HIVEC as an alternative option in non-muscle-invasive bladder cancer: Experiences from a high-volume center

BACKGROUND

High risk non-muscle invasive bladder cancer (NMIBC) is usually treated with intravesical BCG-therapy. In case of BCG failure radical cystectomy (RC) is the treatment of choice. Nevertheless, many patients are unfit for or unwilling to undergo RC. Hyperthermic intravesical chemotherapy (HIVEC) is a promising bladder sparing therapy in such cases. It was the purpose of the study to evaluate the efficacy of HIVEC in patients with BCG failure as well as in BCG naïve patients in case of BCG shortage or given contra-indications for BCG.

METHODS

We analyzed the first 60 patients who received hyperthermic intravesical chemotherapy (HIVEC) at our department. The therapy regimen consisted of an induction course of 6 weekly sessions, followed by a maintenance course with 6 monthly sessions. Fluorescence cystoscopy with urine cytology and bladder mapping was performed after completion of induction and maintenance therapy at 3 and 12 months. About 68.6 % had received a recurrence after or during BCG treatment, 55% of the subjects were BCG-unresponsive NMIBC according to EAU guidelines.

RESULTS

The median follow up was 12 months with 12 cycles of HIVEC therapy being administered on average, representing completion of induction and maintenance therapy with 6 cycles each. The 1- and 2-year recurrence-free-survival (RFS) was 67% and 40% respectively. Only one out of 60 patients developed progression to muscle invasion with progression-free-survival (PFS) of 98% at 2 years. No statistical differences were found in RFS for patients failure to BCG compared to patients that were BCG-naïve (BCG unresponsive vs. BCG-naïve) and patients that carried carcinoma in situ (CIS) compared to patients without CIS (CIS vs. no CIS).

CONCLUSION

Chemohyperthermia using HIVEC results in high recurrence-free survival and a 2-year progression-free survival rate of 98% with a bladder preservation rate of almost 80%. Comparing our data, HIVEC shows better oncological results together with better tolerability and safety making HIVEC a good alternative for patients who refuse radical cystectomy or who are ineligible for radical cystectomy.

Cystic Pelvic Masses in Men: A Presentation of Uncommon Cases and a Literature Review

Unclear cystic masses in the pelvis in male patients are a rare situation and could be of benign or malignant origin. The underlying diseases demand for specific diagnostic and therapeutic approaches. We present a case series of 3 male patients with different clinical symptoms (perineal pain, urinary retention and a large scrotal cyst) related to cystic lesions in the pelvic region. On all patients initial histopathological workup was unclear. All patients underwent surgery with complete resection of the tumor which revealed a broad spectrum of histopathological findings: unusual form of cystic adenocarcinoma of the prostate, malignant transformation of a dysontogenetic cyst, and finally a very rare diagnosis of a malignant tumor of the Cowper gland. This case series and literature review provide clues for a possible diagnostic and therapeutic approach in the case of unclear pelvic cystic masses and could support urologists during the therapy selection in the future.

Cost-effectiveness analysis of different treatment modalities in BCG-unresponsive NMIBC

OBJECTIVE

Radical cystectomy (RC) is the standard of care (SOC) in BCG-unresponsive NMIBC and is associated with a significant health-related quality-of-life burden. Recently, promising results have been published on Gemcitabine/Docetaxel, Pembrolizumab, and Hyperthermic Intravesical Chemotherapy (HIVEC) as salvage therapy options trying to increase the rate of bladder preservation. Here, we performed a Cost-Effectiveness-Analysis of those treatment modalities.

PATIENTS AND METHODS

We developed a Markov model from a payer's perspective drawing on clinical data of single-arm trials testing intravesical gemcitabine/docetaxel and pembrolizumab in BCG-unresponsive NMIBC, as well as clinical data from patients receiving hyperthermic intravesical chemotherapy HIVEC (n = 29) as intravesical salvage chemotherapy at our uro-oncological centre in Cologne. Costs were simulated utilising a non-commercial diagnosis-related groups grouper, utilities were derived from comparable cost-effectiveness studies. We used a Monte Carlo simulation to identify the optimal treatment, comparing the incremental cost effectiveness ratios (ICERs) at a willingness-to-pay threshold of €50 000 (euro)/quality-adjusted life year (QALY).

RESULTS

Over a horizon of 10 years, gemcitabine/docetaxel, HIVEC, and pembrolizumab were associated with costs of €48 353, €64 438, and €204 580, as well as a gain of QALYs of 6.16, 6.48, and 6.00, resulting in an ICER of €26 482, €42 567, and €184 533 respectively, in comparison to RC with total costs of €21 871 and a gain of QALYs of 5.01. Monte Carlo simulation identified HIVEC as the treatment of choice under assumption of a WTP of <€50 000.

CONCLUSION

Considering a WTP of <€50 000/QALY, gemcitabine/docetaxel and HIVEC are highly cost-effective therapeutic options in BCG-refractory NMIBC, while RC remains the cheapest option. At its current price, pembrolizumab would only be cost-effective assuming a price reduction of at least 70%.

[Emergencies in cancer therapy: surgical indications under systemic therapy]

Emergency surgery due to side-effects of cancer therapy in patients with metastatic disease of the genitourinary tract is rare. Nevertheless, there are a number of emergencies that require rapid intervention and should be recognized by every uro-oncologist. The following review will work out important side-effects requiring surgical treatment, highlighting the main symptoms and the initial management.

Importance of magnetic resonance imaging and prostate-specific membrane antigen PET-CT in patients treated with salvage radical prostatectomy for radiorecurrent prostate cancer

BACKGROUND

Accurate staging and identification of optimal candidates for local salvage therapy, such as salvage radical prostatectomy (SRP), is necessary to ensure optimal care in patients with radiorecurrent prostate cancer (PCa). We aimed to analyze performance of magnetic resonance imaging (MRI) and prostate-specific membrane antigen (PSMA)-positron emission tomography (PET)/computed tomography (CT) for predicting pathologic nonorgan confined disease (pT3) and lymph node involvement (pN+) in patients treated with SRP for radiorecurrent PCa.

METHODS

We retrospectively reviewed the institutional database to identify patients who underwent MRI or ⁶⁸ Ga-PSMA-PET/CT before SRP for radiorecurrent PCa. The diagnostic estimates of MRI and PSMA-PET/CT for pT3 and pN+, were calculated.

RESULTS

We identified 113 patients with radiorecurrent PCa who underwent preoperative MRI followed by SRP; 53 had preoperative ⁶⁸ Ga-PSMA-PET/CT. For the detection of pT3 disease, the overall accuracy of MRI was 70% (95% confidence interval [CI] 61-78), sensitivity 40% (95% CI 26-55) and specificity 94% (95% CI 85-98); PSMA-PET/CT had slightly higher accuracy of 77% (95% CI 64-88), and higher sensitivity of 90% (95% CI 68-99), but lower specificity of 70% (95% CI 51-84). For pN+ disease, MRI had poor sensitivity of 14% (95% CI 3-36), specificity of 50 (95% CI 39-61) and total accuracy of 43% (95% CI 34-53); PSMA-PET/CT had an accuracy of 85% (95% CI 72-93), sensitivity of 27% (95% CI 6-61), and specificity of 100% (95% CI 92-100).

