Management of complications of mega-implants following treatment of primary and periprosthetic fractures of the lower extremities

In recent years, indications for implanting mega-implants were established in managing major bone defects linked to revision arthroplasty due to loosening, periprosthetic fractures, re-implantation following periprosthetic joint infection, non-union following fractures as well as complex intraarticular primary fractures. This study was conducted to discuss and analyze the strategy of diagnosis and management of complications following the use of mega-implants in treating primary and periprosthetic fractures of the lower extremities. This is a monocentric retrospective study. Patients aged ≥ 18 years who underwent implantation of a megaendoprosthesis due to periprosthetic or primary fractures of the lower extremity between January 2010 and February 2023 were identified from the authors' hospital information system. We identified 96 patients with equal numbers of fractures (71 periprosthetic fractures and 25 primary fractures). 90 cases out of 96 were investigated in this study. The drop-out rate was 6.25% (six cases). The average follow-up period was 22 months (1 to 8 years) with a minimum follow-up of 1 year. The diagnosis of complications was provided on the basis of subjective symptoms, clinical signs, radiological findings and laboratory investigations such as C-reactive protein, leucocyte count and the microbiological findings. The indications for implantations of modular mega-implants of the lower extremities were periprosthetic fractures (65 cases/72.22%) and primary fractures (25 cases/27.78%). Pathological fractures due to malignancy were encountered in 23 cases (25.56%), in one case due to primary tumor (1.11%) and 22 cases due to metastatic lesions (24.44%). Two cases (2.22%) presented with primary intraarticular fractures with severe osteoporosis and primary arthrosis. In all cases with malignancy staging was performed. Regarding localization, proximal femur replacement was encountered in 60 cases (66.67%), followed by distal femur replacement (28 cases/31.11%) and total femur replacement (2 cases/2.22%). The overall complication rate was 23.33% (21 complications in 21 patients). The most common complication was dislocation which was encountered in nine cases (10%), all following proximal femoral replacement (9 cases out of 60, making 15% of cases with proximal femoral replacement). The second most common complication was infection (six cases, 6.67%), followed by four aseptic loosenings (4.44%), further intraoperative periprosthetic fracture in one case (1.11%) and a broken implant in one case (1.11%). We noticed no cases with wear and tear of the polyethylene components and no cases of disconnections of the modular components. Mega-endoprostheses enable versatile management options in the treatment of primary and periprosthetic fractures of the lower extremities. The rate of complications such as loosening, implant failure, dislocation and infection are within an acceptable range in this preliminary analysis. However, implantation of mega-endoprostheses must be strictly indicated due the limited salvage options following surgery.

Exploring the Spatial Relative Risk of COVID-19 in Berlin-Neukölln

Identifying areas with high and low infection rates can provide important etiological clues. Usually, areas with high and low infection rates are identified by aggregating epidemiological data into geographical units, such as administrative areas. This assumes that the distribution of population numbers, infection rates, and resulting risks is constant across space. This assumption is, however, often false and is commonly known as the modifiable area unit problem. This article develops a spatial relative risk surface by using kernel density estimation to identify statistically significant areas of high risk by comparing the spatial distribution of address-level COVID-19 cases and the underlying population at risk in Berlin-Neukölln. Our findings show that there are varying areas of statistically significant high and low risk that straddle administrative boundaries. The findings of this exploratory analysis further highlight topics such as, e.g., Why were mostly affluent areas affected during the first wave? What lessons can be learned from areas with low infection rates? How important are built structures as drivers of COVID-19? How large is the effect of the socio-economic situation on COVID-19 infections? We conclude that it is of great importance to provide access to and analyse fine-resolution data to be able to understand the spread of the disease and address tailored health measures in urban settings.

Exploration of the COVID-19 pandemic at the neighborhood level in an intra-urban setting

The COVID-19 pandemic represents a worldwide threat to health. Since its onset in 2019, the pandemic has proceeded in different phases, which have been shaped by a complex set of influencing factors, including public health and social measures, the emergence of new virus variants, and seasonality. Understanding the development of COVID-19 incidence and its spatiotemporal patterns at a neighborhood level is crucial for local health authorities to identify high-risk areas and develop tailored mitigation strategies. However, analyses at the neighborhood level are scarce and mostly limited to specific phases of the pandemic. The aim of this study was to explore the development of COVID-19 incidence and spatiotemporal patterns of incidence at a neighborhood scale in an intra-urban setting over several pandemic phases (March 2020-December 2021). We used reported COVID-19 case data from the health department of the district Berlin-Neukölln, Germany, additional socio-demographic data, and text documents and materials on implemented public health and social measures. We examined incidence over time in the context of the measures and other influencing factors, with a particular focus on age groups. We used incidence maps and spatial scan statistics to reveal changing spatiotemporal patterns. Our results show that several factors may have influenced the development of COVID-19 incidence. In particular, the far-reaching measures for contact reduction showed a substantial impact on incidence in Neukölln. We observed several age group-specific effects: school closures had an effect on incidence in the younger population (< 18 years), whereas the start of the vaccination campaign had an impact primarily on incidence among the elderly (> 65  years). The spatial analysis revealed that high-risk areas were heterogeneously distributed across the district. The location of high-risk areas also changed across the pandemic phases. In this study, existing intra-urban studies were supplemented by our investigation of the course of the pandemic and the underlying processes at a small scale over a long period of time. Our findings provide new insights for public health authorities, community planners, and policymakers about the spatiotemporal development of the COVID-19 pandemic at the neighborhood level. These insights are crucial for guiding decision-makers in implementing mitigation strategies.

