A comparative assessment of neutropenia events, healthcare resource use, and costs among cancer patients treated with lipegfilgrastim compared with pegfilgrastim in Germany

PURPOSE

We assessed the occurrence of neutropenia and febrile neutropenia (FN) and the associated healthcare resource in cancer patients receiving myelosuppressive chemotherapy in combination with pegfilgrastim versus lipegfilgrastim.

METHODS

This is a retrospective analysis using a German health insurance claims database. Adults receiving chemotherapy with a prescription code for pegfilgrastim (n = 734) or lipegfilgrastim (n = 346) were observed over a 1-year follow-up period. Patient subgroups were analyzed according to cancer type and FN risk. FN risk was based on the chemotherapy regimen and any additional neutropenia risk factors. Outcomes were adjusted via regression analysis.

RESULTS

Most patients were classified as high FN risk (70.0% pegfilgrastim; 65.6% lipegfilgrastim cohort). The mean age was 58.2 years in the pegfilgrastim cohort and 58.0 years in the lipegfilgrastim cohort, with more female patients than male patients (77.3% vs 79.8%, respectively), and the majority had breast cancer (64.9% and 68.8%, respectively). Overall, 10.0% and 10.4% of patients receiving pegfilgrastim or lipegfilgrastim experienced a neutropenia event (p = 0.82), with 4.4% and 3.5% of patients experiencing a FN event (p = 0.49). The mean neutropenia event-related healthcare costs were €604 and €441 for the pegfilgrastim and lipegfilgrastim cohorts; among patients with lymphoma, these costs were significantly greater (p = 0.03) with pegfilgrastim (€1,612) versus lipegfilgrastim (€382). The mean all-cause hospitalizations were significantly (p < 0.01) higher for lymphoma patients receiving pegfilgrastim (2.76) versus lipegfilgrastim (1.60).

CONCLUSION

Overall, patients treated with pegfilgrastim and lipegfilgrastim were comparable in terms of neutropenia occurrences in the 1-year follow-up. In patients with lymphoma, neutropenia event-related healthcare costs and all-cause hospitalizations were significantly higher with pegfilgrastim compared with lipegfilgrastim in this study; however, this should be interpreted with caution in light of the limited sample size and the absence of clinical information.

Comparison of procedure times and collection efficiencies using integrated and multistep nonintegrated procedures for extracorporeal photopheresis

Background

Extracorporeal photopheresis (ECP) is a blood‐based therapeutic procedure increasingly used for modulation of immune dysregulation in various underlying disease settings. The aim of this study was to compare the procedure times and blood collection efficiencies between the two approaches currently utilized in European centers: the integrated versus the multistep nonintegrated procedures.

Methods

A retrospective data analysis was conducted, comparing treatment data from patients who received ECP therapy at the Central Institute for Blood Transfusion & Department of Immunology (ZIB) of the Tirol Kliniken GmbH, where the integrated and multistep nonintegrated procedures are routinely used in an approximated setup.

Results

During the observation period, a total of 15 patients who were treated with alternating systems on 2 consecutive days were identified. This allowed treatment pair comparisons with minimal interpatient variabilities, similar to a cross‐over design even though analyzed retrospectively. Total average procedure times with the integrated system were 99.3 vs 122.0 minutes with the multistep nonintegrated procedures, respectively. Significant differences were observed for all steps of the ECP procedure: (a) time for buffy coat collection, 66.5 vs 74.7; (b) handling/transfer, 2.8 vs 18.7; (c) irradiation, 20.3 vs 11.7; and (d) reinfusion/handling time, 9.6 vs 16.3 minutes. The calculated collection throughput was 7.79 mL/min for the integrated and 7.84 mL/min for the multistep nonintegrated procedures, and with a white blood cell (WBC) collection efficiency of 34.2% and 21.0%, respectively.

Conclusion

The data presented in this study show a significant shorter overall procedure time and higher WBC collection efficiency for the integrated ECP system.

Healthcare resource utilization and costs of cardiovascular events in patients with atherosclerotic cardiovascular disease in Germany - results of a claims database study

OBJECTIVES

We assessed healthcare resource utilization (HCRU) and costs of cardiovascular (CV) events in patients with a history of atherosclerotic cardiovascular disease (ASCVD) in Germany.

METHODS

We conducted a retrospective matched case-control study based on German claims data from 1 January 2012 to 31 December 2017 using the "Institute for Applied Health Research Berlin" (InGef) Research Database. Cases who had a myocardial infarction (MI), stroke and angina pectoris identified by ICD-10-GM codes between 1 January 2014 and 31 December 2016 were matched to event-free controls by an exact matching approach without replacement at a ratio of 1:2. Costs and HCRU were assessed in individual 1-year follow-up periods after the index event for the overall cohort and subgroups of MI cases and stroke cases.

RESULTS

The overall cohort consisted of a total of 14,169 cases with a CV index event matched to 28,338 controls. The mean age of the overall cohort was 73.3 years, 34.1% of the patients were female, 3,717 (26.2%) had an MI, and 3,752 (26.5%) had stroke. Following the index events, 12.2% of cases in the overall cohort, 12.6% of MI cases, and 8.7% of stroke cases experienced a recurrent CV event. CV cases had on average 1.7 more all-cause hospitalizations (p <0.001) and 6.1 more outpatient visits (p <0.001) during the 1-year follow-up period than did controls. In the MI and stroke subgroups, cases had on average 1.8 and 1.6 more all-cause hospitalizations and 7.0 and 4.0 more outpatient visits, respectively (differences were statistically significant). Compared to controls, cases incurred on average higher total healthcare costs: by €11,898 for overall cases, by €16,349 for MI, and by €14,360 in stroke cases (overall: p <0.001; MI: p <0.001; stroke: p <0.001).

CONCLUSION

CV events in ASCVD patients pose a considerable clinical burden on patients and cause significant costs for the German statutory healthcare system.

The burden of hyperkalemia in Germany - a real world evidence study assessing the treatment and costs of hyperkalemia

Background

Hyperkalemia (HK) can affect health outcomes and quality of life, as it is referred to as a potentially life-threatening condition caused by an increased serum potassium concentration in the blood. Patients suffering from heart failure or chronic kidney diseases are at a higher risk of HK, which can further be amplified by the treatment received. To date, data on HK prevalence is lacking for Germany and the aims of this study were to assess HK and compare health-relevant outcomes and healthcare costs between HK patients and non-HK patients.

