[Can we transfer the mechanisms of the generics market to biosimilars?]

Personalized medicines such as biologics and their generic equivalents, biosimilars, are pouring onto the pharmaceutical markets. Data of 16 private health insurance companies were used to describe the market shares of selected biosimilars available in 2014 and 2015. The purpose of this study focuses on the question of whether market access of biosimilars will lead to a price competition of the expense of innovation competition. The results show that prescriptions of biosimilars made up 37% of total prescriptions in 2015 compared to 35% in 2014, and that their share of prescription costs went up from 21% to 23% in the same period. Price competition similar to that found in the generic markets has been established for erythropoietin and filgrastim. The same has not been observed for follitropin alfa and somatropin due to the limited number of competitors and products available at this stage. No definitive conclusions can be drown from the results at this stage. Time will tell whether it will be possible for physicians and individuals with private health insurance to fully leverage the savings potential of biosimilars while safeguarding patient safety.

[Pharmaceutical prescription for multiple sclerosis : evaluation of pharmaceutical consumption at private health insurance]. / Arzneimittelversorgung bei Multipler Sklerose : Evaluation des Arzneimittelverbrauchs bei der Privaten Krankenversicherung.

BACKGROUND: For persons covered by statutory health insurance (SHI) an increase in the number of defined daily doses (DDD) for pharmaceuticals to treat multiple sclerosis (MS) is known but so far there has been no comparable survey for private health insurance (PHI). Moreover, there are gaps in knowledge of the reasons for the increase and concerning the number of the MS patients in Germany. MATERIAL AND METHODS: The study is based on pharmaceutical data of the PHI in Germany. The projection takes into account the different prevalence and the different male/female relationship in SHI and PHI in an extrapolation to the total population. RESULTS: From 2006 to 2010 the number of DDDs of MS pharmaceuticals increased by approximately 91.6 % (SHI 39.9 %) per insured person. The increase in the PHI is mainly based for on an increase in the number of MS patients. The total number of MS patients in Germany was estimated to be approximately 146,000 whereby some 12,700 MS patients (8.7 %) were insured in PHI. CONCLUSION: There is a need for research into the reasons for the increase in MS patients. The disproportional increase in the PHI compared to SHI could be a result of the increase of insured persons and an increased inclusion of persons with a higher risk of the disease.

[Prevalence of HIV treatment in PHI]. / Behandlungsprävalenz von HIV in der PKV.

The importance of HIV in PHI is examined on the basis of the "AIDS statistics" of the Association of PHI and pharmaceutical data from PHI. The observation period is from 2007 to 2011. We define a HIV case if a private insured person has submitted at least one HIV-related invoice (e.g., an antiretroviral drug) for reimbursement during the observation period. In 2011, 7,624 people in PHI received HIV therapy, that is 32% (+1888) more than in 2007. The number of new HIV cases in 2011 was 673, and thus 12% (-92) lower than in 2007. The proportion of people receiving antiretroviral therapy in PHI is higher than in the general population in Germany. HIV infections occur in all age groups, but peaks in the age group 41 to 50 years old. Men are affected more than women. In contrast, the number of HIV cases among 11- to 15-year-old girls is higher compared to boys of the same age.

Adult fulminant subacute sclerosing panencephalitis: pathological and molecular studies--a case report.

Subacute sclerosing panencephalitis is an uncommon progressive neurological disorder caused by a persistent defective measles virus, typically affecting children. We describe a case of fulminant subacute sclerosing panencephalitis in a 25-year-old male. Brain tissue biopsy showed histologic evidence of encephalitis with eosinophilic intranuclear inclusion bodies (Cowdry Type A and B), intracytoplasmic inclusion bodies, perivascular lymphoplasmacytic infiltration and gliosis. Immunohistochemical studies were positive using an anti-measles antibody. Reverse transcriptase-PCR detected measles virus RNA and phylogenetic analysis indicated a C2 genotype. The rare adult-onset form is often atypical and difficult to diagnose and should be included in the differential diagnosis of subacute "unexplained" neurological diseases and uncommon infectious disorders.

