Hydrological benefits of filtering swales for metal removal

This paper studies the hydraulic performance of two swales composed of filters for stormwater management (filtering swales) in a large-scale experimental study and compares them to the performance of a swale composed of traditional bioretention soil (bioswale). Using experimental data, dimensionless formulations are derived to reflect the influence of swale design parameters on hydraulic performance. The developed formulas can be used to design swales accounting for practical factors for decision makers such as local rainfall patterns, volume capture requirements, and drainage area. The experimental data show that while the bioswale is characterized by large overland flows, the tested filtering swales manage, in the majority of cases, the complete inflow volume without overland flow. The longitudinal slope of the swales does not affect the infiltration capacity of the filtering swales for the tested experimental boundary conditions, only the inflow rate and media water content are found to be statistically significant. As an example, filtering swales tested in this study captured 90% of the runoff generated by a 12.2 mm/h storm (approximately a 5-year return period 1-h duration storm event in the city of Trondheim) on a road 40 times larger than the swale. This highlights the capacity of such swales for handling infrequent events.

Specificity of late-night salivary cortisol measured by automated electrochemiluminescence immunoassay for Cushing's disease in an obese population

PURPOSE

Data about the specificity of late-night salivary cortisol (LNSC) in obese subjects are still conflicting. Therefore, with this study, we aimed to evaluate the specificity of LNSC measurement in an obese cohort with or without type 2 diabetes mellitus (T2DM) using an automated electrochemiluminescence immunoassay (ECLIA).

METHODS

A total number of 157 patients involving 40 healthy subjects (HS) with BMI < 25 kg/m², 83 obese subjects (OS) with BMI ≥ 35 kg/m², and 34 histopathologically proven Cushing's disease (CD) were included. All patients underwent LNSC testing. Salivary cortisol was measured at 11 p.m. for all groups using an ECLIA. Reference range was established using values of LNSCs of HS and ROC curves were used to determine diagnostic cutoffs.

RESULTS

In the HS group, mean LNSC was 4.7 nmol/l (SD ± 3.1), while the OS group had a mean value of 10.9 nmol/l (SD ± 7.5) and the CD group of 19.9 nmol/l (SD ± 15.4). All groups differed significantly (p < 0.001). The ROC analysis of CD against HS alone showed a sensitivity of 85.3% and a specificity of 87.5% with a cut-off value of 8.3 nmol/l. The ROC analysis between OS and CD showed a maximum sensitivity of 67.6% and specificity of 78.3% for a cut-off value of 12.3 nmol/l. Taken both (HS and OS) groups together against the CD group, ROC analysis showed a maximum sensitivity of 67.6% and specificity of 85.4% for a cut-off value of 12.3 nmol/l. No correlation was found between BMI, T2DM, and LNSC for all groups.

CONCLUSIONS

In our obese cohort, we found that LNSC assayed by ECLIA had a low specificity in the diagnosis of CD.

Adaptive changes in pancreas post Roux-en-Y gastric bypass induced weight loss

BACKGROUND

Obesity has been shown to trigger adaptive increases in pancreas parenchymal and fat volume. Consecutively, pancreatic steatosis may lead to beta-cell dysfunction. However, it is not known whether the pancreatic tissue components decrease with weight loss and pancreatic steatosis is reversible following Roux-en-Y gastric bypass (RYGB). Therefore, the objective of the study was to investigate the effects of RYGB-induced weight loss on pancreatic volume and glucose homeostasis.

METHODS

Eleven patients were recruited in the Obesity Centre of the University Medical Centre Hamburg-Eppendorf. Before and 6 months after RYGB, total GLP-1 levels were measured during oral glucose tolerance test. To assess changes in visceral adipose tissue and pancreatic volume, MRI was performed. Measures of glucose homeostasis and insulin indices were assessed. Fractional beta-cell area was estimated by correlation with the C-peptide-to-glucose ratio; beta-cell mass was calculated by the product of beta-cell area and pancreas parenchymal weight.

RESULTS

Pancreas volume decreased from 83.8 (75.7-92.0) to 70.5 (58.8-82.3) cm³ (mean [95% CI], P = .001). The decrease in total volume was associated with a significant decrease in fat volume. Fasting insulin and C-peptide were lower post RYGB. HOMA-IR levels decreased, whereas insulin sensitivity increased (P = .03). This was consistent with a reduction in the estimated beta-cell area and mass.

