[Certification of a University Department of Otolaryngology according to DIN EN ISO 9001:2008]

INTRODUCTION

Quality management (QM) is a control tool for the implementation of a wide range of organizational measures aimed at achieving process orientation and process optimization. The organizational framework for these measures can be structured to fulfill the requirements of certification to the DIN EN ISO 9001 standard. The objective was to implement this tool within a university otorhinolaryngology department.

MATERIAL AND METHOD

After drawing up a project plan, the measures required to fulfill the audit requirements were put into practice by a QM core team, which included employees from four areas: healthcare, research, nursing and teaching.

RESULTS

The measures carried out resulted in the achievement of certification, provided that annual surveillance audits are performed.

DISCUSSION

The attainment of the certificate requires continuous fulfillment of the required standards. Future requirements, such as the demands placed on knowledge management, necessitate further appropriate measures.

Interleukin-1alpha treatment of meniscal explants stimulates the production and release of aggrecanase-generated, GAG-substituted aggrecan products and also the release of pre-formed, aggrecanase-generated G1 and m-calpain-generated G1-G2

Pro-inflammatory cytokines induce meniscal matrix degradation and inhibition of endogenous repair mechanisms, but the pathogenic mechanisms behind this are mostly unknown. Therefore, we investigated details of interleukin-1 (IL-1alpha)-induced aggrecan turnover in mature meniscal tissue explants. Fibro-cartilagenous disks (3 mm diameter x 1 mm thickness) were isolated from the central, weight-bearing region of menisci from 2-year-old cattle. After 3 or 6 days of IL-1alpha-treatment, GAG loss (DMMB assay), biosynthetic activity ([(35)SO(4)]-sulfate and [(3)H]-proline incorporation), gene expression (quantitative RT-PCR) and the abundance (zymography, Western blot) of matrix-degrading enzymes and specific aggrecan products were determined. Meniscal fibrocartilage had a 4-fold lower GAG content (per wet weight) than adjacent articular cartilage, and expressed MMPs-1, -2, -3 and ADAMTS4 constitutively, whereas ADAMTS5 m-RNA was essentially undetectable. Significant IL-1 effects were a decrease in biosynthetic activity, an increase in GAG release and in the expression/abundance of MMP-2, MMP-3 and ADAMTS4. Fresh tissue contained aggrecan core protein products similar to those previously described for bovine articular cartilage of this age. IL-1 induced the release of aggrecanase-generated CS-substituted products including both high (>250 kDa) and low molecular weight (about 75 kDa) species. TIMP-3 (but not TIMP-1 and -2 or a broad spectrum MMP inhibitor) inhibited IL-1-dependent GAG loss. In addition, IL-1 induced the release of preformed pools of three known G1-bearing products. We conclude that aggrecanases are responsible for IL-1-stimulated GAG release from meniscal explants, and that IL-1 also stimulates release of G1-bearing products, by a process possibly involving hyaluronan fragmentation.

Tumor necrosis factor alpha-dependent aggrecan cleavage and release of glycosaminoglycans in the meniscus is mediated by nitrous oxide-independent aggrecanase activity in vitro

Introduction

Little is known about factors that induce meniscus damage. Since joint inflammation appears to be a causative factor for meniscal destruction, we investigated the influence of tumor necrosis factor (TNFα) on glycosaminoglycan (GAG) release and aggrecan cleavage in an in vitro model.

Methods

Meniscal explant disks (3 mm diameter × 1 mm thickness) were isolated from 2-year-old cattle. After 3 days of TNFα-treatment GAG release (DMMB assay), biosynthetic activity (sulfate incorporation), nitric oxide (NO) production (Griess assay), gene expression of matrix-degrading enzymes (quantitative RT-PCR, zymography), and immunostaining of the aggrecan fragment NITEGE were determined.

Results

TNFα induced release of GAG as well as production of NO in a dose-dependent manner, while sulfate incorporation was decreased. TNFα increased matrix metalloproteinase (MMP)-3 and a disintegrin and metalloproteinase with thrombospondin motifs (ADAMTS)-4 mRNA expression, whereas collagen type I was decreased, and aggrecan, collagen type II as well as MMP-1, -2, -13 and ADAMTS-5 were variably affected. Zymography also showed a TNFα-dependent increase in MMP-3 expression, but pre-dominantly in the pro-form. TNFα-dependent formation of the aggrecanase-specific aggrecan neoepitope NITEGE was induced. Tissue inhibitor of metalloproteinases (TIMP)-3, but not TIMP-1 or -2 inhibited TNFα-dependent GAG release and NITEGE production, whereas inhibition of TNFα-dependent NO generation with the NO-synthetase inhibitor L-NMMA failed to inhibit GAG release and NITEGE production.

Conclusions

Our study shows that aggrecanase activity (a) is responsible for early TNFα-dependent aggrecan cleavage and GAG release in the meniscus and (b) might be involved in meniscal degeneration. Additionally, the meniscus is a TNFα-dependent source for MMP-3. However, the TNFα-dependent NO production seems not to be involved in release of proteoglycans under the given circumstances.