PATHOLOGIC FINDINGS IN GENDER-AFFIRMING MASTECTOMY: A SYSTEMATIC REVIEW

Following increased cultural awareness, expanded access to care, and decreased stigmatization, the number of transgender individuals seeking gender affirmation surgery such as gender-affirmation mastectomy (GAM) continues to rise. While post-mastectomy breast tissue is often sent for pathologic evaluation, few studies address the utility and standardization of this practice. This literature review evaluates the pathology findings in GAM specimens reported in the medical literature. A systematic review following PRISMA guidelines was performed to evaluate all medical publications related to pathology reports following GAM. The overall type and incidence of benign and malignant breast lesions were analyzed to elucidate which patient characteristics significantly affect the pathology findings. Overall, eight of 488 identified studies met inclusion criteria (1278 patients). The incidence of pre-malignant lesions was 2.42%, including flat epithelial atypia (0.08%), atypical hyperplasia (0.23%), atypical ductal hyperplasia (1.33%), atypical lobular hyperplasia (0.39%), and lobular carcinoma in situ (0.39%).Patient age, hormonal therapy, and family / patient history of breast cancer were inconsistently reported among included studies. Lack of standardized pathologic classification did not permit further statistical analysis. Although patients who undergo GAM are unlikely to have premalignant or malignant findings on breast pathology examination, pathologic evaluation of breast tissue remains common practice. Additional studies, which include a standardized method of pathologic evaluation, are necessary before practice guidelines can be recommended.

Characterization of COVID-19 outbreaks in three nursing homes during the first wave in Berlin, Germany

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) belongs to the coronavirus family and is characterized by its high transmission competence. Elderly COVID-19 patients are at significantly higher risk of severe course of disease and death. Therefore, outbreaks in nursing homes are particularly challenging for facility managers and health authorities. Here, we report three outbreaks of COVID-19 related to nursing homes (NH01.a, NH02 and NH03) with almost 1000 affected individuals during the first COVID-19 wave in Berlin, Germany. The occurrence of cases and the measures taken were analyzed retrospectively. In all three outbreaks, the index persons were nursing home employees or volunteers. Measures taken were quarantine of contacts, close-meshed tests, separation of the affected housing unit, suspension of admission, ban on visiting, and equipping staff with personal protective equipment, of which there was a shortage in Germany at the beginning of the pandemic. A court-ordered quarantine became necessary for three residents of NH01.a due to cognitive disabilities. In total, 61 persons were tested positive for SARS-CoV-2 in NH01.a, ten persons in NH02, and sixteen persons in NH03. Seventeen patients (27.9%) of NH01.a and three patients (18.8%) of NH03 were referred to hospital. Of all confirmed cases, thirteen (21.3%) related to NH01.a and four (25.0%) related to NH03 died as a result of the infection. Besides one 82 year old volunteer, all deceased persons were residents aged between 66 and 98. Our results emphasize the importance of a previously developed containment and cluster strategy for nursing homes. Due to the particular vulnerability of the residents, immediate action, close cooperation and communication between the facility management, residents, visitors and the health authorities are essential in the case of confirmed COVID-19 cases in healthcare facilities.

Use of PET-CT in diagnostic workup of periprosthetic infection of hip and knee joints: significance in detecting additional infectious focus

Introduction

The diagnosis and management of periprosthetic knee and hip infections as well as the identification and management of possible additional infectious foci is of great importance for successful therapy. This study analyses the importance of ¹⁸F deoxyglucose PET-CT (PET-CT) in the identification of additional infectious focus and subsequent impact on management of periprosthetic infection (PPI).

Material and methods

A retrospective analysis of the clinical data and findings in the period from January 2008 to December 2018 was carried out. One hundred and four patients with in-hospital treatment due to PPI of a hip or knee joint were identified and included in this study. All patients underwent a standardized clinical examination and further surgical and antibiotic therapy. The reevaluation of performed PET-CTs was specifically carried out with regard to the local PPI or detection of secondary foci.

Results

PET-CT successfully verified the PPI in 84.2% of the patients. A total of 78 possible additional foci were detected in PET-CT in 56 (53.8%) of the examined patients. Predilection sites for possible secondary foci were joints (42.3%), pulmonary (15.4%), ear-nose-throat (15.4%), spine (11.5%), and the musculocutaneous tissues (11.5%). Fifty-four positive PET-CT findings were confirmed clinically with need of additional adequate treatment.

Conclusion

PET-CT is a valuable diagnostic tool to confirm periprosthetic joint infection. At the same time, the whole-body PET/CT may detect additional foci of infection with impact on subsequent treatment strategy. PET was of special value in detecting infections at distant locations far from the primary infected joint in significant number. These distant infection locations can be potential cause of a re-infection. This clearly reflects the need of their diagnosis.

BCG scarring and improved child survival: a combined analysis of studies of BCG scarring

Bacillus Calmette-Guérin (BCG) vaccine against tuberculosis (TB) is recommended at birth in TB-endemic areas. Currently, BCG vaccination programmes use "BCG vaccination coverage by 12 months of age" as the performance indicator. Previous studies suggest that BCG-vaccinated children, who develop a scar, have better overall survival compared with BCG-vaccinated children, who do not develop a scar. We summarized the available studies of BCG scarring and child survival. A structured literature search for studies with original data and analysis of BCG scarring and mortality were performed. Combined analyses on the effect of BCG scarring on overall mortality. We identified six studies covering seven cohorts, all from Guinea-Bissau, West Africa, with evaluation of BCG scarring amongst BCG-vaccinated children and follow-up for mortality. Determinants of BCG scarring were BCG strain, intradermal injection route, size of injection wheal, and co-administered vaccines and micronutrients. In a combined analysis, having a BCG scar vs. no BCG scar was associated with a mortality rate ratio (MRR) of 0.61 (95% CI: 0.51-0.74). The proportion with a BCG scar varied from 52 to 93%; the estimated effect of a BCG scar was not associated with the scar prevalence. The effect was strongest in the first (MRR = 0.48 (0.37-0.62)) and second (MRR = 0.63 (0.44-0.92)) year of life, and in children BCG-vaccinated in the neonatal period (MRR = 0.45 (0.36-0.55)). The effect was not explained by protection against TB. Confounding and genetic factors are unlikely to explain the strong association between BCG scarring and subsequent survival. Including "BCG scar prevalence" as a BCG vaccination programme performance indicator should be considered. The effect of revaccinating scar-negative children should be studied.

