PARADISE-MI – event rates and treatment effect of sacubitril/valsartan v ramipril by the presence or absence of transient pulmonary congestion and/or LVEF less or greater than 40

Background/Introduction

Sacubitril/valsartan was compared to ramipril in patients with acute myocardial infarction in the PARADISE-MI trial. In the whole trial population sacubitril/valsartan did not reduce the composite primary outcome of CV death or incident heart failure compared to ramipril. Whether or not event rates and/or treatment effects vary in patients with different baseline characteristics is unknown.

Purpose

To investigate a) event rates b) the treatment effect of sacubitril/valsartan compared to ramipril and c) safety by the presence or absence of transient pulmonary congestion and/or left ventricular ejection fraction (LVEF) ≤40%.

Methods

PARADISE-MI was a double-blind, randomised clinical trial that compared sacubitril/valsartan to ramipril in 5661 patients with an acute myocardial infarction with either LVEF ≤40% and/or transient pulmonary congestion. 3 groups were investigated: 1) LVEF ≤40% with pulmonary congestion (n=2012) and 2) LVEF ≤40% without pulmonary congestion (n=2596) and 3) LVEF not ≤40% with pulmonary congestion (n=1044).

Results

Patients with pulmonary congestion (with and without LVEF ≤40%) were more likely to have had a prior MI, prior CABG or PCI, had more atrial fibrillation and were more often treated with mineralocorticoid receptor antagonists and diuretics than patients with no pulmonary congestion and LVEF ≤40%. Patients with LVEF ≤40% and pulmonary congestion had more than twice the rate of the primary composite outcome compared to those with LVEF ≤40% without pulmonary congestion: 10.2 (95% CI 9.2–11.3) vs. 4.8 (4.3–5.5) events per 100 patient-years, respectively). Patients with pulmonary congestion and LVEF not ≤40% had an intermediate event rate (6.6, 5.5–7.9, events per 100 patient-years). A similar pattern of event rates was seen for the components of the primary outcome and for all secondary outcomes whether Clinical Events Committee or investigator-reported events were analysed. The treatment effect of sacubitril/ valsartan versus ramipril did not vary between the 3 congestion/ LVEF subgroups. The safety of sacubitril/valsartan compared to ramipril did not vary between congestion/LVEF subgroups.

Conclusion

Patients with pulmonary congestion with or without LVEF ≤40% had higher rates of primary and all secondary outcomes than those without pulmonary congestion and LVEF ≤40%. The treatment effect, and safety, of sacubitril/valsartan compared to ramipril was consistent in patients with or without pulmonary congestion and with or without LVEF ≤40%.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Novartis

Identification of Health Systems Science in a Problem-Based Learning Clinical Reasoning Exercise

The creation of developmentally appropriate and meaningfully complex clinical reasoning exercises in the pre-clerkship curriculum is a common challenge for many medical schools. We provide an overview of one component of the pre-clerkship clinical reasoning curriculum at Case Western Reserve University School of Medicine, and present evidence that inclusion of Health Systems Science in this exercise facilitates integrated thinking in a Problem-Based Learning curriculum.

Drug-Induced Sleep Endoscopy and Surgical Outcomes: A Multicenter Cohort Study

OBJECTIVE

To evaluate the association between findings of blinded reviews of preoperative drug-induced sleep endoscopy (DISE) examinations using the VOTE Classification and obstructive sleep apnea (OSA) surgical outcomes in a large multicenter, international cohort.

METHODS

Retrospective, multi-center cohort study of adults without tonsillar hypertrophy who underwent pharyngeal surgery for OSA. The study included only participants without enlarged tonsils. Four independent reviewers performed blinded review of preoperative DISE videos using the VOTE Classification system and scoring of a primary structure contributing to airway obstruction. DISE findings were examined for an association with surgical outcomes with univariate analyses and multiple regression.

RESULTS

Two hundred seventy-five study participants were included from 14 centers. Mean age was 51.4 ± 11.8 years, and body mass index was 30.1 ± 5.2 kg/m² . There was moderate interrater reliability (kappa = 0.40-0.60) for DISE findings. Oropharyngeal lateral wall-related obstruction was associated with poorer surgical outcomes (adjusted odds ratio (AOR) 0.51; 95% CI 0.27, 0.93). Complete tongue-related obstruction was associated with a lower odds of surgical response in moderate to severe OSA (AOR 0.52; 95% CI 0.28, 0.98), with findings that were similar but not statistically significant in other analyses. Surgical outcomes were not clearly associated with the degree and configuration of velum-related obstruction or the degree of epiglottis-related obstruction. Surgical response was associated with tonsil size and body mass index (inversely).

CONCLUSION

DISE findings concerning the oropharyngeal lateral walls and tongue may be the most important findings of this evaluation technique.

LEVEL OF EVIDENCE

2B Laryngoscope, 129:761-770, 2019.

