[175 years of anesthesia and narcosis-Towards a "human right to unconsciousness"]

The Ether Day, a key moment in the history of mankind, commemorates its 175th anniversary on 16 October 2021. On that day the dentist William T. G. Morton successfully gave the first public ether anesthesia in Boston. From then on it was possible to save people from pain with justifiable risk and at the same time to protect them from psychological damage by inducing unconsciousness. The German philosopher Peter Sloterdijk, one of the most renowned and effective philosophers of our times, deduced that from then on humans, to some extent, had a right to unconsciousness when in psychophysical distress. This postulate unfolded from his concept of "anthropotechnics" developed around 1997, meaning the idea of treating human nature as an object of possible improvements. According to Sloterdijk, in favorable cases a synthesis of man and technology can result in a significant improvement of human capabilities in the sense of "enhancement", i.e. an increase, an improvement or even an expansion of intellectual, physical or psychological possibilities, as it were in a transgression of the human (so-called transhumanism). Man should go into vertical tension, i.e. strive for higher aims and exploit his inherent potential, he should not dwell in the horizontal. This is not meant as an appeal but as an imperative: "You must change your life!". In this context modern anesthesia may prove helpful: be operated on by others in order to undergo an enhancement. Or, in its most extreme form, the operation in the "auto-operational curved space", a person can even operate on himself as has been dramatically demonstrated by Rogozov, a young Russian physician and trainee surgeon who successfully performed a self-appendectomy under local anesthesia at the Novolazarevskaya Antarctic Station in 1961; however, the implementation of this idea is a long way off. On the one hand, many countries lack qualified personnel in sufficiently large numbers to perform even vital operations with patients under anesthesia. On the other hand, over the decades it has become clear that anesthesia is obviously beneficial for mankind in that it offers relief from pain and psychological stress but that it can also often show its dark side: substance abuse, use of anesthetics in torture and in executions. In addition, the role of anesthetics in resuscitation, palliative care, and allaying executions is unclear or controversial. Finally, the necessary formal legal steps to acknowledge a "human right to unconsciousness" have not yet been implemented.

[A critical carol : Being an essay on anemia, suffocation, starvation, and other forms of intensive care, after the manner of Dickens]

Irgendwo in den USA – Einige Tage vor Heiligabend wird der angetrunkene Charlie Cratchit bei dem Versuch, eine Straße zu überqueren, von einem Bus angefahren und schwer verletzt: Rippenserienfraktur, Femur- und Fibulafraktur, Milz- und Pankreaslazeration, Darmrisse. In einem US-amerikanischen Krankenhaus der Maximalversorgung wird er operativ versorgt und anschließend auf die Intensivtherapiestation verlegt und dort kontinuierlich von einem namenlosen, sehr erfahrenen Arzt betreut. Vier Tage vor Heiligabend, erscheint am Patientenbett der Geist des berühmten britischen Physiologen Ernest Henry Starling. Er tritt in einen Dialog mit dem namenlosen Arzt, interessiert sich sehr für den Swan-Ganz-Katheter und verschwindet dann wieder. Die Besuche wiederholen sich in den kommenden 3 Nächten. Einmal kritisiert er Cratchits niedrigen Hämatokrit, beim nächsten Mal zeigt er sich unzufrieden mit der Respiratoreinstellung, und beim letzten Besuch ist er äußerst besorgt über den Ernährungszustand des Patienten. Der namenlose Arzt ist zunächst indigniert über des Geistes Kritik und Belehrungen, erkennt aber, dass darin der Schlüssel zu Cratchits Genesung liegt und handelt letztlich nach seinen Vorschlägen. Mit Erfolg: Nach der vom Geist Starlings angeregten Umstellung der maschinellen Ventilation, Gabe von 3 Erythrozytenkonzentraten und Aufnahme einer parenteralen Ernährung kann Charlie Cratchit am Weihnachtsabend extubiert und am Neujahrstag von der Intensivtherapiestation entlassen werden. In diesem Essay hat Robert Bartlett Charles Dickens’ „Weihnachtsgeschichte“ in die Welt der Intensivmedizin verlegt. Sie soll den Intensivmediziner anregen, therapeutische Interventionen wie maschinelle Ventilation, hämodynamische Interventionen und Gabe von Blutprodukten kritisch zu hinterfragen. Hintergrundinformationen und Kommentare zu den angesprochenen aktuellen Problemen der modernen Intensivmedizin ergänzen den Essay.

Potential Leukemic Cells Engraftment After Hematopoietic Stem Cell Transplantation From Unrelated Donors With Undiagnosed Chronic Leukemia

BACKGROUND

Donor-related neoplasms are a potential complication of treatment strategies involving stem cell transplantation. Although mechanisms for detection of short-term complications after these procedures are well developed, complications with delayed onset, notably transmission of chronic diseases such as chronic myeloid leukemia (CML), have been difficult to assess. Consequently, we studied the potential of human CML cells to engraft hematopoietic tissues after intravenous implantation in mice.

METHODS

Human peripheral blood cells, collected from CML patients presenting with moderately increased white blood cells count before treatment, were transplanted into sub-lethally irradiated, immunodeficient mice. Five weeks after transplantation the nuclear cells were isolated from the murine bone marrow, spleen, and peripheral blood and were used to quantitatively detect human CD45 antigen by flow cytometry; qRT-PCR was used to detect the BCR-ABL1 fusion gene, and the human or murine beta-glucuronidase housekeeping gene was used to examine human-murine chimerism.

RESULTS

We found that all evaluated animals had donor chimerism at the selected interval after transplant and the presence of a specific BCR-ABL1 fusion gene transcript was also detected.

CONCLUSIONS

Our results suggest that the risk of neoplasm transmission cannot be eliminated during hematopoietic stem cell transplantation from undiagnosed CML donors with borderline leukocytosis. The obtained data confirms the potential of leukemic cells to viably engraft the hematopoietic organs post-transplantation in an immunosuppressed recipient.