Tailored intervention with peer-to-peer as a tool to promote childhood vaccination in migrants

Background

A tailored intervention about childhood vaccination in Stockholm, Sweden, has focused on different activities with the aim to improve vaccination confidence and in particular Measles, Mumps and Rubella (MMR) vaccination coverage. The intervention included provided peer education focusing on vaccination information, the vaccine-preventable diseases, child development and communication skills in Somali and Swedish language and for the peers to further inform other parents in their communities.

Aim

This study aims to explore peers’ experiences of the interventions and their role to promote vaccination confidence.

Methods

This study follows a qualitative methodology with in-depth interviews and the data collection is ongoing. The study participants consist of seven peers who participated in the program. The interviews aimed to explore how the peers used the training in real life. All interviews conducted were tape-recorded and transcribed verbatim in order to facilitate deep content analysis. The analysis followed a content analysis, by first coding the data and then developing categories and emerging themes.

Results

Preliminary findings show that peers expressed the importance of having a training that equipped them with knowledge and confidence to discuss fact-based information with hesitant parents. The peers shared that after the training they had several opportunities to talk about childhood vaccinations in particular MMR vaccination with other parents. Some peers took an active role in reaching other parents by utilising the film and the cards to facilitate their dialogue. Other also acknowledged that when they could not answer a specific question, they encouraged the parents to address the query with the child health clinic nurses.

Conclusions

The use of a peer-to-peer concept to increase vaccination confidence provides additional forums for parents to dialogue about their concerns and receive correct vaccination information.

Key messages

Tailored interventions in close collaboration with communities are crucial for sustainable improvements of vaccination acceptance and coverage. The peer-to-peer concept provides a new arena to reach vaccination hesitant parents and can complement the communication on vaccination from health care provides.

Polycyclic aromatic hydrocarbons (PAH) in urine of children and adolescents in Germany - human biomonitoring results of the German Environmental Survey 2014-2017 (GerES V)

Polycyclic aromatic hydrocarbons (PAH) mainly originate from incomplete combustion of organic materials and are, among other sources, found in traffic emissions, smoked or barbecued food, leafy vegetables, and tobacco smoke. Some PAH or their metabolites are hazardous for health and classified as carcinogenic, mutagenic, or toxic to reproduction. Urine samples from 3- to 17-year-old children and adolescents living in Germany were analysed for concentrations of metabolites of the PAH fluorene, naphthalene, phenanthrene, and pyrene in the population-representative German Environmental Survey for Children and Adolescents GerES V (2014-2017). PAH metabolites were analysed in urine samples of 516 participants and could be quantified in 88-100% of the samples. Geometric mean concentrations were: 0.785 μg/L (0.688 μg/g_creatinine) for 1-OH-naphthalene, 4.233 μg/L (3.706 μg/g_crea) for 2-OH-naphthalene, 0.139 μg/L (0.122 μg/g_crea) for 1-OH-phenanthrene, 0.085 μg/L (0.075 μg/g_crea) for 2-OH-phenanthrene, 0.131 μg/L (0.115 μg/g_crea) for 3-OH-phenanthrene, 0.045 μg/L (0.040 μg/g_crea) for 4-OH-phenanthrene, 0.058 μg/L (0.050 μg/g_crea) for 9-OH-phenanthrene, 0.511 μg/L (0.448 μg/g_crea) for Σ-OH-phenanthrene, and 0.099 μg/L (0.087 μg/g_crea) for 1-OH-pyrene. Analyses of subgroups revealed higher PAH metabolite concentrations in young children compared to adolescents, and also in residents of former East Germany compared to those living in former West Germany. Increased urinary PAH metabolite concentrations were found in participants using domestic fuel for heating or gas for cooking. Plastic objects were identified as another potential source of exposure. Urinary concentrations of naphthalene and fluorene metabolites were elevated in active smokers and to the same extent in non-smokers exposed to passive smoking. Comparison with previous cycles of GerES revealed a decrease over time and a further decline in the still significant differences in urinary PAH metabolite concentrations of participants living in former East versus West Germany.

[Bone marrow edema-differential diagnosis of the femoral head necrosis]

In patients with hip pain, clinical examination is of only restricted value in the differential diagnosis. Besides a patient's age, their medical history is often helpful in finding the correct diagnosis. Additionally, imaging can give valuable hints for excluding or validating a differential diagnosis. Nowadays, magnetic resonance imaging (MRI) is often used as a primary imaging modality in Germany. These MRIs show a bone marrow edema (BME) in many different pathologies. BME occurs in transitory bone marrow edema and outside of the atraumatic femoral head necrosis, concomitant with coxarthrosis, arthritis, herniation pit, and osteoid osteoma, amongst other conditions. This article describes several frequent differential diagnoses and gives hints on how to find the correct diagnosis.

Adaptive functioning in pediatric brain tumor survivors: An examination of ethnicity and socioeconomic status

BACKGROUND

Survivors of pediatric brain tumor are at risk for adaptive difficulties. The present study examined adaptive functioning in a multiethnic sample of survivors accounting for socioeconomic status, and whether demographic, diagnostic, and/or treatment-related variables predict adaptive outcomes.

METHOD

Participants included a multiethnic sample of survivors (58 Caucasian, 34 Hispanic, and 22 other non-Caucasian; M age = 14.05 years, SD = 4.33) who were approximately seven years post-treatment. Parents rated adaptive functioning and provided demographic information. Diagnostic and treatment-related information was abstracted from the electronic medical record.

RESULTS

Parent ratings of adaptive functioning were similar across Caucasian, Hispanic, and other non-Caucasian survivors covarying for family income and primary caregiver education, both of which served as proxies for socioeconomic status. All ethnic groups were rated lower than the normative mean in overall adaptive functioning as well as the specific domains of conceptual, social, and practical skills. Demographic, diagnostic, and treatment-related variables were differentially associated with adaptive functioning in survivors of pediatric brain tumor, though socioeconomic status emerged as a strong significant predictor of adaptive functioning domains.