The molecular mechanisms of increased radiosensitivity of HPV-positive oropharyngeal squamous cell carcinoma (OPSCC): an extensive review

Head and neck carcinomas (HNCs) collectively are the sixth most common cancer with an annual incidence of about 400,000 cases in the US. The most well-established risk factors for HNCs are tobacco and alcohol abuse. With the increasing public awareness, the incidence of HNCs is decreasing. But there is an increasing incidence of oropharyngeal squamous cell carcinoma (OPSCC) has been observed during the last decade. This phenomena is associated with persistent infection with high-risk HPV. HPV associated OPSCC patients tend to be younger males of high socioeconomic status. The increasing incidence causes a significant loss to social resources, given that it's reported that HPV associated OPSCC represents about 60% of OPSCC cases. There is a growing amount of data supporting the hypothesis that HPV-associated OPSCC has a better survival rate due to a higher sensitivity to chemotherapy and radiotherapy as compared to HPV-unrelated OPSCC. Although the HPV positivity is associated with increased radio-sensitivity, the underlying mechanisms are not yet fully understood. This review summarizes the current knowledge on the effects of HPV infection and its carcinogenesis on the radiosensitivity of OPSCC, from the molecular to histologic level, providing a comprehensive insight of this special tumor entity.

Chicks' Responses to Familiar Stimuli in Unfamiliar Environments

The aim of the present experiments was to find out how imprinted chicks respond to familiar figures in unfamiliar settings. Experiment I showed that chicks individually imprinted with a coloured stationary disc did not readily approach it when later confronted with it in a larger pen—a confirmation of an earlier finding. Experiment II showed a similar disruptive effect when the chicks were individually presented with a stationary object (a ball) in a pen differing in colour from the original one. Experiment III, however, in which chicks were imprinted to a moving ball, showed unattenuated imprinting when testing took place in a strange environment. It was concluded that the disruptive effect of neophobia can be overcome when a high degree of figure salience ensures powerful imprinting.

Measures of user experience in a streptococcal pharyngitis and pneumonia clinical decision support tools

OBJECTIVE

To understand clinician adoption of CDS tools as this may provide important insights for the implementation and dissemination of future CDS tools.

MATERIALS AND METHODS

Clinicians (n=168) at a large academic center were randomized into intervention and control arms to assess the impact of strep and pneumonia CDS tools. Intervention arm data were analyzed to examine provider adoption and clinical workflow. Electronic health record data were collected on trigger location, the use of each component and whether an antibiotic, other medication or test was ordered. Frequencies were tabulated and regression analyses were used to determine the association of tool component use and physician orders.

RESULTS

The CDS tool was triggered 586 times over the study period. Diagnosis was the most frequent workflow trigger of the CDS tool (57%) as compared to chief complaint (30%) and diagnosis/antibiotic combinations (13%). Conversely, chief complaint was associated with the highest rate (83%) of triggers leading to an initiation of the CDS tool (opening the risk prediction calculator). Similar patterns were noted for initiation of the CDS bundled ordered set and completion of the entire CDS tool pathway. Completion of risk prediction and bundled order set components were associated with lower rates of antibiotic prescribing (OR 0.5; CI 0.2-1.2 and OR 0.5; CI 0.3-0.9, respectively).

DISCUSSION

Different CDS trigger points in the clinician user workflow lead to substantial variation in downstream use of the CDS tool components. These variations were important as they were associated with significant differences in antibiotic ordering.

CONCLUSIONS

These results highlight the importance of workflow integration and flexibility for CDS success.

Abstract OT3-2-11: A phase II study of letrozole and lapatinib followed by an addition of everolimus in postmenopausal women with advanced endocrine resistant breast cancer (BC)

Background: Several preclinical studies demonstrated that crosstalk between growth factor receptor pathways, particularly HER2, and ER signaling confers resistance to endocrine therapy (ET). There are emerging data showing the involvement of immune system and miRNA with endocrine resistance. EGF30008 trial showed a benefit of lapatinib in combination with letrozole, mainly in HER2-positive (HER+) metastatic BC (MBC) while a subset analysis of this trial showed that HER2-negative (HER2-) patients (pts) with acquired endocrine resistance may also benefit from this combination. Our preclinical study suggests that everolimus is synergistic with letrozole and lapatinib.

Trial Design: This is a single arm phase II study for postmenopausal women with hormone receptor-positive MBC progressing after aromatase inhibitor, tamoxifen, or fulvestrant. The total target accrual is 76 pts (38 HER2+ pts and 38 HER- pts). In the first phase of the study, pts will be treated with letrozole and lapatinib (1,500 mg daily). Upon disease progression, pts will enter the second phase where everolimus (5 mg daily) will be added to letrozole and the dose of lapatinib will be reduced to 1,250 mg daily. For correlative studies, peripheral blood samples will be serially collected to evaluate for serum HER2 extracellular domain (ECD), circulating miRNAs, PC cell-derived growth factor (GP88), immune regulatory cells including myeloid-derived suppressor cells, NK cells, and Treg cells. These parameters will be correlated with tumor response. In pts with accessible tumors, optional serial biopsies will be performed at baseline and upon progression in each phase of the study. The tumor tissue will be tested for total HER1, HER2, and HER2 expressions as well as HER2:HER2 homodimers, HER2:HER3 heterodimers, HER1:HER2 heterodimers, p95, and HER3/PI3K (p85 subunit) using VeraTag assay.