Evidence of thromboembolism prophylaxis in bariatric surgery-results of a quality assurance trial in bariatric surgery in Germany from 2005 to 2007 and review of the literature

BACKGROUND

Since January 1st, 2005, the current situation for bariatric surgery has been examined by means of a voluntary quality assurance study in Germany with a multicenter design in which 38 hospitals and surgical departments participated. The data are registered in cooperation with the Institute of Quality Assurance in Surgery at the Otto-von-Guericke University of Magdeburg (Germany).

METHODS

Data describing peri-interventional characteristics were prospectively documented in an internet online data registry. All primary bariatric procedures performed since January 1st, 2005, were registered. In addition, reoperations in patients who had previously undergone primary surgical intervention were included. As a representative excerpt from the overall prospective multicenter observational study on obesity surgery, data on the type, regimen, and time course of deep venous thrombosis (DVT) prophylaxis were documented. From the number and spectrum of complications, the incidences of clinically manifest DVT or pulmonary embolism (PE) were derived during the in-hospital course and follow-up in conjunction with the type of surgical procedure and body mass index (BMI).

RESULTS

Overall, 3,122 bariatric procedures were performed at 38 German hospitals between January 2005 and December 2007. These procedures were subdivided into 2,869 primary operations and 253 revisions (sex ratio, male to female = 25.6:74.4%). The average BMI of all patients was 48.5 kg/m(2) in 2005, 48.4 kg/m(2) in 2006, and 48.0 kg/m(2) in 2007. In 2005 and 2006, gastric banding (GB) was the most commonly performed operation, followed by Roux-en-Y gastric bypass (RYGBP). In 2007, RYGBP was carried out in 42.1% of all bariatric procedures. Interestingly, the incidence of deep venous thrombosis (DVT) was only 0.06%, whereas PE occurred in 0.06% of patients only after hospital discharge. The DVT prophylaxis protocol used has been changed for the last 2 years: the majority of patients with a BMI above 50 kg/m(2) received low-molecular-weight heparin twice a day.

CONCLUSION

In Germany, a trend from GB to sleeve gastrectomy (SG) and malabsorptive approach has been evaluated. This trend is associated with differences of the DVT prophylaxis regimen in the profile of bariatric surgical patients depending on BMI and the type of bariatric procedure. Despite the low incidence of DVT and pulmonary embolism (PE) detected, there is a lack of evidence on a reasonable regimen for sufficient DVT prophylaxis in bariatric surgery; instead, there are only recommendations from the guidelines and statements of a specific medical society. Therefore, prospective studies are necessary to determine the optimal DVT prophylaxis for bariatric surgical patients as well as obese patients undergoing surgery.

A nationwide survey on bariatric surgery in Germany--results 2005-2007

BACKGROUND

Most studies on bariatric surgery outcomes are performed as clinical trials or reflect the clinical experience in single centers. The status of bariatric surgery in Germany has been examined since January 1st, 2005 with the cooperation of clinics and hospitals at the Institute of Quality Assurance in Surgery at the Otto-von-Guericke University of Magdeburg (Germany).

METHODS

In this prospective multicenter observational study, the data obtained for all primary bariatric procedures, including all repeated operations, performed on consecutive patients with morbid obesity at participating hospitals from 2005 to 2007 were prospectively collected using an Internet online data registry. In particular, perioperative characteristics, such as the spectrum of diagnostic measurements, type of surgical procedures, and short- and long-term outcomes, were investigated.

RESULTS

During the study period, 629 surgical procedures were performed at 21 hospitals in 2005, 828 procedures at 32 hospitals in 2006, and 1,666 procedures at 35 hospitals in 2007. In 2005 and 2006, gastric banding was the most frequently performed operation, followed by the Roux-en-Y gastric bypass (RYGBP). In 2007, a RYGBP was carried out in 42.1% of all bariatric procedures. Among all patients, 74.4% were female. The mean body mass index (BMI) was 48.5 kg/m(2) in 2005, 48.4 kg/m(2) in 2006, and 48.0 kg/m(2) in 2007. Follow-up data after 12 months were available for 63.8% of the patients in 2005 and 2006; these data showed greater reduction of BMI after malabsorptive rather than restrictive bariatric procedures. The mortality was 0.1% (30 days) and 0.16% (overall).

CONCLUSION

As indicated by the worldwide trend, there is an ongoing change from restrictive bariatric procedures to malabsorptive procedures and sleeve gastrectomy. Although the BMIs of German patients undergoing bariatric surgery appear to be substantially higher than those of patients from most other countries, there were no differences in intraoperative and short-term complications or in overall outcomes during follow-up when compared with published studies.

