Implementation Science in Radiation Oncology: Case Study for Liver SBRT

PURPOSE/OBJECTIVE(S)

The translation of research into clinical practice is challenging and implementation science is becoming as important as the trial design and development. Implementation science methodologies have been shown to reduce research-to-practice gap in other clinical settings. This is especially true for the field of Radiation Oncology where modern hypofractionated techniques, like Stereotactic Ablative Body Radiotherapy for Liver are at a high risk of over enthusiastic implementation as well as underutilization. We present the results of a multicomponent implementation methodology utilized to develop our Liver SBRT program as a model to safely translate a complex technology into clinical practice.

MATERIALS/METHODS

After review of literature and market research a setup was created with focus on machine requirements, immobilization devices, motion management techniques and QA techniques. Clinical tools in the form of checklists were developed for patient selection, simulation along with image fusion, target delineation, planning (conformity indices, dose constraint criteria) and treatment delivery. All patients were treated on Truebeam® after Bodyfix® immobilization with plastic wrap. Planning was completed on Eclipse TPS with dose constraints and conformity guidelines defined per the RTOG 1112 and TG 101. Clinical outcomes including clinical and imaging follow-up for tumor control and toxicity were recorded. For this report, all patients treated were reviewed and compared to published data to assess the success of the implementation methodology.

RESULTS

A total of 64 consecutive Patients treated with liver SBRT at Dignity Health Cancer Institute (DHCI) were eligible for the study. 58 patients treated for primary liver malignancies were included in this analysis to assess outcomes including control of disease and toxicity to compare to the published literature. Median follow up for these patients 6.5 months (4-46mnths). Median GTV volume was 38.7cc (0.1cc-2056.1 cc), median PTV volume was 159.35 cc (21.5cc-2673.5cc). Median SBRT prescription dose was 50 Gy/5 fractions (35-50 Gy). Median Liver- GTV was 1595.8 cc(770.7cc-2983.0cc). Following toxicities were noted- Grade 1- 10.3%, Grade 2 - 1.72%, Grade 3- 3.44%. No Grade 4 toxicity was noted. 1 year LC rate was 96.6%. 8.6% showed out of field liver failure and 6.9% developed distant metastasis. These results were compared to the current published literature and are shown to be comparable.

CONCLUSION

Strong and well thought out Implementation methodologies can ensure reproducing results in clinical practice, comparable to the controlled environment of trials. These are crucial in translation of clinical trials utilizing advanced technologies to promote the culture of safety in clinical practice of Radiation Oncology. Regular assessment and tracking of clinical outcomes can be used as Quality markers for directing care and reimbursements for future.

PI3Kγ is a novel regulator of TNFα signaling in the human colon cell line HT29/B6

Phosphoinositide 3-kinases (PI3Ks) are a family of enzymes phosphorylating phospholipids in the membrane, thereby, promoting the PI3K/AKT signaling cascade. PI3Ks are involved in a variety of fundamental cellular functions, including tumor necrosis factor α (TNFα)-induced tight junction (TJ) impairment-a hallmark of inflammatory bowel diseases. Most of the studies analyzing the role of class I PI3K signaling in epithelial barrier maintenance did not decipher which of the isoforms are responsible for the observed effects. By using wild-type and PI3Kγ-deficient HT-29/B6 cells, we characterized the functional role of PI3Kγ in these cells under inflammatory conditions. Measurement of the transepithelial electrical resistance and the paracellular flux of macromolecules revealed that monolayers of PI3Kγ-deficient cells, compared with wild-type cells, were protected against TNFα-induced barrier dysfunction. This effect was independent of any PI3K activity because treatment with a pan-PI3K inhibitor did not alter this observation. By immunostaining, we found correlative changes in the distribution of the TJ marker ZO-1. Furthermore, the absence of PI3Kγ reduced the basal level of the pore-forming TJ protein claudin-2. Our study suggests a novel noncanonical, kinase-independent scaffolding function of PI3Kγ in TNFα-induced barrier dysfunction.

Simulation of Radiative Transfer Within X-ray Microcalorimeter Absorbers

We present Monte Carlo simulations of radiative transfer within the absorbers of X-ray microcalorimeters, utilizing a numerical model for the photon propagation and photon absorption process within the absorber structure. In our model, we include effects of Compton scattering off bound electrons and fluorescence. Scattered or fluorescence photons as well as Auger and photoelectrons escaping the absorber can result in partial energy depositions. By implementing a simplified description of the physical processes compared to existing comprehensive particle transport software frameworks, our model aims to provide representative results at a small computational effort. This approach makes it possible to use our model for quick assessments, parametric studies, and application in other Monte Carlo-based instrument simulators like SIXTE, a software package for X-ray astronomical instrumentation. To study the impact of the energy loss effects on the spectral response of a microcalorimeter, we apply our model to the sensors of the cryogenic X-ray spectrometer X-IFU onboard the future Athena X-ray observatory.

Adsorption of GST-PI3Kgamma at the air-buffer interface and at substrate and nonsubstrate phospholipid monolayers

The recruitment of phosphoinositide 3-kinase gamma (PI3Kgamma) to the cell membrane is a crucial requirement for the initiation of inflammation cascades by second-messenger production. In addition to identifying other regulation pathways, it has been found that PI3Kgamma is able to bind phospholipids directly. In this study, the adsorption behavior of glutathione S-transferase (GST)-PI3Kgamma to nonsubstrate model phospholipids, as well as to commercially available substrate inositol phospholipids (phosphoinositides), was investigated by use of infrared reflection-absorption spectroscopy (IRRAS). The nonsubstrate phospholipid monolayers also yielded important information about structural requirements for protein adsorption. The enzyme did not interact with condensed zwitterionic or anionic monolayers; however, it could penetrate into uncompressed fluid monolayers. Compression to values above its equilibrium pressure led to a squeezing out and desorption of the protein. Protein affinity for the monolayer surface increased considerably when the lipid had an anionic headgroup and contained an arachidonoyl fatty acyl chain in sn-2 position. Similar results on a much higher level were observed with substrate phosphoinositides. No structural response of GST-PI3Kgamma to lipid interaction was detected by IRRAS. On the other hand, protein adsorption caused a condensing effect in phosphoinositide monolayers. In addition, the protein reduced the charge density at the interface probably by shifting the pK values of the phosphate groups attached to the inositol headgroups. Because of their strongly polar headgroups, an interaction of the inositides with the water molecules of the subphase can be expected. This interaction is disturbed by protein adsorption, causing the ionization state of the phosphates to change.

