[Laparotomy closure and incisional hernia prevention - what are the surgical requirements?]

In the light of an incisional hernia incidence of between 10 and 20 % that remains constantly high in spite of modifications of suture materials and suture techniques, intensified scientific efforts aiming at incisional hernia prevention are -required. This article reviews the scientific results dealing with incisional hernia incidence, time of manifestation, risk factors and the influence of suture material and suture technique. A lack of evidence-based data and no current consensus concerning the ideal material and technique to close laparotomies has to be mentioned. To encourage a novel approach to incisional hernia -prevention, the results of experimental studies which demonstrate the negative effects of conventional laparotomy closure on the abdominal wall are discussed. Histology and additionally -laser-fluorescence angiography reveal the weak-en-ing of abdominal wall structures and abdominal wall perfusion after directly suturing the -incisional edges. Additionally, inadequate suture -tension has an influence on collagen quantity and quality in the healing incision. Further investigations with a suture simulator have made clear that surgical sutures vary widely in precision and reproducibility of suture tension when completed only under visual and tactile control. As suture tension dynamics cannot be measured due to the lack of adequate devices, an implantable sensor has been developed that reveals a loss of suture tension of up to 60 % of the initial tension in the first 2 hours after completion of laparotomy closure. These results have led to the development and experimental use of a bridging closure with a tension-banding technique. This technique has almost no influence on abdominal wall per-fusion, leaves the architecture and dynamics of the abdominal wall intact, and results in a favour-able ultra-structural composition of collagen and a mechanically stable laparotomy healing after 15 months. Measures to prevent incisional hernia formation - which is in fact the post-operative complication in surgery most frequently leading to re-operation - require intensified research activities. Success will only be achieved if the development of -unconventional closure techniques is encouraged and the beaten path of suturing the incisional edges is discarded.

Once-daily prolonged-release tacrolimus (ADVAGRAF) versus twice-daily tacrolimus (PROGRAF) in liver transplantation

The efficacy and safety of dual-therapy regimens of twice-daily tacrolimus (BID; Prograf) and once-daily tacrolimus (QD; Advagraf) administered with steroids, without antibody induction, were compared in a multicenter, 1:1-randomized, two-arm, parallel-group study in 475 primary liver transplant recipients. A double-blind, double-dummy 24-week period was followed by an open extension to 12 months posttransplant. The primary endpoint, event rate of biopsy-proven acute rejection (BPAR) at 24 weeks, was 33.7% for tacrolimus BID versus 36.3% for tacrolimus QD (Per-protocol set; p = 0.512; treatment difference 2.6%, 95% confidence interval -7.3%, 12.4%), falling within the predefined 15% noninferiority margin. At 12 months, BPAR episodes requiring treatment were similar for tacrolimus BID and QD (28.1% and 24.7%). Twelve-month patient and graft survival was 90.8% and 85.6% for tacrolimus BID and 89.2% and 85.3% for tacrolimus QD. Adverse event (AE) profiles were similar for both tacrolimus BID and QD with comparable incidences of AEs and serious AEs. Tacrolimus QD was well tolerated with similar efficacy and safety profiles to tacrolimus BID.

Coincidence of immune thrombocytopenia, intracranial hemorrhage and graft-versus-host disease in an 11-year-old girl

Primary immune thrombocytopenia (ITP) in children is usually self-limiting and harmless but can, rarely, result in life-threatening complications. The case of an 11-year-old girl with ITP is presented who developed recurrent intracranial hemorrhages followed by cerebral infarctions. The clinical course was complicated by a graft-versus-host disease involving several organs. Treatment was performed according to the current international consensus report of 2010 with glucocorticoids, immunoglobulin G, anti-D-immunoglobulin and additionally embolisation of the splenic artery. The girl survived. Reliable predictors, preventive measures for life-threatening complications in ITP and more information about the effectiveness and side-effects of the recommended treatment are urgently needed.

Recent and future warm extreme events and high-mountain slope stability

The number of large slope failures in some high-mountain regions such as the European Alps has increased during the past two to three decades. There is concern that recent climate change is driving this increase in slope failures, thus possibly further exacerbating the hazard in the future. Although the effects of a gradual temperature rise on glaciers and permafrost have been extensively studied, the impacts of short-term, unusually warm temperature increases on slope stability in high mountains remain largely unexplored. We describe several large slope failures in rock and ice in recent years in Alaska, New Zealand and the European Alps, and analyse weather patterns in the days and weeks before the failures. Although we did not find one general temperature pattern, all the failures were preceded by unusually warm periods; some happened immediately after temperatures suddenly dropped to freezing. We assessed the frequency of warm extremes in the future by analysing eight regional climate models from the recently completed European Union programme ENSEMBLES for the central Swiss Alps. The models show an increase in the higher frequency of high-temperature events for the period 2001-2050 compared with a 1951-2000 reference period. Warm events lasting 5, 10 and 30 days are projected to increase by about 1.5-4 times by 2050 and in some models by up to 10 times. Warm extremes can trigger large landslides in temperature-sensitive high mountains by enhancing the production of water by melt of snow and ice, and by rapid thaw. Although these processes reduce slope strength, they must be considered within the local geological, glaciological and topographic context of a slope.

