Transition for adolescents with a rare disease: results of a nationwide German project

PURPOSE

The transition process from paediatric/adolescent to adult medical care settings is of utmost importance for the future health of adolescents with chronic diseases and poses even more difficulties in the context of rare diseases (RDs). Paediatric care teams are challenged to deliver adolescent-appropriate information and structures. Here we present a structured transition pathway which is patient-focused and adoptable for different RDs.

METHODS

The transition pathway for adolescents 16 years and older was developed and implemented as part of a multi-centre study in 10 university hospitals in Germany. Key elements of the pathway included: assessment of patients' disease-related knowledge and needs, training/educational and counselling sessions, a structured epicrisis and a transfer appointment jointly with the paediatric and adult specialist. Specific care coordinators from the participating university hospitals were in charge of organization and coordination of the transition process.

RESULTS

Of a total of 292 patients, 286 completed the pathway. Deficits in disease-specific knowledge were present in more than 90% of participants. A need for genetic or socio-legal counselling was indicated by > 60%. A mean of 2.1 training sessions per patient were provided over a period of almost 1 year, followed by the transfer to adult care in 267 cases. Twelve patients remained in paediatric care as no adult health care specialist could be identified. Targeted training and counselling resulted in improved disease-specific knowledge and contributed to empowering of patients.

CONCLUSION

The described transition pathway succeeds to improve health literacy in adolescents with RDs and can be implemented by paediatric care teams in any RD specialty. Patient empowerment was mainly achieved by individualized training and counselling.

Vitrectomy with or without encircling band for pseudophakic retinal detachment: a multi-centre, three-arm, randomised clinical trial. VIPER Study Report No. 1--design and enrolment

PURPOSE

Scleral buckling is currently used in addition to vitrectomy for the treatment of pseudophakic retinal detachment (PRD) to better support the vitreous base and better visualisation of the periphery.

AIMS

The aims of this study are to evaluate (1) whether the combination of 20 G vitrectomy and scleral buckling is superior to 20 G vitrectomy alone (control) (confirmatory), and (2) whether transconjunctival 23/25 G vitrectomy is non-inferior to 20 G vitrectomy (both without scleral buckling) regarding operation success (exploratory).

METHODS

The VIPER (Vitrectomy Plus Encircling Band Vs. Vitrectomy Alone For The Treatment Of Pseudophakic Retinal Detachment) study is an unmasked, multi-centre, three-arm randomised trial. Patients with PRD were eligible, excluding complicated retinal detachment or otherwise severe ophthalmologic impairment. Patients were randomised to one of three interventions: 20 G vitrectomy alone (control C), combination of 20 G vitrectomy and circumferential scleral buckling (experimental treatment E1) or 23/25 G vitrectomy alone (experimental treatment E2). The primary endpoint is the absence of any indication for a retina re-attaching procedure during 6 months of follow-up. Secondary endpoints include best corrected visual acuity, retina re-attaching procedures, complications and adverse events.

RESULTS

From June 2011 to August 2013, 257 patients were enrolled in the study. The internet randomisation service assigned 100 patients each to the treatment arms C and E1, and 57 patients to treatment E2. The imbalance is due to the fact that several retinal surgeons did not qualify for performing E2. The random assignment was stratified and balanced (ie, 1:1 or 1:1:1 ratio) by surgeon.

CONCLUSIONS

The described study represents a methodologically rigorous protocol evaluating the benefits of three different vitrectomy approaches to PRD. The projected results will help to establish their overall efficacy and will permit conclusions regarding their relative value.

TRIAL REGISTRATION NUMBER

DRKS00003158 (German Clinical Trials Register, DRKS).

