PUM1 and PGK1 are Favorable Housekeeping Genes over Established Biodosimetry-related Housekeeping Genes such as HPRT1, ITFG1, DPM1, MRPS5, 18S rRNA and Others after Radiation Exposure.

In gene expression (GE) studies, housekeeping genes (HKGs) are required for normalization purposes. In large-scale inter-laboratory comparison studies, significant differences in dose estimates are reported and divergent HKGs are employed by the teams. Among them, the 18S rRNA HKG is known for its robustness. However, the high abundance of 18S rRNA copy numbers requires dilution, which is time-consuming and a possible source of errors. This study was conducted to identify the most promising HKGs showing the least radiation-induced GE variance after radiation exposure. In the screening stage of this study, 35 HKGs were analyzed. This included selected HKGs (ITFG1, MRPS5, and DPM1) used in large-scale biodosimetry studies which were not covered on an additionally employed pre-designed 96-well platform comprising another 32 HKGs used for different exposures. Altogether 41 samples were examined, including 27 ex vivo X-ray irradiated blood samples (0, 0.5, 4 Gy), six X-irradiated samples (0, 0.5, 5 Gy) from two cell lines (U118, A549), as well as eight non-irradiated tissue samples to encompass multiple biological entities. In the independent validation stage, the most suitable candidate genes were examined from another 257 blood samples, taking advantage of already stored material originating from three studies. These comprise 100 blood samples from ex vivo X-ray irradiated (0-4 Gy) healthy donors, 68 blood samples from 5.8 Gy irradiated (cobalt-60) Rhesus macaques (RM) (LD29/60) collected 0-60 days postirradiation, and 89 blood samples from chemotherapy-(CTx) treated breast tumor patients. CTx and radiation-induced GE changes in previous studies appeared comparable. RNA was isolated, converted into cDNA, and GE was quantified employing TaqMan assays and quantitative RT-PCR. We calculated the standard deviation (SD) and the interquartile range (IQR) as measures of GE variance using raw cycle threshold (Ct) values and ranked the HKGs accordingly. Dose, time, age, and sex-dependent GE changes were examined employing the parametrical t-test and non-parametrical Kruskal Wallis test, as well as linear regression analysis. Generally, similar ranking results evolved using either SD or IQR GE measures of variance, indicating a tight distribution of GE values. PUM1 and PGK1 showed the lowest variance among the first ten most suitable genes in the screening phase. MRPL19 revealed low variance among the first ten most suitable genes in the screening phase only for blood and cells, but certain comparisons indicated a weak association of MRPL19 with dose (P = 0.02-0.09). In the validation phase, these results could be confirmed. Here, IQR Ct values from, e.g., X-irradiated blood samples were 0.6 raw Ct values for PUM1 and PGK1, which is considered to represent GE differences as expected due to methodological variance. Overall, when compared, the GE variance of both genes was either comparable or lower compared to 18S rRNA. Compared with the IQR GE values of PUM1 and PGKI, twofold-fivefold increased values were calculated for the biodosimetry HKG HPRT1, and comparable values were calculated for biodosimetry HKGs ITFG1, MRPS5, and DPM1. Significant dose-dependent associations were found for ITFG1 and MRPS5 (P = 0.001-0.07) and widely absent or weak (P = 0.02-0.07) for HPRT1 and DPM1. In summary, PUM1 and PGK1 appeared most promising for radiation exposure studies among the 35 HKGs examined, considering GE variance and adverse associations of GE with dose.

Inter-laboratory comparison of gene expression biodosimetry for protracted radiation exposures as part of the RENEB and EURADOS WG10 2019 exercise.