Methods

The InGef research database containing healthcare claims of over 4 million individuals in Germany was utilized for this retrospective, matched cohort analysis. Patients with non-acute outpatient treated and a subgroup of patients with chronic HK, were identified in 2015 with an individual 1 year pre- and post-index period, taking the first observable HK diagnosis/treatment in 2015 into account as the index event. To identify non-acute outpatient treated HK patients, at least two ICD-10-GM diagnosis codes E87.5 “Hyperkalemia” and/or prescriptions of polystyrene sulfonate were required. Chronic HK patients had additional diagnoses and/or prescriptions in all quarters following the first observable HK diagnosis. Patients without HK were matched 1:1 to the respective HK cohorts.

Results

In the year 2015, 3333 patients with non-acute outpatient treated HK were identified of which 1693 were patients with chronic HK. After matching, 3191 and 1664 HK patients and controls were available for analysis. A significantly higher number of hospitalizations was observed for both HK cohorts in comparison to their matched controls. Dialysis initiation as well as the healthcare costs were higher for both HK cohorts when compared to their matched counterparts.

Conclusions

The disease burden was higher for patients with HK, based on a higher proportion of patients with dialysis initiation and higher healthcare costs.

Factor XII truncation accelerates activation in solution

Essentials During contact system activation, factor XII is progressively cleaved by plasma kallikrein. We investigated the role of factor XII truncation in biochemical studies. Factor XII contains naturally occurring truncating cleavage sites for a variety of enzymes. Truncation of factor XII primes it for activation in solution through exposure of R353. SUMMARY: Background The contact activation system and innate immune system are interlinked in inflammatory pathology. Plasma kallikrein (PKa) is held responsible for the stepwise processing of factor XII (FXII). A first cleavage activates FXII (into FXIIa); subsequent cleavages truncate it. This truncation eliminates its surface-binding domains, which negatively regulates surface-dependent coagulation. Objectives To investigate the influence of FXII truncation on its activation and downstream kallikrein-kinin system activation. Methods We study activation of recombinant FXII variants by chromogenic assays, by FXIIa ELISA and western blotting. Results We demonstrate that FXII truncation primes it for activation by PKa in solution. We demonstrate this phenomenon in three settings. (i) Truncation at a naturally occurring PKa-sensitive cleavage site, R334, accelerates FXIIa formation in solution. A site-directed mutant FXII-R334A displays ~50% reduced activity when exposed to PKa. (ii) A pathogenic mutation in FXII that causes hereditary angioedema, introduces an additional plasmin-sensitive cleavage site. Truncation at this site synergistically accelerates FXII activation in solution. (iii) We identify new, naturally occurring cleavage sites in FXII that have so far not been functionally linked to contact system activation. As examples, we show that non-activating truncation of FXII by neutrophil elastase and cathepsin K primes it for activation by PKa in solution. Conclusions FXII truncation, mediated by either pathogenic mutations or naturally occurring cleavage sites, primes FXII for activation in solution. We propose that the surface-binding domains of FXII shield its activating cleavage site, R353. This may help to explain how the contact system contributes to inflammatory pathology.

Hereditary angioedema: the plasma contact system out of control

The plasma contact system contributes to thrombosis in experimental models. Even though our standard blood coagulation tests are prolonged when plasma lacks contact factors, this enzyme system appears to have a minor (if any) role in hemostasis. In this review, we explore the clinical phenotype of C1 esterase inhibitor (C1-INH) deficiency. C1-INH is the key plasma inhibitor of the contact system enzymes, and its deficiency causes hereditary angioedema (HAE). This inflammatory disorder is characterized by recurrent aggressive attacks of tissue swelling that occur at unpredictable locations throughout the body. Bradykinin, which is considered to be a byproduct of the plasma contact system during in vitro coagulation, is the main disease mediator in HAE. Surprisingly, there is little evidence for thrombotic events in HAE patients, suggesting mechanistic uncoupling from the intrinsic pathway of coagulation. In addition, it is questionable whether a surface is responsible for contact system activation in HAE. In this review, we discuss the clinical phenotype, disease modifiers and diagnostic challenges of HAE. We subsequently describe the underlying biochemical mechanisms and contributing disease mediators. Furthermore, we review three types of HAE that are not caused by C1-INH inhibitor deficiency. Finally, we propose a central enzymatic axis that we hypothesize to be responsible for bradykinin production in health and disease.

Extracellular vesicles from human saliva promote hemostasis by delivering coagulant tissue factor to activated platelets

Essentials Human salivary extracellular vesicles (EVs) expose coagulant tissue factor (TF). Salivary EVs expose CD24, a ligand of P-selectin. CD24 and coagulant TF co-localize on salivary EVs. TF+ /CD24+ salivary EVs bind to activated platelets and trigger coagulation.

SUMMARY

Background Extracellular vesicles (EVs) from human saliva expose coagulant tissue factor (TF). Whether such TF-exposing EVs contribute to hemostasis, however, is unknown. Recently, in a mice model, tumor cell-derived EVs were shown to deliver coagulant TF to activated platelets at a site of vascular injury via interaction between P-selectin glycoprotein ligand-1 (PSGL-1) and P-selectin. Objectives We hypothesized that salivary EVs may deliver coagulant TF to activated platelets via interaction with P-selectin. Methods We investigated the presence of two ligands of P-selectin on salivary EVs, PSGL-1 and CD24. Results Salivary EVs expose CD24 but PSGL-1 was not detected. Immune depletion of CD24-exposing EVs completely abolished the TF-dependent coagulant activity of cell-free saliva, showing that coagulant TF and CD24 co-localize on salivary EVs. In a whole blood perfusion model, salivary EVs accumulated at the surface of activated platelets and promoted fibrin generation, which was abolished by an inhibitory antibody against human CD24. Conclusions A subset of EVs in human saliva expose coagulant TF and CD24, a ligand of P-selectin, suggesting that such EVs may facilitate hemostasis at a site of skin injury where the wound is licked in a reflex action.

