Medizin - Open Access LMU - Teil 20/22

Favre-Racouchot disease commonly presents as comedones, cysts andelastosis in the periocular region of older men. Its etiology has beenlinked to several exogenous factors. Here we present 2 patients withstrictly unilateral manifestation of the disease and a correspondinghistory of predominantly one-sided chronic occupational sun exposure andsmoking, making the case for the causative role of these two factors.

The International Consensus Conference on the treatment of primary breast cancer takes place every two years in St. Gallen, Switzerland.The panel in St. Gallen is composed of international experts from different countries. From a German perspective, it seems reasonable to interpret the voting results in the light of AGO-recommendations and S3-guidelines for everyday practice in Germany. Consequently, a team of eight breast cancer experts, of whom two are members of the international St. Gallen panel, commented on the voting results of the St. Gallen Consensus Conference (2013). The main topics at this year’s St. Gallen conference were surgical issues of the breast and axilla, radio-therapeutic and systemic treatment options, and the clinical relevance of tumour biology. The clinical utility of multigene assays for supporting individual treatment decisions was also intensively discussed.

Background: Adjuvant treatment decision-making based on conventional clinical/pathological and prognostic single molecular markers or genomic signatures is a therapeutic area in which over-/under-treatment are still key clinical problems even though substantial and continuous improvement of outcome has been achieved over the past decades. Response to therapy is currently not considered in the decision-making procedure. ADAPT is one of the first new generation (neo) adjuvant trials dealing with individualization of (neo) adjuvant decision-making in early breast cancer and aims to establish early predictive surrogate markers, e. g., Ki-67, for therapy response under a short induction treatment in order to maximally individualize therapy and avoid unnecessary toxicity by ineffective treatment. Methods/design: The prospective, multi-center, controlled, non-blinded, randomized, investigator initiated phase II/III ADAPT trial has an innovative ``umbrella{''} protocol design. The ``umbrella{''} is common for all patients, consisting of dynamic testing of early therapy response. ADAPT will recruit 4,936 patients according to their respective breast cancer subtype in four distinct sub-trials at 80 trial sites in Germany; 4,000 patients with hormone receptor positive (HR+) and HER2 negative disease will be included in the ADAPT HR+/HER2-sub-trial, where treatment decision is based on risk assessment and therapy response to induction therapy, and 380 patients will be included in ADAPT HER2+/HR+. A further 220 patients will be included in ADAPT HER2+/HR- and 336 patients will be recruited for ADAPT Triple Negative. These three sub-trials focus on identification of early surrogate markers for therapy success in the neoadjuvant setting. Patients will be allocated to the respective sub-trial according to the result of their diagnostic core biopsy, as reported by local/central pathology for HR and HER2 status. Discussion: Recent trials, such as the GeparTrio, have shown that response-guided therapy using clinical response may improve outcome. For chemotherapy or HER2-targeted treatment, pathologic complete response in a neoadjuvant setting is an excellent predictor of outcome. For endocrine therapy, response to short induction treatment - as defined by decrease in tumor cell proliferation - strongly correlates with outcome. ADAPT now aims to combine static prognostic and dynamic predictive markers, focusing not just on single therapeutic targets, but also on general markers of proliferation and cell death. Biomarker analysis will help to optimize selection of subtype-specific treatment. Trial registration: ClinicalTrials.gov: ADAPT Umbrella: NCT01781338; ADAPT HR+/HER2-: NCT01779206; ADAPT HER2+/HR+: NCT01745965; ADAPT HER2+/HR-: NCT01817452; ADAPT TN: NCT01815242.

Tue, 1 Jan 2013 12:00:00 +0100 https://epub.ub.uni-muenchen.de/21771/1/10_1159_000357416.pdf Harbeck, Nadia; Thomssen, Christoph

Background: GLP-1 is an incretine hormone which gets secreted from intestinal L-cells in response to nutritional stimuli leading to pancreatic insulin secretion and suppression of glucagon release. GLP-1 further inhibits gastric motility and reduces appetite which in conjunction improves postprandial glucose metabolism. Additional vasoprotective effects have been described for GLP-1 in experimental models. Despite these vasoprotective actions, associations between endogenous levels of GLP-1 and cardiovascular disease have yet not been investigated in humans which was the aim of the present study. Methods: GLP-1 serum levels were assessed in a cohort of 303 patients receiving coronary CT-angiography due to typical or atypical chest pain. Results: GLP-1 was found to be positively associated with total coronary plaque burden in a fully adjusted model containing age, sex, BMI, hypertension, diabetes mellitus, smoking, triglycerides, LDL-C (low density lipoprotein cholesterol), hsCRP (high-sensitive C-reactive protein), and eGFR (estimated glomerular filtration rate) (OR: 2.53 (95% CI: 1.12 - 6.08; p = 0.03). Conclusion: Circulating GLP-1 was found to be positivity associated with coronary atherosclerosis in humans. The clinical relevance of this observation needs further investigations.

In 1994, in a prospective control trial in cyclosporine-treated, kidneytransplant patients, we observed that treatment of a non-specificallograft injury (postischemic reperfusion injury) leads to asignificant reduction in the incidence of both specificalloimmune-mediated allograft rejection and chronic allograft failure. From these convincing clinical data, we concluded in terms of an‘argumentum e contrario’: it is the tissue injury that induces immunity. As from where we stand today in innate immunity research, these earlyclinical observations can be regarded as the discovery of the existence of a human innate immune system activated by tissue injury and precedingadaptive immunity.

Background: The obesity epidemic has resulted in more overweight/obesewomen before and during pregnancy. Their offspring tend to have higherbirth weights and more body fat, and carry an increased risk of obesitylater in life. These effects may partly be related to the heightenedrisk of gestational diabetes, occurring in at least 16% of allpregnancies irrespective of current body weight. Methods: An ILSI Europeworkshop reviewed the key contributors leading to adverse outcomes inpregnancy and childhood, including gestational weight gain andnutrition. New research opportunities from prospective mother-childcohort studies were explored. Results: Simple measures of gestationalweight gain provide insufficient detail of the underlying physiologicaland metabolic adaptations occurring in pregnancy, and should becomplemented by measures of body composition, metabolic and endocrineresponses. Recordings of maternal dietary intake and nutrient status areoften limited and potential correlations with gestational weight gainhave been poorly studied. Many pregnancies in overweight/obese women areuncomplicated and result in offspring of normal weight, leaving the maindeterminants of later adverse outcomes to be clarified. Conclusions: Theworkshop provided insights of primary measurements for thecharacterization of sustainable nutritional intervention strategies inthe mother, infant and child for preventing obesity in later life.

The independent evolution of heteromorphic sex chromosomes in 19 speciesfrom 4 families of flowering plants permits studying X/Y divergenceafter the initial recombination suppression. Here, we documentautosome/Y divergence in the tropical Cucurbitaceae Coccinia grandis,which is ca. 3 myr old. Karyotyping and C-value measurements show thatthe C. grandis Y chromosome has twice the size of any of the otherchromosomes, with a male/female C-value difference of 0.094 pg or 10%of the total genome. FISH staining revealed 5S and 45S rDNA sites onautosomes but not on the Y chromosome, making it unlikely that rDNAcontributed to the elongation of the Y chromosome; recent end-to-endfusion also seems unlikely given the lack of interstitial telomericsignals. GISH with different concentrations of female blocking DNAdetected a possible pseudo-autosomal region on the Y chromosome, andC-banding suggests that the entire Y chromosome in C. grandis isheterochromatic. During meiosis, there is an end-to-end connectionbetween the X and the Y chromosome, but the X does not otherwise differfrom the remaining chromosomes. These findings and a review of plantswith heteromorphic sex chromosomes reveal no relationship betweenspecies age and degree of sex chromosome dimorphism. Its relativelysmall genome size (0.943 pg/2C in males), large Y chromosome, andphylogenetic proximity to the fully sequenced Cucumis sativus make C.grandis a promising model to study sex chromosome evolution.