Large-scale radiation emergency scenarios involving protracted low dose rate radiation exposure (e.g. a hidden radioactive source in a train) necessitate the development of high throughput methods for providing rapid individual dose estimates. During the RENEB (Running the European Network of Biodosimetry) 2019 exercise, four EDTA-blood samples were exposed to an Iridium-192 source (1.36 TBq, Tech-Ops 880 Sentinal) at varying distances and geometries. This resulted in protracted doses ranging between 0.2 and 2.4 Gy using dose rates of 1.5-40 mGy/min and exposure times of 1 or 2.5 h. Blood samples were exposed in thermo bottles that maintained temperatures between 39 and 27.7 °C. After exposure, EDTA-blood samples were transferred into PAXGene tubes to preserve RNA. RNA was isolated in one laboratory and aliquots of four blinded RNA were sent to another five teams for dose estimation based on gene expression changes. Using an X-ray machine, samples for two calibration curves (first: constant dose rate of 8.3 mGy/min and 0.5-8 h varying exposure times; second: varying dose rates of 0.5-8.3 mGy/min and 4 h exposure time) were generated for distribution. Assays were run in each laboratory according to locally established protocols using either a microarray platform (one team) or quantitative real-time PCR (qRT-PCR, five teams). The qRT-PCR measurements were highly reproducible with coefficient of variation below 15% in ≥ 75% of measurements resulting in reported dose estimates ranging between 0 and 0.5 Gy in all samples and in all laboratories. Up to twofold reductions in RNA copy numbers per degree Celsius relative to 37 °C were observed. However, when irradiating independent samples equivalent to the blinded samples but increasing the combined exposure and incubation time to 4 h at 37 °C, expected gene expression changes corresponding to the absorbed doses were observed. Clearly, time and an optimal temperature of 37 °C must be allowed for the biological response to manifest as gene expression changes prior to running the gene expression assay. In conclusion, dose reconstructions based on gene expression measurements are highly reproducible across different techniques, protocols and laboratories. Even a radiation dose of 0.25 Gy protracted over 4 h (1 mGy/min) can be identified. These results demonstrate the importance of the incubation conditions and time span between radiation exposure and measurements of gene expression changes when using this method in a field exercise or real emergency situation.

[A glimpse into the future: smart technologies and enhanced recovery after surgery (ERAS)]. / Blick in die Zukunft: smarte Technologien und ERAS ("enhanced recovery after surgery").

Smart technologies facilitate our daily life in many respects, e.g. by rendering travel safer. In medicine, however, they have so far hardly been used, even though the demographic changes with an aging population in small or single households warrant an urgent change of our traditional care structures. Furthermore, patients are more demanding and better informed than they were a few decades ago. Enhanced recovery after surgery (ERAS) focusses on good prehabilitation as well as fast rehabilitation and therefore represents, even almost 20 years after the first publication, a modern and evidence-based treatment concept. Nevertheless, it is still not comprehensively implemented nationwide. The reasons for this may be concerns regarding an early discharge. In addition, there is often a gap in care care between discharge from hospital and start of the follow-up rehabilitation. In order to improve acceptance of the ERAS concept, to fulfil the patients' needs for better information while decreasing the workload of the medical staff and to close the gap in care after discharge from hospital, integrating ERAS into the concept of a smart hospital with subsequent transition into a temporary smart home is an appealing idea. With the use of an individually configurated online learning platform, a large part of the information flow can be transferred from the outpatient clinic to the pre-outpatient area (i.e. the patient's home). Consequently, patients will be better prepared for their first contact with the hospital. After a short stay in hospital the patient is then discharged into the serviced apartments of the smart quarter, where a stress-free recovery in a home-like environment is possible. The further rehabilitation is undertaken there under virtual guidance, following individualized schedules on demand.

Predicting the Radiation Sensitivity of Male and Female Rhesus Macaques Using Gene Expression.

Radiosensitivity differs in humans and likely among closely-related primates. Reasons for variation in radiosensitivity are not well known. We examined preirradiation gene expression in peripheral blood among male and female rhesus macaques which did or did not survive (up to 60 days) after whole-body irradiation with 700 cGy (LD66/60). RNA samples originated from a blinded randomized Good Laboratory Practice study in 142 irradiated rhesus macaques. Animals were untreated (placebo), or treated using recombinant human IL-12, G-CSF or combination of the two. We evaluated gene expression in a two-phase study design where phase I was a whole genome screen [next generation sequencing (NGS)] for mRNAs (RNA-seq) using five RNA samples from untreated male and female animals per group of survivor and non-survivor (total n = 20). Differential gene expression (DGE) was defined as a statistically significant and ≥2-fold up- or downregulation of mRNA species and was calculated between groups of survivors and non-survivors (reference) and by gender. Altogether 659 genes were identified, but the overlapping number of differentially expressed genes (DGE) observed in both genders was small (n = 36). Fifty-eight candidate mRNAs were chosen for independent validation in phase II using the remaining samples (n = 122) evaluated with qRT-PCR. Among the 58 candidates, 16 were of significance or borderline significance (t test) by DGE. Univariate and multivariate logistic regression analysis and receiver operating characteristic (ROC) curve analysis further refined and identified the most outstanding validated genes and gene combinations. For untreated male macaques, we identified EPX (P = 0.005, ROC=1.0), IGF2BP1 (P = 0.05, ROC=0.74) and the combination of EPX with SLC22A4 (P = 0.03, ROC=0.85) which appeared most predictive for the clinical outcome for treated and combined (untreated and treated) male macaque groups, respectively. For untreated, treated and both combined female macaque groups the same gene (MBOAT4, P = 0.0004, ROC = 0.81) was most predictive. Based on the probability function of the ROC curves, up to 74% of preirradiation RNA measurements predicted survival with a positive and negative predictive value ranging between 85-100% and associated odds ratios reflecting a 2-3-fold elevated risk for surviving per unit change (cycle threshold value) in gene expression. In conclusion, we identified gender-dependent genes and gene combinations in preirradiation blood samples for survival prediction after irradiation in rhesus macaques.