Peripheral estradiol induces temporomandibular joint antinociception in rats by activating the nitric oxide/cyclic guanosine monophosphate signaling pathway

Recently, we have reported that high physiological estradiol level during the proestrus phase of the estrous cycle or systemic estradiol administration in ovariectomized rats decreases formalin-induced temporomandibular joint nociception. However, the mechanisms underlying the antinociceptive effect of estradiol are presently unknown. In this study, we used the temporomandibular joint formalin model in rats to investigate whether estradiol decreases nociception by a peripheral non-genomic mechanism, and if so, whether this mechanism is mediated by the activation of the nitric oxide-cyclic guanosine monophosphate signaling pathway and of opioid receptors. The administration of estradiol into the ipsilateral, but not into the contralateral temporomandibular joint significantly reduced formalin-induced temporomandibular joint nociception in ovariectomized and diestrus but not in proestrus females. However, the administration of the estrogen receptor antagonist ICI 182780 into the ipsilateral, but not into the contralateral temporomandibular joint blocked the antinociceptive effect of serum estradiol in proestrus females, suggesting that the physiological effect of estradiol in nociception is mediated, at least in part, by a peripheral mechanism. The administration of estradiol into the ipisilateral temporomandibular joint did not affect formalin-induced nociception in male rats. The antinociceptive effect of temporomandibular joint estradiol administration in ovariectomized and diestrus females was mimicked by estradiol conjugated with bovine serum albumin, which does not diffuse through the plasma membrane, and was blocked by the estrogen receptor antagonist ICI 182780. The administration of the nitric oxide synthase inhibitor (nitro-l-arginine) or of a guanylate cyclase inhibitor (1H-(1,2,4)-oxadiasolo (4,2-a) quinoxalin-1-one) into the ipsilateral, but not into the contralateral temporomandibular joint blocked the antinociceptive effect of estradiol and of estradiol conjugated with bovine serum albumin, while the opioid receptor antagonist naloxone had no effect. These findings suggest that estradiol decreases temporomandibular joint nociception in female rats through a peripheral non-genomic activation of the nitric oxide-cyclic guanosine monophosphate signaling pathway.

CXCL13 and CXCL12 in central nervous system (CNS) lymphoma patients

2071

Background: Homing of malignant lymphocytes to the CNS may play a role in the pathogenesis of CNS lymphoma. Recently, the expression of the chemokine receptors CXCR4 and CXCR5 as well as their chemokine ligands CXCL12 and CXCL13 by tumor cells in primary CNS lymphoma (PCNSL) has been demonstrated. In this study, we evaluated CXCL12 and CXCL13 in cerebrospinal fluid (CSF) and serum of patients with CNS lymphoma. Methods: Samples from 30 patients with CNS lymphoma (23 with PCNSL and seven with secondary CNS lymphoma) and 40 controls (10 patients with other CNS malignancies and 30 without a malignant CNS disease) were examined. CXCL12 and CXCL13 concentrations were measured using enzyme-linked immunosorbent assays. The grade of blood brain barrier (BBB) disruption was estimated by the CSF/serum albumin ratio. Results: CNS lymphoma patients and controls did not differ in CXCL12 serum and CSF levels. Serum levels of CXCL13 were generally low. CXCL13 CSF levels, however, were high only in CNS lymphoma patients but not in controls (p < 0.0001). Chemokine levels in CSF and serum did not correlate. In CNS lymphoma CXCL13 concentration in CSF correlated with BBB disruption (R = 0.66, p = 0.003). Elevated CSF levels of CXCL12 and CXCL13 measured in seven CNS lymphoma patients decreased in five patients which responded to chemotherapy, and increased in two with lymphoma progression. Conclusions: Our results suggest a production of CXCL13 within the CNS of CNS lymphoma patients which decreases with response to therapy. Thus, CXCL13 may represent a marker for further diagnostic and prognostic studies.

No significant financial relationships to disclose.