Randomized trial of rifabutin-based triple therapy and high-dose dual therapy for rescue treatment of Helicobacter pylori resistant to both metronidazole and clarithromycin

BACKGROUND

The clinical management of Helicobacter pylori infected patients who failed standard eradication therapies remains a challenge.

AIM

To investigate the efficacy of rifabutin-based triple therapy and high-dose dual therapy for rescue treatment of H. pylori, and the correlation between cytochrome P450 2C19 (CYP2C19) polymorphisms and treatment outcome.

METHODS

Patients infected with H. pylori resistant to both metronidazole and clarithromycin (n = 145) were randomized to either esomeprazole 20 mg, rifabutin 150 mg and amoxicillin 1 g, each given b.d. for 7 days (ERA), or to omeprazole 40 mg and amoxicillin 1000 mg, each given t.d.s. for 14 days (OA). Crossover therapy was offered in cases of persistent infection. CYP2C19 polymorphisms were determined by polymerase chain reaction restriction fragment length polymorphism.

RESULTS

Intention-to-treat and per-protocol eradication rates were: ERA 74% (62.4-83.6) and 78% (66.7-87.3); high-dose OA 70% (57.5-79.7) and 75% (62.5-84.5). Crossover therapy was successful in seven of 10 patients with ERA and in eight of 10 patients with OA. Premature discontinuation of treatment occurred in 2% and 5% of patients, respectively. There was only a non-significant trend to lower eradication rates in homozygous extensive metabolizers.

CONCLUSIONS

Triple therapy with esomeprazole, rifabutin and amoxicillin and high-dose omeprazole/amoxicillin are comparable and effective and safe for rescue therapy of H. pylori regardless of the patient's CYP2C19 genotype.

Long chain CoA esters as competitive antagonists of phosphatidylinositol 4,5-bisphosphate activation in Kir channels

Long chain fatty acid esters of coenzyme A (LC-CoA) are potent activators of ATP-sensitive (K(ATP)) channels, and elevated levels have been implicated in the pathophysiology of type 2 diabetes. This stimulatory effect is thought to involve a mechanism similar to phosphatidylinositol 4,5-bisphosphate (PIP2), which activates all known inwardly rectifying potassium (Kir) channels. However, the effect of LC-CoA on other Kir channels has not been well characterized. In this study, we show that in contrast to their stimulatory effect on K(ATP) channels, LC-CoA (e.g. oleoyl-CoA) potently and reversibly inhibits all other Kir channels tested (Kir1.1, Kir2.1, Kir3.4, Kir7.1). We also demonstrate that the inhibitory potency of the LC-CoA increases with the chain length of the fatty acid chain, while both its activatory and inhibitory effects critically depend on the presence of the 3'-ribose phosphate on the CoA group. Biochemical studies also demonstrate that PIP2 and LC-CoA bind with similar affinity to the C-terminal domains of Kir2.1 and Kir6.2 and that PIP2 binding can be competitively antagonized by LC-CoA, suggesting that the mechanism of LC-CoA inhibition involves displacement of PIP2. Furthermore, we demonstrate that in contrast to its stimulatory effect on K(ATP) channels, phosphatidylinositol 3,4-bisphosphate has an inhibitory effect on Kir1.1 and Kir2.1. These results demonstrate a bi-directional modulation of Kir channel activity by LC-CoA and phosphoinositides and suggest that changes in fatty acid metabolism (e.g. LC-CoA production) could have profound and widespread effects on cellular electrical activity.

Functions of sorting nexin 17 domains and recognition motif for P-selectin trafficking

SNX17 is a member of the sorting nexin family (SNX), a group of hydrophilic proteins whose common characteristic property is a phox homology (PX) domain. The PX domain directs SNXs to phosphatidylinositides containing membranes of the endosomal compartment, where the SNXs are involved in the sorting of transmembrane proteins. SNX17 is known to interact with P-selectin and the LDL receptor family. Here, we report that the PX domain of SNX17 specifically binds to phosphatidylinositol 3-phosphate-containing membranes. The functional part of SNX17 that binds P-selectin or Patched (PTCH) consists of a truncated FERM domain and a unique C terminus together (FC-unit). In a yeast two-hybrid analysis a putative recognition motif for the FC-unit was revealed within P-selectin as FxNaa(F/Y). When HepG2 cells overexpress P-selectin together with SNX17, SNX17 changes its distribution from early endosomes to lysobisphosphatidic acid-containing late endosomes. Furthermore, overexpressed SNX17 restrains P-selectin in the outer membrane of the late endosomal compartment, thus preventing the normal lysosomal accumulation of P-selectin. These results suggest that the PX domain is necessary for the intracellular localisation, while the FC-unit is required for cargo recognition. We hypothesise that the expression level of SNX17 may regulate the lysosomal degradation, at least for P-selectin, by suppressing its entry into the inner vesicles of the multi-vesicular bodies (MVBs).

Intragastric acidity during treatment with esomeprazole 40 mg twice daily or pantoprazole 40 mg twice daily--a randomized, two-way crossover study

BACKGROUND

Patients with severe or complicated reflux disease may require higher than standard doses of a proton pump inhibitor for sufficient acid suppression.

AIM

To test the hypothesis that esomeprazole 40 mg twice daily is superior to pantoprazole 40 mg twice daily in lowering intragastric acidity.

METHODS

In a randomized, single-blinded, two-way crossover study, healthy subjects received esomeprazole 40 mg twice daily or pantoprazole 40 mg twice daily orally for five consecutive days. Continuous ambulatory 24-h intragastric pH was recorded on day 5 of each treatment.

