Guidelines for surveillance of individuals with constitutional mismatch repair-deficiency proposed by the European Consortium "Care for CMMR-D" (C4CMMR-D).

Lynch syndrome (LS) is an autosomal dominant disorder caused by a defect in one of the DNA mismatch repair genes: MLH1, MSH2, MSH6 and PMS2. In the last 15 years, an increasing number of patients have been described with biallelic mismatch repair gene mutations causing a syndrome referred to as 'constitutional mismatch repair-deficiency' (CMMR-D). The spectrum of cancers observed in this syndrome differs from that found in LS, as about half develop brain tumours, around half develop digestive tract cancers and a third develop haematological malignancies. Brain tumours and haematological malignancies are mainly diagnosed in the first decade of life, and colorectal cancer (CRC) and small bowel cancer in the second and third decades of life. Surveillance for CRC in patients with LS is very effective. Therefore, an important question is whether surveillance for the most common CMMR-D-associated cancers will also be effective. Recently, a new European consortium was established with the aim of improving care for patients with CMMR-D. At a workshop of this group held in Paris in June 2013, one of the issues addressed was the development of surveillance guidelines. In 1968, criteria were proposed by WHO that should be met prior to the implementation of screening programmes. These criteria were used to assess surveillance in CMMR-D. The evaluation showed that surveillance for CRC is the only part of the programme that largely complies with the WHO criteria. The values of all other suggested screening protocols are unknown. In particular, it is questionable whether surveillance for haematological malignancies improves the already favourable outcome for patients with these tumours. Based on the available knowledge and the discussions at the workshop, the European consortium proposed a surveillance protocol. Prospective collection of all results of the surveillance is needed to evaluate the effectiveness of the programme.

Pediatric Nodular Lymphocyte-predominant Hodgkin Lymphoma: Treatment Recommendations of the GPOH-HD Study Group.

Nodular lymphocyte-predominant Hodgkin lymphoma (nLPHL) is a very rare disease in childhood and adolescence. In Germany, about 15 newly diagnosed patients present with this disease annually; this number comprises less than 10% of all pediatric Hodgkin lymphoma cases. Since the EuroNet-PHL-LP1 trial for early stage nLPHL patients stopped recruiting in Germany in October 2014, the GPOH-HD writing committee reviewed the literature and decided to deliver treatment recommendations for childhood and adolescent nLPHL patients. These guidelines shall be applicable to young nLPHL patients in European countries that will no longer be able to participate in nLPHL trials for young patients. Therefore, the EuroNet-PHL-nLPHL-registry will be installed to provide quality assured central review of staging and response assessment for registered patients by the Central Review Board of EuroNet-PHL in Halle/Leipzig, Germany.

Cardiomyopathy in Duchenne Muscular Dystrophy: Current Value of Clinical, Electrophysiological and Imaging Findings in Children and Teenagers.

BACKGROUND: Progressive cardiomyopathy (CMP) is one main cause of death in DMD. This cross-sectional assessment of different cardiac diagnostic procedures focusses on preterm diagnosis of cardiac dysfunction. PATIENTS: 39 male DMD patients aged 6-20 years were included. 6 patients were still ambulatory, 21 patients received corticosteroid therapy. METHODS: All patients were investigated by ECG, Holter ECG and heart rate variability (HRV), B-type natriuretic peptide (BNP), echocardiography (TTE), tissue Doppler Imaging (TD) and magnetic resonance imaging (MRI) with Late Gadolinium enhancement (LE) and segmental wall motion analysis (WMA). RESULTS: 56% of the patients showed repolarization abnormalities and 76% altered HRV. Subnormal ventricular function was found in 25% by TTE and in 34% by MRI. TD differed from normal controls only in the apical septum. In MRI 89% of the patients showed different distribution and intensity of LE and WM restriction. The extent of LE was less in patients after steroid treatment (p<0.05). DISCUSSION: MRI with segmental LE- and WM-analysis seems to be superior to TTE and TD in exploring regional distribution and severity of damage of the myocardium. ECG and HRV abnormalities are common in DMD-patients but not tightly predictive for segmental and global left ventricular dysfunction. Targeted treatment of CMP in DMD needs prospective evaluation. CONCLUSION: A timely cardiac MRI is the most sensitive investigation for the identification of early myocardial changes in DMD which is a prerequisite for early interventions and therapeutic strategies.

Consensus of German transplant centers on hematopoietic stem cell transplantation in Fanconi anemia.

