[Compression therapy for inflammatory dermatoses of the legs]

In addition to venous and lymphatic diseases, there is increasing scientific evidence that inflammatory dermatoses of the legs are also indications for compression therapy. Specifically, diseases such as pyoderma gangrenosum, livedoid vasculopathy, cutaneous vasculitides, necrobiosis lipoidica, psoriasis, or erysipelas are conditions for which adjunctive compression therapy may be used when manifestations occur on the lower extremities. When inflammatory dermatoses are accompanied by edema, compression therapy is not an off-label use. Especially because of the often problematic pain symptoms, compression therapy can be performed with low resting pressures around 20 mmHg, especially in inflammatory dermatoses.In this review article, the current scientific aspects of compression therapy in inflammatory dermatoses of the legs and the corresponding limitations are presented in a differentiated manner.

Continuous Nanoprecipitation of Polycaprolactone in Additively Manufactured Micromixers

The polymeric ouzo effect is an energy-efficient and robust method to create nanoparticles with biologically degradable polymers. Usually, a discontinuous or semi-continuous process is employed due to its low technical effort and the fact that the amount of dispersions needed in a laboratory is relatively small. However, the number of particles produced in this method is not enough to make this process economically feasible. Therefore, it is necessary to improve the productivity of the process and create a controllable and robust continuous process with the potential to control parameters, such as the particle size or surface properties. In this study, nanoparticles were formulated from polycaprolactone (PCL) in a continuous process using additively manufactured micromixers. The main goal was to be able to exert control on the particle parameters in terms of size and zeta potential. The results showed that particle size could be adjusted in the range of 130 to 465 nm by using different flow rates of the organic and aqueous phase and varying concentrations of PCL dissolved in the organic phase. Particle surface charge was successfully shifted from a slightly negative potential of −14.1 mV to a negative, positive, or neutral value applying the appropriate surfactant. In summary, a continuous process of nanoprecipitation not only improves the cost of the method, but furthermore increases the control over the particle’s parameters.

Multicomponent compression system use in patients with chronic venous insufficiency: a real-life prospective study

OBJECTIVE

Compression therapy is the cornerstone of therapeutic management of patients with chronic venous insufficiency (CVI). This study aimed to evaluate the efficacy and safety of a multicomponent compression system in an unselected population of patients with CVI problems under real-life conditions.

METHOD

A prospective, multicentre, observational study with a multicomponent two-bandage compression system (UrgoK2, Laboratoires Urgo, France) was conducted in 103 centres in Germany. Main outcomes included wound healing rate, wound healing progression, assessment of oedema and ankle mobility, local tolerability and acceptance of the compression therapy.

RESULTS

A total of 702 patients with venous leg ulcers (VLU) and/or with lower limb oedema due to CVI were treated with the evaluated system for a mean (±standard deviation) duration of 27±17 days. By the last visit, 30.9% of wounds had healed and 61.8% had improved. Limb oedema was resolved in 66.7% of patients and an improvement of ankle mobility was reported in 44.2% of patients. The skin condition under the compression therapy was also considered as improved in 73.9% of patients and a substantial reduction of pain was achieved, both in number of patients reporting pain and in pain intensity. Compression therapy with the evaluated system was 'very well' or 'well' tolerated and 'very well' or 'well' accepted by >95% of patients. These positive outcomes were in line with the general opinion of physicians on the evaluated compression bandages, which were judged 'very useful' or 'useful' for >96.6% of patients. Similar results were reported regardless of the treated condition, VLU and/or limb oedema.

CONCLUSION

Real-life data documented in this large observational study of non-selected patients receiving compression therapy in daily practice confirm the benefits and safety profile of the evaluated compression system. This study also confirms the high-level of performance and acceptability of the system, regardless of the characteristics of the wounds or patients at initiation of the treatment. The data support the use of this multicomponent compression system as one first-line intervention in patients with symptoms caused by CVI.