Background: Fueled by rapid progress in high-throughput sequencing, the size of public sequence databases doubles every two years. Searching the ever larger and more redundant databases is getting increasingly inefficient. Clustering can help to organize sequences into homologous and functionally similar groups and can improve the speed, sensitivity, and readability of homology searches. However, because the clustering time is quadratic in the number of sequences, standard sequence search methods are becoming impracticable. Results: Here we present a method to cluster large protein sequence databases such as UniProt within days down to 20%-30% maximum pairwise sequence identity. kClust owes its speed and sensitivity to an alignment-free prefilter that calculates the cumulative score of all similar 6-mers between pairs of sequences, and to a dynamic programming algorithm that operates on pairs of similar 4-mers. To increase sensitivity further, kClust can run in profile-sequence comparison mode, with profiles computed from the clusters of a previous kClust iteration. kClust is two to three orders of magnitude faster than clustering based on NCBI BLAST, and on multidomain sequences of 20%-30% maximum pairwise sequence identity it achieves comparable sensitivity and a lower false discovery rate. It also compares favorably to CD-HIT and UCLUST in terms of false discovery rate, sensitivity, and speed. Conclusions: kClust fills the need for a fast, sensitive, and accurate tool to cluster large protein sequence databases to below 30% sequence identity. kClust is freely available under GPL at ftp://toolkit.lmb.uni-muenchen.de/pub/kClust/.

Tue, 1 Jan 2013 12:00:00 +0100 https://epub.ub.uni-muenchen.de/21775/1/10_1159_000350712.pdf Soehnlein, Oliver ddc:610, Medizin 0

It still remains unclear to which extent the presence and the amount ofretinal debris seen in internal limiting membrane (ILM) specimensharvested during macular surgery for macular holes or epiretinalmembranes are related to the procedure of ILM peeling itself or tomodifications of the surgical technique, such as application of vitaldyes for visualization of the ILM, or to pathological conditions withepiretinal membrane formation at the vitreoretinal interface. Thepresence of cellular fragments on the retinal side of the removed ILMappears to be of multifactorial origin, and additional causes besidesdye application need to be considered. However, morphological studieswith evaluation of vital dyes are still of relevance and provideadditional insights into the ultrastructure of the vitreoretinalinterface and its interaction with adjuvants used during macularsurgery. Chromovitrectomy is an emerging field in vitreoretinal surgery.It is of importance to better understand the tissue-dye interactions,which not only alter the mechanical properties of the tissue beingstained, but may also have an impact on the functional resultpostoperatively.

Background: The FHIT tumor suppressor gene is arguably the most commonly altered gene in cancer since it is inactivated in about 60% of human tumors. The Fhit protein is a member of the ubiquitous histidine triad proteins which hydrolyze dinucleoside polyphosphates such as Ap(3)A. Despite the fact that Fhit functions as a tumor suppressor, the pathway through which Fhit inhibits growth of cancer cells remains largely unknown. Phosphorylation by Src tyrosine kinases provides a linkage between Fhit and growth factor signaling. Since many G proteins can regulate cell proliferation through multiple signaling components including Src, we explored the relationship between G alpha subunits and Fhit. Results: Several members of the G alpha(q) subfamily (G alpha(16), G alpha(14), and G alpha(q)) were found to co-immunoprecipitate with Fhit in their GTP-bound active state in HEK293 cells. The binding of activated G alpha(q) members to Fhit appeared to be direct and was detectable in native DLD-1 colon carcinoma cells. The use of G alpha(16/z) chimeras further enabled the mapping of the Fhit-interacting domain to the alpha 2-beta 4 region of G alpha(16). However, G alpha(q)/Fhit did not affect either Ap(3)A binding and hydrolysis by Fhit, or the ability of G alpha(q/16) to regulate downstream effectors including phospholipase C beta, Ras, ERK, STAT3, and IKK. Functional mutants of Fhit including the H96D, Y114F, L25W and L25W/I10W showed comparable abilities to associate with G alpha(q). Despite the lack of functional regulation of G(q) signaling by Fhit, stimulation of G(q)-coupled receptors in HEK293 and H1299 cells stably overexpressing Fhit led to reduced cell proliferation, as opposed to an enhanced cell proliferation typically seen with parental cells. Conclusions: Activated G alpha(q) members interact with Fhit through their alpha 2-beta 4 region which may result in enhancement of the growth inhibitory effect of Fhit, thus providing a possible avenue for G protein-coupled receptors to modulate tumor suppression.

Background/Aims: Since detection of the prion protein gene (PRNP) morethan 30 mutations have been discovered. Some have only been found insingle case reports without known intrafamilial accumulation orneuropathological proof so that the causal connection between mutationand disease could not be proved. Those patients often present atypicalclinical phenotypes, and it is not unusual that they are classified asdiseases other than Creutzfeldt-Jakob disease (CJD). Methods: Cases ofsuspected CJD have been reported to the national reference center forprion diseases. Clinical and diagnostic data were collected, and aclassification of definite, possible or probable prion disease was made.Molecular analysis of PRNP was performed by capillary sequencing.Results: We have described 4 cases with atypical clinical and diagnosticfindings and unknown mutations in PRNP so far. Conclusion: Threepatients fulfilled the criteria of probable CJD, and 1 patient fulfilledthe criteria of possible CJD but the clinical picture in none of thepatients was typical CJD; hence, it remained questionable whether themutations were causal of the disease.

Introduction: During the last decade, a number of meta-analyses questioned the clinically relevant efficacy of antidepressants. Part of the debate concerned the method used in each of these meta-analyses as well as the quality of the data set. Materials and methods: The Kirsch data set was analysed with a number of different methods, and eight key questions were tackled. We fit random effects models in both Bayesian and frequentist statistical frameworks using raw mean difference and standardised mean difference scales. We also compare between-study heterogeneity estimates and produce treatment rank probabilities for all antidepressants. The role of the initial severity is further examined using meta-regression methods. Results: The results suggest that antidepressants have a standardised effect size equal to 0.34 which is lower but comparable to the effect of antipsychotics in schizophrenia and acute mania. The raw HDRS difference from placebo is 2.82 with the value of 3 included in the confidence interval (2.21-3.44). No role of initial severity was found after partially controlling for the effect of structural (mathematical) coupling. Although data are not definite, even after controlling for baseline severity, there is a strong possibility that venlafaxine is superior to fluoxetine, with the other two agents positioned in the middle. The decrease in the difference between the agent and placebo in more recent studies in comparison to older ones is attributed to baseline severity alone. Discussion: The results reported here conclude the debate on the efficacy of antidepressants and suggest that antidepressants are clearly superior to placebo. They also suggest that baseline severity cannot be utilized to dictate whether the treatment should include medication or not. Suggestions like this, proposed by guidelines or institutions (e.g. the NICE), should be considered mistaken.

Background: The assessment of personality organization and its observable behavioral manifestations, i.e. personality functioning, has a long tradition in psychodynamic psychiatry. Recently, the DSM-5 Levels of Personality Functioning Scale has moved it into the focus of psychiatric diagnostics. Based on Kernberg's concept of personality organization the Structured Interview of Personality Organization (STIPO) was developed for diagnosing personality functioning. The STIPO covers seven dimensions: (1) identity, (2) object relations, (3) primitive defenses, (4) coping/rigidity, (5) aggression, (6) moral values, and (7) reality testing and perceptual distortions. The English version of the STIPO has previously revealed satisfying psychometric properties. Methods: Validity and reliability of the German version of the 100-item instrument have been evaluated in 122 psychiatric patients. All patients were diagnosed according to the Diagnostic and Statistical Manual for Mental Disorders (DSM-IV) and were assessed by means of the STIPO. Moreover, all patients completed eight questionnaires that served as criteria for external validity of the STIPO. Results: Interrater reliability varied between intraclass correlations of .89 and 1.0, Crohnbach's a for the seven dimensions was .69 to .93. All a priori selected questionnaire scales correlated significantly with the corresponding STIPO dimensions. Patients with personality disorder (PD) revealed significantly higher STIPO scores (i.e. worse personality functioning) than patients without PD; patients cluster B PD showed significantly higher STIPO scores than patients with cluster C PD. Conclusions: Interrater reliability, Crohnbach's a, concurrent validity, and differential validity of the STIPO are satisfying. The STIPO represents an appropriate instrument for the assessment of personality functioning in clinical and research settings.