Statistical Method: The primary objective is to evaluate the clinical benefit rate (CBR: CR, PR, SD > 24 weeks) of the combination of letrozole and lapatinib as well as the combination of everolimus, letrozole, and lapatinib. This is a three-stage design which is an extension of the Simon's two-stage design. The sample size is based on the assumption that a CBR below 10% (null hypothesis) would indicate ineffective therapy and the statistical power is set at a higher CBR of 30% which we consider is plausible. Therefore, if 0 of the first 10 pts in each cohort have clinical benefit, the study will be closed; otherwise additional 8 pts will be enrolled. If ≤ 1 of the total 18 pts has clinical benefit, the study will be closed; otherwise an additional 9 pts will be enrolled. If ≤ 5 pts have clinical benefit the therapy is considered not promising; and if ≥ 6 pts of the total of 27 have clinical benefit, the therapy is considered worth pursuing. This design has ∼90% probability to accept the therapy for further trials if the true CBR is indeed at least 30% and 10% probability to accept it if the true clinical benefit is indeed below 10%.

To date, there are a total of 6 pts enrolled. Accrual is currently ongoing. Please contact ntait@umm.edu for further information.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr OT3-2-11.

[Arthroscopically assisted reduction of acute acromioclavicular joint separations: comparison of clinical and radiological results of single versus double TightRope™ technique]

BACKGROUND

The aim of this study was to compare the results of the single (STR) versus double TightRope™ (DTR) technique for stabilisation of acute separations of the AC joint with the hypothesis that DTR achieves lower CC distance.

PATIENTS AND METHODS

A total of 29 consecutive patients treated operatively with the TR technique (mean age 38.1 years, n=26 male) were analysed in a cohort study with a mean follow-up of 13.3 months (12.0-21.7). Acute AC joint separations types III and V according to Rockwood (R) were included; R types I, II, IV and VI were excluded. The prospective scores determined pre-op and 3, 6 and 12 months post-op and X-rays were evaluated.

RESULTS

Of the patients 12 suffered an R type III and 17 an R V separation; 14 were treated with STR and 15 with DTR. With STR, 8 R III and 6 R V injuries and with DTR 4 R III and 11 R V injuries were treated arthroscopically. STR achieved an increased CC distance >125% compared to the contralateral AC joint in five cases (36%). Two of them occurred as R V and three as R III injury. DTR achieved a CC distance >125% in two cases of an R V injury (13%).

CONCLUSION

The DTR technique provides lower CC distance compared to the STR technique, without a significant difference of CC distance and scores.

Under-ice noise generated from diamond exploration in a Canadian sub-arctic lake and potential impacts on fishes

Mineral exploration is increasing in Canada, particularly in the north where extensive diamond mining and exploration are occurring. This study measured the under-ice noise produced by a variety of anthropogenic sources (drilling rigs, helicopters, aircraft landing and takeoff, ice-road traffic, augers, snowmobiles, and chisels) at a winter-based diamond exploration project on Kennady Lake in the Northwest Territories, Canada to infer the potential impact of noise on fishes in the lake. The root-mean-square noise level measured 5 m from a small diameter drill was approximately 46 dB greater (22 kHz bandwidth) than ambient noise, while the acoustic particle velocity was approximately 40 dB higher than ambient levels. The loudest sounds at the exploration site were produced by ice cracking, both natural and during landing and takeoff of a C130 Hercules aircraft. However, even walking on the snow above the ice raised ambient sound levels by approximately 30 dB. Most of the anthropogenic sounds are likely detectable by fishes with hearing specializations, such as chubs and suckers. Other species without specialized hearing adaptations will detect these sounds only close to the source. The greatest potential impact of noise from diamond exploration is likely to be the masking of sounds for fishes with sensitive hearing.