CONCLUSIONS

Adaptive outcomes do not differ as a function of ethnicity after accounting for primary caregiver education and family income. Racial and ethnic minorities may be at increased risk for poorer outcomes given their overrepresentation at lower income levels. Assessing demographic and treatment-related variables early on may be helpful in identifying children likely to develop adaptive difficulties.

Azulenocyanines immobilized on graphene; on the way to panchromatic absorption and efficient DSSC blocking layers

Herein, a novel electron donor-acceptor hybrid consisting of a NIR absorbing azulenocyanine as an electron donor and few-layer graphene as an electron acceptor was prepared. The extended aromatic core of azulenocyanine (1) assists in the exfoliation of graphite and allows the formation of a very high-quality few-layer graphene azulenocyanine hybrid system (2). The formation of a stable azulenocyanine/graphene hybrid was verified by means of an arsenal of spectroscopic and microscopic techniques. Notable is the fact that the absorption spectrum recorded for 1 and likewise that for 2 covers large portions of the solar spectrum, that is, from the UV through the visible to the NIR region. In light of the latter, we incorporated 1 as well as 2 as a photosensitizer in dye sensitized solar cells (DSSCs) and probed their light harvesting. Besides an increase in the photovoltaic conversion efficiency we focused on the stability of DSSCs by preventing charge recombination between FTO and the liquid electrolyte. We used 2 as a blocking layer and in comparison with a TiCl4 pretreated blocking layer a superior conversion efficiency was realized.

[Challenges of primary hip arthroplasty with high hip dislocation]

BACKGROUND

Endoprosthetic care of high hip dislocation is a surgical challenge. The hip anatomy is greatly altered in these patients, including a rather flat and small acetabulum with impaired bone quality and a relevant chance of a bony defect of the acetabular roof. Additionally, the front coverage and in some cases even the dorsal coverage of the hip are missing. The proximal femur is characterized with an increased antetorsion, a coxa valga position and an enlarged greater trochanter. The medullary cavity is narrowed, the offset is reduced, and the absolut leg length can be enlarged. Further anatomic variations can have been caused by previous surgeries.

AIM OF THE TREATMENT

The goal of the endoprosthetic care is the re-creation of a hip with an anatomic center of rotation, an anatomic offset and equal leg length.

TREATMENT

This can be achieved by a medial shift of the acetabular cup. An acetabular osteotomy including central cancellous bone graft or a bony graft to reinforce the acetabular roof might be necessary. In cases in which an anatomic acetabular cup placement is not possible, a more cranial placement can be done. Further strategies that are essential in several cases are shortening or re-orientation osteotomies of the femur, reaming of the medullary cavity and correct implant selection. Additionally, thorough soft tissue management is of main importance. Generally, the surgery should be well prepared preoperatively.

Low-grade infections as a possible cause of arthrofibrosis after total knee arthroplasty

Purpose

Arthrofibrosis after total knee arthroplasty represents a considerable burden for the patient and a therapeutic challenge for the practitioner. One possible cause discussed in the literature is a low-grade infection. This hypothesis should be examined within the scope of this retrospective study.

Patients and methods

Nineteen patients with clinical symptoms of arthrofibrosis after primary total knee arthroplasty were examined between January, 1999 and January, 2012. Incorrect positioning was radiologically ruled out. All patients were examined clinically (score of Freeman as well as Blauth and Jäger), radiologically (component and leg alignment, patella height according to Insall and Salvati), microbiologically (culture-based procedures), molecular biologically (PCR) and histologically in the course of an open revision of the prosthesis.

Results

According to the score of Freeman et al. (1977), a highly significant improvement in pain (p = 0.007) and in the overall score (p = 0.003) was shown. The knee joint mobility did not change significantly (p = 0.795). PCR was negative in 17 patients. One patient showed a PCR-positive result of the synovial membrane for Corynebacterium spp., while Staphylococcus warneri was detected in the culture. Another patient had a positive result of synovia PCR for Enterococcus cecorum as well as Corynebacterium spp. However, this culture was sterile. In 16 patient samples, no bacterial growth was detectable. Two samples were not evaluable. The main histopathological findings were synovialitis and fibrosis.

Conclusion

The hypothesis of low-grade-infection-induced arthrofibrosis after total knee arthroplasty could not be confirmed in this study. However, based on this small study population the conclusion needs to be confirmed by new and larger studies, ideally prospectively designed including a control group.

Metabolite profiles evaluated, according to sex, do not predict resting energy expenditure and lean body mass in healthy non-obese subjects

PURPOSE

Differences in resting energy expenditure (REE) between men and women mainly result from sex-related differences in lean body mass (LBM). So far, a little is known about whether REE and LBM are reflected by a distinct human metabolite profile. Therefore, we aimed to identify plasma and urine metabolite patterns that are associated with REE and LBM of healthy subjects.

METHODS

We investigated 301 healthy male and female subjects (18-80 years) under standardized conditions in the cross-sectional KarMeN (Karlsruhe Metabolomics and Nutrition) study. REE was determined by indirect calorimetry and LBM by dual X-ray absorptiometry. Fasting blood and 24 h urine samples were analyzed by targeted and non-targeted metabolomics methods using GC × GC-MS, GC-MS, LC-MS, and NMR. Data were evaluated by predictive modeling of combined data using different machine learning algorithms, namely SVM, glmnet, and PLS.

RESULTS

When evaluating data of men and women combined, we were able to predict REE and LBM with high accuracy (> 90%). This, however, was a clear effect of sex, which is supported by the high degree of overlap in identified important metabolites for LBM, REE, and sex, respectively. The applied machine learning algorithms did not reveal a metabolite pattern predictive of REE or LBM, when analyzing data for men and women, separately.

CONCLUSIONS

We could not identify a sex independent predictive metabolite pattern for REE or LBM. REE and LBM have no impact on plasma and urine metabolite profiles in the KarMeN Study participants. Studies applying metabolomics in healthy humans need to consider sex specific data evaluation.

