A Standardized Treatment Pathway for Telehealth-Based Care of Chronic Wounds in Austria

Chronic wounds present a significant healthcare challenge in Austria as well as in other countries. The interdisciplinary approach to wound treatment involving various caregivers, doctors, and relatives, poses challenges in documentation and information exchange. To overcome these barriers and promote patient-centered care, a new telehealth-supported treatment pathway for chronic wounds has been developed. The primary focus was to regularly update the status of the chronic wound by responding to predefined questions and transmitted images of the chronic wound. This was achieved by an interdisciplinary team of experts in chronic wound care, providing a new perspective for digital implementation in the healthcare system.

Individualized targeted treatment in a case of a rare TFG::ROS1 fusion positive inflammatory myofibroblastic tumor (IMT)

BACKGROUND

Inflammatory myofibroblastic tumor (IMTs) are rare mesenchymal neoplasms with slow growth. Resection is considered as therapeutic standard, with chemotherapy being insufficiently effective in advanced disease. ALK translocations are present in 50% of cases, ROS1 fusions (YWHAE::ROS1, TFG::ROS1) are extremely rare. Here, we present a case with TFG::ROS1 fusion and highlight the significance of molecular tumor boards (MTBs) in clinical precision oncology for post-last-line therapy.

CASE PRESENTATION

A 32-year-old woman presented with IMT diagnosed at age 27 for biopsy and treatment evaluation. Previous treatments included multiple resections and systemic therapy with vinblastine, cyclophosphamide, and methotrexate. A computed tomography scan showed extensive tumor infiltration of the psoas muscles and the posterior abdomen. Next generation sequencing revealed an actionable ROS1 fusion (TFG::ROS1) with breakpoints at exon 4/35 including the kinase domain and activating the RAS-pathway. TFG, the Trk-fused gene, exerts functions such as intracellular trafficking and exhibits high sequence homology between species. Based on single reports about efficacy of ROS1-targeting in ROS1 translocation positive IMTs the patient was started on crizotinib, an ATP-competitive small molecule c-MET, ALK and ROS1-inhibitor. With a follow-up of more than 9 months, the patient continues to show a profound response with major tumor regression, improved quality of life and no evidence for severe adverse events.

CONCLUSION

This case underscores the importance of the availability of modern molecular diagnostics and interdisciplinarity in precision oncology to identify rare, disease-defining genotypes that make an otherwise difficult-to-treat disease targetable.

Efficacy and Safety of Vedolizumab in Patients with Inflammatory Bowel Disease in Association with Vedolizumab Drug Levels

BACKGROUND

Vedolizumab (VDZ) is a well-established and important therapeutic option in the treatment of patients with inflammatory bowel disease (IBD). However, the significance of therapeutic drug monitoring (TDM) with VDZ remains a contradictory field in daily clinical practice. Our study aims to clarify the predictive impact of VDZ drug levels in long-term clinical outcomes in a real-world cohort.

METHODS

Patients with moderate to severe ulcerative colitis (UC) and Crohn's disease (CD) from a tertiary IBD referral center at the University Hospital Augsburg, Germany, were enrolled in this single-center retrospective data analysis. Clinical and endoscopic data were collected at month 6, month 12, and at the last time of follow-up, and outcomes were correlated with VDZ levels at week 6.

RESULTS

This study included 95 patients, 68.4% (n = 65) with UC, 24.2% (n = 23) with CD, and 7.4% (n = 7) with indeterminate colitis (CI). Patients with a mean VDZ treatment time of 17.83 months ± 14.56 showed clinical response in 29.5% (n = 28) and clinical remission in 45.3% (n = 43) at the end of the study. Endoscopic response occurred in 20.0% (n = 19) and endoscopic remission in 29.5% (n = 28) at the end of the study. The sustained beneficial effect of VDZ was also reflected in a significant change in biomarker levels. VDZ trough level at week 6 was determined in 48.4% (n = 46) with a mean of 41.79 µg/mL ± 24.58. A significant association between VDZ level at week 6 and both short and long-term outcomes could not be demonstrated. However, numerically higher VDZ levels were seen in patients with endoscopic and clinical improvement at month 6 and at the time of last follow-up.

CONCLUSIONS

This study demonstrated efficacy and safety for VDZ in a real-world cohort. Although, for some parameters, a clear trend for higher VDZ levels at week 6 was seen, the efficacy of VDZ was not significantly correlated to VDZ level at week 6, which questions the predictive value of VDZ levels in the real world.

No association of malignant B-cell non-Hodgkin lymphomas with ipsilateral SARS-CoV-2 vaccination

PURPOSE

SARS-CoV-2 vaccines cause acute ipsilateral lymph node swelling in an important proportion of vaccines. Thus far, no malignant lymphadenopathies have been reported in temporal context to vaccination in the ipsilateral draining lymph node areas.

EXPERIMENTAL DESIGN

Prompted by two cases with unilateral axillary lymphomas that occurred ipsilaterally to prior SARS-CoV-2 vaccination, we systematically retrieved all B-cell non-Hodgkin lymphomas at two German University Medical Centers diagnosed before and after introduction of SARS-CoV-2 vaccines in Germany. Available lymphoma tissue (n=19) was subjected to next-generation immunosequencing of the IGH locus. Malignant clonotypes were mined in the CoVabDab database and published data sets from 342 uninfected individuals, 55 individuals 28 days after anti-SARS-CoV-2 vaccination and 139 individuals with acute COVID-19 together encompassing over 1 million CDR3 sequences in total.