CONCLUSION

In patients with radiorecurrent PCa, both, MRI, and ⁶⁸ Ga-PSMA PET/CT are valuable tools for the pre-SRP staging and should be integrated into the standard workup. For lymph node metastases, ⁶⁸ Ga-PSMA PET/CT is a strong rule-in test with nearly perfect specificity; in contrast MRI had a low accuracy for lymph node metastases.

Cytoreductive radical prostatectomy: who benefits from the surgical approach?

PURPOSE OF REVIEW

Local treatment in oligometastatic prostate cancer patients is associated with improved survival. Nevertheless, in term of surgery, cytoreductive radical prostatectomy has no level of evidence 1 and is an individual treatment approach. We reviewed the recent literature to highlight parameters for selecting patients for a surgical approach.

RECENT FINDINGS

Retrospective data on oncologic outcome for cytoreductive prostatectomy are confirmed. We identified several parameters that help to select patients for surgery. Patients with a favorable prostate-specific antigen (PSA) decline after androgen deprivation therapy (ADT) have excellent oncologic long-term control. Circulating tumor cells (CTC's) are frequently analyzed in more advanced prostate cancer. In case of C-reactive protein (CRP) at least a longer interval to develop castration resistant prostate cancer (CRPC) is shown in case of low CTC count at time of surgery. Nutrition status analyzed as the hemoglobin, albumin, lymphocyte, and platelet (HALP)-score is of significant value in demonstrating an effect of CRP.

SUMMARY

From retrospective findings we have several clinical and basic science parameters to select patients for CRP. PSA at the time of surgery is the most frequently analyzed one, whereas CTC and HALP-score are promising tools to select patients that need to be validated.

Prediction of response to neoadjuvant chemotherapy of patients with muscle invasive bladder cancer by molecular subtyping and radioligand target quantitation: Preview of the Bladder BRIDGister

543

Background: Patients with muscle invasive urothelial carcinoma achieving pathological complete response (pCR) upon neoadjuvant chemotherapy (NACT) have improved prognosis. Molecular subtypes of bladder cancer differ markedly with regard to sensitivity to cisplatinum based chemotherapy and harbour FGFR treatment targets to various content. Previously we did show that lumina tumors respond better to NACT, while FGFR1 expression is associated with chemo resistance (Ecke et al. 2022). The objective of this study was to determine wether radioligand therapy may be an appropriate option in chemoresistent tumors to justify subsequent prospective validation within the "Bladder BRIDGister". Methods: Formalin fixed paraffin embedded (FFPE) tissues from transurethral resections (TUR) before chemotherapy and cystectomy samples after NACT of 36 patients were retrospectively collected. RNA from FFPE tissues were extracted by commercial kits, relative gene expression of subtyping markers (KRT5, KRT20, FGFR1) and radioligand target genes (CXCR4, FAP) were analyzed by standardized RT-qPCR systems (STRATIFYER Molecular Pathology GmbH, Cologne). Spearman correlation, hierarchical clustering, Kruskal-Wallis, chi square and contingency tests were done by JMP 9.0.0 (SAS software). Results: The neoadjuvant cohort consisted of 36 patients (median age: 69, male 83% vs. female 17%) with 92% of patients being histopathologically node negative. When comparing pretreatment with post treatment samples the median expression of KRT20 dropped 128fold, while FGFR1, CXCR4 and FAP mRNA expression increased 6,8fold, 1,9 fold and 2,9 fold, respectively. FAP was positively associated with KRT5, FGFR1 and CXCR4 in treatment naïve TUR biopsies (r=0.4051 p=0.0141, r=0.6458 p<0.0001 and r=0.7586 p<0.0001, respectively), but negatively associated with KRT20 (r=-0.3879 p=0.0194). As previously described, FGFR1 was negatively associated with pCR (r=-0.6418 p<0.0001). Similarly, CXCR4 and FAP trended to be negatively associated with pCR (r=-0.3181 p=0.0586; r=-0.3072 p=0.0684). Hierarchical clustering revealed that CXCR4 and FAP are elevated in stromal rich, KRT5 & KRT20 negative tumors not responding to NACT. Elevated FAP above median mRNA expression was significantly associated with resistance to NACT (chi2 4.314 p=0,0378). Combining elevated FAP and CXCR4 mRNA expression did identify 28% of the patients to be at high risk of NACT resistance (90%). Conclusions: Expression of the radioligand targets CXCR4 and FAP are associated with basal/stromal enriched tumors and resistance to NACT. Theranostic targeting of CXCR4 and FAP before NACT might increase response towards NACT in this poor prognosis group.

Prediction of response to neoadjuvant chemotherapy of patients with muscle invasive bladder cancer by molecular subtyping and antibody drug conjugate target gene quantitation: Preview of Bladder BRIDGister

545

Background: Patients with muscle invasive urothelial carcinoma achieving pathological complete response (pCR) upon neoadjuvant chemotherapy (NACT) have improved prognosis. Molecular subtypes of bladder cancer differ markedly with regard to sensitivity to cisplatinum based chemotherapy. Previously we did show that luminal tumors respond better to NACT, while FGFR1 expression is associated with chemo resistance (Ecke et al. 2022). The objective of this study was to determine which patients may benefit from Antibody Drug Conjugate (ADC) treatment in addition to NACT to justify subsequent prospective analysis within the "Bladder BRIDGister". Methods: Formalin fixed paraffin embedded (FFPE) tissues from transurethral resections (TUR) before chemotherapy and cystectomy samples after NACT of 36 patients were retrospectively collected. RNA from FFPE tissues were extracted by commercial kits, relative gene expression of subtyping markers (KRT5, KRT20, FGFR1) and radioligand target genes (NECTIN4, TROP2) were analyzed by standardized RT-qPCR systems (STRATIFYER Molecular Pathology GmbH, Cologne). Spearman correlation, hierarchical clustering, Kruskal-Wallis, chi square and contingency tests were done by JMP 9.0.0 (SAS software). Results: The neoadjuvant cohort consisted of 36 patients (median age: 69, male 83% vs. female 17%) with 92% of patients being pathohistologically node negative. When comparing pretreatment with post treatment samples the median expression of KRT20 dropped 128fold, while FGFR1 expression increased 6.8 fold. Interestingly, TROP2 and NECTIN4 mRNA expression also dropped significantly upon NACT by 5.7 fold and 7.1 fold, respectively. TROP2 and NECTIN4 were positively associated with the response marker KRT20 in therapy naïve TUR biopsies (r=0.5562 p=0.0004; r=0.5833 p=0.0002), but negatively associated with the resistance marker FGFR1 (r=-0.2903 p=0,0858; r=-0.3396 p=0,0427). However, TROP2 and NECTIN4 were not associated with pCR in spearman analysis with minor trend for TROP2 (r=0,2139 p=0,2103). Cluster analysis revealed a subgroup of KRT20 positive and FGFR1 negative tumors expression TROP2 and NECTIN4, which achieved 80% pCR. In addition elevated TROP2 and NECTIN4 expression was found in KRT20 positive tumors coexpressing FGFR1 and being resistant to NACT. Conclusions: Expression of the ADC targets TROP2 and NECTIN4 is associated with KRT20 positive, luminal tumors being highly sensitive to neoadjuvant chemotherapy alone. KRT5 positive, basal tumors do exhibit only very low expression of TROP2 and NECTIN4 mRNA. In view of toxicities the addition of TROP2 and NECTIN4 treatment to NACT might be considered only in luminal tumors exhibiting elevated FGFR1 expression as resistance mechanism and therefore do not respond to NACT.