Bcl-2 expression in rituximab refractory cutaneous B-cell lymphoma

Rituximab has been established as an effective and safe therapy for cutaneous B-cell lymphoma (CBCL). Different survival pathways, that is the Raf/MEK/Erk- or the p38MAPK cascade, have been suggested as downstream mediators of rituximab and may be involved in treatment failure. Biopsies from four patients, suffering from different subtypes of CBCL, which were obtained at various time points of relapse during or after therapy with 375 mg rituximab per m² of body surface area, were analysed for the expression of CD20, CD3, Ki-67, Raf-kinase inhibitory protein (RKIP) and bcl-2 by immunohistochemistry. No CD20-loss variants, that is the suggested main tumour escape mechanism to rituximab therapy, were observed in any specimen of relapsing CBCL. Notably, the expression of proapoptotic RKIP remained increased in these tumour samples. This was concomitated by a constant to slightly reduced proliferation status as demonstrated by Ki-67 staining. However, relapsing CBCL exhibited a strong upregulation of the antiapoptotic molecule bcl-2 in comparison to pretherapeutic levels. The immunohistochemical analyses of this case series of rituximab refractory CBCL suggest that upregulation of bcl-2 may play a major role in therapy resistance.

Determination of exposure due to mobile phone base stations in an epidemiological study

To investigate a supposed relationship between exposure by mobile phone base stations and wellbeing, an epidemiological cross sectional study is carried out within the German Mobile Telecommunication Research Program. In a parallel project, a method for the classification of electromagnetic exposure due to mobile phone base stations has been developed. This is based on the results of measurements of high frequency immissions in the interior of more than 1100 rooms and at outdoor locations, the calculation of the emissions of mobile phone antennas under free space propagation conditions and empirically determined transmission factors for the propagation of electromagnetic waves in different types of residential areas for passage of walls and windows. Standard tests (correlation-test, kappa-test, Bland-Altman-Plot, analysis of sensitivity and specificity) show that the method for computational exposure assessment developed in this project is applicable for a first classification of exposures due to mobile phone base stations in epidemiological studies.

CD28-mediated costimulation impacts on the differentiation of DC vaccination-induced T cell responses

Costimulatory signals such as the ones elicited by CD28/B7 receptor ligation are essential for efficient T cell activation but their role in anti-tumour immune responses remains controversial. In the present study we compared the efficacy of DC vaccination-induced melanoma specific T cell responses to control the development of subcutaneous tumours and pulmonary metastases in CD28-deficient mice. Lack of CD28-mediated costimulatory signals accelerated tumour development in both model systems and also the load of pulmonary metastases was strongly increased by the end of the observation period. To scrutinize whether lack of CD28 signalling influences priming, homing or effector function of Trp-2(180-188)/K(b)-reactive T cells we investigated the characteristics of circulating and tumour infiltrating T cells. No difference in the frequency of Trp-2(180-188)/K(b)-reactive CD8+ T cells could be demonstrated among the cellular infiltrate of subcutaneous tumours after DC vaccination between both genotypes. However, the number of IFN-gamma-producing Trp-2-reactive cells was substantially lower in CD28-deficient mice and also their cytotoxicity was reduced. This suggests that CD28-mediated costimulatory signals are essential for differentiation of functional tumour-specific CD8+ T-effector cells despite having no impact on the homing of primed CD8+ T cells.

[Arterial hypertension and dementia]

Arterial hypertension (AH) is considered to be an important risk factor for vascular cognitive impairment and probably for Alzheimer's disease, too. In the current review we provide an overview of the major prospective clinical trials on this issue. With respect to the inconsistent findings of these studies one must state that the interrelations between AH and dementia are still incompletely understood. Regarding therapy there thus is a simple rule: AH should be treated until normal blood pressure values are reached. As long as the hypothesis of a J-curve between blood pressure and cognitive dysfunction has not been disproved, overaggressive blood pressure lowering cannot be recommended. Regarding the aim of preventing dementia, there is no evidence for the superiority of a specific antihypertensive treatment regimen.

Some physico-chemical parameters that influence proteinase K resistance and the infectivity of PrP Sc after high pressure treatment

Crude brain homogenates of terminally diseased hamsters infected with the 263 K strain of scrapie (PrP Sc) were heated and/or pressurized at 800 MPa at 60 degrees C for different times (a few seconds or 5, 30, 120 min) in phosphate-buffered saline (PBS) of different pH and concentration. Prion proteins were analyzed on immunoblots for their proteinase K (PK) resistance, and in hamster bioassays for their infectivity. Samples pressurized under initially neutral conditions and containing native PrP Sc were negative on immunoblots after PK treatment, and a 6-7 log reduction of infectious units per gram was found when the samples were pressurized in PBS of pH 7.4 for 2 h. A pressure-induced change in the protein conformation of native PrP Sc may lead to less PK resistant and less infectious prions. However, opposite results were obtained after pressurizing native infectious prions at slightly acidic pH and in PBS of higher concentration. In this case an extensive fraction of native PrP Sc remained PK resistant after pressure treatment, indicating a protective effect possibly due to induced aggregation of prion proteins in such buffers.

