SAT0143 A PHASE 1 STUDY IN HEALTHY VOLUNTEERS EXPLORING THE SAFETY, PHARMACOKINETICS AND PHARMACODYNAMICS OF ATI-450: A NOVEL ORAL MK2 INHIBITOR

Background:

ATI-450, is an investigational small molecule inhibitor of the MAPK-activated protein kinase 2 (MK2) signaling pathway. This pathway drives the expression of multiple cytokines including TNFα, IL-1α and β, and IL-6.

Objectives:

We evaluated the safety and tolerability of ATI-450 in healthy volunteers as well as pharmacokinetics (PK) and pharmacodynamics (PD). Here we present data from single and multiple ascending dose cohorts. The aim was to select a dose for evaluation in phase 2 in patients with rheumatoid arthritis.

Methods:

Safety, PK and PD were assessed in a randomized, observer-blind, placebo-controlled, phase 1 study in male and female healthy subjects aged 18-55 (n=77).

Safety and tolerability of ATI-450 was evaluated based on adverse events, clinical laboratory, vital signs, 12-lead ECG, Holter monitoring, and physical examination. Blood was drawn for PK analysis at 0.5, 1, 2, 4, 6, 8, 12 hours, 24, 36, and 48 hours post dose in the SAD cohort and on day 7 of the MAD cohort. PD of ATI-450 were explored by investigating the inhibition of a target biomarker, phospho-HSP27 (pHSP27) and proinflammatory cytokines, TNFα, IL1β, IL6 and IL8 inex-vivoLPS-stimulated blood samples collected 4 and 12 hours post dose on day 7 from subjects in the MAD cohorts.

Results:

ATI-450 was generally well tolerated. No serious adverse events or severe adverse events were reported, and no adverse events led to discontinuation of the study medication. The most common adverse events (reported by 2 or more subjects who received ATI-450) observed during the trial were dizziness, headache, upper respiratory tract infection, constipation, nausea, and abdominal pain. All adverse events were mild. A trend of a decrease in absolute neutrophil count (ANC) was observed without correlated clinical sequelae.

ATI-450 had dose proportional PK with a terminal half-life (t½) of 9-12 hours in the MAD cohort on day 7. A dose and concentration dependent inhibition ofex vivostimulated cytokines and target biomarker was observed. On day 7, patients in the 50mg BID dose (the dose with the highest degree of inhibition) recorded mean trough drug levels (12 hours post dose) that were 1.4, 2.5, 2.5 and 2.4 times greater than the IC80for TNFα, IL1β, IL8 and pHSP27 respectively. Mean Cmax drug levels (4 hours post dose) were 3.6, 6.4, 6.2 and 6.0 times greater than the IC80for TNFα, IL1β, IL8 and pHSP27 respectively. IL6 levels were inhibited by more than 50% for part of the dosing interval.

Conclusion:

Oral ATI-450 was generally well tolerated at all doses with dose proportional PK. The t½ suggests that once or twice daily oral dosing may be possible. At the 50mg BID dose, marked inhibition of TNFα, IL1β and IL8, IL6 and pHSP27 was observed. ATI-450 has the potential to be an oral, small molecule drug which can target multiple cytokines. Exploration of its benefit to risk profile in patients with rheumatoid arthritis is warranted.

Disclosure of Interests:

Judy Schnyder Shareholder of: aclaris therapeutics, Employee of: aclaris therapeutics, Joe Monahan Shareholder of: aclaris therapeutics, Employee of: aclaris therapeutics, Walter Smith Shareholder of: aclaris therapeutics, Employee of: aclaris therapeutics, Heidi Hope Shareholder of: aclaris therapeutics, Employee of: aclaris therapeutics, Deborah Kelly Shareholder of: aclaris therapeutics, Employee of: aclaris therapeutics, David Burt Shareholder of: aclaris therapeutics, Employee of: aclaris therapeutics, E Huff Shareholder of: aclaris therapeutics, Employee of: aclaris therapeutics, A Kaul Shareholder of: aclaris therapeutics, Employee of: aclaris therapeutics, A Hildebrand Shareholder of: aclaris therapeutics, Employee of: aclaris therapeutics, B Burnette Shareholder of: aclaris therapeutics, Employee of: aclaris therapeutics, N Klug Shareholder of: aclaris therapeutics, Employee of: aclaris therapeutics, M Bangs Shareholder of: Aclaris Therapeutics, Employee of: Aclaris Therapeutics, David Gordon Shareholder of: aclaris therapeutics, Employee of: aclaris therapeutics

Effect of methylprednisolone on acute kidney injury in patients undergoing cardiac surgery with a cardiopulmonary bypass pump: a randomized controlled trial

BACKGROUND

Perioperative corticosteroid use may reduce acute kidney injury. We sought to test whether methylprednisolone reduces the risk of acute kidney injury after cardiac surgery.

METHODS

We conducted a prespecified substudy of a randomized controlled trial involving patients undergoing cardiac surgery with cardiopulmonary bypass (2007-2014); patients were recruited from 79 centres in 18 countries. Eligibility criteria included a moderate-to-high risk of perioperative death based on a preoperative score of 6 or greater on the European System for Cardiac Operative Risk Evaluation I. Patients (n = 7286) were randomly assigned (1:1) to receive intravenous methylprednisolone (250 mg at anesthetic induction and 250 mg at initiation of cardiopulmonary bypass) or placebo. Patients, caregivers, data collectors and outcome adjudicators were unaware of the assigned intervention. The primary outcome was postoperative acute kidney injury, defined as an increase in the serum creatinine concentration (from the preoperative value) of 0.3 mg/dL or greater (≥ 26.5 μmol/L) or 50% or greater in the 14-day period after surgery, or use of dialysis within 30 days after surgery.