RESULTS

Of 313 newly diagnosed cases in the two centers and observation periods, 27 unilateral manifestations in the defined deltoid draining regions were identified. The majority thereof were diffuse large B-cell lymphomas (18 of 27 cases). Eleven unilateral cases were diagnosed in the era of SARS-CoV-2 vaccination and 16 in the control period before introduction of such vaccines. Of the 11 unilateral lymphomas that occurred during the vaccination period, ten had received a SARS-CoV-2 vaccine prior to lymphoma diagnosis. These cases were further evaluated. While left-sided were more frequent than right-sided lymphomas (19 vs 8 cases), no statistically significant association of vaccination site and laterality of the lymphoma manifestation was found. The unilateral lymphomas showed a normal range of B-cell receptors typically found in these lymphoma subtypes with no evidence for anti-SARS-CoV-2 sequences in the malignant clonotype.

CONCLUSIONS

Together, we found no evidence that the current SARS-CoV-2 vaccines could serve as a trigger for lymphomagenesis in the draining lymph node areas of the deltoid region used for vaccination.

Progressive multifocal leukoencephalopathy associated with chemotherapy induced lymphocytopenia in solid tumors – case report of an underestimated complication

Background

JC virus reactivation causing progressive multifocal leukoencephalopathy (PML) occurs preferentially in human immunodeficiency virus (HIV) positive individuals or patients suffering from hematologic neoplasms due to impaired viral control. Reactivation in patients suffering from solid malignancies is rarely described in published literature.

Case Presentation

Here we describe a case of PML in a male patient suffering from esophageal cancer who underwent neoadjuvant radiochemotherapy and surgical resection in curative intent resulting in complete tumor remission. The radiochemotherapy regimen contained carboplatin and paclitaxel (CROSS protocol). Since therapy onset, the patient presented with persistent and progredient leukopenia and lymphopenia in absence of otherwise known risk factors for PML. Symptom onset, which comprised aphasia, word finding disorder, and paresis, was apparent 7 months after therapy initiation. There was no relief in symptoms despite standard of care PML directed supportive therapy. The patient died two months after therapy onset.

Conclusion

PML is a very rare event in solid tumors without obvious states of immununosuppression and thus harbors the risk of unawareness. The reported patient suffered from lymphopenia, associated with systemic therapy, but was an otherwise immunocompetent individual. In case of neurologic impairment in patients suffering from leukopenia, PML must be considered – even in the absence of hematologic neoplasia or HIV infection.

Integrated Platform for the Management of Chronic Low Back Pain

BACKGROUND

Chronic low back pain is a global health problem having a tremendous effect on the quality of life of patients.

OBJECTIVES

An online therapy management system (TMS) is developed for comprehensive management of chronic low back pain patients.

METHODS

A smartphone and a web app are built based on the Keep-In-Touch Telehealth Platform. The smartphone app allows entering patient reported outcomes and connection to third party devices to monitor physiological data and parameters of therapy.

RESULTS

The TMS has been realized and a wearable auricular vagus nerve stimulation device has been integrated. The TMS is currently evaluated in a randomized clinical trial.

Predictive preoperative clinical score for patients with liver-only oligometastatic colorectal cancer

Background

Resection of liver metastases from colorectal cancer (CRC) in the oligometastatic stage improves survival and is a potentially curative treatment. Thus, predictive scores that reliably identify those patients who especially benefit from surgery are essential.

Patients and methods

In this multicenter analysis, 512 patients had undergone surgery for liver metastases from CRC. We investigated distinct cancer-specific risk factors that are routinely available in clinical practice and developed a predictive preoperative score using a training cohort (TC), which was thereafter tested in a validation cohort (VC).

Results

Inflammatory response to the tumor, a right-sided primary tumor, multiple liver metastases, and node-positive primary tumor were significant adverse variables for overall survival (OS). Patients were stratified in five groups according to the cumulative score given by the presence of these risk factors. Median OS for patients without risk factors was 133.8 months [95% confidence interval (CI) 81.2-not reached (nr)] in the TC and was not reached in the VC. OS decreased significantly for each subsequent group with increasing number of risk factors. Median OS was significantly shorter (P < 0.0001) for patients presenting all four risk factors: 14.3 months (95% CI 10.5 months-nr) in the TC and 16.6 months (95% CI 14.6 months-nr) in the VC.

Conclusions

Including easily obtainable variables, this preoperative score identifies oligometastatic CRC patients with prolonged survival rates that may be cured, and harbors potential to be implemented in daily clinical practice.

•

We identified four variables of adverse outcome for patients treated with surgical resection of liver metastases from CRC.

•

Adverse variables were inflammatory response to the tumor, multiple metastases, right-sided primary tumor, node-positive primary tumor.

•

We developed a preoperative clinical score according to the number of risk factors present.

•

Using easily obtainable variables, this score identified patients with oligometastatic CRC with good prognosis.

•

Patients without risk factors should strongly be considered for surgical resection of their metastases.