Tue, 1 Jan 2013 12:00:00 +0100 https://epub.ub.uni-muenchen.de/21778/1/10_1159_000353617.pdf Müller, Volkmar; Harbeck, Nadia; Thomssen, Christoph; Scharl, Anton

Despite ongoing controversial expert discussions the European Medicines Agency (EMA) recently recommended to suspend marketing authorisations for hydroxyethyl starch. This comment critically evaluates the line of arguments. Basically, the only indication for a colloid is intravascular hypovolemia. Crystalloid use appears reasonable to compensate ongoing extracellular losses beyond. In the hemodynamically instable patient this leads to the distinction between an initial resuscitation phase where colloids might be indicated and a crystalloidal maintenance phase thereafter. It is important to bear this in mind when reevaluating the studies the EMA referred to in the context of its recent decision: i) VISEP compared ringer's lactate to 10% HES 200/0.5 in septic patients and found an increased incidence of renal failure in HES receivers. Unfortunately, study treatment was started only after initial stabilization with HES, randomizing hemodynamically stable patients into a rational (crystalloids) and an irrational (high dose starch until ICU discharge) maintenance treatment. ii) 6S compared ringer's acetate to 6% HES 130/0.42 for fluid resuscitation in septic patients and found an increased need of renal replacement therapy and a higher mortality in the HES group. However, patients of both groups were again randomized only after initial stabilization with colloids, the actual comparison was, therefore, again rational vs. irrational. Beyond that, the documentation is partly fragmentary, leaving many important questions around the fate of the patients unanswered. iii) CHEST randomized ICU patients to receive saline or 6% HES 130/0.4 for fluid resuscitation. Actually, despite partly discussed in a different way, this trial showed no relevant differences in outcome. In all, two studies showed what happens to septic patients if starches are used in a way we do not observe in daily practice. The third one actually proves their safety. The benefit of perioperative goal-directed preload optimization using starches is unquestioned. Taking these informations into account, the recommendation of the EMA starches to be generally dangerous remains mysterious and incomprehensible. An authority being able to dictate behavior should stand clear from oppressively ending a worldwide expert discussion and step back into the role of the observer until science achieves an agreement.

Background: Common cell based strategies for the treatment of osseous defects require the isolation and expansion of autologous cells. Since this makes such approaches time-consuming and expensive, we developed a novel expedited technology creating gene activated muscle grafts. We have previously shown that large segmental bone defects in rats can be regenerated by implantation of muscle tissue fragments activated by BMP-2 gene transfer. Results: In the present study, we compared the bone healing capacities of such gene activated muscle grafts with bone isografts, mimicking autologous bone grafting, the clinical gold standard for treatment of bone defects in patients. Two of 14 male, syngeneic Fischer 344 rats used for this experiment served as donors for muscle and bone. Muscle tissue was harvested from both hind limbs and incubated with an adenoviral vector carrying the cDNA encoding BMP-2. Bone was harvested from the iliac crest and long bone epiphyses. Bone defects (5 mm) were created in the right femora of 12 rats and were filled with either BMP-2 activated muscle tissue or bone grafts. After eight weeks, femora were evaluated by radiographs, micro-computed tomography (mu CT), and biomechanical testing. In the group receiving BMP-2 activated muscle grafts as well as in the bone-grafting group, 100% of the bone defects were healed, as documented by radiographs and mu CT-imaging. Bone volume was similar in both groups and biomechanical stability of the two groups was statistically indistinguishable. Conclusions: This study demonstrates that treatment of large bone defects by implantation of BMP-2 gene activated muscle tissue leads to similar bone volume and stability as bone isografts, mimicking autologous bone grafting.

Tue, 1 Jan 2013 12:00:00 +0100 https://epub.ub.uni-muenchen.de/21779/1/10_1159_000357087.pdf Würstlein, Rachel; Cardoso, Fatima; Richters, Lisa; Roethlisberger, Maria

Hypersensitivity pneumonitis (HP) also called exogenous allergic alveolitis = extrinsic allergic alveolitis in children is an uncommon condition and may not be recognized and treated appropriately. To assess current means of diagnosis and therapy and compare this to recommendations, we used the Surveillance Unit for Rare Paediatric Disorders (ESPED) to identify incident cases of HP in Germany during 2005/6. In addition, cases of HP reported for reference from all over Germany to our center in the consecutive year were included. Twenty-three children with confirmed pediatric HP were identified. All (age 9.4 y (4.4-15.1) presented with dyspnoea at rest or with exercise, mean FVC was 39% of predicted, seven of the 23 children already had a chronic disease state at presentation. IgG against bird was elevated in 20, and against fungi in 15. Bronchoalveolar lavage was done in 18 subjects (41% lymphocytes, CD4/CD8 1.99), and lung biopsy in 6. Except 2, all children were treated with prolonged courses of systemic steroids. Outcome was not favourable in all cases. Late diagnosis in up to a quarter of the children with HP and inappropriate steroid treatment must be overcome to improve management of HP. Inclusion of children with HP into international, web-based registry studies will help to study and follow up such rare lung diseases.

Background: Studies that compare neuropsychological functioning in inpatients with mood disorder or schizophrenia come to heterogeneous results. This study aims at investigating the question whether there are different neuropsychological test profiles in stabilised post-acute inpatients with affective disorders or schizophrenia. Method: We were interested in evaluating impairment in specific areas of cognitive functioning in patients with schizophrenia or depression. In clinical reality, patients with depression and schizophrenia are often treated together with little attention to their specific needs. 74 patients with major depression and 38 patients with schizophrenia were assessed in a comprehensive neuropsychological battery. All patients were in a post-acute stage of their illness, i.e. remission of acute symptoms. Results: In spite of a comparable mean score of psychopathological symptoms in the Brief Psychiatric Rating Scale-Expanded (BPRS-E) as well as in the Global Assessment Functioning Scale (GAF), patients with depressive disorder showed significantly better results in verbal and visual short-term memory, verbal fluency, visual-motor coordination, information processing in visual-verbal functioning and selective attention compared to patients with schizophrenia. No significant differences between both samples were found in practical reasoning, general verbal abstraction, spatial-figural functioning, speed of cognitive processing. Conclusions: These results show that there are differences in scores in psychopathology (BPRS-E, GAF) in patients with affective disorders or schizophrenia and different neuropsychological test profiles in the post-acute stage of their illness.

Background: Dictyostelium harbors several paralogous Sec7 genes that encode members of three subfamilies of the Sec7 superfamily of guanine nucleotide exchange factors. One of them is the cytohesin family represented by three members in D. discoideum, SecG, Sec7 and a further protein distinguished by several transmembrane domains. Cytohesins are characterized by a Sec7-PH tandem domain and have roles in cell adhesion and migration. Results: We study here Sec7. In vitro its PH domain bound preferentially to phosphatidylinositol 3,4-bisphosphate (PI(3,4) P-2), phosphatidylinositol 4,5-bisphosphate (PI(4,5)P-2) and phosphatidylinositol 3,4,5-trisphosphate (PI(3,4,5)P-3). When following the distribution of GFP-Sec7 in vivo we observed the protein in the cytosol and at the plasma membrane. Strikingly, when cells formed pseudopods, macropinosomes or phagosomes, GFP-Sec7 was conspicuously absent from areas of the plasma membrane which were involved in these processes. Mutant cells lacking Sec7 exhibited an impaired phagocytosis and showed significantly reduced speed and less persistence during migration. Cellular properties associated with mammalian cytohesins like cell-cell and cell-substratum adhesion were not altered. Proteins with roles in membrane trafficking and signal transduction have been identified as putative interaction partners consistent with the data obtained from mutant analysis. Conclusions: Sec7 is a cytosolic component and is associated with the plasma membrane in a pattern distinctly different from the accumulation of PI(3,4,5)P-3. Mutant analysis reveals that loss of the protein affects cellular processes that involve membrane flow and the actin cytoskeleton.

