Prognostic factors and follow-up parameters in patients with paroxysmal nocturnal hemoglobinuria (PNH): experience of the Austrian PNH network.

Paroxysmal nocturnal hemoglobinuria (PNH) is a rare hematologic disease characterized by a deregulated complement system, chronic Coombs-negative, intravascular hemolysis, and a variable clinical course with substantial risk to develop thromboembolic events. We analyzed diagnostic and prognostic parameters as well as clinical endpoints in 59 adult patients suffering from PNH in 5 hematology centers in Austria (observation period: 1978-2015). Median follow-up time was 5.6 years. The median clone size at diagnosis amounted to 55% and was higher in patients with classical PNH (81%) compared to patients with PNH associated with aplastic anemia (AA) or myelodysplastic syndromes (MDS) (50%). The clone size also correlated with lactate dehydrogenase (LDH) levels. In one patient, anemia improved spontaneously and disappeared with complete normalization of LDH after 16 years. Seventeen patients received therapy with eculizumab. The rate of thromboembolic events was higher in the pre-eculizumab era compared with eculizumab-treated patients but did not correlate with the presence of age-related clonal hematopoiesis or any other clinical or laboratory parameters. Peripheral blood colony-forming progenitor cell counts were lower in PNH patients compared with healthy controls. Only two patients with classical PNH developed MDS. Overall, 7/59 patients died after 0.5-32 years. Causes of death were acute pulmonary hypertension, Budd-Chiari syndrome, and septicemia. Overall survival (OS) was mainly influenced by age and was similar to OS measured in an age-matched healthy Austrian control cohort. Together, compared with previous times, the clinical course and OS in PNH are favorable, which may be due to better diagnosis, early recognition, and eculizumab therapy.

The KIT D816V allele burden predicts survival in patients with mastocytosis and correlates with the WHO type of the disease.

KIT D816V is present in a majority of patients with systemic mastocytosis (SM). We determined the KIT D816V allele burden by quantitative real-time PCR in bone marrow and peripheral blood of 105 patients with mastocytosis. KIT D816V was detected in 92/105 patients (88%). Significant differences in the median allele burden were observed between disease subgroups: cutaneous mastocytosis (0.042%), indolent SM (0.285%), smoldering SM (5.991%), aggressive SM (9.346%), and SM with associated hematologic non-mast cell lineage disease (3.761%) (P < 0.001). The KIT D816V burden also correlated with serum tryptase (R = 0.5, P < 0.005) but not with mast cell infiltration in bone marrow or mediator symptoms. Moreover, the allele burden was of prognostic significance regarding survival (P < 0.01). Patients responding to cytoreductive therapy showed a significant decrease in KIT D816V (P < 0.05). To conclude, the KIT D816V burden correlates with the variant of mastocytosis, predicts survival, and is a valuable follow-up parameter in SM.

Cross talk between stimulated NF-kappaB and the tumor suppressor p53.

Nuclear factor-kappaB (NF-kappaB) and p53 critically determine cancer development and progression. Defining the cross talk between these transcription factors can expand our knowledge on molecular mechanisms of tumorigenesis. Here, we show that induction of replicational stress activates NF-kappaB p65 and triggers its interaction with p53 in the nucleus. Experiments with knockout cells show that p65 and p53 are both required for enhanced NF-kappaB activity during S-phase checkpoint activation involving ataxia-telangiectasia mutated and checkpoint kinase-1. Accordingly, the pro-inflammatory cytokine tumor necrosis factor-alpha (TNF-alpha) also triggers formation of a transcriptionally active complex containing nuclear p65 and p53 on kappaB response elements. Gene expression analyses revealed that, independent of NF-kappaB activation in the cytosol, TNF-induced NF-kappaB-directed gene expression relies on p53. Hence, p53 is unexpectedly necessary for NF-kappaB-mediated gene expression induced by atypical and classical stimuli. Remarkably, data from gain- and loss-of function approaches argue that anti-apoptotic NF-kappaB p65 activity is constitutively evoked by a p53 hot-spot mutant frequently found in tumors. Our observations suggest explanations for the outstanding question why p53 mutations rather than p53 deletions arise in tumors of various origins.