Cyclophosphamide, Adriamycin and Platinum (CAP) Combination Chemotherapy, A New Effective Approach in the Treatment of Disseminated Breast Cancer. Preliminary Report

The prospective controlled Phase III clinical trial tested the therapeutic value of the cis-platinum-adriamycin-cyclophosphamide combination (CAP), compared with the combination including cyclophosphamide, methotrexate, 5-fluorouracil, vincristine and prednisolone (CMFVP), in untreated metastatic breast cancer. One hundred and twenty-three patients (> 2 cycles) were evaluated: 61 on the CAP, and 62 on the CMFVP schedule. An objective response (CR+PR) to CAP combination chemotherapy was achieved in 72% of patients (43/61), with a high rate (36%) of complete remissions. In terms of metastatic site, the response rate appeared to be particularly high in soft tissue and visceral organ (lung, liver) metastases. In the CMFVP group, an objective response was noted in 26 of 62 patients (42%), with 16% complete remissions. The difference in overall therapeutic response - and in the complete remission rate as well - was statistically significant to the advantage of the CAP regimen (P < 0.01). The duration of remissions was 6-28 + months (mean = 14) for the CAP, and 4-15+ months (mean = 9) for the CMFVP schedule. Toxic side effects were more pronounced in the CAP group, particularly myelosuppression, with anemia prevailing. Side effects to CMFVP treatment were moderate. In 39 CMFVP previously treated cases, CAP was administered as second-line treatment, and an objective response was observed in 51% of cases (20/39). Results of this controlled trial showed the advantage of the CAP combination chemotherapy in the treatment of metastatic breast cancer.

High Doses of 5-Fluorouracil and Epirubicin with or without Cisplatin in Advanced Gastric Cancer: A Randomized Study

Background

A prospective randomized clinical study was performed in patients with locally advanced or metastatic gastric cancer. The purpose of the study was to determine the activity of high doses of 5-fluorouracil and epirubicin (FE) vs the same combination + cisplatin (FEP), and particularly the value of cisplatin in the combination.

Patients and Methods

A total of 122 patients was included in the study; 110 of them were assessable. In the FE arm, the treatment involved 1000 mg/m2 in a 6-hr infusion of 5-fluorouracil on days 1, 2, 3, 4 and 5 and 120 mg/m2 of epirubicin iv on day 1. In the FEP arm, the same combination of cytostatics + cisplatin (30 mg/m2) was administered on days 2 and 4. The cycles were repeated after 4 weeks. Altogether, 468 cycles of chemotherapy were given (FE, 240; FEP, 228).

Results

In the FE arm, 56 patients were assessable, with 2 complete and 14 partial remissions (28.6%); in the FEP arm, 4 complete and 19 partial remissions (42.6%) were observed in 54 assessable patients. Median survival in the FE group was 7.1 months and in the FEP group 9.6 months. The survival difference was statistically significant (Cox's test, P<0.05). The most frequent side effects included grade 2 and 3 alopecia (FE, 93%; FEP, 94%) and grade 2 and 3 vomiting (FE, 20%; FEP, 35%). Grade 3 and 4 leukopenia was observed in 9% of patients in the FE group and in 13% of patients in the FEP group, with 6 cases of febrile neutropenia (FE, 4%; FEP, 7%). Stenocardia was registered in 1 patient in the FE group and in 2 patients in the FEP group. No treatment-related death was registered.

Conclusions

The addition of cisplatin to high doses of 5-fluorouracil and epirubicin resulted in a statistically significant better survival of treated patients.

Open Phase II with 5-Fluorouracil, 4-Epi-Doxorubicin and Mitomycin C (Fem) in Advanced Gastric Cancer

Forty-four patients with advanced gastric cancer were treated with a combination including 5-fluorouracil, 4-epi-doxorubicin and mitomycin C. 4-Epi-doxorubicin was substituted for adriamycin in MacDonald's original schedule. The combined treatment involved 600 mg/m2 i.v. of 5-fluorouracil on days 1, 8, 29 and 36; 80 mg/m2 i.v. of 4-epi-doxorubicin on days 1 and 29; and 10 g/m2 i.v. of mitomycin C on day 1. The cycle was repeated on day 57 after the start of treatment. Out of 44 patients, 39 were evaluable. Thirteen partial remissions (33 %) were achieved. The average duration of remission was 7 months (range, 3–12 months). The average survival of the responders was 9 months, and that of nonresponders 3.5 months. Toxicity was moderate, well-tolerated and, as compared with the FAM schedule, less pronounced, particularly as regards myelotoxicity. Thus, the substitution of 4-epi-doxorubicin for adriamycin in the original schedule of MacDonald et al. (1980) did not improve treatment results, but the observed toxicity was less pronounced.

Methylprednisolone as an Antiemetic in Patients on Cis-Platinum Chemotherapy. Results of a Controlled Randomized Study

In cytostatic drug treatment, nausea and vomiting are very frequent, unpleasent and undesirable side effects that cause considerable discomfort to the patient. However, many established antiemetics (Torecan, haloperidol, Valium, Largactil etc.) have not shown significant antiemetic activity in the patients to whom cytostatics were applied. In our controlled randomized clinical trial, the antiemetic activity of methylprednisolone was investigated and compared with placebo (10 ml saline) and Torecan. All the compounds were injected before cis-platinum administration, knowing that this agent induces vomiting in almost 100% of patients. Ninety patients entered the study and have been evaluated. The results of the trial have shown that methylprednisolone in the single dose of 250 mg applied i.v. 2 h before injection of a cytostatic agent experienced pronounced antiemetic activity in 48% of the patients (15/31), as compared to Torecan 21% (6/29) and placebo 13% (4/30). This difference was statistically significant (P < 0.01). No side effects were recorded after methylprednisolone application. The results of the study showed that methylprednisolone possesses a pronounced antiemetic activity in almost half of the patients treated with cis-platinum.

