[Keratoplasty in Children and Adolescents]. / Keratoplastiken im Kindes- und Jugendalter.

BACKGROUND: The conditions for long-term graft survival in infants and children are unfavorable, due to the different immunological features, the impaired clinical examination and the reduced compliance and treatment adherence. However, penetrating keratoplasty is often the only option to prevent amblyopia and there may be no alternative. We examined the different indications, graft survival and complications in two specialised centres. MATERIAL AND METHODS: We identified all patients who were under the age of 18 years at the time of their penetrating keratoplasty. We then assessed the electronic file on indications, graft failure, visual acuity, enucleation and further complications. RESULTS: A total of 104 eyes of 95 patients (54 % female) were identified. Median age at the time of surgery was 14 years (quartiles 8 and 16 years). Median follow-up was 2.7 years. The following indications were identified: keratoconus (39 %), penetrating injury (18 %), non-herpetic corneal scars (12 %), herpetic corneal scars (6 %), sclerocornea (3 %), chemical burn (3 %) and miscellaneous indications (19 %). Clear graft survival according to the Kaplan-Meier method ranged from 100 % (keratoconus) to 35 % (sclerocornea). Enucleation was only necessary in patients with penetrating injuries (n = 2). Kaplan-Meier analysis estimated the failure of all grafts after one year in infants. In older patients, 90 % of grafts were still clear at that time. CONCLUSION: Prognosis of penetrating keratoplasty in children is related to the indication, and therefore the underlying disease, as well as the patients' age. In particular, infants exhibited poor prognosis, with only a very short period of clear graft survival. In indications, keratoconus showed the best prognosis, whereas sclerocornea and penetrating injuries had the worst prognosis.

[Long-term prognosis of Peters anomaly]. / Langzeitprognose der Peters-Anomalie.

BACKGROUND: Peters anomaly normally presents in early childhood. Common features are central corneal opacities and dysgeneses of the anterior eye segment. Early surgery is commonly warranted to prevent deep amblyopia or because of severe glaucoma. We herein present the clinical outcomes of all patients treated in the Eye Center of the Albert Ludwigs University of Freiburg since 2005. Emphasis is placed on the Peters subtype. METHODS: Data were collected retrospectively by means of chart review. Kaplan-Meier analyses were used to estimate visual prognosis, the indication for keratoplasty, and the incidence of retinal detachment. RESULTS: A total of 23 patients were identified. Subtype distribution was 40% type 1, 50% type 2, and 10% Peters plus syndrome. Ten patients were female (45%). Mean age at first presentation was 5 years; mean follow-up period censored in terms of eyeball preservation was 2 years (0 months-8 years). At mean follow-up, 40.5% of all patients had undergone at least one keratoplasty (up to six per eye); 43% had undergone glaucoma surgery (cylophotocoagulation, trabeculectomy, implants) at this time. Important complications were retinal detachment (31%) and phthisis bulbi (15%). After 4 years, visual acuity in the better eye was at most 0.05 in every second patient. CONCLUSION: Prognosis of visual acuity in Peters anomaly is poor. It is generally not possible to restore visual function in the long run, i. e., reading-grade visual acuity is rarely achieved. Surgical interventions are associated with a high risk of severe complications. Therefore, the young patients should be connected to institutions for visually impaired persons at an early stage.

Phase I study of FOLFIRI plus pimasertib as second-line treatment for KRAS-mutated metastatic colorectal cancer.

BACKGROUND: The mitogen-activated protein kinase (MAPK) pathway has been implicated in the molecular pathogenesis of human cancers, including metastatic colorectal cancer (mCRC). This provides a rationale for the development of MAPK-targeted agents such as pimasertib. METHODS: Patients with KRAS mutant mCRC were treated in the second-line setting with FOLFIRI (5-fluorouracil/folinic acid/irinotecan) plus pimasertib. The primary objective of the safety run-in phase was to determine the maximum-tolerated dose (MTD) and the recommended phase II dose of pimasertib combined with FOLFIRI. RESULTS: Sixteen patients were enrolled in the trial. Ten and six patients were treated daily with 45 and 60 mg of pimasertib plus FOLFIRI, respectively. The MTD was considered to be 45 mg per day. The most common treatment-emergent adverse events were diarrhoea, nausea, vomiting, asthenia and skin/rash event. Of the 15 patients in the efficacy analysis group, two patients had partial response, nine patients had stable disease, three patients had progressive disease as their best overall response and one patient could not be evaluated. CONCLUSIONS: Dose escalation of pimasertib in combination with FOLFIRI was limited by toxicity. At the MTD of 45 mg per day, pimasertib was adequately tolerated in patients with mCRC and no unexpected or new safety signals or concerns were identified.