Molecular mechanisms for leptin regulation of VEGF in breast cancer cells

Abstract #3071

Background: We have previously reported that in vitro and in vivo leptin signaling mediates proliferation of mouse 4T1 mammary tumor (MT) cells and levels of VEGF and VEGFR2. Therefore, we hypothesize that leptin can contribute to MT growth by augmenting angiogenesis through the regulation of VEGF expression. To test this we assessed whether leptin regulates VEGF promoter activity in mouse MT cells and if leptin-induced factors (HIF-1α, NFκB, AP1, SP1) regulate the VEGF promoter. Materials and Methods: Mouse MT cells (4T1, EM6 and MMT) were transiently transfected with molecular engineered luciferase-reporters (pGL3) for mouse VEGF promoter (full-length) and transcription factor-binding deletions for hypoxia responsive element (HRE), AP1, SP1 and NFκB. Leptin dose-response effects on reporter activity and VEGF levels (protein and mRNA) were investigated using ELISA, Western blot and real-time PCR, respectively. To further assess leptin regulation of VEGF expression in MT cells the effects of hypoxia (CoCl2, hypoxia mimetic agent) alone and combined with leptin on VEGF promoter activity were investigated. To assess which leptin-induced signaling pathways/transcription factors are linked to VEGF regulation in MT cells inhibitors for: (1) JAK2/STAT3, MEK-1/MAPK and PI-3K/Akt-1 pathways and; (2) target molecules NFκB; SP1; AP1 and HIF-1α were used. The effects of leptin/CoCl2 and inhibitors on luciferase activity of transfected cells were compared using pRL-TK renilla luciferase as control and the Dual-Luciferase Reporter Assay System. Results: Our data suggest that leptin signaling can regulate the transcriptional activity of VEGF gene in breast cancer cells by activating gene transcription at several sites of the VEGF promoter. Leptin-induced HIF-1α has a relevant role in the regulation of VEGF expression in MT cells. Leptin can also increase VEGF-levels (protein and mRNA) through the specific activation of AP1, SP1, and NFκB. PI-3K activity was mainly linked to leptin regulatory effects on VEGF. However, diverse mechanisms for leptin regulation of VEGF expression were found in the different MT cells. Discussion: Our results provide novel information on the molecular mechanisms for leptin-induced angiogenic effects in breast cancer. Our data further suggest that disruption of leptin signaling could impact angiogenesis and MT growth by inhibiting VEGF expression. Thus targeted disruption of leptin-signaling could serve as method of prevention/treatment of breast cancer. This work was supported in part by the Susan G. Komen Foundation for the Cure (to R.R.G.; BC 504370); UAB Breast SPORE Award (to R.R.G) and Contraceptive Research and Development Program (CONRAD; CIG-07-114 to R.R.G).

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 3071.

Evidence for induction of the ornithine transcarbamylase expression in Alzheimer's disease

To more rapidly identify candidate genes located within chromosomal regions of interest defined by genome scan studies in Alzheimer's disease (AD), we have developed a customized microarray containing all the ORFs (n=2741) located within nine of these regions. Levels of gene expression were assessed in total RNA from brain tissue of 12 controls and 12 AD patients. Of all genes showing differential expression, we focused on the ornithine transcarbamylase (OTC) gene on Xp21.1., a key enzyme of the urea cycle which we found to be expressed in AD brains but not in controls, as confirmed by RT-PCR. We also detected mRNA expression of all the other urea cycle enzymes in AD brains. Immunochemistry experiments revealed that the OTC expression was strictly restricted to vascular endothelial cells in brain. Furthermore, OTC activity was 880% increased in the CSF of probable AD cases compared with controls. We analysed the association of the OTC -389 G/A and -241 A/G promoter polymorphisms with the risk of developing AD. We observed that rare haplotypes may be associated with the risk of AD through a possible modulation of the methylation of the OTC promoter. In conclusion, our results suggest the involvement of a new pathway in AD brains involving the urea cycle.

[Quality of recorded data used for external quality assessment of proximal femoral neck fractures]

BACKGROUND AND OBJECTIVES

Fracture of the proximal femur is a frequent injury, especially in elderly people, with considerable subsequent risks. For this reason its treatment is an obligatory part of external quality assessment. The results are affected by the quality of documentation and validity of the data. The aim of this study was to systematically analyse recorded data on the treatment of this fractures for the purpose of external quality assessment at a trauma surgery ward at the University Hospitals Giessen and Marburg, located at Marburg in 2005.

METHODS

Independently controlled data were used to analyse and compare the quality of the recorded data, both descriptively and statistically.

RESULTS

13.5% of recorded cases did not match inclusion criteria. There were high error rates in the documentation of delay of operation (39%), the scoring system of the American Society of Anesthesiology (60%) and general medical complications (30%).

CONCLUSIONS

Seen from the viewpoint of data quality several improvements will be necessary in support of the surgeons who are obliged to record data for external quality assessment. Otherwise such assessment will be quite inaccurate.

Evidence for the association of the S100beta gene with low cognitive performance and dementia in the elderly

Variations in the S100beta gene may be instrumental in producing a continuum from mild cognitive decline to overt dementia. After screening 25 single nucleotide polymorphisms (SNPs) in S100beta, we observed association of the rs2300403 intron 2 SNP with poorer cognitive function in three independent populations. Moreover, we detected a significant association of this SNP with increased risk of developing dementia or Alzheimer's disease (AD) in six independent populations, especially in women and in the oldest. Furthermore, we characterised a new primate-specific exon within intron 2 (the corresponding mRNA isoform was called S100beta2). S100beta2 expression was increased in AD brain compared with controls, and the rs2300403 SNP was associated with elevated levels of S100beta2 mRNA in AD brains, especially in women. Therefore, this genetic variant in S100beta increases the risk of low cognitive performance and dementia, possibly by favouring a splicing event increasing S100beta2 isoform expression in the brain.

Hydrogenation of single-walled carbon nanotubes

Towards the development of a useful mechanism for hydrogen storage, we have studied the hydrogenation of single-walled carbon nanotubes with atomic hydrogen using core-level photoelectron spectroscopy and x-ray absorption spectroscopy. We find that atomic hydrogen creates C-H bonds with the carbon atoms in the nanotube walls, and such C-H bonds can be completely broken by heating to 600 degrees C. We demonstrate approximately 65 +/- 15 at % hydrogenation of carbon atoms in the single-walled carbon nanotubes, which is equivalent to 5.1 +/- 1.2 wt % hydrogen capacity. We also show that the hydrogenation is a reversible process.