Therapeutischer Nutzen von niedermolekularem Heparin bei Frauen mit rezidivierenden Aborten

Rezidivierende Aborte sind leider häufig. Möglicherweise hilft eine Therapie mit niedermolekularem Heparin (NMH), eine weitere Schwangerschaft erfolgreich auszutragen. Bei Frauen mit rezidivierenden Aborten werden eine systemische, inflammatorische Immunantwort und vermehrt vaskuläre Thrombosen in der Plazenta nachgewiesen. Weil Heparine sowohl eine antikoagulatorische als auch eine antiinflammatorische Komponente besitzen, untersuchten wir die Wirksamkeit einer Thera-pie mit NMH.

Patienten und Methode: Die Wirksamkeit einer Monotherapie mit NMH (5 000 I.E. täglich) bei Frauen mit mindestens zwei Frühaborten oder einem Spätabort in der Anamnese wurde retrospektiv untersucht. Dazu wur-den die Daten von 147 Schwangerschaften ausgewertet. Zielvariable war die Lebendgeburtenrate. Zudem wurde untersucht, ob bestimmte Faktoren die Wahrscheinlichkeit eines Abortes erhöhen.

Ergebnisse: Es wurde eine Lebendgeburtenrate von 86,4 % erreicht. Es sind keine schwer- wiegenden Nebenwirkungen des Heparins aufgetreten. Als Risikofaktoren, trotz Therapie einen Abort zu erleiden, fanden wir eine im ers-ten Trimenon erhöhte Protein S-Aktivität und eine erniedrigte Faktor VIII-Aktivität sowie einen aktiven Nikotinabusus.

Schlussfolgerung: Es wurde eine Lebendgeburtenrate erreicht (86,4 %), die der von gesunden Frauen (87,2 %) entspricht. Dabei ist es unwesentlich, ob die Frauen Träger thrombophiler Genpolymorphismen sind oder nicht. Trotz einer Therapie mit NMH stellen aktiver Nikotinabusus und fehlende schwangerschaftstypische Veränderungen der Gerinnung, Risikofaktoren für einen Abort dar. Wir empfehlen diese Werte in Risikoschwangerschaften zu kontrollieren.

Two-dimensional microrheology of freely suspended liquid crystal films

Smectic liquid crystals form freely-suspended, fluid films of highly uniform structure and thickness, making them ideal systems for studies of hydrodynamics in two dimensions. We have measured particle mobility and shear viscosity by direct observation of the gravitational drift of silica spheres and smectic islands included in these fluid membranes. In thick films, we observe a hydrodynamic regime dominated by lateral confinement effects, with the mobility of the inclusion determined predominantly by coupling of the fluid flow to the fixed boundaries of the film. In thin films, the mobility of inclusions is governed primarily by coupling of the fluid to the surrounding air, as predicted by Saffman-Delbrück theory.

Evaluation of advanced treatment technologies for the elimination of pharmaceutical compounds

Pharmaceuticals and their metabolites have developed as ecotoxicologically relevant micropollutants in the aquatic environment. During conventional biological wastewater treatment they are eliminated insufficiently and therefore reach surface waters via discharges. They are either partially or completely non-biodegradable and/or hardly eliminable by activated sludge adsorption because they often have polar structures. Membrane bioreactor treatment (MBR) was applied to pre-treat wastewater containing pharmaceutical compounds, e.g., antibiotics like floxacins and their synthetic precursor compounds. Our objectives were to eliminate these persistent target compounds from wastewater prior to discharge into receiving waters. Therefore an advanced treatment applying MBR combined with different chemical and physicochemical processes was performed. The addition of powdered activated carbon (PAC), nano filtration (NF), reverse osmosis (UO) or ozone (O3) and O3/UV were applied to MBR permeate spiked with the selected target compounds. Treatment efficiency was assessed using conventional inorganic and organic chemical analyses besides advanced physicochemical methods like liquid chromatography coupled with mass and tandem mass spectrometry (LC-MS and -MS-MS).