CONCLUSIONS

Following RYGB, pancreatic volume and steatosis adaptively decreased to "normal" levels with accompanying improvement in glucose homeostasis. Moreover, obesity-driven beta-cell expansion seems to be reversible; however, future studies must define a method to more accurately estimate functional beta-cell mass to increase our understanding of glucose homeostasis after RYGB.

Safety and efficacy of pasireotide in dumping syndrome-results from a phase 2, multicentre study

BACKGROUND

Dumping syndrome is a prevalent complication of oesophageal and gastric surgery characterised by early (postprandial tachycardia) and late (hypoglycaemia) postprandial symptoms.

AIM

To evaluate efficacy and safety of the somatostatin analogue, pasireotide in patients with dumping syndrome after bariatric or upper gastrointestinal cancer surgery.

METHODS

A single-arm, open-label, multicentre, intrapatient dose-escalation, phase 2 study with 4 phases: screening, 3-month SC (subcutaneous), 3-month IM (intramuscular) and 6-month optional extension IM phase. Primary endpoint was the proportion of patients without hypoglycaemia (plasma glucose <3.3 mmol/L [60 mg/dL] during an oral glucose tolerance test, OGTT) at the end of 3-month SC phase. A ≥50% response rate was considered clinically relevant.

RESULTS

Forty-three patients with late dumping were enrolled; 33 completed the 3-month SC phase and 23 completed the 12-month study. The proportion of patients without hypoglycaemia at month 3 (primary endpoint) was 60.5% (26 of 43; 95% confidence interval, 44.4%-75.0%). Improvement in quality of life was observed during SC phase, which was maintained in the IM phase. The proportion of patients with a rise in pulse rate of ≥10 beats/min during OGTT reduced from baseline (60.5%) to month 3 (18.6%) and month 12 (27.3%). Overall (month 0-12), the most frequent (>20% of patients) adverse events were headache (34.9%); diarrhoea, hypoglycaemia (27.9% each); fatigue, nausea (23.3% each); and abdominal pain (20.9%).

CONCLUSION

These results suggest that pasireotide is a promising option in patients with dumping syndrome after bariatric or upper gastrointestinal cancer surgery.

Health-related Quality of Life in Patients After Treatment of Cushing's Disease

BACKGROUND

Patients suffering from Cushing's disease are known to be restricted due to a wide range of symptoms. Despite biochemical cure, symptoms might last life-long. These include - among well-known somatic symptoms - several neuropsychiatric symptoms that cannot be as easily tested, but lead to a serious negative impact on quality of life. We aimed to evaluate what factors diminish the self-perceived quality of life the most using 3 questionnaires visualizing those impairments. Furthermore we investigated whether there would be differences in quality of life between patients still being affected by the disease and those that are already in remission.

PATIENTS AND METHODS

We reviewed patient charts treated between April 2008 and June 2012 for Cushing's disease and sent 3 questionnaires to the patients for evaluation. For this purpose we used the SF-36, the BDI and the Tuebingen CD-25. 54 patients complied with our request and returned the completed questionnaires. The average time after surgery was 36 months.

RESULTS

In all 8 dimensions of the SF-36 significant differences between the patient collective and the expected age- and gender-specific scores could be observed and thus a detectable impairment in quality of life. The BDI revealed that every other patient suffering from Cushing's disease presented depressive symptoms, partially with clinical relevance. In all 6 dimensions of the Tuebingen CD-25 there were notable restrictions in patients. Those restrictions particularly concerned bodily restrictions and cognitive performance. The self-perceived quality of life of active patients was - although not statistically significant - in almost all measured fields worse than the test results of patients in remission after TSS.

CONCLUSION

Former and active Cushing's disease patients suffer from a wide range of neuropsychiatric symptoms. Those symptoms might dominate the clinical picture and lead to a serious impairment in quality of life as well as extend periods of suffering and might persist even years after being found healthy. Therefore it is important to evaluate quality of life as an independent factor in every patient being affected by Cushing's disease and to include a holistic view in their therapy. Concomitant therapeutic measures should be accessible at any time for Cushing's disease patients as the normalization of pathologically increased laboratory values doesn't obligatory lead to an improvement of the patients subjectively felt well-being.