Cytoreductive radical prostatectomy (cRP) in the management of patients with newly diagnosed metastatic hormone-sensitive prostate cancer (mHSPC)

161

Background: Although still discussed controversially, cRP represents a therapeutic option for mHSPC patients in the context of a multimodality approach. It was the purpose of our study to retrospectively review the oncological and functional outcome of a single-center cohort of cRP patients. Methods: A total of 134 mHSPC patients underwent cRP with pelvic lymphadenectomy. All patients received neoadjuvant androgen deprivation therapy (ADT, n = 34), ADT + docetaxel (n=15), or ADT plus ABI/ENZA/APA (n=85) for 6 months which was continued postop. Follow-up studies were performed at 3-month intervals, new imaging studies with 68Ga-PSMA PET/CT was done at PSA-levels > 1.0 ng/ml. Perioperative complications were evaluated according to Clavien-Dindo classification. Clinical progression free survival (cPFS) and cancer specific survival (CSS) were calculated via Kaplan-Maier analysis. Multivariate regression analysis was used to assess the impact of biopsy ISUP grade, PSA at diagnosis and preop., PSA decrease, T stage, and metastatic burden on PFS and CSS. Results: 115 and 19 had low and high volume mHSPC, resp. Mean age was 64.2 (42-88) years, mean preop. PSA was 3.2 (0.1-21.6) ng/ml. The median Follow-up ist 53.7 (4 – 168) months. M1a, M1b and M1c were present in 28 (20.9%), 98 (73.1%) and 8 (6.0%) men. Pathohistology demonstrated pT0 in 3 (2.2%), pT2a-c in 21 (15.7%), pT3 and pT4 in 105 (78.3%) and 5 (3.7%). pN0 and pN+ was diagnosed in 38 (28.3%) and 96 (71.7%) pts. There was no significant difference between type of ADT and final pathohistology. Clavien-Dindo Grad 3a-b and 4 complications were observed in 13 (9.7%) and 2 (1.5%) pts. CSS was 88.1% and cPFS was 53%. None of the pts developed locally recurrent disease. Overall survival was reduced in M1 high volume (61.9% vs 92.8%, p=0.002) and pN+ (85.7% vs 96.7%, p=0.001). cT≥3b (HR=2.24, p=0.02) and M1 high volume (HR=2.35, p=0.01) were associated with reduced cPFS; M1 high volume (HR=1.49, p=0.03) and relative PSA decrease £60% (HR=1.37, p=0.03) were associated with reduced CSS. Conclusions: cRP can be performed with minimal morbidity. mHSPC patients with clinically localized high risk PCA, low metastatic burden and good response to nADT benefit most from this approach. The risk for symptomatic local relapse is low. Limitation of the study is its retrospective design.

Prediction of Response to Cisplatin-Based Neoadjuvant Chemotherapy of Muscle-Invasive Bladder Cancer Patients by Molecular Subtyping including KRT and FGFR Target Gene Assessment

Patients with muscle-invasive urothelial carcinoma achieving pathological complete response (pCR) upon neoadjuvant chemotherapy (NAC) have improved prognosis. Molecular subtypes of bladder cancer differ markedly regarding sensitivity to cisplatin-based chemotherapy and harbor FGFR treatment targets to various content. The objective of the present study was to evaluate whether preoperative assessment of molecular subtype as well as FGFR target gene expression is predictive for therapeutic outcome—rate of ypT0 status—to justify subsequent prospective validation within the “BladderBRIDGister”. Formalin-fixed paraffin-embedded (FFPE) tissue specimens from transurethral bladder tumor resections (TUR) prior to neoadjuvant chemotherapy and corresponding radical cystectomy samples after chemotherapy of 36 patients were retrospectively collected. RNA from FFPE tissues were extracted by commercial kits, Relative gene expression of subtyping markers (e.g., KRT5, KRT20) and target genes (FGFR1, FGFR3) was analyzed by standardized RT-qPCR systems (STRATIFYER Molecular Pathology GmbH, Cologne). Spearman correlation, Kruskal−Wallis, Mann−Whitney and sensitivity/specificity tests were performed by JMP 9.0.0 (SAS software). The neoadjuvant cohort consisted of 36 patients (median age: 69, male 83% vs. female 17%) with 92% of patients being node-negative during radical cystectomy after 1 to 4 cycles of NAC. When comparing pretreatment with post-treatment samples, the median expression of KRT20 dropped most significantly from DCT 37.38 to 30.65, which compares with a 128-fold decrease. The reduction in gene expression was modest for other luminal marker genes (GATA3 6.8-fold, ERBB2 6.3-fold). In contrast, FGFR1 mRNA expression increased from 33.28 to 35.88 (~6.8-fold increase). Spearman correlation revealed positive association of pretreatment KRT20 mRNA levels with achieving pCR (r = 0.3072: p = 0.0684), whereas pretreatment FGFR1 mRNA was associated with resistance to chemotherapy (r = −0.6418: p < 0.0001). Hierarchical clustering identified luminal tumors of high KRT20 mRNA expression being associated with high pCR rate (10/16; 63%), while the double-negative subgroup with high FGFR1 expression did not respond with pCR (0/9; 0%). Molecular subtyping distinguishes patients with high probability of response from tumors as resistant to neoadjuvant chemotherapy. Targeting FGFR1 in less-differentiated bladder cancer subgroups may sensitize tumors for adopted treatments or subsequent chemotherapy.

Bryostatin-1 Attenuates Ischemia-Elicited Neutrophil Transmigration and Ameliorates Graft Injury after Kidney Transplantation

Ischemia reperfusion injury (IRI) is a form of sterile inflammation whose severity determines short- and long-term graft fates in kidney transplantation. Neutrophils are now recognized as a key cell type mediating early graft injury, which activates further innate immune responses and intensifies acquired immunity and alloimmunity. Since the macrolide Bryostatin-1 has been shown to block neutrophil transmigration, we aimed to determine whether these findings could be translated to the field of kidney transplantation. To study the effects of Bryostatin-1 on ischemia-elicited neutrophil transmigration, an in vitro model of hypoxia and normoxia was equipped with human endothelial cells and neutrophils. To translate these findings, a porcine renal autotransplantation model with eight hours of reperfusion was used to study neutrophil infiltration in vivo. Graft-specific treatment using Bryostatin-1 (100 nM) was applied during static cold storage. Bryostatin-1 dose-dependently blocked neutrophil activation and transmigration over ischemically challenged endothelial cell monolayers. When applied to porcine renal autografts, Bryostatin-1 reduced neutrophil graft infiltration, attenuated histological and ultrastructural damage, and improved renal function. Our novel findings demonstrate that Bryostatin-1 is a promising pharmacological candidate for graft-specific treatment in kidney transplantation, as it provides protection by blocking neutrophil infiltration and attenuating functional graft injury.