TAVI for patients with pulmonary arterial hypertension – impact of the anesthesia regime on the short-term outcome

Objectives and background

Pulmonary Arterial Hypertension (PAH) has been independently associated with increased rates of postoperative heart-failure, hemodynamic instability, respiratory failure and delayed extubation. PAH has been described as a common comorbidity in patients undergoing transfemoral Transcatheter Aortic Valve Implantation (tf-TAVI). Two different anesthetic methods, general anesthesia (TAVI-GA) and conscious sedation (TAVI-S) have become established. Both must be measured by their influence on pulmonary vascular resistance, as all factors worsening PAH have to be avoided. To date, there are no practice guidelines advising the the optimal anesthetic approach for patients with PAH.

Methods

We included all consecutive tf-TAVI patients between 2014 and 2019 in our prospective TAVI registry. A combined endpoint covering the aspects of hemodynamic stability, ventilation and awareness was chosen as primary endpoint. 1. Freedom from catecholaminergic support, 2. Spontaneous breathing and 3. Alertness, defined as GCS &gt;12 points were prerequisite for achieving. PAH was diagnosed by echocardiography immediately before the procedure. The choice for TAVI-GA or TAVI was made by the anesthesiologist.

Results

A total of 1390 patients were included in this analysis. PAH was diagnosed in 74% (n=1031) of the patients. As shown in Tab.1, patients with and without PAH were comparable in terms of pre-procedural comorbidities, blood gas analysis before and after their procedure and procedural data. Postprocedural, a longer stay on ICU was observed in patients with PAH. This was also seen after propensity-score marching. In terms of the primary endpoint, no difference was found between the groups. In addition, the single points catecholaminergic support, spontaneous ventilation and awareness at the time of transfers revealed no difference. Same holds true for secondary endpoints like 30-day mortality, heart failure and adverse procedural events. An analysis based on the choice of anesthesia showed a clear difference in the successful achievement of the primary endpoint. Independent of the presence of PAH, patients undergoing the procedure in TAVI-GA the primary endpoint was less often successfully documented. TAVI-GA patients were more often in need of catecholaminergic support at the end of the procedure and a reduced alertness was more often found.

In patients with PAH and TAVI-GA, a longer length of ICU-stay and a higher incidence of congestive heart failure (CHF) within 30days was found.

Conclusion

Independent of PAH, patients undergoing tf-TAVI in TAVI-GA, were more often in need of catecholaminergic support and less often awake at the end of the procedure. General anesthesia was also more often associated with CHF but not death at 30 days. The achievement of the primary endpoint was independent of the presence of PAH. tf-TAVI can be done under sedation safely in patients with PAH.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Deutsches Herzzentrum München, Technische Universität München Table 1. Analysis with regard to PAHTable 2. Analysis with regard to Anesth

Early safety outcome in patients requiring conversion to general anesthesia during transfemoral transcatheter aortic valve replacement

Background

Transfemoral TAVR (tf-TAVR) has become an established therapy. Conscious sedation (CS) is a alternative to general anesthesia (GA). So far, the outcome of patients undergoing unplanned conversion from CS to GA has not been investigated.

Methods

All patients undergoing tf-TAVR in CS between 2014 and 2019 were included. Primary endpoint was early safety at 30 days according to VARC-2 criteria. The reasons for conversion and length of ICU-/ hospital-stay were further analyzed.

Results

Of 1058 patients 35 (3.3%) required a conversion. Baseline characteristics were similar among groups. The combined VARC-2 endpoint was documented in 13 (37%) of the converted and 110 (11%) of non-converted patients (p&lt;0.001). Four major sub-groups were underlying causes: unrest in 11/35, procedural complications in 10/35, respiratory distress in 8/35 and cardiovascular decompensation in 6/35 patients. An univariable analysis was performed to identify risk factors for unplanned conversion due to respiratory distress or cardiovascular decompensation (Table). Compared to the group without conversion (Median [IQR], 4 [4–5] days), length of hospital stay was longest in the group with procedural complications (6 [1–11] days) followed by cardiovascular decompensation (5 [4–7] days).

Conclusions

The conversion rate to general anesthesia was overall low but associated with a higher observation of the composite endpoint. Hospital stay was longer dependent on the reason for conversion. A thorough understanding of the frequency, causal factors and clinical significance of unplanned conversion to general anesthesia is of utmost clinical relevance taking a general trend towards a minimalist approach into consideration.

Funding Acknowledgement

Type of funding source: None

Interobserver Variability in the Assessment of Tumor Budding in pT 3/4 Colon Cancer: Improvement by Supporting Immunohistochemistry?

The prognostic significance of tumor budding in colon cancer is unequivocally documented, and the recommendations of the International Tumor Budding Consensus Conference (ITBCC) are currently the accepted basis for its assessment. Up to now, it is unknown whether the general use of a supporting cytokeratin immunohistochemistry can improve the interobserver variability and prognostic significance. Six investigators with different levels of experience reassessed 229 cases of colon carcinoma (pT3/4, N+/−, M0) with a supporting cytokeratin immunohistochemistry. The results were compared to previous assessments, which have been performed only on H & E. Bd3 was significantly associated with the occurrence of distant metastases according to the assessments of three out of six investigators (p < 0.05). Only one single investigator reached significant results concerning the cancer specific survival (p = 0.01). The pairwise kappa values range between a poor and moderate level of agreement (range 0.17–0.45; median 0.21). In conclusion, the results show no superiority of the use of an additional cytokeratin immunohistochemistry compared to the conventional analysis on sole H & E slides. Therefore, the general supporting use of a cytokeratin immunohistochemical staining seems to be inadvisable in colon cancer in consideration of necessary resources and costs.