Amplified endogenous plasmin activity resolves acute thrombotic thrombocytopenic purpura in mice

Essentials Plasmin is able to proteolyse von Willebrand factor. It was unclear if plasmin influences acute thrombotic thrombocytopenic purpura (TTP). Plasmin levels are increased during acute TTP though suppressed via plasmin(ogen) inhibitors. Allowing amplified endogenous plasmin activity in mice results in resolution of TTP signs.

SUMMARY

Background Thrombotic thrombocytopenic purpura (TTP) is an acute life-threatening pathology, caused by occlusive von Willebrand factor (VWF)-rich microthrombi that accumulate in the absence of ADAMTS-13. We previously demonstrated that plasmin can cleave VWF and that plasmin is generated in patients during acute TTP. However, the exact role of plasmin in TTP remains unclear. Objectives Investigate if endogenous plasmin-mediated proteolysis of VWF can influence acute TTP episodes. Results In mice with an acquired ADAMTS-13 deficiency, plasmin is generated during TTP as reflected by increased plasmin-α2-antiplasmin (PAP)-complex levels. However, mice still developed TTP, suggesting that this increase is not sufficient to control the pathology. As mice with TTP also had increased plasminogen activator inhibitor 1 (PAI-1) levels, we investigated whether blocking the plasmin(ogen) inhibitors would result in the generation of sufficient plasmin to influence TTP outcome in mice. Interestingly, when amplified plasmin activity was allowed (α2-antiplasmin-/- mice with inhibited PAI-1) in mice with an acquired ADAMTS-13 deficiency, a resolution of TTP signs was observed as a result of an increased proteolysis of VWF. In line with this, in patients with acute TTP, increased PAP-complex and PAI-1 levels were also observed. However, neither PAP-complex levels nor PAI-1 levels were related to TTP signs and outcome. Conclusions In conclusion, endogenous plasmin levels are increased during acute TTP, although limited via suppression through α2-antiplasmin and PAI-1. Only when amplified plasmin activity is allowed, plasmin can function as a back-up for ADAMTS-13 in mice and resolve TTP signs as a result of an increased proteolysis of VWF.

Factor XII: form determines function

Factor XII is a mysterious plasma protein without a clear physiologic function. It was identified as a clotting factor, but has no clear role in hemostasis. However, FXII also contributes to the production of bradykinin, a short-lived inflammatory peptide. A growing body of mechanistic research from animal models indicates that FXII contributes to thrombotic disease by triggering excessive coagulation. FXII is evolutionarily conserved, suggesting that this molecule does have a physiologic function. This leads to intriguing questions: What does FXII really do? Is it even a real clotting factor at all? Before the groundbreaking discovery of a role for FXII in thrombotic disease, many studies investigated the biochemical properties of FXII and its activators. In this review, we highlight several biochemical studies that reveal much about the natural behavior of FXII. On the basis of these findings, it is possible to draft a conceptual model to explain how FXII reacts to surface materials. We then discuss how this model applies to the activities of FXII in its natural environment. There are two tentative physiologic functions of FXII that can operate exclusively: (i) maintenance of thrombus stability; (ii) local regulation of vascular permeability. Either, or both, of these natural functions may explain the evolutionary development and maintenance of FXII.

CLL cells are resistant to smac mimetics because of an inability to form a ripoptosome complex

In the lymph node (LN) environment, chronic lymphocytic leukemia (CLL) cells display increased NF-κB activity compared with peripheral blood CLL cells, which contributes to chemoresistance. Antagonists of cellular inhibitor of apoptosis proteins (cIAPs) can induce apoptosis in various cancer cells in a tumor necrosis factor-α (TNFα)-dependent manner and are in preclinical development. Smac-mimetics promote degradation of cIAP1 and cIAP2, which results in TNFR-mediated apoptosis via formation of a ripoptosome complex, comprising RIPK1, Fas-associated protein with death domain, FLICE-like inhibitory protein and caspase-8. CD40 stimulation of CLL cells in vitro is used as a model to mimic the LN microenvironment and results in NF-κB activation and TNFα production. In this study, we investigated the response of CLL cells to smac-mimetics in the context of CD40 stimulation. We found that treatment with smac-mimetics results in cIAP1 and cIAP2 degradation, yet although TNFα is produced, this did not induce apoptosis. Despite the presence of all components, the ripoptosome complex did not form upon smac-mimetic treatment in CLL cells. Thus, CLL cells seem to possess aberrant upstream NF-κB regulation that prevents ripoptosome formation upon IAP degradation. Unraveling the exact molecular mechanisms of disturbed ripoptosome formation may offer novel targets for treatment in CLL.

A nanobody-based method for tracking factor XII activation in plasma

The physiological role of the plasma protein factor XII (FXII), as well as its involvement in human pathology, is poorly understood. While FXII is implicated in thrombotic pathology as a coagulation factor, it can contribute to inflammatory conditions without triggering coagulation. We recently generated nanobodies against the catalytic domain of activated FXII (FXIIa). Here, we describe two of these nanobodies, A10 and B7, both of which do not recognise FXII. Nanobody A10 recognises the catalytic domain of purified α-FXIIa (80 kDa), but not that of purified β-FXIIa (28 kDa), whereas nanobody B7 recognises both. This suggests minute differences in the catalytic domain between these isoforms of FXIIa. The detection of FXIIa by these nanobodies in plasma can become compromised through inactivation by serine protease inhibitors. This effect can be efficiently countered through the addition of the small-molecular protease inhibitor PPACK. Finally, we show that our nanobody-based assays in vitro distinguish various activation products of FXII that differ with the type of activator present: whereas procoagulant activators solely trigger the formation of a species that is captured by B7, proinflammatory activators first generate a species that is recognised by B7, which is later converted into a species that is recognised by A10. These findings suggest that a progressive proteolysis of FXIIa results in the generation a non-procoagulant form of FXIIa, whereas retention of intermediate forms triggers coagulation. Moreover, our findings indicate the development of nanobodies against activated enzymes offers improved opportunities to investigate their contribution to health and disease.

A historic cohort study on accelerated advancement of enteral feeding volumes in very premature infants

BACKGROUND

The optimal rate of enteral feeding (EF) advancement in very low birth weight infants is under debate.

OBJECTIVES

To evaluate the effects of accelerated EF advancement on the time to full enteral feeds, on early postnatal growth as well as on the frequency of necrotizing enterocolitis (NEC) and focal intestinal perforation (FIP) in very premature infants.