[Further development of the diagnosis-related groups system--fact or fiction? Differentiation of case severities in patients with proximal femoral fractures 2003-2005]

BACKGROUND

The previous system of hospital financing based on the returns (consisting of payments received minus cost of patient treatment) is undergoing considerable changes on the basis of learning to apply the new Diagnosis-Related Groups (G-DRG) system which differentiates the financial returns according to the individual severity of each case.

AIM OF THE STUDY

1. What are the differences in cost and returns when applying the G-DRG systems 2003, 2004 and 2005 to well-defined groups of patients (for example, surgery of proximal femoral fractures)? 2. The influence exercised by secondary (supplementary) diagnosis on the grouping of the patients. 3. Has the G-DRG system been appropriately developed further in respect of improved differentiation according to severity of the cases and homogenisation of the patient groups?

PATIENTS AND METHODS

The study was based on comprehensive clinical data of 169 proximal femur fracture patients. We assessed the Case-Mix index, relative weights and returns, basic DRG, DRG, the number and weight of secondary diagnoses relevant for complexity and comorbidity levels (CCL), the summands of the CCL's and the resulting PCCL values (Patient Clinical Complexity Levels). The data were subjected to analysis of variance and graphically descriptive analysis.

RESULTS

The effective Case Mix index decreases in the 2004 and 2005 systems compared to 2003. This is due to a significant drop in returns based on an unchanged rate of receipts of 3000 . The progressive development of the systems was partly associated with major changes in grouping without significant intra-group homogenisation or improved inter-group discrimination of indications. The differentiation process does not fully utilise the differentiation potential of the basic data.

CONCLUSIONS

No definite improvement of the differentiation potential of the G-DRG systems seems to have been achieved by the 2004 and 2005 systems compared to 2003 using the data of the relevant group of patients with proximal femoral fractures. From 2005 onward the financial lumpsum receipts and returns will definitely affect hospital budgets. Hence, a substantial improvement of the the basis of calculation is imperative for 2005 as well as complete publication of the relevant data. It is indeed doubtful whether the extension of the convergence phase to 5 years presently under discussion would provide sufficient time for an adequate solution of the financial and system problems.

Myocardial cytokine gene expression is higher in aortic stenosis than in idiopathic dilated cardiomyopathy

OBJECTIVE

To investigate cytokine gene expression in patients with aortic valve stenosis (AS) and with idiopathic dilated cardiomyopathy (DCM), and to correlate wall stress with myocardial proinflammatory cytokine gene expression.

METHODS

Human left ventricular (LV) myocardial biopsies were obtained for subsequent reverse transcription polymerase chain reaction of tumour necrosis factor alpha (TNFalpha), interleukin (IL)-1beta, and IL-6 mRNA. The study population consisted of 24 patients with AS and 10 patients with idiopathic DCM.

RESULTS

Patients with AS had a larger ejection fraction (56 (5) v 37 (4)%, p < 0.01), smaller LV end diastolic volumes (146 (11) v 267 (21) ml, p < 0.01), and lower end systolic wall stress (44 (7) v 112 (11) kdyn/cm2, p < 0.001). Upregulation of TNFalpha, IL-1beta, and IL-6 gene expression was detected in both groups. However, TNFalpha gene expression was significantly higher in AS than in DCM (p = 0.009). No correlation was found between haemodynamic parameters and TNFalpha gene expression. In patients with AS there was a strong inverse relation between circulating TNFalpha and TNFalpha gene expression (r = -0.685, p = 0.014), between circulating TNFalpha and IL-1beta gene expression (r = -0.664, p = 0.018), and between soluble TNF receptor 2 and TNFalpha gene expression (r = -0.685, p = 0.020). Myocardial gene expression of TNFalpha was significantly higher in patients with well compensated AS than in patients with decompensated AS (p = 0.017). Similarly, patients with decompensated DCM were characterised by significantly lower TNFalpha gene expression than were patients with well compensated DCM (p = 0.011).

CONCLUSION

TNFalpha gene expression is significantly higher in patients with pressure overload than in normal hearts, in patients with idiopathic DCM, and in patients with compensated versus decompensated heart failure. Secondly, in patients with AS proinflammatory cytokine gene expression did not affect systolic performance. The higher TNFalpha gene expression in patients with compensated heart failure suggests that cytokine gene expression has an adaptive role in the early phase of LV remodelling.

Is there a relation between APOE expression and brain amyloid load in Alzheimer's disease?

BACKGROUND

It has been proposed that, independent of the epsilon4 allele, APOE promoter polymorphisms (-491 A/T and -219 G/T) may be risks factor for Alzheimer's disease by modulating APOE expression.

OBJECTIVE

To measure the level of APOE expression in Alzheimer's disease.

METHODS

Brains were obtained at necropsy from 114 patients with early and late onset sporadic Alzheimer's disease in Greater Manchester (UK) during years 1986 to 2001. Total RNA was extracted from 84 brains. Purified lymphocytes were obtained from fresh blood from 16 probable Alzheimer cases from Lille (France). APOE and beta-actin gene expression was determined by reverse transcriptase polymerase chain reaction in brain and lymphocytes.