Performance of membrane bioreactors used for the treatment of wastewater from the chemical and textile industries

Within the scope of the study, nine waste waters from the chemical and textile industries were treated in bench-scale (laboratory scale) and small-scale (pilot scale) membrane bioreactors. Depending on wastewater characteristics, the resulting performance varied significantly. It was observed that MBR effectiveness was determined primarily by the degree of biodegradability of the wastewater. In the course of several months of operation, no significant changes associated with the complete retention of the biomass by the membranes were observed. In some cases, it was possible to improve effluent quality by using smaller molecular separation sizes. The flux performance of the membrane modules was dependent on wastewater composition. Occasionally, non-degradable macromolecular substances concentrated in the bioreactor, resulting in strongly reduced filterability and flow performance of the membrane modules, consequently also reducing the economic viability of the process. The results demonstrate that wastewater-specific pilot tests are absolutely necessary, in particular if the technology is to be used for new applications.

Saponins from Hacquetia epipactis

Four new estersaponins were isolated from hacquetia epipactis. Using GC-MS, FAB-MS and various 2D-NMR techniques they were identified as 3-O-[beta-D-glucopyranosyl-(1-->2)-[alpha-L-arabinopyranosyl-(1--> 3)]- beta-D-glucuronopyranosyl-(1-->)]-21-acetyl-22-(2-methylbutyryl)- barringtogenol C (hacquetiasaponin 1), the corresponding 21-(2-acetoxy-2-methylbutyryl)-22-acetyl-derivative (hacquetiasaponin 2), 3-O-[beta-D-glucopyranosyl-(1-->2)-[alpha-L-arabinopyranosyl- (1-->3)]-beta-D-glucuronopyranosyl-(1-->)]-21-acetyl-22-(2-methylb utyryl)- R1-barrigenol (hacquetiasaponin 3) and its corresponding 21-(2-acetoxy-2-methylbutyryl)-22-acetyl-derivative (hacquetiasaponin 4).

Oral contraceptives and pituitary response to GnRH: comparative study of progestin-related effects

GnRH double stimulation (2 X 25 micrograms i.v. at a two-hour interval) was used to assess the dynamics of LH and FSH release in 25 healthy women on oral contraceptives, all containing 50 micrograms of ethinylestradiol (EE). The study included two sequential regimens (50 micrograms EE X 7 days, 50 micrograms EE + 0.125 mg desogestrel X 15 days; 50 micrograms EE X 7 days, 50 micrograms EE + 2.5 mg lynestrenol X 15 days) and three combined preparations (biphasic: 50 micrograms EE + 1 mg norethisterone acetate (NETA) X 11 days, 50 micrograms EE + 2 mg NETA X 10 days; monophasic: 50 micrograms EE + 2 mg cyproterone acetate X 21 days; 50 micrograms EE + 2.5 mg lynestrenol X 21 days). The tests were always performed on days 19 to 21 of the first treatment cycle and compared to results obtained in normally cycling controls and in women receiving 50 micrograms EE daily alone. It was found that the EE-induced augmentation of pituitary responsiveness to GnRH is diminished by the addition of progestins. LH and FSH reactions to stimulation were both affected. The degree of inhibition depended not only on the chemical structure and daily dose of the progestin component, but also on the duration of its administration per treatment cycle.

Anti-estrogenic effects of contraceptive progestins on the dynamics of gonadotropin release

The hypophysiotropic effects of ethinylestradiol (EE) alone and in combination with three different progestins at various doses were assessed in 39 normal women. The compounds were given orally for 7 to 21 days. Serum LH and FSH were measured before and after GnRH double stimulation (2 x 25 micrograms i.v. at a two-hour interval); the ratio between second and first response served as an index of gonadotropin-synthesis capacity. Compared to pretreatment early follicular phase controls (LH and FSH ratios of 1.3 and 1.4), administration of 40 and 50 micrograms of EE daily elicited a significant amplification of LH and FSH synthesis (LH ratios of 2.2 and 3.3; FSH ratios of 2.8 and 3.3). By contrast, 80 micrograms of EE daily caused little change. The EE-induced rise of pituitary responsiveness to GnRH could be counteracted by the addition of progestins. The degree of inhibition as dependent on the type and dose of the progestational compound. It is concluded that the standardization GnRH double stimulation technique may serve as a pharmacodynamic model to quantitate the estrogenic and anti-estrogenic effects of contraceptive steroids at the pituitary level.