Genomic and epidemiological monitoring of yellow fever virus transmission potential

The yellow fever virus (YFV) epidemic in Brazil is the largest in decades. The recent discovery of YFV in Brazilian Aedes species mosquitos highlights a need to monitor the risk of reestablishment of urban YFV transmission in the Americas. We use a suite of epidemiological, spatial, and genomic approaches to characterize YFV transmission. We show that the age and sex distribution of human cases is characteristic of sylvatic transmission. Analysis of YFV cases combined with genomes generated locally reveals an early phase of sylvatic YFV transmission and spatial expansion toward previously YFV-free areas, followed by a rise in viral spillover to humans in late 2016. Our results establish a framework for monitoring YFV transmission in real time that will contribute to a global strategy to eliminate future YFV epidemics.

Extracorporeal Lung Assist with Heparin-Coated Systems

Extracorporeal lung assist (ELA) has been recommended for the treatment of ARDS if conventional therapy fails. However, the need for nearly complete anticoagulation is a major risk factor for hemorrhagic complications. We describe our experience with 13 ARDS patients treated with ELA using heparin-coated systems (Carmeda). Maintaining partial thromboplastin time and activated clotting time within or close to the normal range, even major surgery (20 thoracotomies and 2 laparotomies) could be performed without undue bleeding complications related to anticoagulation during extracorporeal support. Eight of the 13 patients survived. The use of heparin-coated systems allows prolonged ELA with nearly physiological coagulation function, permitting major surgical intervention. It enhances the safety margin of extracorporeal gas exchange and may ultimately extend its indications.

Coexistence of JAK2 or CALR mutation is a rare but clinically important event in chronic myeloid leukemia patients treated with tyrosine kinase inhibitors

INTRODUCTION

There are 7 designated conditions under the category of myeloproliferative neoplasms (MPN), including chronic myelogenous leukemia (CML) and classical MPN, that is, polycythemia vera (PV), essential thrombocythaemia (ET), and primary myelofibrosis (PMF). Recently, reports about Philadelphia and JAK2 V617F-positive MPN cases have been described in literature. The coexistence of different molecular defects may change the clinical and laboratory manifestation of MPN and may result in an inappropriate interpretation of the response to treatment with tyrosine kinase inhibitors in CML patients.

METHODS

The morphological, cytogenetic, and molecular genetic data from a retrospective analysis of 592 adult patients aged 18-86 years diagnosed with CML were analyzed.

RESULTS

In 5 CML patients, the presence of JAK2 V617F or CALR mutation was confirmed. Three of 4 TKI-treated patients did not reach complete hematologic response due to the persistence of thrombocytosis and/or splenomegaly. In all of them (in 3 with JAK2 V617F mutation and 1 with CALR mutation), thrombocytosis was present at the time when complete cytogenetic response was documented. In 3 out of 4 reported CML patients, thrombocytosis and/or splenomegaly were still present even at the time when deep molecular response was reached.

CONCLUSION

In our opinion, a detailed evaluation and appropriate interpretation of clinical and laboratory data in such a category of patients seem to be extremely important, especially when a decision about the TKI change due to therapy failure is considered.

[The old man and the I sea U : Essay on faith, fate and evidence - after the manner of Hemingway]

Robert Bartlett, emeritus Professor of surgery at the University of Michigan in Ann Arbor, USA, transformed classical works of world literature (Charles Dickens: A Christmas Carol, Lewis Carroll: Alice in Wonderland) into teaching aids for advanced training in intensive care medicine. He recently turned his hand to the well-known work of Ernest Hemingway: the Nobel Prize winning novel The Old Man and the Sea. Subsequent to Robert Bartlett's essay this article provides background information and comments on the current problems in modern intensive care medicine addressed in his essay.

[Short version S2e guidelines: "Positioning therapy and early mobilization for prophylaxis or therapy of pulmonary function disorders"]

The German Society of Anesthesiology and Intensive Care Medicine (DGAI) commissioned a revision of the S2 guidelines on "positioning therapy for prophylaxis or therapy of pulmonary function disorders" from 2008. Because of the increasing clinical and scientific relevance the guidelines were extended to include the issue of "early mobilization" and the following main topics are therefore included: use of positioning therapy and early mobilization for prophylaxis and therapy of pulmonary function disorders, undesired effects and complications of positioning therapy and early mobilization as well as practical aspects of the use of positioning therapy and early mobilization. These guidelines are the result of a systematic literature search and the subsequent critical evaluation of the evidence with scientific methods. The methodological approach for the process of development of the guidelines followed the requirements of evidence-based medicine, as defined as the standard by the Association of the Scientific Medical Societies in Germany. Recently published articles after 2005 were examined with respect to positioning therapy and the recently accepted aspect of early mobilization incorporates all literature published up to June 2014.

S2e guideline: positioning and early mobilisation in prophylaxis or therapy of pulmonary disorders : Revision 2015: S2e guideline of the German Society of Anaesthesiology and Intensive Care Medicine (DGAI)

The German Society of Anesthesiology and Intensive Care Medicine (DGAI) commissioneda revision of the S2 guidelines on "positioning therapy for prophylaxis or therapy of pulmonary function disorders" from 2008. Because of the increasing clinical and scientificrelevance the guidelines were extended to include the issue of "early mobilization"and the following main topics are therefore included: use of positioning therapy and earlymobilization for prophylaxis and therapy of pulmonary function disorders, undesired effects and complications of positioning therapy and early mobilization as well as practical aspects of the use of positioning therapy and early mobilization. These guidelines are the result of a systematic literature search and the subsequent critical evaluation of the evidence with scientific methods. The methodological approach for the process of development of the guidelines followed the requirements of evidence-based medicine, as defined as the standard by the Association of the Scientific Medical Societies in Germany. Recently published articles after 2005 were examined with respect to positioning therapy and the recently accepted aspect of early mobilization incorporates all literature published up to June 2014.