Background: Portal pressure (PP) results from the interplay ofvasoconstrictors and vasodilators. Recently, we have shown that Kupffercell (KC) activation increases PP. Aims: The role of the vasodilatingcompounds nitric oxide (NO) and carbon monoxide (CO) was studied. Thehypothesis of the present study was that these vasodilators counteractthe PP increase following KC activation. Methods: Livers of ratsweighing 180-200 g were isolated and perfused. KCs were activated byzymosan A (cell wall particles from yeast; 150 mu g/ml). The effects ofNO and guanylate cyclase (GC) were evaluated by the NO synthaseinhibitor N-G-nitro-L-arginine methylester (L-NAME; 0.3 m M, and the GCinhibitor 4H-8-bromo-1,2,4-oxadiazolo(3,4-d)benz(b)(1,4)oxazin-1-one(NS-2028, 1.0 mu M); the effects of the heme oxygenase (HO) derivedcompound CO were evaluated by direct administration of CO or inhibitionof HO by zinc protoporphyrin IX (ZnPP IX, 1.0 mu M). Results: Inisolated perfused rat livers, administration of L-NAME or NS-2028further raised PP increase following KC activation. This effect could bereduced by the cGMP analogue 8-Br-cGMP. Inhibition of HO caused markedamplification of PP increase in zymosan-treated organs. CO preventedthis PP increase cGMP independently. Interestingly, KC activation andsimultaneous inhibition of HO augmented the production of prostaglandinsD-2 and F-2 alpha and of thromboxane A(2). Accordingly, indomethacinblunted the increase of PP in zymosan/ZnPP-treated livers. Conclusions:NO restricts the initial PP increase after KC activation by GC-mediatedcGMP. CO from heme degradation limits the increase of PP after KCactivation eicosanoid dependently, but cGMP independently.

Background: The aim of this study was to evaluate the expression of the cell adhesion-related glycoproteins MUC-1, beta-catenin and E-cadherin in multicentric/multifocal breast cancer in comparison to unifocal disease in order to identify potential differences in the biology of these tumor types. Methods: A retrospective analysis was performed on the expression of MUC1, beta-catenin and E-cadherin by immunohistochemistry on tumor tissues of a series of 112 breast cancer patients (total collective) treated in Munich between 2000 and 2002. By matched-pair analysis, 46 patients were entered into two comparable groups of 23 patients after categorizing them as having multicentric/multifocal or unifocal breast cancer. Matching criteria were tumor size, histology grade and lymph node status; based on these criteria, patients were distributed equally between the two groups (p = 1.000 each). Data were analyzed with the Kruskal-Wallis and the Mann-Whitney tests. Results: In the matched groups, we found a significantly down-regulated expression of E-cadherin in multicentric/multifocal breast cancer compared to unifocal disease (p = 0.024). The total collective showed even higher significance with a value of p < 0.0001. In contrast, no significant differences were observed in the expression of beta-catenin between multicentric/multifocal and unifocal tumors (p = 0.636 and p = 0.914, respectively). When comparing the expression of MUC1, E-cadherin and beta-catenin within the unifocal group, we found a significant positive correlation between E-cadherin and beta-catenin (p = 0.003). In the multicentric/multifocal group we observed, in contrast to the unifocal group, a significant decrease of MUC1 expression with increased grading (p = 0.027). Conclusion: This study demonstrates that multicentric/multifocal and unifocal breast cancers with identical TNM-staging clearly differ in the expression level of E-cadherin. We suggest that the down-regulation of E-cadherin in multicentric/multifocal breast cancer is causally connected with the worse prognosis of this tumor type.

Background: Excessive gestational weight gain (GWG) is associated with short- and long-term health problems among mothers and their offspring. There is a strong need for effective intervention strategies targeting excessive GWG to prevent adverse outcomes. Methods: We performed a cluster-randomized controlled intervention trial in eight gynecological practices evaluating the feasibility and effectiveness of a lifestyle intervention presented to all pregnant women; 250 healthy, pregnant women were recruited for the study. The intervention program consisted of two individually delivered counseling sessions focusing on diet, physical activity, and weight monitoring. The primary outcome was the proportion of pregnant women exceeding weight gain recommendations of the Institute of Medicine (IOM). Secondary outcome variables were maternal weight retention and short-term obstetric and neonatal outcomes. Results: The intervention resulted in a lower proportion of women exceeding IOM guidelines among women in the intervention group (38%) compared with the control group (60%) (odds ratio (OR): 0.5; 95% confidence interval (CI): 0.3 to 0.9) without prompting an increase in the proportion of pregnancies with suboptimal weight gain (19% vs. 21%). Participants in the intervention group gained significantly less weight than those in the control group. Only 17% of the women in the intervention group showed substantial weight retention of more than 5 kg compared with 31% of those in the control group at month four postpartum (pp) (OR: 0.5; 95% CI: 0.2 to 0.9). There were no significant differences in obstetric and neonatal outcomes. Conclusions: Lifestyle counseling given to pregnant women reduced the proportion of pregnancies with excessive GWG without increasing suboptimal weight gain, and may exert favorable effects on pp weight retention.

Background: This study compared manually delineated gross tumour volume (GTV) and automatically generated biological tumour volume (BTV) based on fluoro-deoxy-glucose (FDG) positron emission tomography (PET)/CT to assess the robustness of predefined PET algorithms for radiotherapy (RT) planning in routine clinical practice. Methods: RT-planning data from 20 consecutive patients (lung-(40%), oesophageal-(25%), gynaecological-(25%) and colorectal (10%) cancer) who had undergone FDG-PET/CT planning between 08/2010 and 09/2011 were retrospectively analysed, five of them underwent neoadjuvant chemotherapy before radiotherapy. In addition to manual GTV contouring, automated segmentation algorithms were applied-among these 38%, 42%, 47% and 50% SUVmax as well as the PERCIST total lesion glycolysis (TLG) algorithm. Different ratios were calculated to assess the overlap of GTV and BTV including the conformity index and the ratio GTV included within the BTV. Results: Median age of the patients was 66 years and median tumour SUVmax 9.2. Median size of the GTVs defined by the radiation oncologist was 43.7 ml. Median conformity indices were between 30.0-37.8%. The highest amount of BTV within GTV was seen with the 38% SUVmax algorithm (49.0%), the lowest with 50% SUVmax (36.0%). Best agreement was obtained for oesophageal cancer patients with a conformity index of 56.4% and BTV within GTV ratio of 71.1%. Conclusions: At present there is only low concordance between manually derived GTVs and automatically segmented FDG-PET/CT based BTVs indicating the need for further research in order to achieve higher volumetric conformity and therefore to get access to the full potential of FDG-PET/CT for optimization of radiotherapy planning.

Tue, 1 Jan 2013 12:00:00 +0100 https://epub.ub.uni-muenchen.de/21781/1/10_1159_000346282.pdf Lamerz, Rolf ddc:610, Medizin

Most kidney disorders involve some degree of inflammation, i.e. induction of pro-inflammatory mediators and leukocyte recruitment. But what are the factors that determine inflammation as a trigger or a consequence of kidney injury? Which types of renal inflammation can be targeted by the novel more selective immunosuppressive and anti-inflammatory agents? How to dissect the mechanisms behind innate and adaptive immune responses that are orchestrated inside or outside the kidney but both cause renal immunopathology i.e. renal inflammation? How to dissect leukocytic cell infiltrates into pro-inflammatory leukocytes from anti-inflammatory and pro-regenerative leukocytes? How to dissect leukocytes that support epithelial repair from those that promote renal fibrosis. The term `renal inflammation' has moved far beyond the descriptive category of `mixed leukocytic cell infiltrates' as commonly described in kidney biopsies. It is time to face the complexity of renal inflammation to finally benefit from the new age of novel immunomodulatory medicines.