RESULTS

An inverse correlation between APOE expression level and A beta loads was observed. As previously described and extended to 114 cases here, an association between the -219 TT genotype and a higher level of parenchymal A beta deposition was found, irrespective of APOE epsilon4 allele status. This effect was more pronounced in older individuals, whereas higher A beta load appeared more closely related to epsilon4 in the younger age group (cut off point at the median age at death (72.5 years)). The -219 TT genotype was associated with a decrease in APOE expression. There was a 60% decrease in APOE expression in lymphocytes from probable Alzheimer cases v controls (p = 0.01).

CONCLUSIONS

In the oldest individuals, reduced APOE expression, modulated in part by -219 G/T polymorphism, may influence risk and constitute a determinant A beta load in Alzheimer's disease.

[Quality management and strategic consequences of assessing documentation and coding under the German Diagnostic Related Groups system]

INTRODUCTION

The introduction of the German Diagnostic Related Groups (D-DRG) system requires redesigning administrative patient management strategies. Wrong coding leads to inaccurate grouping and endangers the reimbursement of treatment costs. This situation emphasizes the roles of documentation and coding as factors of economical success.

PURPOSE

The aims of this study were to assess the quantity and quality of initial documentation and coding (ICD-10 and OPS-301) and find operative strategies to improve efficiency and strategic means to ensure optimal documentation and coding quality.

METHODS

In a prospective study, documentation and coding quality were evaluated in a standardized way by weekly assessment.

RESULTS

Clinical data from 1385 inpatients were processed for initial correctness and quality of documentation and coding. Principal diagnoses were found to be accurate in 82.7% of cases, inexact in 7.1%, and wrong in 10.1%. Effects on financial returns occurred in 16%. Based on these findings, an optimized, interdisciplinary, and multiprofessional workflow on medical documentation, coding, and data control was developed.

CONCLUSIONS

Workflow incorporating regular assessment of documentation and coding quality is required by the DRG system to ensure efficient accounting of hospital services. Interdisciplinary and multiprofessional cooperation is recognized to be an important factor in establishing an efficient workflow in medical documentation and coding.

Knochendichte bei postmenopausalen Frauen mit proximaler Femurfraktur

INTRODUCTION

Osteoporosis associated proximal femoral fracture is a major public health problem. Diagnostic assessment includes patients history, laboratory testings and bone mineral density measurements. Hereby, dual X-ray absorptiometry (DXA) is regarded as the "Goldstandard". Quantitative ultrasonometry (QUS) of bone is a safe, simple, free of radiation, portable, cost-effective and therefore powerful diagnostic tool. QUS should be taken in account for primary assessment in patients with supposed osteoporosis in clinical practice.

AIM OF THE STUDY

We performed this cross sectional pilot study to evaluate the ability of two different QUS-devices (os calcis) in comparison to DXA (lumbar spine and femoral neck) to discriminate postmenopausal women with proximal femoral fractures from healthy, age- and BMI-matched controls.

PATIENTS AND METHODS

All together, 44 postmenopausal women were included. Of these, 22 suffered a proximal femoral fracture and were compared with 22 healthy, age- and BMI-matched controls. Bone assessments were performed by DXA (femoral neck and lumbar spine) and QUS of the heel using Achilles and Insight.

RESULTS

T- and Z-Score of DXA (femoral neck) were significantly lower in women with hip fracture compared to controls (p < 0.008 and p < 0.01). QUS-Insight also revealed significantly lower values of T- and Z-Score in women with hip fracture compared to controls (p < 0.01 and p < 0.005). QUS-Achilles measurement results also comprised significant differences between the groups (T-Score und Z-Score: p < 0.02). In accordance to the T-Score (femoral neck), all three devices (DXA femoral neck, Achilles and Insight) showed an equal significant correlation (p < 0.001). The correlation in between both QUS-devices was higher (0.956; p < 0.0001) than in between DXA-results (femoral neck vs. lumbar spine, 0.577; p < 0.01). The Z-Score also showed a significant correlation. DXA (lumbar spine) didn't show any significant differences in T- and Z-Score.

CONCLUSION

In comparison to the gold standard DXA (femoral neck), both QUS-devices showed an equal ability to significantly discriminate postmenopausal women with proximal femoral fractures from healthy, age- and BMI-matched controls. If our results are confirmed by more cross-sectional and longitudinal studies, QUS could be a helpful and valuable technique in clinical practice. Finally, all patients with osteoporosis-related fractures should be thoroughly investigated during their hospitalisation and effective treatment must be instituted.

Partitioning apoptosis: A novel form of the execution phase of apoptosis

Apoptosis is characterized by chromatin condensation, DNA cleavage, redistribution of phosphatidylserine, and apoptotic body formation via an actin-dependent process. We describe a novel form of the execution phase of apoptosis in human multiple myeloma cells that is morphologically and mechanistically distinct from classical apoptosis, but is caspase-dependent and inhibited by IL-6 and overexpression of Bcl-2. Electron microscopic analysis of these cells demonstrated chromatin condensation without nuclear fragmentation, and 'partitioning' of cell constituents into two components: a single, large bleb containing soluble protein and free ribosomes, and a region containing the nucleus, organelles, and RER. In some cases, the bleb separated, becoming a free vesicle exhibiting random kinetic motion. These morphologic features occurred despite inhibition of the actin and tubulin cytoskeletal systems. This novel form of apoptosis, called partitioning apoptosis, was observed in a variety of tumor cell types and in primary cells. The execution phase of apoptosis can occur in a manner that is morphologically and mechanistically distinct from classical apoptosis.