RESULTS

Acute kidney injury occurred in 1479/3647 patients (40.6%) in the methylprednisolone group and in 1426/3639 patients (39.2%) in the placebo group (adjusted relative risk 1.04, 95% confidence interval 0.96 to 1.11). Results were consistent across several definitions of acute kidney injury and in patients with preoperative chronic kidney disease.

INTERPRETATION

Intraoperative corticosteroid use did not reduce the risk of acute kidney injury in patients with a moderate-to-high risk of perioperative death who had cardiac surgery with cardiopulmonary bypass. Our results do not support the prophylactic use of steroids during cardiopulmonary bypass surgery. Trial registration: ClinicalTrials.gov, no. NCT00427388.

Steroids In caRdiac Surgery (SIRS) trial: acute kidney injury substudy protocol of an international randomised controlled trial

INTRODUCTION

Steroids In caRdiac Surgery trial (SIRS) is a large international randomised controlled trial of methylprednisolone or placebo in patients undergoing cardiac surgery with the use of a cardiopulmonary bypass pump. At the time of surgery, compared with placebo, methylprednisolone divided into two intravenous doses of 250 mg each may reduce the risk of postoperative acute kidney injury (AKI).

METHODS AND ANALYSIS

With respect to the study schedule, over 7000 substudy eligible patients from 81 centres in 18 countries were randomised in December 2013. The authors will use a logistic regression to estimate the adjusted OR of methylprednisolone versus placebo on the primary outcome of AKI in the 14 days following surgery (a postoperative increase in serum creatinine of ≥50%, or ≥26.5 μmol/L, from the preoperative value). The stage of AKI will also be considered, as will the outcome of AKI in those with and without preoperative chronic kidney disease. After receipt of grant funding, the authors began to record additional perioperative serum creatinine measurements in consecutive patients enrolled at substudy participating centres, and patients were invited to enroll in a 6-month serum creatinine collection. In these trial subpopulations, the authors will consider the outcome of AKI defined in alternate ways, and the outcome of a 6-month change in kidney function from the preoperative value.

ETHICS AND DISSEMINATION

The authors were competitively awarded a grant from the Canadian Institutes of Health Research for this SIRS AKI substudy. Ethics approval was obtained for additional serum creatinine recordings in consecutive patients enrolled at participating centres. The additional kidney data collection first began for patients enrolled after 1 March 2012. In patients who provided consent, the last 6-month kidney outcome data will be collected in 2014. The results will be reported no later than 2015.

CLINICAL TRIAL REGISTRATION

Number NCT00427388.

Attending rounds: microangiopathic hemolytic anemia with renal insufficiency

The classification of thrombotic microangiopathy has evolved and expanded due to treatment and advances in understanding of the diseases associated with this clinical presentation. The three clinical forms of thrombotic microangiopathy-thrombotic thrombocytopenic purpura (TTP), hemolytic uremic syndrome (HUS), and disseminated intravascular coagulation-encompass a wide range of disorders that can be classified as either primary (idiopathic) or secondary to another identifiable disease or clinical context. Identification of an inhibitor to a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 (ADAMTS13) in the idiopathic and acute forms of TTP, recognition of the absence of ADAMTS13 inhibition in diarrheal HUS, identification of complement abnormalities in atypical HUS, and a better understanding of the role of plasma therapy, rituximab, and eculizumab therapy have all had a major effect on current understanding of the thrombotic microangiopathies. In this Attending Rounds, a patient with a thrombotic microangiopathy is presented, along with discussion highlighting the difficulty of differentiating TTP from HUS and disseminated intravascular coagulation, the need for a prompt diagnosis, and the role for plasma therapy in appropriately selected patients. The discussion attempts to provide a simple clinical approach to the diagnosis, treatment options, and future course of adults and children suffering from a thrombotic microangiopathy.

Zearalenone and its metabolites as endocrine disrupting chemicals

Zearalenone (ZEA) is a macrocyclic β-resorcylic acid lactone produced by numerous species of Fusarium. It frequently contaminates corn and cereal products in many regions of the world. The biological activity of ZEA is dominated by its pronounced oestrogenicity, which is even enhanced in certain reductive metabolites. This review updates the metabolism in fungi, plants and mammalian systems, as well as the pharmacokinetics of ZEA. The present evidence for the hormonal effects of the parent mycoestrogen and some of its metabolites in vitro and in farm and experimental animals in vivo is reviewed, together with its association with endocrine-disruptive effects in humans. Possible mechanisms of the oestrogenic and carcinogenic activity of ZEA are discussed and future areas of research proposed.

Peritonitis and exit site infections in First Nations patients on peritoneal dialysis

BACKGROUND AND OBJECTIVES

First Nations (FN) patients on peritoneal dialysis experience poor outcomes. Whether discrepancies exist regarding the microbiology, rate of infections, and outcomes between FN and non-FN peoples remains unknown. Design, setting, participants, & measures: All adult peritoneal dialysis patients (n = 727) from 1997 to 2007 residing in Manitoba, Canada, were included. Parametric and nonparametric tests were used as necessary. Negative binomial regression was used to determine the relationship of rates of exit site infections (ESIs) and peritonitis between FN and non-FN peoples.

