical suggesting that the different fates of the segments cannot be attributed to differences in the immediate response of the segments to axotomy.

The effects of microenvironment on the redifferentiation of regenerating neurones: neurite architecture, acetylcholine receptors and Ca2+ channel distribution

Severed adult neurones, which are capable of regrowth, encounter different microenvironments from those encountered during development. Moreover, adult neurones may respond in a different manner from developing neurones to the same environmental cues. Thus, the recovery of the integrative and transmission capabilities (which depend on the neuronal architecture, passive and active membrane properties, and synaptic receptor distribution) by a regenerating adult neurone may not be complete. In the present review, we examine several aspects of the outcome of the interaction between the microenvironment and regrowing neurones using the cockroach giant interneurones (GINs) as a model system. We demonstrate that whereas extrinsic cues govern the morphological redifferentiation and distribution of synaptic receptors, the distribution of voltage-dependent Ca2+ channels is to a large extent determined by intrinsic factors. The pathway of regrowth and the architecture of regenerating GINs were studied by examination of intracellularly stained fibres. The environments provided by the connectives and ganglia are different. The elongating sprouts in the connective appeared as smooth cylinders. Within the ganglionic domain, the main longitudinal sprouts emitted neurites which extended and branched into the neuropile. The local cues for branching of neurites were eliminated by freezing and thawing of the ganglia prior to the arrival of the growing tips. The failure to extend neurites under these conditions is attributed to the elimination of extrinsic signals for morphological redifferentiation of the fibres, since the same fibres emit neurites in anterior ganglia which have not been subjected to freezing and thawing. The distribution of acetylcholine receptors (AChRs) on the GINs was mapped by ionophoretic application of ACh. In both the intact and regenerating GINs receptors were located only on the neurites. Freezing and thawing of a ganglion eliminated the local signals for insertion and/or activation of AChRs on the neurites. Thus, both the morphological redifferentiation and the distribution of AChRs are affected by the microenvironment. Voltage-dependent Ca2+ channels were detected after intracellular injection of tetraethylammonium into the GIN and in the presence of tetrodotoxin (TTX) and Ba2+ in the extracellular space. The regrowing axon tips always revealed large barium action potentials independent of the CNS microenvironment. This observation is consistent with the hypothesis that Ca2+ plays an important role in the growth process. However, increased Ba2+ responsiveness was also observed in axonal segments proximal to the region of neuronal extension.(ABSTRACT TRUNCATED AT 400 WORDS)

Comparison of ultrastructural changes in proximal and distal segments of transected giant fibers of the cockroach Periplaneta americana

When the giant axons of the cockroach Periplaneta americana are transected the proximal segment (the part connected to the soma) regenerates by tip sprouting and the distal segment degenerates. The initial ultrastructural response (24-48 h post-transection) occurring in the cut ends of the proximal and distal segments are similar. This response includes the disappearance of neurotubules; appearance of amorphous material in the axoplasm and a gradual accumulation of large numbers of small mitochondria, vesicles of various sizes and smooth endoplasmic reticulum. The axolemma in the region of organelle accumulation invaginates and glial processes are present in the invagination. The similarity of the changes that occur in the cut ends of the proximal and distal segments indicates that the primary reaction to axotomy is of a local nature and does not depend on the soma. Two to four days after transection, the cut end of the distal axonal segment reveals signs of degeneration. These include the appearance of swollen mitochondria, lysosomes, myelinated bodies and shrinking of the axon. In addition there is a massive proliferation of glial processes around the degenerating axons. Sprouting from the tip of the proximal segment starts 5--7 days post axotomy. Sprouts were identified as profiles containing few neurotubules, many vesicles and abundant smooth endoplasmic reticulum. 'Growth cone-like' structures were identified. The ultrastructural reorganization of the cut end of the proximal segment is discussed in relation to changes in membrane properties of the regenerating tip, as previously described by us.

Aurothiomalate as an ultrastructural marker. Electron microscopy and x-ray microanalysis of various tissues after in vivo gold injections

Rabbits and rats were given single injections of aurothiomalate by different routes. The animals were killed at progressive intervals, and sections from various organs were examined by electron microscopic x-ray microanalysis. Ultrastructurally, characteristic material was regularly found in vacuoles, dense and heterogeneous bodies of macrophages, hepatocytes and renal epithelial cells. Occasionally, other mesenchymal cells also contained gold. Histochemical and analytical tests showed that the gold-containing organelles were devoid of acid phosphatase activity. The generalized rapid spread, retention and selectivity of localization after a single small dose make aurothiomalate a useful marker substance for ultrastructural studies.