Does ultrasound-guided intervention during repeat cesarean sections improve uterine scar architecture and reduce the number of scars? A prospective controlled clinical intervention trial

Purpose To evaluate whether intraoperative ultrasound-guided detection and resection of the uterine scar during repeat/second cesarean can reduce the number of scars and improve uterine scar architecture. Materials and methods A prospective controlled clinical intervention trial was performed with the following groups: control group 1 (CS1-G): first cesarean; control group 2 (CS2-G): second cesarean utilizing the usual procedure and intervention group (Int-G): repeat/second cesarean with intervention. Transvaginal ultrasound scans were performed 6-9 months after each cesarean. Both primary (double scarring rate) and secondary outcomes [deficiency ratio=d/(b+d)] were analyzed. The deficiency ratio describes the thinning of the remaining myometrium (d=residual myometrial thickness) over the "apparent" defect (b=scar depth). Results In total, 124 of the 156 recruited women were examined, eight were excluded from analysis. The double scarring rate decreased from 42.9% (12/28) in CS2-G to 7.1% (2/28) in the Int-G [difference: 35.8%; 95% confidence interval (CI) (13.2, 54.5); P=0.002]. Two-way analysis of variance (ANOVA) revealed a significant difference between CS2-G and the Int-G in the deficiency ratio adjusted for elective/primary cesareans, with thicker remaining myometrium over the scar defect in the Int-G [difference: -0.24; 95% CI (-0.34, -0.15); P<0.001]. Conclusion Ultrasound-guided resection of the uterine scar area during repeat cesareans reduces the scarring rate and improves thickness of the remaining myometrium as detected by ultrasonography 6-9 months postoperatively.

Technique of sonographic assessment of lower uterine segment in women with previous cesarean delivery: a prospective, pre/intraoperative comparative ultrasound study

OBJECTIVE

The purpose of this study was: (A) to establish the effects of different ultrasound measurement methods (linear versus curved array) and measuring conditions [impact of pressure by fetal head/pelvis on the lower uterine segment (LUS)] during LUS-muscular-thickness measurement, (B) to introduce the intraoperative ultrasound measurement of LUS-muscular thickness (reference measurement method), and (C) to evaluate the correlation between different combinations of LUS-muscular-thickness measurement ultrasound techniques at birth planning and preoperative versus intraoperative measurements.

METHODS

A prospective clinical observational study of women with the previous cesarean delivery was conducted. LUS-muscular thickness was measured: first at birth planning and second preoperatively using linear and curved probes (transabdominal) and an endocavitar probe (transvaginal), examined with and without pressure by fetal head/pelvis on LUS during measurement and third intraoperatively during repeat cesarean. Bland-Altman plots, paired t tests, Pearson's correlation coefficient, and scatter plots were used.

RESULTS

Thirty-three women were included in the study (ultrasound measurements: n = 601). There was no systematic difference between LUS-muscular-thickness measurements with linear versus curved array (mean difference = 0.06 mm; p = 0.24; n_m = 133) but between measurements with pressure by the fetus versus without (mean difference = - 0.37 mm; p < 0.001; n_m = 243). The highest correlation coefficients were detected for the preoperative (at the day of cesarean section), transabdominal-vaginal approach combined ultrasound measurements versus the intraoperative ultrasound measurements of LUS-muscular thickness-as long as the measurements were made without pressure from the fetal head/pelvis on the LUS [0.86, p < 0.001, n = 24, 95% CI (0.70, 0.94)].

CONCLUSIONS

The systematic application of predetermined measuring conditions, standardized setup criteria improves the performance of LUS thickness measurement by ultrasound near term. CLINICALTRIALS.

GOV IDENTIFIER

NCT02827604.

Positron Emission Tomography (PET) and PET/CT in Thyroid Cancer: A Systematic Review and Meta-Analysis

BACKGROUND

Positron emission tomography (PET) and PET/CT are functional imaging methods that are widely used in diagnostic procedures in oncology.

OBJECTIVES

The objective of this study was to assess the patient-relevant benefit of PET or PET/CT in patients with thyroid cancer based on a literature review and meta-analysis.

METHODS

A systematic review including studies that had been published until December 2013 was performed. To be included, studies had to prospectively investigate patients with thyroid cancer in a clinical setting of staging, restaging, or diagnosing tumour recurrence.

RESULTS

Out of 3,506 potentially relevant articles, 29 studies were included. No study directly evaluated the benefits of PET. Twenty-eight studies dealt with the diagnostic accuracy of PET or PET/CT, and 1 study evaluated the prognostic value of PET/CT. The authors showed that a positive result of PET/CT in restaging patients with differentiated thyroid cancer yielded a significant decrease in overall survival (hazard ratio, HR 5.01, CI 3.41-6.62). In patients with suspected recurrence of differentiated thyroid cancer, meta-analysis showed higher sensitivity of PET (89.7%, CI 78-99%) and PET/CT (94.3%, CI 87-97%) compared with conventional imaging (65.4%, CI 32-88%) and comparable results for specificity. Due to the low numbers of studies and patients, meta-analyses on medullary carcinoma did not produce meaningful results.

CONCLUSION

The patient-relevant benefits of PET or PET/CT in thyroid cancer could not be evaluated satisfactorily based on the included studies. It remains unclear whether higher diagnostic test accuracy leads to changes in therapeutic strategies and better patient-relevant outcomes.

Survival of Hypercapnic Patients with COPD and Obesity Hypoventilation Syndrome Treated with High Intensity Non Invasive Ventilation in the Daily Routine Care

BACKGROUND

Home ventilation is an effective treatment option for obesity hypoventilation syndrome (OHS). This therapy is still controversial for stable chronic obstructive pulmonary disease (COPD). A recent study showed reduced mortality for COPD patients receiving home ventilation with high inflation pressures and back-up respiratory rates [so called High Intensity non-invasive ventilation (NIV)].

OBJECTIVE

The purpose of this study is whether High Intensity NIV applied in the routine care of COPD and OHS patients can lead to CO₂ reduction and survival data comparable to data from controlled studies.

METHOD

In this prospective non interventional study fifty-one patients with COPD (FEV1 0.95l, corr. 32.8%) and 34 patients with OHS (VC 1.74l, corr. 50.7%) with chronic hypercapnic respiratory failure, who were treated with NIV were followed up for four years.

RESULTS

Elevated CO₂ values before NIV in COPD patients (8.6kPa), and in OHS patients (8.3kPa), could be lowered significantly to the upper normal range (COPD: 5.9kPa; OHS: 5.85kPa). The one-, two-, and three-year survival rates for COPD patients were 83%, 73%, and 55%, respectively. The one-, two-, and three-year survival rates for OHS patients were 85%, 72%, and 68%, respectively.

CONCLUSION

High intensity NIV within routine care is effective in reducing blood CO₂ levels in COPD- and in OHS- related chronic respiratory insufficiency. The survival rates obtained here are comparable to data from controlled clinical trials on COPD.

Etiology and clinical relevance of elevated platelet count in ICU patients : A retrospective analysis

BACKGROUND

Thrombocytosis is a common phenomenon in critically ill patients. Although thrombocytosis is an independent risk factor for complications, it does not seem to influence mortality in intensive care (ICU) patients.

OBJECTIVES

Our investigation aimed to evaluate the etiological and clinical relevance of a platelet count greater than 450 × 10⁹/l in ICU patients.

MATERIALS AND METHODS

Patients admitted for a minimum of 4 days to an interdisciplinary ICU during a 45-month period were enrolled in this retrospective observational study. Thrombocytopenic patients (platelet count <150 × 10⁹/l in at least one measurement) were excluded. The study patients were divided into two groups: thrombocytosis group (thrombocytes >450 × 10⁹/l in at least one measurement) and control group (thrombocytes = 150 - 450 × 10⁹/l during ICU stay). Univariate and multiple regression analysis were used to determine the influence of severe co-morbidities on the development of thrombocytosis and the association of elevated platelet count with thrombotic embolism, length of stay (LOS) in ICU, and mortality.

RESULTS

A total of 307 patients were analyzed, of whom thrombocytosis was observed in 119 cases. Independent risk factors for the development of thrombocytosis included SIRS, mechanical ventilation, and acute bleeding. Increasing age reduced the risk of thrombocytosis. Thromboembolism occurred in 16 patients (13.4%) with an elevated platelet count and only in nine patients (4.7%) with physiological platelet values (OR: 3.1; 95% CI: 1.3-7.2; p = 0.009). Mean duration of LOS was significantly longer in patients with thrombocytosis (25.2 vs.11.7 days, p < 0.0001). Elevated platelet count showed a negative correlation with ICU mortality (OR: 0.32; 95%-CI: 0.12-0.83; p = 0.019).