RESULTS

A total of 161 FN and 566 non-FN subjects were included in the analyses. The unadjusted relative rates of peritonitis and ESIs in FN subjects were 132.7 and 86.0/100 patient-years compared with 87.8 and 78.2/100 patient-years in non-FN populations, respectively. FN subjects were more likely to have culture-negative peritonitis (36.5 versus 20.8%, P < 0.0001) and Staphylococcus ESIs (54.1 versus 32.9%, P < 0.0001). The crude and adjusted rates of peritonitis were higher in FN subjects for total episodes and culture-negative and gram-negative peritonitis. Catheter removal because of peritonitis was similar in both groups (42.9 versus 38.1% for FN and non-FN subjects, respectively; P = 0.261).

CONCLUSIONS

FN patients experience higher rates of peritonitis and similar rates of ESIs compared with non-FN patients. Interventions to improve outcomes and prevent infections should specifically be targeted to the FN population.

[Familial syringoma: a rare clinical variant]

Syringomas usually occur either sporadically in a periorbital localized or truncal eruptive form. We report on two families with very uncommon hereditary syringomas. Multiple syringomas developed in the periorbital area of affected patients in the first family while the face, neck, trunk, and extremities were involved in the second family. The lesions first appeared during puberty and their number and distribution varied among the family members. Autosomal dominant inheritance equally affecting both sexes appears most likely. The incidence of familial syringomas may be widely underestimated. For treatment, carbon dioxide laser yielded good results while an excellent cosmetic outcome was achieved on the face with a special surgical technique using a springaction microscissors.

Immunophenotypic analysis of simultaneous specimens from different sites from the same patient with malignant lymphoma

Immunophenotypic analysis of simultaneous specimens from different sites from the same patient with malignant lymphoma The assumption that immunophenotypic characteristics of different specimens obtained simultaneously from the same patient remain unchanged has rarely been evaluated. Using flow cytometry, we reviewed our experience of 29 patients with non Hodgkin's lymphoma (NHL). From these patients, 60 simultaneous specimens taken from the peripheral blood, bone marrow, effusions, fine needle aspirates from lymph nodes or cerebrospinal fluid were studied. In 26 out of 29 patients, the immunophenotype in the different specimens was identical. In one patient with unclassifiable low-grade B-NHL, immunophenotyping showed additionally a CD38 expression in the effusion which was not seen in the bone marrow. In one patient with mantle cell lymphoma, expression of CD10 in the lymph node was noted which was lacking in the peripheral blood. In the remaining patient with unclassifiable low-grade B-NHL, CD23 expression was noted in the lymph node but not in the peripheral blood. This retrospective study suggests that discordant antigen expression in samples from different body sites within the same patient is a rare event.

Combined cytomorphologic and immunophenotypic analysis in the diagnostic workup of lymphomatous effusions

OBJECTIVE

To analyze the results of cytomorphology and immunophenotyping in 54 patients with lymphomatous effusions.

STUDY DESIGN

We report the results of cytomorphology and immunophenotyping in 54 patients with lymphomatous effusions. Twenty-three of the 54 had a previous diagnosis of NHL. In the remaining 31 patients, lymphomatous involvement was clinically suspected.

RESULTS

Thirty-three lymphomatous effusions were positive for involvement by NHL. Twenty-one of these 33 patients (64%) had a previous diagnosis of NHL. Of the remaining 12 patients with newly diagnosed NHL, 11 had high grade lymphoma, and one had follicular center lymphoma. Twenty effusions were considered to be reactive; only two of these patients had NHL. One effusion revealed involvement by a previously unknown carcinoma. We observed seven false negative results if only one of both methods was considered. A high grade NHL was not diagnosed by immunophenotyping in one case, and six cases of low grade NHL could not be detected by cytomorphology. The combined strategy of cytomorphology and immunophenotyping had a sensitivity of 100% and specificity of 100% in our study, confirmed by follow-up studies.

CONCLUSION

Both methods have shown difficulties in the examination of lymphomatous effusions. Cytomorphology has problems distinguishing reactive effusions from low grade NHL. The detection of high grade NHL by immunophenotyping is difficult. However, both methods together offer the advantage of dual staining ability and are most helpful in distinguishing clonal lymphomatous from reactive effusions.

Bioadhesion of supramolecular structures at supported planar bilayers as studied by the quartz crystal microbalance

A quartz crystal microbalance (QCM) was used to study the adhesion behavior of supramolecular aggregates at supported planar bilayers (SPBs). The QCM technique is a suitable method to detect the adsorption of biomolecules at the quartz surface owing to its sensitivity for changes in mass and viscoelastic properties. To simulate biomembranes, the quartz plates were coated with highly ordered lipid films. Therefore, a combination of self-assembled monolayers and Langmuir-Blodgett films was used. Firstly, the adsorption of liposomes coupled with the lectin concanavalin A was investigated at glycolipid-containing model membranes. Using different carbohydrates, it was possible to determine specific and nonspecific parts of the interactions. The adhesion occurred owing to specific lectin-carbohydrate interactions (about 20%) and to nonspecific interactions (about 80%). The composition of the liposomes was changed to simulate the structure of a native biomembrane consisting of the glycocalix, the lipid-protein bilayer, and the cytoskeleton. An artificial glycocalix was created by incorporating poly(ethylene glycol) into the liposomes. Liposomes which were intravesicular polymerized with polyacrylamide or polyacrylcholate simulated the cytoskeleton. It was determined that the modified liposomes had significant lower interactions with SPBs. The adsorption was reduced by approximately 80% compared to unmodified liposomes. Secondly, a model was developed for the detection of interactions between simple or mixed bile salt micelles and model membranes. It was found that simple bile salts did not adsorb at model membranes. Binary systems consisting of bile salt and phospholipid induced only small interactions. On the other hand, ternary systems consisting of bile salt, phospholipid, and fatty acid showed strong interactions. A dependence on the chain length of the fatty acid was observed. Thirdly, the interaction between ganglioside-containing model membranes and cholera toxin (beta-subunit) was investigated. Different ganglioside fractions showed varying adsorption in the following sequence: GM1 > GD1a > GD1b > GT1b.