Initial experience with transvaginal incisional hernia repair

INTRODUCTION

Natural orifice surgery has evolved from a preclinical setting into a common occurrence at the University of California San Diego (UCSD). With close to 40 transvaginal cases, we have become comfortable with this technique and are exploring other indications. One of the perceived advantages in natural orifice surgery is the potential reduction in the incidence of hernia formation. Patients with abdominal wall hernias may be at increased risk of forming additional hernias at incision sites. In addition, patients with recurrent incisional hernias may, likewise, be at increased risk. We believe that reducing or eliminating abdominal wall incisions may be of benefit in the repair of abdominal wall hernias. Here, we describe what we believe to be the first natural orifice transluminal endoscopic surgical (NOTES) approach to the repair of an abdominal wall hernia.

METHODS

The patient is a 38-year-old female with a painful recurrent umbilical hernia, previously repaired 8 years prior with a polypropylene-based mesh. The patient underwent a transvaginal recurrent umbilical hernia repair with one other 5-mm port in the abdomen for safety.

RESULTS

The patient had no intraoperative or postoperative complications. At 5 months follow up, the patient had no complaints, no evidence of hernia recurrence, and was very pleased with her result.

CONCLUSIONS

The repair of primary and incisional hernias of the ventral abdominal wall via a transvaginal approach is technically feasible, and the result of our initial case was exceptional. However, there are still significant obstacles which must be addressed before this approach can be widely utilized. These obstacles include safe entrance into the abdominal cavity via a transvaginal approach, the proper mesh to be placed during the repair, and the risk of infection.

Randomized clinical trial of a modified Seldinger technique for open central venous cannulation for implantable access devices

INTRODUCTION

Totally implantable access ports (TIAPs) are often used for patients who need permanent venous access. The primary success rate using direct open insertion is about 80 per cent, so rescue strategies are needed. This study compared the primary success rates of standard open insertion and a modified Seldinger technique.

METHODS

This randomized trial recruited 164 patients scheduled for primary implantation of a TIAP and compared two interventions. The primary endpoint was the success rate of the implantation technique.

RESULTS

The primary success rates were similar: 66 (80 per cent) of 82 patients who had standard open insertion versus 69 (84 per cent) of 82 patients undergoing the modified Seldinger method (P = 0.686). A logistic mixed regression analysis including treatment group, age, Karnofsky index, body mass index and surgeon's experience showed no advantage for the Seldinger method: odds ratio 1.30 (95 per cent confidence interval 0.62 to 2.70). TIAPs were eventually implanted successfully in 163 (99.4 per cent) of 164 patients. In 11 patients randomized to standard surgery, the Seldinger method was a successful rescue strategy.

CONCLUSION

The primary success rate was similar for both open insertion methods. The modified Seldinger method is useful if standard open insertion fails.

REGISTRATION NUMBER

ISRCTN 52368201 (http://www.controlled-trials.com).

[The Treatment of the Complex Regional Pain Syndrome (CRPS 1 and CRPS 2) of the Upper Limb with Repeated Local Anaesthesia to the Stellate Ganglion.]

Two female patients were referred to us with a complex regional pain syndrome (CRPS) of the upper limb. One patient developed a CRPS type 1 after a radius fracture, the other presented a CRPS type 2 after a wrist trauma with a nerve injury of N. ulnaris. Both patients had progressive pain in spite of medical treatment (NSAID, Gabapentine, Calcitonine), physiotherapy, occupational therapy and osteopathy. In addition to pain they also showed the typical autonomic symptoms like oedema, hyperhidrosis, disturbances of skin colour and temperature and a severely limited motility of wrist and fingers. The clinical symptoms of both types of CRPS are identical and not restricted to the peripheral nerve distribution. The sympathetic nerve system is not only involved in the pain mechanism with reflectory processes in the segment and with the sympathetic afferent coupling, it also takes part in the neuroplasticity and in the neurogenic inflammation. The logical therapeutic intervention is therefore to normalize the hyperactivity of the sympathetic nerve systems with local anaesthetics. This regulation is done with injections to the stellate ganglion if upper limbs are affected (affections of lower limbs are treated with injections to the lumbar sympathetic trunk). Repeated injections to the stellate ganglion caused immediate improvement of pain and other symptoms in both patients.

No relevant difference in quality of life and functional outcome at 12 months' follow-up-a randomised controlled trial comparing robot-assisted versus conventional laparoscopic Nissen fundoplication

PURPOSE

The present randomised pilot trial was designed to compare robot-assisted (RALF) and conventional laparoscopic fundoplication (CLF) focussing on post-operative quality of life (QOL) and functional outcome. Any long-lasting advantages for patients in this regard could be a justification for the use of RALF for the treatment of gastroesophageal reflux disease (GERD).