Differentiating Total- or Partial-Body Irradiation in Baboons Using mRNA Expression Patterns: A Proof of Concept.

To better predict clinical outcome after radiation exposure, it is very important to know the absorbed dose and body areas exposed. Previously we found that 22 miRNAs appeared to predict total- and partial-body irradiation (TBI and PBI, respectively) patterns and were suggestive of the percentage of the body exposed in a baboon model. Motivated by these results, we performed a similar analysis on the transcriptional level (mRNAs) using whole genome microarrays. From 17 irradiated baboons, blood samples were taken before, and at 1, 2, 7, 28 and 75-106 days postirradiation to an equivalent TBI dose of 2.5 or 5 Gy applied either to the total body or to different parts of the body such as the upper body (UBE) or left hemibody (LHB). We compared quantile normalized log2-transformed gene expression values with three exposure pattern comparisons, namely TBI vs. PBI, TBI vs. LHB and UBE vs. LHB using Kruskal-Wallis and logistic regression analysis for receiver-operator characteristic (ROC) calculation. We found several hundred significantly (P < 0.05) and ≥2-fold deregulated mRNAs per exposure pattern comparison with a peak of 163-860 mRNAs at day 28. Lower numbers on day 2 (60 mRNAs) and day 7 (91-162 mRNAs) were observed, with the lowest number of deregulated mRNAs at day 75-106 (22-58 mRNAs). The 14 most promising mRNAs (e.g., LTF, DEFA3, OLFM4) appeared 10.1-46.2-fold upregulated and the exposure groups were completely or almost completely discriminated (ROC between 0.8-1.0). Several of the mRNA gene expression changes were significantly associated with the percentage of the body exposed. The numbers of overlapping genes used for diagnosis on consecutive days postirradiation were mostly 0 or less than 10. Bioinformatic analysis confirmed that at each time point different biological processes predominated. Our results suggest mRNA changes over time may be used to retrospectively determine radiation exposure patterns as partial or total body. mRNA gene expression changes likely could be applied over a longer time frame (2-75 days postirradiation) than miRNA, but due to the transient gene expression changes a different set of candidate mRNAs appears to be required at each day after irradiation.

[Intraoperative completion diagnostics in open vascular surgery]. / Intraoperative Diagnostik in der offenen Gefäßchirurgie.

Intraoperative imaging diagnostics during open vascular surgical procedures aim to enhance diagnostic certainty during the operation, ensure quality control documentation and reduce avoidable complications; however, the evidence for the various diagnostic imaging procedures with respect to improvement of perioperative outcome is not confirmed for carotid endarterectomy or for infrainguinal bypass surgery. Nevertheless, an intraoperative diagnostic control is principally recommended. The advantage of intraoperative imaging is confirmed and essential for the surgical reconstruction of bypass occlusions and acute thromboembolic occlusions.

[Surgical treatment of peritoneal metastases of colorectal cancer]. / Chirurgische Therapie der Peritonealkarzinose kolorektaler Karzinome.

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) may significantly improve overall survival in selected patients with peritoneal metastases of colorectal cancer. For good oncological results complete macroscopic cytoreduction is crucial; furthermore, a linear correlation between peritoneal tumor load, as determined by the peritoneal cancer index (PCI) and overall survival has been demonstrated; therefore, surgical treatment should be initiated as early as possible. Synchronous resection of up to three liver metastases may be performed safely and with good results and no influence on the morbidity. With respect to intraperitoneal chemotherapy, mitomycin C and oxaliplatin are most commonly used and may be regarded as equal; however, for perioperative chemotherapy study results are so far inconclusive with some trials hinting at decreased overall survival following neoadjuvant chemotherapy. Adjuvant therapy is likely to improve overall survival if at least 6 cycles are applied. Early detection of peritoneal metastases is difficult at present but might be facilitated in the future by the use of liquid biopsies, which may detect circulating free tumor-specific DNA or RNA. In the meantime, planned second-look laparotomy should be considered for patients at high risk of peritoneal recurrence. In addition, several international studies are currently evaluating the concept of adjuvant or prophylactic HIPEC. The CRS and HIPEC may be repeated in cases of recurrence and should be considered in suitable patients, applying the same criteria as for primary CRS and HIPEC. A recurrence-free interval of >2 years is associated with a significantly better prognosis.