Lactate concentration in plasma and red blood cells during incremental exercise

The purpose of this study was to investigate the distribution of lactate in plasma and red blood cells (RBC) in capillary blood during and after incremental exercise. We measured capillary plasma lactate and whole blood lactate of 10 subjects during incremental treadmill running and the first 20 min of recovery. To minimize lactate exchange from plasma to RBC between sampling and analysis, a recently developed rapid plasma separation method was used. RBC lactate was calculated. The RBC/plasma lactate concentration ratio decreased from 1.0 (0.85-1.28) before to 0.37 (0.25-0.45) after exhaustive exercise (plasma lactate 15.9 (12.2-19.5)mmol x I(-1), RBC lactate 4.8 (4.0-7.0) mmol x 1(-1)), thus showing that capillary plasma lactate increased much more rapidly than intracellular lactate during incremental exercise. In the first 5 minutes of recovery intracellular lactate still rose while plasma lactate already declined. Then both decreased while the concentration ratio as well as the absolute concentration gradient remained nearly constant (ratio 20 min after exercise termination: 0.43 (0.19-0.54).

Diagnosis of granulocytic sarcoma by fine-needle aspiration cytology

Granulocytic sarcoma (GS) occurs in patients with chronic myeloproliferative disorders as well as in patients with acute myeloid leukemia (AML). These tumorous masses can occur anywhere in the body and have to be differentiated from lymphoma, carcinoma or infectious processes. We report the results of fine-needle aspiration cytology (FNAC) in 26 patients with GS. Seventeen patients suffered from AML and 9 from chronic myeloid leukemia (CML) blast crisis. In 5 patients with AML, GS was the initial presentation of hematological malignancy, in the remaining 21 patients, FNAC confirmed relapse of AML or extramedullary blast crisis of CML. In 8 patients, GS was located in the skin, in 17 in the lymph node and in another patient in the spinal canal. This study demonstrates the clinical utility and diagnostic accuracy of FNAC in the evaluation of GS from multiple sites.

Pregnancy in essential thrombocythaemia: treatment and outcome of 17 pregnancies

OBJECTIVE

To evaluate treatment and outcome of 17 pregnancies in nine patients with essential thrombocythaemia (ET) seen at our institution from 1988 to 1998.

METHODS

Treatment and outcome of 17 pregnancies in nine ET patients were retrospectively analyzed.

RESULTS

Seventeen pregnancies in nine patients with ET resulted in 11 (65%) live births and ended in six (35%) spontaneous abortions. Abortion could not be predicted from ET-associated complications before (p= 0.23) or during (p = 0.39) pregnancy. Maternal complications occurred during six pregnancies (35%): Three major bleedings in two patients with an acquired von Willebrand disease and two minor bleedings in patients treated with low-dose acetylsalicylic acid (ASA) were observed during pregnancy or at term; one patient suffered from transient visual loss while pausing low-dose ASA. Platelet counts prior to pregnancy were significantly higher as compared to the platelet nadir observed during pregnancy (p = 0.0017). Postpartum clinical course was uneventful in all patients. No specific treatment was given during 11 pregnancies. Six women received low-dose ASA during pregnancy followed by low-molecular-weight heparin until the end of the sixth week postpartum in five cases. This treatment was correlated with a favourable outcome (live birth versus abortion) when compared to no treatment (p=0.04).

CONCLUSION

Pregnancy in ET can be complicated by first trimester abortion and/or maternal haemorrhage. Our limited observation suggest a positive impact of low-dose ASA during pregnancy followed by low-molecular-weight heparin postpartum on pregnancy outcome in ET; nevertheless, confirmation by prospective documentation is mandatory.

Paroxysmal nocturnal haemoglobinuria: a replacement of haematopoietic tissue?

Acquired somatic mutations of the PIG-A gene lead to deficient expression of glycosyl-phosphatidyl-inositol-anchored proteins (GPI-AP) by haematopoietic cells and play a causative role in the pathogenesis of paroxysmal nocturnal haemoglobinuria (PNH). However, PIG-A mutations do not explain how the defective PNH clone can expand. It was hypothesized that a selection process conferring a relative advantage to the GPI-AP-deficient population is required. Since GPI-AP-deficient cells are also detectable in a substantial proportion of patients with otherwise typical aplastic anaemia (AA), the mechanisms inducing bone marrow failure might selectively spare the GPI-deficient cells. In order to examine the growth characteristics of GPI-AP-deficient cells in more detail, we performed repeated analyses of GPI-AP expression on peripheral blood cells in 41 patients with AA. We observed four patterns of the course of GPI-AP-deficient populations: (1) 13 patients showed normal expression of GPI-AP in the first analysis and in at least two follow-up studies at a median time of 709 days after the first analysis. (2) Secondary evolution of a GPI-AP-deficient population was a rare event. Only 4 patients with initially normal GPI-AP expression developed a GPI-AP-deficient population during follow up after immunosuppressive treatment. (3) Persistence of GPI-AP-deficient cells was observed in 16 patients during a median follow-up time of 774 days. However, in some patients, the size of the GPI-AP-deficient population increased substantially. (4) Disappearance of a GPI-AP-deficient population was observed in 8 patients. The time course of GPI-AP expression in relation to the treatment suggests that therapeutic interventions might modulate the ratio of normal versus GPI-AP-deficient haematopoiesis. Overall, these data argue against an 'absolute growth advantage' of GPI-AP-deficient cells. Our data are consistent with the hypothesis that haematopoietic failure caused by damage to normal haematopoiesis allows the outgrowth of a GPI-AP-deficient population. Thus, in at least some patients GPI-AP-deficient cells might pre-exist at a very low percentage and replace haematopoiesis after an insult to the normal cells.