Genome sequence analysis of Ebola virus in clinical samples from three British healthcare workers, August 2014 to March 2015

We determined complete viral genome sequences from three British healthcare workers infected with Ebola virus (EBOV) in Sierra Leone, directly from clinical samples. These sequences closely resemble those previously observed in the current Ebola virus disease outbreak in West Africa, with glycoprotein and polymerase genes showing the most sequence variation. Our data indicate that current PCR diagnostic assays remain suitable for detection of EBOV in this epidemic and provide confidence for their continued use in diagnosis.

Microscopic examination of bone marrow aspirate in healthy adults - comparison of two techniques of slide preparation

INTRODUCTION

According to the International Council for Standardization in Hematology (ICSH) guidelines for the standardization of bone marrow specimens and reports, smears from bone marrow aspirates for microscopic examination should be prepared using two techniques simultaneously: the wedge-spread and the crush technique. However, the outcomes of these techniques have never been compared.

METHODS

We investigated the bone marrow of 105 adult, haematologically healthy subjects, using bone marrow smears prepared via both techniques simultaneously.

RESULTS

Comparison of the two techniques revealed significant differences in terms of the composition of bone marrow cells. Only the percentages of lymphocytes, mature eosinophils and basophils did not differ significantly. The reference ranges for each technique were established.

CONCLUSIONS

The crush technique seems to be more valuable than the wedge-spread technique because of the lack of a blood dilution effect and better assessment of megakaryopoiesis. We recommend the crush technique for the evaluation of the percentage composition of bone marrow cells. In a very small number of patients with irregular cell localization in the bone marrow particles, the wedge-spread technique may be more beneficial for the assessment of total cellularity. The recommendation to routinely prepare slides using both of these techniques is fully justified.

Intraglobular structures in multiblock copolymer chains from a Monte Carlo simulation

Multiblock copolymer chains in implicit nonselective solvents are studied by using a Monte Carlo method, which employs a parallel tempering algorithm. Chains consisting of 120 A and 120 B monomers, arranged in three distinct microarchitectures: (10-10)12, (6-6)20, and (3-3)40, collapse to globular states upon cooling, as expected. By varying both the reduced temperature T* and the compatibility between monomers ω, numerous intraglobular structures are obtained: diclusters (handshake, spiral, torus with a core, etc.), triclusters, and n clusters with n>3 (lamellar and other), which are reminiscent of the block copolymer nanophases for spherically confined geometries. Phase diagrams for various chains in the (T*,ω) space are mapped. The structure factor S(k), for a selected microarchitecture and ω, is calculated. Since S(k) can be measured in scattering experiments, it can be used to relate simulation results to an experiment. Self-assembly in those systems is interpreted in terms of competition between minimization of the interfacial area separating different types of monomers and minimization of contacts between chain and solvent. Finally, the relevance of this model to the protein folding is addressed.

A novel hydrogen sulfide donor causes stomatal opening and reduces nitric oxide accumulation

Effects of hydrogen sulfide (H(2)S) on plant physiology have been previously studied, but such studies have relied on the use of NaSH as a method for supplying H(2)S to tissues. Now new compounds which give a less severe H(2)S shock and a more prolonged exposure to H(2)S have been developed. Here the effects of one such compound, GYY4137, has been investigated to determine its effects on stomatal closure in Arabidopsis thaliana. It was found that both NaSH and GYY4137 caused stomatal opening in the light and prevented stomatal closure in the dark. Nitric oxide (NO) has been well established as a mediator of stomatal movements and here it was found that both NaSH and GYY4137 reduced the accumulation of NO in guard cells, perhaps suggesting a mode of action for H(2)S in this system. GYY4137, and future related compounds, will be important tools to unravel the effects of plant exposure to H(2)S and to determine how H(2)S may fit into plant cell signalling pathways.

Efficacy and Safety of Fludarabine and Cyclophosphamide Combined Therapy in Patients with Refractory/Recurrent B-Cell Chronic Lymphocytic Leukaemia (B-CLL)—Polish Multicentre Study

The aim of this study was to investigate the efficacy of a combination of fludarabine (F) and cyclophosphamide (C) in the treatment of patients with refractory/recurrent B-cell chronic lymphocytic leukaemia (B-CLL). Between November 1999 and December 2001, 63 patients with B-CLL (median age 60 years) received a regimen that consisted of F 25 mg/m2 and C 250 mg/m2, days 1-3, intravenously, every 4 weeks, for a maximum of 6 courses, Response and toxicity were assessed according to current criteria (NCI-WG and WHO). Complete and partial remissions were achieved in 17.5% and 55.6% of patients, respectively; 19% of patients had stable disease and 7.9% of patients showed disease progression. The median follow-up was 16.5 (range 1.5-32) months. The median duration of progression-free survival (PFS) has not been reached among patients treated with FC regimen as second-line therapy. The median PFS was 13 (range 8-26) months in the 19 responding patients treated with FC regimen as third-line therapy. The most frequent side-effects were neutropenia (45%), thrombocytopenia (42%) and infections (57%). We conclude that the combination of fludarabine and cyclophosphamide demonstrated significant efficacy in pretreated, advanced B-CLL patients, with tolerable toxicity.

[Mechanical ventilation of morbidly obese patients in anaesthesia and intensive care]

Sculptures from the Stone Age hint at the possibility that morbidly obese humans have always existed. Today, obesity represents a global epidemic with far-reaching consequences affecting health systems worldwide. Increasingly often, anaesthetists and intensivists are challenged with the treatment of extremely obese patients perioperatively. In addition to insufficient logistics and inappropriate technical equipment, the large number of obesity-related diseases, combined with the distinct pathophysiological changes of the respiratory system, put the morbidly obese patient at a significantly increased risk of perioperative complications. If, however, elaborate logistics and adequate airway management--followed by lung protective mechanical ventilation--are combined with appropriately conducted anaesthesia and intensive care, the morbidly obese patients' intensive care survival rates and hospital survival rates can be similar to those of patients of normal weight.