RESULTS

Thirty subjects were analysed. Esomeprazole provided significantly higher intragastric pH-values over the 24-h period [median intragastric pH 6.4 for esomeprazole and 5.1 for pantoprazole (P < 0.00005)]. Intragastric pH > 4 was maintained for 21.1 h with esomeprazole and 16.8 h with pantoprazole (P < 0.0001). An intragastric pH > 4 for more than 16 h was achieved in 96.7 and 56.7% of subjects, respectively (P = 0.0002). During night-time the proportion of time with intragastric pH > 4 was 85.4% with esomeprazole and 63.6% with pantoprazole (P = 0.0001). Nocturnal acid break through occurred less frequently on esomeprazole.

CONCLUSIONS

Esomeprazole 40 mg twice daily provides better and more consistent intragastric acid control than pantoprazole 40 mg twice daily.

Signal transduction of c-Kit receptor tyrosine kinase in CHRF myeloid leukemia cells

PURPOSE

The tyrosine kinase receptor c-Kit (stem cell factor receptor, CD117) is a potential target for signal transduction therapy in different cancers. In this study we investigated c-Kit in CHRF cells, a megakaryoblastic cell line of Acute Myeloid Leukemia (FAB M7).

MATERIALS AND METHODS

We characterized the interactions between c-Kit and PI 3-kinase (p85) after stimulation with SCF (stem cell factor) as well as the regulation of SHP-1 and SHP-2 associated with Kit in this cell line.

RESULTS

Stimulation with SCF leads to a significant increase in interaction between Kit and p85 as well as in receptor associated PI 3-kinase activity. Interestingly, using different kinds of substances (AG 1295, CGP 53716) to inhibit the tyrosine kinase activity of c-Kit blocked activation of c-Kit, but the association of p85 still increased after SCF stimulation even when the tyrosine kinase activity of the receptor was completely blocked. In contrast, the other known interaction partners of c-Kit, SHP-1 and SHP-2, exhibited a basal association with c-Kit and no change of the association could be detected after stimulation of CHRF cells with SCF or treatment with the kinase inhibitors.

CONCLUSIONS

Therefore, we suggest that association of p85, SHP-1, and SHP-2 to c-Kit in CHRF cells can, at least in part, occur in a c-Kit kinase-activity independent manner. In contrast, the kinase activity of c-Kit is necessary for the activation of receptor-associated PI 3-kinase.

Esomeprazole-based one-week triple therapy with clarithromycin and metronidazole is effective in eradicating Helicobacter pylori in the absence of antimicrobial resistance

AIM

This study aimed to investigate the effectiveness of a one-week triple therapy with esomeprazole, clarithromycin and metronidazole for eradication of Helicobacter pylori infection in the absence of antimicrobial resistance.

METHODS

Patients testing positive for H. pylori susceptible to metronidazole and clarithromycin (E-test) were randomized to receive a one-week regimen with either esomeprazole 2 x 20 mg or omeprazole 2 x 20 mg in combination with clarithromycin 2 x 250 mg and metronidazole 2 x 400 mg. Follow-up endoscopy with histology and culture and/or rapid urease test was performed 4-8 weeks after the end of treatment.

RESULTS

Eighty patients were randomized. Helicobacter pylori infection was cured in 38/39 patients of the esomeprazole group and 31/33 patients of the omeprazole group (per protocol 97.4% (95% confidence interval [CI], 86.2-99.9), 93.7% (95% CI, 79.2-99.2), P=0.59); intention-to-treat 90.4% (95% CI: 77.4-97.3), 81.6% (95% CI: 65.7-92.3), respectively. No major side effects occurred. Minor side effects occurred in eight (20%) and six (23%) patients during esomeprazole and omeprazole therapy, respectively. Post-treatment susceptibility testing revealed resistance to both metronidazole and clarithromycin in two of the three patients who failed.

CONCLUSION

We conclude that esomeprazole, clarithromycin and metronidazole as one-week triple therapy is effective for eradication of H. pylori in the absence of antimicrobial resistance.

Brain Cholesterol, Statins and Alzheimer’s Disease

Growing evidence suggests that cellular cholesterol homeostasis is causally involved in different steps leading to pathological events in the brain of Alzheimer's Disease (AD) patients. It was previously demonstrated that the processing of the amyloid beta-peptide precursor protein (APP) is modulated by pronounced alterations in cellular cholesterol levels using statins or cholesterol extracting agents. However, a cholesterol-rich diet was found to enhance amyloid beta-peptide (Abeta) burden in the brain of transgenic mice without clearly affecting total brain cholesterol levels. Recent retrospective epidemiological studies have reported that the use of statins potentially suppresses the development of AD. Although some HMG-CoA reductase inhibitors seem to influence the central cholesterol pool in vivo, the above epidemiological findings are probably not linked to statin-induced changes in brain membrane cholesterol levels per se since not all statins active in preventing AD enter the central nervous system (CNS). Recently, we reported that different statins, regardless of their brain availability, induce alterations in cellular cholesterol distribution in the brain. Such pleiotropic, cholesterol-synthesis independent statin effects might be indirect and are possibly mediated at the blood-brain barrier (BBB) via nitric oxide (NO) or apolipoprotein E (ApoE).

Brain-membrane cholesterol in Alzheimer's disease

Cholesterol represents an important determinant of the physical state of biological membranes. Growing evidence indicate that changes in brain cholesterol and variations in neuronal membrane structure are involved in the development of Alzheimer's disease (AD). Cholesterol modulates the cleavage of the amyloid precursor protein and thus affect cellular production of beta-amyloid peptides (Ab). On the other hand, cholesterol seems to be protective against the neurotoxic and membrane disordering properties of Ab. Present review summarizes reports focusing on brain membrane changes in AD and the effects of Ab on these structures. Since it has been shown that these Ab effects are cholesterol dependent, recent findings are presented indicating that the modulation of membrane cholesterol refers to different cholesterol pools within the membranes. Further, consequences thereof for possible pharmacological strategies are discussed.