CONCLUSION

In our retrospective analysis the occurrence of thrombocytosis in a cohort of interdisciplinary ICU patients was associated with a higher rate of complications and longer LOS in the ICU. Despite these findings, thrombocytosis seems to reduce mortality in critical ill patients.

[Prognostic value of lacrimal duct diagnostics after tube removal : Retrospective analysis of risk of relapse during the first postoperative year after transcanalicular lacrimal duct surgery with silicone tubing]

BACKGROUND

Transcanalicular lacrimal duct surgery has become more important over the past two decades.

OBJECTIVES

The aim of the study was to prove the prognostic value of postoperative lacrimal syringing and the testing of spontaneous drainage of lacrimal fluid immediately after tube removal.

METHODS

A total of 110 cases with postoperative lacrimal syringing and 183 cases with verification of the postoperative lacrimal fluid drainage performed between January 2001 and August 2008 were retrospectively evaluated. The indication for postoperative diagnostics was set by the investigator. The prognostic value of these two procedures was determined by using prognostic parameters (positive predictive value, PPV; negative predictive value, NPV) and analyzing recurrence nonexistence via Cox regression and Kaplan-Meier estimator. The observation period was limited to 12 months. Predominantly, recurrence was defined on the patient's satisfaction and absence of symptoms, which was determined with the help of a questionnaire.

RESULTS

Postoperative verification of the lacrimal syringing is a suitable instrument to estimate surgical success within the first year after lacrimal surgery with a PPV of 92.31%. Testing of the spontaneous drainage of lacrimal fluid after tube removal reached a PPV of 63.33%.

CONCLUSION

The proven prognostic value shows that syringing of the lacrimal duct and verification of spontaneous drainage should be integrated into postoperative care in a standardized manner. Hereby, early information for the patient about the expected result of the surgical procedure is enabled.

[Dentists' Knowledge of Ethical Questions Regarding Dental Medicine - A Survey of Dentists from Saxony, Saxony-Anhalt and Thuringia (Germany)]

Background: Subjects regarding ethical questions in dental medicine are only slightly touched in the study of dental medicine or in the working regulations of the dentists' association. However, dentists are confronted with these matters in everyday working life. The empirical study at hand collects current data regarding the ethical knowledge about dental medicine in the practical experience of dentists in Saxony, Saxony-Anhalt, and Thuringia. Methods: The tool used in the survey was a structured questionnaire. Out of 600 randomly chosen and contacted dentists from Saxony, Saxony-Anhalt, and Thuringia, 290 replied (response rate: 48.3%). The anonymised assessment took place between June and November 2013. Results: Dentists frequently encounter ethical questions regarding dental matters. The dentists interviewed in the study are in favour of a participative relationship between patient and dentist. Simultaneously, the patient's health is predominantly seen as the good of higher value than his or her self-determination. The dentists show competent knowledge of ethical dental subjects, although increased uncertainties could be observed in more complex situations, e. g. considering contact with patients who are HIV-positive. Conclusions: Questions dealing with dental ethical questions do play a major role in the daily professional life of dentists. In order to further support and strengthen dentists in their individual dental ethical competence, we see a need for advanced training and further education regarding questions and problems in the area of ethics in dental medicine. Also, these topics should become a component in the curriculum of the study of dental medicine.

[Drug delivery strategies for targeted treatment of inflammatory bowel disease]

Inflammatory bowel disease (IBD) is a frequently occurring disease in young people, which is characterized by chronic inflammation of the gastrointestinal tract. The therapy of IBD is dominated by the administration of anti-inflammatory and immunosuppressive agents, which suppress the intestinal inflammatory burden and improve the disease-related symptoms. Present treatment strategies are characterized by a limited therapeutical efficacy and the occurrence of adverse drug reactions. The development of novel disease-targeted drug delivery strategies is preferable for a more effective therapy and thus demonstrates the potential to address unmet medical needs. This review gives an overview about drug delivery strategies for the treatment of IBD. Therefore, established intestine-targeting strategies for a selective drug release into the diseased part of the gastrointestinal tract will be presented, including prodrugs, and dosage forms with pH-/time-dependent drug release. Furthermore future-oriented disease-targeting strategies for a selective drug release into the intestinal inflammation will be described, including micro-/nanosized synthetic and biologic drug carriers. This novel therapeutic approach may enable a more effective anti-inflammatory treatment of IBD with reduced risks of adverse reactions.

Immune signature of tumor infiltrating immune cells in renal cancer

Tumor-associated immune cells have been discussed as an essential factor for the prediction of the outcome of tumor patients. Lymphocyte-specific genes are associated with a favorable prognosis in colorectal cancer but with poor survival in renal cell carcinoma (RCC). Flow cytometric analyses combined with immunohistochemistry were performed to study the phenotypic profiles of tumor infiltrating lymphocytes (TIL) and the frequency of T cells and macrophages in RCC lesions. Data were correlated with clinicopathological parameters and survival of patients. Comparing oncocytoma and clear cell (cc)RCC, T cell numbers as well as activation-associated T cell markers were higher in ccRCC, whereas the frequency of NK cells was higher in oncocytoma. An intratumoral increase of T cell numbers was found with higher tumor grades (G1:G2:G3/4 = 1:3:4). Tumor-associated macrophages slightly increased with dedifferentiation, although the macrophage-to-T cell ratio was highest in G1 tumor lesions. A high expression of CD57 was found in T cells of early tumor grades, whereas T cells in dedifferentiated RCC lesions expressed higher levels of CD69 and CTLA4. TIL composition did not differ between older (>70 y) and younger (<58 y) patients. Enhanced patients' survival was associated with a higher percentage of tumor infiltrating NK cells and Th1 markers, e.g. HLA-DR+ and CXCR3+ T cells, whereas a high number of T cells, especially with high CD69 expression correlated with a worse prognosis of patients. Our results suggest that immunomonitoring of RCC patients might represent a useful tool for the prediction of the outcome of RCC patients.

Abstract 4725: Elevated co-expression of CCL2 and CX3CL1 is associated with apoptosis and good prognosis in soft tissue sarcoma patients

Background: Chemokines represent a group of chemotactic cytokines, which are involved in both negative and positive regulation of inflammatory processes, angiogenesis, cancer cell proliferation and chemoattraciton of tumor cells to metastatic sites.

Material and methods: mRNA expression of CCL2 and CX3CL1 was determined in 126 patients with soft-tissue sarcoma using quantitative real-time PCR. Patient groups displaying low or high expression in their tumors were separated by the median expression of the markers. Kaplan-Meier analysis and multivariate Cox's regression analysis were performed to assess the correlation between chemokine expression levels and disease-specific survival in STS. To gain insight into the cell physiological consequences of inhibition of CCL2 and CX3CL1, siRNA-mediated knockdown was used. The effect on proliferation was analyzed by a BrdU Elisa. The effect on inhibition of apoptosis was analyzed by adding etoposide after transfection with the respective siRNA, followed by FACS analysis.

Results: The mRNA levels of CCL2, CCL7, and CX3CL1 were analyzed in tumor tissues from 126 STS patients using qPCR. Low mRNA expression of CCL2 and CX3CL1 was significantly correlated with a worse prognosis (RR = 1.98; p = 0.019 and RR = 2.10; p = 0.014; multivariate Cox's regression analysis). A combined low expression of CCL2 and CX3CL1 was associated with a significantly increased risk of tumor-related death compared to patients with high expression levels of both chemokines (RR = 3.08; p = 0.003). A gender-specific multivariate analysis revealed that female STS patients with low CX3CL1 mRNA expression had a 3.46-fold increased risk of death (p = 0.004). Low expression of both CCL2 and CX3CL1 mRNAs resulted in an additive 5.37-fold increased risk of tumor-related death (p = 0.003) compared to those with high expression of both parameters in female patients.

Treatment with siRNA against CX3CL1 revealed a significantly increased cell proliferation after 24h but this effect disappeared after 48h and 72 h, respectively. To test the effect of siRNA treatment against CCL2 or CX3CL1 on induction of apoptosis, after transfection with the respective siRNA, etoposide was added to induce apoptosis. A significant decrease in apoptosis induction could be detected after combined treatment with etoposide and siRNA against CCL2 (p = 0.0047) or against CX3CL1 (p = 0.0043) compared with the etoposide and non-targeting siRNAs treated control cells.