Bedeutende Virusinfektionen mit Haut- und Schleimhautmanifestation beim Schaf

Gegenstand und Ziel: Ecthyma contagiosum (Orf), Maulund Klauenseuche (MKS) sowie Bluetongue (Blauzungenkrankheit, BT) sind Virusinfektionen der Schafe, die mit Haut- und Schleimhautveränderungen einhergehen. Ziel dieser vergleichenden Betrachtung ist die Problematik der differenzialdiagnostischen Abgrenzung dieser drei Krankheiten des Schafes und der infektionsmedizinischen sowie seuchenrechtlichen Konsequenzen. Schlussfolgerungen und klinische Relevanz: Eine eindeutige Differenzierung der genannten Krankheiten ausschließlich auf der Basis der klinischen Veränderungen ist häufig nicht möglich. Allerdings handelt es sich bei den beiden in Deutschland, Österreich und der Schweiz derzeit nicht vorkommenden Krankheiten MKS und BT um schwere Allgemeinerkrankungen, während Ecthyma contagiosum eine lokale Virusinfektion darstellt. Aufgrund der großen volkswirtschaftlichen Bedeutung von MKS und BT sowie der durchaus realen Bedrohung einer Einschleppung dieser Tierseuchen ist eine sorgfältige Untersuchung von Schafen mit den gezeigten klinischen Symptomen unverzichtbar. MKS und BT müssen dabei, unter Berücksichtigung der äußeren Umstände, stets differenzialdiagnostisch bedacht werden, auch wenn Orf in den heimischen Schafherden endemisch vorkommt und von den Tierbesitzern in der Regel als belanglos angesehen wird.

IL-4 instructs TH1 responses and resistance to Leishmania major in susceptible BALB/c mice

Immunity to infection with intracellular pathogens is regulated by interleukin 12 (IL-12), which mediates protective T helper type 1 (TH1) responses, or IL-4, which induces TH2 cells and susceptibility. Paradoxically, we show here that when present during the initial activation of dendritic cells (DCs) by infectious agents, IL-4 instructed DCs to produce IL-12 and promote TH1 development. This TH1 response established resistance to Leishmania major in susceptible BALB/c mice. When present later, during the period of T cell priming, IL-4 induced TH2 differentiation and progressive leishmaniasis in resistant mice. Because immune responses developed via the consecutive activation of DCs and then T cells, the contrasting effects of IL-4 on DC development and T cell differentiation led to immune responses that had opposing functional phenotypes.

Repeated low-dose treatment of rats with pilocarpine: low mortality but high proportion of rats developing epilepsy

Systemic administration of pilocarpine in rats can result in a chronic behavioral state that is similar to human temporal lobe epilepsy. The pilocarpine model of epilepsy is widely used for studying the factors that contribute to the development of epilepsy as a consequence of status epilepticus (SE). For this purpose, pilocarpine is either administered alone at a high systemic dose or in combination with lithium, which markedly potentiates the convulsant effect of pilocarpine. Both experimental protocols, however, are associated with high mortality rates. In the present study, we evaluated whether mortality rate in rats can be decreased by repeated administration of low doses of pilocarpine. The time the rats spent in SE was limited by diazepam. Preliminary experiments in lithium-free rats indicated that repeated low-dose administration of pilocarpine is too time-consuming to produce SE compared to single high-dose administration. All subsequent experiments were performed in lithium-pretreated rats. Single-dose injection of 30 mg/kg pilocarpine produced SE in approximately 70% of the animals, but 45% of the rats died although SE was interrupted by diazepam after 90 min. Repeated i.p. administration of 10 mg/kg pilocarpine at 30-min intervals resulted in SE after 2-4 injections; the mean dose of pilocarpine needed to induce SE was 26 mg/kg. When SE was interrupted after 90 min, mortality rate was below 10%, which was significantly lower compared to the protocol with one single administration of 30 mg/kg pilocarpine. In contrast to mortality rate, the development of spontaneous recurrent seizures did not differ between experimental protocols. Almost all rats which had experienced a SE of at least 60 min developed chronic epilepsy. Average latency to the first spontaneous seizure was approximately 40 days. The frequency and severity of spontaneous seizures was not significantly different between protocols, although animal groups with repeated low-dose treatment tended to have higher frequencies of spontaneous seizures compared to single-dose administration. The present study demonstrates that systemic treatment of lithium-pretreated rats with several low doses of pilocarpine efficiently produces SE and chronic epilepsy with much lower mortality rates than single-dose pilocarpine.

New insights into the role of the cytoskeleton in phagocytosis of Entamoeba histolytica

Entamoeba histolytica, a human parasite, crosses the natural barriers of the intestine and, in turn, spreads into the deeper organs, resulting in amoebiasis. The motility of the parasite and its ability to lyse or phagocytose human cells facilitates passage of the amoeba through the intestinal epithelium. Little is known about the uptake of material by this parasite; nevertheless, the cytoskeleton is believed to play a role in phagocytosis. Myosin IB, an actin-binding protein, localizes to the phagocytic cup and, with time, surrounds the internalized phagosome itself. The role of unconventional myosins in phagocytosis has also been demonstrated in other cell types, suggesting that this molecular mechanism is a common denominator in phagocytic events. Here, we summarize the emerging view of the role of unconventional myosins as well as other cytoskeleton-associated proteins in pseudopod formation at early stages of phagocytosis and during the late step of this process in E. histolytica.