T-peel test for the analysis of articular cartilage integration.

A central aim of current research is to determine the molecular mechanisms of articular cartilage repair. One major issue of articular cartilage repair is the achievable mechanical strength which has been correlated with the collagen metabolism, deposition and collagen cross-linking. Current in vitro techniques, leading to cartilage integration used a shear test to failure. Another well established in vitro method to investigate articular cartilage integration is the insert-ring push out model which is mainly utilized investigating the integration of tissue engineered cartilage to native cartilage. Finite element modeling illustrates at least for the shear test to failure that the contact area is not homogeneously loaded. For the mechanical analysis of articular cartilage integration in regard to its inhomogeneous integration a higher mechanical resolution method is needed. Furthermore the shear test to failure as well as the ring-insert model lacks a comparison to in situ trauma situation, where ruptured or fractured articular cartilage surfaces are opposed after surgical reduction. Considering all these a T-peel test has been introduced in literature but never been experimentally performed. This project deals with the establishment of a T-peel test as a topographical sensitive tool in mechanical analysis of T-peel data and its potential to investigate articular cartilage in vitro integration in comparison to articular cartilage rupture strength.

Correction of susceptibility artifacts in diffusion tensor data using non-linear registration.

Diffusion tensor imaging can be used to localize major white matter tracts within the human brain. For surgery of tumors near eloquent brain areas such as the pyramidal tract this information is of importance to achieve an optimal resection while avoiding post-operative neurological deficits. However, due to the small bandwidth of echo planar imaging, diffusion tensor images suffer from susceptibility artifacts resulting in positional shifts and distortion. As a consequence, the fiber tracts computed from echo planar imaging data are spatially distorted. We present an approach based on non-linear registration using Bézier functions to efficiently correct distortions due to susceptibility artifacts. The approach makes extensive use of graphics hardware to accelerate the non-linear registration procedure. An improvement presented in this paper is a more robust and efficient optimization strategy based on simultaneous perturbation stochastic approximation (SPSA). Since the accuracy of non-linear registration is crucial for the value of the presented correction method, two techniques were applied in order to prove the quality of the proposed framework. First, the registration accuracy was evaluated by recovering a known transformation with non-linear registration. Second, landmark-based evaluation of the registration method for anatomical and diffusion tensor data was performed. The registration was then applied to patients with lesions adjacent to the pyramidal tract in order to compensate for susceptibility artifacts. The effect of the correction on the pyramidal tract was then quantified by measuring the position of the tract before and after registration. As a result, the distortions observed in phase encoding direction were most prominent at the cortex and the brainstem. The presented approach allows correcting fiber tract distortions which is an important prerequisite when tractography data are integrated into a stereotactic setup for intra-operative guidance.

Determination of the elasticity parameters of brain tissue with combined simulation and registration.

Reliable elasticity parameters describing the behavior of a given material are an important issue in the context of physically-based simulation. In this paper we introduce a method for the determination of the mechanical properties of brain tissue. Elasticity parameters Young's modulus E and Poisson's ratio nu are estimated in an iterative framework coupling a finite element simulation with image registration. Within this framework, the outcome of the simulation is parameterized with both elasticity moduli that are automatically varied until optimal image correspondence between the simulated and the intraoperative data is achieved. We calculated optimal mechanical properties of brain tissue in six cases. The statistical analysis of the obtained values showed a good correlation of the results, thus proving the value of the method. An approach combining simulation and registration for the determination of the mechanical brain tissue properties is presented. This contributes to performing reliable physically-based simulation of soft tissue movement.