A comparison of thyroidal protection by iodine and perchlorate against radioiodine exposure in Caucasians and Japanese

Radioactive iodine released in nuclear accidents may accumulate in the thyroid and by irradiation enhances the risk of cancer. Radioiodine uptake into the gland can be inhibited by large doses of stable iodine or perchlorate. Nutritional iodine daily intake may impact thyroid physiology, so that radiological doses absorbed by the thyroid as well as thyroid blocking efficacy may differ in Japanese with a very rich iodine diet compared to Caucasians. Based on established biokinetic-dosimetric models for the thyroid, we derived the parameters for Caucasians and Japanese to quantitatively compare the effects of radioiodine exposure and the protective efficacy of thyroid blocking by stable iodine at the officially recommended dosages (100 mg in Germany, 76 mg in Japan) or perchlorate. The maximum transport capacity for iodine uptake into the thyroid is lower in Japanese compared to Caucasians. For the same radioiodine exposure pattern, the radiological equivalent thyroid dose is substantially lower in Japanese in the absence of thyroid blocking treatments. In the case of acute radioiodine exposure, stable iodine is less potent in Japanese (ED50 = 41.6 mg) than in Caucasians (ED50 = 2.7 mg) and confers less thyroid protection at the recommended dosages because of a delayed responsiveness to iodine saturation of the gland (Wolff-Chaikoff effect). Perchlorate (ED50 = 10 mg in Caucasians) at a dose of 1000 mg has roughly the same thyroid blocking effect as 100 mg iodine in Caucasians, whereas it confers a much better protection than 76 mg iodine in Japanese. For prolonged exposures, a single dose of iodine offer substantially lower protection than after acute radioiodine exposure in both groups. Repetitive daily iodine administrations improve efficacy without reaching levels after acute radioiodine exposure and achieve only slightly better protection in Japanese than in Caucasians. However, in the case of continuous radioiodine exposure, daily doses of 1000 mg perchlorate achieve a high protective efficacy in Caucasians as well as Japanese (> 0.98). In Caucasians, iodine (100 mg) and perchlorate (1000 mg) at the recommended dosages seem alternatives in case of acute radioiodine exposure, whereas perchlorate has a higher protective efficacy in the case of longer lasting radioiodine exposures. In Japanese, considering protective efficacy, preference should be given to perchlorate in acute as well as prolonged radioiodine exposure scenarios.

[Diagnosis and therapy of erysipelas: A position paper of the Society Initiative Chronische Wunde (ICW) e. V.]

Erysipelas is a bacterial soft tissue infection caused by β-haemolytic streptococci that spreads proximally along the lymphatic system of the skin. The entry sites of the pathogens can be minor injuries or chronic wounds. The diagnosis of erysipelas is made clinically by the spreading eythema and overheating of the skin, the reduced general condition with fever and chills as well as by means of serological inflammation parameters and must be distinguished from numerous differential diagnoses.Systemic therapy is carried out with penicillin usually. In local therapy, the value of measures such as compression therapy or cooling is currently still controversial. Long-term therapy of the lymphoedema and the consistent avoidance and treatment of entry sites are essential, especially for the prevention of recurrence.

[Is compression therapy contraindicated for lower leg erysipelas? : Results of a retrospective analysis]

In many medical expert recommendations and guidelines, the use of compression therapy for acute erysipelas is designated as a contraindication. Due to the sometimes massive oedema, compression therapy is nevertheless used in some clinics. This led to the question whether compression therapy for erysipelas of the lower leg actually leads to complications due to the acute infection and thus represents a contraindication. For the period 01 January 2018 to 30 June 2019, the records of 56 inpatients with acute erysipelas of the lower leg who received compression therapy in addition to systemic antibiotic therapy were retrospectively evaluated. The duration of inpatient treatment, the infection parameters determined as part of the ward routine and any complications that occurred were evaluated. While treated as inpatients the blood parameters for infection clearly dropped. Compression therapy was started on admission day in 92.9% of patients and continued until discharge. None of the patients showed an increase in fever or clinical signs of sepsis during the hospital stay. In this retrospective analysis it could be shown for the first time that compression therapy does not cause a clinical worsening or trigger a septic clinical picture in patients with acute erysipelas. Therefore, the authors consider the declaration of acute erysipelas as contraindication for compression therapy as not justified.