Moderate versus deep hypothermia for arterial switch operation.

BACKGROUND: We evaluated the impact of moderate versus deep intraoperative hypothermia on postoperative morbidity in patients receiving a standard arterial switch operation (ASO). METHODS: 71 newborns underwent ASO from 9/98 onwards. Patients were operated using moderate hypothermia (M, 24 degrees C to 30 degrees C, n=21) or deep hypothermia (D, 16-22 degrees C, n=50). Mean patient age was 9.5 (M) versus 10 (D) days, body weight 3.6+/-0.7 (M) versus 3.8+/-0.9 kg (D), P=n. s. Coronary anatomy was complex in 9.5% (M) versus 16% (D) of patients; additional VSD was present in 23.8 (M) versus 38% (D) of the patients, respectively. Mean follow-up is 2.3+/-1.6 years. RESULTS: Intraoperative rectal temperature was 25+/-2 degrees C (M) and 19+/-2 degrees C (D). Cross-clamping time was 95+/-24 (M) versus 108+/-31 min (D), P=n. s. Conventional ultrafiltration was performed at 114+/-46 (M) versus 129+/-69 ml/kg (D), P=n. s. One patient (D) with complex anatomy suffered myocardial ischemia required ECMO support and died. In-hospital mortality was 1.4%. All other patients were safely weaned from extracorporeal circulation with moderate inotropic support. Secondary chest closure was performed in 33% (M) versus 54 % (D) of the patients. Patients were extubated after 7.4 (M) versus 6 (D) days. There was no renal failure and no other serious complications. CONCLUSIONS: ASO can be safely performed using moderate hypothermia, even with complex anatomy, leading to comparatively good results compared to a conventional approach.

Dendritic cells recruitment and in vivo priming of CD8+ CTL induced by a single topical or transepithelial immunization via the buccal mucosa with measles virus nucleoprotein.

The buccal mucosa, a prototype of pluristratified mucosal epithelia, contains a network of directly accessible class II(+) epithelial dendritic cells (DC), similar to skin Langerhans cells. We showed that a single buccal immunization with measles virus nucleoprotein (NP), by either topical application onto or intradermal injection in the buccal mucosa, induced in vivo priming of protective class I-restricted specific CD8(+) CTL. Both routes of immunization with NP induced a rapid recruitment of DC into the mucosa, which peaked at 2 h and decreased by 24 h. Treatment of mice with Flt3 ligand resulted in an increased number of DC in the buccal mucosa and enhanced the frequency of IFN-gamma-producing NP-specific effectors and the NP-specific CTL response generated after buccal immunization with NP. Finally, NP-pulsed bone marrow-derived DC induced NP-specific IFN-gamma-producing cells upon adoptive transfer to naive mice. These data demonstrate that a viral protein delivered to DC of the buccal mucosa induces in vivo priming of protective anti-viral CD8(+) CTL.

Inhibition of HIV-1, HIV-2 and SIV envelope glycoprotein-mediated cell fusion by calmodulin.

Calmodulin, an EF-hand protein, inhibited the fusion between CD4+ human cells and cells stably expressing HIV-1 envelope proteins. Fusion was also inhibited when HIV-1, HIV-2 or SIV envelope glycoproteins were expressed by vaccinia virus (VV) recombinants, but calmodulin did not inhibit syncytia formation induced by measles virus glycoproteins. Calmodulin also inhibited fusion induced by vPE17, a VV-recombinant expressing a truncated form of HIV-1gp160 which lacks the two known calmodulin-binding sites located in the cytoplasmic domain of gp41. The inhibitory activity was specific to calmodulin among the EF-hand proteins. These observations may be important in understanding the mechanism of retroviral envelope glycoprotein-mediated cell fusion. Several possible mechanisms of action are discussed.