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

Influenza virus infections in patients with malignancies -- characteristics and outcome of the season 2014/15. A survey conducted by the Infectious Diseases Working Party (AGIHO) of the German Society of Haematology and Medical Oncology (DGHO)

Influenza virus infections (IVI) may pose a vital threat to immunocompromised patients such as those suffering from malignancies, but specific data on epidemiology and outcome in these patients are scarce. In this study, we collected data on patients with active cancer or with a history of cancer, presenting with documented IVI in eight centres in Germany. Two hundred and three patients were identified, suffering from haematological malignancies or solid tumours; 109 (54 %) patients had active malignant disease. Influenza A was detected in 155 (77 %) and Influenza B in 46 (23 %) of patients (genera not determined in two patients). Clinical symptoms were consistent with upper respiratory tract infection in 55/203 (27 %), influenza-like illness in 82/203 (40 %), and pneumonia in 67/203 (33 %). Anti-viral treatment with oseltamivir was received by 116/195 (59 %). Superinfections occurred in 37/203 (18 %), and admission on an intensive care unit was required in 26/203 (13 %). Seventeen patients (9 %) died. Independent risk factors for death were delayed diagnosis of IVI and bacterial or fungal superinfection, but not underlying malignancy or ongoing immunosuppression. In conclusion, patients with IVI show high rates of pneumonia and mortality. Early and rapid diagnosis is essential. The high rate of pneumonia and superinfections should be taken into account when managing IVI in these patients.

Diagnosis and antimicrobial therapy of lung infiltrates in febrile neutropenic patients (allogeneic SCT excluded): updated guidelines of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO)

Up to 25% of patients with profound neutropenia lasting for >10 days develop lung infiltrates, which frequently do not respond to broad-spectrum antibacterial therapy. While a causative pathogen remains undetected in the majority of cases, Aspergillus spp., Pneumocystis jirovecii, multi-resistant Gram-negative pathogens, mycobacteria or respiratory viruses may be involved. In at-risk patients who have received trimethoprim-sulfamethoxazole (TMP/SMX) prophylaxis, filamentous fungal pathogens appear to be predominant, yet commonly not proven at the time of treatment initiation. Pathogens isolated from blood cultures, bronchoalveolar lavage (BAL) or respiratory secretions are not always relevant for the etiology of pulmonary infiltrates and should therefore be interpreted critically. Laboratory tests for detecting Aspergillus galactomannan, β-D-glucan or DNA from blood, BAL or tissue samples may facilitate the diagnosis; however, most polymerase chain reaction assays are not yet standardized and validated. Apart from infectious agents, pulmonary side-effects from cytotoxic drugs, radiotherapy or pulmonary involvement by the underlying malignancy should be included into differential diagnosis and eventually be clarified by invasive diagnostic procedures. Pre-emptive treatment with mold-active systemic antifungal agents improves clinical outcome, while other microorganisms are preferably treated only when microbiologically documented. High-dose TMP/SMX is first choice for treatment of Pneumocystis pneumonia, while cytomegalovirus pneumonia is treated primarily with ganciclovir or foscarnet in most patients. In a considerable number of patients, clinical outcome may be favorable despite respiratory failure, so that intensive care should be unrestrictedly provided in patients whose prognosis is not desperate due to other reasons.

Safety and efficacy of a new extensively hydrolyzed formula for infants with cow's milk protein allergy

Cow's milk protein allergy (CMPA) is best treated by complete elimination of cow's milk from the diet. For infants with CMPA who cannot be breast-fed, formulas based on extensively hydrolyzed proteins or on amino acids are the preferred substitutes for cow's milk-based formulas. In this study, we compared the tolerance and growth of infants with CMPA who were fed a new extensively hydrolyzed formula containing lactose (eHF) with those who were fed an amino acid formula (AAF). This was a prospective, multi-center, randomized, reference-controlled study. Seventy-seven infants <12 months old with suspected CMPA were enrolled. In 66 of these, CMPA was confirmed by oral challenge in a double-blind, placebo-controlled food challenge (DBPCFC) or by a medical history of severe allergic reaction to cow's milk and a positive skin prick test. These infants were then tested for their reaction to eHF and AAF in a DBPCFC. All infants tolerated both formulas and were randomized to receive either eHF (n = 34) or AAF (n = 32) for 180 days. Growth (weight, length, and head circumference) and tolerance [skin, gastro-intestinal, and respiratory tract symptoms of allergy] were evaluated after 30, 60, 90, and 180 days. There were no significant differences between the two groups in any of the growth measurements. Length and head circumference were similar to Euro-growth standards, but weight was slightly lower. Gastro-intestinal and respiratory tract symptoms of allergy were also similar in the two groups. However, whereas SCORAD scores for atopic dermatitis remained constant throughout the study in infants-fed eHF, there was a slight decrease in those fed AAF. Infants-fed eHF had significantly fewer incidents of vomiting than infants-fed AAF and a significantly higher frequency of soft stools. The new eHF is safe and well tolerated in infants diagnosed with CMPA.

Polony analysis of gene expression in ES cells and blastocysts

Expression profiling of stem cells is challenging due to their small numbers and heterogeneity. The PCR colony (polony) approach has theoretical advantages as an assay for stem cells but has not been applied to small numbers of cells. An assay has been developed that is sensitive enough to detect mRNAs from small numbers of ES cells and from fractions of a single mouse blastocyst. Genes assayed include Oct3, Rex1, Nanog, Cdx2 and GLUT-1. The assay is highly sensitive so that multiple mRNAs from a single blastocyst were easily detected in the same assay. In its present version, the assay is an attractive alternative to conventional RT–PCR for profiling small populations of stem cells. The assay is also amenable to improvements that will increase its sensitivity and ability to analyze many cDNAs simultaneously.

Breakthrough infection of Trichosporon asahii during posaconazole treatment in a patient with acute myeloid leukaemia

A neutropenic patient with acute myeloid leukaemia experienced a breakthrough infection of Trichosporon asahii during posaconazole treatment. After treatment was changed to a combination therapy with voriconazole and liposomal amphotericin B, the infection resolved. Posaconazole works effectively as an antifungal prophylaxis and salvage therapy in rare invasive fungal infections. This case however illustrates that breakthrough infections with T. asahii may occur during posaconazole treatment.

[Maternal tobacco consumption can be reduced by simple intervention of the paediatrician]

BACKGROUND

Exposure to environmental tobacco smoke at home increases the risk for numerous diseases in childhood. In this study we asked if maternal tobacco consumption can be reduced by a written advice of the paediatrician.

