The prospective Hemophilia Inhibitor PUP Study reveals distinct antibody signatures prior to FVIII inhibitor development.

Preventing factor VIII (FVIII) inhibitors following replacement therapies with FVIII products in patients with hemophilia A remains an unmet medical need. Better understanding of the early events of evolving FVIII inhibitors is essential for risk identification and the design of novel strategies to prevent inhibitor development. The Hemophilia Inhibitor Previously Untreated Patients (PUPs) Study (HIPS; www.clinicaltrials.gov #NCT01652027) is the first prospective cohort study to evaluate comprehensive changes in the immune system during the first 50 exposure days (EDs) to FVIII in patients with severe hemophilia A. HIPS participants were enrolled prior to their first exposure to FVIII or blood products ("true PUPs") and were evaluated for different immunological and clinical parameters at specified time points during their first 50 EDs to a single source of recombinant FVIII. Longitudinal antibody data resulting from this study indicate that there are 4 subgroups of patients expressing distinct signatures of FVIII-binding antibodies. Subgroup 1 did not develop any detectable FVIII-binding immunoglobulin G (IgG) antibodies. Subgroup 2 developed nonneutralizing, FVIII-binding IgG1 antibodies, but other FVIII-binding IgG subclasses were not observed. Subgroup 3 developed transient FVIII inhibitors associated with FVIII-binding IgG1 antibodies, similar to subgroup 2. Subgroup 4 developed persistent FVIII inhibitors associated with an initial development of high-affinity, FVIII-binding IgG1 antibodies, followed by IgG3 and IgG4 antibodies. Appearance of FVIII-binding IgG3 was always associated with persistent FVIII inhibitors and the subsequent development of FVIII-binding IgG4. Some of the antibody signatures identified in HIPS could serve as candidates for early biomarkers of FVIII inhibitor development.

[Late complications following neo-/adjuvant radiotherapy and surgery for sarcomas of the extremities or pelvis/retroperitoneum : Preventative measures]. / Spätkomplikationen nach neo-/adjuvanter Strahlentherapie und Resektion von Sarkomen der Extremitäten oder des Beckens/Retroperitoneums : Ansätze zur Prävention.

Radiotherapy is one of the pillars in the multimodal therapy of sarcomas of the extremities or pelvis/retroperitoneum. It can be delivered prior to or following surgery. Novel radiation techniques, such as intensity-modulated radiotherapy using high-energy photons or protons, contribute to the reduction of acute and late toxicities. This review article summarizes these concepts.

[Biopsy of musculoskeletal tumors : Complications and avoidable errors]. / Biopsie muskuloskeletaler Tumoren : Komplikationen und vermeidbare Fehler.

Biopsy followed by histopathological assessment is the key procedure to establish the correct diagnosis of unclear bone or soft tissue tumors. There are several possibilities to obtain a biopsy specimen. The indication for biopsy should be established in a specialized center, as should the type of biopsy (fine needle, incisional, excisional, percutaneous CT-guided/navigated biopsy), which must be performed according to established guidelines. The tumor biopsy must be representative and adequate in terms of quantity, to enable a conclusive histopathological diagnosis and planning of appropriate treatment. For the correct biopsy tract, the surgical approach for definitive resection must be considered; thus, biopsy should be conducted in the center where the subsequent resection will be performed. Of note, patients whose biopsy is performed at a specialized musculoskeletal tumor center benefit in terms of improved local tumor control.

[Complication profile and revision concepts for megaprosthetic reconstruction following tumour resection at the hip]. / Komplikationsprofil und Revisionsstrategien nach Tumorspezialendoprothetik am Hüftgelenk.

BACKGROUND: Tumourous destruction of the periacetabular region and the proximal femur is a typical consequence of either primary malignant bone tumour manifestation or skeletal metastatic diseases. Pathological fractures of the proximal femur and periacetabular regions due to primary manifestation or metastatic disorders are frequent. OBJECTIVES: Presentation of the most common complications of tumour endoprostheses at the hip and a description of management strategies, including therapeutic recommendations and concepts for complication avoidance. MATERIALS AND METHODS: The current knowledge and our own experience of complication management with the use of megaprostheses around the hip are presented. RESULTS: Compared to elective/primary total hip arthroplasty, megaprosthetic reconstructions following tumour resections have an increased rate of postoperative deep infections, dislocations, incidence of pathological and periprosthetic fractures and of deep vein thrombosis. The postoperative mortality and local tumour recurrence along with deep infections represent the most serious complications. CONCLUSIONS: In comparison to primary arthroplasty, the risk of failure and complications following tumour-endoprosthetic replacement is increased. Precise surgical planning and careful selection and preoperative preparation of suitable patients should be performed in close interdisciplinary cooperation with final decision-making on an interdisciplinary tumour board. Wide resection and advanced reconstruction, as well as complicated palliative stabilization due to malignant bone tumour growth around the hip joint should be performed in musculoskeletal tumour centres with profound expertise in osteosynthetic and endoprosthetic reconstruction and consecutive complication management of the pelvis and the proximal femur.