Einsatz des ProC®-Global-Tests zum Thrombophiliescreening

Hereditäre und erworbene Defekte im Protein-C-System führen zu einem erhöhten Thromboserisiko. Mit ProC® Global steht seit Ί997 ein Screeningtest für das gesamte Protein-C-System zur Verfügung, bei dem das Zusammenwirken der einzelnen Komponenten (Protein C, Protein S, APC-Resistenz, erhöhte Faktor-VIII : C-Spiegel und zum gegenwärtigen Zeitpunkt noch unbekannte Risikofaktoren) erfaßt werden. Dieser Assay wurde unter Routinebedingungen an über 4000 Patienten evaluiert. Als indirekt diesen Test beeinflussende Größen wurden Lupus-Antikoagulans, Hyperhomocysteinämie, das Auftreten der Pro-thrombinmutation 20210G→A und der Einfluß von Reaktionen der Akutphase unmittelbar postoperativ untersucht. Die Auswertung erfolgte jeweils getrennt nach Patienten mit arteriellen und venösen Thrombosen. Als wichtigstes Resultat wurde gefunden: ProC® Global ist als rationeller Screeningtest für das Protein-C-System einsetzbar. Das Zusammenwirken aller Komponenten in diesem Test liefert teilweise wertvollere Aussagen als hämostaseologische Einzelfaktoren-Tests.

Myosin IB from Entamoeba histolytica is involved in phagocytosis of human erythrocytes

Entamoeba histolytica is a protozoan parasite that causes amoebic dysentery in humans. The disease is prevalent worldwide. Infection with E. histolytica results in invasion of the intestine by the parasite, followed by tissue damage and inflammation. During this invasive process, parasites kill and phagocytose human epithelial cells, immune cells and erythrocytes. Expression of amoebic pathogenicity requires a dynamic cytoskeleton that allows movement, tissue penetration and changes in parasite morphology. Myosin IB is a member of the myosin I family of motor proteins. Studies conducted both with Dictyostelium discoideum, a non-pathogenic amoeba, and with the yeast Saccharomyces cerevisiae indicate the involvement of myosin IB in cellular processes including movement, phagocytosis and endocytosis. Recently, we isolated the gene encoding myosin IB from E. histolytica. Thus, we decided to analyze the role of myosin IB in pathogenesis of amoeba. Using a specific anti-myosin IB antibody, this protein was localized in cell regions including the pseudopod, vesicles and underneath the plasma membrane. When E. histolytica was activated for erythrophagocytosis, myosin IB was markedly recruited to both the phagocytic cup and around internalized phagosomes. To analyze the role of myosin IB in phagocytosis, a strain overexpressing the myosin IB gene was constructed. This strain synthesizes threefold more myosin IB than the wild-type strain. Challenge of the transfected cell line with erythrocytes showed that these amoebae were deficient in erythrophagocytosis mainly in the uptake step, suggesting a role for myosin IB in the pathogenic activity of a human parasite.

Effizienz der lokoregionären Thrombolysetherapie mit rt-PA

Es wurden 46 lokoregionäre Thrombolysetherapien mit rt-PA und 49 systemische Thrombolysetherapien mit Streptokinase und/oder Urokinase bei Patienten mit tiefer Becken-/Beinvenen-Thrombose durchgeführt. Ein Therapieerfolg (Vollund Teilrekanalisierung) wurde bei 66% der mit rt-PA und bei 89% der mit Streptokinase/Urokinase behandelten Patienten erreicht. Schwere und mittelschwere Blutungskomplikationen traten in der rt-PA-Gruppe bei 11% und in der Streptokinase-/Urokinase-Gruppe bei 53% auf. Bei Klinikaufnahme hatten 18% der Patienten eine symptomatische und 30% eine asymptomatische Lungenembolie. Postthrombotische Frühveränderungen nach einem Jahr fanden sich bei 22% der mit rt-PA und bei 10% der mit Streptokinase/Urokinase behandelten Patienten. Die vorliegende Untersuchung zeigte, daß die lokoregionäre Thrombolyse mit rt-PA hinsichtlich der Wirksamkeit bei tiefer Becken-/BeinvenenThrombose der systemischen Streptokinase-/Urokinase-Therapie unterlegen ist.

Molecular characterization of myosin IB from the lower eukaryote Entamoeba histolytica, a human parasite

The complete amino acid sequence of the Entamoeba histolytica unconventional myosin IB (Eh-myosin IB) is reported. Sequencing of overlapping cDNA fragments reveals a single open reading frame which predicts a 130 kDa protein of 1049 aa. Eh-myosin IB presents the three characteristics domains of myosins I subclass 1. This protein presents homology with myosins IB from other amoebae, but striking homologies with vertebrate unconventional myosins were also observed. The predicted actin and ATP-binding sites are located in the head domain. The heavy chain phosphorylation region is homologous to metazoan myosins I with an acidic residue present at the phosphorylation site. In the neck domain, an IQ motif indicates potential binding of calmodulin to the myosin I heavy chain. In the tail of Eh-myosin IB the three characteristic regions of myosin I are found. A putative membrane binding domain a very short domain rich in alanine and proline we demonstrate to be functional for actin binding, and the src-homology 3 domain. The Entamoeba histolytica myosin IB is the first unconventional myosin so far described in a lower eukaryote.