Good clinical outcome after accidental intra-arterial injection of flunitrazepam tablets in 16 drug abusers with critical limb ischaemia.

OBJECTIVES: Inadvertent intra-arterial injection of flunitrazepam tablets intended for intravenous use by drug abusers has devastating effects. We report here on the clinical outcome of 16 drug abusers developing critical limb ischaemia after flunitrazepam injection. METHODS: Treatment combined immediate analgesia and anticoagulation, long-lasting local thrombolysis and vasodilatation, antibiotic prophylaxis, and physical mobilization. The immediate bolus injection of 5,000 IU heparin was followed by a continuous heparin infusion up to the target partial thromboplastin time. Under arteriographic control local intra-arterial infusion with alternating 4-h cycles of 5 mg recombinant tissue plasminogen activator followed by 5 µg prostaglandinE1 (PGE1) was performed for 24-48 hours. Subsequently, 60 µg PGE1 was applied once daily. RESULTS: Drug abusers, having been injected with 4-30 mg flunitrazepam, were treated 3-72 hours after the accident, with six of them not being treated until after 24 hours. All showed a high tissue ischaemia score. At the time of being discharged from hospital 13 patients had a normal extremity. In one patient, first receiving treatment 72 hours after injection, minor amputation of fingers was necessary. The life of the patient who injected 30 mg flunitrazepam in the leg was saved after hip disarticulation. One patient developed neurological dysfunction in the affected toes. CONCLUSIONS: Intensive treatment after inadvertent intra-arterial drug injection normalized the affected extremity in most drug abusers, even after the late onset of therapy.

Calcein assay: a high-throughput method to assess P-gp inhibition.

Transporter mediated drug-drug interactions (tDDI) mediated by ABCB1 have been shown to be clinically relevant. Hence, the assessment of the ABCB1 tDDI potential early in the drug development process has gained interest. We have evaluated the Calcein assay as a means of assessing the ABCB1 tDDI that is amenable to high throughout and compared it with the monolayer efflux assay. We found the Calcein assay, when performed in K562MDR cells using the protocol originally published more sensitive than digoxin transport inhibition in MDCKII-MDR1 cells. Application of the Calcein assay to cell lines containing different amounts of ABCB1, yielded IC(50) values that varied 10-100-fold. The differences observed for IC(50) values for the same compounds were in the following rank order: IC(50, MDCKII-MDR1) >IC(50, K562MDR)>IC(50, hCMEC/D3). Higher IC(50) values were obtained in cells with higher ABCB1 expression. The Calcein assay is a high-throughput alternative to digoxin transport inhibition as it appears to have a comparable selectivity but higher sensitivity than previously published digoxin transport inhibition in MDCKII-MDR1 cells. In addition, it can be performed in a barrier-specific manner highlighting the dependence of ABCB1 IC(50) values on different ABCB1 expression levels.

[Pustules from the cow barn]. / Pusteln aus dem Kuhstall.

A 54-year-old cattle farmer presented with crusty purulent plaques in the neck area. The clinical picture and microscopical proof of hyphae in the skin smear combined with Wood's lamp testing led to the diagnosis of Tinea barbae, a mycological infection of the skin transmitted by cattle (typically Trichophyton verrucosum). Therapy with itraconazole 200 mg q.d. p.o. and miconazole ointment 1×/day over 2 weeks was successful. This case report and its image are designed to bring attention to this rarely diagnosed pathology.

Approaching the evolutionary advantage of ancillary types of haemoglobin in Daphnia magna by simulation of oxygen supply.