Comparison of fibrinolytic and metabolic system parameters in obese patients with polycystic ovary syndrome and women with simple obesity

The present study aimed to assess the fibrinolytic and metabolic system parameters in obese patients with polycystic ovary syndrome (PCOS) and to compare them in obese PCOS patients and women with simple obesity. We studied 19 obese women with PCOS (age: 25.1 +/- 4.6 years, body mass index (BMI): 34.7 +/- 3.9 kg/m2; mean +/- standard deviation) and 20 age- and BMI-matched ovulatory controls. We measured blood levels of 17beta-estradiol, testosterone, prolactin, luteinizing hormone (LH), follicle-stimulating hormone (FSH), dehydroepiandrosterone sulfate (DHEAS), total cholesterol (TC), triglycerides (TG), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), glucose and insulin. The following fibrinolytic tests were also performed: euglobulin clot lysis time, plasminogen level, alpha2-antiplasmin activity, plasminogen activator inhibitor-1 activity, fibrinogen concentration and estimated fibrinolytic activity. Testosterone and LH levels were significantly higher in obese women with PCOS (p < 0.01 and p < 0.001, respectively). The groups did not differ with regard to 17beta-estradiol, prolactin, FSH, DHEAS, TC, TG, HDL-C, LDL-C, glucose and insulin. All of the fibrinolysis parameters with the exception of plasminogen were comparable between the two groups. Serum plasminogen level was lower in obese PCOS patients than in women with simple obesity (p < 0.05). Euglobulin clot lysis time was positively correlated with insulin (r = 0.88, p < 0.05) in both groups. Our results show that fibrinolysis is not suppressed in women with PCOS and that there is no difference in fibrinolytic activity between obese patients with PCOS and women with simple obesity.

Epidemiology of ARDS

For decades the incidence of the acute respiratory distress syndrome (ARDS) has been unclear. A first effort to tackle the problem was undertaken by the National Heart and Lung Task Force who, in 1972, provided the scientific community with an arguable estimate of 75 cases per 100,000 inhabitants/year for the USA. Nearly 20 years later, the first population based studies yielded figures of 1.5-4.5 cases per 100 000 inhabitants/year in Europe. Epidemiologic research became much more focused when in 1992 the new ARDS and acute lung injury (ALI) definitions of the American-European Consensus Conference became available. In subsequent studies in which these refined definitions were used, incidence figures ranging from 13-23 cases per 100,000 inhabitants/year for ARDS and 18 cases per 100,000 inhabitants/year for ALI were reported. Latest results from a high-class epidemiological study conducted in Seattle, suggested ARDS/ALI incidence figures of 59 and 79 cases per 100,000 inhabitants/year, respectively. These new figures, similar to the one proposed in 1972, led to a paradigm shift: ARDS and ALI are no longer viewed as rare syndromes but as widespread diseases with a massive socio-economic impact that is comparable with the burden from breast cancer, AIDS, asthma or myocardial infarction.

[Scoring systems in the intensive care unit]

Scoring systems represent classification systems or point systems which have been designed for making quantitative statements regarding the severity of a disease, its prognosis, and its course. Furthermore, scores may serve the purposes of assessing therapies, of quality control and of quality assurance, and of an economic evaluation of intensive care. Like all measuring methods, scores are susceptible to failures and systematic mistakes. The clinical user should be well aware of these limitations. Generally, one would recommend only using scores which have been rigorously tested for their reliability, validity, and practicability. These include, but are not limited to, the updated versions of the APACHE, the SAPS, and the MPM. Although great strides have been made concerning development, verification, and clinical applicability, scores still exhibit a level of uncertainty which precludes their use in individual patients. Frequently, it may be of benefit to combine the more general scores with one or several organ dysfunction scores to determine the extent of functional impairment of specific organs. If, however, well-trained medical personnel apply tried and tested scoring systems, intensive care units will definitely gain a lot from it.

Second malignancies and Richter's syndrome in patients with chronic lymphocytic leukaemia treated with cladribine

The increased frequency of second malignancies in chronic lymphocytic leukaemia (CLL) is well known. Moreover, antineoplastic therapy additionally increases the risk of secondary cancers. In this study, we analysed whether treatment with cladribine (2-chlorodeoxyadenosine, 2-CdA) during the course of CLL had an impact on the subsequent occurrence of either secondary solid tumours or Richter's syndrome. There were 1487 eligible patients, 251 treated with 2-CdA alone, 913 treated with alkylating agents (AA)-based regimens alone and 323 treated with both 2-CdA and AA. Median time from the start of CLL treatment to the diagnosis of secondary malignancy was 1.9 years (0.5-5.1 years) for the 2-CdA group, 1.8 years (0.3-7.9 years) for the AA group and 3.9 years (0.3-8.4 years) for the 2-CdA+AA group. A total of 68 malignancies were reported in 65 patients. Ten events were non-melanotic skin cancers and were excluded from the analysis, leaving 58 events in 58 patients. In the group of patients treated with 2-CdA alone, there were 15 (6.0%) cases, in the group of patients treated with AA alone there were 26 (2.8%) cases, and in the group treated with 2-CdA+AA there were 17 (5.3%) cases of secondary malignancies. The differences between the frequency of secondary malignancies in the 2-CdA and 2-CdA+AA versus AA alone groups were not significant (P=0.05 and P=0.06, respectively). Only lung cancers occurred significantly more frequently in the 2-CdA (2.8%) and 2-CdA+AA (2.2%) treated groups compared with the AA patients (0.3%) (P<0.001 and P<0.01, respectively). In conclusion, 2-CdA in CLL patients does not seem to increase the risk of secondary malignancies except for lung cancers. However, further studies are necessary to establish the real risk of lung cancer in CLL patients treated with 2-CdA.