Off-label antiobesity treatment in patients without diabetes with GLP-1 agonists in clinical practice

The aim of the work was to investigate whether continuation of treatment, side effects, and effect on weight loss of GLP-1 agonists in obese patients without diabetes are equally promising in daily clinical-practice-settings compared to controlled clinical trials. Obese patients without diabetes of our interdisciplinary obesity centre were treated off-label with GLP-1-agonists for different time periods. Application was started with low-dose and increased if side effects were tolerable. Monthly costs were € 125 for daily applications of 1.2 mg liraglutide or 10 μg exenatide twice daily. Data were obtained by telephone interviews about baseline characteristics, weight loss, sensation of satiation, duration of therapy, side effects, and reasons for discontinuation. Of 43 included cases (5 males, mean age 43±11 years, mean weight 107±24 kg, mean excess weight 35±21 kg) 7 were treated with exenatide and 36 with liraglutide. Excess weight loss in linear regression models was 6.7% per month (p <0.05) under control of age, sex, initial weight, and type of GLP-1 analogue treatment and did not significantly differ between liraglutide and exenatide. Overall, 58% of patients reported side effects mostly concerning the gastrointestinal tract. Surprisingly no patient reported vomiting. One patient developed a severe pancreatitis. At time of telephone interview only 30.2% were continuing treatment. Mean treatment duration was 2.98±2.71 months. Common reasons for discontinuation of treatment were no/little effect on weight loss (27.9%), intolerable side effects (20.9%), or financial reasons (14%). GLP-1 agonist treatment in obese patients without diabetes also correlates with significant weight loss in clinical practice. However, side effects and discontinuation of treatment are common. Therefore, long-term effect on weight loss might not be as promising as suggested by data from clinical trials.

Hyponatremia after trans-sphenoidal surgery

Fluid and electrolyte imbalances are the most frequent complications following pituitary surgery. Among the several patterns of occurrence, hyponatremia can occur in an isolated fashion or as part of a bi- or triphasic pattern. The frequency of hyponatremia after trans-sphenoidal surgery is between 2% and 25%, according to the literature. However, these numbers are probably underestimating the real prevalence, since mild hyponatremia does not lead to symptoms and measurement of sodium level. No association has been described between entity of the pituitary tumor or tumor size and hyponatremia. Therefore no predictors exist to determine patients with a higher risk for electrolyte imbalances after surgery. However, since delayed hyponatremia occurs mainly around the 8-10th day after surgery, routine measurement of sodium should be recommended on the day of hospital dismission. In case of a symptomatic hyponatremia, insufficiency of the corticotrophe pituitary function as the leading differential diagnosis needs to be ruled out. If the patient is euvoleme, pretest probability of syndrome of inadequate antidiuretic hormone production (SIADH) is very high and therapy may be started according to this. In case of SIADH, therapeutic options include fluid restriction or vaptane therapy. Only in severe cases infusion of hypertonic saline is appropriate. Usually SIADH following pituitary surgery is a self-limiting condition and will cease within 2-5 days.

DHEA(S)--a novel marker in Cushing's disease

INTRODUCTION

Dehydroepiandrosterone sulfate (DHEA(S)) is a multi-functional steroid implicated in a broad range of biological effects, including obesity, diabetes, bone metabolism, neuroprotection, and anti-tumorigenesis. It has not yet undergone wider research in the context of Cushing's disease. The objective of this study was to determine if perioperative blood levels of DHEA(S) correlate with levels of ACTH and cortisol, and therefore may be useful as a new, additional marker for the early definition of cure in patients suffering from Cushing's disease.

METHODS

Forty-two consecutive patients undergoing transsphenoidal surgery for Cushing's disease from September 2009 to September 2010 were perioperatively monitored for ACTH, cortisol, and DHEA(S).