Which factors affect the long-term survival of patients with hepatocellular carcinoma UICC stage IV?

AIM: In the 7th edition of the TNM classification, not only HCC with distant metastases but also those with regional lymph node metastases are classified as stage IV. MATERIALS AND METHODS, RESULTS: From our prospectively recorded tumor registry, 138 patients (17 %) with HCC were in stage IV. Among those were 68 and 70, respectively, in stage IVA (regional lymph node metastases) and IVB (distant metastases). The tumors were less frequently treated with resection or local ablative treatment (chemoembolization, RFA, SIRT, percutaneous radiation) than patients in stage I-III. Ten HCCs were resected. Five of the resected patients were in stage IVA and five in stage IVB. After tumor resection, patients lived longer than those who underwent local or systemic treatment only (p = 0.003 or p = 0.001, respectively). In the univariate survival analysis, the stage IV patients' long-term survival was decreased statistically significantly through elevated bilirubin, low albumin, Okuda stage III and BCLC stage D. Patients' age and sex, pre-treatment AFP level, Child stage and the presence of venous invasion did not influence survival. In the multivariate analysis (Cox regression), tumor resection and BCLC stage were independent prognostic factors. CONCLUSION: Patients with HCC in TNM stage IV have a very poor prognosis. Only few patients are eligible for resection because of the extent of tumor growth, comorbidities and general condition. These, however, benefit markedly from tumor resection with lymph node dissection and possibly resection of distant metastases.

[Incidence of non-metastatic liver lesions in tumor patients: consequences for chemotherapy and local ablative procedures]. / Inzidenz nichtmetastatischer Leberläsionen bei Tumorpatienten: Konsequenzen für Chemotherapie und lokal-ablative Verfahren.

INTRODUCTION: Even in patients with a history of solid malignant tumors, especially of gastrointestinal origin, newly diagnosed solid liver lesions do not necessarily correspond to metastases of the respective primary tumor. A reliable diagnosis can only be made by definitive histological examination. MATERIAL AND METHODS: Data of all patients who underwent liver resection under the preoperative diagnosis of liver metastases between 1997 and 2011 and for whom liver specimens were examined histologically, were extracted from the prospectively maintained cancer registry. RESULTS: An unexpected histological result occurred in 47 out of 770 patients (6.1 %). Primary tumors in these patients included renal cell (n=12), colorectal (n=11), breast (n=8), gastric (n=4), pancreatic (n=3), skin (n=3) and other cancers (n=6). Liver lesions were diagnosed synchronously in 15 cases or metachronously after a median of 17 months following primary therapy in 32 patients. Histology revealed a benign tumor in 38 cases (81 %) as well as 6 cases of HCC, 2 cases of CCC and in 1 case metastasis of a previously unknown colorectal cancer in a patient with known esophageal carcinoma. Suspicion of metastatic disease was based on four different imaging modalities in two cases and on three different imaging modalities in nine cases. Either computed tomography (CT) or magnetic resonance imaging (MRI) was combined with ultrasound in another 23 patients and with positron emission tomography (PET) CT in 6 more cases. In two patients CT plus MRI and CT only, respectively, was performed. In the remaining three patients, suspicion of metastases occurred intraoperatively after macroscopic examination of the liver. Preoperative percutaneous biopsy was attempted in four patients with indeterminate results. CONCLUSION: Even with modern diagnostics the risk of treating a benign or other form of malignant tumor with neoadjuvant or palliative chemotherapy persists. The same holds true for local ablative procedures. Prior to local ablation or definitive palliative chemotherapy histological confirmation of metastases should be attempted.

[Diagnostic procedures and results in surgical therapy for cholangiocarcinoma]. / Diagnostisches Vorgehen und Ergebnisse in der chirurgischen Therapie von Gallenwegstumoren.