Serum levels of prolactin, TSH and gonadotrophins following LRH/TRH--double stimulation tests during the menstrual cycle

The objective of this study was to re-investigate the capacity of pituitary prolactin (Prl) and thyrotrophin (TSH) secretion throughout the normal menstrual cycle to respond to repeated thyrotrophin releasing hormone (TRH) stimulation analogous to the double luteinizing hormone-releasing hormone (LRH) stimulation test. This test has been shown to be a sensitive parameter for oestrogenic effects on the gonadotrophs. In addition, the volunteers were selected carefully on the basis of ovulatory cycles and otherwise normal endocrine function.

In 9 women a combined LRH/TRH double stimulation test was performed during the early follicular, periovulatory and mid-luteal phases. TRH (200 μg) and LRH (25 μg) each were given iv twice, 2 h apart.

Basal and LRH stimulated luteinizing hormone (LH) and follicle stimulating hormone (FSH) were found to follow characteristic cyclic response patterns. The LH responses after both LRH stimulations were greatest in the periovulatory phase; Δ1 and Δ2 were higher in the mid-luteal phase than in the follicular phase. Maximum FSH response to LRH was found during the periovulatory phase, but the FSH response in the early follicular phase was greater than that found in the mid-luteal phase. In contrast, basal and TRH stimulated serum concentrations of TSH and Prl remained constant throughout the cycle.

The gonadotrophin ratios Δ2:Δ1 were generally greater than 1. They increased from 1.4 in the early follicular phase to 3.0 in the late follicular phase, concomitant with the rise in oestrogens. The Δ2: Δ1 ratios for TSH and Prl were less than 1, ranging from 0.66 to 0.98 for TSH and from 0.26 to 0.99 for Prl. They did not show any cyclic changes.

Thus, this study shows that after LRH/TRH double stimulation, the gonadotrophin but not the Prl and TSH responses vary with the physiological changes in oestrogens during the menstrual cycle.

The supposed mechanism of oestrogen effects on pituitary hormone secretion and their possible clinical significance are discussed.

Repetitive intravenous TRH-stimulations at short intervals in euthyroid and hypothyroid subjects

In 17 euthyroid normal volunteers and 17 hypothyroid patients, serum concentrations of TSH, T3 and T4 were measured after multiple stimulations with TRH. All subjects received 6 TRH-injections (200 μg iv) at intervals of 2 h. Three euthyroid normal volunteers were stimulated 12 times with TRH in the same way.

The TSH response (ΔTSH) was significantly decreased (P<0.01) after the 4th injection, and after the 5th of 6th stimulation, it was significantly raised (P<0.02) compared with the 4th. In the case of the 12-fold stimulations, the ΔTSH also rose after the 9th or 10th injection compared with the response after the 8th of 9th.

In 5 of the 17 normals, the increase in ΔTSH observed after the 5th or 6th TRH-injection was greater than the ΔTSH after the first stimlation.

Serum T3 and T4 levels rose already after the first TRH-stimulation (P<0.01) and remained at these increased levels thereafter.

The hypothyroid patients also showed initial decrease of ΔTSH (P<0.01). The increase of the TSH-response to TRH, however, was observed after the 4th TRH-injection (P<0.05) rather than after the 5th or 6th, followed by another decrease of ΔTSH after the 5th stimulation (P = 0.02). In 11 of the 17 hypothyroid patients, there was a second increase of ΔTSH after the 6th TRH-stimulation. This second increase was greater than the first in 10 of the 11 subjects. Serum T3 and T4 levels in the hypothyroid subjects remained unchanged during the entire examination period.

From these results, it can be concluded that the cause for the TSH response pattern in TRH-stimulations repeated at brief intervals cannot be due to the feed-back of thyroid hormones, but rather to the activity of TSH-producing pituitary cells.