METHODS

Forty patients with GERD were randomised to either RALF or to CLF. During a follow-up period of 12 months, patients' QOL and functional outcome were investigated using disease-specific questionnaires.

RESULTS

There were no significant differences in the mean QOL (1.3 versus 1.1; P = 0.374) and functional outcome (1.27 versus 1.3; P = 0.913) between both groups. Minor side effects such as bloating and persistent diarrhoea were present in four patients of each group.

CONCLUSION

The present study did not show any benefit for RALF over CLF regarding QOL and functional outcome at 12 months' follow-up.

Meningeal dissemination in primary CNS lymphoma: prospective evaluation of 282 patients

BACKGROUND

The impact of meningeal dissemination in primary CNS lymphoma (PCNSL) is debated, and the reported frequency varies. We prospectively evaluated the diagnostic value of PCR in comparison with CSF cytomorphology and MRI for diagnosing meningeal dissemination in PCNSL.

METHODS

We evaluated 282 patients from a multicenter therapy study for PCNSL for the presence of meningeal dissemination: 205 with CSF cytomorphology, 171 with PCR of the rearranged immunoglobulin heavy-chain genes in CSF, and 217 with cranial MRI.

RESULTS

Meningeal dissemination was found in 33 of 205 patients (16%) by cytomorphology, in 19 of 171 (11%) patients evaluated by PCR, and in 8 of 217 patients (4%) by MRI. Considering either of these methods, the relative frequency of meningeal dissemination was 17.4% (49 of 282 patients). PCR was monoclonal in 6 of 19 (32%) samples with positive cytomorphology, 1 of 13 samples (8%) with suspicious cytology, and in 10 of 105 (10%) cytologically negative samples. In 11 samples with positive and 12 with suspicious cytology, PCR showed only a polyclonal pattern. The probability of meningeal dissemination detection was higher in cases with CSF pleocytosis (>5/microL) with an OR of 2.48 (95% CI 1.15-5.34, p = 0.018). CSF protein had no predictive value for meningeal dissemination detection.

CONCLUSIONS

We found a low rate of meningeal dissemination in primary CNS lymphoma in this large prospective study. The rate of discordant PCR and cytomorphologic results was high. Thus, the methods should be regarded as complementary. CSF pleocytosis had predictive value for meningeal dissemination detection.

The groove model of osteoarthritis applied to the ovine fetlock joint

OBJECTIVE

Until now there have been no appropriate models for metacarpophalangeal osteoarthritis (OA), even though OA in this joint is a significant medical and economic problem in horses. A good model would be useful to evaluate progression and treatment of OA, particularly in this joint. Therefore, we translated the canine Groove model to the ovine metacarpophalangeal (fetlock) joint.

METHOD

Cartilage surfaces of the metacarpal side of one fetlock joint were surgically damaged (grooved), followed by intermittent forced loading of the experimental joint. After 15 and 37 weeks, cartilage, synovial tissue and subchondral bone were analyzed by the use of macroscopy, histology, biochemistry and micro-CT.

RESULTS

Technically, the model was difficult to use because cartilage surfaces were very thin. Nonetheless, all macroscopic, histologic, and biochemical cartilage parameters demonstrated adverse changes in chondrocyte activity and matrix integrity. Decreased proteoglycan content suggested slow progression of cartilage degeneration over time, while synovial inflammation diminished. Impaired subchondral bone quality and osteophyte formation were found. Although osteophyte formation was progressive, subchondral bone changes diminished over time.

CONCLUSION

The canine Groove model appears to a limited extent transferable to the ovine fetlock joint. However, despite development of adverse changes consistent with early changes of OA, use of the Groove model in the ovine fetlock joint has technical limitations. Using larger animals, such as horses, may significantly improve the technical procedures and with that may provide a more reliable model of metacarpophalangeal OA that is based primarily on intrinsic cartilage damage, appropriate to evaluate the progression and treatment of OA in this particular joint.

Clinical outcome and long-term survival in 118 consecutive patients with neuroendocrine tumours of the pancreas

BACKGROUND

The aim was to assess the clinical relevance of the World Health Organization and tumour node metastasis (TNM) classifications in patients with pancreatic neuroendocrine tumours (pNETs).

METHODS

Prospectively collected data from 118 consecutive patients with a pNET receiving surgical intervention were analysed.