Cytogenetic Analysis After Temporary Residence in the Area of the Uncontrolled Ruthenium-106 Release in Russia in September 2017

In September and October 2017, elevated atmospheric ruthenium contamination was measured in several European countries. The most probable origin of this release of radionuclides was reconstructed to be the Southern Ural region. During that time, five workers from a German company stayed up to 2 wk about 120 km from the Chelyabinsk region in Ekaterinburg, Russia. No clinical symptoms were reported during or after the suspected radiation exposure, and no internal contamination was found in whole-body measurements. However, to investigate radiation protection issues and to clarify the workers' situation in order to reassure them, as they planned to continue working in Ekaterinburg, our laboratory was urgently requested by the company's occupational physician to perform biodosimetry using dicentric analysis to determine if the workers have been exposed to radiation by incorporation of radionuclides. The workers' dicentric yields have been compared to reference data of background frequencies in unexposed individuals, but, as it is not reasonable to quantify individual absorbed radiation doses from internalized beta emitters due to various confounding factors, individual dose estimation has not been performed. Dicentric frequencies for two workers differed significantly from the mean laboratory background level, which could have been induced by an exposure to incorporated radionuclides due to beta emissions by Ru or to gamma irradiation by the decay nuclide of Ru. However, the maximum absorbed radiation doses calculated for a resident in the Ru-contaminated area during that time does not correspond to the observed dicentric frequencies. It cannot be excluded that their dicentric frequencies were already elevated before September 2017, potentially induced by an earlier radiation exposure to diagnostic x rays or even by chance.

A quantitative comparison of the chemo- and radiotoxicity of uranium at different enrichment grades

OBJECTIVE

The radiotoxic effects of uranium are often in the focus of the public fears but the chemical toxic effects of uranium are reported to surpass radiation effects. As there is no uranium isotope that is not radioactive, it is not possible to study chemical effects fully independently from radiation effects. In order to quantitate and compare radio- and chemotoxicity, we determined the median lethal doses of uranium due to its chemical toxicity and calculated the absorbed radiological doses resulting from the ingestion or inhalation of corresponding amounts depending on the isotopic enrichment grade. Committed effective doses over 50 years are related to the stochastic health effects like cancer occurrence and can be converted to a loss of statistical life time (mean loss 0.4 day / mSv). The equivalent doses absorbed within a short time frame permits conclusion on the induction of deterministic effects (e.g. acute radiation sickness).

METHOD

Simulations were based on the biokinetic models of the International Commission for Radioprotection and performed using Integrated Modules for Bioassay Analysis software. Results were compared with the doses given by the calculator of the WISE uranium project. The fractions of the total doses absorbed within different time periods were derived from the respective areas under the activity-time curves in the whole body.

RESULTS

The distribution of the total dose on the organs and tissues depends on the invasion pathway and the solubility of the compound. In the case of inhalation, the absorption of the total dose is more protracted than after ingestion. The incorporation of depleted or natural uranium in lethal amounts due to nephrotoxicity does not lead to deterministic radiation effects and is associated with committed effective doses reaching at most about 200 mSv (proposed possible threshold for therapeutic interventions after accidental radionuclide incorporation). The inhalation of low enriched uranium leads to higher effective doses up to 690 mSv, but they are still insufficient to cause acute deterministic effects. Even highly enriched uranium seems not to induce radiation nephropathy, but deterministic effects on the hematopoetic system cannot be excluded in particularly sensitive patients. But the equivalent doses to the lungs associated with the inhalation of poorly soluble compounds of highly enriched uranium are in a range that may induce radiation pneumonitis.

CONCLUSION

Our findings give clear evidence that for depleted and natural uranium chemical toxicity is much more marked than radiotoxicity. However, this conclusion must not be drawn for enriched and in particular highly enriched compounds that besides stochastic effects may even cause deterministic radiation effects.