[Symptomatic cyst of the pancreas and asymptomatic bilateral phaeochromocytoma]

Symptomatic cyst of the pancreas and asymptomatic bilateral phaeochromocytoma. HISTORY AND CLINICAL FINDINGS: A 39-year-old woman was admitted to our department of gastroenterology with recurrent epigastrical pain. Ten years previously the diagnosis of von Hippel-Lindau (VHL)-syndrome has been established. Two years before a germ line mutation in exon 3 of the VHL-tumour suppressor gene has been detected. The patient has a healthy son with a normal VHL-gene and four healthy siblings who had refused a genetic blood test. INVESTIGATIONS: At abdominal ultrasound at the head of the pancreas three 4 2 cm large cysts and in the region of the left adrenal gland a 2,9 2,7 cm large tumor were visible. MRI of the abdomen revealed in addition a 2,2 1,5 cm large tumour of the right adrenal gland. An asymptomatic biadrenal phaeochromocytoma was detected by elevated urine catecholamines and 123I-MIBG-scintigraphy. TREATMENT AND COURSE: The cysts of the pancreas were punctured under endosonographical control and analysis of the cyst fluid was not suspicious of a malignant cystic tumour. The patient had no further abdominal complaints. After oral treatment with the alpha-blocker phentolamine the biadrenal phaeochromocytoma was treated by retroperitoneal laparoscopic surgery in an organ-sparing fashion. Postoperatively ACTH-stimulating test revealed a normal cortisol response. CONCLUSION: Adrenocortical function can be preserved by la-paroscopic adrenal-sparing surgery in bilateral phaeochromocytoma.

Influence of the sagittal advancement of mandibulae on myofibrillar ATPase activity and myosin heavy chain content in the masticatory muscles of pigs

Endurance muscle stress leads to polymorphic expression of myosin heavy chains (MyHC). Histochemical and electrophoretic analyses were performed on different masticatory muscles (masseter, temporal, geniohyoid and medial pterygoid) of 10 weeks old pigs after 28 days of chronic sagittal advancement of the mandibulae. The differentiation between fiber types was investigated histochemically with the myofibrillar ATPase (mATPase) method and by immunohistochemistry. Expression of different MyHC isoforms was also assessed by means of immunoblotting with monoclonal antibodies. The results of both methods were compared. Chronic sagittal advancement of the mandibulae led to an increase in the cross-sectional area of type I fibers and type I MyHC in the anterior part of the masseter, the distal part of the temporal and the medial pterygoid muscle. In the present study, clear differentiation between type I and type II muscle fibers in all histological analyses was possible. However, mATPase classification of subtypes of type II fibers may lead to misinterpretations. Additionally, a direct correlation between the type I MyHC concentration and the type I fibers was seen in enzyme histochemical and immunohistochemical staining. The defined cross section of fibers is important for the histological investigation in small muscles. The immunoblot method seems to be more sensitive and less subjective for measurement of muscle changes. It can be concluded that the immunoblot method used for measuring the MyHC content is a valid alternative for fiber typing in small muscles as it is less time-consuming and more sensitive than qualitative histochemistry.

Membrane-disordering effects of beta-amyloid peptides

beta-Amyloid (Abeta) protein is the major constituent of senile plaques and cerebrovascular deposits characteristic of Alzheimer's disease (AD). The causal relationship between Abeta and AD-specific lesions like neurodegeneration and atrophy is still not known. The present article summarizes our studies indicating that rather low concentrations of Abeta significantly alter the fluidity of cell membranes and subcellular fractions from different tissues and different species including humans, as a possible initial step of its biological effects. Using different fluorescent probes our data show clearly that Abeta peptides specifically disturb the acyl-chain layer of cell membranes in a very distinct fashion. By contrast, membrane properties at the level of the polar heads of the phospholipid bilayer at the interface with membrane proteins are much less affected.

Differential effects of lovastatin treatment on brain cholesterol levels in normal and apoE-deficient mice

Growing evidence indicates that membrane cholesterol is involved in the development of Alzheimer's disease. Therefore, the availability of pharmacological strategies to modify brain cholesterol is of increasing importance. Accordingly, we investigated the effects of the HMG-CoA reductase inhibitor lovastatin on brain cholesterol levels in vivo. Brain cholesterol was significantly decreased by lovastatin treatment (100 mg/kg/day) in 1- and 12-month-old C57BL/6J mice. Reduced brain cholesterol was associated with decreased pyrene-excimer fluorescence, indicating altered membrane function. Lovastatin had no effect on brain cholesterol ApoE-/- mice. Peripheral cholesterol levels were not affected by lovastatin in all three groups of mice. We demonstrate for the first time that lovastatin represents a valid pharmacological tool to significantly modulate brain cholesterol levels.

Helicobacter pylori and gastric cancer: current status of the Austrain-Czech-German gastric cancer prevention trial (PRISMA-Study)

AIM: To test the hypothesis that Helicobacter pylori eradication alone can reduce the incidence of gastric cancer in a subgroup of individuals with an increased risk for this fatal disease.

METHODS: It is a prospective, randomized, double blind, placebo controlled multinational multicenter trial. Men between 55 and 65 years of age with a gastric cancer phenotype of Helicobacter pylori gastritis are randomized to receive a 7 day course of omeprazole 2 × 20 mg, clarithromycin 2 × 500 mg, and amoxicillin 2 × 1 g for 7 days, or omeprazole 2 × 20 mg plus placebo. Follow-up endoscopy is scheduled 3 months after therapy, and thereafter in one-year intervals. Predefined study endpoints are gastric cancer, precancerous lesions (dysplasia, adenoma), other cancers, and death.

RESULTS: Since March 1998, 1524 target patients have been screened, 279 patients (18.3%) had a corpus dominant type of H. pylori gastritis, and 167 of those were randomized (58.8%). In the active treatment group (n = 86), H. pylori infection infection was cured in 88.9% of patients. Currently, the cumulative follow-up time is 3046 months (253. 38 patient years, median follow up 16 months). So far, none of the patients developed gastric cancer or any precancerous lesion. Three (1.8%) patients reached study endpoints other than gastric cancer.