RESULTS

Forty-one patients had well differentiated neuroendocrine tumours, 64 had well differentiated neuroendocrine carcinomas and 13 had poorly differentiated neuroendocrine carcinomas. Five-year survival rates were 95, 44 and 0 per cent respectively (P < 0.001). There was no difference in survival after R0 and R1/R2 resections in patients with neuroendocrine carcinomas (P = 0.905). In those with well differentiated neuroendocrine carcinomas, any resection and having a clinically non-functional tumour significantly increased survival (P = 0.003 and P = 0.037 respectively). The TNM stage was I in 37 patients, II in 15 patients, III in 32 patients and IV in 34 patients. There were significant differences in 5-year survival between stage I and II (88 and 85 per cent respectively) and stage III and IV (31 and 42 per cent respectively) (P = 0.010).

CONCLUSION

Both classifications accurately reflect the clinical outcome of patients with pNET. The resection status may not be critical for long-term survival in patients with pNET.

Intercontinental comparison of patient cohorts: what can we learn from it?

Survival after liver transplantation in the United Kingdom and Ireland compared with the United States

The molecular mechanism of the inhibition by licofelone of the biosynthesis of 5-lipoxygenase products

BACKGROUND AND PURPOSE

Licofelone is a dual inhibitor of the cyclooxygenase and 5-lipoxygenase (5-LO) pathway, and has been developed for the treatment of inflammatory diseases. Here, we investigated the molecular mechanisms underlying the inhibition by licofelone of the formation of 5-LO products.

EXPERIMENTAL APPROACH

The efficacy of licofelone to inhibit the formation of 5-LO products was analysed in human isolated polymorphonuclear leukocytes (PMNL) or transfected HeLa cells, as well as in cell-free assays using respective cell homogenates or purified recombinant 5-LO. Moreover, the effects of licofelone on the subcellular redistribution of 5-LO were studied.

KEY RESULTS

Licofelone potently blocked synthesis of 5-LO products in Ca(2+)-ionophore-activated PMNL (IC(50)=1.7 microM) but was a weak inhibitor of 5-LO activity in cell-free assays (IC(50)>>10 microM). The structures of licofelone and MK-886, an inhibitor of the 5-LO-activating protein (FLAP), were superimposable. The potencies of both licofelone and MK-886 in ionophore-activated PMNL were impaired upon increasing the concentration of arachidonic acid, or under conditions where 5-LO product formation was evoked by genotoxic, oxidative or hyperosmotic stress. Furthermore, licofelone prevented nuclear redistribution of 5-LO in ionophore-activated PMNL, as had been observed for FLAP inhibitors. Finally, licofelone as well as MK-886 caused only moderate inhibition of the synthesis of 5-LO products in HeLa cells, unless FLAP was co-transfected.

CONCLUSIONS AND IMPLICATIONS

Our data suggest that the potent inhibition of the biosynthesis of 5-LO products by licofelone requires an intact cellular environment and appears to be due to interference with FLAP.

High-dose methotrexate and ifosfamide for CNS relapse of aggressive lymphoma

12524

Background: CNS involvement is a grave complication of malignant lymphoma. Therapy traditionally includes intrathecal chemotherapy, radiotherapy and systemic chemotherapy for concomitant systemic lymphoma. However, optimal therapy has not been established thus far for CNS lymphoma. In this pilot study a combination of systemic high-dose (HD) methotrexate (MTX) and ifosfamide (IFO) was evaluated for toxicity and response rate. Methods: 10 patients (pts.) with CNS relapses of aggressive lymphoma (5 nodal DLBCL, 4 PCNSL/PIOL and 1 T-NHL) were treated. Nine pts. had intracerebral lesions, the meningeal compartment was involved in three. Three pts. had systemic manifestations. Median age was 63 years (32 - 83). Therapy consisted of 4g/m2 MTX (4h infusion on day 1) with dose adjustment for creatinine clearance (CC) < 100ml/min (CC/100 * 4g/m2) and 1.5 to 2g/m2/day IFO (3h infusion day 3 to 5). Supportive therapy included mesna and a leucovorin rescue beginning at 24h after start of MTX. Two pts. were treated with intrathecal chemotherapy before MTX/IFO. Results: A median of 4 cycles chemotherapy was administered. Treatment response was documented in 9 pts. (3 CR, 6 PR), and one patient had stable disease. The toxicity was mainly hematologic with grade 3/4 neutropenia in 6 pts., grade 3/4 thrombocytopenia in 4 pts. and grade 3 anemia in 2 pts. One pat. died from sepsis in neutropenia and one pat. with long-term corticosteroid therapy developed an aspergillus pneumonia grade 3. Nephrotoxicity grade 1/2 was observed in 6 pts.. Four pts. were further treated with HD chemotherapy followed by autologous stem cell transplantation or salvage radio-/chemotherapy. A median progression free survival of 6.5+ months (range 1–41+) for all pts. has been reached with persisting remission after 4 to 41 months in 5 pts.. Conclusions: Systemic combination therapy with MTX and IFO is feasible and exhibits a promising activity in CNS relapses of aggressive lymphoma.