Conclusion: Our findings demonstrate that mRNA expression of CCL2 and CX3CL1 was significantly correlated with prognosis. Interestingly, there was a gender-specific impact of CCL2 on disease-specific survival. A significant decrease in apoptosis induction could be detected when cells were transfected with siRNA targeting CCL2 or CX3CL1 compared to the cells transfected with non-targeting siRNA.

Citation Format: Elke Nolte, Astrid Kehlen, Thomas Greither, Sven Wach, Matthias Kappler, Matthias Bache, Hans-Jürgen Holzhausen, Christine Lautenschläger, Steffen Göbel, Peter Würl, Uta-Dorothee Immel, Abbas Agaimy, Bernd Wullich, Helge Taubert. Elevated co-expression of CCL2 and CX3CL1 is associated with apoptosis and good prognosis in soft tissue sarcoma patients. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 4725. doi:10.1158/1538-7445.AM2014-4725

High coexpression of CCL2 and CX3CL1 is gender-specifically associated with good prognosis in soft tissue sarcoma patients

Chemokines are involved in both the negative and positive regulation of inflammatory processes, angiogenesis and cancer/cancer stem cell proliferation as well as the chemoattraction of tumor cells to metastatic sites. The aim of this study was to measure the mRNA expression levels of three chemokines, CCL2, CCL7 and CX3CL1, in soft tissue sarcomas (STSs) and to assess the correlations between these levels as well as their correlations with clinicopathological data and the disease-specific survival of STS patients. The mRNA levels of CCL2, CCL7 and CX3CL1 were analyzed in tumor tissues from 126 STS patients using qPCR. Low mRNA expression of CCL2 and CX3CL1 was significantly correlated with a worse prognosis (RR = 1.98; p = 0.019 and RR = 2.10; p = 0.014; multivariate Cox's regression analysis). A combined low expression of CCL2 and CX3CL1 was associated with a significantly increased risk of tumor-related death as compared to patients with high expression levels of both chemokines (RR = 3.08; p = 0.003). A gender-specific multivariate analysis revealed that female STS patients with low CX3CL1 mRNA expression had a 3.46-fold increased risk of death (p = 0.004). Low expression of both CCL2 and CX3CL1 mRNAs resulted in an additive 5.37-fold increased risk of tumor-related death (p = 0.003) as compared to those with high expression of both parameters in female patients. In conclusion, this is the first study to show a significant correlation between combined low expression of CCL2 and CX3CL1 and a poor prognosis for STS patients, particularly in female patients.

Confocal laser endomicroscopy reliably detects sepsis-related and treatment-associated changes in intestinal mucosal microcirculation

BACKGROUND

Microcirculatory alterations play a central role in the pathophysiology of sepsis. We investigated probe-based confocal laser endomicroscopy (pCLE) to assess alterations in mucosal microcirculatory perfusion in vivo in a porcine model of septic shock and in patients fulfilling consensus criteria for severe sepsis.

METHODS

Septic shock was induced using a faecal peritonitis model in anaesthetized, mechanically ventilated pigs. Mucosal microcirculation was assessed using pCLE in the stomach, duodenum, terminal ileum, and rectum. Duodenal microcirculation was further evaluated in 10 patients with severe sepsis and in 8 healthy controls to quantify capillary diameter, capillary length, and functional capillary density (FCD).

RESULTS

In the animal model, FCD was markedly decreased in duodenal (P<0.001), ileal (P<0.001), gastric (P<0.001), and rectal mucosa (P<0.005) 4 h after induction of sepsis. After volume therapy, FCD partially recovered to 90.0% (duodenum), 94.4% (ileum), 95.4% (gastric), and 97% (rectum) of baseline values, indicating decoupling of microvascular and macrovascular flow. In septic patients, the mean capillary diameter (P<0.01) and FCD (P<0.05) in duodenal mucosa were decreased compared with healthy controls.

CONCLUSIONS

pCLE reliably detected and quantified microcirculatory alterations in the gastrointestinal mucosa in a porcine model of sepsis and in patients with severe sepsis. Our data suggest that pCLE is a promising tool to assess the efficacy of therapeutic interventions on mucosal microcirculation in real-time, even in the clinical context.

Cyclosporine area under the curve after allogeneic hematopoietic stem cell transplantation is an indicator of Epstein-Barr virus DNAemia

Epstein-Barr virus (EBV) DNAemia and reactivation is a typical complication after allogeneic hematopoietic stem cell transplantation (HSCT). The degree of immunosuppression is closely linked to the risk of developing EBV DNAemia. An association of cyclosporine levels with EBV DNAemia has not been interrogated. Here, we analyzed cyclosporine levels in 58 patients after allogeneic HSCT. We discovered a wide range of cyclosporine trough level variation in the individual patient (median coefficient of variation [CV] 0.29, range 0.19-0.78). To overcome this high intra-individual variation in serum trough levels of cyclosporine, we calculated respective areas under the curve (AUC) and performed correlations with EBV DNAemia in 28 stem cell recipients at increased risk for EBV DNAemia. This resulted in a significant association of high cyclosporine AUC (> 6000 ng/mL × days) with EBV DNAemia after day 30 (relative risk [RR] 6.067, 95% confidence interval [CI] 1.107-33.238, p = 0.038). Conversely, mean cyclosporine values (threshold 200 ng/mL) between days 0 and 30 were not found to correlate with EBV DNAemia after day 30. Furthermore, CD3 + CD8 + graft content was inversely correlated with EBV DNAemia after day 30. These findings might establish a clinical role for the AUC of cyclosporine.

Expression of human Piwi-like genes is associated with prognosis for soft tissue sarcoma patients

Background

Argonaute genes are essential for RNA interference, stem cell maintenance and differentiation. The Piwi-like genes, a subclass of the Argonaute genes, are expressed mainly in the germline. These genes may be re-expressed in tumors, and expression of the Piwi-like genes is associated with prognosis in several types of tumors.

Methods

We measured the expression of Piwi-like mRNAs (Piwi-like 2–4) in 125 soft tissue sarcoma (STS) samples by qPCRs. Statistical tests were applied to study the correlation of expression levels with tumor-specific survival for STS patients.

Results

In multivariate Cox’s regression analyses, we showed that low Piwi-like 2 and Piwi-like 4 mRNA expression were significantly associated with a worse prognosis (RR = 1.87; p = 0.032 and RR = 1.82; p = 0.039). Low expression of both genes was associated with a 2.58-fold increased risk of tumor-related death (p = 0.01). Piwi-like 4 and combined Piwi-like 2 and 4 mRNA levels correlated significantly with prognosis (RR = 3.53; p = 0.002 and RR = 5.23; p = 0.004) only for female but not for male patients. However, combined low Piwi-like 2 and 3 transcript levels were associated with worse survival (RR = 5.90; p = 0.02) for male patients.

Conclusions

In this study, we identified a significant association between the expression of Piwi-like 2 and 4 mRNAs and the tumor-specific survival of soft tissue sarcoma patients. Furthermore, a connection between sex and the impact of Piwi-like mRNA expressions on STS patients’ prognosis was shown for the first time.

Factors influencing heterogeneity of radiation-induced DNA-damage measured by the alkaline comet assay

Background

To investigate whether different conditions of DNA structure and radiation treatment could modify heterogeneity of response. Additionally to study variance as a potential parameter of heterogeneity for radiosensitivity testing.

Methods

Two-hundred leukocytes per sample of healthy donors were split into four groups. I: Intact chromatin structure; II: Nucleoids of histone-depleted DNA; III: Nucleoids of histone-depleted DNA with 90 mM DMSO as antioxidant. Response to single (I-III) and twice (IV) irradiation with 4 Gy and repair kinetics were evaluated using %Tail-DNA. Heterogeneity of DNA damage was determined by calculation of variance of DNA-damage (V) and mean variance (Mvar), mutual comparisons were done by one-way analysis of variance (ANOVA).

Results

Heterogeneity of initial DNA-damage (I, 0 min repair) increased without histones (II). Absence of histones was balanced by addition of antioxidants (III). Repair reduced heterogeneity of all samples (with and without irradiation). However double irradiation plus repair led to a higher level of heterogeneity distinguishable from single irradiation and repair in intact cells. Increase of mean DNA damage was associated with a similarly elevated variance of DNA damage (r = +0.88).

Conclusions

Heterogeneity of DNA-damage can be modified by histone level, antioxidant concentration, repair and radiation dose and was positively correlated with DNA damage. Experimental conditions might be optimized by reducing scatter of comet assay data by repair and antioxidants, potentially allowing better discrimination of small differences. Amount of heterogeneity measured by variance might be an additional useful parameter to characterize radiosensitivity.