RESULTS

Pre-operative blood samples revealed ACTH levels of median 65 ng/l (range 11-1,183 ng/l, standard deviation 183.76), cortisol of median 257 μg/l (range 93-803 μg/l, standard deviation 140.88), and DHEA(S) of median 2.22 mg/l (range 0.44-7.79 mg/l, standard deviation 1.82) according to the pathology of Cushing's disease. Postoperative blood samples drawn over a 7-day time span showed a drop in median ACTH to just 14.5 % (median: 9 ng/l, range 2-44, standard deviation 12.75) of its median preoperative figure. Median cortisol levels were reduced to 6.9 % (median: 18 μg/l, range 10-190 μg/l, standard deviation 38.04) of their preoperative values and DHEA(S) levels decreased to 17 % (median: 0.38 mg/l, range 0.05-2.29, standard deviation 0.51). In persistent disease, no patient showed a drop in DHEA(S) below 38 % of its preoperative figures.

CONCLUSIONS

DHEA(S) shows the potential to become an additional marker in the diagnosis and follow-up of patients. However, it needs to be examined further, including whether DHEA(S) may also be a useful predictor of recovery of the HPA-axis after successful surgery.

Resequencing the apolipoprotein A5 (APOA5) gene in patients with various forms of hypertriglyceridemia

OBJECTIVE

Genomewide association studies (GWAS), conventional association studies and the characterization of families with ApoA5 deficiency have shown that variation in the apolipoprotein A5 (APOA5) gene is associated with plasma triglyceride levels. The aim of this study was to determine the frequency of rare variants in the APOA5 gene in patients with various forms of hypertriglyceridemia.

METHODS

The DNA sequence of the exons plus exon/intron boundaries of the APOA5 gene of 291 patients with triglycerides above the 95th percentile for age and sex (98 of whom had triglycerides above 875 mg/dl), 111 patients with APOE2/2 genotype of whom 100 had Type III Hyperlipidemia and 108 probands with triglycerides below the 25th percentile for age and sex was determined.

RESULTS

Twenty four variants were detected of which eight have been previously reported. There were nine patients with triglycerides above 875 mg/dl and nine patients with moderately elevated triglycerides who were carriers of at least one deleterious mutation in the APOA5 gene. Of the patients with Type III HLP, three (3%) were carriers of rare variants and there was a single rare variant detected in the group of probands with triglycerides below the 25th percentile for age and sex.

CONCLUSION

Rare mutations in the APOA5 gene are more frequent in patients with elevated triglycerides than in those with Type III HLP.

Metformin after bariatric surgery--an acid problem

Metformin is the oral drug of first choice in type 2 diabetes. Therefore a large number of patients undergoing bariatric surgery will be on Metformin treatment. However, use of Metformin has been associated with lactate acidosis. Weight loss following bariatric surgery is most pronounced during the first weeks after the operation and this creates a phase of negative energy balance with ketone body formation. To shed more light on this situation we measured ketone bodies in 90 patients 5 days-18 months after bariatric surgery. Ketone bodies were markedly elevated during the first 3-4 months. Metformin use should therefore be critically reconsidered after bariatric operations.

[Hypertension and hypokalemia - a reninoma as the cause of suspected liquorice-induced arterial hypertension]

HISTORY AND CLINICAL FINDINGS

A 28-year-old woman presented with dizziness and arterial hypertension. She reported a daily intake of 300 mg liquorice.

INVESTIGATIONS

Laboratory analysis revealed hypokalaemia of 2.5 mmol/l and an elevated serum renin activity of 18.6 µg/l/h. Abdominal ultrasound and magnetic resonance imaging showed a circumscribed non-homogenuous round lesion (18 × 22 mm) in the upper third of the right kidney. Selective catheterization of the renal veins revealed increased renin activity in blood from the right renal vein, suggestive of a renin-producing tumor.

TREATMENT AND COURSE

Initially antihypertensive therapy with the direct renin receptor antagonist aliskiren was started and followed by a partial nephrectomy, which brought about adequate blood pressure and potassium levels.

CONCLUSION

The constellation of hypokalaemia and hypertension often leads to important causes of secondary hypertension such as primary hyperaldosteronism or renal artery stenosis. But less frequent causes should also be considered in the differential diagnoses, such as liquorice overindulgence or reninoma.