Color Doppler imaging of modified Blalock-Taussig shunts during infancy.

To assess the role of color Doppler echocardiography in the early postoperative evaluation of patients with a Blalock-Taussig shunt we examined 13 consecutive infants who underwent insertion of either a modified right (6 patients) or a modified left (7 patients) Blalock-Taussig shunt (age range 7 days to 6 months, mean age 8 weeks). Examination of the patients in a high parasternal right or left long axis was able to determine patency of the shunt in 12 patients. In the remaining patient, who did not show flow in the shunt, complete occlusion of the shunt was confirmed by angiography. From subcostal views we were able to demonstrate patency of the shunt in 75% of the infants and in all patients younger than 4 weeks of age. In our experience color Doppler echocardiography is a highly reliable method for early postoperative evaluation of infants with a Blalock-Taussig shunt.

Color Doppler imaging of modified Blalock-Taussig shunts during infancy.

To assess the role of color Doppler echocardiography in the early postoperative evaluation of patients with a Blalock-Taussig shunt we examined 13 consecutive infants who underwent insertion of either a modified right (6 patients) or a modified left (7 patients) Blalock-Taussig shunt (age range 7 days to 6 months, mean age 8 weeks). Examination of the patients in a high parasternal right or left long axis was able to determine patency of the shunt in 12 patients. In the remaining patient, who did not show flow in the shunt, complete occlusion of the shunt was confirmed by angiography. From subcostal views we were able to demonstrate patency of the shunt in 75% of the infants and in all patients younger than 4 weeks of age. In our experience color Doppler echocardiography is a highly reliable method for early postoperative evaluation of infants with a Blalock-Taussig shunt.

[Doppler echocardiography assessment of hemodynamic values and additional heart defects in atrial septal defects]. / Dopplerechokardiographische Ermittlung hmodynamischer Messwerte und zusätzlicher kardialer Fehlbildungen bei Vorhofseptumdefekten.

Due to the rapid progress in (Doppler-) echocardiography "one must question whether cardiac catheterisation remains a necessary prelude to cardiac surgery in atrial septal defects" (8). Although the estimation of the magnitude of the intracardiac shunt and the anatomical size of the defect ist possible by (Doppler-) echocardiography there remains the problem of associated disorders (e.g. anomalies of the pulmonary venous connection) which may not be detected by transthoracic echocardiography. In 25 children submitted to cardiac catheterisation studies in the period between 1990 and 1992, the anatomical size of an atrial septal defect was measured echocardiographically. The haemodynamic parameters Qp/Qs and Rp/Rs were employed to calculate the so-called effective resistance of the defect (Rd/Rs), which was derived from an electrical analogue and represents the ratio of the resistance of the defect (Rd) to the systemic vascular resistance (Rs). The echocardiographically measured anatomical size (expressed as the ratio of the area of the defect to the cross-sectional area of the ascending aorta) was related to the effective resistance of the defect. A significant (non-linear) correlation was found between Rd/Rs and the anatomical size of defect. Based on these data we developed a nomogram describing the relationship of the size of the defect to the haemodynamic parameters (Qp/Qs and Rp/Rs). If the data of a patient do not comply with this nomogram there is strong evidence of an additional cardiovascular malformation, necessitating further evaluation. A second cohort of four patients with associated defects (partial and total anomalous pulmonary venous connection and a corresponding sinus venosus defect) was clearly identified by the nomogram method.

Analysis of the human immunodeficiency virus type 1 envelope protein interaction with the CD4 host cell receptor.