Synthesis and biological activities of new side chain and backbone cyclic bradykinin analogues.

A series of conformationally constrained cyclic analogues of the peptide hormone bradykinin (BK, Arg-Pro-Pro-Gly-Phe-Ser-Pro-Phe-Arg) was synthesized to check different turned structures proposed for the bioactive conformation of BK agonists and antagonists. Cycles differing in the size and direction of the lactam bridge were performed at the C- and N-terminal sequences of the molecule. Glutamic acid and lysine were introduced into the native BK sequence at different positions for cyclization through their side chains. Backbone cyclic analogues were synthesized by incorporation of N-carboxy alkylated and N-amino alkylated amino acids into the peptide chain. Although the coupling of Fmoc-glycine to the N-alkylated phenylalanine derivatives was effected with DIC/HOAt in SPPS, the dipeptide building units with more bulky amino acids were pre-built in solution. For backbone cyclization at the C-terminus an alternative building unit with an acylated reduced peptide bond was preformed in solution. Both types of building units were handled in the SPPS in the same manner as amino acids. The agonistic and antagonistic activities of the cyclic BK analogues were determined in rat uterus (RUT) and guinea-pig ileum (GPI) assays. Additionally, the potentiation of the BK-induced effects was examined. Among the series of cyclic BK agonists only compound 3 with backbone cyclization between positions 2 and 5 shows a significant agonistic activity on RUT. To study the influence of intramolecular ring closure we used an antagonistic analogue with weak activity, [D-Phe7]-BK. Side chain as well as backbone cyclization in the N-terminus of [D-Phe7]-BK resulted in analogues with moderate antagonistic activity on RUT. Also, compound 18 in which a lactam bridge between positions 6 and 9 was achieved via an acylated reduced peptide bond has moderate antagonistic activity on RUT. These results support the hypothesis of turn structures in both parts of the molecule as a requirement for BK antagonism. Certain active and inactive agonists and antagonists are able to potentiate the bradykinin-induced contraction of guinea-pig ileum.

Quantification of, visualization of, and compensation for brain shift using intraoperative magnetic resonance imaging.

OBJECTIVE: Modern neuronavigation systems lack spatial accuracy during ongoing surgical procedures because of increasing brain deformation, known as brain shift. Intraoperative magnetic resonance imaging was used for quantitative analysis and visualization of this phenomenon. METHODS: For a total of 64 patients, we used a 0.2-T, open-configuration, magnetic resonance imaging scanner, located in an operating theater, for pre- and intraoperative imaging. The three-dimensional imaging data were aligned using rigid registration methods. The maximal displacements of the brain surface, deep tumor margin, and midline structures were measured. Brain shift was observed in two-dimensional image planes using split-screen or overlay techniques, and three-dimensional, color-coded, deformable surface-based data were computed. In selected cases, intraoperative images were transferred to the neuronavigation system to compensate for the effects of brain shift. RESULTS: The results demonstrated that there was great variability in brain shift, ranging up to 24 mm for cortical displacement and exceeding 3 mm for the deep tumor margin in 66% of all cases. Brain shift was influenced by tissue characteristics, intraoperative patient positioning, opening of the ventricular system, craniotomy size, and resected volume. Intraoperative neuronavigation updating (n = 14) compensated for brain shift, resulting in reliable navigation with high accuracy. CONCLUSION: Without brain shift compensation, neuronavigation systems cannot be trusted at critical steps of the surgical procedure, e.g., identification of the deep tumor margin. Intraoperative imaging allows not only evaluation of and compensation for brain shift but also assessment of the quality of mathematical models that attempt to describe and compensate for brain shift.

Synthesis of different types of dipeptide building units containing N- or C-terminal arginine for the assembly of backbone cyclic peptides.