Adriamycin Alone and in Combination with Radiotherapy in the Treatment of Inoperable Esophageal Cancer

Thirty-three patients with inoperable esophageal cancer were treated in a randomized study. There were 24 squamous cell, 2 anaplastic, 4 unclassified, and 3 adenocarcinomas. Eighteen patients were treated with 6 cycles of adriamycin with a 3 week rest period between cycles. Adriamycin was administered in doses of 40 mg/m2 body surface daily for 2 days during each cycle. The other group of 15 patients were treated with both adriamycin and radiation. The tumor was irradiated with speed electrons (4500–5200 rads total dose), and during irradiation, 3 cycles of adriamycin were given. All patients previously had had no treatment. In the group of patients treated with adriamycin, the response rate (> 50 % tumor regression) was 33 % (6/18) with 1 complete and 5 partial remissions. In the combined treatment group, there were 4 complete and 5 partial remissions (9/15) with a response rate of 60 %. In both groups of patients, remissions were obtained in the squamous cell carcinomas, except 1 patient with anaplastic carcinoma in the adriamycin-treated group, and 1 adenocarcinoma in the combined treated group. Remissions lasted 2–12 months (M = 3.2 months) in the adriamycin-treated group and 3–15 months (M = 8.6 months) in the combined treatment group. There were no significant differences in the toxic side effects, except a slightly increased myelodepression in the combined treatment modality. One patient of the combined treatment group showed a potentiation of radiation dermititis. The results obtained show that adriamycin does have an antitumor effect on esophageal (squamous cell) carcinoma, which so far has not been proven. Significantly better results with longer remission duration can be obtained when both adriamycin and radiation are combined.

The Value of Two Combined Chemoradiotherapy Approaches in the Treatment of Inoperable Esophageal Cancer

The antitumor activity of 5-fluorouracil (5-FU), combined either with bleomycin or adriamycin plus radiation, was studied in a controlled randomized clinical trial. Sixty-one previously untreated inoperable esophageal cancer patients entered the study and 56 have been evaluated: 58 male and 3 female patints with a mean age of 57 years (range 37–74). Concerning localization of the tumors in the esophagus, 2 were in the upper third, 36 in the middle third and 18 in the lower third. The length of the filling defects in the esophagogram (X-ray) was in 9 patients < 5 cm, in 31 5–8 cm, and in 16 patients > 8 cm. Squamous cell carcinoma was found in 51 patients, adenocarcinoma in 3, and anaplastic (squamous cell) carcinoma in 2 patients. Modality A consisted of a combination of 5-FU (10 mg/kg i.v. 2 × weekly, 4 weeks) and bleomycin (10 mg/m2 i.v., 2 × 4 weeks) which was given concurrently with radiation (3600–4000 rad - 1000 rad weekly). In modality B the combination of 5-FU (same dose) and adriamycin (30 mg/m2 i.v. day 1, 2, 23 and 24) was applied with the same schedule and dosage of radiation. Seventy-five percent of the patients (21/28) have responded to treatment (CR + PR) in modality A, with 11 complete and 10 partial responses. In arm B, response was recorded in 64 % of patients (18/28), with 2 complete and 16 partial responses. The difference in complete responses (39 % vs 8 %) was statistically significant (P < 0.05). The median remission duration in complete responders was 12 months in modality A (range 6–18 months), and 6.8 months in modality B (range 3–10 months). All the responses occurred in patients with squamous cell carcinoma, except one partial response in a case of adenocarcinoma. As far as the age is concerned (< 55 vs > 55 years), no significant difference in response rate was found (67 % vs 71 %). More favorable results were observed in the group of patients with < 10 % weight loss (79 % vs 63 %). Toxicity was moderate (myelosuppression, cardiotoxicity), but one treatment-related death (pulmonary fibrosis, cardiac failure) was recorded in arm A, as well as one death (rupture of aorta) in group B. Approximately 60 % of patients in both modalities suffered from severe mucositis and retrosternal pain. The results of the study showed that the combination of 5-FU with adriamycin and particularly with bleomycin, given concurrently with lower radiation dosage, is an effective palliative treatment for inoperable esophageal cancer.

Histologic and Cytologic Liver Changes in 120 Patients with Malignant Lymphomas

The purpose of this study was to determine the frequency of liver involvement in malignant lymphomas. Non-specific liver changes were also registered. Percutaneous liver biopsy was performed on 120 patients with untreated malignant lymphomas. There were 38 patients with Hodgkin's disease, 42 with histiocytic and 40 with lymphocytic lymphomas. AH the biopsy specimens were histologically and cytologically analyzed. Positive liver findings (lymphomatous infiltration) were observed in 27.5% of patients with lymphocytic, 23.8% with histiocytic lymphomas, and 7.8% with Hodgkin's disease. Liver involvement in non-Hodgkin's lymphomas was significantly higher (P < 0.025) than in Hodgkin's disease. In the whole group of patients, there were non-specific liver changes: 23 chronic persistent hepatitis, 5 aggressive hepatitis, 9 liver steatosis and 4 liver hemosiderosis. Based on these results, it can be concluded that liver involvement with lymphomatous tissue is more common in non-Hodgkin's lymphomas. Knowledge of this is relevant for clinical staging and the treatment program. These findings also confirm that percutaneous liver biopsy is a valuable diagnostic procedure in the staging of malignant lymphomas.

Therapy of Advanced Esophageal Cancer with Bleomycin, Irradiation and Combination of Bleomycin with Irradiation

Results from treating 51 patients with advanced esophageal cancer are presented. Fifteen patients were treated with Bleomycin, 12 with radiotherapy, and 24 with a combination of Bleomycin and radiotherapy. The best results were achieved in the group of patients treated with combined therapy showing 62% objective remissions (15/24) which was statistically significant (P < 0.001) in comparison to the other groups. In the Bleomycin therapy group, there were 26% objective remissions (4/15), and in the group treated only with radiotherapy 33% (4/12). The median duration of remission was 9 months in the combined therapy group, 6.3 months in the group treated with radiotherapy, and 2.6 months in the Bleomycin treated group. The authors concluded that the combination of Bleomycin and radiotherapy seems to be a further step in palliative treatment of advanced esophageal cancer.