CONCLUSION: Among men between 55 and 65 years of age, the gastric cancer phenotype of H. pylori gastritis appears to be more common than expected. Further follow up and continuing recruitment are necessary to fulfil the main aim of the study.

Anionic phospholipids are involved in membrane targeting of PI 3-kinase gamma

Phosphoinositide 3-kinases (PI 3-kinases) have critical roles in diverse cellular signaling processes and in protein trafficking. In contrast to the class I PI 3-kinases alpha, beta, and delta which bind via src homology 2 (SH2) domains of adaptor proteins to tyrosine kinase receptors, the mechanism of recruitment of the PI 3-kinase gamma to membranes is unknown. We report in vitro experiments using immobilized proteins and small unilamellar vesicles which suggest an involvement of anionic phospholipids in membrane association of PI 3-kinase gamma. Furthermore we provide evidence that the enzyme displays beside the catalytic center a phospholipid binding domain which is essential for enzyme activity.

The role of hypertension in bromocriptine-related puerperal intracranial hemorrhage

The spate of medicolegal inquiries following the disqualification of Parlodel (bromocriptine mesylate) by the Food and Drug Administration for postpartum ablactation, uncovered previously unreported side effects associated with its postpartum administration. In 1994, bromocriptine mesylate was withdrawn from the market as a milk suppressant. Since this time, over a dozen cases of postpartum intracranial hemorrhages associated with its use have been reported. We describe three additional cases of postpartum intracranial hemorrhage related to bromocriptine usage. One patient, previously normotensive, developed hypertension and a headache; initial CT was normal, but CT 24 h later demonstrated intracranial hemorrhage. This suggests that the blood-pressure elevation was drug-induced and was the cause, rather than the consequence, of bromocriptine-related intracranial hemorrhage.

Helicobacter pylori vacA, iceA, and cagA status and pattern of gastritis in patients with malignant and benign gastroduodenal disease

OBJECTIVE

Both bacterial virulence factors and the pattern of Helicobacter pylori (H. pylori) gastritis may contribute to the development of clinically relevant gastroduodenal disease. The aim of our study was to investigate the frequency of H. pylori vacA alleles, iceA, and cagA, and the pattern of gastritis in patients with gastric cancer (GC), gastric lymphoma (MALT), duodenal ulcer (DU), and functional dyspepsia (FD).

METHODS

H. pylori was cultured from 141 patients (34 GC, 26 MALT, 49 DU, 32 FD). Allelic variants of vacA and iceA, and cagA were identified by polymerase chain reaction. Antrum and corpus biopsies were obtained for assessment of gastritis according to the updated Sydney System.

RESULTS

The vacA sl,ml genotype was more frequently detected in H. pylori from GC patients (70.6%) than from MALT, DU, and FD patients (p < 0.05). The frequency of iceA1 and cagA did not differ among the groups. The proportion of patients with severe gastritis in the corpus was significantly higher in patients with GC and MALT compared with patients with DU (p < 0.001).

CONCLUSIONS

In a German patient population, only the vacA s1,m1 genotype of H. pylori is associated with GC, and therefore may be useful to identify infected patients being at an increased risk for GC.

A highly specific pathogen-responsive promoter element from the immediate-early activated CMPG1 gene in Petroselinum crispum

Within the complex signalling network from pathogen-derived elicitor perception to defense-related gene activation, some immediate-early responding genes may have pivotal roles in downstream transcriptional regulation. We have identified the parsley (Petroselinum crispum) ELI17 gene as a particularly fast-responding gene possessing a new type of W box-containing, elicitor-responsive promoter element, E17. Highly selective E17-mediated reporter gene expression at pathogen infection sites in transgenic Arabidopsis thaliana plants demonstrated the potential of this promoter element for designing new strategies in resistance breeding as well as for further analysis of the early components of defense-related gene activation mechanisms. The protein encoded by the ELI17 gene exhibits various structural characteristics of established transcription factors and is designated as a CMPG protein according to the first four strictly conserved amino acids defining a newly emerging class of plant-specific proteins.

Multiple PIP2 binding sites in Kir2.1 inwardly rectifying potassium channels

Inwardly rectifying potassium channels require binding of phosphatidylinositol-4,5-bisphosphate (PIP2) for channel activity. Three independent sites (aa 175-206, aa 207-246, aa 324-365) were located in the C-terminal domain of Kir2.1 channels by assaying the binding of overlapping fragments to PIP2 containing liposomes. Mutations in the first site, which abolished channel activity, reduced PIP2 binding of this fragment but not of the complete C-terminus. Point mutations in the third site also reduced both, channel activity and PIP2 binding of this segment. The relevance of the third PIP2 binding site provides a basis for the understanding of constitutively active Kir2 channels.

[Secondary high-grade MALT lymphoma of the stomach in a 69-year-old patient with gastrocolic fistula]

A 69-year-old man was referred to our department with an exorbitant foetor ex ore, dysphagia and dyspepsia. Upper endoscopy had been performed prior by an outpatient gastroenterologist and the patient had received an eradication therapy for a Helicobacter pylori-induced gastritis. At admission upper endoscopy showed a gastric ulcer which drained a stinking fluid. Endosonography, computed tomography and an upper gastrointestinal series with water soluble media revealed a gastrocolic fistula. Multiple biopsies showed a low-grade gastric MALT lymphoma. Therefore, a surgical reconstruction with Roux-en-Y esophagojejunostomy and transverso-descendostomy was performed. The histology of the completely removed stomach revealed a high-grade Non Hodgkin Lymphoma (NHL) with parts of a low-grade NHL. 3 weeks after surgery chemotherapy was started with the CHOP-regime which was well-tolerated by the patient.