No significant financial relationships to disclose.

PCR of immunoglobulin heavy-chain (IgH) complementary determining region III (CDRIII) for diagnosis of meningeal dissemination (MD) in primary CNS lymphoma (PCNSL): A prospective evaluation

2082

Background: The prognostic impact of MD in PCNSL is unclear. Cytomorphological examination of cerebrospinal fluid (CSF) cells is the gold standard for detection of MD. PCR for detection of a clonal B-cell population may represent a more sensitive and specific method for MD detection. Methods: CSF was collected by lumbar puncture before treatment in patients with newly diagnosed PCNSL of B cell type, histologically proven. CSF cytomorphological examination was performed by an experienced hematopathologist or neurologist immediately after sampling at the treating institution. A sample of native CSF was sent for PCR examination to our central moleculargenetic laboratory. Here, DNA from CSF cell pellets was extracted using commercially available kits. A seminested PCR of the IgH chain CDR III region was performed using the primers LJH in the first, VLJH in the second and FR3A in both PCR reactions. PCR products were subjected to an automated fluorescent fragment analysis (ALF) to detect a monoclonal vs. polyclonal pattern, and results were compared to conventional cytology. Results: From January 2001 to August 2006 CSF from 215 patients was collected. Here, data from the first 146 patients examined is presented ( Table ). MD was detected in 15 of 106 examined patients (14%) by cytomorphological evaluation and in 17 of 146 patients (11.6%) using PCR. In 8 patients with negative cytology the PCR product was monoclonal, and in 7 patients with positive cytology a polyclonal PCR product was found. Conclusion: The frequency of MD in PCNSL detected by PCR of the IgH CDR III region is low and comparable to that detected by cytomorphological evaluation. However, discordant PCR and cytology results are frequent. Thus, PCR analysis appears to be an important adjunct for MD diagnosis.

[Table: see text]

No significant financial relationships to disclose.

Ifosfamide or trofosfamide for intraocular lymphoma: Long-term results of a prospective study

18524

Background: The prognosis of intraocular lymphoma (IOL) is poor, and the optimal treatment has not yet been defined. In a prospective study, ifosfamide (IFO) or trofosfamide (TRO) have been assessed for treating IOL. Here, long-term results are presented. Patients and Methods: Patients with histologically proven isolated IOL were included. The median age of the patients was 74 years (range 46–83 years); 4 patients had a newly diagnosed disease and 6 a relapse. IFO was administered intravenously at a dose of 1.5 - 2.0 g/m2/day for 3 days every three weeks. TRO was given at a dose of 150 or 400 mg/day (continuous or intermittent administration) to 4 patients considered unable to receive intensive intravenous hydration. IFO, TRO and their active 4-hydroxy (4-OH) metabolites were measured in aqueous humor of 9 patients. Results: The median number of IFO courses was 6 (range 2–8), the median duration of TRO therapy was 8.5 months (range 6–18 months). All patients responded. Toxicity > WHO grade 2 was: anemia grade 2 in 2 patients, leukopenia grade 2–3 in 2 patients, nausea/vomiting grade 2 in 2 patients, thrombopenia and cystitis grade 2 in 1 patient each. Thus far, three patients each have developed cerebral and ocular relapse. Median progression-free survival from the study treatment was 9.5 months (range 6 - 24+ months), median overall survival was 15.5 months (range 6–34 months). Both patients retreated with IFO on ocular relapse responded. In 6 of 6 patients, 4-OH metabolites were detected in the aqueous humor immediately after IFO infusion with an aqueous/serum ratio of 0.19–0.54. Three to 16 hours after ingestion of TRO, 4-OH metabolites could be detected in one of 3 patients. Conclusions: Response rate of IOL to IFO or TRO is high with a tolerable toxicity even in elderly patients. However, long-term remissions are infrequent. Combining IFO/TRO with other cytostatics seems reasonable to improve long-term disease control.

No significant financial relationships to disclose.