Prevention and health promotion in undergraduate medical education: Preferences, attitudes and previous knowledge of medical students - a cross-sectional study

Objective: The interdisciplinary topic "prevention and health promotion" (Q10) was introduced into the medical training in Germany by the new medical licensing regulations in 2004. For the conception of an effective curriculum, it is helpful to know student preferences concerning teaching-formats, attitudes and self-estimated previous knowledge. Little is known concerning student perception of “prevention and health promotion” in Germany. Thus, this explorative cross-sectional study aims to provide a first step for closing this gap.

Methods: Medical students (n=220) in the fifth academic year were asked to fill in a standardized questionnaire prior to the Q10 curriculum. Questions focused on preferences for teaching and testing formats and self-estimated previous knowledge as well as on rating the importance of prevention topics and health risks. The questions were multiple choice, five-point Likert scales and open-ended questions.

Results: A total of 94 students filled questionnaires (42% response rate). Prevention and health promotion was rated as “important” or “very important” for their “own medical professionalism” by 68% of students. Ratings showed preferences for self-directed teaching and learning strategies, including case-based learning, and 78% wished for predominantly oral examinations. The self-estimated knowledge about prevention and health promotion is rated as “rather poor”. The most favored training aim was “decision making within the physician-patient-relationship”. Regarding medical health consultation, students frequently estimate “lifestyle factors” and “psychological disease” as being "very important".

Conclusion: Students’ self-estimated poor previous knowledge of prevention and health promotion creates special challenges for curriculum development. High ratings of relevance assigned to prevention-related topics point to a motivational potential which should be utilized through suitable selection of teaching and testing formats to achieve effective and practice-relevant instructional content.

Combined mRNA expression levels of members of the urokinase plasminogen activator (uPA) system correlate with disease-associated survival of soft-tissue sarcoma patients

Background

Members of the urokinase-type plasminogen activator (uPA) system are up-regulated in various solid malignant tumors. High antigen levels of uPA, its inhibitor PAI-1 and its receptor uPAR have recently been shown to be associated with poor prognosis in soft-tissue sarcoma (STS) patients. However, the mRNA expression of uPA system components has not yet been comprehensively investigated in STS patients.

Methods

The mRNA expression level of uPA, PAI-1, uPAR and an uPAR splice variant, uPAR-del4/5, was analyzed in tumor tissue from 78 STS patients by quantitative PCR.

Results

Elevated mRNA expression levels of PAI-1 and uPAR-del4/5 were significantly associated with clinical parameters such as histological subtype (P = 0.037 and P < 0.001, respectively) and higher tumor grade (P = 0.017 and P = 0.003, respectively). In addition, high uPAR-del4/5 mRNA values were significantly related to higher tumor stage of STS patients (P = 0.031). On the other hand, mRNA expression of uPA system components was not significantly associated with patients' survival. However, in STS patients with complete tumor resection (R0), high PAI-1 and uPAR-del4/5 mRNA levels were associated with a distinctly increased risk of tumor-related death (RR = 6.55, P = 0.054 and RR = 6.00, P = 0.088, respectively). Strikingly, R0 patients with both high PAI-1 and uPAR-del4/5 mRNA expression levels showed a significant, 19-fold increased risk of tumor-related death (P = 0.044) compared to the low expression group.

Conclusion

Our results suggest that PAI-1 and uPAR-del4/5 mRNA levels may add prognostic information in STS patients with R0 status and distinguish a subgroup of R0 patients with low PAI-1 and/or low uPAR-del4/5 values who have a better outcome compared to patients with high marker levels.

Expression of microRNA 210 associates with poor survival and age of tumor onset of soft-tissue sarcoma patients

Expression of microRNAs can affect age of tumor onset and prognosis of cancer patients. However, nothing is known about the effects of microRNAs on altered age of cancer onset and disease-specific survival of soft-tissue sarcoma (STS) patients. The levels of miR-210, also known as hypoxia-regulated microRNA, were analyzed by quantitative real-time (RT)-PCR in the tumors of 78 STS patients. The patients were stratified according to their microRNA levels with low, intermediate and high expression levels and the association of microRNA expression and patients' survival was analyzed using multivariate Cox's regression hazard analyses. A significant correlation between an intermediate miR-210 expression and disease-specific death of STS patients [relative risk (RR) = 3.19; p = 0.018] was observed compared with patients with high expression levels in their tumors. Interestingly, the association between an intermediate expression of miR-210 and a poor prognosis was only significant in female STS patients (RR = 11.28; p = 0.010), but not observed in male individuals. Furthermore, the expression of miR-210 showed a significant association with the age of tumor onset in a gender-specific manner. Specifically, male patients with an intermediate expression of miR-210 associated with a 9.6-year later age of tumor onset (p = 0.017) compared with males with a low expression of miR-210 in their tumors. However, no significant differences in the female patients were observed. This study provides the first evidence of a correlation of expression levels of a single microRNA (miR-210) with the prognosis and age of tumor onset in a gender-specific manner in STS patients.

["Without any practical relevance?": 3 years of student evaluation of an interdisciplinary curriculum for prevention and health promotion in undergraduate medical education]

BACKGROUND

The topic "prevention and health promotion" (Q10) was introduced into the medical training in Germany by the new medical licensing regulations in 2004. For the conception of an effective curriculum in the context of quality assurance, a continuous evaluation by the target group is necessary. Of importance are particularly the subjective success in learning and its interdependence to invested time, achievement expenditure and perceived relevance of the topics.

METHODS

Medical students (N=660) of the fifth academic years of 2007-2009 at the Martin-Luther-University Halle-Wittenberg were asked about their opinion after completing their Q10 curriculums by means of a standardised questionnaires. Emphasis of the questioning was placed on self estimates about success in learning, expenditure of time, evaluation of instruction elements, perceived relevance of prevention topics and the motivation for further occupation with the topic field. The collection instruments covered multiple choice questions, decimal number data and 5-point Likert scales.

RESULTS

510 questionnaires (77% return) could be evaluated. The curriculum "prevention and health promotion" was continuously evaluated over 3 years with increasingly indicated performance requirements and expenditure of time regarding instruction elements and success in learning. The invested time in lecture visits correlated positively with relevance-attribution (r=0.16, p<0.01) and subjective success in learning (r=0.29, p<0.001). The strongest correlations regarding subjective success in learning were shown in the evaluation of the instruction elements (r=0.65, p<0.001), perceived relevance of the topic (r=0.42, p<0.001) and motivation (r=0.45, p<0.001).

CONCLUSIONS

Self-estimated success in learning within the interdisciplinary field of prevention and health promotion can be fostered by elucidating the relevance of the topic. Increasing requirements and expenditure of time for the preparation of performance records seem to be a less effective stimulus for successes in learning as the promotion of the lecture visit. The selection of suitable teaching and testing formats for prevention and health should orient itself - apart from objective success measurement - also on student evaluations.

Medical examination of fitness for police custody in two large German towns

Worldwide, there is a high risk of medical complications or death in police custody. This risk is often increased by unclear legislation, a lack of clearly defined responsibility and medical examination standards. Any solution to these problems requires as a very basis the systematic analysis of the medical examinations that determine whether a person is fit to be detained in custody. We analysed a total of 3,674 medical records on fitness for custody, taken from two large German towns (Halle/S and Bremen). The examined individuals were predominantly males or of a younger age. The indication in the majority of cases was acute alcoholic intoxication or drug withdrawal syndromes. Traumata and internal or mental diseases were also quite frequent. For approximately 50% of all cases, fitness for custody was declared on certain conditions. Only 39.8% were found to be unconditionally fit for detention in custody. In just under 10% of the cases, the person was found unfit for custody. These cases concerned mainly persons with psychological symptoms and advanced alcohol or drug withdrawal syndromes. We were able to show that the recent introduction of new police custody regulations in Halle/S had a significant influence on the medical decision on fitness for custody. Our detailed assessment has provided us with the basis to develop solutions for the improvement of medical care in police custody. The focus lies here on the organisation and legal regulation of the medical aspects of custody but also on policing and medical work.