The Helicobacter pylori vacA s1, m1 genotype and cagA is associated with gastric carcinoma in Germany

BACKGROUND

The H. pylori vacuolating cytotoxin encoded by vacA and the cytotoxin-associated protein encoded by cagA are considered to be important virulence determinants that have been implicated in the development of peptic ulcers and gastric carcinoma. However, conflicting results regarding the association between these virulence factors and clinical disease have been reported from different geographic regions.

AIMS

To determine the frequency of vacA genotypes, vacuolating cytotoxin activity, and cagA in H. pylori isolates obtained from patients with gastric cancer in Germany.

METHODS

H. pylori isolates were obtained from 34 patients with gastric cancer and from 35 subjects with asymptomatic H. pylori gastritis. vacA genotypes and cagA were identified by PCR. Cytotoxic activity was determined by HeLa cell assays. Gastritis was assessed according to the updated Sydney System.

RESULTS

The H. pylori vacA s1,m1 genotype was significantly more frequent in patients with gastric cancer (24/34, 70.6%) as compared with controls (12/35, 34. 3%) (p = 0.005). Cytotoxic activity was detected in 24 (70.6%) and 15 (42.9%) H. pylori isolates from gastric cancer patients and controls, respectively (p = 0.03). The cagA gene was identified in 30 (88.2%) and 21 (60%) H. pylori isolates in the respective groups (p = 0.01).

CONCLUSIONS

Our study suggests a significant association between the H. pylori vacA s1,m1 genotype, cytotoxic activity, cagA, and gastric cancer. Detection of H. pylori possessing these virulence determinants may help to identify patients being at an increased risk to develop gastric cancer in our population.

The Helicobacter pylori vacA s1, m1 genotype and cagA is associated with gastric carcinoma in Germany

BACKGROUND

The H. pylori vacuolating cytotoxin encoded by vacA and the cytotoxin-associated protein encoded by cagA are considered to be important virulence determinants that have been implicated in the development of peptic ulcers and gastric carcinoma. However, conflicting results regarding the association between these virulence factors and clinical disease have been reported from different geographic regions.

AIMS

To determine the frequency of vacA genotypes, vacuolating cytotoxin activity, and cagA in H. pylori isolates obtained from patients with gastric cancer in Germany.

METHODS

H. pylori isolates were obtained from 34 patients with gastric cancer and from 35 subjects with asymptomatic H. pylori gastritis. vacA genotypes and cagA were identified by PCR. Cytotoxic activity was determined by HeLa cell assays. Gastritis was assessed according to the updated Sydney System.

RESULTS

The H. pylori vacA s1,m1 genotype was significantly more frequent in patients with gastric cancer (24/34, 70.6%) as compared with controls (12/35, 34. 3%) (p = 0.005). Cytotoxic activity was detected in 24 (70.6%) and 15 (42.9%) H. pylori isolates from gastric cancer patients and controls, respectively (p = 0.03). The cagA gene was identified in 30 (88.2%) and 21 (60%) H. pylori isolates in the respective groups (p = 0.01).

CONCLUSIONS

Our study suggests a significant association between the H. pylori vacA s1,m1 genotype, cytotoxic activity, cagA, and gastric cancer. Detection of H. pylori possessing these virulence determinants may help to identify patients being at an increased risk to develop gastric cancer in our population.

The Helicobacter pylori vacA s1, m1 genotype and cagA is associated with gastric carcinoma in Germany

BACKGROUND

The H. pylori vacuolating cytotoxin encoded by vacA and the cytotoxin-associated protein encoded by cagA are considered to be important virulence determinants that have been implicated in the development of peptic ulcers and gastric carcinoma. However, conflicting results regarding the association between these virulence factors and clinical disease have been reported from different geographic regions.

AIMS

To determine the frequency of vacA genotypes, vacuolating cytotoxin activity, and cagA in H. pylori isolates obtained from patients with gastric cancer in Germany.

METHODS

H. pylori isolates were obtained from 34 patients with gastric cancer and from 35 subjects with asymptomatic H. pylori gastritis. vacA genotypes and cagA were identified by PCR. Cytotoxic activity was determined by HeLa cell assays. Gastritis was assessed according to the updated Sydney System.

RESULTS

The H. pylori vacA s1,m1 genotype was significantly more frequent in patients with gastric cancer (24/34, 70.6%) as compared with controls (12/35, 34. 3%) (p = 0.005). Cytotoxic activity was detected in 24 (70.6%) and 15 (42.9%) H. pylori isolates from gastric cancer patients and controls, respectively (p = 0.03). The cagA gene was identified in 30 (88.2%) and 21 (60%) H. pylori isolates in the respective groups (p = 0.01).

CONCLUSIONS

Our study suggests a significant association between the H. pylori vacA s1,m1 genotype, cytotoxic activity, cagA, and gastric cancer. Detection of H. pylori possessing these virulence determinants may help to identify patients being at an increased risk to develop gastric cancer in our population.

The Helicobacter pylori vacA s1, m1 genotype and cagA is associated with gastric carcinoma in Germany

BACKGROUND

The H. pylori vacuolating cytotoxin encoded by vacA and the cytotoxin-associated protein encoded by cagA are considered to be important virulence determinants that have been implicated in the development of peptic ulcers and gastric carcinoma. However, conflicting results regarding the association between these virulence factors and clinical disease have been reported from different geographic regions.

AIMS

To determine the frequency of vacA genotypes, vacuolating cytotoxin activity, and cagA in H. pylori isolates obtained from patients with gastric cancer in Germany.

METHODS

H. pylori isolates were obtained from 34 patients with gastric cancer and from 35 subjects with asymptomatic H. pylori gastritis. vacA genotypes and cagA were identified by PCR. Cytotoxic activity was determined by HeLa cell assays. Gastritis was assessed according to the updated Sydney System.

RESULTS

The H. pylori vacA s1,m1 genotype was significantly more frequent in patients with gastric cancer (24/34, 70.6%) as compared with controls (12/35, 34. 3%) (p = 0.005). Cytotoxic activity was detected in 24 (70.6%) and 15 (42.9%) H. pylori isolates from gastric cancer patients and controls, respectively (p = 0.03). The cagA gene was identified in 30 (88.2%) and 21 (60%) H. pylori isolates in the respective groups (p = 0.01).