METHODS

In a retrospective single-center historic cohort study, infants with a gestational age <32 weeks at birth and birth weight <1,500 g, born between January 1, 2006, and December 31, 2007 (n = 136), were compared with infants born between January 1, 2010, and December 31, 2010 (n = 88). In 2006/2007, enteral feeds were initiated on day 1 with 10-15 ml/kg/day and advanced by 15-20 ml/kg/day. In 2010, enteral feeds were initiated with 20 ml/kg/day on day 1 and advanced by 25-30 ml/kg/day. Full enteral feeds were defined as ≥ 140 ml/kg/day. Data are presented as median (P25-P75).

RESULTS

The time to establish full enteral feeds was shorter in 2010: 8 (7-11) days in 2006/2007 versus 6 (5-9) days in 2010. The incidences of NEC and FIP were 2.7 and 4.1% in 2006/2007 and 3.3 and 2.2% in 2010, respectively. Weight gain was not affected by the rate of EF advancement. Higher parenteral protein intake during week 1 in 2006/2007 was associated with better head circumference growth.

CONCLUSIONS

The new approach was associated with a significantly shorter period to establish full enteral feeds. No difference in the incidence of FIP or NEC was observed; however, the study was underpowered to detect small but possibly important differences.

[Prevention of bone mineral deficiency in premature infants: review of the literature with focus on monitoring of urinary calcium and phosphate]

BACKGROUND

Bone mineral deficiency of prematurity (BMDoP) is caused by the lack of simultaneous availability of calcium (Ca) and anorganic phosphate (P) during rapid skeletal growth.

METHODS

Review of the literature on the prevention of BMDoP, with specific attention to the limitations of the monitoring of urinary calcium and phosphate concentrations.

RESULTS

Intrauterine bone mineral accretion (BMA) can be achieved in preterm infants if urinary concentrations of Ca and P continuously show that the supplementation with these ions slightly exceeds the actual need. An individually adjusted supplementation with Ca and P appears rational because both growth velocity and enteral Ca absorption are highly variable and determine the need for enteral Ca and P administration. If, however, urinary concentrations of Ca and P are used to determine whether Ca and P supplementation is adequate, mechanisms affecting the urinary excretion of these ions other than nutrition have to be taken into account. Specifically, methylxanthines and diuretics increase the renal Ca losses, and the renal P threshold may be lowered in premature infants. A positive effect of physical activity on BMA has been shown in several studies.

CONCLUSIONS

An individualized Ca and P supplementation in preterm infants aiming for supplementation in a slight excess of the actual need and guided by urinary Ca and P concentrations appears able to prevent BMDoP. Monitoring of urinary Ca and P concentrations needs to take into account non-nutritional factors affecting these concentrations. BMA may further be improved by physical activity.

Bid can mediate a pro-apoptotic response to etoposide and ionizing radiation without cleavage in its unstructured loop and in the absence of p53

BH3-only protein Bid is a key player in death receptor-induced apoptosis, because it provides the link with the mitochondrial route for caspase activation. In this pathway, Bid is activated upon cleavage by caspase-8. Its BH3 domain-containing carboxy-terminal fragment subsequently provokes mitochondrial outer membrane permeabilization by Bak/Bax activation. Bid has also been implicated in the apoptotic response to ionizing radiation (IR) and the topoisomerase inhibitor etoposide, anti-cancer regimens that cause double-strand (ds)DNA breaks. We confirm the existence of this pathway and show that it is p53-independent. However, the degree of Bid participation in the apoptotic response to dsDNA breaks depends on the nature of cell transformation. We used Bid-deficient mouse embryonic fibroblast (MEF) lines that were reconstituted with Bid to control the cellular background and demonstrated that the Bid-dependent apoptotic pathway induced by IR and etoposide operates in MEFs that are transformed by SV40, but is not evident in E1A/Ras-transformed MEFs. The Bid-dependent apoptotic response in p53-deficient SV40-transformed MEFs contributed to clonogenic execution of the cells, implying relevance for treatment outcome. In these cells, Bid acted in a conventional manner in that it required its BH3 domain to mediate apoptosis in response to IR and etoposide, and triggered apoptotic execution by indirect activation of Bak/Bax, mitochondrial permeabilization and caspase-9 activation. However, the mechanism of Bid activation was unconventional, because elimination of all known or suspected cleavage sites for caspases or other proteolytic enzymes and even complete elimination of its unstructured cleavage loop left Bid's pro-apoptotic role in the response to IR and etoposide unaffected.

Acute scrotum in a neonate caused by renal vein thrombosis

The authors report on a rare case of neonatal scrotal oedema occurring concurrently with pain upon palpation of the spermatic cord on the first day of life. An ultrasound examination showed poor perfusion of the left testicle and a thrombosis of the left renal vein; intraoperative exploration indicated necrosis of the left testicle without signs of torsion. Gorged vessels with paravasal bleeding were found in the spermatic cord. The authors hypothesise that necrosis of the testicle may result from haemorrhagic infarction caused by renal venous thrombosis. Acute scrotal discolouration with pain upon palpation in neonates is usually attributed to testicular torsion. The authors report a case where these symptoms had a different cause.

Smac/DIABLO release from mitochondria and XIAP inhibition are essential to limit clonogenicity of Type I tumor cells after TRAIL receptor stimulation

Death receptors, such as Fas/CD95 and TRAIL receptors, engage the extrinsic pathway for caspase activation, but also couple to the intrinsic mitochondrial route. In so-called Type II cells, death receptors require the mitochondrial pathway for apoptotic execution, whereas in Type I cells they reportedly do not. For established tumor cell lines, the Type I/Type II distinction is based on short-term apoptosis assays. We report here that the mitochondrial pathway is essential for apoptotic execution of Type I tumor cells by death receptors, when long-term clonogenicity is taken into account. A blockade of the mitochondrial pathway in Type I tumor cells - by RNA interference for Bid or Bcl-2 overexpression - reduced effector caspase activity and mediated significant clonogenic resistance to TRAIL. Downstream from the mitochondria, Caspase-9 did not contribute to clonogenic death of TRAIL-treated Type I cells. Rather, the release of Smac/DIABLO and the inhibition of XIAP activity proved to be crucial for full effector caspase activity and clonogenic execution. Thus, in Type I cells the intrinsic pathway downstream from death receptors is not redundant, but limits clonogenicity by virtue of Smac/DIABLO release and XIAP inhibition. This finding is relevant for cancer therapy using death receptor agonists.