Hemodynamic effects of eating and prolonged supine position in healthy subjects studied under clinical-pharmacological test conditions

The influences of both being in a supine position for a prolonged period and food intake on cardiovascular variables were studied under clinical-pharmacological test conditions. In a randomized crossover design study without drug or placebo administration, 6 healthy male volunteers received a light standard meal before and during test A and fasted in test B. In both tests, while they were continuously supine for more than 8 h, a synchronous recording of cardiovascular variables was done at 24, 26 and 28 min after starting the supine position (first recordings) and 25 times from 2 to 480 min after the first recordings. Using a multifactorial statistical analysis, each parameter was evaluated regarding the factors eating and time of supine recording. Eating led to a significant decrease in diastolic and mean blood pressure, PQ time and QS₂ time, a downward trend in systemic vascular resistance and an upward trend in systolic blood pressure and cardiac output. When the subjects remained in a supine position for prolonged periods, significant increases in systolic, diastolic, mean blood pressure and systemic vascular resistance were noted as well as significant decreases in cardiac output and QS₂ time. Thus, eating and remaining in a supine position for prolonged periods should be considered as sources of bias in clinical-pharmacological studies on cardiovascular drug effects and accompanying placebo controls.

Longevity of frictional telescopic crowns in the severely reduced dentition: 3-year results of a longitudinal prospective clinical study

OBJECTIVES

The longevity of frictional telescopic crowns (FTC) in severely reduced dentitions with 1 to 3 remaining teeth per jaw has not yet been studied prospectively and exclusively. Aims of this study were to estimate risks of telescope loss and abutment tooth loss and to determine abutment tooth mobility over time.

METHOD AND MATERIALS

A total of 74 patients with severely reduced dentitions received 82 telescopic removable partial dentures (TRPDs) retained with 173 FTCs. Dentures were reexamined after 1 week and 3, 6, 12, 18, 24, 30, and 36 months. Tooth mobility was monitored with Periotest values. Adjuvant therapies were carried out if necessary. Survival probabilities of telescopes and abutment teeth as well as the influence of clinical factors (age, sex, jaw, vitality, opposing dentition, axis inclination, end Periotest value, crown length, crown margin quality, wearing mode, tooth types, abutment distribution, number of telescopes) were calculated with Kaplan-Meier estimators. The relative risks for telescope loss were calculated with Cox regression.

RESULTS

The survival rate was 93.9% for abutment teeth and 87.5% for telescopes. Number of telescopes, abutment distribution, vitality, and gender as factors influenced the survival rates (Kaplan-Meier). In combination with the jaw as a factor, these affected the risk for telescope loss (Cox regression). Periotest values (mean of abutment teeth per examination) decreased significantly (P < .0001). Altogether, 11% of teeth fractured and 4.6% of teeth were extracted. Patients were mostly very satisfied.

CONCLUSION

TRPDs proved to be a favorable treatment concept for severely reduced dentitions. FTCs can be considered as elements with a good benefit-maintenance relation. A general increase of abutment tooth mobility could not be verified.

Expression and distribution of tenascin in rat submandibular glands following irradiation

The aim of this study was to investigate the late changes in the expression of tenascin-C (TN-C) in salivary glands (SG) following irradiation (IRR).

MATERIALS AND METHODS

In 124 submandibular SG from 62 Wistar rats, the effect of IRR dose (fractionated IRR, 2 Gy per day, total dose of 20, 40, or 60 Gy), time since IRR (6 months vs. 12 months), and animal age (1 year vs. 1.5 years) on TN-C expression profile and its distribution pattern was investigated.

RESULTS

Expression of TN-C showed slight to moderate alterations in the irradiated specimens. The expression differed in frequency and degree among various tissue structures. The most striking finding was pronounced dose-dependent heterogeneity, with increases, decreases and fluctuations in staining.

CONCLUSION

The staining of TN-C predominantly showed notable dose-dependent heterogeneity, persisting for up to 1 year after completion of IRR. Thus, these findings can be attributed to late radiation effects. The altered expression of tenascin-C may play at least a partial role in late radiogenic dysfunction of the submandibular SG.

Snoezelen, structured reminiscence therapy and 10-minutes activation in long term care residents with dementia (WISDE): study protocol of a cluster randomized controlled trial

BACKGROUND

People with dementia are often inapproachable due to symptoms of their illness. Therefore nurses should establish relationships with dementia patients via their remaining resources and facilitate communication. In order to achieve this, different targeted non-pharmacological interventions are recommended and practiced. However there is no sufficient evidence about the efficacy of most of these interventions. A number of publications highlight the urgent need for methodological sound studies so that more robust conclusions may be drawn.

METHODS/DESIGN

The trial is designed as a cluster randomized controlled trial with 20 nursing homes in Saxony and Saxony-Anhalt (Germany) as the units of randomization. Nursing homes will be randomly allocated into 4 study groups consisting of 5 clusters and 90 residents: snoezelen, structured reminiscence therapy, 10-minutes activation or unstructured verbal communication (control group). The purpose is to determine whether the interventions are effective to reduce apathy in long-term care residents with dementia (N = 360) as the main outcome measure. Assessments will be done at baseline, 3, 6 and 12 months after beginning of the interventions.

DISCUSSION

This trial will particularly contribute to the evidence on efficacy of non-pharmacological interventions in dementia care.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00653731.

Co-detection of members of the urokinase plasminogen activator system in tumour tissue and serum correlates with a poor prognosis for soft-tissue sarcoma patients

Background:

The urokinase plasminogen activator (uPA) system is one of the best-investigated protease systems, both under physiological and pathological conditions, including various types of cancer. However, effects of co-expression of members of the uPA system in soft-tissue sarcoma (STS) patients at the protein level in both tumour tissue and serum have not been investigated yet.

Methods:

We examined 82 STS patients for protein levels of uPA, PAI-1and uPAR in tumour tissue and serum by ELISA.

Results:

A significant correlation between high antigen levels of uPA, PAI-1 or uPAR in tumour tissue, and of uPAR in serum, with poor outcome of STS patients was found for the first time. Most strikingly, we observed an additive effect of combined uPA, PAI-1 or uPAR levels in tumour tissue extracts with uPAR levels in serum on patients’ prognosis. High uPA/uPAR, PAI-1/uPAR and uPAR/uPAR antigen levels in tumour tissue/serum were associated with a 5.9-fold, 5.8-fold and 6.2-fold increased risk of tumour-related death (P=0.003, 0.001 and 0.002, respectively) compared with those patients who displayed low levels of the respective marker combination.

Conclusion:

As expression of members of the uPA system in tumour tissue and serum is additively correlated with prognosis of STS patients, our results suggest that combinations of these biomarkers can identify STS patients with a higher risk of tumour-related death.

Elevated expression of microRNAs 155, 203, 210 and 222 in pancreatic tumors is associated with poorer survival

Pancreatic cancer is the eighth most common cancer and has an overall 5-year survival rate lower than 10%. Because of their ability to regulate gene expression, microRNAs can act as oncogenes or tumor-suppressor genes and so have garnered interest as possible prognostic and therapeutic markers during the last decade. However, the prognostic value of microRNA expression in pancreatic cancer has not been thoroughly investigated. We measured the levels of miR-155, miR-203, miR-210, miR-216, miR-217 and miR-222 by quantitative RT-PCR in a cohort of 56 microdissected pancreatic ductal adenocarcinomas (PDAC). These microRNAs were chosen as they had previously been shown to be differentially expressed in pancreatic tumors compared to normal tissues. The possible association of microRNA expression and patients' survival was examined using multivariate Cox's regression hazard analyses. Interestingly, significant correlations between elevated microRNA expression and overall survival were observed for miR-155 (RR = 2.50; p = 0.005), miR-203 (RR = 2.21; p = 0.017), miR-210 (RR = 2.48; p = 0.005) and miR-222 (RR = 2.05; p = 0.035). Furthermore, tumors from patients demonstrating elevated expression levels of all 4 microRNAs possessed a 6.2-fold increased risk of tumor-related death compared to patients whose tumors showed a lower expression of these microRNAs. This study provides the first evidence for an oncogenic activity of miR-155, miR-203, miR-210 and miR-222 in the development of pancreatic cancer as has been reported for other tumor types. Furthermore, the putative target genes for these microRNAs suggest a complex signaling network that can affect PDAC tumorigenesis and tumor progression.