Immunization of puppies in the presence of maternally derived antibodies against canine distemper virus

Vaccination of dams with modified-live canine distemper virus (CDV) vaccines will elicit high concentrations of colostral antibody, that although vital for protection of the pup during the first weeks of life, can interfere with active vaccination against the virus. In the present study, 12 pups, 7-9 weeks of age, with maternally derived immunity to CDV, were vaccinated with a canarypox-vectored CDV vaccine. These pups were protected against intravenous challenge with CDV. Three littermate pups that were unvaccinated all developed clinical signs of infection after challenge, and two of these control pups died.

DNA vaccination against pseudorabies virus and bovine respiratory syncytial virus infections of young animals in the face of maternally derived immunity

DNA vaccination represents a unique opportunity to overcome the limitations of conventional early life vaccine strategy which is restricted by the effects of maternally derived immunity. The pseudorabies virus (PRV) infection model in neonatal piglets was employed to demonstrate that a single DNA vaccination was able to prime memory humoral immune responses in the face of high concentrations of maternally derived antibodies. Immunity induced under these conditions protected against challenge with virulent PRV at the end of the fattening period, but long-term protective responses were not correlated with the kinetics of the initial serological responses. The bovine respiratory syncytial virus (BRSV) infection model in young calves was similarly studied, however the ability of DNA vaccination to prime memory humoral responses in the face of high concentrations of maternally derived antibodies was not confirmed, illustrating that the performance of DNA vaccination varies between species and/or infectious disease targets. However, in the BRSV model system it was evident that DNA vaccination could prime cell-mediated immunity in the face of high concentrations of maternally derived antibodies. Although not sufficient to ensure protection against clinical disease or viral excretion as a standalone vaccination strategy, priming by DNA vaccination was proven to establish cell-mediated immune responses for subsequent recall with an inactivated vaccine booster. Under these conditions, protection against challenge virus re-excretion was correlated with interferon (IFN) gamma-producing T-cell responses. The safety and the efficacy of DNA vaccine priming in very young animals in the face of high concentrations of maternally derived antibody provides a unique opportunity to design innovative and flexible vaccination programs to ensure uninterrupted protection under field conditions.

Phosphatidylinositol 3-kinase facilitates bile acid-induced Ca(2+) responses in pancreatic acinar cells

Bile acids are known to induce Ca(2+) signals in pancreatic acinar cells. We have recently shown that phosphatidylinositol 3-kinase (PI3K) regulates changes in free cytosolic Ca(2+) concentration ([Ca(2+)](i)) elicited by CCK by inhibiting sarco(endo)plasmic reticulum Ca(2+)-ATPase (SERCA). The present study sought to determine whether PI3K regulates bile acid-induced [Ca(2+)](i) responses. In pancreatic acinar cells, pharmacological inhibition of PI3K with LY-294002 or wortmannin inhibited [Ca(2+)](i) responses to taurolithocholic acid 3-sulfate (TLC-S) and taurochenodeoxycholate (TCDC). Furthermore, genetic deletion of the PI3K gamma-isoform also decreased [Ca(2+)](i) responses to bile acids. Depletion of CCK-sensitive intracellular Ca(2+) pools or application of caffeine inhibited bile acid-induced [Ca(2+)](i) signals, indicating that bile acids release Ca(2+) from agonist-sensitive endoplasmic reticulum (ER) stores via an inositol (1,4,5)-trisphosphate-dependent mechanism. PI3K inhibitors increased the amount of Ca(2+) in intracellular stores during the exposure of acinar cells to bile acids, suggesting that PI3K negatively regulates SERCA-dependent Ca(2+) reloading into the ER. Bile acids inhibited Ca(2+) reloading into ER in permeabilized acinar cells. This effect was augmented by phosphatidylinositol (3,4,5)-trisphosphate (PIP(3)), suggesting that both bile acids and PI3K act synergistically to inhibit SERCA. Furthermore, inhibition of PI3K by LY-294002 completely inhibited trypsinogen activation caused by the bile acid TLC-S. Our results indicate that PI3K and its product, PIP(3), facilitate bile acid-induced [Ca(2+)](i) responses in pancreatic acinar cells through inhibition of SERCA-dependent Ca(2+) reloading into the ER and that bile acid-induced trypsinogen activation is mediated by PI3K. The findings have important implications for the mechanism of acute pancreatitis since [Ca(2+)](i) increases and trypsinogen activation mediate key pathological processes in this disorder.