PATIENTS AND METHODS

In a paediatrician's practice we recruited 40 mothers who smoked ten or more cigarettes per day according to their own statement. The paediatrician's intervention consisted in a short written advice to reduce tobacco consumption. At the beginning of the study and six weeks later we obtained urine samples of the mothers in order to measure the concentrations of the nicotine metabolite cotinine. A subgroup of the study population was informed about the initial concentration of cotinine, the other subgroup was not informed.

MAIN RESULTS

Following the written advice of the paediatrician mothers reduced their consumption of tobacco products according to their own information as well as according to the concentrations of cotinine. Confronting mothers with their initial concentrations of cotinine was not found to be an additional factor reducing tobacco consumption.

CONCLUSIONS

Maternal consumption of tobacco products can be reduced significantly by an advice of the paediatrician at least for a short time.

[Measles and mumps antibody concentrations in newborns and their mothers--follow up first year of life]

BACKGROUND

During the last twenty years the incidence of measles and mumps decreased after introduction of vaccinations in the industrial nations. The vaccination rate of the population in Germany lies currently under the required elimination rate. The epidemiological situation has changed altogether. The illness age has on the one hand moved up, teenager and adult suffer more frequent these so-called children's diseases with an increased complication rate. On the other hand illness cases in infancy seeming to increase. It was aim of this study to examinate the current serological situation for measles and mumps antibody status in women in childbed and their healthy newborns at birth time and during the first seven to nine life months.

PATIENTS AND METHOD

237 healthy newborns, born in 1999 in Bochum, West-Germany and their mothers were included. The mothers were asked if and when they did suffer from measles and mumps or were questioned to active vaccinations against these diseases. Immediately antepartal from all mothers was taken a venous blood sample. Immediately postpartal from all newborn childs umbilical cord blood was taken and again a blood sample in the age of six to eight months. In the serum tests the measle and mumps IgG antibody concentrations were examined quantitatively with ELISA methods. In cases with negative or borderline positive values the plaque neutralization test was also used for measuring of the measle antibodies.

CONCLUSIONS

Between the maternal and neonatal titers results the knownly positive correlation. Maternal lending immunity against measle and mumps lasts more less into infancy as generally suspected. An earlier first active immunization against measles and mumps could be discussed. The strict realisation of the present vaccinating recommendations should be operated as a matter of priority to lead to the desired measles and mumps eradication.

Prospective study of fever after bronchoalveolar lavage in children

BACKGROUND

We investigated the significance of bronchoalveolar lavage fluid (BALF) characteristics and bacterial pathogens isolated in bronchoalveolar lavage fluids, oropharyngeal cultures and blood cultures for the development of fever in children after flexible bronchoscopy.

METHOD

We studied 41 consecutive patients (age 4 months to 15 years), who underwent bronchoalveolar lavage (BAL) and 24 hours temperature monitoring. Two blood cultures of each patient drawn at two sites, oropharyngeal swabs, total cell counts, cell differentials and microbial cultures from lavage fluid were studied.

RESULTS

Postbronchoscopic temperature increase was significantly higher in patients with positive BALF cultures (p = 0.04). Seven out of 41 patients had postbronchoscopic fever and positive bacterial cultures of BALF. Bacteraemia (with an identical pathogen isolated in BALF) was found in one febrile patient. There was a significantly higher total cell count (p = 0.03) and concentration of neutrophils (p = 0.001) in BALF among the children with presence of positive bacterial cultures.

CONCLUSION

We conclude that fever is a frequent adverse event following BAL in children and is rarely associated with bacteraemia. Findings associated with the risk to develop fever are positive bacterial cultures and high neutrophil numbers in BALF.

Nachweis von pneumonischen Infiltraten mit der MRT

Magnetic resonance imaging (MRI) of the lung is challenging because of substantial drawbacks. However, lung pathologies that are associated with increased attenuation values in CT enhance visualization in MRI: proton density is increased and tissue-air interfaces, resulting in susceptibility artifacts, are reduced in pneumonia, pneumonitis, edema, and carcinoma. On the other hand, many lung diseases result in shortness of breath, so that patients cannot hold their breath for long periods. Therefore, fast imaging techniques are required which should also allow for high spatial resolution so that small lesions can be detected. Calcifications and air pockets within lesions are not readily recognized with MRI. Thin section CT is standard for the diagnosis of pneumonia. With parallel imaging techniques, MRI examination of the lungs can be performed with short periods of breath holding, which allow for sub-centimeter resolution in the z-axis. Especially for follow-up examinations in immunocompromised patients and, in some instances, for the staging of malignant diseases (malignant pleural mesothelioma, lung cancer, respectively), MRI is very promising and may contribute to a decrease in the radiation exposure of the patients.

Chlamydophila pneumoniae and Mycoplasma pneumoniae in respiratory specimens of children with chronic lung diseases

BACKGROUND

Persistent infection with Mycoplasma pneumoniae and Chlamydophila pneumoniae has been implicated in the progression or induction of asthma and chronic obstructive pulmonary disease. Evidence for this hypothesis has been obtained in adults either by serological methods or by direct pathogen detection using invasive procedures.

METHODS

We investigated nasal brush specimens and induced sputum from 38 children with stable chronic lung disease (asthma, n = 26; chronic bronchitis n = 12) and from 42 healthy controls for the presence of M pneumoniae or C. pneumoniae DNA by polymerase chain reaction (PCR) using nested primers.

RESULTS

None of the controls but 23.6% and 10.5% of the children with lung disease had positive PCR for C pneumoniae (p = 0.001) and M pneumoniae (p = 0.044) respectively. Significantly more children with non-atopic asthma than with atopic asthma were positive for C pneumoniae or M pneumoniae (4/8 v 1/18; p = 0.018). There were no unwanted side effects from sputum induction. No correlation was found between detection of Chlamydophila and severity of lung disease. Colonisation with both organisms had occurred before adulthood in a significant proportion of children with stable chronic lung diseases.

CONCLUSION

Combining nasal brush specimens with induced sputum may be a useful non-invasive method for studying the role of C pneumoniae and M pneumoniae infection in children with different chronic lung diseases.

Interstitial lung disease in a baby with a de novo mutation in the SFTPC gene

Mutations in the surfactant protein C gene (SFTPC) were recently reported in patients with interstitial lung disease. In a 13-month-old infant with severe respiratory insufficiency, a lung biopsy elicited combined histological patterns of nonspecific interstitial pneumonia and pulmonary alveolar proteinosis. Immunohistochemical and biochemical analyses showed an intra-alveolar accumulation of surfactant protein (SP)-A, precursors of SP-B, mature SP-B, aberrantly processed proSP-C, as well as mono- and dimeric SP-C. Sequencing of genomic DNA detected a de novo heterozygous missense mutation of the SFTPC gene (g.1286T>C) resulting in a substitution of threonine for isoleucine (173T) in the C-terminal propeptide. At the ultrastructural level, abnormal transport vesicles were detected in type-II pneumocytes. Fusion proteins, consisting of enhanced green fluorescent protein and wild-type or mutant proSP-C, were used to evaluate protein trafficking in vitro. In contrast to wild-type proSP-C, mutant proSP-C was routed to early endosomes when transfected into A549 epithelial cells. In contrast to previously reported mutations, the 173T represents a new class of surfactant protein C gene mutations, which is marked by a distinct trafficking, processing, palmitoylation, and secretion of the mutant and wild-type surfactant protein C. This report heralds the emerging diversity of phenotypes associated with the expression of mutant surfactant C proteins.