Association of HDM2 transcript levels with age of onset and prognosis in soft tissue sarcomas

The p53 stress response is crucial for the prevention of tumor formation. The oncogene HDM2 is one of the key negative regulators of p53 and is a central node in the p53 pathway. P53 and HDM2 form an oscillating feedback loop. HDM2 expression is regulated by different promoters. To evaluate its clinical relevance, we determined the levels of HDM2 transcripts originating from the constitutive P1 and p53-sensitive P2 promoter in 133 soft tissue sarcomas and correlated the results with the age of diagnosis and the patients' outcome. We show that only high levels of the HDM2-P1 transcript but not the P2 transcript are associated with an 11-year earlier age of onset (50.5 years) compared with low P1 levels (61.5 years; P < 0.0001, t test). In addition, low P1 and P2 mRNA expression levels were independent predictors of poor outcome for patients with soft tissue sarcomas (low P1: relative risk, 3.7; P < 0.0001; low P2: relative risk, 2.5; P = 0.001). A change in the expression levels of the HDM2 transcripts originating from the two HDM2 promoters could disrupt the oscillating P53-HDM2 feedback loop in a way that elevated levels of HDM2-P1 transcript are associated with an earlier age of tumor onset and that reduced levels of HDM2-P1 or HDM2-P2 transcripts are correlated with poor prognosis of patients with soft tissue sarcomas.

Simultaneous expression of Cathepsins B and K in pulmonary adenocarcinomas and squamous cell carcinomas predicts poor recurrence-free and overall survival

PURPOSE

Patient survival after resection of non-small cell lung cancer (NSCLC) strongly correlated with the occurrence of distant metastasis. Cathepsins are members of the lysosomal cysteine proteases family and can support the metastatic process by degrading the extracellular matrix. The purpose of this study was to identify members of the Cathepsin family that correlate with recurrence-free and overall survival of NSCLC patients.

PATIENTS AND METHODS

The expression of 13 Cathepsins was examined using DNA-microarray technology in tumor tissues of 89 surgically treated NSCLC patients. All NSCLC samples were classified according to median Cathepsin expression value into either a high or a low expression group. All Cathepsin expression groups were subjected to clinical prognostic analyses regarding survival and local as well as distant recurrences.

RESULTS

Patients with high Cathepsin C tumor expression showed higher tumor recurrence rate compared to patients with low Cathepsin C expression (p = 0.02). The tumor expression of Cathepsins K and B significantly correlated with recurrence-free and overall survival as determined by multivariate analysis. A high expression of Cathepsin B or K was associated with a considerable reduction of recurrence-free as well as overall survival. NSCLC patients with a high expression of both Cathepsin B and K had a significantly (p = 0.001) poorer outcome (5-year survival rate: 13%) than patients with low expression of both genes (5-year survival rate: 75%).

CONCLUSIONS

The combined expression level of Cathepsins B and K identifies high-risk NSCLC patients. A selection of gene expression panels is theoretically superior to established clinical and pathological criteria.

Growing old at home - a randomized controlled trial to investigate the effectiveness and cost-effectiveness of preventive home visits to reduce nursing home admissions: study protocol [NCT00644826]

Background

Regarding demographic changes in Germany it can be assumed that the number of elderly and the resulting need for long term care is increasing in the near future. It is not only an individual's interest but also of public concern to avoid a nursing home admission. Current evidence indicates that preventive home visits can be an effective way to reduce the admission rate in this way making it possible for elderly people to stay longer at home than without home visits. As the effectiveness and cost-effectiveness of preventive home visits strongly depends on existing services in the social and health system existing international results cannot be merely transferred to Germany. Therefore it is necessary to investigate the effectiveness and cost-effectiveness of such an intervention in Germany by a randomized controlled trial.

Methods

The trial is designed as a prospective multi-center randomized controlled trial in the cities of Halle and Leipzig. The trial includes an intervention and a control group. The control group receives usual care. The intervention group receives three additional home visits by non-physician health professionals (1) geriatric assessment, (2) consultation, (3) booster session.

The nursing home admission rate after 18 months will be defined as the primary outcome. An absolute risk reduction from a 20% in the control-group to a 7% admission rate in the intervention group including an assumed drop out rate of 30% resulted in a required sample size of N = 320 (n = 160 vs. n = 160).

Parallel to the clinical outcome measurement the intervention will be evaluated economically. The economic evaluation will be performed from a society perspective.

Discussion

To the authors' knowledge for the first time a trial will investigate the effectiveness and cost-effectiveness of preventive home visits for people aged 80 and over in Germany using the design of a randomized controlled trial. Thus, the trial will contribute to the existing evidence on preventive home visits especially in Germany.

Expression and distribution of cytokeratins and vimentin in rat larynx and trachea following irradiation

BACKGROUND

External irradiation (IRR) of advanced head and neck tumors often includes tissues of the larynx and trachea unaffected by cancer. In these normal tissues, both single-cell damage (necrosis, apoptosis, functional cell death) and interstitial damage (edema, fibrosis, vascular alterations, cellular infiltrations) resulting in tissue remodeling can occur, depending on various IRR parameters. However, reports on radiogenic intermediate filament protein alterations in laryngeal-tracheal tissues are very rare. In this study, we investigated the phenotypic characterization of the normal integrity-supporting cytokeratins (CK) and vimentin following a clinically relevant IRR protocol in laryngeal-tracheal tissues.

MATERIALS AND METHODS

In 61 laryngo-tracheal specimens from Wistar rats the expression profile and distribution pattern of CK (CK13, CK17/19, CK18) and vimentin were investigated according to IRR dose (fractionated IRR, 2 Gy per day, total dose of 20, 40 or 60 Gy), time from IRR (6 months vs. 12 months) and animal age (1 year vs. 1.5 years) using immunohistochemical methods, semiquantitative assessment and multivariate analysis.

RESULTS

In irradiated specimens, expression of both CK and vimentin showed slight to moderate dose-dependent alterations. The expression differed in frequency and level among the various tissue structures and showed remarkable heterogeneity, with increases, decreases and fluctuations in staining. In the glottic mucosal layer (non-keratinizing squamous epithelium), CK13 expression decreased with increasing dose. The CK17/19 expression of supra- and subglottic respiratory epithelia following 20 and 60 Gy exposure was significantly lower than in controls. The respiratory epithelia and, in part, the cuboidal epithelia of the indifferent type at the inner side of the aryepiglottic fold revealed increasing CK17/19 immunoreactions up to 40 Gy IRR, but a distinct decrease in expression at 60 Gy. In subglottic gland structures, CK18 was detected at significantly higher levels than in controls. There was increasing expression with increasing dose. CK18 reactions of supra- and subglottic respiratory mucosal layer, supraglottic gland structures and thyrocytes tended towards increasing expression with increasing dose and in older animals. Tracheal mucosal epithelia, tracheal glands, and respiratory epithelia of the inner side of the aryepiglottic fold tended towards decreasing expression of CK18 with increasing dose and in older animals. In part, these tissues showed dose-dependent fluctuations. Furthermore, the vimentin reactions showed dose-dependent, heterogeneous patterns, with increases, decreases, and fluctuations in staining. Moreover, there were differences in frequency and intensity of expression among the various tissue structures. Age and time from IRR had no significant effect on immunoreaction.

CONCLUSION

The staining of CK and vimentin predominantly showed a notable dose-dependent heterogeneity, with increases, decreases and fluctuations in expression. The expression pattern persisted for up to 1 year after the completion of irradiation. Thus, these findings must reflect late radiation effects. The altered expression of CK and vimentin may play at least a partial role in structural (e.g. edema) and functional (e.g. voice disorders) changes associated with irradiation of the head and neck.

Stem cell-associated genes are extremely poor prognostic factors for soft-tissue sarcoma patients

Cancer stem cells can play an important role in tumorigenesis and tumor progression. However, it is still difficult to detect and isolate cancer stem cells. An alternative approach is to analyse stem cell-associated gene expression. We investigated the coexpression of three stem cell-associated genes, Hiwi, hTERT and survivin, by quantitative real-time-PCR in 104 primary soft-tissue sarcomas (STS). Multivariate Cox's proportional hazards regression analyses allowed correlating gene expression with overall survival for STS patients. Coexpression of all three stem cell-associated genes resulted in a significantly increased risk of tumor-related death. Importantly, tumors of patients with the poorest prognosis were of all four tumor stages, suggesting that their risk is based upon coexpression of stem cell-associated genes rather than on tumor stage.