[Can lung protective ventilation methods modify outcome?--A critical review]

A large body of experimental and clinical work leaves no room for doubt that mechanical ventilation can contribute to the progression of a lung disease or, in the worst case, produce acute pulmonary damage. The pathophysiological processes involved have been described as barotrauma, volutrauma, atelectrauma and biotrauma. In response, a socalled lung-protective ventilation strategy has been proposed, especially for patients with acute respiratory distress syndrome (ARDS). Such an approach seeks to apply limited airway pressures, small tidal volumes and appropriate levels of positive end-expiratory pressures even if, as a consequence, non-physiological gas exchange values (i.e. elevated PaCO2-levels) need to be tolerated. A recent large prospective randomized trial demonstrated reduced mortality rates using such a strategy. To support lung-protective ventilation in ARDS patients, an array of therapeutic measures has been proposed, including meticulous attention to fluid and transfusion management, prone position, extracorporeal membrane oxygenation (ECMO), inhalation of nitric oxide, implementation of spontaneous breathing, partial liquid ventilation and tracheal gas insufflation. Of these, only prone positioning has become part of routine clinical management, while ECMO is applied in selected cases only. Unfortunately, thus far, none of these measures has passed the litmus test of a randomized controlled trial. Recent large prospective observational studies, however, suggest that only an optimized concert of therapeutic interventions, but not a single measure alone, may improve the outcome of ARDS patients.

Transmission of HCV infection among long-term hospitalized onco-haematological patients

Hepatitis C virus (HCV) infection is becoming a substantial problem in long-term hospitalized patients. Onco-haematological patients undergoing chemotherapy are especially prone to HCV infection. These patients are usually immunosuppressed and therefore antibodies to HCV are not produced despite the presence of HCV RNA in peripheral blood. The aim of the study was to see how often long-term hospitalized patients acquired HCV infection, and what were the possible sources and routes of virus transmission. The study involved 129 children with lymphoproliferative diseases, 36 patients with solid tumours, and 61 healthcare workers from onco-haematological wards. All were HCV RNA and anti-HCV negative at the time of first hospitalization. During a two and a half-year follow-up study among 165 onco-haematological patients, HCV RNA appeared in 87 in subsequent hospitalizations. The majority of infections were (82/87) were 1a genotype, 2 were 1b, 1 was 1a + 1b and 1 was 1a + 3a. In an attempt to establish the origin of HCV infection, healthcare workers were screened for HCV genotyping. All HCV-infected staff working on wards had the same genotype (1a). None of the staff was infected with 1b genotype. As the most prevalent genotype in Polish blood donors is 1b, HCV infection in onco-haematological patients is most likely due to horizontal transmission, probably involving genotype 1a, and potential horizontal transmission of HCV is implied by the presence of 1a genotype of HCV in saliva and urine of selected patients. Spread of hospital HCV infection among children may be facilitated by micro-injury of the skin and mucosa. Early detection of HCV RNA is important in such immunosuppressed patients, as they are not able to produce anti-HCV antibodies. This may enable the introduction of prophylactic steps to prevent the spread of HCV infection by horizontal transmission.

Significance of molecular identification of hepatitis C virus RNA in diagnosis of cryptogenic hepatitis in children

Viral etiology of hepatitis is routinely proved by standard immunological tests detecting specific antibodies. However, identification of specific antibodies cannot always be conclusive. Since specific hepatitis C virus (HCV) antibodies may appear after some months of the infection, identification of HCV RNA and/or hepatitis G virus (HGV) RNA should clarify the etiology of hepatitis. The aim of this study was to diagnose etiologically unknown hepatitis by a reverse transcription-polymerase chain reaction (RT-PCR) testing of the presence of HCV RNA and HGV RNA. The study involved 33 children with histologically proved hepatitis. The presence of HCV and any signs of autoimmune disease were not observed at the beginning of the follow-up study. During 2.5 years of the follow-up HCV-RNA was found in the blood and liver biopsies in 17 patients. Eight of them became HCV antibodies-positive during the follow-up. None of them eliminated the virus from the blood during the follow-up. In two other patients HCV-RNA was found only in the liver. HGV infection in all cryptogenic patients was excluded by PCR testing. Identification of HCV RNA RT-PCR allowed to diagnose 19 out of 33 (57.6%) patients with cryptogenic hepatitis. The etiology of the hepatitis in remaining 12 patients has to be established.

Hepatitis G virus co-infection may affect the elimination of hepatitis C virus RNA from the peripheral blood of hemodialysis patients

Hemodialysis patients are at risk for hepatitis C virus (HCV) and hepatitis G virus (HGV) infection. The aim of this study was to investigate the possible influence of HGV co-infection on HCV RNA elimination from the peripheral blood of hemodialysis patients. The study involved 144 persons, all with HCV antibodies and HCV RNA. Among 144 patients 24 (16.7%) were positive for HGV RNA. After 2.5 years of observation 80 patients (55.6%) were still HCV RNA-positive. In the latter group 18 patients were co-infected with HGV and 62 were HGV RNA-negative. During 2.5 years of the follow-up study 64 patients eliminated HCV RNA from the serum. In this group only 6 patients were HGV co-infected. None of the HGV-positive patients eliminated HGV RNA from the serum. The higher incidence of HGV co-infection in the group of patients who remained HCV RNA-positive (18/80, 22.5%), in comparison to the group of HCV antibodies-positive patients who lost HCV in the blood (6/64, 9.4%, P < 0.0001) suggests, that the co-infection with HGV may delay the spontaneous elimination of HCV RNA from the blood.

Comparative studies of the Acinetobacter genus and the species identification method based on the recA sequences