[Compression therapy of venous leg ulcers in the decongestion phase]

Compression therapy is the basis for successful treatment in most patients with venous leg ulcers. Concerning compression therapy, the initial phase of decongestion and the following phase of maintenance should be differentiated. While in the maintenance phase (ulcer) stocking systems are now frequently recommended, in the decongestion phase compression bandages are mostly still used, which however are often inappropriately applied. In German-speaking countries, compression therapy with short-stretch bandages has a long tradition. However, their correct application requires good training and monitoring, which is often lacking in daily practice. Less error-prone treatment alternatives are multicomponent systems, some of which have an optical marker for the control of the correct subbandage pressure. In another new type of compression system, which is called adaptive or wrap bandages, the compression pressure can be adjusted using a Velcro fastener. Accompanying intermittent pneumatic compression therapy can also be used in the decongestion phase. Thus, there are now several different treatment options that can be used for the decongestion phase in patients with venous leg ulcers. Often bandages with short-stretch materials are very prone to errors and should in most cases be replaced by other compression systems today. The patient's preference, need, and capability should be considered when selecting the appropriate system for the individual patient.

Safety and efficacy of thiotepa-based conditioning for allogeneic transplantation in AML: a survey from the ALWP of the EBMT

This study evaluated the safety and efficacy of thiotepa-based regimens before allogeneic stem cell transplantation in 310 adult patients with AML. Disease status at the time of transplantation was CR1 in 50%, CR2+ in 23.5% and advanced disease in 26.5%. Transplantation was performed from haploidentical (35%), matched sibling (27%), unrelated (20%) or cord blood (18%) donors. As for safety: mucositis occurred in 46.8% of the patients and the cumulative incidence (CI) of sinusoidal obstruction syndrome was 4.0%. With a median follow-up of 37 months, the CI of acute GvHD grade>II was 26.5%, whereas CI of chronic GvHD was 28.1% at 3 years. CI for non-relapse mortality at 3 years was 38.4%, 49.7% and 45.4% for patients in CR1, CR2+ and advanced disease, respectively (P=0.10). Relapse incidence at 3 years was 20.2, 30.7 and 40.6% in these three respective groups (P=0.002). CI for 3-year leukemia-free survival and overall survival were 41.4% and 45.6% (CR1), 19.6% and 27.7% (CR2+), and 13.9% and 13.6% (advanced disease), respectively (P<10^-4 for both). Our data suggest that thiotepa-based conditioning therapy in AML is feasible, effective and safe, as investigated for sinusoidal obstruction syndrome and mucositis.

The Impact of Time on Decorporation Efficacy After a "Dirty Bomb" Attack Studied by Simulation

Background: In the case of a nuclear or radiological incident, there is a risk of external and internal contamination with radionuclides in addition to external irradiation. There is no consensus whether decorporation treatment should be initiated right away on spec or pending the results of internal dosimetry to determine the indication. Method: Based on biokinetic models for plutonium-239, americium-241 and cesium-137, the efficacy of a decorporation treatment using DTPA or Prussian blue was simulated depending on the initiation time and the duration of treatment for different invasion pathways and physicochemical properties of the inhaled compounds. Results: For the same level of radioactivity incorporated, the committed effective dose increases with the speed of the invasion process. The impact of the initiation time of a decorporation treatment is particularly important when the absorption of the radionuclide is fast. Even if started early after incorporation, the therapeutic efficacy is less for americium-241 or cesium-137 compared to plutonium-239. Therapeutic efficacy increases with treatment duration up to about 90 days for plutonium-239 and cesium-137, whereas a prolongation of the treatment over this limit may further enhance efficacy in the case of americium-241. Conclusion: In the case of a nuclear incident, several fractions with different but a priori unknown physicochemical properties may be inhaled. Thus, decorporation therapy should be started as soon as possible after the incorporation of the radionuclide(s), as a loss of efficacy caused by a delay of treatment initiation possibly cannot be compensated later on. Treatment should be pursued for several months.