Neoadjuvant and Definitive Radiochemotherapeutic Approaches in Esophageal Cancer: A Retrospective Evaluation of 122 Cases in Daily Clinical Routine

INTRODUCTION

Esophageal cancer (EC) is a common malignant tumor entity with increasing occurrence. The incidence of esophageal adenocarcinoma (AC), particularly, is constantly rising in the Western world. The mainstays of therapy with curative intent for EC in advanced stages are neoadjuvant radiochemotherapy (neoRCT) with surgery and definitive radiochemotherapy (defRCT).

METHODS

We examined our internal files to identify patients suffering from EC. Palliative cases were excluded. Statistical testing was performed by χ2 test, Student's t test, Kaplan-Meier analyses, and the Mann-Whitney U test.

RESULTS

One hundred and twenty-two cases were included. Histology revealed squamous cell carcinoma in 92 cases and AC in 23 cases. Ninety-five patients underwent defRCT, 27 underwent neoRCT, and 114 (in both therapy regimes) received simultaneous chemotherapy. There was no difference in the overall survival (OS) (p = 0.654; HR 1.145; 95% CI 0.629-2.086) or and progression-free survival (PFS) (p = 0.912) of patients who underwent neoRCT or defRCT. Median OS was 13.5 (2-197) months for defRCT patients and 19.5 (2-134) months for neoRCT patients (p = 0.751). Karnofsky index (KI) with a cut-off of 70% was strongest, but not a significant parameter for OS (p = 0.608) or PFS (p = 0.137).

CONCLUSION

defRCT is a valid and an equal alternative to neoRCT for patients suffering from EC. Selection of patients for therapy is of crucial relevance. Further studies and improvements in follow-up are needed when neoRCT has been completed before surgery, in order to spare the patient undergoing operative treatment if there is complete remission. The identification of valid markers urgently needed to limit treatment side effects.

Tumor proportion in colon cancer: results from a semiautomatic image analysis approach

The tumor stroma ratio (TSR) is a promising prognostic biomarker in colon cancer, which could provide additional risk stratification for therapy adaption. The objective of our study was the investigation of the prognostic significance of TSR at different tumor sites in a simple semiautomatic approach with the open-source program ImageJ. We investigated 206 pT3 and pT4 adenocarcinomas of no special type. According to our established thresholds, 31 tumors (15%) were classified as low tumor proportion (TP) (≤ 15% TP), 42 tumors (20%) were classified as high TP (≥ 54% TP), and 133 tumors (65%) were classified as medium TP. High and low TP were associated with an adverse overall survival in comparison to medium TP (p = 0.001 and p = 0.03). Furthermore, the TP was an independent risk factor of occurrence of distant metastasis next to T status, microsatellite status, and tumor budding. The 5-year survival rate was 49% in patients with high TP, 48% in patients with low TP, and 68% in patients with medium TP (p = 0.042, n = 160). Patients with a high TP had less often tumor budding (p = 0.012), lymphovascular invasion (p = 0.049), and less harvested lymph nodes (p = 0.042) in comparison to low TP tumors. The results provide first evidence that a high tumor proportion/low stroma proportion is also associated with an adverse prognosis and that this subgroup might be difficult to identify with other classical histopathologic characteristics that are linked to an adverse prognosis.

Level of interobserver variability estimation as a valuable tool: assessment of tumour budding in colon cancer

AIMS

Tumour budding is considered to be a good marker for progression and prognosis in colorectal carcinomas. A uniform classification system has been established recently. The natural element of uncertainty in the practice of human medicine is also exhibited in the assessment of tumour budding. We tested the hypothesis that interobserver variability can be estimated during the assessment process and investigated its potential clinical implication.

METHODS AND RESULTS

Six investigators with different levels of experience could perceive different levels of difficulty (LOD) and estimated different levels of interobserver variability (LOIV) (Li1, lower than average; Li2, average; Li3, higher than average) during the assessment of tumour budding in 244 cases of colon cancer (pT3/4). In total, the LOIV showed following distribution: Li1: 36.1%, Li2: 43.9% and Li3: 20.0%. The LOIV was correlated significantly with the LOD given by the investigator. In total, the agreement rates with the final consensus classification were: Li1: 93.4%, Li2: 78.5% and Li3: 58.4%. The relative risk of disagreement with the final consensus classification was more than six times higher when a case was estimated to have a high rather than a low interobserver variability.

CONCLUSION

Our data show that the investigator can estimate the interobserver variability during the ongoing rating process in pT3/4 colon cancer. The LOIV/LOD seems to be a valuable parameter of the assessment quality. For Li3 cases further measures seem mandatory.

Interobserver variability in the H&E-based assessment of tumor budding in pT3/4 colon cancer: does it affect the prognostic relevance?