Allogeneic hematopoietic stem cell transplantation (HSCT) is currently the only curative therapy for the severe hematopoietic complications associated with Fanconi anemia (FA). In Germany, it is estimated that 10-15 transplants are performed annually for FA. However, because FA is a DNA repair disorder, standard conditioning regimens confer a high risk of excessive regimen-related toxicities and mortality, and reduced intensity regimens are linked with graft failure in some FA patients. Moreover, development of graft-versus-host disease is a major contributing factor for secondary solid tumors. The relative rarity of the disorder limits HSCT experience at any single center. Consensus meetings were convened to develop a national approach for HSCT in FA. This manuscript outlines current experience and knowledge about HSCT in FA and, based on this analysis, general recommendations reached at these meetings.

Cardiac function after repair of tetralogy of fallot: how are the atria performing? pilot study by cardiac magnetic resonance imaging.

The atria of the heart function as reservoir, conduit, and active pump and are critical for ventricular filling and cardiac output. We sought to evaluate right (RA) and left atrial (LA) function in patients after tetralogy of Fallot (TOF) repair by using cardiovascular magnetic resonance. Twelve TOF patients, age 16.7 ± 6.1 years, weight 50.9 ± 14.9 kg, were compared to 10 healthy volunteers, age 18.8 ± 6.8 years, weight 52.3 ± 20.8 kg. Both atria and both ventricles were imaged in short-axis planes by Steady State Free Precession. Volume changes and all derived atrial functional parameters were calculated from the volume/time curves obtained after segmentation on the cine images. Blood flow across the AV valves was used to define ventricular diastolic dysfunction. TOF patients showed similar maximal RA volume compared to controls, but increased volumes at mid-diastole (p < 0.05), resulting in a decreased cyclic volume change and atrial filling fraction (p < 0.01), and a decreased passive emptying volume and fraction (p < 0.01). In patients with diastolic dysfunction, conduit volume was increased (p < 0.05), and active emptying volume and fraction tended to be increased, respectively. No significant changes were found in LA, except for a decreased passive emptying fraction (p < 0.05). RA function and particularly reservoir function are impaired in TOF patients. The RA conduit/reservoir ratio is increased and reflects the lost of the ability of the atrium to fill the ventricle by pulsatile flow.

Effective childhood cancer treatment: the impact of large scale clinical trials in Germany and Austria.

In Germany and Austria, more than 90% of pediatric cancer patients are enrolled into nationwide disease-specific first-line clinical trials or interim registries. Essential components are a pediatric cancer registry and centralized reference laboratories, imaging review, and tumor board assistance. The five-year overall survival rate in countries where such infrastructures are established has improved from <20% before 1950 to >80% since 1995. Today, treatment intensity is tailored to the individual patient's risk to provide the highest chances of survival while minimizing deleterious late effects. Multicenter clinical trials are internationalized and serve as platforms for further improvements by novel drugs and biologicals.

Hepatic 3D cultures but not 2D cultures preserve specific transporter activity for acetaminophen-induced hepatotoxicity.

Primary human hepatocytes (PHH) are the "gold standard" for in vitro toxicity tests. However, 2D PHH cultures have limitations that are due to a time-dependent dedifferentiation process visible by morphological changes closely connected to a decline of albumin production and CYP450 activity. The 3D in vitro culture corresponds to in vivo-like tissue architecture, which preserves functional characteristics of hepatocytes, and therefore can at least partially overcome the restrictions of 2D cultures. Consequently, several drug toxicities observed in vivo cannot be reproduced in 2D in vitro models, for example, the toxic effects of acetaminophen. The objective of this study was to identify molecular differences between 2D and 3D cultivation which explain the observed toxicity response. Our data demonstrated an increase in cell death after treatment with acetaminophen in 3D, but not in 2D cultures. Additionally, an acetaminophen concentration-dependent increase in the CYP2E1 expression level in 3D cultures was detected. However, during the treatment with 10 mM acetaminophen, the expression level of SOD gradually decreased in 3D cultures and was undetectable after 24 h. In line with these findings, we observed higher import/export rates in the membrane transport protein, multidrug resistance-associated protein-1, which is known to be specific for acetaminophen transport. The presented data demonstrate that PHH cultured in 3D preserve certain metabolic functions. Therefore, they have closer resemblance to the in vivo situation than PHH in 2D cultures. In consequence, 3D cultures will allow for a more accurate hepatotoxicity prediction in in vitro models in the future.

Mouse hepatoma cell lines differing in aryl hydrocarbon receptor-mediated signaling have different activities for glucuronidation.