[Infection-related emergencies in oncology]

Infections in immunosuppressed patients have always to be regarded as emergencies, as they have a high rate of complications and mortality. The most important risk factor is severity and duration of granulocytopenia. Risk scores help to identify patients who, despite their immune deficiency have a low risk of complications. Diagnostic measures to identify the causative microorganism and the source of infection is necessary. However, diagnostic investigation must not delay the immediate onset of antimicrobial treatment. Patients often have to be treated empirically as the identification of the causative microorganism or the source of infection are often unknown at the beginning of clinical symptoms. Empirical treatment has to be broad to cover possible microorganisms. Especially meningitis, abdominal infections, sepsis and pneumonia can be regarded as infectiological emergencies. Patients with these infections have to be treated with intensive antimicrobial treatment, taking into account the possible causative agents.

Incidence and severity of ifosfamide-induced encephalopathy

This retrospective trial was performed to determine risk factors, incidence and severity of ifosfamide-induced encephalopathy in correlation with patient and treatment characteristics. Patients receiving ifosfamide were included consecutively with no restrictions concerning disease, prior chemotherapy or disease stage. Incidence and severity of encephalopathy were graduated according to common toxicity criteria. Between July 2001 and July 2002, 60 patients (32 male, 28 female, median age 47.5 years) were included; 26.6% of the patients (n = 16) developed neurological symptoms [grade 1: 6.7% (n = 4); grade 2: 3.3% (n = 2); grade 3: 11.7% (n = 7); grade 4: 5% (n = 3)]. Encephalopathy occurred for the first time in 87.5% (n = 14) in chemotherapy courses 1 and 2. In 56.25% (n = 9) of these 16 patients only one episode was observed. There was no significant difference concerning age (38 versus 50 years, p = 0.08) and dosage (median 2.9 versus 2.8 g, p = 0.74) between patients with and without encephalopathy. No risk factors could be identified by this study, suggesting an individual predisposition in each patient. On the other hand, ifosfamide can be administered in older patients without increased risk of neurotoxicity.

[Measurement of the deposition of salbutamol in the bronchial lavage fluid of infants and young children]

BACKGROUND

Inhaled salbutamol is well known to be effective in obstructive lung disease in the paediatric age group. However, the individually necessary dose cannot be predicted in a single patient. Two inhalation techniques were compared measuring the concentrations of salbutamol in the bronchial lavage fluid.

PATIENTS AND METHODS

Forty nine children, age 2 to 73 months, inhaled salbutamol immediately before bronchoscopy, either 200 microg using a metered dose inhaler (MDI) or 2000 microg using a nebulizer (NEB). The concentrations of salbutamol were measured in the bronchial lavage fluid.

RESULTS

In spite of different inhaled doses the concentrations of salbutamol were similar in the nebulizer group (n = 29) and the metered dose inhaler group (n = 20) (medians 160 vs. 163 ng/ml; p = 0.27) with a wide range in both groups (12 to 1139 and 5.2 to 641 ng/ml, respectively). In a single patient the concentrations differed by the factor 159 between the right and the left lung. The concentrations of salbutamol were not age dependent (p = 0.06 for NEB, p = 0.28 for MDI).

CONCLUSIONS

In infants and young children the concentrations of salbutamol in the bronchial lavage fluid vary widely after a single inhalation using either a metered dose inhaler or a nebulizer.

Airway compression following thymus hyperplasia in an infant with Pierre Robin sequence and congenital diaphragmatic hernia

A female infant with respiratory embarrassment due to external compression of the tracheobronchial tree by the thymus is presented. After successful intrauterine drainage of pleural effusions, she was born with a diaphragmatic hernia and Pierre Robin sequence, which required long-term mechanical ventilation and several surgical interventions, including tracheostomy, until she breathed spontaneously. At age 7 months, she was rehospitalized in respiratory failure because of pneumonia. At this time, thymus hyperplasia was first diagnosed, which had caused tracheobronchomalacia and displacement of the tracheobronchial tree. Weaning from the ventilator was unsuccessful for 8 weeks. She underwent thymectomy, following which impairment of breathing resolved immediately. Different manifestations of thymus enlargement and their relation to impaired breathing are discussed.

Multivariate analysis of oral hygiene data from a representative sample

BACKGROUND

This analysis was based on an oral health survey with dental examination and interview by questionnaire.

METHOD

The data set comprised a representative random sample of the over 14-year-old residents of the German Federal State of Saxony (n=714), in which a multivariate logistic regression analysis was conducted. The dependent variable was the debris index (DI) score of the oral hygiene index scoring system. The subjects were split into 2 groups by dividing DI scores into tertiles: those with acceptable oral hygiene (1st tertile, DI 0.00< or =1.20) and unacceptable oral hygiene (2nd and 3rd tertile, DI>1.20). The most important explanatory variable was the community periodontal index of treatment need (CPITN).

RESULTS

The higher the CPITN score, the lower the probability of acceptable oral hygiene. In relation to the reference category score 0, higher CPITN scores were associated with acceptable oral hygiene, with an odds ratio 0.05 (95% confidence interval (CI)=0.01-0.23) for CPITN score 1, and an odds ratio 0.02 (95% CI: 0.01-0.08) for score 4. Further significant variables were: self-evaluation of tooth condition, gender, and the number of missing teeth.

Prosthetic treatment need in a representative German sample

Regarding declining resources epidemiological data on needs for oral rehabilitation are required. Within the framework of an oral health survey a non-stratified two-stage random sample was taken to represent the over 14-year-old population of Saxony/Germany. The participation rate was 55%. Normative need was determined by dental assessment and guidelines developed in a consensus process, subjective prosthetic treatment need by self-complete questionnaire. About 97% of the realized sample could be planned within the guidelines. About 81% had normative prosthetic treatment need. Compared with the rate of normative need the rate of subjective need (13%) was considerably lower (chi(2) P < 0;01). Different predictive parameters of subjective need were identified by logistic regression. Besides other factors subjective need was associated with giving dentist's recommendation as significant reason for prosthetic restorations [odds ratio (OR)=5;43], not believing that the own teeth were all right (OR=0;17), and the existence of prosthetic restorations (OR=3;87 for fixed restorations; OR=4;05 for removable dentures). The guidelines proved their suitability to assess normative prosthetic treatment need in oral health surveys. Further research is necessary to find adequate options for including patients' preferences in an adequate need definition.