Bleomycin Infusions Combined with Radiotherapy in the Treatment of Inoperable Esophageal Cancer

A combination of bleomycin, in a 12 h infusion, and radiotherapy was applied in 25 patients with untreated inoperable esophageal cancer. Bleomycin was administered 15 mg/m2 twice weekly, concurrently with irradiation (total dose 3600–4000 rad). Such combined treatment produced 3 complete remissions of the esophageal tumor, 10 partial remissions (response rate 52 % - 13/25), 3 stable disease cases, while in 9 cases the disease progressed in spite of therapy. The median duration of remissions was 8.7 months in complete responders, 6.0 months in partial responders, and 3.0 months in stable disease cases. Similarly, median survival was the longest in complete remission cases (10.3 months). Patients who did not respond to therapy had a median survival of only 2.8 months. Adverse treatment reactions were of a milder character, except retrosternal pain and burning caused by irradiation mucositis, which occurred in 80 % of patients. The trial showed that the combination of bleomycin applied in the form of 12 h infusion and irradiation can produce remissions in 50 % of inoperable esophageal cancer cases, i.e., a rate of remission which is similar to that achieved by irradiation and bleomycin applied in the form of rapid (push) i.v. injections.

Combination Chemotherapy with 1-Methyl-1-Nitrosourea and Cyclophosphamide in Metastatic Melanoma

Twenty one patients with advanced metastatic melanoma were treated with a combination of 1-methyl-1-nitrosourea (MNU) and cyclophosphamide. AH the patients had not previously been treated with cytostatics. MNU in the dose of 4 mg/kg and cyclophosphamide in the dose of 8 mg/kg body weight was administered daily. The drugs were given in 6 day cycles. Objective response (> 50% tumor regression) was obtained in 8 (38%) of the 21 treated patients, with 2 complete and 6 partial remissions. The duration of remission was 2–12 months (M = 6.2 months). Injections of MNU caused nausea and vomiting in approximately all the treated patients. Combination of these drugs, however, produced myelodepression in 33% of treated patients. This combination of drugs showed antitumor activity in metastatic malignant melanoma, particularly in melanoma metastasis of the lung, brain and lymph nodes and needs further investigation.

Preliminary Report on Antitumorigenic Activity of CIS-Dichlorodiamine Platinum in Metastatic Brain Tumors

In spite of pharmacokinetic studies, which have shown that only cis-DDP traces are found in brain tissue, cytotoxic activity of this drug in primary brain tumors has recently been reported. The purpose of our study was to examine whether cis-DDP also has antitumor properties in metastatic brain tumors. Twelve consecutive untreated patients with brain metastases recorded by CAT scans or radionuclide scans plus neurologic examinations underwent the treatment. Histology of primaries revealed 4 bronchial, 3 breast, 1 gastric, 1 colorectal carcinoma, 2 melanomas, and 1 soft tissue sarcoma. Cis-DDP was administered at the doses of 30 mg/m2 body surface daily for 4 days. All the patients were evaluated. Objective response (3 complete and 2 partial remissions) was observed in 5 of 12 patients (response rate 42%). Three stable disease cases were also noted; however, in the remaining 4 patients the disease in the brain progressed. Complete response (5 months) was observed in a breast cancer patient, in a melanoma (4+ months), and in a microcellular bronchial cancer (2+ months). Two partial responses (lung, breast) lasted 2+ and 2+ months. Toxicity was moderate but tolerable for the patients. The preliminary results of this study show that cis-DDP posesses antitumorigenic properties also in patients with metastatic brain tumors, which has not been proved till now.

A water-soluble, bay-functionalized perylenediimide derivative - correlating aggregation and excited state dynamics

The aggregation and the photophysics of a water soluble perylenediimide (PDI) derivative that features two bromine substituents in the bay positions has been probed. Non-fluorescent aggregates were found to be present at concentrations of 1.0 × 10^-5 M. In situ small-angle X-ray scattering (SAXS) measurements and complementary molecular modeling showed the presence of PDI aggregates. In their singlet excited states, the PDI aggregates are characterized by distinct transient fingerprints and rapid deactivation, as revealed by pump-probe experiments on the femto-, pico-, nano-, and microsecond timescales. The product of this deactivation is a PDI triplet excited state. The efficiency of the triplet formation depends on the concentration, and hence on the degree of aggregation. Notably, for PDI concentrations in the range of the critical micelle concentration, the efficiency of intersystem crossing is close to zero. In short, we have demonstrated, for the first time, aggregation-induced formation of triplet excited states for PDI derivatives.

Atypische Femurfraktur bei liegender Hüfttotalendoprothese unter langjähriger Bisphophonat-Therapie

Der vorliegende Fall beschreibt das Auftreten von Oberschenkelschmerzen bei einer 71-jährigen Patientin zehn Jahre nach zurückliegender Hüft-TEP-Implantation der linken Seite mit einer anschließenden periprothetischen Femurfraktur nach Niedrigener gietrauma unter langjähriger-Bisphosphonat Therapie. Für die Oberschenkelschmerzen wurden primär differenzialdiagnostisch aus-geprägte degenerative Veränderungen der Lendenwirbelsäule und ein radiologisch festgestellter Inlayverschleiß der Hüft-TEP als Ur sache diskutiert. Erst in der Gesamtschau al ler Befunde zeigte sich eine subprothetische diaphysäre Fissur, welche bereits einige Tage vor dem Trauma radiologisch nachweisbar war und die spätere Frakturlinie darstellte. Als Ursache wird die Behandlung der Osteo-porose durch die Einnahme von Bisphosphonaten über einen Zeitraum von mehr als fünf Jahren vermutet.

Fullerenes – how 25 years of charge transfer chemistry have shaped our understanding of (interfacial) interactions

Over 25 years research in charge transfer chemistry are highlighted in terms of interfacial interactions between fullerenes and porphyrins in electron donor–acceptor systems.