For studies on the aryl hydrocarbon receptor (AhR)-dependent toxicity of the mycotoxins alternariol (AOH) and alternariol methyl ether (AME), three mouse hepatoma (Hepa-1) cell lines with intact and with compromised AhR signaling were compared with respect to their activities for hydroxylation, methylation, and glucuronidation. Whereas the activities of cytochrome P450-mediated monooxygenase and catechol-O-methyl transferase were very low and did not differ between the three cell lines, a pronounced difference was observed for UDP-glucuronosyl transferase activity, which was much higher in Hepa-1c1c4 than in c1c7 and c1c12 cells. In all three cell types, the rate of glucuronidation of AOH was about four times higher than that of AME. Whereas AME caused a concentration-dependent G2/M arrest in each cell line, AOH arrested Hepa-1c1c7 and c1c12 cells but not c1c4 cells. However, Hepa-1c1c4 cells were arrested by AOH when ß-glucuronidase was added to the incubation medium in order to reverse the formation of AOH glucuronides. We conclude that the failure of AOH to cause cell cycle inhibition in Hepa-1c1c4 cells is due to its efficient glucuronidation. The considerable UDP-glucuronosyl transferase activity of Hepa-1c1c4 cells should be taken into account when other compounds are studied in this cell line. Moreover, we demonstrate that differences in glucuronide formation between cell types can be overcome by the addition of ß-glucuronidase to the cell culture medium.

Loss of heterozygosity on chromosome 6q14-q24 is associated with poor outcome in children and adolescents with T-cell lymphoblastic lymphoma.

Deletions of chromosome 6q have been reported in several hematological malignancies, but data are not conclusive regarding their biological and prognostic impact. Therefore, we focused on pediatric patients diagnosed with T-cell lymphoblastic lymphoma (T-LBL) treated uniformly according to the NHL-BFM95 protocol. We used loss-of-heterozygosity (LOH) analysis of 25 microsatellite markers located on chromosome 6q14-q24. Fragment-length analysis was performed on ABI-PRISM3100 Genetic-Analyzer. Eligibility criterion was > or =3 informative markers. Between April 1995 and March 2003, 185 T-LBL patients were treated according to the NHL-BFM95 protocol. Five-year event-free (EFS) and disease-free survival (DFS) were 79+/-3 and 87+/-3% (median follow-up 4.7 [1.2-10.1] years). Sixty-one patients were evaluable for LOH analysis, including 18 out of 23 patients with relapse. EFS and DFS were 67+/-6 and 69+/-6% for these 61 patients. Testing of 853 markers in the 61 patients identified the presence of LOH in 19 patients (31%): 13 of the 18 relapse patients and five of the 41 in complete remission (odds ratio 18.7, 95% confidence interval 4.7-75.3). One LOH-positive patient died from treatment-related toxicity. We conclude that LOH on chromosome 6q14-q24 may have conferred a high risk of relapse on our group of children with T-LBL treated according to the NHL-BFM95 protocol.

Mammalian cells express two VPS4 proteins both of which are involved in intracellular protein trafficking.

The yeast Vps4 protein (Vps4p) is a member of the AAA protein family (ATPases associated with diverse cellular activities) and a key player in the transport of proteins out of a prevacuolar endosomal compartment. In human cells, we identified two non-allelic orthologous proteins (VPS4-A and VPS4-B) of yeast Vps4p. The human VPS4-A and VPS4-B proteins display a high degree of sequence identity to each other (80 %) and to the yeast Vps4 protein (59 and 60 %, respectively). Yeast cells lacking a functional VPS4 gene exhibit a temperature-sensitive growth defect and mislocalise a carboxypeptidase Y-invertase fusion protein to the cell surface. Heterologous expression of human VPS4 genes in vps4 mutant yeast strains led, in the case of human VPS4-A, to a partial and, in the case of human VPS4-B, to a complete suppression of the temperature-sensitive growth defect. The vacuolar protein sorting defect of vps4 mutant yeast cells was complemented completely by heterologous expressed human VPS4-B protein, and partially by the human VPS4-A protein. Expression of mutant human VPS4-A (E228Q) and VPS4-B (E235Q) proteins, harbouring single amino acid exchanges in their AAA domains, induced dominant-negative vacuolar protein sorting defects in wild-type yeast cells in both cases. Two-hybrid experiments suggest that the human VPS4-A and VPS4-B proteins can form heteromeric complexes, and subcellular localisation experiments indicate that both human VPS4 proteins associate with endosomal compartments in yeast. Based on these results, we conclude that both human VPS4 proteins are involved in intracellular protein trafficking, presumably at a late endosomal protein transport step, similar to the Vps4p in yeast.