Background: Solid-organ transplantations (SOT) are usually life-saving high-tech medical procedures. The transplantation itself and the intensive care unit stay could be traumatic stressors triggering posttraumatic stress symptoms (PTSS). Our retrospective follow-up study aimed to explore preoperative risk factors of PTSS in a cohort of SOT recipients, and we investigated how PTSS are associated with health-related quality of life (HRQOL) and life satisfaction. Methods: 126 SOT recipients were enrolled in this investigation. Psychiatric examination of all SOT candidates based on the Transplant Evaluation Rating Scale was carried out before SOT, and after SOT, recipients completed the PTSS-10, the SF-36 and the FLZ. Results: After the surgical intervention 19 (15.1%) SOT recipients had clinical significant PTSS. Preoperative risk factors for developing postoperative PTSS were: 1.) preexisting psychiatric morbidity, 2.) history of retransplantation, 3.) chronic benzodiazepine consumption, 4.) age, and 5.) type of transplantation. SOT-related PTSS were associated with maximal decrements in HRQOL and life satisfaction. The following HRQOL and life satisfaction domains were affected: Physical Functioning, Role Physical, Pain, General Health, Vitality, Social Functioning, Role Emotional, Mental Health, Occupation/Work and Character/Own Skills. Conclusion: SOT recipients may face a major risk of transplantation-and treatment-related PTSS and the development of impairments to HRQOL and life satisfaction.

Aims: The present study investigated whether sociodemographic factorsand physical activity (PA) are associated with differences in serum25-hydroxyvitamin D [25(OH)D] levels and whether these differences areassociated with varying levels of endurance performance and body massindex (BMI) in children and adolescents. Subjects and Methods: Pathanalyses were based on data of a nationwide, cross-sectional GermanHealth Interview and Examination Survey for Children (KiGGS; 2003 until2006) for 25(OH)D and the embedded ‘motor function module’ for PA andendurance performance. The data were collected from 3,437 children andadolescents aged 6-17 years clustered in three age groups: 6-10, 11-13and 14-17 years. Results: PA is affected by socioeconomic status and(non-)immigration background, 25(OH)D is only affected by(non-)immigration background and only in childhood. PA and 25(OH)D werenot associated in those aged 11-13 years. In adolescence, lower 25(OH)Dlevels are associated with lower endurance performance and a higher BMI.Conclusions: Our results did not reveal a universally significant effectof sociodemographic factors on 25(OH)D. The association between 25(OH)Dand endurance performance might reflect the effects of 25(OH)D on musclefunction. Predictors of 25(OH)D status other than sunlight exposure andits health effects in the pediatric age group should be exploredfurther.

Background: Conjugated linoleic acids (CLA) in general, and in particular the trans-10, cis-12 (t10, c12-CLA) isomer are potent modulators of milk fat synthesis in dairy cows. Studies in rodents, such as mice, have revealed that t10, c12-CLA is responsible for hepatic lipodystrophy and decreased adipose tissue with subsequent changes in the fatty acid distribution. The present study aimed to investigate the fatty acid distribution of lipids in several body tissues compared to their distribution in milk fat in early lactating cows in response to CLA treatment. Effects in mammary gland are further analyzed at gene expression level. Methods: Twenty-five Holstein heifers were fed a diet supplemented with (CLA groups) or without (CON groups) a rumen-protected CLA supplement that provided 6 g/d of c9, t11-and t10, c12-CLA. Five groups of randomly assigned cows were analyzed according to experimental design based on feeding and time of slaughter. Cows in the first group received no CLA supplement and were slaughtered one day postpartum (CON0). Milk samples were taken from the remaining cows in CON and CLA groups until slaughter at 42 (period 1) and 105 (period 2) days in milk (DIM). Immediately after slaughter, tissue samples from liver, retroperitoneal fat, mammary gland and M. longissimus (13th rib) were obtained and analyzed for fatty acid distribution. Relevant genes involved in lipid metabolism of the mammary gland were analyzed using a custom-made microarray platform. Results: Both supplemented CLA isomers increased significantly in milk fat. Furthermore, preformed fatty acids increased at the expense of de novo-synthesized fatty acids. Total and single trans-octadecenoic acids (e. g., t10-18:1 and t11-18:1) also significantly increased. Fatty acid distribution of the mammary gland showed similar changes to those in milk fat, due mainly to residual milk but without affecting gene expression. Liver fatty acids were not altered except for trans-octadecenoic acids, which were increased. Adipose tissue and M. longissimus were only marginally affected by CLA supplementation. Conclusions: Daily supplementation with CLA led to typical alterations usually observed in milk fat depression (reduction of de novo-synthesized fatty acids) but only marginally affected tissue lipids. Gene expression of the mammary gland was not influenced by CLA supplementation.

Background: In the field of acute medicine, the vast majority of riskfuland prognosis-relevant procedures are not performed by individuals butrather by (ad hoc) teams. Method: Findings in scientific papersimpressively show the causes of medical mishaps and severe errors aswell as the lasting effectiveness of training in team resource formats(Team Resource Management, TRM) in order to combat these chains oferrors in acute medicine. Results: The analysis of the literature since2003 and the numerous findings regarding the research of medical errorsshow that more than 70% of the severe and prognosis-relevant mishapsand complications can be assigned to the medical providers themselves.The implementation and continuous advancement of patient safety in thefield of human factors as well as the application of TRM-relatedprinciples requires a sound and widely accepted safety culture as abasis. Conclusions: TRM training measures and non-punitive criticalincident reporting systems effectively contribute to an increasing andmeasurable improvement of the safety culture in acute medicine.

Background: The number of patients presenting with acute myocardial infarction (AMI) and being untreatable by interventional cardiologists increased during the last years. Previous experience in emergency coronary artery bypass grafting (CABG) in these patients spurred us towards a more liberal acceptance for surgery. Following a prospective protocol, patients were operated on and further analysed. Methods: Within a two year interval, 127 patients (38 female, age 68 +/- 12 years, EuroScore (ES) II 6.7 +/- 7.2%) presenting with AMI (86 non-ST-elevated myocardial infarction (NSTEMI), 41 STEMI) were immediately accepted for emergency CABG and operated on within six hours after cardiac catheterisation (77% three-vessel-disease, 47% left main stem stenosis, 11% cardiogenic shock, 21% preoperative intraaortic balloon pump (IABP), left ventricular ejection fraction 48 +/- 15%). Results: 30-day-mortality was 6% (8 patients, 2 NSTEMI (2%) 6 STEMI (15%), p=0.014). Complete revascularisation could be achieved in 80% of the patients using 2 +/- 1 grafts and 3 +/- 1 distal anastomoses. In total, 66% were supported by IABP, extracorporal life support (ECLS) systems were implanted in two patients. Logistic regression analysis revealed the ES II as an independent risk factor for mortality (p

Background: Our objective was to assess the auditory function ofgynaecological tumour patients who had received cytotoxic agents and todetermine their associated risk of ototoxicity. Patients and Methods: 87patients who had undergone chemotherapy for gynaecological malignancieswere investigated. Of these patients, 79% had breast cancer, and 14%ovarian cancer. All of the patients had a subjective assessment of theirhearing function on a visual analogue scale. Audiometric tests wereperformed before and at 9 weeks, 18 weeks and 3 months after completionof chemotherapy. Results: The age of the patients ranged from 32 to 71years (mean age of 53.5 +/- 10.5 years). The average subjective ratingof the patients’ hearing function was 83.0 +/- 17.2 before and 84.8 +/-16.9 3 months after completion of chemotherapy. No significantaudiometric change at either the speech hearing frequency range (0.5-2KHz) or high frequencies was observed in the patients afterchemotherapy. There was also no significant difference in the hearingthreshold of the patients who had received platinum analogue-basedchemotherapy compared to non-platinum analogue-based chemotherapy.Conclusion: Hearing loss is uncommon in patients treated with thetypical gynaecological chemotherapy protocols. Hence, routineaudiometric testing in these patients is not necessary.