Survey of practices regarding utilization of inhaled steroids in 223 German neonatal units

BACKGROUND

No survey has been published in recent years which primarily focuses on the prescription of inhaled corticosteroids in neonatal practice. Thus, the utilization rate of inhaled corticosteroids is unknown.

OBJECTIVES

To elucidate the current utilization rate of inhaled corticosteroids in the prevention and therapy of bronchopulmonary dysplasia (BPD).

METHODS

We developed an 18-item questionnaire that was distributed in March 2009, via electronic mail, to the pediatricians-in-chief of all the 343 German pediatric hospitals with a neonatal unit (all levels of neonatal care). We sent electronic reminders after 4 and 8 weeks.

RESULTS

223 hospitals (65%) returned the questionnaire. Of these, 102 (46%) administered inhaled corticosteroids to premature infants either as prophylaxis or treatment for BPD. Predominantly, treatment with inhaled steroids was seen as a 'rescue therapy' and used only if other therapeutic approaches had failed. Of the hospitals not administering inhaled steroids, the most frequently stated reason was 'insufficient robust evidence to support benefit of therapy' (57%). In the majority of hospitals (81%), the active substance of choice was budesonide.

CONCLUSIONS

Of the responders, approximately 50% administer inhaled corticosteroids to premature infants either as a prophylaxis or treatment for BPD. Lack of beneficial evidence was the main reason for not administering inhaled steroids in about half of the units which took this approach. Future trials should address this discrepancy by aiming to establish a clear benefit-risk ratio of inhaled corticosteroids.

Neuronal depolarization modifies motor protein mobility

Active neuronal transport along microtubules participates in the targeting of mRNAs, proteins and organelles to their sites of action. Cytoplasmic dynein represents a minus-end-directed microtubule-dependent motor protein. Due to the polarity of microtubules in axonal and distal dendritic compartments, with microtubule minus-ends pointing toward the inside of the cell, dyneins mainly mediate retrograde transport pathways in neurons. Since dyneins transport synaptic proteins, we asked whether changes in neuronal activity would in general influence dynein transport. KCl-induced depolarization, a condition that mimics the effects of neuronal activity, or pharmacological blockade of neuronal action potentials, respectively, was combined with neuronal live cell imaging, using an autofluorescent dynein intermediate chain fusion (monomeric red fluorescent protein [mRFP]-dynein intermediate chain [DIC]) as a model protein. Notably, we found that induced activity significantly reduced dynein particle mobility, as well as both the total distance and velocity of movements in mouse cultured hippocampal neurons. In contrast, blockade of neuronal action potentials through TTX did not alter any of the parameters analyzed. Neuronal depolarization processes therefore represent candidate mechanisms to regulate intracellular transport of neuronal cargoes.

The effect of body mass index on fasting blood glucose after initiation of thiazide therapy in hypertensive patients

BACKGROUND

The prevalence of obesity, hypertension, and type 2 diabetes mellitus is increasing in the United States. In this setting, it is important to understand the effects of antihypertensives on glucose metabolism. We therefore examined the association between body mass index (BMI) (kg/m(2)) and fasting blood glucose (FBG) in subjects in whom thiazide antihypertensive therapy had been initiated.

METHODS

A retrospective observational study was carried out on individuals with hypertension who had been started on thiazide therapy. The subjects' age, thiazide dose, BMI, serum potassium, FBG, new onset of diabetes mellitus, and concurrent use of other antihypertensives were included in the analysis. Predictors of change in FBG were analyzed using multiple linear regression analysis, while predictors of new-onset diabetes mellitus were determined using multiple logistic regression.

RESULTS

A total of 2,624 individuals who had been started on thiazide therapy for hypertension were divided into quartiles of increasing BMI. FBG was found to be associated with baseline BMI and, after thiazide initiation, there was a step-wise increase in the magnitude of change in FBG with increasing BMI (P < 0.001 for both). Analysis using multiple linear regression found that BMI and baseline FBG predicted the magnitude of FBG change in subjects initiated on thiazide treatment (P < 0.001 for both). Analysis with logistic regression found that, after thiazide initiation, BMI, serum potassium baseline (P < 0.05 for both), and baseline FBG (P < 0.001) predicted the development of diabetes mellitus.

CONCLUSIONS

There is an overall increase in FBG in individuals who are started on treatment with thiazides for hypertension. The magnitude of change in FBG and the development of new-onset diabetes mellitus after thiazide initiation were associated with increases in BMI and baseline FBG. American Journal of Hypertension (2008) doi:10.1038/ajh.2007.75American Journal of Hypertension (2008); 21 4. 438-442 doi:10.1038/ajh.2007.75.

[Newborn with phocomelia and thrombocytopenia. Case report]

Associated malformations and symptoms may be decisive in the differential diagnosis of neonatal phocomelia. We report on a neonate with phocomelia, petechiae and thrombocytopenia. This constellation is typical for the phocomelia-thrombocytopenia-syndrome, a variant of the thrombocytopenia-absent radius-(TAR) syndrome. During the neonatal period platelet transfusions were necessary. Relevant bleeding and development delays were not evident until the age of seven months. Cardinal symptoms of the TAR syndrome are bilaterally absent radius and neonatal thrombocytopenia. The patient presented with phocomelia of the upper extremities which occurs in only 5 - 10 % of the patients with TAR syndrome. Further abnormalities include additional bone and joint disorders and haematopoietic problems, such as thrombocytopenia. Bleeding episodes mainly occur in the first year of life, hence platelet transfusions may be necessary during this period. A new experimental approach is the Interleukin-6-mediated stimulation of thrombopoiesis. Usually platelet counts reach normal values in adults. The main problem remains a satisfactory management of various limb defects.

Family problems and youth unemployment

This study attempted to determine the extent to which family and personal characteristics relate to the employment situation of adolescents. Data were drawn from the Utrecht Study of Adolescent Development (USAD), which investigated, longitudinally, a national sample of Dutch youths aged 12 to 24 years in 1991. Specifically, two waves of a sample of 955 non-school-going respondents between 18 and 27 years old were analyzed. Parental divorce, parental unemployment (only for males), low parental affective involvement, and adolescent relationship problems were related to youth unemployment, but educational career and work commitment were not. For males, parental unemployment demonstrated the strongest correlation with youth unemployment. For females, only variables in the relational domain played a role in explaining unemployment; relationship variables were also important predictors of male unemployment. The results suggest that the family factors included in this study are better predictors of youth unemployment than are the classic individual (personal) variables.