Molecular remission of CML after autotransplantation followed by adoptive transfer of costimulated autologous T cells

Four patients with chronic myelogenous leukemia (CML) that was refractory to interferon alpha (two patients) or imatinib mesylate (two patients), and who lacked donors for allogeneic stem cell transplantation, received autotransplants followed by infusions of ex vivo costimulated autologous T cells. At day +30 (about 14 days after T-cell infusion), the mean CD4+ cell count was 481 cells/microl (range 270-834) and the mean CD8+ count was 516 cells/microl (range 173-1261). One patient had a relative lymphocytosis at 3.5 months after T-cell infusion, with CD4 and CD8 levels of 750 and 1985 cells/microl, respectively. All the four patients had complete cytogenetic remissions early after transplantation, three of whom also became PCR negative for the bcr/abl fusion mRNA. One patient, who had experienced progressive CML while on interferon alpha therapy, became PCR- post transplant, and remained in a molecular CR at 3.0 years of follow-up. All the four patients survived at 6, 9, 40, and 44 months post transplant; the patient who remained PCR+ had a cytogenetic and hematologic relapse of CML, but entered a molecular remission on imatinib. Autotransplantation followed by costimulated autologous T cells is feasible for patients with chronic phase CML, who lack allogeneic donors and can be associated with molecular remissions.

Diagnostik und Therapie akuter Beschwerden nach ?HWS-Distorsion? in Deutschland

Whiplash injury of the cervical spine is a relevant medical and socioeconomic problem, which is still the subject of controversy. We performed a survey to evaluate the current status of diagnostics, classification, treatment, and doctors' subjective opinions at surgical and trauma departments in Germany. A total of 1568 hospitals were addressed to answer a standardized questionnaire on their proceedings and opinions concerning whiplash injury. We received 540 (34.44%) completed questionnaires. There was overall agreement concerning the need for physical examination. The radiological assessment included an a.p. and a lateral plain X-ray of the cervical spine in 82.6%. The indication for functional X-rays in flexion/extension was inconsistent. On average they were performed in 39.1% of all patients. In most cases (68.9%) whiplash injury was not classified; 13.2% of doctors used the classification according to the Quebec Task Force and 13.9% according to Erdmann. A cervical collar was prescribed in 85%. While 30% of patients received only a cervical collar, 55.6% underwent additional physiotherapy. Only 8.3% were treated by physiotherapy without immobilization. The doctors' subjective opinions indicated psychological factors to be important for long-lasting problems, but not for the acute period of complaints. There is no homogeneous concept for diagnostics, classification, and treatment of patients who suffered a whiplash injury in Germany. This situation reflects the current problems in management of this condition. Scientific evidence for functional treatment to avoid adverse influence of immobilization by cervical collars has not yet been transferred to our daily routine in Germany.

Association study of Notch 4 polymorphisms with Alzheimer's disease

BACKGROUND

The NOTCH4 gene is located at 6p21.3, a site shown in several studies to have significant linkage with Alzheimer's disease.

OBJECTIVE

To investigate the potential impact of two polymorphisms within this gene on the risk of developing Alzheimer's disease.

METHODS

Genotyping of promoter and 5'-UTR polymorphisms was done in Scottish, English, and French populations. The potential functionality of the 5'-UTR polymorphism was assessed by testing its impact on A beta load in Alzheimer brains and also by undertaking electrophoretic mobility shift assays and transfection experiments.

RESULTS

No association of the Notch4 polymorphisms alone with the disease was observed in any of the populations. However, an interaction of the 5'-UTR C/T polymorphism with the epsilon 4 allele of the APOE gene was detected in United Kingdom populations but not in the French. No relation between the 5'-UTR polymorphism and A beta loads was detected overall or in the presence or absence of the epsilon 4 allele. No DNA protein specific binding was found with proteins from neuroblastoma, glioma, or astrocytoma cells, and no allele dependent transcriptional activity was detected.

CONCLUSIONS

No association between two NOTCH4 polymorphisms alone and Alzheimer's disease was observed in the three populations, but there was evidence of an increased risk associated with the 5'-UTR CC genotype in epsilon 4 bearers in the United Kingdom. As no functionality for this polymorphism could be determined, it is likely that the interaction is spurious or results from a linkage disequilibrium of this 5'-UTR polymorphism with another marker elsewhere in the 6p21.3 locus.

Feasibility study of using air as a contrast medium in MR colonography

AIM

To evaluate the feasibility of using air as intraluminal contrast medium in magnetic resonance (MR) colonography.