[Management of complications following tumor endoprosthetic replacement]. / Komplikationsmanagement nach Tumorendoprothesen.

BACKGROUND: Tumor endoprostheses are available as modular systems with which bone defects can be partially reconstructed, usually close to the joints, or as a total replacement of long tubular bones. As a result of continuously improved survival times, they are used with bone tumors, skeletal metastases and, increasingly, in revision arthroplasty. OBJECTIVES: Presentation of the most common complications of tumor endoprostheses and a description of their management, including treatment recommendations. MATERIALS AND METHODS: The current knowledge and our own experience of complication management with the use of megaprostheses are presented. RESULTS: The number of tumor endoprostheses procedures is limited, so that a limited number of studies and classifications are available. Periprosthetic infections involving the soft tissues represent the most serious failure after perioperative dying and local recurrence of the tumor. Two-stage revision remains the gold standard in periprosthetic infection, even if one-stage revision is justifiable in selective indications. Periprosthetic infection and local recurrence is associated with the risk of secondary amputations. Mechanical failure can be treated more easily. Specific socket systems for proximal femoral replacement and attachment tubing allow for adequate soft tissue reconstruction, restoration of joint function, and minimize the risk of dislocation. CONCLUSIONS: In comparison to primary arthroplasty, the risk of failure following tumor endoprosthetic replacement is increased but is basically controllable by revision surgery.

[Benign tumours and tumour-like lesions of the bone : General treatment principles]. / Benigne Tumoren und tumorähnliche Läsionen des Knochens : Allgemeine Behandlungsprinzipien.

BACKGROUND: Benign bone lesions are much more common than malignant lesions. Some benign bone tumors have a characteristic and typical radiographic appearance, while others are more challenging. Therapy of benign bone tumors differs greatly. While the majority of benign bone tumors do not require surgical therapy, other specific lesions, e. g. aneurysmal bone cysts or giant cell tumors (GCT) of the bone require surgery due to their locally aggressive behavior. DIAGNOSTICS: The major challenge for the radiologist and/or pathologist is the differentiation between a benign and low-grade malignant lesion (e. g. enchondroma versus low-grade chondrosarcoma) for which all available clinical and radiographic information is mandatory. Therefore, surgical therapy is rather more often performed than necessary due to uncertainty in many cases. THERAPY: Novel systemic therapies are available for fibrous dysplasia and GCT of the bone: Fibrous dysplasia can be treated with bisphosphonates, and GCT responds to denosumab. In fact, denosumab has been approved for the treatment of irresectable GCT. Osteoid osteoma is fairly easy to recognize and also to treat given the characteristic clinical presentation and rapid and effective response to local therapy (possible as percutaneous thermo-/laser ablation). In summary, several therapeutic options exist for benign bone tumors, and the choice depends upon the tendency/risk of local recurrence, the rate of surgical complications, options for defect reconstruction, postoperative functional deficits, and specific patient characteristics.

Effects of insulin therapy on porosity, non-enzymatic glycation and mechanical competence in the bone of rats with type 2 diabetes mellitus.