Reconsidering Current Decorporation Strategies after Incorporation of Radionuclides

In the case of a nuclear accident or a terrorist attack by a "dirty bomb," there is a risk of external and internal contamination with radionuclides in addition to external irradiation. Internal irradiation as a consequence of radionuclide incorporation is associated with a higher risk of stochastic radiation effects (e.g., tumors). Decorporation treatment will enhance the elimination of radionuclides and reduce the committed effective dose as a metric of stochastic health effects. Although treatment efficacy is better when started early, beginning the therapy without knowing the committed effective dose may unnecessarily expose the patient to the side effects of the medication. The question is: Delay the therapy to wait for the results of internal dosimetry or start the therapy promptly on spec? To prove insight into this question, a selective review of the literature was conducted. The importance of the initiation time of treatment in the efficacy of decorporation treatment can be explained with pharmacokinetic laws and first order processes determining the disposition of xenobiotics in the organism. Nevertheless, there is no internationally accepted standard on when to start a decorporation therapy (exception: iodide). The "precautionary approach," emphasizing the importance of the committed effective dose for the indication of treatment, is competing with the "urgent approach" advocating the administration of medication "a priori" within several hours. A review of the literature actually indicates that the most important drugs used for decorporation are well tolerated with few adverse effects. In consideration of the higher efficacy and the low side-effects of a short-term treatment, initiating decorporation therapy as soon as possible after internal contamination, even before the committed effective dose has been assessed, appears to be a reasonable approach. The decision of continuation or discontinuation of the therapy should be taken after internal dosimetry is completed on the basis of the committed effective dose.

Seminal fluid promotes in vitro sperm-oviduct binding in the domestic cat (Felis catus)

From many endangered or threatened species which are expected to profit from assisted reproduction techniques, mainly epididymal sperm of dead or freshly castrated males are available. These sperm had contact to epididymal secretion products but not to seminal fluid components. Notably, products of accessory sex glands have been shown in domestic animals to condition sperm for fertilization, in particular by mediating sperm-oviduct interaction. We report for the first time that motile epididymal sperm from domestic cats are able to bind to fresh oviduct epithelial cell explants from preovulatory females (median [min, max] of 10 [8, 16] and 10 [8, 17] sperm per 0.01 mm(2) explant surface from both isthmic and ampullar regions, respectively). More sperm attach to the explants when epididymal sperm were preincubated for 30 minutes with seminal fluid separated from electroejaculates of mature tomcats (median [min, max] of 17 [13, 25] and 16 [12, 21] sperm per 0.01 mm(2) explant surface from isthmus and ampulla, respectively). The proportion of bound sperm increased from a median of 54% to 62% by seminal fluid treatment. Sperm-oviduct binding could be facilitated by the decelerated sperm motion which was observed in seminal fluid-treated samples or supported by seminal fluid proteins newly attached to the sperm surface. Seminal fluid had no effect on the proportion of sperm with active mitochondria. Extent and pattern of sperm interaction in vitro were independent of explant origin from isthmus or ampulla. Sperm were attached to both cilia and microvilli of the main epithelial cell types present in all explants. In contrast to published sperm-binding studies with porcine and bovine oviduct explants where predominantly the anterior head region of sperm was attached to ciliated cells, the tails of some cat sperm were firmly stuck to the oviduct cell surfaces, whereas the heads were wobbling. Whether this response is a preliminary step toward phagocytosis or a precondition to capacitation and fertilization remains to be determined. In conclusion, treatment of epididymal sperm with seminal fluid or particular protein components should be considered in future investigations for its potential to improve the outcome of artificial insemination in felids.

Bortezomib administered subcutaneously is well tolerated in bortezomib-based combination regimens used in patients with multiple myeloma

OBJECTIVE

Bortezomib (Btz) has emerged as a standard of care in the treatment of patients with multiple myeloma (MM), but Btz-induced peripheral neuropathy (PNP) has a particularly negative impact on patients' quality of life. According to a recent study, PNP was significantly less frequent with subcutaneous administration of Btz. Here, we report our experience regarding the efficacy and tolerability of standard combination regimens in MM with subcutaneous Btz.