CONCLUSIONS

Our study suggests a significant association between the H. pylori vacA s1,m1 genotype, cytotoxic activity, cagA, and gastric cancer. Detection of H. pylori possessing these virulence determinants may help to identify patients being at an increased risk to develop gastric cancer in our population.

A novel regulatory element involved in rapid activation of parsley ELI7 gene family members by fungal elicitor or pathogen infection

Abstract In parsley (Petroselinum crispum), members of the ELI7 gene family were rapidly transcriptionally activated following treatment with an elicitor derived from the phytopathogen Phytophthora sojae. Several cDNA and genomic ELI7 clones were isolated. The deduced amino acid sequences revealed close similarity to fatty acid desaturases/hydroxylases, however, the precise functions are still unknown. Analysis of the promoters of two strongly elicitor-induced family members, ELI7.1 and ELI7.2, allowed us to functionally pinpoint a novel, independently acting regulatory region (S box), the only major sequence similarity between the two gene promoters. In situ RNA/RNA hybridization using an ELI7.1 gene-specific probe demonstrated that expression of this gene is rapidly and locally induced around infection sites in planta as well.

[No therapy possible? A group therapy model for psychologically disturbed and socially disadvantaged children]

The authors have developed a group therapy model specifically for children who are difficult to treat using traditional psychotherapeutic techniques. In the present article they describe this model, which has been employed successfully for the past four years in an elementary school in an area of high social deprivation, in collaboration with teaching staff and a social worker.

Identification of 55 kDa phosphatidylinositol 4-kinase in HaCaT cells: comparison with the epithelial cell line A431

Phosphatidylinositol kinases play a crucial role in signal transduction in many cell types. The 55 kDa isoform of phosphatidylinositol 4-kinases is a key enzyme in the metabolism of phosphoinositides, which work as regulators of cell function itself or as precursors of signal molecules. The experiments with HaCaT cells presented suggest that the phosphatidylinositol 4-kinase activity in this cell line corresponds to the 55 kDa isoform concerning kinetic parameters and specific activity in comparison with the malignant cell line A431. Km (for ATP and phosphatidyl-inositol) and Ki values (for Ca2+ and adenosine) are in good agreement with the parameters described for other cells. The findings support the idea that the 55 kDa phosphatidylinositol 4-kinase represents a key enzyme in the inositide signal transduction pathway.

Rapid and transient induction of a parsley microsomal delta 12 fatty acid desaturase mRNA by fungal elicitor

Treatment of cultured parsley (Petroselinum crispum L.) cells with a structurally defined peptide elicitor (Pep25) of fungal origin has previously been shown to cause rapid and large changes in the levels of various desaturated fatty acids. We isolated two distinct parsley cDNAs sharing high sequence similarity with microsomal omega-6 fatty acid desaturases (FADs). One of them was functionally identified as a delta 12 FAD by expression in the yeast Saccharomyces cerevisiae. Two dienoic fatty acids, hexadecadienoic and linoleic, which were not detectable in control cells, together constituted up to 12% of the total fatty acids in the transformed yeast cells. delta 12 FAD mRNA accumulated rapidly and transiently in elicitor-treated parsley cells, protoplasts, and leaves. These and previous results indicate that fatty acid desaturation is an important early component of the complex defense response of parsley to attempted fungal infection.

Lipid kinase and protein kinase activities of G-protein-coupled phosphoinositide 3-kinase gamma: structure-activity analysis and interactions with wortmannin

Signalling via seven transmembrane helix receptors can lead to a massive increase in cellular PtdIns(3,4,5)P3, which is critical for the induction of various cell responses and is likely to be produced by a trimeric G-protein-sensitive phosphoinositide 3-kinase (PI3Kgamma). We show here that PI3Kgamma is a bifunctional lipid kinase and protein kinase, and that both activities are inhibited by wortmannin at concentrations equal to those affecting the p85/p110alpha heterodimeric PI3K (IC50 approx. 2 nM). The binding of wortmannin to PI3Kgamma, as detected by anti-wortmannin antisera, closely followed the inhibition of the kinase activities. Truncation of more than the 98 N-terminal amino acid residues from PI3Kgamma produced proteins that were inactive in wortmannin binding and kinase assays. This suggests that regions apart from the core catalytic domain are important in catalysis and inhibitor interaction. The covalent reaction of wortmannin with PI3Kgamma was prevented by preincubation with phosphoinositides, ATP and its analogues adenine and 5'-(4-fluorosulphonylbenzoyl)adenine. Proteolytic analysis of wortmannin-prelabelled PI3Kgamma revealed candidate wortmannin-binding peptides around Lys-799. Replacement of Lys-799 by Arg through site-directed mutagenesis aborted the covalent reaction with wortmannin and the lipid kinase and protein kinase activities completely. The above illustrates that Lys-799 is crucial to the phosphate transfer reaction and wortmannin reactivity. Parallel inhibition of the PI3Kgamma-associated protein kinase and lipid kinase by wortmannin and by the Lys-799-->Arg mutation reveals that both activities are inherent in the PI3Kgamma polypeptide.

Rapid, transient, and highly localized induction of plastidial omega-3 fatty acid desaturase mRNA at fungal infection sites in Petroselinum crispum

Parsley (Petroselinum crispum) plants and suspension-cultured cells have been used extensively for studies of non-host-resistance mechanisms in plant/pathogen interactions. We now show that treatment of cultured parsley cells with a defined peptide elicitor of fungal origin causes rapid and large changes in the levels of various unsaturated fatty acids. While linoleic acid decreased and linolenic acid increased steadily for several hours, comparatively sharp increases in oleic acid followed a biphasic time course. In contrast, the overall level of stearic acid remained unaffected. Using a PCR-based approach, a parsley cDNA was isolated sharing high sequence similarity with omega-3 fatty acid desaturases. Subsequent isolation and characterization of a full-length cDNA enabled its functional identification as a plastid-localized omega-3 fatty acid desaturase by complementation of the Arabidopsis thaliana fad7/8 double mutant which is low in trienoic fatty acids. omega-3 Fatty acid desaturase mRNA accumulated rapidly and transiently in elicitor-treated cultured parsley cells, protoplasts, and leaves, as well as highly localized around fungal infection sites in parsley leaf buds. These results indicate that unsaturated fatty acid metabolism is yet another component of the highly complex, transcriptionally regulated pathogen defense response in plants.