Fine needle aspiration cytology in extramedullary plasmacytoma

OBJECTIVE

Extramedullary plasmacytoma is a rare plasma cell neoplasm. It can occur as the sole manifestation of plasma cell neoplasm, as a metastasis from another extramedullary plasmacytoma, as a solitary plasmacytoma of the bone or as a consequence of multiple myeloma. These plasma cell tumors can occur anywhere and have to be differentiated from other neoplasms, infectious processes and chloroma.

STUDY DESIGN

We report the findings of fine needle aspiration cytology (FNAC) in 18 patients with extramedullary plasmacytoma. In six patients extramedullary plasmacytoma was the initial presentation of plasma cell neoplasm. In the remaining 12 patients the tumors occurred under or after treatment of plasma cell disease.

RESULTS

Eleven lesions were located in the skin, seven in the lymph nodes, one in the liver and another in the spleen. Two patients with known diagnoses of plasma cell disease were thought, before FNAC, to have an infection, and two had a histologic diagnosis of non-Hodgkin's lymphoma. In 13 of 18 patients, cytologic smears showed anaplastic plasma cells.

CONCLUSION

FNAC is a front-line investigative procedure in diagnosing extramedullary plasmacytoma.

Healing characteristics of small-calibre vascular prostheses coated with plasmin-treated fibrin--an experimental study

BACKGROUND

The autogenous vein represents the graft material of choice in crural and pedal bypass surgery. Because of the numerous problems concerning the graft harvesting and the quality of autogenous vein material an equally good allogenous graft is urgently needed. Up to the present times no such graft material has been able to achieve the success of vein grafts.

METHODS

We investigated the knitted polyester prosthesis Terumo PF-V (Terumo Comp., Japan), diameter 5 mm with outer reinforce, which is characterized by a new coating of plasmin-treated fibrin. Grafts were implanted as bypass into the ligated carotid (n = 10) and femoral arteries (n = 10) of 10 dogs (beagles). As a control 5 mm-ePTFE-prostheses (Impra Carboflo) were implanted simultaneously on the contralateral side.

RESULTS

After 6 months, seven of 20 PF-V-grafts and 8 of 20 PTFE-grafts were patent. All prostheses presented with good macroscopic healing characteristics. In the patent grafts, angiography showed no substantial stenoses. The histological examination of the material was performed using light microscopy, transmission polarising microscopy, scanning electron microscopy, and transmission electron microscopy. Both types of prostheses showed the typical pattern of graft healing by migration of mesenchymal cells through the prosthesis, formation of capillaries, and growing of a neointima with endothelium-like cells. All failed bypass grafts presented with an occluding proliferation from the arterial wall into the anastomotic region.

CONCLUSIONS

Using clinically or histologically evaluation, neither graft demonstrated superiority over the other. The results indicate that the coating plays only a minor role for graft healing if any. For proper graft function, the arterial wall proliferation at the anastomotic region, which is not dependent on the type of prosthesis, appears to be most important. The overall results concerning both types of prostheses were disappointing.

[3D models for diagnosis and treatment planning in cardiology]

Due to the development new of imaging devices which produce a large number of tomographic slices, advanced techniques for the evaluation of the large amount of data are required. Computer supported extraction of dynamic 3D-models of the patients anatomy from temporal series thus is highly desirable. Since the diagnostician should be able to quickly make sensible decisions based on the models, high accuracy is required within a minimum of time. We present modeling and visualization techniques that are realized within the Cardiac Station. Results for the application of these techniques to cardiac image data demonstrate their usability. Besides giving information about the patients morphology functional parameters can be derived from the data and visualized together with the model. In order to verify the model with the original image data and for the planning of real intervention interaction techniques are presented.

[Congenital poikiloderma with verruciform hyperkeratoses (Dowling type)]

A male patient with congenital poikiloderma (type Dowling) developed Bowen's disease and initial squamous cell carcinoma. As the patient suffered from hypertriglyceridaemia (Frederickson type IV) and a long term tumor prophylaxis with retinoids was not appropriate, we attempted to treat the hyperkeratotic plaques with dermabrasion. After a period of six month we found complete healing of several plaques and only slight keratoses left in a few others. Long term follow up results are not yet available. Through this case report, the heterogenous clinical picture of congenital poikiloderma with warty hyperkeratoses and its high risk of malignancies is discussed.

Recent developments in the treatment of atopic eczema

Atopic eczema remains a therapeutic challenge. However, new developments in the understanding of the pathogenesis of this complex disease have prompted new therapeutic strategies. This review focuses on recently described treatment modalities for atopic eczema that are currently available or under investigation. The effectiveness of phototherapy, cytokines, and immunosuppressive drugs is evaluated. In addition, some new and promising but still experimental approaches are discussed.