Type 2 diabetes mellitus increases skeletal fragility; however, the contributing mechanisms and optimal treatment strategies remain unclear. We studied the effects of diabetes and insulin therapy on non-enzymatic glycation (NEG), cortical porosity (Ct.Po) and biomechanics of the bone tissue in Zucker Diabetic Fatty (ZDF) rats. Eleven-week old ZDF diabetic and non-diabetic rats were given insulin to achieve glycaemic control or vehicle seven days per week over twelve weeks (insulin dose adapted individually 0.5 international units (IU) at week 1 to 13.0IU at week 12). The right femora were excised, micro-CT scanned, and tested in 3-point bending to measure biomechanics. NEG of the midshaft was determined from bulk fluorescence. Diabetes led to increased NEG (+50.1%, p=0.001) and Ct.Po (+22.9%, p=0.004), as well as to reduced mechanical competence (max. stress: -14.2%, p=0.041, toughness: -29.7%, p=0.016) in the bone tissue. NEG and Ct.Po both correlated positively to serum glucose (NEG: R(2)=0.41, p<0.001, Ct.Po: R(2)=0.34, p=0.003) and HbA1c (NEG: R(2)=0.42, p<0.001, Ct.Po: R(2)=0.28, p=0.008) levels, while NEG correlated negatively with bone biomechanics (elastic modulus: R(2)=0.21, p=0.023, yield stress: R(2)=0.17, p=0.047). Twelve weeks of insulin therapy had no significant effect on NEG or Ct.Po, and was unable to improve the mechanical competence of the bone tissue. A reduction of mechanical competence was observed in the bone tissue of the diabetic rats, which was explained in part by increased collagen NEG. Twelve weeks of insulin therapy did not alter NEG, Ct.Po or bone biomechanics. However, significant correlations between NEG and serum glucose and HbA1c were observed, both of which were reduced with insulin therapy. This suggests that a longer duration of insulin therapy may be required to reduce the NEG of the bone collagen and restore the mechanical competence of diabetic bone.

Effects of parathyroid hormone on cortical porosity, non-enzymatic glycation and bone tissue mechanics in rats with type 2 diabetes mellitus.

Type 2 diabetes mellitus increases skeletal fragility; however, the contributing mechanisms and the efficacy of bone-forming agents are unclear. We studied diabetes and parathyroid hormone (PTH) treatment effects on cortical porosity (Ct.Po), non-enzymatic glycation (NEG) and bone mechanics in Zucker diabetic fatty (ZDF) rats. Eleven-week old ZDF diabetic (DB) and non-diabetic (ND) rats were given 75µg/kg PTH (1-84) or vehicle 5days per week over 12weeks. The right femora and L4 vertebrae were excised, micro-CT scanned, and tested in 3-point bending and uniaxial compression, respectively. NEG of the samples was determined using fluorescence. Diabetes increased Ct.Po (vertebra (vert): +40.6%, femur (fem): +15.5% vs. ND group, p<0.05) but had no effect on NEG. PTH therapy reduced vertebral NEG in the ND animals only (-73% vs untreated group, p<0.05), and increased femoral NEG in the DB vs. ND groups (+63%, p<0.05). PTH therapy had no effect on Ct.Po. Diabetes negatively affected bone tissue mechanics where reductions in vertebral maximum strain (-22%) and toughness (-42%) were observed in the DB vs. ND group (p<0.05). PTH improved maximum strain in the vertebra of the ND animals (+21%, p<0.05) but did not have an effect in the DB group. PTH increased femoral maximum strain (+21%) and toughness (+28%) in ND and decreased femoral maximum stress (-13%) and toughness (-27%) in the DB animals (treated vs. untreated, p<0.05). Ct.Po correlated negatively with maximum stress (fem: R=-0.35, p<0.05, vert: R=-0.57, p<0.01), maximum strain (fem: R=-0.35, p<0.05, vert: R=-0.43, p<0.05) and toughness (fem: R=-0.34, p<0.05, vert: R=-0.55, p<0.01), and NEG correlated negatively with toughness at the femur (R=-0.34, p<0.05) and maximum strain at the vertebra (R=-0.49, p<0.05). Diabetes increased cortical porosity and reduced bone mechanics, which were not improved with PTH treatment. PTH therapy alone may worsen diabetic bone mechanics through formation of new bone with high AGEs cross-linking. Optimal treatment regimens must address both improvements of bone mass and glycemic control in order to successfully reduce diabetic bone fragility. This article is part of a Special Issue entitled "Bone and diabetes".

Bone defect regeneration and cortical bone parameters of type 2 diabetic rats are improved by insulin therapy.