Background: In 2004, routine varicella vaccination was recommended in Germany for children 11-14 months of age with one dose, and since 2009, with a second dose at 15-23 months of age. The effects on varicella epidemiology were investigated. Methods: Data on varicella vaccinations, cases and complications were collected from annual parent surveys (2006-2011), monthly paediatric practice surveillance (Oct 2006 - Sep 2011; five varicella seasons) and paediatric hospital databases (2005-2009) in the area of Munich (about 238,000 paediatric inhabitants); annual incidences of cases and hospitalisations were estimated. Results: Varicella vaccination coverage (1st dose) in children 18-36 months of age increased in two steps (38%, 51%, 53%, 53%, 66% and 68%); second-dose coverage reached 59% in the 2011 survey. A monthly mean of 82 (62%) practices participated; they applied a total of 50,059 first-dose and 40,541 second-dose varicella vaccinations, with preferential use of combined MMR-varicella vaccine after recommendation of two doses, and reported a total of 16,054 varicella cases

Background: Prostate smooth muscle tone is regulated by alpha 1-adrenoceptor-induced contraction and cAMP-mediated relaxation. EPAC is an effector of cAMP, being involved in smooth muscle relaxation and cell cycle control outside the lower urinary tract. Here, we investigated the expression and function of EPAC in human prostate tissues from patients undergoing radical prostatectomy. Results: mRNA and protein expression of EPAC was detected in all prostate tissues by RT-PCR and Western blot analysis. Immunoreactivity was observed in stromal cells, and colocalized with immunofluorescence for a-smooth muscle actin and calponin. Under normal conditions, noradrenaline-or phenylephrine-induced contraction of prostate strips in the organ bath was not affected by the EPAC activator pCPT (SP-8-pCPT-2'-O-Me-cAMPS.NA) (30 mu M). However, when the cyclooxygenase inhibitor indomethacin (50 mu M) was added, EPAC activators pCPT and OME (8-CPT-2'-O-Me-cAMP.Na) (30 mu M) significantly reduced contractions by low concentrations of phenylephrine. These effects were not observed on noradrenaline-induced contraction. OME and pCPT caused phosphorylation of the transcription factor Elk1 in prostate tissues. Elk1 activation was confirmed by EMSA (electrophoretic mobility shift assay), where OME and pCPT incresed Elk1 binding to a specific DNA probe. Conclusions: EPAC activation may reduce alpha 1-adrenergic prostate contraction in the human prostate, although this effect is masked by cyclooxygenases and beta-adrenoceptors. A main EPAC function in the human prostate may be the regulation of the transcription factor Elk1.

Accumulation of classical monocytes is imperative for the progression ofatherosclerosis. Hence, therapeutic interference with mechanisms oflesional monocyte recruitment, the primary mechanism controllingmacrophage accumulation, may allow for targeting atheroprogression andits clinical complications. Here, we review the important role ofclassical monocytes in atheroprogression as well as their routes ofarterial recruitment. We specifically highlight the role of celladhesion molecules as well as of platelet-derived chemokines andneutrophil-borne alarmins.

Background: Patients with B cell malignancies refractory to allogeneic stem cell transplantation (SCT) can be treated by subsequent immunotherapy with donor lymphocyte infusions (DLI). But unlike myeloid leukemia, B cell leukemia and lymphoma are less sensitive to allogeneic adoptive immunotherapy. Moreover, the beneficial graft-versus-lymphoma (GVL) effect may be associated with moderate to severe graft-versus-host disease (GVHD). Thus, novel therapeutic approaches augmenting the anti-tumor efficacy of DLI and dissociating the GVL effect from GVHD are needed. The anti-CD20 x anti-CD3 trifunctional bispecific antibody (trAb) FBTA05 may improve the targeting of tumor cells by redirecting immune allogeneic effector cells while reducing the risk of undesirable reactivity against normal host cells. Hence, FBTA05 may maximize GVL effects by simultaneously decreasing the incidence and severity of GVHD. Methods/Design: Based on this underlying treatment concept and on promising data taken from preclinical results and a small pilot study, an open-label, non-randomized, uncontrolled, dose-escalating phase I/II-study is conducted to evaluate safety and preliminary efficacy of the investigational antibody FBTA05 in combination with DLI for patients suffering from rituximab-and/or alemtuzumab-refractory, CD20-positive low-or high-grade lymphoma after allogeneic SCT. During the first trial phase with emphasis on dose escalation a maximum of 24 patients distributed into 4 cohorts will be enrolled. For the evaluation of preliminary efficacy data a maximum of 12 patients (6 patients with low-grade lymphoma and/or Chronic Lymphocytic Leukemia (CLL) / 6 patients with high-grade or aggressive lymphoma) will attend the second phase of this clinical trial. Discussion: Promising data (e. g. induction of cellular immunity; GVL predominance over GVHD; achievement of partial or complete responses; prolongation of time-to-progression) obtained from this phase I/II trial would represent the first milestone in the clinical evaluation of a novel immunotherapeutic concept for treatment-resistant low- and high-grade lymphoma and NHL patients in relapse.

Background: Patellofemoral complications are one of the main problems after Total Knee Arthroplasty (TKA). Retropatellar pressure distribution after TKA can contribute to these symptoms. Therefore we evaluated retropatellar pressure distribution subdivided on the ridge, medial and lateral surface on non-resurfaced patella before and after TKA. Additionally, we analyzed axial femorotibial rotation and quadriceps load before and after TKA. Methods: Seven fresh frozen cadaver knees were tested in a force controlled knee rig before and after TKA (Aesculap, Tuttlingen, Germany, Columbus CR) while isokinetic flexing the knee from 20 degrees to 120 degrees under weight bearing. Ridge, medial and lateral retropatellar surface were defined and pressure distribution was dynamically measured while quadriceps muscles and hamstring forces were applied. Aside axial femorotibial rotation and quadriceps load was recorded. Results: There was a significant change of patella pressure distribution before and after TKA (p = 0.004). In physiological knees pressure distribution on medial and lateral retropatellar surface was similar. After TKA the ridge of the patella was especially in higher flexion grades strongly loaded (6.09 +/-1.31 MPa) compared to the natural knee (2.92 +/-1.15 MPa, p < 0.0001). Axial femorotibial rotation showed typical internal rotation with increasing flexion both before and after TKA, but postoperatively it was significantly lower. The average amount of axial rotation was 3.5 degrees before and after TKA 1.3 degrees (p = 0.001). Mean quadriceps loading after implantation of knee prosthesis did not change significantly (575 N +/- 60 N in natural knee and after TKA 607 N +/- 96 N; p = 0.28). Conclusions: The increased retropatellar pressure especially on the ridge may be one important reason for anterior knee pain after TKA. The trochlea of the femoral component might highly influence the pressure distribution of the non-resurfaced retropatellar surface. Additionally, lower axial femorotibial rotation after TKA might lead to patella maltracking. Changing the design of the prosthesis or a special way of patella shaping might increase the conformity of the patella to trochlea to maintain natural contact patterns.

Purpose: The purpose of this preliminary and descriptive study was toevaluate a biodegradable drug delivery system in combination with aninnovative ceramic implant. Methods: The delivery of gentamicin ofstandardized samples was measured in the laboratory usingultra-high-performance liquid chromatography. Biocompatibility andbiodegradation of the materials was investigated in an animal experimentin sheep up to 14 months. As carrier epsilon-caprolactone, 1:1 mixedwith gentamicin, intruded into micro-chambered beta-tricalcium-phosphatebeads (MCB (R)) was studied. Results and Discussion: Gentamicin wasreleased in calculable concentrations during the first 30 days. Therelease from epsilon-caprolactone was higher than that frompolymethylmethacrylate and more predictable. The caprolactone carrierwas reabsorbed by osteoclasts.

Background: The current standard treatment of patients with relapsed or refractory diffuse large cell B-Cell lymphoma (DLBCL) primarily consists of intensified salvage therapy and, if the disease is chemo-sensitive, high dose therapy followed with autologous stem cell transplantation. In the rituximab era however, this treatment approach has shown only limited benefit. In particular, patients relapsing after rituximab-containing primary treatment have an adverse prognosis, especially if this occurs within the first year after therapy or if the disease is primarily refractory. Therefore there is an ultimate need for improved salvage treatment approaches. Methods/design: The STORM study is a prospective, multicentre phase I/II study to evaluate the safety, feasibility and activity of salvage therapy consisting of the mTOR inhibitor temsirolimus added to the standard therapy rituximab and DHAP for the treatment of patients with relapsed or refractory DLBCL. The primary objective of the phase I of the trial is to establish the maximum tolerated dose (MTD) of temsirolimus in combination with rituximab and DHAP. The secondary objective is to demonstrate that stem cells can be mobilized during this regimen in patients scheduled to proceed to high dose therapy. In phase II, the previously established maximum tolerated dose of temsirolimus will be used. The primary objective is to evaluate the overall response rate (ORR) in patients with relapsed DLBCL. The secondary objective is to evaluate progression free survival (PFS), overall survival (OS) and toxicity. The study will be accompanied by an analysis of lymphoma subtypes determined by gene expression analysis (GEP). Discussion: The STORM trial evaluates the safety, feasibility and activity of salvage therapy consisting of the mTOR inhibitor temsirolimus added to standard therapy of rituximab and DHAP for the treatment of patients with relapsed or refractory DLBCL. It also might identify predictive markers for this treatment modality.