METHODS

14 consecutive patients with newly diagnosed MM were included in this analysis. Btz was used in different combination regimens (Btz with dexamethasone with/without thalidomide or Btz combined with melphalan and prednisone). Standard criteria were applied to evaluate response and toxicity.

RESULTS

Hematological toxicities occurred only at grades 1-2 and included anemia (71%) and thrombocytopenia (21%). Nonhematologic side effects at grades 1-2 were local skin reactions at the subcutaneous injection site, which were self-limited. No notable gastrointestinal toxicity was observed with subcutaneous Btz, and therefore routine use of intravenous hydration and antiemetics was abandoned. Overall response rate for transplant-eligible patients was 86%.

CONCLUSIONS

Our results confirm the improved toxicity profile of the subcutaneous administration of Btz in various standard Btz-based combination regimens. In addition, patient management with subcutaneous administration has been markedly ameliorated at our center.

Chronic critical limb ischemia

BACKGROUND

Some 40 000 lower limb amputations are performed in Germany each year, 70% of them in diabetics. About 80% of all major amputations may be preventable with the use of new interventional and vascular surgical procedures, particularly on the arteries of the leg and foot. We present the current state of the art in revascularization techniques and evaluate their usefulness for preservation of the lower limb.

METHODS

This overview is based on the guidelines for the diagnosis and treatment of peripheral artery disease (PAD) and diabetic foot syndrome (DFS) that have been issued by the American Heart Association (AHA), the American College of Cardiology (ACC), the German Society of Angiology (DGA), the Trans-Atlantic Intersociety Consensus (TASC II), the German Society of Vascular Surgery (DGG), and the German Diabetes Society (DDG). A selective search in PubMed for relevant articles that appeared from 2000 to 2011 was conducted with the search terms "pedal bypass," "vascular intervention crural pedal," and "crural-pedal revascularization."

RESULTS

Most of the data on crural and pedal revascularization are derived from small-scale studies. The few comparative studies of interventional treatments and bypass surgery have not revealed any significant differences in outcome, but all studies of revascularization have shown good success rates for lower limb preservation.

CONCLUSION

Though the data are still sparse, the high reported rates of limb preservation imply that peripheral revascularization techniques can play a major role in the treatment of chronic critical limb ischemia (CLI). Therefore, these techniques are recommended without exception by the current guidelines.

Molecular dynamics simulations of mixed lubrication with smooth particle post-processing

A post-processing method for molecular dynamics (MD) simulations of friction based on the smooth particle approach is proposed, allowing--among other features--the introduction and evaluation of a solid-solid contact area arising due to direct asperity interaction. In order to illustrate the feasibility of this scheme, a large number of MD calculations of lubricated nanotribological systems with various asperity geometries and carefully selected numbers of lubricant molecules were carried out and analysed. In this manner, it is shown that the friction force as a function of load agrees very well with a three-parameter friction law which, in addition to the adhesion- and the load-controlled terms, contains a load-independent offset.

[Cardiology quality assessment in Germany--pro and contra]

The German National Institute for Quality in Healthcare has also developed a program of external quality assessment in the field of cardiology. Hospitals are committed to collect certain data of diagnostic coronary angiography, percutaneous coronary interventions and pacemaker implantations. If statistical abnormalities are observed a so called structured dialogue is implemented. The responsible physicians of the hospitals are asked to comment possible quality deficits. Appointed members of quality commissions examine the answers and can invite the responsible physicians for interviews or also visit the hospital. However the validity of the quality data is problematic, because audits or check-ups of quality assessment in place are lacking. Therefore the results should not be misused for a comparison or ranking of hospitals with each other. As long as the validity of the quality assessment has not been improved, the results should also not be accessible for other parties, such as health insurances.