Different types of dipeptide building units containing N- or C-terminal arginine were prepared for synthesis of the backbone cyclic analogues of the peptide hormone bradykinin (BK: Arg-Pro-Pro-Gly-Phe-Ser-Pro-Phe-Arg). For cyclization in the N-terminal sequence N-carboxyalkyl and N-aminoalkyl functionalized dipeptide building units were synthesized. In order to avoid lactam formation during the condensation of the N-terminal arginine to the N-alkylated amino acids at position 2, the guanidino function has to be deprotected. The best results were obtained by coupling Z-Arg(Z)2-OH with TFFH/collidine in DCM. Another dipeptide building unit with an acylated reduced peptide bond containing C-terminal arginine was prepared to synthesize BK-analogues with backbone cyclization in the C-terminus. To achieve complete condensation to the resin and to avoid side reactions during activation of the arginine residue, this dipeptide unit was formed on a hydroxycrotonic acid linker. HYCRAM technology was applied using the Boc-Arg(Alloc)2-OH derivative and the Fmoc group to protect the aminoalkyl function. The reduced peptide bond was prepared by reductive alkylation of the arginine derivative with the Boc-protected amino aldehyde, derived from Boc-Phe-OH. The best results for condensation of the branching chain to the reduced peptide bond were obtained using mixed anhydrides. Both types of dipeptide building units can be used in solid-phase synthesis in the same manner as amino acid derivatives.

Cartographic mapping of health data.

Health is a primary, individual interest of the population. The observation of health standard and health risks requires the consideration of geographical information. The cartographic visualization of health data is used to show spatial relations and correlations. A presupposition is that health data has local references. There are various local references: the local reference by domicile is most important in investigating the spatio-temporal occurrence, the geographically spread, the intensity and temporal periodicity of diseases. Cartographic visualization allows a quick and intuitive recognition of the situation in a geographical region.

New thrombin inhibitors based on D-cha-Pro-derivatives.

A series of new analogs with modifications in the C-terminal residue were prepared based on the known thrombin inhibitor D-Phe-Pro-agmatine. These include several compounds alkylated at the N delta-, N omega- and N omega'-atoms of the guanidino group and a number of inhibitors derived from commercially available diamines. All analogs with alkylation of the guanidino group showed very poor activity. In contrast, the most potent and selective inhibitor with a cyclic and basic residue in the P1-position was found to be Ph-CH2-SO2-D-Cha-Pro-4-(amidomethyl) amidinopiperidine 11 with a Ki of 0.27 nM. In addition, a number of compounds were synthesized, in which the basic amidino group of the P1-residue was replaced by a hydroxyl group. Although the inhibition constants of these phenol derivatives showed still remarkable potency (16, Ki = 130 nM), their activity in clotting assays was strongly reduced.

Bradykinin antagonists with dehydrophenylalanine analogues at position 5.

Continuing the studies on structural requirements of bradykinin antagonists, it has been found that analogues with dehydrophenylalanine (deltaPhe) or its ring-substituted analogues (deltaPhe(X)) at position 5 act as antagonists on guinea pig pulmonary artery, and on guinea pig ileum. Because both organs are considered to be bradykinin B2 receptor tissues, the analogues with deltaPhe or deltaPhe(X) at position 5, but without any replacement at position 7, seem to represent a new structural type of B2 receptor antagonist. All the analogues investigated act as partial antagonists; they inhibit the bradykinin-induced contraction at low concentrations and act as agonists at higher concentrations. Ring substitutions by methyl groups or iodine reduce both the agonistic and antagonistic activity. Only substitution by fluorine gives a high potency. Incorporation of deltaPhe into different representative antagonists with key modifications at position 7 does not enhance the antagonist activity of the basic structures, with one exception. Only the combination of deltaPhe at position 5 with DPhe at position 7 increases the antagonistic potency on guinea pig ileum by about one order of magnitude. Radioligand binding studies indicate the importance of position 5 for the discrimination of B2 receptor subtypes. The binding affinity to the low-affinity binding site (KL) was not significantly changed by replacement of Phe by deltaPhe. In contrast, ring-methylation of deltaPhe results in clearly reduced binding to KL. The affinity to the high-affinity binding site (KH) was almost unchanged by the replacement of Phe in position 5 by deltaPhe, whereas the analogue with 2-methyl-dehydrophenylalanine completely failed to detect the KH-site. The peptides were synthesized on the Wang-resin according to the Fmoc/Bu(t) strategy using Mtr protection for the side chain of Arg. The dehydrophenylalanine analogues were prepared by a strategy involving PyBop couplings of the dipeptide unit Fmoc-Gly-deltaPhe(X)-OH to resin-bound fragments.