Mandibular jaw movement capacity in 10-17-yr-old children and adolescents: normative values and the influence of gender, age, and temporomandibular disorders

The aims of this study were, first, to report normative values for jaw movements in Caucasian children and adolescents (maximum opening, laterotrusion, and protrusion) and, second, to investigate the influence of age, gender, and temporomandibular disorders (TMD) on jaw movement capacity. The population-based study included 1,011 randomly selected German children and adolescents, aged 10-17 yr. Case histories, as well as mandibular movements and the presence of TMD, were assessed according to the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD). The mean +/- standard deviation for maximum opening was 50.6 +/- 6.4 mm, for laterotrusion to the right was 10.2 +/- 2.2 mm, for laterotrusion to the left was 10.6 +/- 2.3 mm, and for protrusion was 8.2 +/- 2.5 mm. Bivariable (t-test) and multivariable (linear regression) analyses showed that normative values for jaw opening capacity were influenced by age and gender. No influence on jaw movement capacity was seen when TMD were present. Based on the distribution of the measurements in the population (lowest decentile), the mandibular mobility of subjects with a maximum opening of < 43 mm and laterotrusive movements < 8 mm or protrusive movements < 5 mm might be considered as being limited. However, these limitations do not necessarily require treatment.

Influence of systemically given placebo, trapidil and isosorbide dinitrate on norepinephrine-evoked hand vein constriction in healthy subjects

Since trapidil (CAS 15421-84-8) is able to dilate human hand veins after local intravenous administration, four studies were carried out in healthy male volunteers using the dorsal hand vein compliance technique to test the influence of common systemic single doses of trapidil (200 mg orally, 100 mg intravenously) and isosorbide dinitrate (CAS 87-33-2, 20 mg orally) on norepinephrine (CAS 51-41-2)-evoked hand vein constriction in comparison with oral placebo. Oral placebo and oral trapidil were studied in a randomized double-blind cross-over design in 10 subjects aged 20 to 30 years, and oral isosorbide dinitrate and intravenous trapidil, in a randomized open cross-over design in 8 subjects aged 22 to 29 years. In the three similar studies with oral medications dose-response curves for venoconstriction by locally infused norepinephrine were established before and 1 h, 2 h and 3 h after oral medication and ED50 values of norepinephrine were calculated. The control dose-response curves and ED50 values of norepinephrine did not differ significantly. After oral placebo administration the dose-response curves of norepinephrine did not change significantly, but the ED50 of norepinephrine increased 3 h after placebo (from 12.1 to 31.7 ng/ min), indicating a lessening in norepinephrine effect at this time. After oral trapidil application the dose-response curves of norepinephrine shifted to the left compared with the pre-treatment curve (significantly 2 h after trapidil) and the corresponding curves after placebo with a significant decrease in the ED50 of norepinephrine 3 h after trapidil compared with placebo (from 31.7 to 12.6 ng/ min). After oral isosorbide dinitrate administration the dose-response curves of norepinephrine did not differ significantly from the pre-treatment curve, but they shifted to the left compared with the corresponding curves after placebo (significantly 3 h after isosorbide dinitrate). The ED50 of norephinephrine decreased significantly 2 h after isosorbide dinitrate compared with the pre-treatment value (from 9.4 to 3.3 ng/min) as well as 1 h, 2 h and 3 h after isosorbide dinitrate compared with placebo (from 32.4/21.3/31.7 to 7.3/3.3/6.0 ng/min). Therefore, oral trapidil and isosorbide dinitrate did not weaken norepinephrine-evoked hand vein constriction as expected but strengthened it slightly. Intravenously given trapidil led only to an insignificant short decrease followed by an insignificant increase in permanent venoconstriction due to local norepinephrine infusion. The data suggest that after systemic administration of trapidil or isosorbide dinitrate a hand vein constriction, which could be a reflex consequence of a drug-induced decrease in central venous pressure, exceeds an only discreet direct hand vein dilation.

Expression of the stem cell self-renewal gene Hiwi and risk of tumour-related death in patients with soft-tissue sarcoma

Self-renewal is considered as a common property of stem cells. Dysregulation of stem cell self-renewal is likely a requirement for the development of cancer. Hiwi, the human Piwi gene, encodes a protein responsible for stem cell self-renewal. In this study, we investigated the expression of Hiwi at the RNA level by real-time quantitative PCR in 65 primary soft-tissue sarcomas (STS) and ascertained its impact on prognosis for STS patients. In a multivariate Cox's proportional hazards regression model, we found that an increased expression of Hiwi mRNA is a significant negative prognostic factor for patients with STS (P=0.017; relative risk 4.6, 95% confidence interval (CI) 1.3-16.1) compared to medium expression of Hiwi transcript. However, a low expression of Hiwi transcript is correlated with a 2.4-fold (CI 0.7-8.0) increased risk, but this effect was not significant (P=0.17). Altogether, high-level expression of Hiwi mRNA identifies STS patients at high risk of tumour-related death. This is the first report showing a correlation between expression of a gene involved in stem cell self-renewal and prognosis of cancer patients.

[Cataract types in diabetics and non-diabetics: a densitometric study with the Topcon-Scheimpflug camera]

BACKGROUND

The purpose of this study was to compare types of cataract which appear in patients with the cataractogenous risk factor diabetes mellitus type II and in non-diabetics.

MATERIALS AND METHODS

The opaque lenses of 46 diabetics (group I) and 83 non-diabetics (group II) in the age range of 55-93 years, who had to undergo a cataract operation, were documented using the Topcon-Scheimpflug camera SL-45 followed by densitometric analysis.

RESULTS

Although there was no significant difference relating to the metabolic disorder, we found a higher percentage of opacity of the deeper anterior (I = 8.7 % II = 3.6 %) as well as in the anterior and posterior cortex (I = 13.0 % II = 8.4 %) comparing diabetics and non-diabetics.

CONCLUSION

Diabetics revealed a higher percentage of opacity of the area of the cortex than non-diabetics without detecting any significance. Thereby, we could show positive associations between the existence of diabetes mellitus type II and a higher risk of opacities of the cortex.

Postoperative concurrent radiochemotherapy versus radiotherapy in high-risk SCCA of the head and neck: Results of the German phase III trial ARO 96–3

5507

Background: Despite resection and postoperative irradiation high-risk (3 or more involved lymph nodes, extra-capsular disease and/or microscopically involved mucosal margins of resection) squamous cell carcinomas (SCCAs) of the head and neck frequently recur in the tumor bed. Postoperatively radiochemotherapy (RCT) with cis-Platin (CDDP)/5-FU versus radiotherapy (RT) alone was compared in a randomized trial. Methods: Between 5/97 and 12/04, 440 patients who had high-risk SCCAs of the head and neck were enrolled in this prospectively randomized phase III trial. Following resection and neck dissection, 214 patients were randomly assigned to RT (66 Gy/33 Fx/6.6 weeks) and 226 patients to identical RT plus CDDP (20 mg/m2 on day 1–5, 29–33) and 5-FU (600 mg/m2 on day 1–5, 29–33). Results: The 5 year local-regional control rate is 72.2 ± 3.7% following RT and 88.6 ± 2.4% for the RCT group (p = 0.00259; 5-year progression free survival 50.1 ± 4.0% and 62.4 ± 4.4% (p = 0.024) and 5-year overall survival 48.6 ± 4.4% vs. 58.1 ± 4.6% (p = 0.11). There was no difference in the 5 year incidence of distant metastases (19.3 ± 3.6% vs 25.5 ± 4.6%; p = 0.45). The incidence of grade 3+ acute toxicity was higher during RCT: mucositis 12.6% vs. 20.8% (p = 0.04), leucopenia 0% vs. 4.4% (p = 0.007). Conclusions: Acute toxicity is increased to an acceptable level by RCT. Postoperative RCT compared to RT improves locoregional control and progression free survival; thus survival as a trend is improved by 10% after 5 years. Supported by Deutsche Krebshilfe 70–2140.

No significant financial relationships to disclose.

Changes in the lens epithelium with respect to cataractogenesis—light microscopic and Scheimpflug densitometric analysis of the cataractous and the clear lens of diabetics and non-diabetics

BACKGROUND

We compared the human lens documented, using the Scheimpflug densitometry, with the light microscopic changes in the epithelium of the anterior central lens in patients with age-related cataract and diabetes mellitus type II and verified the findings on the control tissue of the clear eye lens. We wanted to determine the relevance of the lens epithelium in cataract formation in type II diabetics compared to non-diabetics.

MATERIALS AND METHODS

One hundred fifty central lens capsules (138 cataract and 12 clear lenses) of type II diabetics (n=77, 45 female, 32 male) and non-diabetics (n=73, 41 female, 32 male) were examined by light microscope, regarding defined histomorphological parameters. Further criteria were duration of diabetes, diabetic retinopathy, cataract (PENTACAM, scheimpflug densitometric definition), protein content in the aqueous humour (laser flare meter 500 KOWA, tyndallometry), different blood parameters and glucose content in the aqueous humour.