Clinical evaluation of nine hollow-fibre membrane oxygenators

In a comparative study we investigated the performance characteristics of nine hollow-fibre oxygenators. In a clinical setting, 10 units of each type of oxygenator were tested for oxygen exchange, transoxygenator pressure drop, heat exchanger performance and blood trauma. The oxygenators included are Maxima PRF Plus, Affinity, Forte, Affinity NT, Quantum, Optima, Capiox 1.8, Hilite and Quadrox. Ninety patients scheduled for elective coronary bypass surgery were enrolled in the study. Cardiotomy suction blood was not allowed to mix with the circulating blood. Samples were taken preoperatively (t1), immediately after cooling and crossclamping of the aorta (t2), during rewarming (t3), and postoperatively (t4). The results showed that under clinical conditions all of the tested oxygenators are well capable of meeting the normal and above-normal oxygen needs. The Quantum and Affinity NT are the best performing oxygenators with respect to oxygen transfer. The Quantum oxygenator with a small membrane surface area of 1.9 m2 has also the highest oxygen transfer per square metre. A direct relationship between shunt fraction and blood flow could not be established in all oxygenators. The lowest shunt fraction at 4 litres blood flow was seen in the Maxima, Quantum and Affinity NT groups (15%). At near physiological PaO2-values, we noticed a negative influence on the shunt fraction. Large differences exist in pressure drop between the oxygenators under standardized conditions with circulating priming, as well as during bypass. The lowest pressure drop was noticed in the Quadrox and Affinity NT, the highest in the Quantum, Capiox and Optima. However, we did not measure any differences in pressure drop after cooling and during re-warming. Differences exist between the heat exchanger performances. The Quadrox oxygenator is the most efficient, while the Maxima has the smallest performance factor. It was not possible to calculate heat exchanger performance for the Hilite due to incorrect temperature measurement. The high pressure gradients in some of the devices did not result in higher haemolysis. Plasma free haemoglobin values were low in each oxygenator. There are no differences in platelet drop postoperatively. The influence on blood trauma of the higher pressure drop in some of the tested devices, in combination with the higher centrifugal pump revolutions needed to overcome this gradient, has to be studied with longer perfusion times.

Mechanical properties of medical grade expanded polytetrafluoroethylene: the effects of internodal distance, density, and displacement rate

Expanded polytetrafluoroethylene (e-PTFE) is used successfully in a multitude of biomedical and clinical applications. The success of this biomaterial is due to its microporous structure that allows biointegration for fixation, as well as overall mechanical integrity. The mechanical properties and degree of tissue ingrowth depend on the microstructure of the expanded polymer foam, yet little is known about the correlation of the internodal distance and other microstructural features with the monotonic tensile properties. Complete structure-property correlation can be used to provide invaluable knowledge for the design of biomedical devices. The purpose of this study was to investigate the monotonic tensile properties of e-PTFE over a range of medically relevant microstructural features and manufacturing parameters. The microstructural and manufacturing parameters considered were internodal distance, linear density, volumetric density, and reduction ratio. Additionally, the effect of displacement rate on mechanical properties was studied. We found that the ultimate stress and strain increased linearly with linear density (R2 = 0.88 and 0.67, respectively). Surprisingly, elastic modulus did not correlate with any parameter measured and only weak correlations were found between all properties and internodal distance. The yield and ultimate stresses increased with increasing displacement rate (R2 = 0.88 and 0.57, respectively). The findings from this study indicate that linear density is a better predictor of mechanical properties than internodal distance and may be the preferred parameter to control when specifying a material for implantation in load bearing situations.

The use of the Biomedicus centrifugal pump in combination with a separate reservoir with integrated heat exchanger in aneurysms of the thoracic aorta

The surgical correction of aneurysms in the descending thoracic aorta necessitates clamping the aorta both proximal and distal to the aneurysm. The affected length can vary from a few centimetres to large portions of the upper and lower descending aorta. Clamping times can vary from a few minutes to more than one hour. No matter which technique is applied, these operations are often accompanied by excessive blood loss and the need for rapid transfusion, resulting in substantial haemodynamic fluctuations. Hypothermia may become a problem in these patients because most blood warmers are unable to warm blood adequately ( greater than 35 degrees C) at high flow rates (>100 cc/min). This may result in clotting problems. For this reason, our clinic decided from November 1990 to integrate a reservoir with its own heat exchanger (Cobe) into our left-left bypass system. This system largely regulates transfusion during partial extracorporeal circulation (PECC). The advantages of such a system are that (1) the transfusion rate can be adapted to blood loss and is not dependent on the quality and quantity of the infusion systems; (2) blood products and other infusion liquids are filtered; and (3) the transfusion blood is warmed. In this article, we describe our experience with this application of PECC on three patients who suffered excessive blood loss during operations for large thoracic aneurysms.

Transcription of the Arabidopsis CPD gene, encoding a steroidogenic cytochrome P450, is negatively controlled by brassinosteroids

The Arabidopsis CPD gene encodes a cytochrome P450 steroid side-chain hydroxylase (CYP90) that plays an essential role in the biosynthesis of the plant hormone brassinolide. Expression of the CPD gene is confined to cotyledons and leaf primordia in etiolated seedlings and detectable in the adaxial parenchyma of expanding leaves in light-grown plants. Transcription of the CPD gene is not affected by the plant growth factors auxin, ethylene, gibberellin, cytokinin, jasmonic acid and salicylic acid, but is specifically down-regulated by brassinolide in both dark and light. Steady-state mRNA levels of a CPD promoter-driven uidA reporter gene correlate with the expression of resident CPD gene in transgenic plants. Intermediates of the early and late C-6 oxidation pathways of brassinolide, carrying C-22 and C-23 side-chain hydroxyls, efficiently inhibit the activity of the CPD promoter. Repression of CPD transcription by brassinosteroids is sensitive to the protein synthesis inhibitor cycloheximide, indicating a requirement for de novo synthesis of a regulatory factor.