Adaptive Designs with Discrete Test Statistics and Consideration of Overrunning.

BACKGROUND: Interim analyses are used in clinical trials in order to enable early decisions for medical, ethical, and economic reasons. However, it appears unfeasible to stop a trial during such an interim analysis. New patients will thus enter the trial while the interim analysis is ongoing. Moreover, depending on the event kinetics of the specific disease, the trial design, and the corresponding endpoints, some patients might still be unevaluable at the interim analysis due to not yet completed follow-up. Occurrence of these types of patients is characteristic for sequentially analyzed trials. Such patients are referred to as interim patients. In trials with multiple primary endpoints, another type of interim patients occurs. If some but not all null hypotheses can be rejected at the interim analysis, the trial might be continued to a second stage in order to answer the remaining questions. These second stage patients, however, provide new data to all trial questions including the already rejected ones and thus formally act as interim patients regarding the already rejected null hypotheses. Although all kinds of interim patients are not part of the interim analysis, the data collected on those patients have to be sent to the office of regulatory affairs and will be analyzed. If a smaller or contrasting treatment effect is observed in interim patients, this might lead to a withdrawal of an earlier superiority proof. OBJECTIVES: Presently, interim patients and their data are usually not considered in the confirmatory test. We offer a strategy to deal with interim patients in sequentially analyzed trials with discrete test statistics. The method covers sequentially analyzed single- and multi-arm trials with one or multiple primary endpoints. METHODS: When planning adaptive designs, it is common practice to assume that the stage-wise p-values are independent and standard uniformly distributed under the null hypothesis. In the context of discrete test statistics, this implies conservative tests. We provide an algorithm which iteratively optimizes an initially given design while adjusting for both discreteness of test statistics and interim patients. The algorithm is described verbally, graphically and formally to facilitate immediate implementation in computer software. RESULTS: The optimized design exploits the aspired significance level better and is more powerful than the initial one. The algorithm applies to fixed sample and planned flexible adaptive designs for single- and multi-arm trials with one or multiple primary endpoints. The benefit increases with the number of interim patients. CONCLUSIONS: When planning a trial with interim analyses, the rules for decisions must be adjusted to interim patients. Otherwise, the test procedure is conservative resulting in loss of power. This is essential in situations where the number of interim patients is important compared to the first stage, particularly in trials with multiple primary endpoints.

Capsular contracture: hard breasts, soft data.

Fibrous capsular contracture is by far the most common cause of unsatisfactory results following augmentation mammaplasty. This article reviews the evidence for its various proposed etiologies, the techniques advocated for its prevention, and the procedures currently available for its correction.

The effect of Biocell texturing and povidone-iodine irrigation on capsular contracture around saline-inflatable breast implants.

We performed a prospective, concurrently controlled, and blinded 4-year clinical study on 60 patient volunteers to determine the effects of two independent variables, McGhan's Biocell texturization and Betadine antibacterial irrigation, on the incidence of fibrous capsular contracture around saline-inflatable implants following retromammary augmentation. Each patient was randomly assigned both a textured and a smooth implant and both saline and Betadine irrigation so that each patient served as her own control. The textured devices irrigated with Betadine experienced an overall incidence of contracture of only 4 percent compared with 50 percent for the smooth devices irrigated with saline solution. The Betadine-irrigated devices in general had a lower incidence of contracture than the saline-irrigated devices, and the textured-surface devices in general had a lower incidence of contracture than the smooth devices. Antibacterial irrigation and surface texturization may work in a cumulative manner to reduce the early incidence of capsular contracture.

The safety and efficacy of breast implants for augmentation mammaplasty.

This review of the efficacy and safety of breast implants was intended to focus on our current body of knowledge about these devices. There are informational gaps, but not all of these can be laid at the door of imperfect studies or failed scientific methods. Certain properties of the implants are still unmeasurable, immunologic investigation is still evolving, the cause of wound contraction is inexplicable here or in the burnscar contracture, and the indications for and results of this surgery necessarily are subjective. Still, there are a number of investigative avenues open to us, and our cumulative experience shows no reluctance on the part of plastic surgeons to initiate further studies.

The effect of Siltex texturing and povidone-iodine irrigation on capsular contracture around saline inflatable breast implants.

A prospective, controlled, and blinded clinical study was performed on 56 patient volunteers to determine the effects of two independent variables--the Siltex textured inflatable implant and povidone-iodine irrigation--on the incidence of fibrous capsular contracture following retromammary augmentation. Each patient was randomly assigned both textured and smooth implants and povidone-iodine and saline irrigation, so that each patient served as her own control. The Siltex devices experienced an incidence of class III-IV contracture of only 2 percent, as compared with an incidence of 40 percent around the smooth devices. Most patients, however, preferred the smooth devices despite the higher contracture incidence because the Siltex device was more easily palpable. Povidone-iodine did not reduce the final incidence of contracture. It appeared to delay the onset of contracture, but not with statistical significance.