Bioethics for clinicians: 5. Substitute decision-making.

Substitute decision-making is a means of making health care decisions on behalf of people who are incapable of making these decisions for themselves. It is based on the ethical principle of respect for autonomy. Substitute decision-making poses two main questions: Who-should make the decision for the incapable person, and, How should the decision be made? Because the applicable statutory and common law varies across Canada, clinicians should become familiar with the legal requirements of their own province or territory.

A new type of bradykinin B2 receptor antagonists: bradykinin analogs with N-alkyl amino acids at position 2.

It is commonly assumed that bradykinin B2 receptor antagonists bind to a receptor site partially different from that for agonists. Thus, it is likely that there exists more than one key modification to convert bradykinin receptor agonists into antagonists. In this respect, [L-NMePhe2]-BK represents the basic structure of a new type of bradykinin B2 receptor antagonists without any replacement at position 7. This compound inhibits both in vitro bradykinin-induced contraction of the guinea pig lung strip and in vivo bradykinin-induced bronchoconstriction. Furthermore, this analog shows analgesic activity, blocks in a dose-dependent manner the bradykinin-induced Ca2+ release from macrophages and inhibits at a concentration of 10(-13) M the bradykinin-induced cytokine release from mononuclear cells. Combinations with structural modifications previously performed for other B2 receptor antagonists rather reduce than enhance the potency.

A comparative immunocytochemical study using an antiserum against a synthetic analogue of the corpora cardiaca peptide Pea-CAH-I (MI, neurohormone D) of Periplaneta americana.

An antiserum against the octapeptide Pea-CAH-I, a member of the adipokinetic hormone/red pigment-concentrating hormone family, has been produced for immunocytochemical staining in insects and various other invertebrate species. The anti-Pea-CAH-I serum stains the glandular corpora cardiaca cells of those insect species that synthesize identical or structurally similar peptides. In the corpora cardiaca of species producing peptides with a different C-terminus, these cells remain unstained. Pea-CAH-I-like immunoreactivity has also been found in neurons of the central nervous system of all invertebrate orders studied. The antiserum recognizes the C-terminal sequence Pro-Asn-Trp-NH2 of the Pea-CAH-I molecule as established by enzyme immunoassay. The widespread Pea-CAH-I-like immunoreactivity in all nervous systems of the studied animals probably does not reflect the presence of Pea-CAH-I but the occurrence of peptides carrying similar epitopes.

Design, synthesis and characterization of bradykinin antagonists via cyclization of the modified backbone.

With the aim of synthesizing cyclic antagonists of the nonapeptide hormone bradykinin with minimal side chain modification, we performed backbone to backbone and backbone to side chain cyclization. To probe and compare different strategies for this new kind of cyclization, the branched peptide bonds were formed by both reductive alkylation on the solid phase and by using preformed building units. Lactam bridges between the modified amide groups were formed by the use of the phenylalanine derivatives N(CH2COOH)Phe and N(CH2CH2NH2)Phe. The best results in the formation of the N-alkylamide bond were obtained with the coupling reagent PyBrop. The coupling rate was monitored by estimation of the N-terminal Fmoc-group. The cyclization was performed on the solid support. Unexpected difficulties resulted from the instability of the N-alkylamide bond under strong acidic conditions, as used for deprotection and for removal from the resin. We synthesized peptides with backbone to backbone cyclization between positions 2 and 5, as well as backbone to side chain cyclizations between positions 0 and 5, and between 2 and 6. The relatively high biological activities of some of the cyclic analogues support the supposed receptor-bound conformation of bradykinin antagonists with a beta-turn in the N-terminal sequence.