[Prurigo pigmentosa]

We report the first case of prurigo pigmentosa in the German literature. For over a year, a 16-year old white girl developed an immensely pruritic symmetrical reticular, papulovesicular eruption on the trunk, axillae and pubic region. Histologically a superficial perivascular spongiotic and lichenoid inflammatory pattern with prominent pigmentary incontinence in older lesions was observed. Topical corticosteroids and systemic antihistamines had no effect. Systemic corticosteroids and diaminophenylsulphone (DADPS) produced improvement but could not prevent recurrences. Healing occurred only after 4 weeks of systemic-minocycline.

Virtual reality in the operating room of the future

In cooperation with the Max-Delbrück-Centrum/Robert-Rössle-Klinik (MDC/RRK) in Berlin, the Fraunhofer Institute for Computer Graphics is currently designing and developing a scenario for the operating room of the future. The goal of this project is to integrate new analysis, visualization and interaction tools in order to optimize and refine tumor diagnostics and therapy in combination with laser technology and remote stereoscopic video transfer. Hence, a human 3-D reference model is reconstructed using CT, MR, and anatomical cryosection images from the National Library of Medicine's Visible Human Project. Applying segmentation algorithms and surface-polygonization methods a 3-D representation is obtained. In addition, a "fly-through" the virtual patient is realized using 3-D input devices (data glove, tracking system, 6-DOF mouse). In this way, the surgeon can experience really new perspectives of the human anatomy. Moreover, using a virtual cutting plane any cut of the CT volume can be interactively placed and visualized in realtime. In conclusion, this project delivers visions for the application of effective visualization and VR systems. Commonly known as Virtual Prototyping and applied by the automotive industry long ago, this project shows, that the use of VR techniques can also prototype an operating room. After evaluating design and functionality of the virtual operating room, MDC plans to build real ORs in the near future. The use of VR techniques provides a more natural interface for the surgeon in the OR (e.g., controlling interactions by voice input). Besides preoperative planning future work will focus on supporting the surgeon in performing surgical interventions. An optimal synthesis of real and synthetic data, and the inclusion of visual, aural, and tactile senses in virtual environments can meet these requirements. This Augmented Reality could represent the environment for the surgeons of tomorrow.

Successful treatment of generalized lichen planus with recombinant interferon alfa-2b

Three patients with generalized lichen planus were treated with interferon alfa-2b. The therapy was tolerated well by all patients with only minor side effects. A response was observed within 2 to 3 weeks. Itching and erythema decreased first, followed by gradual flattening and disappearance of papules and plaques after 8 to 10 weeks of treatment. After 12 weeks, therapy was discontinued after stepwise dosage reduction. In two patients, minor lesions recurred during dosage reduction. Both flares were controlled by readministration of interferon.

Successful treatment of epidermolysis bullosa acquisita using intravenous immunoglobulins

We report a 55-year-old man with severe inflammatory epidermolysis bullosa acquisita. The skin lesions did not respond to various immunosuppressive treatments. The combined administration of prednisone, azathioprine, dapsone and colchicine resulted only in a transient and incomplete resolution of the lesions. The bullae and increased skin fragility were successfully controlled by the addition of high-dose intravenous immunoglobulin therapy.

Eosinophilic pustular folliculitis: successful treatment with interferon-alpha

Eosinophilic pustular folliculitis (Ofuji's disease) is a rare skin disease of unknown etiology characterized by infiltrated circinate plaques with sterile follicular pustules in primarily seborrheic areas. Several therapeutic regimens have been reported to control the disease with inconsistent results. We here report on a patient with Ofuji's disease, who was successfully treated with interferon-alpha 2b.

Interaction of the small interstitial proteoglycans biglycan, decorin and fibromodulin with transforming growth factor beta

We have analysed the interactions of three proteoglycans of the decorin family, decorin, biglycan and fibromodulin, with transforming growth factor beta (TGF-beta). The proteoglycan core proteins, expressed from human cDNAs as fusion proteins with Escherichia coli maltose-binding protein, each bound TGF-beta 1. They showed only negligible binding to several other growth factors. Intact decorin, biglycan and fibromodulin isolated from bovine tissues competed with the fusion proteins for the TGF-beta binding. Affinity measurements suggest a two-site binding model with Kd values ranging from 1 to 20 nM for a high-affinity binding site and 50 to 200 nM for the lower-affinity binding site. The stoichiometry indicated that the high-affinity binding site was present in one of ten proteoglycan core molecules and that each molecule contained a low-affinity binding site. Tissue-derived biglycan and decorin were less effective competitors for TGF-beta binding than fibromodulin or the non-glycosylated fusion proteins; removal of the chondroitin/dermatan sulphate chains of decorin and biglycan (fibromodulin is a keratan sulphate proteoglycan) increased the activities of decorin and biglycan, suggesting that the glycosaminoglycan chains may hinder the interaction of the core proteins with TGF-beta. The fusion proteins competed for the binding of radiolabelled TGF-beta to Mv 1 Lu cells and endothelial cells. Affinity labelling showed that the binding of TGF-beta to betaglycan and the type-I receptors in Mv 1 Lu cells and to endoglin in endothelial cells was reduced, but the binding to the type-II receptors was unaffected. TGF-beta 2 and 3 also bound to all three fusion proteins. Latent recombinant TGF-beta 1 precursor bound slightly to fibromodulin and not at all to decorin and biglycan. The results show that the three decorin-type proteoglycans each bind TGF-beta isoforms and that slight differences exist in their binding properties. They may regulate TGF-beta activities by sequestering TGF-beta into extracellular matrix.