Rare variants in the lipoprotein lipase (LPL) gene are common in hypertriglyceridemia but rare in Type III hyperlipidemia

OBJECTIVE

Genomewide association studies (GWAS) have shown that variation in the lipoprotein lipase gene (LPL) is associated with plasma triglyceride levels but that common variants account for only 1.25% of the variance. The aim of this study was to determine the frequency of rare variants in the LPL gene in patients with various forms of hypertriglyceridemia.

METHODS

The DNA sequence of the exons plus exon/intron boundaries of the LPL gene of 313 patients with triglycerides above the 95th percentile for age and sex (107 of whom had triglycerides above 875 mg/dl) and 121 patients with Type III hyperlipidemia was determined.

RESULTS

Twenty rare variants were detected of which seven have been previously reported. All of the rare variants were present as heterozygotes. Sixteen were missense mutations, two were short deletion mutants and there were single nonsense and insertion mutations. Fifteen of the missense mutations resulted in an amino acid change. There were 13 patients (12.1%) with triglycerides above 875 mg/dl and 10 patients (4.9%) with moderately elevated triglycerides, who were carriers of at least one rare, non-synonymous mutation in the LPL gene. Of the patients with Type III HLP, two were carriers of rare variants.

CONCLUSION

Rare mutations in the LPL gene are frequent in patients with elevated triglycerides.

Very high prevalence of thyroid nodules detected by high frequency (13 MHz) ultrasound examination

BACKGROUND

The prevalence of thyroid nodules in a healthy population is high: in the German Papillon study, nationwide ultrasound screening of more than 90 000 people using 7.5 MHz scanners revealed the presence of thyroid nodules in 33% of the normal population. A study employing more sensitive 13 MHz scanners has not been conducted so far.

MATERIALS AND METHODS

Six hundred and thirty-five consecutive patients (33% female, 67% male, mean 56.7 years) presenting for a preventive health check up underwent ultrasound screening of the thyroid gland (Siemens Acuson Antares, 13 MHz-linear scanner, B-mode and Power mode) and measurement of the basal TSH (thyroid stimulating hormone) value. Size and degree of vascularization of the thyroid gland and of nodules were determined and analysed retrospectively.

RESULTS

In 432 of 635 patients, thyroid nodules could be detected with an increasing incidence with age, in 338 without goiter. Mean thyroid size was 12.3 mL for women and 20.5 mL for men correlating strongly with body weight. Fifty-three percentage of the nodules were smaller than 5 mm. Incidence of thyroid dysfunction was only 4%. No cancerous lesions could be found.

CONCLUSIONS

Using the 13 MHz technology, we found a substantially higher prevalence of thyroid nodules (68%) than the Papillon study (33%). Even if our population is older than in Papillon, the difference remains in comparable age groups. This is due to the higher sensitivity of 13 MHz scanning. Our study underlines the clinical significance of iodine deficiency and should renew the discussion on routine iodine supplementation.

[Operative technique and outcome in metabolic surgery: conventional and banded gastric bypass]

BACKGROUND

The prevalence of morbid obesity and its sequelae is increasing in Germany, Europe and worldwide. Bariatric surgery is thus gaining in importance for the treatment of patients with malignant obesity. Creation of a gastric bypass is one of the most frequently performed procedures for obesity.

DISCUSSION

The gastric bypass has been used -since 1966 as a surgical means of weight reduction in obese patients. In the mean time various modifications have been developed. Thus, for example, the laparoscopic procedure represents the current standard. After the operation most patients experience an excess weight loss (EWL) of between 61 and 83 %. The comorbidities of obesity are also markedly improved and in a high percentage even cured after the operation. It is worthy of note that diabetes mellitus type II improves shortly after the operation even before any weight loss has occurred. The suggests that the operation induces more than "just" a loss of weight.

CONCLUSION

For decades the gastric bypass has been a well known standard operation of overweight and, in addition to the reduction in weight, is also a therapy for diabetes mellitus -type II.