[Patella fractures in knee arthroplasty]

Periprosthetic patella fractures occur both with and without retropatellar joint replacement. A non-operative treatment yields satisfactory results with low morbidity. It can be applied in minimally displaced fractures that have an intact retropatellar component and an intact extensor mechanism, combined with an initial immobilization. The surgical treatment is associated with relatively poor results and with high complication rates. There was only minor improvement of functional results, no matter which surgical technique was used. Surgical intervention is still required in fractures with a loosening of the patellar component, considerable dislocations of fragments, and damage to or rupture of the extensor mechanism. In particular, type II fractures require repair of the extensor mechanism and the fracture or patellectomy. Type III fractures require a revision or resection of the patella, a patelloplasty or total patellectomy. In addition, early or late reconstruction using allograft to restore the extensor mechanism can be taken in consideration.

n- versus p-doping of graphite: what drives its wet-chemical exfoliation?

We have performed the syntheses of a novel pyrene-porphyrazine conjugate (ZnPzPy) and a reference porphyrazine (ZnPz) to promote the wet-chemical exfoliation of graphite based on the synergetic use of ultrasonication, centrifugation, and doping. ZnPzPy features, on one hand, a hydrophobic pyrene to anchor onto the basal plane of graphene, and, on the other hand, an amphoteric porphyrazine to either p- or n-dope graphene. To this end, we have characterized individual building blocks, that is, ZnPzPy and exfoliated graphite, and the resulting electron donor-acceptor nanohybrid, that is, ZnPzPy/graphene (ZnPzPy-G), by means of an arsenal of microscopic and spectroscopic techniques. From a full-fledged characterization we conclude that ZnPzPy facilitates the exfoliation of graphite affording suspensions featuring 9.5% of single- or few-layered ZnPzPy-G with a mean average size of 200 ± 140 nm. Importantly, a notable shift of charge density from graphene to ZnPzPy in the ground state of ZnPzPy-G corroborates the preference of exfoliated graphite to undergo p-doping rather than n-doping. As an immediate consequence, a full charge separation leads in the excited state to a 750 ± 150 ps lived charge separated state.

DSM265 for Plasmodium falciparum chemoprophylaxis: a randomised, double blinded, phase 1 trial with controlled human malaria infection

BACKGROUND

A drug for causal (ie, pre-erythrocytic) prophylaxis of Plasmodium falciparum malaria with prolonged activity would substantially advance malaria control. DSM265 is an experimental antimalarial that selectively inhibits the parasite dihydroorotate dehydrogenase. DSM265 shows in vitro activity against liver and blood stages of P falciparum. We assessed the prophylactic activity of DSM265 against controlled human malaria infection (CHMI).

METHODS

At the Institute of Tropical Medicine, Eberhard Karls University (Tübingen, Germany), healthy, malaria-naive adults were allocated to receive 400 mg DSM265 or placebo either 1 day (cohort 1A) or 7 days (cohort 2) before CHMI by direct venous inoculation (DVI) of 3200 aseptic, purified, cryopreserved P falciparum sporozoites (PfSPZ Challenge; Sanaria Inc, Rockville, MD, USA). An additional group received daily atovaquone-proguanil (250-100 mg) for 9 days, starting 1 day before CHMI (cohort 1B). Allocation to DSM265, atovaquone-proguanil, or placebo was randomised by an interactive web response system. Allocation to cohort 1A and 1B was open-label, within cohorts 1A and 2, allocation to DSM265 and placebo was double-blinded. All treatments were given orally. Volunteers were treated with an antimalarial on day 28, or when parasitaemic, as detected by thick blood smear (TBS) microscopy. The primary efficacy endpoint was time-to-parasitaemia, assessed by TBS. All participants receiving at least one dose of chemoprophylaxis or placebo were considered for safety, those receiving PfSPZ Challenge for efficacy analyses. Log-rank test was used to compare time-to-parasitemia between interventions. The trial was registered with ClinicalTrials.gov, number NCT02450578.

FINDINGS

22 participants were enrolled between Oct 23, 2015, and Jan 18, 2016. Five participants received 400 mg DSM265 and two participants received placebo 1 day before CHMI (cohort 1A), six participants received daily atovaquone-proguanil 1 day before CHMI (cohort 1B), and six participants received 400 mg DSM265 and two participants received placebo 7 days before CHMI (cohort 2). Five of five participants receiving DSM265 1 day before CHMI and six of six in the atovaquone-proguanil cohort were protected, whereas placebo recipients (two of two) developed malaria on days 11 and 14. When given 7 days before CHMI, three of six volunteers receiving DSM265 became TBS positive on days 11, 13, and 24. The remaining three DSM265-treated, TBS-negative participants of cohort 2 developed transient submicroscopic parasitaemia. Both participants receiving placebo 7 days before CHMI became TBS positive on day 11. The only possible DSM265-related adverse event was a moderate transient elevation in serum bilirubin in one participant.

INTERPRETATION

A single dose of 400 mg DSM265 was well tolerated and had causal prophylactic activity when given 1 day before CHMI. Future trials are needed to investigate further the use of DSM265 for the prophylaxis of malaria.

FUNDING

Global Health Innovative Technology Fund, Wellcome Trust, Bill & Melinda Gates Foundation through Medicines for Malaria Venture, and the German Center for Infection Research.

p-Doping of graphene in hybrid materials with 3,10-diazapicenium dications

N,N'-Didodecyl-substituted 3,10-diazapicenium salts featuring bromide and hexafluorophosphate counterions have been designed as novel dopants to realize individualized graphene sheets in a series of cutting edge experiments and to intrinsically stabilize them via p-doping. Importantly, electrochemical studies revealed two consecutive irreversible one-electron reductions of the N,N'-didodecyl-substituted 3,10-diazapicenium salts to yield the corresponding radical cation and neutral quinoidal species. Formation of both species was accompanied by characteristic changes in the absorption spectra. The 3,10-diazapicenium bromide was found to be a potent dopant to produce hybrid materials with exfoliated graphene. Microscopy based on AFM and TEM imaging and spectroscopy based on Raman probing corroborated that, upon drying, the hybrid material consists of few layer (5-8 layers) turbostratic graphene sheets that are p-doped. Our findings identify the newly synthesized N,N'-dialkylated 3,10-diazapicenium salts as highly promising candidates for the fabrication of functional graphene materials with tailored properties.