The recA gene is indispensable for a maintaining and diversification of the bacterial genetic material. Given its important role in ensuring cell viability, it is not surprising that the RecA protein is both ubiquitous and well conserved among a range of prokaryotes. Previously, we reported Acinetobacter genomic species identification method based on PCR amplification of an internal fragment of the recA gene with subsequent restriction analysis (RFLP) with HinfI and MboI enzymes. In present study, the PCR products containing the internal fragment of the recA gene, for 25 Acinetobacter strains belonging to all genomic species, were sequenced. Based on the nucleotide sequences the restriction maps and phylogenetic tree were prepared. The restriction maps revealed that Tsp509I restriction enzyme is the most discriminating for RFLP. To verify the computer analysis, the amplified DNAs from all reference genomic species available (43 strains) and 34 clinical strains were digested with each of the three restriction endonucleases mentioned. The results of digestion confirmed the computer analysis. The reconstructed phylogenetic tree showed linkages between genomic species 1 (Acinetobacter calcoaceticus), 2 (Acinetobacter baumannii), 3, 'between 1 and 3', TU13 and 'close to TU13'; genomic species 4, 6, BJ13, BJ14, BJ15, BJ16 and BJ17; genomic species 7 (Acinetobacter johnsonii) and TU14; genomic species 10 and 11; genomic species 8 (Acinetobacter Iwoffii), 9, 12 (Acinetobacter radioresistens) and TU15; and genomic species 5 (Acinetobacter junii). It is interesting that one branch in the phylogenetic tree contains haemolytic species-genomic species 4 (A. haemolyticus), BJ13, BJ14, BJ15, BJ16 and BJ17. The proposed genotypic method clearly revealed that the RFLP profiles obtained with Tsp509I enzyme might be useful for species identification of Acinetobacter strains. In this context, recA/RFLP genotypic method should be seen as an ideal preliminary screening method for large numbers of isolates, with the ultimate confirmatory role reserved for DNA hybridization analysis.

Creation of an additional glycosylation site as a mechanism for type I antithrombin deficiency

We report the identification of a new mutation resulting in type I antithrombin (AT) deficiency and the mechanism by which the deficiency arose. The single base substitution of G to A at nucleotide 2709 was identified in a proband with a family history of venous thrombosis. The mutation results in a substitution of 82 Ser by Asn, creating a new glycosylation site. Expression studies were then carried out, to confirm Asn-linked glycosylation occurred at this consensus site and that this resulted in the AT deficient phenotype. Cell-free translations using rabbit reticulocyte lysate in the presence of microsomes demonstrated that the 82 Asn variant was post-translationally processed efficiently. The 82 Asn variant protein was of a higher molecular weight than normal AT. consistent with the addition of a fifth glycan chain. Incubation of translation product with endoglycosidase H, confirmed that the higher molecular weight product had resulted from additional carbohydrate. Expression of the 82 Asn variant in COS-7 cells resulted in intracellular accumulation, with a low level of secretion of the protein into culture supernatant, consistent with type I AT deficiency. The addition of an extra carbohydrate side chain to residue 82 of antithrombin may block post-translational folding. trapping the variant intracellulary.

Effects of insulin and glucocorticoids on the leptin system are mediated through free leptin

OBJECTIVE

Insulin and glucocorticoids are known to increase total leptin levels. However, the effects of insulin and glucocorticoids on the components of the leptin system - free leptin (FL), bound leptin (BL) and soluble leptin receptor (SR) - have not been elucidated. The aim of this study was to determine if there is a differential effect of insulin and glucocorticoids on the leptin system.

MATERIAL AND METHODS

In the first of two studies (study 1), we measured free leptin (FL), bound leptin (BL), a soluble leptin receptor (SR) and insulin, by specific RIA methods, in six healthy subjects on a control day, and subsequently during a hyperinsulinaemic euglycaemic clamp study. In the second study (study 2) we measured the same parameters in six healthy subjects, before (day 1) and during administration of dexamethasone over 3 consecutive days.

RESULTS

In study 1, on the control day FL levels rose over the 16 h monitoring period (P = 0.057) and SR levels declined (P < 0.001), but there was no change of BL levels. Even after accounting for diurnal variation, FL levels increased even more substantially over 12 h of insulin infusion than observed on the control day (P < 0.001). In study 2, mean FL concentration doubled from day 1 to day 2 (P = 0.01) and remained elevated subsequently. In contrast to FL, BL and SR levels remained unchanged during the study. Fasting insulin levels (pmol/l) increased from day 1 to day 2, but this rise only approached significance on day 4 (P = 0.05).

CONCLUSION

We conclude that insulin and dexamethasone increase free leptin levels, but do not change the concentrations of bound leptin and soluble leptin receptor. Furthermore, the dexamethasone-induced rise in leptin levels is (at least partially) independent of the effects of glucocorticoid-induced hyperinsulinaemia.

Limited pattern of TCR delta chain gene rearrangement on the RNA level in multiple sclerosis

Susceptibility to multiple sclerosis (MS) is most likely affected by a number of genes, including HLA and T-cell receptor (TCR) genes. T cells expressing gamma/delta receptors seem to contribute to autoagression in MS, as evidenced by their localization in the MS plaques in the brain. The aim of this study was to analyse the TCRdelta chain gene rearrangement at the RNA (cDNA) level and compare to the DNA pattern rearrangement. TCRdelta gene rearrangement was analysed in MS patients and healthy individuals with the use of primers specific for Vdelta1-6 and Jdelta1 genes (at the DNA level) and specific for Vdelta1-6 and Cdelta1 genes (at the cDNA level). The size of PCR products was analysed on agarose gel and by ALF-Express (Pharmacia). Additionally, the lymphocyte surface immunophenotype was studied with specific monoclonal antibodies. At the DNA level a restricted pattern of Vdelta3-Jdelta1 and Vdelta5-Jdelta1 was found only in MS patients. Contrary to DNA, mono-, oligoclonal RNA (cDNA) rearrangements were limited to Vdelta1-Cdelta1, Vdelta2-Cdelta1 and Vdelta3-Cdelta1 only in MS patients as well. Surface immunophenotype analysis revealed in MS a much higher frequency of activated gamma/delta T lymphocytes, i.e. expressing HLA-DR and CD25. An elevated level of CD56 positive cells in MS was recorded. Mono-oligoclonal pattern of TCRdelta gene rearrangement at the RNA level, along with increase in activated gamma/delta T cells, strongly argue for a significant role of gamma/delta T lymphocytes in the pathogenesis of MS.

2-Chlorodeoxyadenosine treatment of Waldenström's macroglobulinemia--the analysis of own experience and the review of literature

INTRODUCTION

The aim of the study was to evaluate the results of treatment of Waldenström's Macroglobulinemia with 2-chlorodeoxyadenosine. The evaluation was based on our own experience as well as on the data published previously in the literature.