[Computer-assisted stress analysis in rehabilitation with ABBA (job requirements and capacity analysis)]

ABBA is a recently devised, ergology-based expert system software for vocational analysis, documentation and evaluation--inter alia in the context of medical and vocational rehabilitation-, drawing on some 20 years of experience in job analysis with the AET (Arbeitswissenschaftliches Erhebungsverfahren zur Tätigkeitsanalyse). Designed for broad and differentiated coverage, a PARADOX data bank comprising the entire data collected enables comparison of job requirements and client performance potential, reaching for beyond individual analysis on account of its integration of job profiles for a given industry or occupation, or for an entire company. The related, and easy-to use, software for data processing and appraisal is now being made available by ABBA along with dialogue-based ergological know-how.

Intermittent antegrade/selective cerebral perfusion during circulatory arrest for repair of the aortic arch

If the aortic arch requires repair or replacement due to an aneurysm or dissection, conventional cardiopulmonary bypass (CPB) is not possible during the period in which the aortic arch is excluded from the circulation. This creates a situation in which there is no cerebral circulation. The brain needs adequate protection from this ischaemic insult. Hypothermic circulatory arrest (HCA), antegrade/selective cerebral perfusion (ASCP) and retrograde cerebral perfusion (RCP) are reported to exhibit their cerebral protective capabilities during procedures involving the aortic arch. HCA can provide adequate protection in procedures of short duration and avoids the complications associated with cerebral perfusion techniques. The main disadvantage of HCA is that the 'safe' duration of circulatory arrest is not clearly defined. Topical cooling of the head may enhance cerebral hypothermia and provide additional protection. If longer periods of circulatory arrest are anticipated or occur unexpectedly, we suggest that ASCP can offer improved cerebral protection by providing adequate brain perfusion and improved cerebral cooling. By using a coronary sinus perfusion catheter as a carotid artery cannula, it is not necessary to snare or clamp the carotid arteries. This technique minimizes the chance of damaging the carotid arteries. In this report, we describe our set-up and ASCP perfusion protocol for the surgical repair of an aortic arch aneurysm.

Enhanced green fluorescence by the expression of an Aequorea victoria green fluorescent protein mutant in mono- and dicotyledonous plant cells

The expression of the jellyfish green fluorescent protein (GFP) in plants was analyzed by transient expression in protoplasts from Nicotiana tabacum, Arabidopsis thaliana, Hordeum vulgare, and Zea mays. Expression of GFP was only observed with a mutated cDNA, from which a recently described cryptic splice site had been removed. However, detectable levels of green fluorescence were only emitted from a small number of protoplasts. Therefore, other mutations in the GFP cDNA leading to single-amino acid exchanges in the chromophore region, which had been previously studied in Escherichia coli, were tested in order to improve the sensitivity of this marker protein. Of the mutations tested so far, the exchange of GFP amino acid tyrosine 66 to histidine (Y66H) led to detection of blue fluorescence in plant protoplasts, while the exchange of amino acid serine 65 to cysteine (S65C) and threonine (S65T) increased the intensity of green fluorescence drastically, thereby significantly raising the detection level for GFP. For GFP S65C, the detectable number of green fluorescing tobacco (BY-2) protoplasts was raised up to 19-fold, while the fluorimetricly determined fluorescence was raised by at least 2 orders of magnitude.

Cooperative binding to nucleic acids by barley yellow mosaic bymovirus coat protein and characterization of a nucleic acid-binding domain

The capacity of several coat protein (CP) mutants of a German isolate of barley yellow mosaic bymovirus (BaYMV) to bind of nucleic acids was studied in vitro. Recombinant CP, produced by overexpression in Escherichia coli, was purified from inclusion bodies and subsequently renatured. Binding to single-stranded (ss) RNA and ssDNA oligonucleotides was found to be cooperative and sequence non-specific. By deletion mutagenesis, several truncated CP derivatives were created and their nucleic acid-binding capacity was investigated in order to define a protein domain responsible for RNA- and DNA-binding. The nucleic acid-binding domain consists of a core which was located to an internal 23 amino acid peptide (aa 125-147) and an adjacent domain (aa 148-184) which stimulates binding.

[Study on the significance of mercury accumulation in the brain from dental amalgam fillings through direct mouth-nose-brain transport]

The transport of mercury (Hg) from the oro-nasal to the cranial cavity via a direct route was investigated. In 55 deceased persons, Hg concentrations were measured in the olfactory bulb and the trigeminal ganglion, and the number of dental amalgam fillings was assessed. For the purpose of comparison, Hg concentrations were also determined in the occipital lobe cortex, the pituitary gland and the kidney cortex. Quantitative Hg analysis was performed by cold vapor atomic absorption spectroscopy after acid digestion using high pressure microwave treatment. In the olfactory bulb (geom. mean 17.4 micrograms/kg w. w.), the Hg concentration was significantly higher than in the occipital lobe cortex (geom. mean 9.2 micrograms/kg w. w.) (p < 0.0001). No significant difference was found between the Hg concentration in the trigeminal ganglion (geom. mean 12 micrograms/kg w. w.) and the occipital lobe cortex (alpha = 0.005; p = 0.0342). Regression analysis did not reveal a statistically significant correlation between the number of dental amalgam fillings and the Hg content in the olfactory bulb and the trigeminal ganglion, respectively (alpha = 0.01). Therefore, these results do not support the hypothesis of a significant flow o Hg from dental amalgam fillings to the cranial cavity by a direct oro-nasal route. In contrast, a statistically significant correlation exists between the number of dental amalgam fillings and the Hg concentration in the kidney cortex (r2 = 0.317; p < 0.0001), and, to a lesser extent, the Hg concentration in the occipital lobe cortex (r2 = 0.17; p = 0.0016). The highest Hg concentrations (geom. mean 93.1 micrograms/kg w. w.) were detected in the kidney cortex, followed by the pituitary gland (geom. mean 30.0 micrograms/kg w. w.). In this study, Hg concentration in the pituitary gland did not correlate with the number of dental amalgam fillings.