Purification and characterization of extracellular, acidic chitinase isoenzymes from elicitor-stimulated parsley cells

Treatment of cultured parsley cells (Petroselinum crispum) with fungal elicitor caused large increases in the activities of chitinase and 1,3-beta-glucanase. Chitinase activity accumulated predominantly in the culture medium, whereas 1,3-beta-glucanase activity was located almost exclusively intracellularly. Extracellular chitinase activity was resolved into six different isoenzymes, all of which were purified and characterized. All six isoforms were acidic proteins (pI 3.8-5.3), with molecular mass 30-38 kDa. Four were exochitinases and two were endochitinases. The most abundant isoform also showed lysozyme activity. Three of the exochitinases were glycoproteins and two of these were reactive with an antiserum specific for xylose in complex glycosidic structures. The exochitinases constituted relatively small proportions of the total chitinase activity and may serve a different function in cellular metabolism compared to the more abundant endochitinases.

[The spontaneous course of compensated autonomous thyroid gland adenomas]

The spontaneous course of 58 patients with compensated autonomous adenoma of the thyroid was followed. Scintigraphic appearance (compensated (CAA) or decompensated (DAA)) was documented and the serum levels of thyroxine (T4), triiodothyronine (T3) and thyroid-stimulating hormone after TSH-stimulating hormone were measured at the beginning of observation and 3.8 years (median) later. During follow-up period, 13 patients (22%) with CAA developed DAA. 9/13 patients (15%) had overt hyperthyroidism with elevated T4 and/or T3 levels, 4/13 patients (7%) had normal thyroid hormone levels. Life table analysis showed a risk for developing hyperthyroidism of 19% at five years. The size of all adenomata measured scintigraphically was increasing during follow-up, and there was no discrimination of CAA from DAA using this technique. Eight CAA patients received iodinated contrast medium but none develop DAA. In conclusion from these results as well as from the literature, there is no indication for surgery or radioiodine therapy of patients with a CAA, even if there are plans to administer iodinated contrast medium.

A controlled evaluation of the addition of cognitive therapy to a home-based biofeedback and relaxation treatment of vascular headache

Seventy-six patients with vascular (migraine or mixed migraine and tension) headache (HA) participated in a controlled evaluation of a minimal-therapist-contact, largely home-based, treatment program which combined relaxation (R) training with thermal biofeedback (TBF). One group received TBF + R administered in 3 office visit over 8 weeks, supplemented by audio tapes and manuals. A second group received the TBF + R plus instruction in cognitive stress coping techniques, all of which was administered in 5 office visits over 8 weeks. A third group monitored headache activity for 8 weeks. Evaluations, based on 4 weeks of HA diary at pre-treatment and after treatment, revealed significantly greater reductions in HA activity and medication consumption for both treated groups than the HA monitoring controls who did not change. Significantly more of the treated patients had clinically significant reductions in HA activity than the controls. The two treated groups did not differ on any measure.

Placebo-controlled evaluation of abbreviated progressive muscle relaxation and of relaxation combined with cognitive therapy in the treatment of tension headache

Sixty-six tension headache patients were randomly assigned to one of four conditions for 8 weeks: (a) progressive muscle relaxation (PMR) alone; (b) PMR plus cognitive therapy (PMR + Cog); (c) pseudomeditation, a credible attention-placebo control; or (d) continued headache monitoring. A comparison of overall headache activity (headache index), derived from a daily headache diary, for 4 weeks before treatment to 4 weeks after treatment, revealed that active treatment (PMR and PMR + Cog) was superior to either control condition. Moreover, level of headache medication consumption decreased significantly for the active treatment groups. Although headache-index comparisons of the two active treatments showed no advantage for adding cognitive therapy to PMR, a measure of clinically significant change showed a trend for PMR + Cog to be superior to PMR alone.

Placebo-controlled evaluation of abbreviated progressive muscle relaxation and of relaxation combined with cognitive therapy in the treatment of tension headache

Sixty-six tension headache patients were randomly assigned to one of four conditions for 8 weeks: (a) progressive muscle relaxation (PMR) alone; (b) PMR plus cognitive therapy (PMR + Cog); (c) pseudomeditation, a credible attention-placebo control; or (d) continued headache monitoring. A comparison of overall headache activity (headache index), derived from a daily headache diary, for 4 weeks before treatment to 4 weeks after treatment, revealed that active treatment (PMR and PMR + Cog) was superior to either control condition. Moreover, level of headache medication consumption decreased significantly for the active treatment groups. Although headache-index comparisons of the two active treatments showed no advantage for adding cognitive therapy to PMR, a measure of clinically significant change showed a trend for PMR + Cog to be superior to PMR alone.

A controlled evaluation of thermal biofeedback and thermal biofeedback combined with cognitive therapy in the treatment of vascular headache

One-hundred-sixteen patients suffering from vascular headache (migraine or combined migraine and tension) were, after 4 weeks of pretreatment baseline headache monitoring, randomly assigned to one of four conditions: (a) thermal biofeedback with adjunctive relaxation training (TBF); (b) TBF plus cognitive therapy; (c) pseudomediation as an ostensible attention-placebo control; or (d) headache monitoring. The first three groups received 16 individual sessions over 8 weeks, while the fourth group continued to monitor headaches. All groups then monitored headaches for a 4-week posttreatment baseline. Analyses revealed that all treated groups improved significantly more than the headache monitoring group with no significant differences among the three treated groups. On a measure of clinically significant improvement, the two TBF groups had slightly higher (51%) degree of improvement than the meditation group (37.5%). It is argued that the attention-placebo control became an active relaxation condition.