Tumor budding is a mostly accepted adverse prognostic factor in colorectal carcinoma. It is on the cusp of a widespread use after agreement was reached recently on uniform assessment criteria. We investigated whether the interobserver variability has a direct influence on the prognostic relevance in pT3/4 colon cancer in the background of different levels of experience of the investigators. In total, six investigators with different levels of experience evaluated tumor budding on H&E slides in 244 cases with primary diagnosed (2002-2011) colon carcinoma (pT3/4, N+/-, M0). High-grade tumor budding/budding grade 3 (defined as majority assessment among the investigators) was significantly associated with an adverse outcome (overall survival p = 0.03, cancer-specific survival p = 0.08) and the occurrence of distant metastasis (p = 0.009). However, a detailed analysis of the rating results of the individual investigators revealed that only ratings of one investigator (advanced resident) were associated with an adverse outcome (p = 0.01 cancer-specific survival, overall survival p = 0.09, distant metastasis p = 0.002). The results of another investigator (consultant) were significantly associated with distant metastasis (p = 0.007). The kappa values among the investigators have a range between 0.077 and 0.357 (median 0.166). Total agreement of all investigators existed in 109 cases (44.7%). Our results demonstrate that the evaluation of tumor budding on H&E slides in pT3/4 colon cancer goes along with a considerable interobserver variability among investigators of different levels of experience. Furthermore, our results reveal that these findings directly influence the prognostic value.

HEALTHeBIKES - Smart E-Bike Prototype for Controlled Exercise in Telerehabilitation Programs

E-Bikes in telerehabilitation programs could be a new intervention for more sustainable rehabilitation results. The aim is to design and build a prototype of an E-Bike usable for rehabilitation - a HEALTHeBIKE. It should avoid over-exercising, work independently of the environment and it should enable cycling in a group despite different reference exercise intensities. To achieve these goals, requirements for this system architecture have been identified. A system architecture including an Arduino microcontroller, an Android smartphone and a telemonitoring platform was presented. A power output regulated proportional-integral controller to adjust the motor assistance has been implemented. A feasibility study with two subjects cycling in a group was performed. Seven test rides on varying terrain (flat, hilly, mountainous and uphill) with the same and different exercise intensities were completed. The mean power output was close to or below the target power output of the cyclist for all test rides with a maximal error of 6.7% above and 27.6% below the target. Although the exercise intensities of the two subjects were clearly different, cycling in a group was possible without over-exercising.

Number of Intratumoral T Lymphocytes Is Associated With Lymph Node Size, Lymph Node Harvest, and Outcome in Node-Negative Colon Cancer

OBJECTIVES

We postulated that lymph node (LN) harvest and LN size are influenced by immunologic effects.

METHODS

To investigate this hypothesis, we performed a retrospective analysis of 170 node-negative colon cancer cases to evaluate the density of intratumoral T lymphocytes (ITLs). CD3- and CD8-positive T cells were counted using a digital system.

RESULTS

The ITL density was significantly increased in cases with sufficient LN harvest and high numbers of LNs larger than 5 mm (LN5). High ITL numbers were associated with improved cancer-specific survival. The analysis of the immune score revealed a significantly different cancer-specific outcome (P = .024), with no cancer-related death in the group with the highest score. The immune score and tumor budding were independently prognostic.

CONCLUSIONS

ITL density is independently prognostic and associated with LN harvest and LN size. The immune response is very likely the true explanation for the known prognostic effect of the LN harvest in colon cancer.

A new simple morphology-based risk score is prognostic in stage I/II colon cancers

A portion of stage I/II colon cancers (10-20%) exhibit an adverse clinical course. The administration of adjuvant chemotherapy is recommended only in certain high-risk situations. However, these risk factors recently failed to predict benefit from adjuvant therapy. We composed a new morphology-based risk score that includes pT1/2 versus 3/4 stage, vascular or lymphovascular invasion, invasion type according to Jass, tumor budding and paucity (less than two) of lymph nodes larger than 5 mm. The occurrence of each of these factors accounts for one point in the score (Range 0-5). This score was evaluated in a retrospective study that included 301 cases. The overall survival differed significantly between the three groups with median survival times of 103, 90, and 48 months, respectively. Multivariable analysis revealed morphology-based risk-high risk and low risk-as the sole independent factors for the prediction of death. Morphology-based risk scoring was superior to microsatellite status and NCCN risk stratification. This method identifies a group of patients that comprises 18% of the stage II cases with an adverse clinical course. Further studies are necessary to confirm its prognostic value and the possible therapeutic consequences.