Background: Cardiovascular magnetic resonance (CMR) has become an important diagnostic imaging modality in cardiovascular medicine. However, insufficient image quality may compromise its diagnostic accuracy. We aimed to describe and validate standardized criteria to evaluate a) cine steady-state free precession (SSFP), b) late gadolinium enhancement (LGE), and c) stress first-pass perfusion images. These criteria will serve for quality assessment in the setting of the Euro-CMR registry. Methods: Thirty-five qualitative criteria were defined (scores 0-3) with lower scores indicating better image quality. In addition, quantitative parameters were measured yielding 2 additional quality criteria, i.e. signal-to-noise ratio (SNR) of non-infarcted myocardium (as a measure of correct signal nulling of healthy myocardium) for LGE and % signal increase during contrast medium first-pass for perfusion images. These qualitative and quantitative criteria were assessed in a total of 90 patients (60 patients scanned at our own institution at 1.5T (n=30) and 3T (n=30) and in 30 patients randomly chosen from the Euro-CMR registry examined at 1.5T). Analyses were performed by 2 SCMR level-3 experts, 1 trained study nurse, and 1 trained medical student. Results: The global quality score was 6.7 +/- 4.6 (n=90, mean of 4 observers, maximum possible score 64), range 6.4-6.9 (p=0.76 between observers). It ranged from 4.0-4.3 for 1.5T (p=0.96 between observers), from 5.9-6.9 for 3T (p=0.33 between observers), and from 8.6-10.3 for the Euro-CMR cases (p=0.40 between observers). The inter- (n=4) and intra-observer (n=2) agreement for the global quality score, i.e. the percentage of assignments to the same quality tertile ranged from 80% to 88% and from 90% to 98%, respectively. The agreement for the quantitative assessment for LGE images (scores 0-2 for SNR 5, respectively) ranged from 78-84% for the entire population, and 70-93% at 1.5T, 64-88% at 3T, and 72-90% for the Euro-CMR cases. The agreement for perfusion images (scores 0-2 for % SI increase >200%, 100%-200%,

Background: The MCMV major immediate early promoter/enhancer (MIEP) is a bidirectional promoter that drives the expression of the three immediate early viral genes, namely ie1, ie2 and ie3. The regulation of their expression is intensively studied, but still incompletely understood. Methods: We constructed a reporter MCMV, (MCMV-MIEPr) expressing YFP and tdTomato under the control of the MIEP as proxies of ie1 and ie2, respectively. Moreover, we generated a liver sinusoidal endothelial cell line (LSEC-uniLT) where cycling is dependent on doxycycline. We used these novel tools to study the kinetics of MIEP-driven gene expression in the context of infection and at the single cell level by flow cytometry and by live imaging of proliferating and G(0)-arrested cells. Results: MCMV replicated to higher titers in G(0)-arrested LSEC, and cycling cells showed less cytopathic effect or YFP and tdTomato expression at 5 days post infection. In the first 24 h post infection, however, there was no difference in MIEP activity in cycling or G(0)-arrested cells, although we could observe different profiles of MIEP gene expression in different cell types, like LSECs, fibroblasts or macrophages. We monitored infected LSEC-uniLT in G(0) by time lapse microscopy over five days and noticed that most cells survived infection for at least 96 h, arguing that quick lysis of infected cells could not account for the spread of the virus. Interestingly, we noticed a strong correlation between the ratio of median YFP and tdTomato expression and length of survival of infected cells. Conclusion: By means of our newly developed genetic tools, we showed that the expression pattern of MCMV IE1 and IE2 genes differs between macrophages, endothelial cells and fibroblasts. Substantial and cell-cycle independent differences in the ie1 and ie2 transcription could also be observed within individual cells of the same population, and marked ie2 gene expression was associated with longer survival of the infected cells.

Background: A key issue for safe and reproducible gene therapy approaches is the autologous and tissue-specific expression of transgenes. Tissue-specific expression in vivo is either achieved by transfer vectors that deliver the gene of interest into a distinct cell type or by use of tissue-specific expression cassettes. Here we present the generation of non-viral, episomally replicating vectors that are able to replicate in a tissue specific manner thus allowing tissue specific transgene expression in combination with episomal replication. The episomal replication of the prototype vector pEPI-1 and its derivatives depends exclusively on a transcription unit starting from a constitutively active promoter extending into the scaffold/matrix attachment region (S/MAR). Results: Here, we exchanged the constitutive promoter in the pEPI derivative pEPito by the tumor specific alpha fetoprotein (AFP) or the muscle specific smooth muscle 22 (SM22) promoter leading to specific transgene expression in AFP positive human hepatocellular carcinoma (HUH7) and in a SM22 positive cell line, respectively. The incorporation of the hCMV enhancer element into the expression cassette further boosted the expression levels with both promoters. Tissue specific-replication could be exemplary proven for the smooth muscle protein 22 (SM22) promoter in vitro. With the AFP promoter-driven pEPito vector hepatocellular carcinoma-specific expression could be achieved in vivo after systemic vector application together with polyethylenimine as transfection enhancer. Conclusions: In this study we present an episomal plasmid system designed for tissue specific transgene expression and replication. The human AFP-promoter in combination with the hCMV enhancer element was demonstrated to be a valuable tissue-specific promoter for targeting hepatocellular carcinomas with non-viral gene delivery system, and tissue specific replication could be shown in vitro with the muscle specific SM22 promoter. In combination with appropriate delivery systems, the tissue specific pEPito vector system will allow higher tissue-specificity with less undesired side effects and is suitable for long term transgene expression in vivo within gene therapeutical approaches.

Background: Obesity is associated with abnormal fasting and postprandial lipids, which may link obesity with atherosclerosis. We explored fasting and postprandial lipids in morbidly obese patients treated with sleeve gastrectomy and in control subjects. Methods: After fasting for 12 h 15 morbidly obese patients (BMI 51.4 +/- 6.5 kg/m(2), 43.7 +/- 12.6 years) received a standardized oral fat load before and 3 months after bariatric surgery (sleeve gastrectomy). Controls (n=9, BMI 23.1 +/- 1.4 kg/m(2)) were studied once. Plasma was obtained fasting and then postprandially every 2 h for 8 h. Triglycerides (TG), chylomicron-TG (CM-TG), VLDL/chylomicron-remnant (VLDL/CR)-TG, cholesterol, LDL-cholesterol, VLDL/CR-cholesterol and HDL-cholesterol were isolated by ultracentrifugation at each time point. Postprandial values were expressed as area under the curve (AUC) and incremental area under the curve (iAUC). In addition, fasting glucose and insulin values and HOMA-IR-Index was measured (n=14). Results: Compared to controls morbidly obese patients had elevated TG and slightly altered postprandial lipids. Following surgery (weight loss 23.4 kg +/- 6.2 kg; 150 mg/dl) a similar pattern was observed. Fasting insulin and HOMA were reduced significantly (-51.9%; p=0.004 and -47.9%; p=0.011). Conclusions: Three months after sleeve gastrectomy fasting and postprandial lipoprotein metabolism and glucose metabolism is improved in morbidly obese patients. The potential mechanisms may relate to decreased caloric intake but also to hormonal changes.