Are more passes better? Safety versus efficacy with the pulsed CO2 laser.

Whether greatly increasing the number of passes with the pulsed CO2 laser compromises safety or enhances effectiveness is unknown. Intuitively speaking, more passes should produce a greater depth of injury with better removal of wrinkles but greater likelihood of scarring. A chamois color has been said to signal laser penetration of the reticular dermis and has been recommended as an end point for safe treatment. Isolated case reports and anecdotal stories suggest that the potential for scarring from deep thermal injury remains significant. With the Coherent Ultrapulse laser at our usual therapeutic settings (300 mj, density of 4 with the Computerized Pattern Generator), the authors treated multiple test panels on in situ breast skin (one to 16 passes) and eyelid skin (one to eight passes) and then compared the panels in the excised skin histologically. The depth of injury did not increase after three passes, and no full-thickness injury was observed even in the thin eyelid skin. After treating severely wrinkled upper lips with up to 11 passes without scarring or other adverse effect, the authors treated a small series of patients with four passes on one side of their lips and 10 passes on the other side. No difference could be detected either at the time or after final healing. The authors believe that injury depth in using the pulsed CO2 laser is automatically limited by progressive dessication of the superficial dermis. The chamois color indicates dessication, not increasing depth. Although more than three or four passes will not produce injury under ordinary circumstances, they do not improve the final result.

The second-look technique in face lifts--does it work?

Charts of 120 patients who have undergone face lifts in a single practice have been reviewed for objective evidence of postoperative hematoma formation following traditional or second-look face lift surgery. The respective rates of hematoma formation-21.7 percent, as compared with 7 percent-were found to be significantly different (P less than 0.025) by chi-square analysis, and no extraneous factors can be asserted to explain this difference. The authors therefore conclude that the second-look technique is responsible for reducing postoperative complication from face lift and that it is a worthwhile modification to the traditional procedure.

Capsules, infection, and intraluminal antibiotics.

Staphylococcus epidermidis, a normal cutaneous inhabitant previously shown to be present in 67 percent of nipple secretions, has been cultured from 55 percent of surgical mammary pockets prior to implant insertion and from the interior of 71 percent of fibrous capsules explored at open capsulotomy. Cephalothin and gentamicin placed within the lumen of inflatable breast implants in vitro have been shown to diffuse outward through the silicone shell. The use of intraluminal cephalothin and gentamicin in vivo has significantly reduced our incidence of capsular contracture following both primary mammary augmentation and secondary open capsulotomy. The authors believe that the cause of fibrous capsular contracture may be a low-grade periprosthetic infection, and that the unique permeability characteristics of the silicone shell may permit sustained antimicrobial activity at the surface of the prosthesis.

Capsular contracture: a prospective study of the effect of local antibacterial agents.

In a prospective, random, double-blind, and concurrently controlled clinical study of 124 patients having augmentation mammaplasty, using multiple independent subjective judges as well as objective compressibility measurements, the use of a variety of local antibacterials in or around inflatable retromammary prosthetic implants reduced the early postoperative onset of class III to IV capsular contracture by sevenfold (85 percent) and the final incidence by more than half (50 percent) (p less than 0.01). We believe this study provides the most unequivocal evidence to date that the cause of capsular contracture in retromammary augmentation is periprosthetic bacterial contamination. Irrigation with a 5 percent povidone-iodine (50 percent Betadine) solution was as effective as other techniques and is currently our procedure of choice.

A time study of staff and student activities in a level II fieldwork program.

A study was conducted to determine the cost and benefits of the occupational therapy Level II fieldwork program at University of Michigan Hospitals in order to complete annual contractual agreements between academic and clinical education agencies. A tally sheet consisting of 34 tasks was used by all staff members (therapists, assistants, and clerical support personnel) to record time spent daily on the student program (cost). Students recorded independent treatment provided (benefit). The cost and benefit of the program was equated to a full-time equivalent staff position. Results showed the following: the time staff devoted to the student program was equivalent to 1.33 of a full-time employee's workload and the treatments provided by students were equivalent to 1.35 of an employee's production. The findings of this study support the accepted assumption that the cost of a clinical program for occupational therapy students is at least balanced by the benefits derived from student production. However, the quality of student efforts may be less than that of staff efforts.