Serum hepcidin concentration in chronic haemodialysis patients: associations and effects of dialysis, iron and erythropoietin therapy

BACKGROUND

Hepcidin, a liver-derived peptide induced by iron overload and inflammation, is a major regulator of iron homeostasis. As hepcidin decreases gastrointestinal iron absorption and recirculation from monocytes, over-expression is associated with the development of anaemia.

METHODS

We studied the associations between circulating hepcidin levels and various laboratory parameters related to anaemia and/or inflammation in 20 patients on chronic haemodialysis. Furthermore, we determined the impact of dialysis and iron and/or erythropoietin (rhEpo) supplementation therapy on hepcidin serum concentrations. The patients were withheld from iron and rhEpo for 2 weeks before study entry. Hepcidin was measured by liquid chromatography-mass spectrometry (LC-MS/MS); serum iron and haematological parameters, cytokines and pro-hepcidin by commercially available enzyme-linked immunosorbent assays (ELISA) or standard automated methods.

RESULTS

While hepcidin levels at baseline were not correlated to pro-hepcidin, interleukin-6 or transforming growth factor-beta concentrations, we found significant associations with reticulocyte count (r = -0.55; P = 0.015), serum iron (r = 0.7; P = 0.004) and ferritin levels (r = 0.63; P = 0.004) and transferrin saturation (r = 0.69, P = 0.001). Dialysis using either a high or a low flux biocompatible dialyser resulted in a significant decrease of hepcidin concentrations, which returned to pre-dialysis values before the next dialysis session. When studying the effects of anaemia treatment, we observed a significant reduction of hepcidin levels following administration of rhEpo but not iron.

CONCLUSIONS

Hepcidin levels in stable haemodialysis patients appear to reflect systemic iron load, but not inflammation. Due to the negative association between reticulocyte counts and hepcidin, the reduction of circulating hepcidin concentrations by dialysis and/or rhEpo treatment may positively affect erythropoiesis.

Decrease of proteinuria in a patient with adult‐onset Still's disease and glomerulonephritis after anti‐TNFα therapy

We report the case of a 41-year-old man diagnosed with Still's disease. Multiple disease-modifying anti-rheumatic drug (DMARD) therapies failed to induce disease remission or to prevent progressive joint destruction. The man presented with active arthritis and classical Still's rash accompanied by fever. Anti-tumour necrosis factor-alpha (TNFalpha) therapy was planned but during the medical check-up prior to the biological therapy, renal insufficiency with marked proteinuria (PU) was discovered. With PU of 912 mg/24 h a renal biopsy was performed and a histopathological evaluation revealed the diagnosis of a residual mesangio-proliferative immunocomplex-based glomerulonephritis (GN). After excluding contraindications, infliximab therapy was initiated and a good response of the arthritis was documented after 6 weeks. A significant decrease in PU (279 mg/24 h) was noted after the third infliximab infusion. Because of an allergic reaction during the fifth dose, the infliximab was discontinued. During the time frame without anti-TNFalpha therapy, active joint disease reoccurred and the proteinuria increased significantly. Because of the active disease entanercept therapy was initiated. The arthritis diminished and the PU was reduced markedly within 4 weeks. In the follow-up period of 12 months a good response to therapy was sustained. As described by other investigators, the joint disease showed a rapid and sustained response to anti-TNFalpha therapy. The decrease in proteinuria during biological therapy was notable. It was concluded that the significant decrease in PU in this patient was achieved by eliminating the inflammatory activity of the underlying kidney disease.

[Perianal fistulas in Crohn's disease--biologicals and surgery: is it worthwhile?]

Perianal fistulas and abscesses are a common manifestation in Crohn's disease (CD), seen in about 30 - 40 % of the patients. Often they are combined with CD of the anal canal and occur as a complex system of fistulas. The evaluation of these fistulas can be done with endoscopic ultrasound or magnetic resonance imaging, the conceptual accuracy of both methods is high. There are accepted therapeutic concepts for surgery and for the conventional drug therapy according to the classification of the fistulas. In contrast, the therapeutic regimens for a complex perianal fistulising CD are not convincing, especially not for maintainance therapy. However, several studies about therapy with anti-TNF-alpha antibodies have shown good results while long-time results with other recent anti-TNF-alpha antibodies apart from infliximab are still lacking. In this review article we analyse the current literature and develop a stage-adapted therapy for the use of biologicals and surgery in fistulising perianal CD.