Genetic variation in two proteins of the endocannabinoid system and their influence on body mass index and metabolism under low fat diet

The endocannabinoid system (ECS) plays an important and not yet fully understood role in hypothalamic and peripheral regulation of food intake, obesity, and metabolism. Two frequent single nucleotide polymorphisms (snp) have been identified in members of the ECS: the 1359 G/A variant in the cannabinoid receptor 1 ( CB1) and the P129T polymorphism in fatty acid amide hydrolase ( FAAH), a key degradation enzyme of endocannabinoids. -While for the 1359 G/A variant an association has been shown only with psychiatric diseases such as drug-abusing schizophrenia, the P129T polymorphism has recently been proved to be correlated to a higher body mass index (BMI) in a group of black and white Americans. However, no knowledge exists as to whether these variants affect the outcome of a low fat diet in obese subjects. Therefore, we genotyped a group of 451 obese and dyslipidaemic participants and observed the biometric and metabolic outcome of a 6 week low fat diet. While no significance was seen for the 1359 G/A variant, carriers of the P129T mutation in FAAH had a significantly greater decrease in triglycerides and total cholesterol as compared to wild type. The reason for our findings remains to be elucidated, however, a hepatic downregulation of endocannabinoid tone may contribute to the observed outcome in studied subjects.

[A sizeable chance--surgical management of profound obesity concurrent with post-traumatic osteoarthrosis]

In times of plentiful nutrition an environmental advantage turns into a problem - obesity. Apart from an increase in morbidity and overall mortality the development of osteoarthrosis is well documented. Pre-arthrotic conditions may arise from trauma and can lead, depending on the pattern of injury, to full-blown arthrosis. The presence of obesity can play the role of a relevant progressive factor in this setting. Here we report about the case of an obese man (BMI 53.5 kg/m(2)), who suffered a fracture of the femoral head with acetabular participation (Pipkin IV) as well as a fracture of the tibial plateau. Operative management and rehabilitation were followed by gastric bypass surgery for weight reduction. The case is discussed with regard to the present literature.

Association of peroxisome proliferator-activated receptor delta +294T/C with body mass index and interaction with peroxisome proliferator-activated receptor alpha L162V

OBJECTIVE

To investigate the association of a polymorphism at position 294 (+294T/C) in the Peroxisome Proliferator-activated Receptor delta (PPARdelta) with body mass index (BMI) and the additional role of a gene-to-gene interaction between PPARdelta, PPARalpha and PPARgamma.

DESIGN

An association between genetic variations in PPARdelta, PPARalpha and PPARgamma and indices of obesity and metabolism.

SUBJECTS

A group of 462 moderately obese (mean BMI 28.9+/-7.7) and dyslipidemic, middle-aged (mean age 43.9+/-13.7), Caucasion men and women.

MEASUREMENTS

The three most frequent single-nucleotide-polymorphisms (snp) in PPARdelta (+294T/C), PPARalpha (L162V) and PPARgamma (P12A) were genotyped and associated with clinical parameters.

RESULTS

The C allele in PPARdelta was significantly associated with a lower body mass index. Moreover an interaction between the polymorphisms in PPARalpha and PPARdelta on body weight could be demonstrated.

CONCLUSION

Our data provide further evidence for an involvement of PPARdelta in the regulation of BMI.

An unusual cause of acute lower gastrointestinal bleeding

A 45 year old male patient was referred to hospital after syncope during defaecation. Rapid peranal blood loss occurred shortly after admission. Gastroscopy and coloscopy performed as first line diagnostic measures failed to detect the source of haemorrhage. Ultrasound (US) revealed a hypoechoic and hypervascularized tumor mass in the right lower abdomen. A gastrointestinal stromal tumor (GIST) of the jejunum was diagnosed after laparatomy. Collectively US should be among the first line diagnostic procedures in younger patients presenting with lower gastrointestinal haemorrhage.

A polymorphism in the apolipoprotein A5 gene is associated with weight loss after short-term diet

Apolipoprotein A5 is a recently discovered apolipoprotein involved primarily in triglyceride metabolism. Several single-nucleotide polymorphisms have been investigated since the initial report. The -1131T>C polymorphism has been associated with higher triglyceride levels and a decreased high-density lipoprotein cholesterol as well as with susceptibility to coronary heart disease. However, no study has so far emphasized on the association of a dietary intervention with apolipoprotein A5 polymorphisms. In a group of 606 hyperlipaemic and overweight men, we investigated how a short-term fat restriction affects lipid traits and body mass index (BMI) in wildtype and carriers of the -1131T>C polymorphism. Our result was that the reduction of BMI was significantly higher in C allele carriers (p=0.0021). Since the -1131T>C polymorphism predisposes to coronary heart disease, a restriction diet is an important therapeutic approach in -1131T>C carriers.