Increased matrix proteins, collagen and transforming growth factor are early markers of hepatotoxicity in patients on long-term methotrexate therapy

BACKGROUND

Hepatotoxicity, which may lead to fibrosis and cirrhosis, often limits the use of long-term low dose methotrexate for psoriasis and autoimmune diseases. Standard light microscopy lacks sensitivity for early fibrosis.

DESIGN

This is a retrospective study of immunohistochemical markers of early fibrosis including laminin and fibronectin, collagen deposition and lipocyte activation in hepatic biopsies of 36 psoriatic patients treated with methotrexate for one to five years, at an average dose of 20 mg/week. Biopsies before initiation of methotrexate (n = 36) showed minimal immunohistochemical expression of desmin, transforming growth factor alpha, matrix proteins, and collagen. Expression of laminin, fibronectin, collagens III and IV increased significantly and progressively over baseline values after cumulative doses of 1.5 +/- 0.25 g (n = 20) and 3 +/- 0.5 g methotrexate, respectively. Increases in desmin, smooth muscle actin and collagen type I also occurred but the changes were less consistent. Light microscopic abnormalities of hepatotoxicity were not detectable in any of these biopsies.

CONCLUSIONS

Immunohistochemical quantification of matrix proteins and collagens type III and IV may be early, sensitive and dose responsive markers of methotrexate hepatotoxicity which progress with increasing cumulative doses of methotrexate.

Topodermatographic image analysis for melanoma screening and the quantitative assessment of tumor dimension parameters of the skin

BACKGROUND

The clinical need to identify and evaluate changes of cutaneous lesions in melanoma screening or follow-up of patients with cancer is of paramount importance. Because skin-lesion changes may be small and numerous, clinical assessment alone does not meet the requirements of quantitative assessment. Using the computer as a diagnostic tool for the image analysis of sequentially captured skin surface images has resulted in the technical problem of insufficient registration reproducibility. This paper describes the technical logistics, setup procedure, and clinical evaluation of the novel technique termed "topodermatography," which performs the quantitative videographic image analysis of skin-lesion changes over time.

METHODS

Digitized measurements of skin-surface image parameters were performed using a high-speed processor with an onboard coprocessor, a high-resolution video camera, specifically designed image processing software, and a position framework for the adjustment of the patient's standing position. The topodermatographic image analysis was performed on 109 consecutive patients who were at risk for melanoma (N = 98), had lesions from Kaposi's sarcoma (N = 4), had metastatic skin deposits from melanoma (N = 3), and had breast cancer (N = 4).

RESULTS

Skin lesion changes over time could be identified reliably within a few millimeters of diametric enlargement. In this series, a 0.51% early melanoma detection rate was assessed in 19 of 98 patients followed for 12 months. By monitoring manifest neoplastic skin lesions, tumor growth kinetics were analyzed quantitatively to determine the total area of skin involvement, thus facilitating precise response assessment.

CONCLUSIONS

Topodermatographic image analysis helps to optimize screening and follow-up procedures for patients with melanoma and populations at risk for melanoma. In addition, metastatic tumor lesions on the skin can be monitored dynamically, facilitating the accurate evaluation of the impact of systemic therapy on multiple skin deposits from melanoma and nonmelanoma cancers.

[Calcium antagonists--determination of current status and therapeutic significance]

The important group of drugs known as calcium antagonists is surveyed from a clinico-pharmacological viewpoint. The recently introduced substances are presented in a detailed manner. Common features and differences in pharmacodynamics and pharmacokinetics of the individual calcium antagonists are explained and their differential therapeutic use in the treatment of chronic cardiovascular diseases is discussed. The article also reports on drug interferences, contraindications and possible extensions of indications. An assessment is made of results achieved so far when applying calcium antagonists in the treatment of chronic cardiovascular diseases and in the prevention of arteriosclerosis.

Cytoreductive combination chemotherapy for regionally advanced unresectable extramammary Paget carcinoma

Extramammary Paget carcinoma (EPC) is considered to originate from the eccrine and apocrine glands of the adnexal skin of the axilla, vulva or penis, scrotum, or perineum. If immunohistochemical techniques with the use of cytoskeletal markers are applied in addition to histologic examination, EPC lesions are found to be multifocal adenocarcinoma of the adnexal sweat glands. So far, therapeutic approaches have included primary surgery, followed optionally by radiation therapy. It is possible to achieve a cure only when manifestations are detected early and confined regionally. The role of palliative chemotherapy has not yet been assessed in this disease, particularly because of the lack of compliance and follow-up in patients with EPC.