INTRODUCTION: Despite a rising incidence worldwide, cholangiocarcinoma (CCC) is one of the infrequent malignancies of the gastrointestinal tract. The surgical approach depends largely on the location of the tumour. PATIENTS AND METHODS: Since 1995, 425 consecutive patients with cholangiocarcinoma were seen at our hospital; their data were prospectively entered in our cancer registry. Tumour-specific data were now retrospectively analysed for prognostic value. RESULTS: Resection with primarily curative intent was performed in 183 of the 425 patients; resection rates were 36 % for intrahepatic (66 patients), 44 % for hilar (69 patients) and 56 % for distal cholangiocarcinoma (48 patients). R0-resection was achieved in 152 patients (83 %) and was found to be the most important factor determining survival. With respect to intrahepatic cholangiocarcinoma, clinical T3- and T4-categories, lymph node metastases as well as UICC stages III and IV had negative predictive value; in hilar carcinomas, this was only seen for the last two factors. In distal cholangiocarcinoma, a low degree of differentiation was associated with a poor prognosis. No differences in survival were seen in the presence of perineural infiltration, angioinvasion or elevation of tumour marker CA 19 - 9.  Regarding the surgical techniques, we found a survival benefit for limited liver resection in intrahepatic cholangiocarcinomas, which is explained by earlier tumour stages seen in these cases, as well as the performance of trisectionectomy or liver transplantation in hilar carcinomas. CONCLUSIONS: Comparable to other malignant gastrointestinal tumours, radical surgery represents the most important prognostic factor in cholangiocarcinomas; for hilar tumours, a survival advantage is seen after extended resections (trisectionectomy or liver transplantation) if compared to more limited resections. At the time of presentation, however, the stage of disease was incurable in most patients, thus accounting for the low overall resection rates.

[Portal vein embolisation prior to extended liver resection - current and future aspects]. / Pfortaderembolisation zur Konditionierung erweiterter Leberresektionen - aktueller Stand und Ausblick.

Extended liver resections are associated with the risk of postoperative liver dysfunction up to liver failure. For this reason, prior to extended liver resections patients are conditioned in multi-modal therapy regimes. Portal vein embolisation is an essential part of such a multi-modal therapy. The aim of this intervention is an induction of hypertrophy of the future remnant liver volume. Thereby, the risk of postoperative liver failure is decreased. This article summarises the actual aspects of portal vein embolisation prior to extended liver resections.

Liver resection in selected patients with metastatic breast cancer: a single-centre analysis and review of literature.

PURPOSE: Despite the development of modern chemotherapeutics and target-specific drugs as well as improved surgical techniques, prognosis of metastatic breast cancer remains poor. Only a small number of selected patients will be eligible for liver resection and/or alternative metastatic ablation. Data on prognostic factors for patients with surgically resectable liver metastases of breast cancer are scarce at present. METHODS: From 1997 to 2010, 50 patients with hepatic metastases of breast cancer have undergone laparotomy with the intention to undergo a curative liver resection at our institution. Data from these patients were collected in a prospectively maintained standardized liver resection data base. RESULTS: Liver resection was performed in 34 patients. Resection margins were clear in 21 cases (R0). Nine patients lived for more than 60 months after liver resection. The observed 5-year survival rate was 21% for all 50 patients, 28% for resected patients and 38% after R0-resection. On univariate analysis, survival rates of the resected patients were statistically significantly influenced by R-classification, age, extrahepatic tumour at the time of liver resection, size of metastases and HER2 expression of liver metastases. Multivariate analysis revealed absence of HER2 expression, presence of extrahepatic tumour and patient's age ≥50 years as independent factors of poor prognosis. CONCLUSIONS: Breast cancer patients younger than 50 years with technically resectable hepatic metastases, minimal extrahepatic tumour and positive HER2 expression appear to be suitable candidates for liver resection with curative intent. An aggressive multi-disciplinary management of those patients including surgical treatment may improve long-term survival.

Randomized controlled multicenter international clinical trial of self-gripping Parietex™ ProGrip™ polyester mesh versus lightweight polypropylene mesh in open inguinal hernia repair: interim results at 3 months.