Loco-regional recurrence after surgical treatment of oral squamous cell carcinoma: Proposals for follow-up imaging based on literature, national guidelines and institutional experience

The recurrence rate following the treatment of oral squamous cell carcinoma (OSCC) by primary surgery is about 10%-26%. The earliest possible diagnosis of residual tumour, recurrence of local tumour disease, and subsequent metastasis is essential for an improvement of the overall survival and of the survival period for affected patients. No international consensus exists for a post-therapeutic surveillance schedule for OSCCs. Based on a review of the literature, existing guidelines, and our institutional experience, we have established an algorithm for the follow-up of these patients regarding the timing and techniques of postoperative imaging. We recommend a follow-up interval of 6 weeks during the first half-year after discharge from hospital by single clinical and alternating clinical check-ups combined with computed tomography (CT) or magnetic resonance imaging (MRI), followed by an interval of 3 months in the second half-year, with clinical and radiological check-ups. In year 2, we recommend a follow-up interval of 3 months with single clinical and alternating clinical check-ups combined with CT or MRI. In year 3, we recommend screening every 6 months, both clinically and via imaging, because of the decreased risk of recurrence. From year 5 onwards, our recommendation is a clinical and imaging-based examination every 6-12 months, depending on patient risk factors and disease progression. Four standard imaging techniques, namely positron emission tomography (PET), CT, MRI, and ultrasound (US), are discussed concerning their range of application, sensitivity, and specificity. Furthermore, the technical aspects of our institutional protocols are described in detail. In highly frequented head and neck cancer centres, PET and US are of secondary importance, since CT and MRI are nowadays highly efficient tools in primary diagnostic and post-therapeutic surveillance.

Glycaemic control in type II diabetic tube-fed patients with a new enteral formula low in carbohydrates and high in monounsaturated fatty acids: a randomised controlled trial

OBJECTIVES

To investigate the effects of long-term treatment with a new enteral formula low in carbohydrates and high in monounsaturated fatty acids (MUFAs), in comparison with a standard formula, on glycaemic control in tube-fed type II diabetic patients.

DESIGN

Randomised, double-blind, controlled, multi-centre trial.

SETTING

Early rehabilitation centres, primary care and nursing facilities.

SUBJECTS

A total of 78 patients with insulin-treated type II diabetes with HbA(1C) > or =7.0% and/or fasting blood glucose >6.66 mmol/l, who required enteral tube feeding due to neurological dysphagia.

INTERVENTIONS

Patients received 113 kJ (27 kcal)/kg of body weight of either test feed or an isoenergetic, isonitrogenous enteral formula (control) for 12 weeks. Glycaemic control (total daily insulin dosage (IU), fasting blood glucose, and HbA(1C)) and gastrointestinal tolerance were monitored daily.

RESULTS

After 12 weeks, median values for changes from baseline were as follows (test group vs control group, 'data as available' analysis): total daily IUs -6.0 vs 0.0 (P=0.0024), fasting blood glucose (mmol/l) -1.59 vs -0.08 (P=0.0068); HbA(1C) (%) -0.8 vs 0.0 (P=0.0016). Both formulas were tolerated comparably.

CONCLUSIONS

This study indicates that in tube-fed insulin-treated type II diabetic patients, the new low-carbohydrate, high MUFA formula results in a more effective glycaemic control than the standard diet, while being comparable in safety.

Modification of diamond single crystals by chromium ion implantation with sacrificial layers

Single-crystal diamond surfaces were implanted with chromium ions. Ion energies chosen were 120 and 180 keV. Ion doses of 1x10(17) cm(-2) were applied at a substrate temperature of 750 degrees C. Reduced lattice damage could be obtained by deposition of a titanium sacrificial layer with a thickness of 10 and 50 nm before implantation. Depth profiles of the elemental binding states were taken by photoelectron spectroscopy. The effect of the sacrificial layer thickness on diamond lattice damage was investigated by infrared spectroscopy.

A randomized placebo-controlled trial of simethicone and cisapride for the treatment of patients with functional dyspepsia

AIM

To compare the efficacy of simethicone with placebo and the prokinetic cisapride in patients with functional dyspepsia.

METHODS

One hundred and eighty-five patients with functional dyspepsia were randomized and treated in a double-dummy technique with simethicone (105 mg t.d.s.), cisapride (10 mg t.d.s.) or placebo (t.d.s.). The primary outcome measure was the O'Brien global measure of the patients' rating of 10 upper gastrointestinal symptoms (graded as absent = 0, moderate = 1, severe = 2 or very severe = 3). Outcome measures were assessed at baseline and after 2, 4 and 8 weeks of treatment (intention-to-treat).

RESULTS

At 2, 4 and 8 weeks, treatment with simethicone and cisapride yielded significantly (all P values < 0.0001) better improvement of symptoms compared to placebo. Simethicone was significantly better than cisapride after 2 weeks (P = 0.0007), but the differences were not statistically significant after 4 and 8 weeks. Patients treated with simethicone judged the efficacy of their treatment as very good in 46% of cases, compared to 15% and 16% receiving cisapride and placebo, respectively.

CONCLUSIONS

Simethicone and cisapride were significantly better than placebo for symptom control in patients with functional dyspepsia after 2, 4 and 8 weeks of treatment. Simethicone was also superior to the prokinetic cisapride in the first 2 weeks of treatment.