Enhanced quantitative resistance against fungal disease by combinatorial expression of different barley antifungal proteins in transgenic tobacco

cDNAs encoding three proteins from barley (Hordeum vulgare), a class-II chitinase (CHI), a class-II beta-1,3-glucanase (GLU) and a Type-I ribosome-inactivating protein (RIP) were expressed in tobacco plants under the control of the CaMV 35S-promoter. High-level expression of the transferred genes was detected in the transgenic plants by Northern and Western blot analysis. The leader peptides in CHI and GLU led to accumulation of these proteins in the intercellular space of tobacco leaves. RIP, which is naturally deposited in the cytosol of barley endosperm cells, was expressed either in its original cytosolic form or fused to a plant secretion peptide (spRIP). Fungal infection assays revealed that expression of the individual genes in each case resulted in an increased protection against the soilborne fungal pathogen Rhizoctonia solani, which infects a range of plant species including tobacco. To create a situation similar to 'multi-gene' tolerance, which traditional breeding experience has shown to provide crops with a longer-lasting protection, several of these antifungal genes were combined and protection against fungal attack resulting from their co-expression in planta was evaluated. Transgenic tobacco lines were generated with tandemly arranged genes coding for RIP and CHI as well as GLU and CHI. The performance of tobacco plants co-expressing the barley transgenes GLU/CHI or CHI/RIP in a Rhizoctonia solani infection assay revealed significantly enhanced protection against fungal attack when compared with the protection levels obtained with corresponding isogenic lines expressing a single barley transgene to a similar level. The data indicate synergistic protective interaction of the co-expressed antifungal proteins in vivo.

The combination of a novel stimulatory element in the first exon of the maize Shrunken-1 gene with the following intron 1 enhances reporter gene expression up to 1000-fold

Both exon 1 and intron 1 of the maize Shrunken-1 (Sh1) gene individually stimulate expression of reporter genes in transient gene expression experiments if present within the transcription unit. The Sh1 exon 1 mediates a 10-fold increase in activity when inserted at the 5' end of the bacterial chloramphenicol transacetylase (CAT) marker gene in both monocot and dicot protoplasts. The Sh1 intron 1 enhances chimeric gene expression in rice and maize protoplasts approximately 100-fold but inhibits CAT expression in tobacco protoplasts. In combination, the stimulatory effects of Sh1 exon 1 and intron 1 are multiplicative in monocot protoplasts resulting in a final enhancement of up to 1000-fold compared to the unmodified CAT or luciferase marker genes.

A feedback control element near the transcription start site of the maize Shrunken gene determines promoter activity

The transcriptional activity of the Shrunken (Sh) promoter of Zea mays was monitored in transient expression assays using the neomycin phosphotransferase (NPT) II gene as a reporter in maize suspension protoplasts. Shortly after transfection, expression of this chimeric NPTII gene was negatively affected by high extracellular sucrose concentrations in the protoplast cultivation medium. However, 3-5 days after transfection an up to 405-fold increase in NPTII activity was observed. This could be blocked by dichlorobenzonitril (DCB) an inhibitor of cellulose biosynthesis. In the analysis of promoter deletions 20 bp upstream of the Sh transcription start site were sufficient to reproduce the expression profile and the activity of the full promoter. Surprisingly this start sequence does not include the natural TATA-box.

Mechanism and optimized conditions for PEG mediated DNA transfection into plant protoplasts

Experimental conditions influencing DNA uptake efficiency by maize protoplasts in polyethyleneglycol (PEG) mediated transfection experiments have been studied systematically. The data provide evidence that the extracellular DNA is precipitated efficiently by combined action of PEG together with divalent cations and DNA is taken up by the plant protoplasts in the precipitated form. The particle size is strongly effected by the pH of the PEG solution. At optimal pH 6- 6.5 a very fine and homogenous precipitate forms in presence of Ca(2+) and Mg(2+) ions and is efficiently incorporated by maize and rice protoplasts.

Structure of the sucrose synthase gene on chromosome 9 of Zea mays L

The structure of the shrunken gene of Zea mays encoding sucrose synthase (EC 2.4.1.13) was determined by (i) sequencing the transcription unit and 1.2 kb of 5' -upstream sequences from a genomic clone, (ii) by sequencing a nearly full length cDNA clone and (iii) by determining the transcription start site by a combination of primer extension experiments with synthetic oligodeoxynucleotide primers and S1 mapping. The sucrose synthase gene is 5.4 kb long, of which 2746 bp are found in the mature mRNA. The gene is interrupted by 15 introns. The first two introns are 1 kb and 0.5 kb in length, respectively, while the other introns are much smaller. A TATA box is located 30 bp upstream from the transcription start site. Approximately 610 bp upstream of the transcription start site a direct repeat of 16 nucleotides, separated by a 4-fold repetition of the sequence GGTGG is detected. The 16-bp sequence has similarities to a sequence repeat found between two promoters of a maize zein gene also expressed in the endosperm tissue. The transposable element Ds in the mutant sh-m5933 and sh-m6233 alleles is inserted in the seventh and first intron, respectively. The genomic and cDNA clones were obtained from different maize lines. This allows the determination of polymorphic sites which are frequent in 3rd codon position and absent in 1st and 2nd codon positions. In addition, the 3' -untranslated sequence shows two duplications that may have arisen by the insertion and subsequent excision of transposable elements.

The Behaviour of Ristocetin Cofactor, F. VIIIREL. Antigen, Inhibitors of Coagulation and Platelet Aggregation in Diabetics

We investigated Ristocetin Cofactor(RistCof), Factor VIII related antigen (FVIIIE: AG),Plasminogen, Antiplasmin, Heparin Cofactor and Platelet Aggregation in 210 diabetics and in 57 healthy males and 99 healthy females. We obtairel the following results: The level of RistCof and FVIIIR: AG increases with advancing age. In diabetics we found a significant increase Of RistCof, FVIIIR: AG, of plaominogen, antiplasmin and heparin cofactor, independent of sex and age. We obtained a highly significant correlation between. HistCcf, FVIIIR: AG and plasminogen. Besides that we got a significant correlation between platelet aggregation and F.VIIIR: AG. The blood-sugar level showed a significant correlation to the values of F.VIIIR: AG The duration of diabetes correlated significantly to the enhanced plate-let aggregation. Conclusion: Our results suggest a stimulated synthesis cr release of RistCof and F.VIIIR:AG in diabetics.

Besides that platelet aggregation, plasmiinogen, antiplasnin and heparin ccfactor were enhanced-independent of sex and age.