MATERIAL AND METHODS

25 patients with Waldenström's Macroglobulinemia (MW) were treated with 2-chlorodeoxyadenosine (2-CdA) at the dose of 0.14 mg/kg b.w./day for five consecutive days as 2-hour intravenous infusions. Chemotherapy was repeated every 28 to 35 days.

RESULTS

In one case (4%) a complete remission and in 15 patients (60%) a partial remission was achieved. In 6 patients (24%) stabilization of the disease was observed while in 3 patients (12%) progression was noted during the treatment. As a result of the therapy, the mean monoclonal protein concentration decreased from 28.7 g/l (range 5.5-62.5 g/l) to 16.7 g/l (range 0-62.9 g/l) and the mean hemoglobin concentration increased from 10.6 g/dl (range 6.9-13.4) to 12.4 g/dl (range 8.2-14.8 g/dl).

CONCLUSION

Our own experience, as well as conclusions of other authors, confirm the effectiveness of 2-CdA in MW treatment. Both the results of treatment and intensity of side effects observed in our treatment group were comparable to those described in previous reports.

Nasal, pulmonary and autoinhaled nitric oxide at rest and during moderate exercise

OBJECTIVE

To investigate nasal nitric oxide (NO) excretion, pulmonary NO excretion, and autoinhalation of nasally released NO at rest compared with that during moderate exercise in smokers and non-smokers.

DESIGN

Prospective observational study.

SETTING

University laboratory.

PARTICIPANTS

Fourteen healthy adult volunteers.

INTERVENTIONS

Breathing of NO-purified air supplied via a tube system at rest and during a bicycle-ergometer workload of 60 Watt over a time of 10 min.

MEASUREMENT AND RESULTS

We examined nasal and pulmonary NO excretion in smoking (n = 7) and non-smoking (n = 7) adult human volunteers. At rest, we measured constant nasal NO excretion rates of 311 +/- 89 nl/min for non-smokers and 261 +/- 142 nl/min for smokers (mean +/- SD, n.s.). During 60 W exercise, nasal NO release remained unchanged, while pulmonary NO excretion doubled compared with the rates at rest (non-smokers: 40 +/- 21 nl/min versus 23 +/- 14 nl/min, p < 0.05; smokers: 41 +/- 8 nl/min versus 22 +/- 8 nl/min, p < 0.05). The differences between smokers and non-smokers in nasal or pulmonary NO excretion were not significant. To determine the autoinhaled amount of nasally released NO, we also measured the NO concentration within the nasopharynx of five volunteers during nasal breathing. The average inhaled NO concentration was 17.8 +/- 3.1 ppb at rest and this decreased to 9.3 +/- 1.8 ppb during exercise of 60 W, while minute ventilation approximately doubled from 9 +/- 2 to 21 +/- 3 l/min.

CONCLUSION

Our results demonstrate that moderate exercise increased exclusively pulmonary NO excretion. Nasal NO release, which is 10 times higher at rest, was not changed. The decrease in autoinhaled NO concentration during exercise results from dilution of the continuous nasal release by the increased respiratory gas flow. The individual NO release allows no conclusion about smoking habits.

Cladribine with or without prednisone in the treatment of previously treated and untreated B-cell chronic lymphocytic leukaemia - updated results of the multicentre study of 378 patients

Between January 1992 and January 1999, we treated 378 B-chronic lymphocytic leukaemia (CLL) patients with cladribine (2-CdA), and 255 of the patients were also treated with prednisone. A total of 194 patients were previously untreated, and 184 had relapsed or refractory disease after previous other therapy. Complete response (CR) was obtained in 111 (29.4%) and partial response (PR) in 138 (36.5%) patients, giving an overall response (OR) rate of 65.9%. CR and OR were achieved more frequently in patients in whom 2-CdA was a first-line treatment (45.4% and 82.5% respectively) than in the pretreated group (12.5% and 48.4% respectively) (P < 0.0001). The median duration of OR for previously untreated patients was 14.7 months and for pretreated patients 13.5 months (P = 0.09). The median survival evaluated from the beginning of 2-CdA treatment was shorter in the pretreated group (16.3 months) than in the untreated group (19.4 months) (P < 0.0001). A total of 117 (63.9%) patients died in the pretreated group and 63 (32.6%) in the untreated group. In pretreated patients, 2-CdA + prednisone (P) and 2-CdA alone resulted in similar OR (51.0% and 45.0% respectively; P = 0.4). In contrast, in untreated patients, 2-CdA + P produced a higher OR (85.4%) than 2-CdA alone (72.1%) (P = 0.04). Infections and fever of unknown origin, observed in 91 (49.4%) pretreated and 74 (38.1%) untreated patients (P = 0.03), were the most frequent toxic effects. Our results indicate that 2-CdA is an effective, relatively well-tolerated drug, especially in previously untreated CLL.

Extracorporeal membrane oxygenation for severe acute respiratory failure

Extracorporeal membrane oxygenation (ECMO) is a technique for providing life support, in case the natural lungs are failing and are not able to maintain a sufficient oxygenation of the body's organ systems. ECMO technique was an adaptation of conventional cardiopulmonary bypass techniques and introduced into treatment of severe acute respiratory distress syndrome (ARDS) in the 1970s. The initial reports of the use of ECMO in ARDS patients were quite enthusiastic, however, in the following years it became clear that ECMO was only of benefit in newborns with acute respiratory failure. In neonates treated with ECMO, survival rates of 80% could be achieved. In adult patients with ARDS, two large randomized controlled trials (RCTs) published in 1979 and 1994 failed to show an advantage of ECMO over conventional treatment; survival rates were only 10% and 33%, respectively, in the ECMO groups. Since then, ECMO technology as well as conventional treatment of adult ARDS have undergone further improvements. In conventional treatment lung-protective ventilation strategies were introduced and ECMO was made safer by applying heparin-coated equipment, membranes and tubings. Many ECMO centres now use these advanced ECMO technology and report survival rates in excess of 50% in uncontrolled data collections. The question, however, of whether the improved ECMO can really challenge the advanced conventional treatment of adult ARDS is unanswered and will need evaluation by a future RCT.