Zucker Diabetic Fatty (ZDF) rats represent an established model of type 2 diabetes mellitus (T2DM) and display several features of human diabetic bone disease, including impaired osteoblast function, decreased bone strength, and delayed bone healing. Here, we determined whether glycemic control by insulin treatment prevents skeletal complications associated with diabetes. Subcritical femur defects were created in diabetic (fa/fa) and non-diabetic (+/+) ZDF rats. Diabetic rats were treated once daily with long-lasting insulin glargin for 12weeks for glycemic control. Insulin treatment successfully maintained serum levels of glycated hemoglobin, while untreated diabetic rats showed a 2-fold increase. Trabecular and cortical bone mass measured by µCT were decreased in diabetic rats. Insulin treatment increased bone mass of the cortical, but not of the trabecular bone compartment. Dynamic histomorphometry revealed a lower bone formation rate at the trabecular and periosteal cortical bone in diabetic animals and decreased serum procollagen type 1 N-terminal propeptide (P1NP, -49%) levels. Insulin treatment partially improved these parameters. In T2DM, serum levels of tartrate-resistant acid phosphatase (TRAP, +32%) and C-terminal telopeptide (CTX, +49%) were increased. Insulin treatment further elevated TRAP levels, but did not affect CTX levels. While diabetes impaired bone defect healing, glycemic control with insulin fully reversed these negative effects. In conclusion, insulin treatment reversed the adverse effects of T2DM on bone defect regeneration in rats mainly by improving osteoblast function and bone formation. This article is part of a Special Issue entitled Bone and diabetes.

Temporal patterns of digestive enzyme activities and feeding rate in gammarids (Gammarus fossarum) exposed to inland polluted waters.

The aim of this study was to use digestive enzyme activities in Gammarus fossarum as biomarkers during active biomonitoring. Standardised gammarids were transplanted for 7 days to five sites in the Riou Mort watershed contaminated by polymetallic pollution. This experiment was conducted on seven different dates from February 2009 to June 2010. Feeding rates were tracked, along with amylase, cellulase and trypsin activities. We found that feeding rate and digestive capacity were reduced in the most polluted site, "Joany," in comparison with the reference site "Up.Lot". The results suggested that trypsin was more sensitive than the other two carbohydrases. In the four other sites, seasonal differences were observed during the 2yr but no clear pattern can be established. This study highlights the ability of G. fossarum to demonstrate environmental disturbances and suggests the use of a caging process in certain seasons. Caging organisms and feeding ad libitum is advantageous, as it reduces inter-individual variability and removes dependence on the native food fluctuations. However, confounding factors other than temperature were present, and the interpretation of digestive enzyme activities is complex.

Late mesh rejection as a complication to transabdominal preperitoneal laparoscopic hernia repair.

BACKGROUND: The use of a mesh in transabdominal preperitoneal laparoscopic hernia repair (TAPP) caries the risk of late rejection or infectious complications related to the mesh. The aim of this study was to describe the extent of these complications. METHODS: We performed a retrospective study of 500 consecutive patients with TAPP for inguinal hernia. RESULTS: Late mesh rejection was observed in three patients at 5-19 months after surgery. The mesh was removed via a suprapubic midline incision. At 3-4 month's follow-up, none of the patients had recurrence of the hernia, even though no hernia repair had been done. CONCLUSION: Late mesh rejection is a potential complication of TAPP and has to be considered when choosing the surgical method of hernia repair.

New international F.I.P. method for the determination of the activity of Aspergillus oryzae proteases.

Proteases of Aspergillus oryzae are used as a drug in the therapy of digestive disorders. To standardize these enzyme the Enzyme Commission of the Fédération Internationale Pharmaceutique (F.I.P.) has tested a new determination method, which will be described below. The standard preparation of a mixture of Aspergillus oryzae proteases used in this test is characterized.

Fusion characteristics of influenza C viruses.

A number of different influenza C virus strains were tested for their fusion properties using a resonance energy assay which allows direct monitoring of fusion between virus membranes and artificial lipid vesicles. The fusion pH of various strains was found to range between 5.6 and 6.1. Haemolytic activity of the different strains with chicken erythrocytes was observed at slightly lower pH values and varied between 5.1 and 5.7. Studies of the kinetics of influenza C virus fusion showed distinct characteristics in fusion activity. A lag before onset of fusion was found with influenza C virus which was not observed for influenza A or B viruses. In addition, studies on the rate of conformational change of the influenza C virus glycoprotein, as determined by morphological changes and endogenous tryptophan fluorescence, suggest that the conformational change is rate-limiting in the fusion process, whereas for influenza A viruses the glycoprotein conformational change is fast and a later step in the fusion process is rate-limiting. Monitoring the conformational change of influenza C virus glycoprotein by the onset of trypsin susceptibility showed, however, that membrane fusion occurred in some cases without onset of trypsin susceptibility, indicating that the trypsin-susceptible conformation is a post-fusogenic conformation.