MATERIALS AND METHODS

Twenty-two patients underwent MR colonography (MRC) using air before colonoscopy. All patients were imaged in prone and supine positions. Each colon was divided into five segments. Two radiologists reviewed the images for the degree of colonic distension, image quality and colonic lesions. The colonic lesions identified using MR were compared with those identified on colonoscopy.

RESULTS

Eight men and 14 women with mean age of 55.5 years were studied. All patients completed the MR examination. One hundred and five out of 110 (95.5%) colonic segments were well distended in both prone and supine positions. Image quality was good in all cases. Colonoscopy detected 16 lesions: three > or = 1 cm, one 7 mm lesion and 12 lesions < or = 5 mm. All lesions 1 cm or larger were detected by MRC.

CONCLUSION

MRC using air and the single-shot half-Fourier rapid acquisition with refocused echoes (RARE) technique is feasible. But in this small pilot study, it had low sensitivity for the detection of polyps less than 1 cm in diameter.

Association of 3'-UTR polymorphisms of the oxidised LDL receptor 1 (OLR1) gene with Alzheimer's disease

Although possession of the epsilon 4 allele of the apolipoprotein E gene appears to be an important biological marker for Alzheimer's disease (AD) susceptibility, strong evidence indicates that at least one additional risk gene exists on chromosome 12. Here, we describe an association of the 3'-UTR +1073 C/T polymorphism of the OLR1 (oxidised LDL receptor 1) on chromosome 12 with AD in French sporadic (589 cases and 663 controls) and American familial (230 affected sibs and 143 unaffected sibs) populations. The age and sex adjusted odds ratio between the CC+CT genotypes versus the TT genotypes was 1.56 (p=0.001) in the French sample and 1.92 (p=0.02) in the American sample. Furthermore, we have discovered a new T/A polymorphism two bases upstream of the +1073 C/T polymorphism. This +1071 T/A polymorphism was not associated with the disease, although it may weakly modulate the impact of the +1073 C/T polymorphism. Using 3'-UTR sequence probes, we have observed specific DNA protein binding with nuclear proteins from lymphocyte, astrocytoma, and neuroblastoma cell lines, but not from the microglia cell line. This binding was modified by both the +1071 T/A and +1073 C/T polymorphisms. In addition, a trend was observed between the presence or absence of the +1073 C allele and the level of astrocytic activation in the brain of AD cases. However, Abeta(40), Abeta(42), Abeta total, and Tau loads or the level of microglial cell activation were not modulated by the 3'-UTR OLR1 polymorphisms. Finally, we assessed the impact of these polymorphisms on the level of OLR1 expression in lymphocytes from AD cases compared with controls. The OLR1 expression was significantly lower in AD cases bearing the CC and CT genotypes compared with controls with the same genotypes. In conclusion, our data suggest that genetic variation in the OLR1 gene may modify the risk of AD.

[Results of elastic stable intramedullary nailing (ESIN) in forearm fractures in childhood]

Conservative treatment of unstable forearm fractures in childhood leads to disappointing results in up to 50%. Therefore the indication for a primary operative treatment is given. In the early 1990s the ORIF (open reduction and internal fixation) Procedure was the commonly practiced treatment. Nowadays elastic stable intramedullary nailing (ESIN) is increasingly recommended. Aim of our prospective investigation was to evaluate difficulties, early results and complications of the elastic stable intramedullary nailing of forearm fractures in children. From January 1998 to December 2000 fifty-four children (23 female, 31 male) with an average age of 8 years (8-16) were treated operatively with ESIN. 48 patients had a single forearm-fracture,6 were multiple injured (ISS<16). Open reduction was necessary in 7,4% cases. Clinically and radiologically a good consolidation was found in all fractures. In one case a large callus formation induced a reduced range of motion. As complications seven superficial infections,which required neither pharmacological nor surgical intervention,were treated. In two cases a temporary paraesthesia of the N. radialis superficialis occurred. In one patient a progressive lesion of the N. ulnaris was observed, due to a constriction of scar-tissue. All fractures healed, in all cases with full range of motion. No relevant difference of length or deviation of the axis was observed. Good clinical results, the low risk of complications and the positive biological impact make the ESIN to the standard procedure in the treatment of unstable forearm fractures in childhood.

An HLA class-II allele frequent in Eskimos and Amerindians is found in the Tyrolean Ice Man

DNA was extracted from specimens derived from the calcaneus of the Tyrolean Ice Man under sterile conditions in a laboratory, where no DNA extractions and PCR experiments had been performed before. Agarose gel electrophoresis and ethidium bromide staining did not reveal any evidence of genomic DNA in the preparation obtained, indicating a high degree of DNA degradation. Nevertheless, we performed PCR amplifications with this sample using primer pairs specific for HLA class II alleles. HLA-DRB and DQB1 alleles were amplified in a nested PCR approach. In one of the reactions, we observed a distinct amplification product, which we directly sequenced. By comparing the obtained nucleotide sequence with a database of HLA alleles we assigned the HLA-DRB1*1402 type to the amplified sample. None of the investigators involved possesses this allele, indicating that no contamination with modern DNA had occurred. The HLA-DRB1*1402 allele is extremely rare in Europe, but is common in Inuits and South American Indians and has previously only once been identified in the laboratory.