RESULTS

The mean cell density in the cataractous lens in type II diabetics was 3,951+/-528 cells/mm(2) and in non-diabetics 4,329+/-580 cells/mm(2) (P<0.001); in the clear lens it corresponded to 4,593+/-409 cells/mm(2) (type II diabetics) and 4,894+/-333 cells/mm(2) (non-diabetics, P=0.207). The cell density of the cataractous lens in type II diabetics (P=0.005) and in non-diabetics (P=0.035) is smaller than that of the clear lens. The cell area of the lens epithelium in the cataractous diabetic lens is larger (P<0.001) and the nucleus-plasma ratio is lower (P<0.001) than those of the clear non-diabetic lens. The increase in damage of the lens epithelium correlates with the decrease of cell density (P< 0.001), the increase of nucleus area and volume (P< 0.001), and the decrease of nucleus-plasma ratio (P< 0.001). Risk factors for the decrease of cell density are advanced age (P=0.015), type II diabetes (P=0.01), increase in glucose content in the aqueous humour (P=0.014), increase in blood sugar (P=0.003) and increase in glycosylated haemoglobin (P=0.039).

CONCLUSIONS

The lens epithelium is primarily damaged in type II diabetics who develop age-related cataract. This might play an important role in cataract formation.

Elevated expression of survivin-splice variants predicts a poor outcome for soft-tissue sarcomas patients

The aim of this study was to investigate the level and the prognostic value of the expression of different survivin transcript variants--survivin, survivin-DeltaEx3 and survivin-2B--in tumours of 76 soft tissue sarcoma (STS) patients. The expression of survivin transcript variants in STS tissue samples and in 12 nonmalignant control tissues was analysed by quantitative RT-PCRs. Expression levels of all survivin transcript variants were strongly elevated in STS compared to normal tissues. A positive correlation between expression of splice variants and tumour stage was found (P=0.02; chi2 test). The multivariate Cox's proportional hazards regression model revealed a 7.3-fold increased risk of tumour-related death for patients with survivin-DeltaEx3 overexpressing tumours (P=0.007). The effect of surivivin (wildtype variant) and survivin-2B was less pronounced but still significant (2.2- and 1.9-fold, resp., P<0.05 each). Our results show for the first time that mRNA expression of survivin-variants is significantly correlated to a poor prognosis for STS patients, and we suggest expression of survivin splice variants together with tumour stage as independent predictor of survival.

Radioprotective effects of amifostine in vitro and in vivo measured with the comet assay

PURPOSE

The authors investigated whether a potential radioprotective effect of amifostine (WR-2721) after in vitro or in vivo administration can be detected with the comet assay. Moreover, it was determined whether radioprotection by WR-2721 is dependent on the concentration of amifostine or alkaline phosphatase (AP, the enzyme which activates the prodrug). Furthermore, the authors tried to detect possible interindividual differences in radioprotection by amifostine.

MATERIAL AND METHODS

In vitro administration of amifostine: Freshly isolated lymphocytes from two healthy volunteers were incubated with different concentrations of AP (0-210 U/ml) and amifostine (0-5,000 microg/ml). IN VIVO ADMINISTRATION OF AMIFOSTINE: Blood samples were collected from six postoperative rectal cancer patients before and after intravenous administration of amifostine 500 mg (no pretreatment with radio- or chemotherapy). Leukocytes and lymphocytes were irradiated and repaired in vitro and investigated with the alkaline comet assay. The radioprotective effect was evaluated by calculating dose-modifying factors (DMFs) and the paired t-test.

RESULTS

Amifostine alone did not alter the radiation-induced DNA damage in vitro. The addition of at least 0.5-1 U/ml AP was required. A significant radioprotective effect (p < 0.05) was seen after administration of amifostine in vitro for all concentrations investigated (250-5,000 microg/ml, initial DNA damage). A comparable radioprotective effect after in vivo administration of 500 mg amifostine was measured with a mean DMF of 0.87. Interindividual differences were present in vivo and in vitro.

CONCLUSION

Amifostine 500 mg intravenously yields an adequate radioprotective concentration. The effect was only marginally improved by extreme concentrations of amifostine in in vitro experiments. The comet assay is capable of detecting small changes in radiosensitivity by amifostine.

Epithelial hyaluronic acid and CD44v6 are mutually involved in invasion of colorectal adenocarcinomas and linked to patient prognosis

Desmoplastic stroma of colorectal adenocarcinomas contains a variety of extracellular matrix molecules, including hyaluronic acid (HA). Overexpression of the HA receptor CD44 and, in particular, its splicing variant CD44v6 has been described as a prognostic factor for patients with colorectal adenocarcinomas in some studies, but converse reports also exist. Our hypothesis is that these divergent results may be related to the fact that the function of CD44v6 depends on the HA content of cell-surrounding matrix. Therefore, we studied the expression of HA and CD44v6 in tissue samples of 145 patients suffering from colorectal adenocarcinomas using immunohistochemistry. Expression of HA was separately evaluated in tumor epithelium and stroma. We additionally examined the influence of HA on invasion and adhesion of colorectal adenocarcinoma cells in vitro. The results show that epithelial HA expression was not correlated with tumor stage but with lymph-node or distant metastasis. Patients with tumors expressing epithelial HA had a decreased overall survival ( P=0.017) as well as tumors with coexpression of epithelial HA and CD44v6 ( P=0.011). The latter issue remained an independent prognostic factor in multivariate analysis (relative risk 5.06; 95% confidence interval, 1.18-21.57; P=0.028). HA exclusively stimulated in vitro invasion of CD44v6-expressing cells. This stimulation was partly reversed by an anti-CD44v6 antibody. Our findings suggest that the adverse prognostic effect of CD44v6 in colorectal adenocarcinoma might be restricted to those tumors that have pericellular HA.

Loss of heterozygosity at 12q14-15 often occurs in stage I soft tissue sarcomas and is associated with MDM2 amplification in tumors at various stages

Few studies have investigated the loss of heterozygosity and microsatellite instability in soft tissue sarcomas. Therefore, we analyzed samples of human soft tissue sarcomas to determine the status of the chromosomal region 12q14-15, which contains the MDM2 gene encoding the well-known counterpart of the tumor suppressor p53. In addition, we determined whether an amplified MDM2 gene was present in the samples. Of the 88 soft tissue sarcoma samples, 24 (27%) showed evidence of loss of heterozygosity of markers representing 12q14-15, and 12 (14%) showed evidence of microsatellite instability. Of the 72 samples analyzed by semiquantitative polymerase chain reaction, 15 (21%) possessed an amplified MDM2 gene. Loss of heterozygosity (P =.008) and microsatellite instability (P =.035) were significantly more common in Stage I tumors than in higher stage tumors. This result indicated that these alterations occur early in soft tissue sarcoma progression and possibly define a subgroup of soft tissue sarcoma. Surprisingly, MDM2 amplification in soft tissue sarcoma patients was associated with a prognosis better than that of patients without the amplification; however, this difference was not statistically significant (P =.6). Furthermore, of the tumors with an MDM2 amplification, 40% (6/15) also experienced loss of heterozygosity at 12q14-15; in contrast, only 16% of tumors without an MDM2 amplification (9/57) underwent a loss of heterozygosity. A concomitant occurrence of deletions and amplifications resulting from deficiencies in the nonhomologous end-joining pathway could in part explain this finding.

The tall-cell variant of papillary thyroid carcinoma: a multivariate analysis of clinical risk factors

BACKGROUND

The biological behaviour of the tall-cell variant (TCV) of papillary thyroid carcinoma (PTC) remains to be clarified in a multivariate analysis that controls for all relevant clinicopathological parameters.

PATIENTS AND METHODS

A retrospective analysis was carried out of 332 consecutive PTC patients operated on at a university hospital between November 1994 and February 2003.

RESULTS

A total of 16 TCV tumours (4.8%) was identified among the 332 PTC patients. Nodal and (predominantly pulmonary) distant metastases were identified at surgery in, respectively, 50% and 31% of TCV tumours. On univariate analysis, only the association between the TCV and distant metastasis retained statistical significance after adjustment for multiple testing. On multivariate logistic regression analysis, the presence of distant metastasis increased more than fourfold [odds ratio (OR) 4.2] the chance of having the TCV of PTC, with controls for extrathyroidal extension, nodal metastasis, operation status, patient gender, categorized patient age, and categorized primary tumour diameter.

CONCLUSION

The increased risk of distant metastasis associated with the TCV morphology of PTC warrants an extensive post-operative search for distant metastasis to facilitate early diagnosis and treatment of tumour deposits in distant organs.