[Diagnosis of lung embolism with multislice spiral CT]

In recent years CT has been established as the method of choice for the diagnosis of central pulmonary embolism to the level of the segmental arteries. The key advantage of CT over competing modalities is the reliable detection of relevant alternative or additional disease causing the patient's symptoms. Although the clinical relevance of isolated peripheral emboli remains unclear, the alleged poor sensitivity of CT for the detection of such small clots has to date prevented the acceptance of CT as the gold standard for diagnosing pulmonary embolism. With the advent of multislice CT we can now cover the entire chest of a patient with 1-mm slices within one breath-hold. In comparison with thicker sections the detection rate of subsegmental emboli can be significantly increased with 1-mm sections. In addition the interobserver correlation which can be achieved with 1-mm sections by far exceeds the reproducibility of competing modalities. Meanwhile use of multislice CT for a combined diagnosis of pulmonary embolism and deep venous thrombosis with the same modality appears to be clinically accepted. In the vast majority of patients who receive a combined thoracic and venous multislice CT examination the scan either confirms the suspected diagnosis or reveals relevant alternative or additional disease. The therapeutic regimen is usually chosen based on the functional effect of embolic vascular occlusion. With the advent of fast CT scanning techniques, also functional parameters of lung perfusion can be non-invasively assessed by CT imaging. These advantages let multislice CT appear as an attractive modality for a non-invasive, fast, accurate and comprehensive diagnosis of pulmonary embolism, its causes, effects and differential diagnoses.

[Utilization of dental services--results of an oral hygiene study in Saxony]

The utilisation of dental services is a precondition for professional preventive measures. The representative oral survey "Bevölkerungsrepräsentative Studie zum zahnärztlich-prothetischen Versorgungsgrad und Behandlungsbedarf" aimed at gaining data on the frequency and motives for dental visits and the existence of barriers. The sample consisted of 714 subjects aged fifteen years and older. It was representative for the German Federal State Saxony. Socio-economic and behavioural data were collected via self-completed questionnaire. The caries history was evaluated by assessing the DMFT Index. Data collection in 1996 was carried out by three calibrated dentists. Utilisation of dental services was found to be high. Subjective barriers played no crucial role in the decision to utilise dental services. Costs as an objective barrier to dental visits had a growing importance with age. Lower rates of tooth loss and enhanced levels of restoration were found in subjects aged over 24 years who regularly utilised dental services compared to subjects with non-regular utilisation. These differences were significant for subjects over 54 years (tooth loss) and subjects aged 25-44 years and over 54 years (level of restoration). Compared to previous studies the utilisation was similar or higher in our sample. The enhanced oral health belief paves the way for professional preventive measures. In the over 64-year-olds the need for regular dental visits was obvious and this age group must definitely be given more relevant information on the subject.

Infants colonized with enterotoxin-producing staphylococci at 3 months display a decreased frequency of interferon-gamma-producing CD45RO lymphocytes upon stimulation with staphylococcal enterotoxin A at birth but not at 6 months of age

The aim of the study was to elucidate the relationship between the cytokine response to staphylococcal enterotoxin A (SEA) at birth and subsequent staphylococcal colonization in the first months of life. In a cohort of 45 newborns, cord blood lymphocytes were stimulated with SEA (10 ng/ml) in vitro, re-stimulated with PMA (phorbol myristate acetate) and ionomycin at day 3 and assessed for CD45RO expression and cytokine generation by flow cytometry. The infants were classified into three groups according to nasal staphylococcal colonization and enterotoxin generation at 3 months: There were 16 infants with either no colonization or non-enterotoxin-producing staphylococci, 16 infants with enterotoxins B, C, D and E, and 13 infants colonized with SEA-producing staphylococci. At birth, the group without subsequent colonization displayed a significantly higher frequency of CD45RO-positive interferon-gamma-producing cells (1.7%; range 0.0-9.3%) in comparison to the SEA-positive group (0.1%; range 0.0-0.4%) and also to the group positive for other enterotoxins (0.50%; range 0.0-2.5%). Comparable but less pronounced results were found for interleukin-5 but not for interleukins 2 and 4. At 6 months, no differences in cytokine generation were detected between the three groups. The results provide evidence that a non-specific immunologic immaturity at birth is a risk factor for early bacterial colonization. Furthermore, it is remarkable that this immaturity is similar to that seen in infants destined to be atopic with respect to disequilibrium of interferon-gamma to interleukin-4 generation. Thus the link between early staphylococcal colonization and subsequent atopy requires further investigation.

Latex type I sensitization and allergy in children with atopic dermatitis. Evaluation of cross-reactivity to some foods

Recent studies have demonstrated that allergy to natural rubber latex (NRL) is associated with cross-reactivity to certain foods. The aim of this study was to investigate the prevalence of NRL sensitization and allergy in children with atopic dermatitis (n=74). We also examined cross-reactions between latex and foods, and compared the frequency of suspected latex cross-reacting fruits in children with and without NRL-specific immunoglobulin E (IgE). Twelve of the 74 atopic children studied (16.2%; 95% confidence interval (CI), 8.7-26.6%) had circulating IgE antibodies to latex. These NRL-sensitized children were older and they showed significantly higher total IgE values (p<0.003) when compared with the group of children without NRL sensitization. Of the specific food IgE evaluations, 18.4% (93 out of 505) were positive, and 69.9% were observed in the group of children with latex-specific IgE, most frequently to potato, tomato, sweet pepper, and avocado. An isolated latex-specific IgE response without food-specific IgE was never observed. Exclusively in the latex-positive group, conformity with the report of allergic symptoms after ingestion of food and increased food-specific IgE was found. Twenty children without proven latex sensitization showed increased food-specific IgE, most frequently to potato, banana, and chestnut. Avocado-specific IgE was never determined in this patient group. No significant differences were detected concerning the sensitization to potato, banana, and kiwi between NRL-sensitized children and the group of 20 children without latex-specific IgE. The competitive CAP inhibition using sera from children with specific IgE to both latex and food showed different cross-reactivities between latex and the specific food. A close relationship existed between latex and avocado (median inhibition: 100%), whereas sensitization to latex and kiwi seemed to be independent in our study group (inhibition: <25%). In particular, for potato, cross-reactivity and co-sensitization existed. Our study demonstrated that children with atopic dermatitis are a high-risk group for latex sensitization. Increasing age, additional sensitization to ubiquitous inhaled allergens, and enhanced total serum IgE values seemed to be important variables for latex sensitization and further sensitization to the latex-associated foods. Cross-reactivity and, in some cases, co-sensitization to specific fruits and vegetables, were observed.

Aerosol bolus dispersion in healthy subjects

Aerosol bolus dispersion is a physiological test of lungs, which uses monodisperse submicron particles to measure intrapulmonary convective gas mixing. In this study, aerosol bolus dispersion was measured in healthy subjects in order to assess reference values for possible clinical applications, to assess the reproducibility of these values, and to identify physical and physiological factors influencing aerosol bolus dispersion. Aerosol bolus dispersion was measured in 79 healthy subjects using 20 cm3 aerosol boluses consisting of monodisperse di-2-ethylhexyl sebacate (DEHS) particles. The reproducibility of parameters characterizing the width of the exhaled bolus was of the same order as that of parameters of the flow-volume curve (10%). Aerosol bolus dispersion was independent of the level of lung inflation, and the slope of the relationship between flow rate and dispersion was on average not significantly different from zero (range 100-700 cm3.s-1). Multiple linear regression showed that aerosol bolus dispersion increased with increasing total lung capacity of the subject. We conclude that differences in total lung capacity between individuals should be taken into account when using measures of aerosol bolus dispersion for possible clinical applications.