Transient-state and steady-state kinetic studies of the mechanism of NADH-dependent aldehyde reduction catalyzed by xylose reductase from the yeast Candida tenuis

Microbial xylose reductase, a representative aldo-keto reductase of primary sugar metabolism, catalyzes the NAD(P)H-dependent reduction of D-xylose with a turnover number approximately 100 times that of human aldose reductase for the same reaction. To determine the mechanistic basis for that physiologically relevant difference and pinpoint features that are unique to the microbial enzyme among other aldo/keto reductases, we carried out stopped-flow studies with wild-type xylose reductase from the yeast Candida tenuis. Analysis of transient kinetic data for binding of NAD(+) and NADH, and reduction of D-xylose and oxidation of xylitol at pH 7.0 and 25 degrees C provided estimates of rate constants for the following mechanism: E + NADH right arrow over left arrow E.NADH right arrow over left arrow E.NADH + D-xylose right arrow over left arrow E.NADH.D-xylose right arrow over left arrow E.NAD(+).xylitol right arrow over left arrow E.NAD(+) right arrow over left arrow E.NAD(+) right arrow over left arrow E + NAD(+). The net rate constant of dissociation of NAD(+) is approximately 90% rate limiting for k(cat) of D-xylose reduction. It is controlled by the conformational change which precedes nucleotide release and whose rate constant of 40 s(-)(1) is 200 times that of completely rate-limiting E.NADP(+) --> E.NADP(+) step in aldehyde reduction catalyzed by human aldose reductase [Grimshaw, C. E., et al. (1995) Biochemistry 34, 14356-14365]. Hydride transfer from NADH occurs with a rate constant of approximately 170 s(-1). In reverse reaction, the E.NADH --> E.NADH step takes place with a rate constant of 15 s(-1), and the rate constant of ternary-complex interconversion (3.8 s(-1)) largely determines xylitol turnover (0.9 s(-1)). The bound-state equilibrium constant for C. tenuis xylose reductase is estimated to be approximately 45 (=170/3.8), thus greatly favoring aldehyde reduction. Formation of productive complexes, E.NAD(+) and E.NADH, leads to a 7- and 9-fold decrease of dissociation constants of initial binary complexes, respectively, demonstrating that 12-fold differential binding of NADH (K(i) = 16 microM) vs NAD(+) (K(i) = 195 microM) chiefly reflects difference in stabilities of E.NADH and E.NAD(+). Primary deuterium isotope effects on k(cat) and k(cat)/K(xylose) were, respectively, 1.55 +/- 0.09 and 2.09 +/- 0.31 in H(2)O, and 1.26 +/- 0.06 and 1.58 +/- 0.17 in D(2)O. No deuterium solvent isotope effect on k(cat)/K(xylose) was observed. When deuteration of coenzyme selectively slowed the hydride transfer step, (D)()2(O)(k(cat)/K(xylose)) was inverse (0.89 +/- 0.14). The isotope effect data suggest a chemical mechanism of carbonyl reduction by xylose reductase in which transfer of hydride ion is a partially rate-limiting step and precedes the proton-transfer step.

Probing protein stabilization by glycerol using electrospray mass spectrometry

This study shows that electrospray ionization mass spectrometry (ESI-MS), combined with a heated turbo ion-spray interface, allows monitoring protein stabilization by glycerol in solution. Measurements obtained with the two proteins lysozyme and cytochrome c are presented. The observed mass-to-charge (m/z) distributions reveal the stabilizing effect of the additive on the protein conformations against temperature and acid-induced unfolding, as well as against denaturation by acetonitrile. The data obtained with lysozyme allow detection of minor conformational changes upon glycerol addition to the native protein, and suggest that the protein structure in the presence of the additive is slightly compressed compared with its state in water. This result corroborates previous evidence obtained by nuclear magnetic resonance. It is also shown that analysis of the m/z distributions obtained by ESI-MS can lead to detection of partially folded and partially populated states in protein samples.

Structural and functional properties of aldose xylose reductase from the D-xylose-metabolizing yeast Candida tenuis

The primary structure of the aldose xylose reductase from Candida tenuis (CtAR) is shown to be 39% identical to that of human aldose reductase (hAR). The catalytic tetrad of hAR is completely conserved in CtAR (Tyr51, Lys80, Asp46, His113). The amino acid residues involved in binding of NADPH by hAR (D.K. Wilson, et al., Science 257 (1992) 81-84) are 64% identical in CtAR. Like hAR the yeast enzyme is specific for transferring the 4-pro-R hydrogen of the coenzyme. These properties suggest that CtAR is a member of the aldo/keto reductase superfamily. Unlike hAR the enzyme from C. tenuis has a dual coenzyme specificity and shows similar specificity constants for NADPH and NADH. It binds NADP(+) approximately 250 times less tightly than hAR. Typical turnover numbers for aldehyde reduction by CtAR (15-20 s(-1)) are up to 100-fold higher than corresponding values for hAR, probably reflecting an overall faster dissociation of NAD(P)(+) in the reaction catalyzed by the yeast enzyme.

D-Xylose metabolism by Candida intermedia: isolation and characterisation of two forms of aldose reductase with different coenzyme specificities

To study individual enzyme components responsible for the initial step of D-xylose utilisation by the yeast Candida intermedia, a two-step protocol has been developed that enables clear-cut separation and isolation of two structurally similar but functionally different aldose reductases (ALRs) in high yield. In the first step, the yeast cell extract is fractionated efficiently by biomimetic chromatography using the dye HE-3B (reactive Red 120) as pseudoaffinity ligand coupled to Sepharose CL-4B. In the second step, optimised high-resolution anion-exchange chromatography using Mono Q yields purified ALR1 and ALR2 in overall yields of 63 and 62%, respectively. ALR1 is strictly specific for NADPH (2.4 x 10(5) M(-1) s(-1)) whereas ALR2 utilises NADH and NADPH with similar specificity constants of approximately 2-4 x 10(5) M(-1) s(-1). Both enzymes are dimers with a subunit molecular mass of 36000 but they differ in pI and the number of titratable sulphydryl groups in the native protein. The chromatographic procedure identifies microheterogeneity in recombinant aldose reductase from Candida tenuis overexpressed in Escherichia coli.