A 19-year-old male with generalized seizures, unconsciousness and a deviation of gaze

Light chain deposition disease (LCDD) is a form of monoclonal immunoglobulin deposition diseases (MIDD) which in contrast to light-chain derived (AL) amyloidosis is characterized by non-congophilic, non-fibrillary monoclonal protein deposits. Systemic organ deposits are common with the kidney being a major target organ. A clonal lymphoplasmocytic proliferation, e.g. plasmacytoma, is present in the majority of cases. Here we report on a 19-year-old male who presented with generalized seizures and an enhancing white matter lesion on MRI scans. A stereotactic brain biopsy revealed a low-grade B cell lymphoma with plasmacellular differentiation as well as lambda light chain deposits without birefringence under polarized microscopy. No systemic lymphoma manifestations or systemic light chain deposits were found, nor was a monoclonal gammopathy detectable in serum and urine. After systemic chemotherapy with three courses high-dose methotrexate the size of the lesion and the condition of the patient have remained stable for 24 months now. This is the first description of cerebral LCDD developing without systemic disease in conjunction with the diagnosis of a cerebral low-grade B cell lymphoma. We present the clinical, laboratory and radiological findings and discuss the pathogenesis of this unusual LCDD manifestation.

Performance of d-amino acid oxidase in presence of ionic liquids

The activity and stability of free and immobilized D-amino acid oxidase (DAAO, EC 1.4.3.3) from Trigonopsis variabilis CBS 4095 in different water-soluble and water-insoluble ionic liquids (ILs) as well as in organic solvents were studied for comparison. The most promising ILs ([BMIM][BF(4)] and [MMIM][MMPO(4)]) were investigated in detail. The kinetic parameters (v(max) = 187 nkat/g dry weight, K(M) = 1.38 mM) with D-phenylalanine as substrate were calculated in 40% [BMIM][BF(4)]. Bioconversions of D/L-phenylalanine in 40% [BMIM][BF(4)] and 20% [MMIM][MMPO(4)] on a 3 ml scale using immobilized DAAO were performed by addition of free catalase from Micrococcus lysodeikticus. After total conversion of substrate in presence of 20% [MMIM][MMPO(4)] the residual activity of the immobilized DAAO was 79% and 100% of the free catalase.

Branching patterns and drainage territories of the middle hepatic vein in computer-simulated right living-donor hepatectomies

Full right hepatic grafts are most frequently used for adult-to-adult living donor liver transplantation (LDLT). One of the major problems is venous drainage of segments 5 and 8. Thus, this study was designed to provide information on venous drainage of right liver lobes for operation-planning. Fifty-six CT data sets from routine clinical imaging were evaluated retrospectively using a liver operation-planning system. We defined and analyzed venous drainage segments and the impact of anatomic variations of the middle hepatic vein (MHV) on venous outflow from segments 5 and 8. MHV variations led to significant shifts of segment 5 drainage between the middle and right hepatic vein. In cases with the most frequent MHV branching pattern (n = 33), a virtual hepatectomy closely right to the MHV intersected drainage vessels that provided drainage for 30% of the potential graft, not taking into account potential veno-venous shunts. In individuals with inferior MHV branches that extend far into segments 5 and 6 (n = 10), the overall graft volume at risk of impaired venous drainage increased by 5% (p < 0.001). If this is confirmed in clinical trials and correlated with intraoperative findings, the use of liver operation-planning systems would be beneficial to improve overall outcome after right lobe LDLT.

Prospective trial on topotecan salvage therapy in primary CNS lymphoma

BACKGROUND

Standard salvage therapy has not been established for recurrent primary central nervous system lymphoma (PCNSL). We report the final results of a prospective study on topotecan chemotherapy in relapsed or refractory PCNSL.

PATIENTS AND METHODS

The study included 27 patients with a median age of 51 years and an ECOG performance status of 2. Fourteen patients were refractory to the last therapy, and 13 relapsed after a median period of 6.0 months. Pretreatment with up to four regimens included chemotherapy in 26 patients and whole brain irradiation in 14. A 30-min daily topotecan infusion of 1.5 mg/m(2) for 5 days was repeated every 3 weeks.

RESULTS

The response rate was 33% with five complete (CR) and four partial remissions (PR). The median follow-up was 37.7 months. All complete responders had sustained remissions lasting for 9 to 28 months. The median event-free survival (EFS) was 2.0 months (9.1 months in responders), the overall survival (OAS) was 8.4 months. CTC grade 3-4 leukopenia occurred in 26% and thrombocytopenia in 11% of the patients. Eight of 12 patients alive without cerebral lymphoma > or = six months after topotecan exhibited deficits attributable to late neurotoxicity.

CONCLUSION

Topotecan as monotherapy is active in relapsed and refractory PCNSL with tolerable toxicity.