Histidine residues near the N terminus of staphylococcal alpha-toxin as reporters of regions that are critical for oligomerization and pore formation

Chemical modification of histidine residues in staphylococcal alpha-toxin leads to loss of functional activity. Site-directed mutants of the toxin in which each of the four histidine residues was replaced by several amino acids were therefore produced. The mutant proteins were purified and characterized. Exchange of H-259 or H-144 was sometimes tolerated without reduction in hemolytic activity. These histidine residues are thus not essential for toxin function. Exchange of H-35 and H-48, however, had marked effects. H-35 mutant toxins bound with high affinity to rabbit erythrocytes but displayed faulty oligomerization and were unable to form pores. H-48 mutant toxins also had severely impaired hemolytic activity due probably to faulty hexamerization. We interpret these results to indicate that the N-terminal domain of alpha-toxin in the region of H-35 and H-48 is involved in protomer-protomer interactions that underlie the hexamerization and pore-forming process.

Localization of transforming growth factor beta binding site in betaglycan. Comparison with small extracellular matrix proteoglycans

The most abundant binding molecule for transforming growth factor beta (TGF-beta) on many cell types is betaglycan, a transmembrane proteoglycan. To localize the binding site for TGF-beta in betaglycan, parts of the betaglycan extracellular portion were expressed as recombinant fusion proteins in bacteria and tested for their ability to compete for the binding of TGF-beta 1 to Hep G2 cells. One fragment encompassing 226 residues near the transmembrane domain (amino acids 543-769) (López-Casillas, F., Cheifetz, S., Doody, J., Andres, J. L., Lane, W. S., and Massagué, J. (1991) Cell 67, 785-795) was active, whereas fusion proteins representing the other parts of the betaglycan ectodomain were inactive. Affinity measurements revealed two classes of binding sites (Kd = 3.9 nM and Kd = 145 nM) for the active fusion protein. The binding of the betaglycan fusion protein to immobilized TGF-beta 1 was inhibited by fusion proteins representing the core proteins of the small interstitial proteoglycans decorin, biglycan and fibromodulin, each also known to bind TGF-beta. The effective concentrations of TGF-beta for binding to these other proteoglycans were similar to those required for binding to betaglycan, indicating similar affinities for the binding of proteoglycans and betaglycan. Affinity cross-linking showed that, at low concentrations, the betaglycan fragment enhanced the binding of TGF-beta to the type II receptor and to endogenous betaglycan but had no effect on the binding to type I receptor. At high concentrations, the TGF-beta binding fragment inhibited the binding of TGF-beta to all these receptors. The fragment enhanced the activity of TGF-beta in mink lung cell bioassay at all active concentrations. The results indicate that betaglycan and the decorin type proteoglycans all bind to the same or closely spaced sites in TGF-beta and compete with one another for the binding. In addition, betaglycan may cooperate with the type II receptor on TGF-beta binding.

A novel integrin specificity exemplified by binding of the alpha v beta 5 integrin to the basic domain of the HIV Tat protein and vitronectin

Several studies have addressed the interaction of the HIV Tat protein with the cell surface. Our analysis of the cell attachment-promoting activity of Tat and peptides derived from it revealed that the basic domain of Tat, not the arg-gly-asp (RGD) sequence, is required for cell attachment to Tat. Affinity chromatography with Tat peptides and immunoprecipitation with various anti-integrin antibodies suggest that the vitronectin-binding integrin, alpha v beta 5, is the cell surface protein that binds to the basic domain of Tat. The Tat basic domain contains the sequence RKKRRQRRR. A related sequence, KKQRFRHRNRKG, present in the heparin-binding domain of an alpha v beta 5 ligand, vitronectin, also bound alpha v beta 5 in affinity chromatography and, in combination with an RGD peptide, was an inhibitor of cell attachment to vitronectin. The alpha v beta 5 interaction with these peptides was not solely due to high content of basic amino acids in the ligand sequences; alpha v beta 5 did not bind substantially to peptides consisting entirely of arginine or lysine, whereas a beta 1 integrin did bind to these peptides. The interaction of alpha v beta 5 with Tat is atypical for integrins in that the binding to Tat is divalent cation independent, whereas the binding of the same integrin to an RGD-containing peptide or to vitronectin requires divalent cations. These data define an auxiliary integrin binding specificity for basic amino acid sequences. These basic domain binding sites may function synergistically with the binding sites that recognize RGD or equivalent sequences.

Staphylococcus aureus alpha-toxin. Dual mechanism of binding to target cells

Staphylococcal alpha-toxin was radiolabeled to high specific radioactivity (1,500-3,000 Ci/mmol) under retention of its hemolytic activity. Binding studies with susceptible rabbit erythrocytes and highly resistant human erythrocytes revealed that binding of alpha-toxin to target cells can occur via two different mechanisms. Binding of alpha-toxin to rabbit erythrocytes initially involves specific binding sites and occurs at low concentrations, with half-maximal binding at 1-2 nM. In contrast, toxin binding to human erythrocytes is absorptive and nonspecific, in this case, significant binding as well as hemolysis occur only at alpha-toxin concentrations exceeding 1 microM. Autoradiographic analyses of membrane-associated alpha-toxin from either cell species proved that hemolysis was inevitably associated with the formation of toxin hexamers. Our data indicate that the high susceptibility of certain target cells toward alpha-toxin is caused by the presence of specific binding sites. However, membrane damage of both susceptible and nonsusceptible target cells occurs via a common mechanism involving toxin oligomerization and pore formation.