Effect of a 2-hour infusion of 2-chlorodeoxyadenosine in the treatment of refractory or previously untreated Waldenström's macroglobulinemia

2-Chlorodeoxyadenosine (2-CdA) is a new purine analogue active in indolent lymphoid malignancies. In this retrospective study 22 patients with Waldenström's macroglobulinemia (MW) were treated with 2-CdA given in 2-h intravenous infusions. Nine of them were untreated and 13 relapsed or were refractory to previous therapeutic modalities with chlorambucil/prednisone (11 patients) or COP (2 patients). The patients were given 1-11 (median 4) courses of 2-CdA at the dose of 0.14 mg/kg daily in 2-h intravenous infusion for 5 consecutive days. The courses were repeated every 28-35 d. If severe myelosuppression or infection developed, 2-CdA therapy was stopped until the haematological parameters increased. The effectiveness of the treatment was evaluated after the 3 cycles and after completion of therapy. None of the patients has achieved complete response (CR) after 3 courses of treatment and only one (4.5%) has obtained CR after 5 courses. Partial response (PR) was achieved in 8 (36.4%) patients, giving an overall response rate of 40.9%. Ten further patients (45.4%) responded to the treatment with less than 50% decrease in monoclonal protein (defined as stabilisation). There was no significant difference between the response rate in previously pretreated (38.5%) and untreated (44.4%) patients (p>0.05). Mean observed decrease in monoclonal protein was 41%. In the group of 9 patients responding to 2-CdA treatment mean duration of response was 12 months (range 3-34). Myelosuppression was the most prominent side-effect. Neutropenia was present in 17 (77.3%) and thrombocytopenia in 7 (31.8%) patients. In 6 patients myelosuppression was the reason for treatment discontinuation after 1 or 2 courses without significant therapeutic effect. Seven patients died, including 4 from the responding group and all three non-responding patients. Treatment-related thrombocytopenia and fatal haemorrhage was the course of death in 1 patient. In conclusion, the results of our study show that 2-CdA given in 2-h infusions is an effective agent in WM and may be given on an outpatient basis. However, myelosuppression is frequent and the drug must be administered with caution.

Childhood asthma: exhaled nitric oxide in relation to clinical symptoms

Bronchial asthma is associated with increased levels of exhaled nitric oxide which are suppressible by glucocorticosteroid inhalation. Children with bronchial asthma were studied to elucidate the relation between endogenous NO release and recent symptoms of bronchial obstruction. Twenty-five children with atopic asthma and 11 healthy control subjects were enrolled and exhaled NO was studied using chemiluminescence analysis. The subjects breathed purified air (<0.5 parts per billion (ppb) NO) exclusively through their mouths. Orally expired NO was measured during continuous nasal aspiration (1.3 L x min(-1)) to remove nasally produced NO. Nasal NO concentration was determined within the aspirated gas. Orally expired NO concentration was 2.5+/-0.3 ppb (mean +/-SEM) in healthy control subjects, 3.19+/-0.88 ppb (NS) in symptom-free children, and 8.28+/-0.81 ppb (p< or =0.01) in children with bronchial asthma who had had recent symptoms of bronchial obstruction. Similarly, in the subgroup of children treated regularly with inhaled glucocorticosteroids those with recent symptoms had significantly higher orally exhaled NO concentrations than healthy control subjects (9.5+/-1.5 ppb, p<0.05). The nasal NO concentration was 152.8+/-12.7 ppb in healthy control subjects and not significantly different in asthmatic children. In this group of asthmatic children, recent symptoms of bronchial obstruction were linked to significantly higher concentrations of NO in orally exhaled gas and to increased oral NO excretion rates. If substantiated by further studies, measurement of orally exhaled NO during nasal aspiration may become useful to monitor disease control in asthmatic children.

On-bead combinatorial approach to the design of chiral stationary phases for HPLC

A library of 36 L-amino acid anilides, which are potential selectors for chiral HPLC, was synthesized in solution and attached to functionalized macroporous polymer beads. The best selector from the library was identified by a deconvolution process using the HPLC separation of several racemic N-(3,5-dinitrobenzoyl)-alpha-amino acid alkylamides as a probe. In each deconvolution step, a series of chiral stationary phases (CSPs) containing a subset of the amino acid anilide selector library was screened for enantioselectivity. After the best CSP was chosen, the library was further deconvoluted until the single best selector was found. The highest selectivity was obtained with a L-proline-1-indananilide that exhibited alpha values up to 23 under normal-phase HPLC conditions. In addition, six CSPs were prepared using individual selectors from the library, and screening results indicate that the deconvolution process indeed led to the most selective receptor.

[Knowledge-based diagnosis and therapeutic recommendations with fuzzy-set theory methods in patients with acute lung failure (ARDS)]

OBJECTIVE

Since the treatment of patients with severe ARDS using the extracorporal lung assist (ECLA) methods remains a cost intensive and speculative procedure, a knowledge based computer system should be created and evaluated in order to support clinical decisions.

METHODS

The model was based on the fuzzy set theory and therefore able to give decisions between yes and no, that means that a criterion could also be fulfilled to 35% or 80% for example. The development of this computer program consists of two steps: first, the entry criteria for the ECLA therapy were established within a framework of an international evaluation of clinical data from 3 centres (Berlin, Marburg, Vienna). Here, inherent vagueness, uncertainty of the occurrence and limited availability of medical data are to be considered to establish a useful tool. Secondly, this was done by grouping and weighting of parameters by the system and the status of each patient or patient group was assigned by the percentage of fulfillment of the criterion.

RESULTS

By using a mixed sample of patients from these three centres, the fulfillment of entry criteria according either to definitions of Berlin or to definition of Marburg was different (68% versus 36%). Other differences (36% vs. 22% and 68% vs. 60%) were found between the fuzzy based score and the crisp score which represents the usually performed method.

CONCLUSIONS

This now preevaluated minimal data set to describe severe ARDS patients based on the fuzzy set theory may be useful to evaluate patients for ECLA therapy or for another controlled ARDS-therapy.