[The effect of oral trapidil therapy on clinical and hemorheological parameters in arteriosclerosis obliterans in comparison to pentoxifylline--a pilot study]

20 male patients from 44 to 61 years of age with arteriosclerotic disturbances of the blood supply of the legs (stage II after Fontaine) were in the cross-over treated with 3 x 200 mg trapidil or 3 x 200 mg pentoxifylline daily. The duration of the therapy was in each case 6 weeks with a one-week elutriation phase. Statistically ascertained was an increase of the distance of intermittent claudication for the two drugs in patients with initial values lower than 550 m. On the other hand the tibio-brachial Doppler quotient and the submaximal blood supply established by the venous-occlusion plethysmography did not change. The post-ischaemic recovery phase of the transcutaneous oxygen partial pressure at the lower leg shortened in particular under the influence of trapidil. Lipid parameter, haematocrit, fibrinogen and plasma viscosity remained unchanged. The subjective tolerance of the two remedies was good.

[Beta receptor blockers. Their role and therapeutic importance]

From clinico-pharmacological view the present paper gives a survey of the important drug group of the beta-receptor blockers. While non-selective blockers effect a global depression of the sympathico-adrenergic activity of the organism, the beta 1-selective blockers are characterized by a dose-dependent preferred affinity to the cardiac and renal beta 1-receptors. Thus in low and moderate dosages undesired pulmonary, vascular and metabolic effects can be avoided. Main indications for beta-receptor blockers are the arterial hypertension, the coronary heart disease and the tachycardiac disturbances of the cardiac rhythm. Apart from the increase of the life-quality of the patient the prognosis improving effect in clinical long-term studies confirmed for several beta-receptor blockers should be used therapeutically.

[Hutchinson-Horton ulcero-necrotizing cranial arteritis]

Arteritis cranialis ulcero-necroticans Hutchinson-Horton is the necrotizing variant of giant-cell temporal arteritis, which was first described by Hutchinson in 1890 and Horton in 1932. Although the histomorphological findings (occluding proliferation of the intima, destruction of the elastica interna, giant-cell infiltration) suggest reactive pathomechanisms, the aetiology of the disease remains rather uncertain. The hypothesis currently favoured is that auto-immunological processes originate from vascular alterations and subsequently lead to the recognition of antigenic determinants by the host immune system being followed by immunological response mechanisms clinically manifest as vasculitis. Arteritis cranialis is most frequently found in the temporal artery; however, the reasons for this preferential location are not clearly established, and giant-cell arteritis can also be found elsewhere. Ulceration of the skin can be encountered and may affect large areas of the scalp, depending on the vascular perfusion pattern involved. The case report described in this paper comprises anamnestic data, clinical and serological findings, and the histological picture typical for giant-cell arteritis. Stress is laid on the importance of early diagnosis to prevent irreversible complications with possibly fatal outcome.

[Oral trapidil treatment of Fontaine stage II arteriosclerotic circulatory disorders of the legs--a double-blind study]

In a double blind study altogether 41 patients with obliterating arteriosclerosis at stage II after Fontaine have been treated for 26 weeks either with 3 X 100 mg Trapidil (Rocornal) daily or placebo. In the second half of the study under Trapidil in contrast to placebo a clinically relevant additional increase of the distance of the intermitent claudication was the result. On the other hand, the plethysmographically measured reserve of the arterial blood supply did not show any changes in the two groups. A specific influence of Trapidil on the lipoprotein metabolism is apparently not present, since there appeared favourable influence on the hyperlipoproteinaemia diagnosed in 37 out of 41 patients both under placebo and under Trapidil.

[Differential diagnosis of non-thrombotic insufficiency of the conductive veins]

The differential diagnosis of the non-thrombotic insufficiency of conducting veins is in general possible by anamnesis and clinical angiological examination, even if non-vascular diseases are taken into consideration. In other patients, particularly in isolated insufficiency of the conducting veins, in addition to this non-invasive and, if the occasion arises, invasive angiological methods must be used.

[Possibilities and limits of pharmacotherapy of chronic venous insufficiency]

The conservative therapy of the chronic venous insufficiency is always carried out with etiopathogenetic orientation and according to the stages of disease. Of the medicamentous therapy oedema-protective and vein-tonicising drugs, oral anticoagulants and non-steroidal antiphlogistics are discussed. Furthermore, the alternative and supplementary prescription of physiotherapy and movement cure depending on findings is dealt with.

[Expert assessment of chronic venous insufficiency]

In the expertise of a chronic venous insufficiency kind and stage of the venous disease must be proved as objectively as possible. The diagnostic demands in the individual step programmes serve for the exact assessment of the remaining part of efficiency. The criteria of valuation are summarized, in which case we also deal with several possibilities of combination with other vascular diseases. The expert opinion of an accident is discussed. References to the inability to work, rating of nursing money, increased material benefit in impairments of health and to the acknowledgement of an identity card for injured persons supplement the statements.

[Systemically administered regional tumor therapy. Regional hemi-body chemotherapy of metastatic malignant melanoma--an experimental therapy concept]

Since systemic application of a high-dose chemotherapy is limited by the extent of intolerable toxicity and overall response rates so far are rather poor, the systemic mode of chemotherapy for metastatic melanoma appears to be of only limited benefit. On the other hand, results from isolated limb perfusion for satellitosis and in-transit metastasis suggest distinct dose-response correlations with tumoricidal properties of appropriate antineoplastic agents. This experience prompted the idea to pilot the anti-tumor action of a high-dose regimen confined to one hemibody compartment for targeted tumor therapy. After having standardized the surgical procedure this goal appeared to be achievable by expanding the perfused area and by simultaneously detoxifying toxic drug levels within the non-perfused compartment by venous filtration. Two initial causal experiences revealed impressive tumor regressions and are therefore reported on preceding subsequent evaluation within a controlled clinical trial being designed at different solid tumors.