A secreted form of human immunodeficiency virus type 1 (HIV-1) envelope glycoprotein (gp160s), expressed in HeLa cells from a vaccinia virus recombinant was analysed by velocity-gradient centrifugation and chemical cross-linking. We showed that gp160s existed predominantly as a dimer, but higher forms corresponding to trimers and tetramers were also found. Soluble CD4 (sCD4) and native CD4 expressed by recombinant vaccinia viruses were analysed by sucrose-gradient sedimentation alone or after complexing with gp160s. The sCD4 sedimented in sucrose gradients as a monomer, whereas after solubilization the native CD4 was in a dimeric state. Both forms of CD4 were able to form complexes when incubated with gp160s. In the case of the sCD4, the M(r) corresponded to a (sCD4)2-(gp160s)2 complex, whereas with CD4 the complexes were of a greater order of magnitude. HIV gp120 was secreted into the medium in a monomeric state. With sCD4 it gave a one-to-one complex, whereas with the native CD4 high M(r) complexes were formed. The importance of the oligomeric state of the virus- and cell-receptor proteins are discussed regarding their avidities.

The role of N-glycosylation in cell fusion induced by a vaccinia recombinant virus expressing both measles virus glycoproteins.

We have evaluated the effect of inhibitors of N-glycosylation on syncytia formation in HeLa cell infected by a recombinant vaccinia virus expressing the measles virus hemagglutinin (HA) and fusion (F) glycoproteins (VV-HA/F). Inhibitors which block glucose trimming of oligosaccharides side chains of glycoproteins (glucosidase inhibitors) prevented syncytium formation. On the other hand, inhibitors which block trimming of mannose residues (mannosidase inhibitors) did not prevent syncytium formation. The HA and F synthesized in the presence of either glucosidase or mannosidase inhibitors oligomerized and were transported to the cell surface. Concanavalin A, a mannose-specific lectin, inhibited syncytium formation. The inhibitors did not block the cleavage of the F protein, but in fact enhanced it. These studies demonstrate the importance of protein N-glycosylation in the process of membrane fusion and suggest that trimming of glucose residues and the presence of terminal mannose residues are required for VV-HA/F syncytium induction.

Establishment and characterisation of murine cells constitutively expressing the fusion, nucleoprotein and matrix proteins of measles virus.

To advance our understanding of the immunobiology of measles virus (MV) infections, we have investigated the possibility of establishing cell lines constitutively expressing the individual MV antigens. In contrast to previously published studies, we show that it is possible to establish cell lines expressing high levels of fusion (F), nucleoprotein (NP) and matrix (M) MV proteins. Once cloned, the cell lines were stable with high levels of expression for more than six months. The size and cell distribution of the NP and F proteins were similar to those observed in MV- or vaccinia-MV recombinant-infected cells. In contrast, the distribution of the M protein, although being similar to that of MV-infected cells, differed from that of Vaccinia-M recombinant virus-infected cells. Preliminary results suggest that these cell lines will be useful tools for studying the contribution of individual MV antigens to the cell-mediated immune response to this virus.

A leucine zipper structure present in the measles virus fusion protein is not required for its tetramerization but is essential for fusion.

The biological role of a leucine zipper motif present in the measles virus fusion (F) protein has been investigated. This motif is present in all paramyxovirus F proteins, all coronavirus spike proteins and many if not all retrovirus envelope proteins. By analogy to its role in certain transcription factors, it has been suggested that the motif may be responsible for the oligomerization of these viral membrane proteins. In this study, one, two or four heptadic leucines in the motif were substituted using site-directed mutagenesis. We found that fusion is prevented when all four heptadic leucines present in the motif are mutated whereas cellular transport and the oligomeric state of the F protein are unaffected.

Characterization of an R-binding site mediating the R-induced activation of the Epstein-Barr virus BMLF1 promoter.