3D-Histological evaluation of surgery in dermatofibrosarcoma protuberans and malignant fibrous histiocytoma: Differences in growth patterns and outcome

AIMS

To evaluate the microscopic growth pattern of dermatofibrosarcoma protuberans (DFSP) and malignant fibrous histiocytoma (MFH) and the long-term outcome using 3D-histologic surgery with paraffin sections to cover complete margins and to detect subclinical spreads very sensitively.

METHODS

One hundred and one patients have been included comprising 70 DFSP, 31 MFH. Data from 87 patients treated since 1992 were collected prospectively.

RESULTS

Mean clinical tumor-size was 45 mm, mean histological tumor size 65 mm. A mean excision margin of 19 mm achieved negative margins. The histological infiltration shows an asymmetrical pattern with horizontal or vertical extension either cord-, sector- or multiple-like up to 70 mm in length, detectable by 3D-histology. Age and localization differed significantly between DFSP and MFH lesions. MFH tumors had a significantly deeper infiltration than DFSP. The mean follow up was 60 months. In 70 patients with DFSP one local recurrence after 62 months occurred, but no metastasis. 31 patients with MFH developed 8 local recurrences, and 4 metastases (lymph nodes and/ or lungs); 3 of them died of the disease, all 3 had a postoperative status of R1 (p=0.001).

CONCLUSIONS

There are significant differences in growth pattern and clinical outcome between DFSP and MFH. DFSP can be cured by surgery following 3D-histology with paraffin sections. MFH is significantly more malignant. After local R0-resection proofed by 3D-histology higher cure rates can be achieved.

Gene expression profiles of human proximal tubular epithelial cells in proteinuric nephropathies

In kidney disease renal proximal tubular epithelial cells (RPTEC) actively contribute to the progression of tubulointerstitial fibrosis by mediating both an inflammatory response and via epithelial-to-mesenchymal transition. Using laser capture microdissection we specifically isolated RPTEC from cryosections of the healthy parts of kidneys removed owing to renal cell carcinoma and from kidney biopsies from patients with proteinuric nephropathies. RNA was extracted and hybridized to complementary DNA microarrays after linear RNA amplification. Statistical analysis identified 168 unique genes with known gene ontology association, which separated patients from controls. Besides distinct alterations in signal-transduction pathways (e.g. Wnt signalling), functional annotation revealed a significant upregulation of genes involved in cell proliferation and cell cycle control (like insulin-like growth factor 1 or cell division cycle 34), cell differentiation (e.g. bone morphogenetic protein 7), immune response, intracellular transport and metabolism in RPTEC from patients. On the contrary we found differential expression of a number of genes responsible for cell adhesion (like BH-protocadherin) with a marked downregulation of most of these transcripts. In summary, our results obtained from RPTEC revealed a differential regulation of genes, which are likely to be involved in either pro-fibrotic or tubulo-protective mechanisms in proteinuric patients at an early stage of kidney disease.

The Impact of Immunological Parameters on the Development of Phantom Pain after Major Amputation

OBJECTIVES

To investigate the relationship between local and systemic inflammatory markers and phantom limb pain.

METHODS

In 39 consecutive patients undergoing major amputations nerve biopsies, serum and clinical data was collected. Patients were followed up for 12 months to report on the incidence and severity of phantom limb pain.

RESULTS

After 12 months, 78% of the surviving patients had phantom pain, the symptom usually commencing within 14 days of operation. The severity of macrophage infiltration within the nerve biopsy was negatively correlated to the inception of phantom pain ( P = 0.026). While serum TNF-alpha concentration was positively correlated to mortality ( P = 0.021).

CONCLUSIONS

The immune status existing before the amputation and the local immunological milieu influence the onset of phantom pain.