Hydrolysis of peptide esters by different enzymes.

The combined use in peptide synthesis of the Fmoc-group with methyl, benzyl or p-nitro benzyl esters is not practical because of the elimination of the Fmoc-group under basic conditions and by catalytic hydrogenation. Nevertheless the solution synthesis of peptides requires those combinations in some cases. For this purpose we have investigated enzymatic hydrolysis of some tri and tetrapeptide esters. The hydrolysis were carried out under pH-control. We measured deprotection of the carboxyl group by thermitase, porcine liver esterase, carboxypeptidase A and alpha-chymotrypsin. The main problems are to suppress proteolytic degradation of the peptide bond and to bring the protected peptides into solution. To solve both problems we used dimethylformamide and dimethylsulfoxide as cosolvents. The ratios between esterolytic and proteolytic activity were estimated under various cosolvent concentrations. Advantages of this method are to avoid side reactions of alkaline instable side chains (e.g. asparagine, glutamine), cleavage of base labile protecting groups and racemization by alkaline saponification. The enzymatic deprotection was followed by HPLC, HPTLC and titration. On a preparative scale this method gives good yields and sufficiently pure products.

Preferred size of peptides that bind to H-2 Kb is sequence dependent.

The identification of naturally processed viral peptides reveals that major histocompatibility complex (MHC) class I epitopes are composed of nine or eight amino acid residues. Peptides eluted from H-2 Kb MHC class I molecules have been suggested, as a class, to be eight amino acid residues long. To assay for peptide-class I interactions, a stabilization assay described for surface labeled "empty" class I molecules was employed, but on biosynthetically labeled class I molecules. The Sendai virus nucleoprotein-derived octapeptide APGNYPAL does not bind and stabilize Kb molecules, whereas other octameric Kb-restricted peptides and the nonameric peptide FAPGNYPAL interact stably. We attribute the failure of Sendai octamer binding to the presence of proline in position two: replacement of proline renders the resulting octamers as efficient as FAPGNYPAL for binding and stabilization of H-2 Kb. Substitution of glycine in position three of APGNYPAL slightly improves its Kb stabilizing capacity. Iodination of the tyrosine residue significantly alters the binding properties of the nonamer peptide. We conclude that the length of epitopes as selected by the class I Kb molecule is influenced by their sequence and suggest that proper positioning of the NH2 terminus of peptides is essential for class I stabilizing properties. The ability to stabilize newly synthesized "empty" class I molecules with peptide argues against an involvement of beta 2 microglobulin exchange in the experiments described here.

[Obstetric and ethical-legal problems in a twin pregnancy with anencephalus and polyhydramnios of the leading twin beyond the 28th week of pregnancy]. / Geburtshilfliche und ethisch-juristische Problematik bei einer Geminigravidität mit Anenzephalus und Polyhydramnion des führenden Zwilling I jenseits von 28 Schwangerschaftswochen.

Malformations are found twice as often in twins than in singletons. In the following case, we report on a twin pregnancy with anencephaly and polyhydramnion of the leading twin I, which was first diagnosed after 28 weeks of pregnancy. The foetal disease of twin I led to an appreciable dyspnoea of the mother that exacerbated to an incipient respiratory failure by the thirty-second week of pregnancy. The projected termination of pregnancy by Caesarean section based on a maternal indication was not performed, but instead a selective foetocide of the diseased twin. The live twin was delivered spontaneously without complications after thirty-eight weeks of pregnancy. The obstetric and legal ethical problems are discussed.