[Effect of an oligo-antigen diet on the behavior of hyperkinetic children]

The influence of an oligoantigenic diet on different dimensions of the behavior of 21 children diagnosed as having attention-deficit hyperactivity disorder (ADHD) was examined. Treatment effects were assessed with three subjective measures (two questionnaires and an interview) and three objective measures (two attention tests and actometer). The study was divided into three phases: baseline, diet and provocation, each lasting three weeks. A crossover design was used. A significant effect was found for the subjective measures, but not for the objective measures. The results are discussed in terms of possible types of effects, e. g. rater effects and environmental effects. It may be that the oligoantigenic diet influences only certain dimensions of hyperactivity.

[Assessment of curriculum by medical students: comparison of participants and non-participants in voluntary anamnesis groups. An empirical study]

A representative sample of medical students (n = 121) was given a questionnaire to assess parts of their medical education (lectures, seminars, clerkships) and to design a subjectively ideal timetable, which was compared with the real faculty program. Overall traditional lectures received a low rating (n = 0.17) and individual studies with the textbooks a high rating (n = 0.53). The information given in programs in psychiatry and psychosomatics in significantly less motivating than information to be learned in other medical subjects. This is surprising because the ground work for training in the doctor-patient relationship should be in these fields. Students with former group experience (participation in peer groups on history taking (wish to have more practically oriented education compared with the students without group experience. It is not clear whether the important factor is participation in group experience before starting medical school. (64% of the participants had group experience in the first group as opposed to only 45% of the other group). This information should be taken into consideration when reforming medical school programs.

Aerosol derived airway morphometry in healthy subjects

Monodisperse aerosol particles can be used to non-invasively probe intrapulmonary airspace dimensions. In this study, the aerosol-derived airway morphometry technique was used to study airspace dimensions in 79 healthy subjects, in order to assess reference data for the future clinical application of aerosol-derived airway morphometry, and to investigate the effect of lung inflation, anthropometric, and lung function parameters on aerosol-derived airway morphometry. Intrapulmonary airspace dimensions were assessed by measuring the deposition of monodisperse, hydrophobic submicron aerosol particles during breathholding. Additionally, measurements of spirometric and body plethysmographic lung function were performed. Airspace dimensions were in good agreement with morphometric lung data. Airspace dimensions increased with increasing lung inflation. Interindividual variation of airspace dimensions was lowest in the lung periphery, at high levels of lung inflation, and when the volumetric lung depth was normalized to the end-inspiratory lung volume. Analysis of variance showed an increase of airspace dimensions with age. The results of this study indicate that aerosol-derived airway morphometry is dependent on the level of lung inflation and the age of the subject. These results suggest that in contrast to conventional lung function techniques, aerosol-derived airway morphometry might be a powerful tool for the detection of small changes in peripheral airway geometry.

Interleukin-4 and interleukin-5 are rarely co-expressed by human T cells

Interleukin (IL)-4 and IL-5 are two cytokines which synergize in the induction of several biological effector functions. They are produced by mouse and human T helper 2 (Th2) and T helper 0 (Th0) cells. Little is known about the regulation of the two cytokines at the single-cell level. Here we show, using a flow cytometric intracellular staining technique, that IL-4 and IL-5 are predominantly produced by different human peripheral CD4+ and CD8+ T cells, whereas interferon (IFN)-gamma and IL-2 are produced by the same cells. In contrast, cloned human Th0 and Th2 cells were able to produce IL-4 and IL-5 simultaneously. The segregation of IL-4 and IL-5 in activated peripheral T cells was found within 72 h of activation upon anti-CD3 or phorbol ester + ionomycin stimulation. The kinetics of IL-4 and IL-5 production were different at the mRNA and the intra- and extracellular protein level, indicating that the cytokines are regulated differently. T cells from three patients with hyper-IgE syndrome did not display a substantial proportion of IL-4/IL-5 double-positive cells. However, simultaneous production could be induced in normal human T cells after prolonged stimulation with a minimum of two restimulation cycles. We conclude that the simultaneous production of IL-4 and IL-5 is a feature of repetitively activated human T cells.

[Fatal course of infectious mononucleosis in an 11-month-old girl]

Fatal infectious mononucleosis is vary rare in the human population. Only two case reports of girls suffering an Epstein-Barr virus-associated lymphoproliferation without evidence of an underlying immunodeficiency came to our knowledge. We report on the case of an 11-months-old girl with fatal infectious mononucleosis. Some findings allow distinct delineation from previous reports. Firstly, the present "pulmonary lymphoid hyperplasia" has been formerly described in patients with HIV infection exclusively. Secondly, only the EBV surface antigen LMP was expressed on infected B-cells. The nuclear antigen complex EBNA could not be demonstrated. Overall, the results suggest a so far unrecognised type of EBV-associated lymphoproliferation in a female infant.

Detection of intracellular cytokines by flow cytometry

During the last years it has become increasingly clear that production of most cytokines is not confined to one cell type. Thus, a method to detect cytokines at the single cell level would be a helpful tool to study the contribution of different cells to cytokine production in heterogeneous cell populations. Recently, Sander et al. (1991) demonstrated that it is possible to detect intracellular cytokines by fixation with paraformaldehyde, permeabilization with saponin and subsequent indirect immunofluorescent staining using fluorescence microscopy. Here, we describe a modified method to increase the specific intracellular staining which enables us to detect IFN-gamma, IL-2 and IL-4 producing cells by single laser flow cytometry. The carboxylic ionophore monensin was used to interrupt intracellular transport processes leading to an accumulation of the cytokine in the Golgi complex. This resulting increase of the signal/noise ratio permitted us to detect weakly fluorescent cells such as IL-4 producing cells. While IL-4 was detected in approximately 1-3% of peripheral mononuclear cells from healthy donors, up to 30% of the cells produced IFN-gamma and nearly 50% IL-2 after phorbol ester and ionomycin stimulation. Microscopic and flow cytometric analysis showed a highly significant correlation. Using three-color flow cytometry it was possible to measure intracellular cytokines and cell surface markers simultaneously. Subpopulations of human T cells (e.g., CD4+ CD45R0-) producing a restricted cytokine pattern could be identified by cell surface staining and were characterized by their cytokine production. Consequently, there was no further need for cell sorting to determine cytokine producing subsets in heterogeneous cell populations. We have tested human T cell clones for intracellular cytokine production and found a high concordance to ELISA analysis of the supernatants. We conclude that detection of intracellular cytokines by flow cytometry is a rapid, easy and semiquantitative assay which may be used to study individual cells in heterogeneous populations as well as to screen homogeneous cells for their cytokine pattern. This method is particularly relevant in view of the accumulating evidence of the functional role that subsets of (T) cells may play in various diseases depending on the pattern of cytokines they produce.