A novel beta-endorphin binding protein. Complement S protein (= vitronectin) exhibits specific non-opioid binding sites for beta-endorphin upon interaction with heparin or surfaces

Human beta-endorphin (1-31) (beta H-endorphin) was found to specifically interact with purified complement S protein from human plasma. As found by chemical cross-linking beta H-endorphin bound to both, the 65- and 75-kDa molecular mass forms of S protein. The interaction of S protein with heparin as well as the adsorption of S protein to surfaces led to an almost 10-fold increase of specific binding which was due to the exposure of further beta H-endorphin-binding sites. The interaction of beta H-endorphin with S protein bore characteristics of a ligand-receptor interaction, such as time dependence, reversibility, high affinity, saturability, and structural specificity and was mediated through the non-opioid COOH terminus of the beta H-endorphin molecule. beta H-Endorphin binding to S protein was observed at physiological pH or cation concentrations, indicating that the interaction may well occur in vivo. Our results provide conclusive evidence that interactions of S protein with very different effectors led to similar conformational changes which uniformly resulted in exposure of a highly specific beta H-endorphin binding domain on S protein. With S protein as major beta H-endorphin-binding protein in the periphery, the molecular basis of a widespread system of humoral target sites of the neuroendocrine effector appears to be established. In view of S protein involvement in processes of inflammation and wound repair and beta-endorphin effects on immunocompetent cells, the demonstrated S protein-beta H-endorphin interaction appears to be of considerable functional significance.

Characterization of albumin-binding properties of Peptostreptococcus magnus

A Peptostreptococcus magnus strain demonstrated binding activity for albumin preparations from humans, mice, and dogs, but not for rabbit or bovine albumin. The albumin binding site appeared to be heat stable and of protein nature. Treatment of P. magnus cells with trypsin under specified conditions enhanced this albumin binding. Electron micrographs and kinetic analyses revealed that this enhancement was the result of the removal of some cell wall associated proteins leading to a higher binding affinity without significant changes in binding site numbers. The albumin-binding proteins could be readily solubilized and purified by affinity chromatography. Upon gel electrophoresis the molecular mass of the albumin-binding proteins was estimated as 130 kilodaltons.

Identification of the beta-endorphin-binding subunit of the SC5b-9 complement complex: S protein exhibits specific beta-endorphin-binding sites upon complex formation with complement proteins

Beta-Endorphin has been reported to specifically interact with SC5b-9 complement complexes via non-opioid binding sites. Covalent cross-linking of [125I]beta H-endorphin to SC5b-9 and analysis of the cross-linking products by gel electrophoresis and subsequent autoradiography revealed a single specifically labelled species which was identical with the S protein subunit of the complement complex. In contrast to SC5b-9, no cross-linking of labelled beta-endorphin to subunits of C5b-9(m) could be observed, indicating that beta-endorphin binding to SC5b-9 was mediated exclusively via S protein. Beta-Endorphin binding to SC5b-9 was compared with binding to purified S protein. Whereas beta-endorphin binding to purified S protein was only modest, complex formation of S protein with complement proteins led to a strong increase in beta-endorphin-binding site concentration, compatible with the exposure of primarily cryptic beta-endorphin-binding sites on S protein.

Hydrophobic labelling of membrane-embedded proteins with lipophilic reagents. Incorporation of [125I]INA and [125I]TID into B lymphocyte membrane immunoglobulins

Hydrophobic labelling is frequently used in the study of membrane-inserted domains of intrinsic proteins. However, the published procedures, fail to incorporate sufficient radioactivity into membrane immunoglobulins of B lymphocytes to permit investigation of their subunit structures and associations with other proteins. In order to increase the specific radioactivity of [125I]iodonaphthylazide ([125I]INA), an improved method for the synthesis of the reagent was developed. In addition, the optimal conditions for labelling B lymphocytes with [125I]INA and the commercially available reagent 3-(trifluoromethyl)-3-(3'-[125I]iodophenyl)diazirine ([125I]TID) were elaborated. Under these optimized conditions, Ig molecules labelled with [125I]INA and [125I]TID were isolated and analysed in detail by SDS-PAGE. The usefulness of the two reagents for the investigation of lipid-embedded domains of membrane proteins is discussed.

Binding activity of Streptococcus canis for albumin and other plasma proteins

All 24 cultures of Streptococcus canis examined bound 125I-labelled human albumin, IgG and fibrinogen; but neither IgA nor haptoglobin. Binding of human albumin was time-dependent, saturable and reversible by the addition of unlabelled albumin. The binding of 125I-labelled human albumin could be inhibited completely by unlabelled albumin preparations from humans, mice and dogs, and partly by bovine albumin. In contrast, binding of 125I-labelled human albumin was not inhibited by unlabelled rabbit albumin, human IgG or human fibrinogen. Data from competition experiments of two S. canis cultures with high 125I-labelled albumin-binding activities yielded KD values of 10 and 15 nmol l-1, respectively. The estimated number of binding sites per bacterial cell ranged from 30,000 to 57,000. The binding factor for albumin could be isolated from S. canis by boiling the bacteria at pH 2, and it was purified by affinity chromatography on human albumin-Sepharose. The isolated albumin-binding proteins had a molecular mass of approximately 51 kDa and inhibited binding of 125I-labelled albumin to S. canis. They formed complexes with human albumin that altered its electrophoretic mobility.