Background/Aims: Chronic hypercortisolism in Cushing’s disease (CD) hasbeen suggested to contribute to an altered personality profile in thesepatients. We aimed to test this hypothesis and attempted to determinethe effects of disease- and treatment-related factors that mightmoderate an altered personality in CD. Methods: We assessed 50 patientswith CD (74% biochemically controlled) and compared them to 60 patientswith non-functioning pituitary adenomas (NFPA) and 100 age-andgender-matched mentally healthy controls. Personality was measured bytwo standardized personality questionnaires, TPQ (Cloninger PersonalityQuestionnaire) and EPQ-RK (Eysenck Personality Questionnaire-RK).Results: Compared to mentally healthy controls, CD patients reportedsignificantly less novelty-seeking behaviour, including less exploratoryexcitability and less extravagance. On harm avoidant subscales, theypresented with more anticipatory worries and pessimism, higher fear ofuncertainty, shyness with strangers, fatigability and asthenia.Moreover, CD patients appeared to be less extraverted, more neurotic andsocially desirable. CD patients differed from NFPA patients in terms ofhigher neuroticism scores, and NFPA patients did not show alterednovelty-seeking behaviour or extraversion. In the subgroup analysis, CDpatients with persistent hypercortisolism displayed significantly higherfear of uncertainty, fatigability and asthenia, indicating high harmavoidance in total, than those in biochemical remission. Conclusion:Patients with CD showed a distinct pattern of personality traitsassociated with high anxiety in combination with traits of lowexternalizing behaviour. Such personality changes should be taken intoaccount in the diagnosis and treatment of CD patients, as they mightinterfere with the patient-physician communication and/or challenge thepatients’ social and psychological functioning.

Background: An association between eosinophilic esophagitis (EoE) and celiac disease (CD) has been suggested in the literature. Our aim was to confirm and quantify the association between these two diseases. Methods: All patients in a large Canadian city diagnosed with EoE or CD over a five-year period were identified. Standardized incidence ratios (SIRs) with 95% confidence intervals (CIs) were calculated. Results: Over the five-year study EoE was diagnosed in 421 patients and CD was diagnosed in 763 patients. The incidence of EoE ranged from 2.1 to 10.7 cases per 100,000 population. The incidence of CD ranged from 10.4 to 15.7 cases per 100,000 population. Among the EoE cohort, 83 (20%) cases of EoE and 245 (32%) cases of CD were diagnosed in pediatric patients. The incidence of EoE in the pediatric subpopulation ranged from 3.7 to 6.9 cases per 100,000 population. The incidence of CD in the pediatric subpopulation ranged from 9.5 to 22.7 cases per 100,000 population. The concomitant diagnosis of both EoE and CD was made in three patients, all of whom were pediatric males. The SIR for EoE in the CD cohort was 48.4 (95% CI = 9.73, 141.41) with a SIR for CD within the paediatric EoE cohort of 75.05 (95% CI = 15.08, 219.28). Conclusions: This study confirms the association between EoE and CD. However, this association may be limited to pediatrics where the risk of each condition is increased 50 to 75-fold in patients diagnosed with the alternative condition. The concomitant diagnosis of these conditions should be considered in pediatric patients with upper gastrointestinal symptoms.

UK Biobank is a prospective cohort study with 500,000 participants aged 40 to 69. Recently an enhanced imaging study received funding. Cardiovascular magnetic resonance (CMR) will be part of a multi-organ, multi-modality imaging visit in 3-4 dedicated UK Biobank imaging centres that will acquire and store imaging data from 100,000 participants (subject to successful piloting). In each of UK Biobank's dedicated bespoke imaging centres, it is proposed that 15-20 participants will undergo a 2 to 3 hour visit per day, seven days a week over a period of 5-6 years. The imaging modalities will include brain MRI at 3 Tesla, CMR and abdominal MRI at 1.5 Tesla, carotid ultrasound and DEXA scans using carefully selected protocols. We reviewed the rationale, challenges and proposed approaches for concise phenotyping using CMR on such a large scale. Here, we discuss the benefits of this imaging study and review existing and planned population based cardiovascular imaging in prospective cohort studies. We will evaluate the CMR protocol, feasibility, process optimisation and costs. Procedures for incidental findings, quality control and data processing and analysis are also presented. As is the case for all other data in the UK Biobank resource, this database of images and related information will be made available through UK Biobank's Access Procedures to researchers (irrespective of their country of origin and whether they are academic or commercial) for health-related research that is in the public interest.

Background: In recent years, personalized medicine (PM) has become a highly regarded line of development in medicine. Yet, it is still a relatively new field. As a consequence, the discussion of its future developments, in particular of its ethical implications, in most cases can only be anticipative. Such anticipative discussions, however, pose several challenges. Nevertheless, they play a crucial role for shaping PM's further developments. Therefore, it is vital to understand how the ethical discourse on PM is conducted, i.e. on what - empirical and normative - assumptions ethical arguments are based regarding PM's current and future developments. Methods: To gather this information, we conducted a qualitative interview study with stakeholders in the German health care system. Our purposive sample included 17 representatives of basic research, clinical research, health economics, regulatory authorities, reimbursement institutions, pharmaceutical industry, patient organizations, as well as clinicians and legal experts involved in PM developments or policy making. We used an interview guide with open-ended questions and analyzed transcriptions of the interviews by means of qualitative content analysis. Results: The respondents addressed a multitude of concerns in the context of research on as well as application of personalized preventive and therapeutic measures both on the individual and on the societal level. Interestingly, regarding future developments of PM the ethical evaluation seemed to follow the rule: the less likely its application, the more problematic a PM measure is assessed. The more likely its application, on the other hand, the less problematic it is evaluated. Conclusions: The results of our study suggest re-focusing the ethical discourse on PM in Germany towards a constructive ethical monitoring which ensures to include only, nevertheless all of the actual and/or potential concerns that are ethically relevant in order to allow balancing them against the actual and potential ethically relevant benefits of PM measures. To render this possible, we propose a strategy for evaluating ethical concerns in the context of PM.

Background: To determine if black-blood 3 T cardiovascular magnetic resonance (bb-CMR) can depict differences between symptomatic and asymptomatic carotid atherosclerotic plaques in acute ischemic stroke patients. Methods: In this prospective monocentric observational study 34 patients (24 males; 70 +/- 9.3 years) with symptomatic carotid disease defined as ischemic brain lesions in one internal carotid artery territory on diffusion weighted images underwent a carotid bb-CMR at 3 T with fat-saturated pre- and post-contrast T1w-, PDw-, T2w- and TOF images using surface coils and Parallel Imaging techniques (PAT factor = 2) within 10 days after symptom onset. All patients underwent extensive clinical workup (lab, brain MR, duplex sonography, 24-hour ECG, transesophageal echocardiography) to exclude other causes of ischemic stroke. Prevalence of American Heart Association lesion type VI (AHA-LT6), status of the fibrous cap, presence of hemorrhage/thrombus and area measurements of calcification, necrotic core and hemorrhage were determined in both carotid arteries in consensus by two reviewers who were blinded to clinical information. McNemar and Wilcoxon's signed rank tests were use for statistical comparison. A p-value

Background: Congenital heart defects (CHD) is the most common cause of death from a congenital structure abnormality in newborns and is often associated with fetal loss. There are many types of CHD. Human genetic studies have identified genes that are responsible for the inheritance of a particular type of CHD and for some types of CHD previously thought to be sporadic. However, occasionally different members of the same family might have anatomically distinct defects - for instance, one member with atrial septal defect, one with tetralogy of Fallot, and one with ventricular septal defect. Our objective is to identify susceptibility loci for CHD in families affected by distinct defects. The occurrence of these apparently discordant clinical phenotypes within one family might hint at a genetic framework common to most types of CHD. Results: We performed a genome-wide linkage analysis using MOD score analysis in families with diverse CHD. Significant linkage was obtained in two regions, at chromosome 15 (15q26.3, P-empirical = 0.0004) and at chromosome 18 (18q21.2, P-empirical = 0.0005). Conclusions: In these two novel regions four candidate genes are located: SELS, SNRPA1, and PCSK6 on 15q26.3, and TCF4 on 18q21.2. The new loci reported here have not previously been described in connection with CHD. Although further studies in other cohorts are needed to confirm these findings, the results presented here together with recent insight into how the heart normally develops will improve the understanding of CHD.