[The clinical significance of serotonin antagonists]

Issuing from the physiological role of the serotonine, the possible significance of this biogenic amine for the pathogenesis of cardiovascular diseases is discussed. From this are derived indications for the use of serotonine antagonists. At present, of these ketanserine is regarded as the best investigated substance. The results of the hitherto performed clinical studies justify the application in hypertension. In contrast to this the assessment of the clinical and therapeutic value in chronic arteriosclerotic occlusive disease at stage II according to Fontaine and in Raynaud's syndrome is rendered difficult.

[Lipid metabolism and peripheral hemodynamics in arteriosclerosis obliterans treated with nifedipine--a comparison with pentoxifylline]

In the present study altogether 51 patients with obliterating arteriosclerosis stage II according to Fontaine were examined concerning the haemodynamic and lipid parameters under influence of nifedipine and pentoxifylline, respectively. An antiatherogenic effect under nifedipine takes place possibly by the diminution of the triglycerides in the serum and the blood pressure as well as by the increase of the linolenic acid in the serum (precursor of the vasoprotective prostacyclin I3). Pentoxifylline essentially behaves lipid-neutral. The increase of the intermittent claudication distance clearly speaks for pentoxifylline. - Nifedipine should only be used in concomitant indications.

[The importance of the trace element selenium in internal diseases]

Issuing from the existence of selenium and its interactions with other elements its essentiality in biochemical processes of man was explained. In correspondence with other research teams also own results speak for a relative selenium deficiency in the Middle-European region. Alterations of the cell integrity caused by selenium deficiency may play a role in the etiopathogenesis and perpetuation of chronic cardiovascular diseases as well as of disturbances of the immunoregulation. Recent epidemiological studies and clinical experimental investigations show potential tendencies for prophylaxis and therapy of diseases which are remarkable in health policy.

[Venous hemodynamics in axillary venous stasis]

By means of venous-occlusion plethysmography in 40 patients (24 men, 16 women) with stasis of the axillary vein the venous return was measured. This was 62.3 +/- 21.5 ml/100 ml/min. on the healthy arm. Long-term venous thromboses had worse return values (43.7%) than short occlusions (71.6% of the healthy side). Responsible for the favourable late results, which express themselves in increasing return values, is in general the development of an efficient collateral circulation and recanalisation, respectively, after thrombolysis or thrombectomy. The plethysmographic measurement of the back flow apart from the phlebography of the arm is recommended for the diagnosis and control of the course of the stasis of the axillary vein.

[The significance of inflammatory vascular diseases]

Out of the from angiological points of view most important inflammatory vascular diseases (obliterating endangiitis, giant cell arteriitis, Takayasu's disease) epidemiological data are compiled. Remarkable is the increasing part of female patients in endangiitis. Furthermore it is referred to the particular functional situation in these vascular diseases, which results from the localisation of a peripheral occlusion, insufficient formation of collaterals or disturbed rheology.

[Serum magnesium and heart arrhythmias in patients with pelvic-leg arteriosclerosis]

In 122 male patients with arteriosclerosis of pelvis and legs up to 5 resting electrocardiograms were registered in the course of 4 years. 5.2% of these electrocardiograms showed disturbances of rhythm. In these cases no significant differences in the serum magnesium level could be ascertained between patients with and without disturbances of rhythm.

Impact of regional chemotherapy for melanoma metastases

Metastatic malignant melanoma requires sophisticated delineation of therapeutic approaches in order that palliation of the disease should be managed effectively. To date, systemic chemotherapy for melanoma metastases appears to be of only limited benefit, since tumoricidal drug levels can hardly be achieved in a way to overcome primary or secondary drug resistance of melanoma cells. With respect to topographically defined patterns of metastasis, therapeutic approaches introducing regional chemotherapy have recently promised improved palliation in the management of advanced solid tumors including melanoma. Among these approaches, isolated limb perfusion has become a well-established procedure in the treatment of melanoma which has metastasized to the extremities. The adjuvant setting of this technique is currently under investigation, and suggests a beneficial outcome in perfused high-risk patients. Intraarterial infusion techniques with or without regional venous drug hemofiltration might provide high cytotoxic tissue levels at the target region, thus subsequently leading to enhanced cell kill rates evidenced in terms of clinical responses. Angioocclusive approaches using persistent (chemoembolization) or transient (microspheres, liposomes) blocking techniques with subsequent reduction of the arterial/arteriolar blood flow may optimize the pharmacological advantage of regional drug delivery. In addition to cytoreductive surgery and systemic chemotherapy, the above-mentioned approaches of regional chemotherapy offer a new perspective in the palliative management of metastatic melanoma.