DNA-binding activity of the transcription factor upstream stimulatory factor 1 (USF-1) is regulated by cyclin-dependent phosphorylation

The ubiquitous transcription factor upstream stimulatory factor (USF) 1 is a member of the bzHLH (leucine zipper-basic-helix-loop-helix) family, which is structurally related to the Myc family of proteins. It plays a role in the regulation of many genes, including the cyclin B1 gene, which is active during the G2/M and M phases of the cell cycle and may also play a role in the regulation of cellular proliferation. We show that the affinity of recombinant USF-1 for DNA is greatly increased by treatment with active cyclin A2-p34(cdc2) or cyclin B1-p34(cdc2) complexes and that its interaction with DNA is dependent on p34(cdc2)-mediated phosphorylation. We have localized the phosphorylation site(s) to a region that lies outside the minimal DNA-binding domain but overlaps with the previously identified USF-specific region. Deletion studies of USF-1 suggest that amino acids 143-197 regulate DNA-binding activity in a phosphorylation-dependent manner.

Binding energy and specificity in the catalytic mechanism of yeast aldose reductases

Derivatives of d-xylose and d-glucose, in which the hydroxy groups at C-5, and C-5 and C-6 were replaced by fluorine, hydrogen and azide, were synthesized and used as substrates of the NAD(P)H-dependent aldehyde reduction catalysed by aldose reductases isolated from the yeasts Candida tenuis, C. intermedia and Cryptococcus flavus. Steady-state kinetic analysis showed that, in comparison with the parent aldoses, the derivatives were reduced with up to 3000-fold increased catalytic efficiencies (k(cat)/K(m)), reflecting apparent substrate binding constants (K(m)) decreased to as little as 1/250 and, for d-glucose derivatives, up to 5.5-fold increased maximum initial rates (k(cat)). The effects on K(m) mirror the relative proportion of free aldehyde that is available in aqueous solution for binding to the binary complex enzyme-NAD(P)H. The effects on k(cat) reflect non-productive binding of the pyranose ring of sugars; this occurs preferentially with the NADPH-dependent enzymes. No transition-state stabilization energy seems to be derived from hydrogen-bonding interactions between enzyme-NAD(P)H and positions C-5 and C-6 of the aldose. In contrast, unfavourable interactions with the C-6 group are used together with non-productive binding to bring about specificity (6-10 kJ/mol) in a series of d-aldoses and to prevent the reaction with poor substrates such as d-glucose. Azide introduced at C-5 or C-6 destabilizes the transition state of reduction of the corresponding hydrogen-substituted aldoses by approx. 4-9 kJ/mol. The total transition state stabilization energy derived from hydrogen bonds between hydroxy groups of the substrate and enzyme-NAD(P)H is similar for all yeast aldose reductases (yALRs), at approx. 12-17 kJ/mol. Three out of four yALRs manage on only hydrophobic enzyme-substrate interactions to achieve optimal k(cat), whereas the NAD(P)H-dependent enzyme from C. intermedia requires additional, probably hydrogen-bonding, interactions with the substrate for efficient turnover.

Randomised double-blind comparison of simethicone with cisapride in functional dyspepsia

AIM

To compare the efficacy of simethicone with cisapride in patients with functional (non-ulcer) dyspepsia.

METHODS

After standardized diagnostic work-up and at least 6-days wash-out of medication, 177 patients with functional dyspepsia were enrolled; 173 of them (age 19-71 years) were randomized and treated using a double-dummy technique with simethicone (84 mg t.d.s.) or cisapride (10 mg t.d.s.). At baseline and after 2 and 4 weeks, the intensity of the symptoms was scored from 0 (absent) to 3 (severe) using a standardized symptom questionnaire. Efficacy of the treatment was judged by the patients as 'very good', 'good', 'moderate' or 'no effect'.

RESULTS

A total of 166 patients completed the trial. After 2 and 4 weeks, 34% and 46% (respectively), of the patients treated with simethicone judged the improvement in symptoms to be excellent compared to 13% and 22% (respectively) of patients treated with cisapride (P < 0.01). After 2 weeks the difference in the improvement in the global symptom score was significantly better (Delta30.7%, P < 0.001) for simethicone than for cisapride, while this difference failed statistical significance after 4 weeks (Delta10.2%, P=0.11).

CONCLUSIONS

In patients with functional dyspepsia, simethicone relieves symptoms during the first 2 weeks of treatment significantly better than cisapride.

Binding and catalysis by yeast aldose reductase: a substrate-analog approach with new aldose derivatives

5-Deoxy-D-xylofuranose derivatives and a range of new 5,6-dideoxy analogs of D-glucofuranose bearing azido or fluoro substituents were synthesised and employed as substrates of the NADH-dependent aldehyde reduction catalysed by yeast aldose reductase. In terms of catalytic efficiencies, these products proved to be superior to the parent compounds.