Expression of cytokeratin-18-related tissue polypeptide-specific (TPS) antigen in Wilms tumor

BACKGROUND

So far, there is no approved tumour marker for diagnosis or follow-up in Wilms tumour (WT). Tissue polypeptide-specific antigen (TPS), a cytokeratin 18 proteolytic fragment, has been suggested to be of value in the clinical management of WT patients. Cytokeratin 18 fragments are an early indicator of apoptosis and cytokeratin 18 might influence tumour cell behaviour. We investigated TPS expression in specimens of WT and other paediatric renal malignancies

PROCEDURE

Immunoreactivity of WT sections (n = 9), clear cell sarcomas (CCSK, n = 3), and a renal cell carcinoma (RCC), and two pediatric kidney tumour cell lines (WT: SK-NEP-1 and rhabdoid tumour of the kidney: G-401) were investigated using the monoclonal antibody M3. Additionally, immunoblotting and RT-PCR analysis were performed. Cell culture supernatants were evaluated for TPS release. Serum TPS was measured in five patients at diagnosis, during chemotherapy and after surgical resection.

RESULTS

Moderate to strong immunoreactivity for TPS was found in tubular and blastemal components of nearly all (8/9) WT specimens. This was confirmed by Western-blotting. Cystic and epithelial-like portions of CCSKs and RCC showed distinct reactivity (3/3). The supernatant of G-401 but not of SK-NEP-1 showed a time- and cell number-dependent increase of TPS release. Interestingly, TPS synthesis was demonstrated in SK-NEP-1 cells. Median preoperative serum TPS was elevated (293 U/l) compared to healthy children and lowest after surgical resection (49.5 U/l).

CONCLUSIONS

This is the first study demonstrating the synthesis and release of TPS by WTs and other paediatric renal malignancies. Considering the elevated levels of TPS in serum of these patients, a further investigation of this marker by larger clinical trials seems to be justified.

A polymorphism, L162V, in the peroxisome proliferator-activated receptor alpha (PPARalpha) gene is associated with lower body mass index in patients with non-insulin-dependent diabetes mellitus

This study examined the effect a polymorphism (L162V) in the gene for peroxisome proliferator activated receptor (PPAR) alpha in the development of non-insulin-dependent diabetes mellitus (type 2 DM), obesity and hyperlipidaemia. The frequency of the L162V polymorphism in the PPARalpha gene was determined in 370 morbidly obese patients who underwent gastric banding surgery, 154 patients attending a type 2 DM clinic, 188 patients attending a lipid clinic and 199 healthy blood donors. The overall frequency of the V allele of the L162V polymorphism was 0.06. There were no significant differences in the allele frequency between patients with morbid obesity, hyperlipidaemia, type 2 DM and healthy controls, suggesting that it does not play a major role in the development of these conditions. The polymorphism was associated with a lower body mass index (BMI) in two independently recruited groups of patients with type 2 DM. There was no effect of the polymorphism on subjects without type 2 DM. Thus a polymorphism in PPARalpha protects type 2 DM patients from the overweight which is frequently associated with their condition.

[Progressive familial intrahepatic cholestasis (Byler disease): current genetics and therapy]

Progressive familial intrahepatic cholestasis (PFIC) is a congenital liver disease. First symptoms can frequently be seen shortly after birth. Quality and expectation of life are substantially reduced due to severe pruritus and the complications of progressive liver cirrhosis. PFIC is diagnosed on the basis of characteristic clinical and laboratory parameters and genetic analysis after exclusion of other liver diseases leading to intrahepatic cholestasis. Medical therapy is only effective in a proportion of children with PFIC. Partial biliary diversion (PBD) is nowadays considered the therapy of choice in patients with therapy-refractive pruritus. If performed in time, damage to the liver can be delayed or arrested, thus orthotopic liver transplantation (OLT) can be postponed or even avoided in at least some patients with PFIC. Besides providing a current overview of PFIC, we report on three patients who were successfully treated surgically. One patient was subjected to a new technique of PBD (cholecysto-appendicostomy), the other two had OLT.