In cells latently infected with Epstein-Barr virus, the switch from latency to productive infection is linked to the expression of two Epstein-Barr virus transcription factors called EB1 and R. R is an enhancer factor, and an R-responsive element (RRE) has been identified in the BMLF1 promoter. In this study, we have used bidirectional deletion mutagenesis to delineate the BMLF1 RRE (RRE-M) to a 44-bp sequence. We also show that R expressed from a recombinant vaccinia virus protects RRE-M against digestion by DNase I. Using mobility shift assays and dimethyl sulfate interferences, we have characterized the contact points between in vitro-translated R and the DNA. R binds in vitro to one site by simultaneously contacting two sequences within the site, which are separated by 8 bp: 5'-catGTCCCtctatcatGGCGCagac-3'. Site-directed mutagenesis of this sequence completely impaired the binding of R in vitro and rendered the BMLF1 promoter nonresponsive to R. The results suggest that the R-inducible BMLF1 enhancer is composed of a single R-binding site, called RRE-M.

[Sonographic and Doppler color sonographic findings in osteosarcoma]. / Sonographische und farbdopplersonographische Befunde beim Osteosarkom.

Till now bone tumors are diagnosed radiologically. In this paper we describe the characteristic sonographic and colour Doppler sonographic features in 5 patients with histologically confirmed osteosarcoma. A large soft tissue tumor with echogenic osteosclerotic areas and echo-free caverns could be shown in all patients. Characteristic signs were destructions of the cortical layer and reactions of the periosteum. Compared to normal tissue an increased number of blood vessels with increased blood flow were visible by colour coded Doppler sonography in the region of the tumor. Sonography and colour coded Doppler sonography are important additions of conventional radiology to describe the structure, extension and blood supply of an osteosarcoma.

[Abdominal Doppler sonography in childhood]. / Abdominelle Dopplersonographie im Kindesalter.

With the help of pulsed Doppler sonography and colour coded Doppler sonography noninvasive measurements of blood flow within the abdominal vessels are possible. Cystic and tubular abdominal masses and vascular structures can be differentiated. Laminar and turbulent flow as well as arterial and venous flow can be distinguished. The direction of blood flow can be shown. Regarding liver circulation Doppler sonography of portal hypertension, portal vein thrombosis, veno-occlusive-disease, Budd-Chiari-Syndrome and transplant rejection or other vascular complications after liver transplantation can be shown. The circulation of the spleen should be examined if aneurysms, thrombosis or portal hypertension are suspected. Mesenterial circulation should be investigated in suspected vascular occlusion, arterial stenosis and necrotizing enterocolitis. Renal Doppler sonography is helpful for the diagnosis of renal artery stenosis, arterio-venous fistulas, renal vein thrombosis and acute transplant rejection.

Contribution of measles virus fusion protein in protective immunity: anti-F monoclonal antibodies neutralize virus infectivity and protect mice against challenge.

To study the contribution of the measles virus fusion (F) protein in the immune response, anti-F monoclonal antibodies were prepared by using a vaccinia-measles virus F recombinant. In contrast to previously described anti-F monoclonal antibodies, these antibodies not only neutralized virus infectivity and inhibited fusion but also passively protected mice. Since these monoclonal antibodies recognize a configurational epitope, presentation of the antigen during infection may play an important role in the immune response. These factors are discussed in relation to vaccination.

Fowlpox virus recombinant encoding the measles virus fusion protein: protection of mice against fatal measles encephalitis.

A recombinant Fowlpox virus engineered to encode the measles virus fusion protein was shown to protect mice against a challenge measles infection. A vaccine dose of about 10(6) p.f.u. was needed to protect nearly 100% of the animals. Mice failed to develop a significant level of antibodies directed against measles virus suggesting that other components of the immune system may be involved.

[Sonographic diagnosis of alobar holoprosencephaly]. / Sonographische Diagnose der alobären Holoprosencephalie.

The alobar form of holoprosencephaly is characterised by a huge spherical ventricle localized in the midline. The monoventricle communicates with a large occipital cyst, the "dorsal sac". Both thalami and plexus chorioidei are fused in the midline. The interhemisperic fissure and the falx cerebri are absent as well as the corpus callosum and the septum pellucidum.