PURPOSE: To compare clinical outcomes following sutureless Parietex™ ProGrip™ mesh repair to traditional Lichtenstein repair with lightweight polypropylene mesh secured with sutures. METHODS: This is a 3-month interim report of a 1-year multicenter international study. Three hundred and two patients were randomized; 153 were treated with Lichtenstein repair (L group) and 149 with Parietex™ ProGrip™ precut mesh (P group) with or without fixation. The primary outcome measure was postoperative pain using the visual analog scale (VAS, 0-150 mm); other outcomes were assessed prior to surgery and up to 3 months postoperatively. RESULTS: Compared to baseline, pain score was lower in the P group at discharge (-10%) and at 7 days (-13%), while pain increased in the L group at discharge (+39%) and at 7 days (+21%). The difference between groups was significant at both time points (P = 0.007 and P = 0.039, respectively). In the P group, patients without fixation suffered less pain compared to those with single-suture fixation (1 month: -20.9 vs. -6.15%, P = 0.02; 3 months: -24.3 vs. -7.7%, P = 0.01). The infection rate was significantly lower in the P group during the 3-month follow-up (2.0 vs. 7.2%, P = 0.032). Surgery duration was significantly shorter in the P group (32.4 vs. 39.1 min; P < 0.001). No recurrence was observed at 3 months in both groups. CONCLUSIONS: Surgery duration, early postoperative, pain and infection rates were significantly reduced with self-gripping polyester mesh compared to Lichtenstein repair with polypropylene mesh. The use of fixation increased postoperative pain in the P group. The absence of early recurrence highlights the gripping efficiency effect.

[Liver transplantation for hilar cholangiocarcinoma]. / Lebertransplantation beim hilären Cholangiokarzinom.

Local non-resectable, hilar cholangiocarcinoma can be cured by performing a liver transplantation. The initially poor results after transplantation have significantly improved since neoadjuvant therapy protocols have been established. Therefore, hilar cholangiocarcinoma is now an accepted indication for liver transplantation in selected patients. This article summarizes the current state, recommendations and results of liver transplantation for these patients.

[The certification of advanced therapy medicinal products. A quality label for product development in small and medium-sized enterprises]. / Die Zertifizierung neuartiger Therapien. Ein Gütesiegel für die Produktentwicklung in kleinen und mittelständischen Unternehmen.

Advanced therapy medicinal products (ATMPs) are gene therapy, cell therapy, and tissue engineered products. To gain access to the market within the European Union, ATMPs must be authorized by the European Commission (EC). Especially for small and medium-sized enterprises (SMEs), the European centralized procedure of marketing authorization that is conducted by the European Medicines Agency (EMA) constitutes a major challenge, because SMEs often have little experience with regulatory procedures and many have limited financial possibilities. To tackle these challenges, a certification procedure exclusively for SMEs and their ATMP development was introduced by the EC. Independently from a marketing authorization application, development and/or production processes can be certified. An issued certificate demonstrates that the respective process meets the current regulatory and scientific requirements of the EMA, representing a valuable milestone for putative investors and licensees. This article highlights the background, the detailed procedure, the minimum requirements, as well as the costs of certification, while giving further noteworthy guidance for interested parties.

Emergency surgery for complications related to percutaneous endoscopic gastrostomy.

Percutaneous endoscopic gastrostomy (PEG) is used to restore enteral nutrition in patients with inadequate oral intake. Because of its minimally invasive nature complications are thought to be rare. We analyzed data on all patients treated for PEG-related complications at the Department of General, Visceral, and Oncologic Surgery at the Klinikum Bremen-Mitte, Germany, between 2005 and 2008. A total of 38 patients with complications required surgical evaluation. Emergency laparotomy was performed for leakage in 16 patients, for a misplaced or dislodged PEG tube in nine patients, for buried bumper with accompanying signs of peritonitis in four patients and for gastrocutaneous fistula in one patient. Eight complications were managed conservatively. Early complications within 10 days (60 %) were related to leakage or mispositioning of the PEG, while PEG device migration and fistula formation represented late complications. Hospital mortality was 17 % with the underlying disease contributing significantly to the fatal outcome. Most PEG-associated major complications were related to technical errors and carried a high mortality.

Regulatory requirements for clinical trial and marketing authorisation application for gene therapy medicinal products.

Over the last two decades, clinical trials using gene therapy medicinal products (GTMPs) have been carried out for a large number of rare, inherited monogeneic disorders as well as common multigeneic diseases such as cancer, cardiovascular and infectious diseases including AIDS. Despite some early difficulties and setbacks, the gene therapy field has slowly progressed and, nowadays, offers the promise of novel treatments for a growing number of diseases. On the other hand, gene therapy approaches are often associated with additional risks due to limited clinical experience with a given gene transfer system, long-lasting effects of the therapeutic gene, and/or a complex mode of action. As a result, specific regulations and guidelines have been introduced within the EU to help address these uncertainties. This article summarises the legislative framework and will provide an overview on the regulatory requirements for clinical trials and marketing authorisation applications.