The planktonic crustacean Daphnia magna synthesizes haemoglobin (Hb) macromolecules of variant subunit composition and oxygen affinity. This is one of the strategies by which the animals cope with variations in environmental conditions such as ambient oxygen tension. The enrichment of high-affinity Hb molecules in the haemolymph of hypoxia-exposed animals is thought to reduce Hb synthesis costs due to an enhanced transport efficiency of these molecules in comparison to the low-affinity Hb molecules. How great this economic advantage is, and under which conditions this benefit disappears, is still not fully understood. Here we implemented a rigorously simplified model of the daphnid body and described the transport of oxygen from the environment via the haemolymph to the tissues in terms of the convection-diffusion-reaction equation. The model was validated by comparing various model predictions with experimental data. A sensitivity analysis was used to evaluate the influence of parameter uncertainties on the model predictions. Cost-benefit analysis revealed in which way at the system's level the increase in Hb oxygen affinity improves the oxygen loading at the respiratory surfaces and impairs the release of oxygen to the tissues. The benefit arising from the improved oxygen loading exceeds the disadvantage of impaired unloading only under conditions where the ambient oxygen tension is critically low and the Hb concentration is high. The low-affinity Hb, on the other hand, provides an advantage given that the Hb concentration is low and the ambient oxygen tension is well above the critical level. Computer-aided modelling and simulation therefore provide valuable mechanistic insights into the driving forces that could have shaped the evolution of globin genes in daphnids.

Multidrug resistance protein 2-mediated estradiol-17beta-D-glucuronide transport potentiation: in vitro-in vivo correlation and species specificity.

Multidrug resistance protein 2 (MRP2) is a multispecific organic anion transporter expressed at important pharmacological barriers, including the canalicular membrane of hepatocytes. At this location it is involved in the elimination of both endogenous and exogenous waste products, mostly as conjugates, to the bile. Estradiol-17beta-d-glucuronide (E(2)17betaG), a widely studied endogenous substrate of MRP2, was shown earlier to recognize two binding sites of the transporter in vesicular transport assays. MRP2 modulators (substrates and nonsubstrates) potentiate the transport of E(2)17betaG by MRP2. We correlated data obtained from studies of different complexities and investigated the species-specific differences between rat and human MRP2-mediated transport. We used vesicular transport assays, sandwich-cultured primary hepatocytes, and in vivo biliary efflux in rats. Our results demonstrate that the rat Mrp2 transporter, unlike the human MRP2, transports E(2)17betaG according to Michaelis-Menten type kinetics. Nevertheless, in the presence of modulator drugs E(2)17betaG transport mediated by the rat transporter also shows cooperative kinetics as potentiation of E(2)17betaG transport was observed in the vesicular transport assay. We also demonstrated that the potentiation exists both in rat and in human hepatocytes and in vivo in rats.

Cholesterol potentiates ABCG2 activity in a heterologous expression system: improved in vitro model to study function of human ABCG2.

ABCG2, a transporter of the ATP-binding cassette family, is known to play a prominent role in the absorption, distribution, metabolism, and excretion of xenobiotics. Drug-transporter interactions are commonly screened by high-throughput systems using transfected insect and/or human cell lines. The determination of ABCG2-ATPase activity is one method to identify ABCG2 substrate and inhibitors. We demonstrate that the ATPase activities of the human ABCG2 transfected Sf9 cell membranes (MXR-Sf9) and ABCG2-overexpressing human cell membranes (MXR-M) differ. Variation due to disparity in the glycosylation level of the protein had no effect on the transporter. The influence of cholesterol on ABCG2-ATPase activity was investigated because the lipid compositions of insect and human cells are largely different from each other. Differences in cholesterol content, shown by cholesterol loading and depletion experiments, conferred the difference in stimulation of basal ABCG2-ATPase of the two cell membranes. Basal ABCG2-ATPase activity could be stimulated by sulfasalazine, prazosin, and topotecan, known substrates of ABCG2 in cholesterol-loaded MXR-Sf9 and MXR-M cell membranes. In contrast, ABCG2-ATPase could not be stimulated in MXR-Sf9 or in cholesterol-depleted MXR-M membranes. Moreover, cholesterol loading significantly improved the drug transport into inside-out membrane vesicles prepared from MXR-Sf9 cells. MXR-M and cholesterol-loaded MXR-Sf9 cell membranes displayed similar ABCG2-ATPase activity and vesicular transport. Our study indicates an essential role of membrane cholesterol for the function of ABCG2.

[Thromboembolic diseases in pregnancy]. / Thromboembolische Erkrankungen in der Schwangerschaft.

In pregnancy, thromboembolic complications are six times more frequent than in nonpregnant women. Maternal age, idiopathic or secondary thrombosis in the patients history, the mode of delivery, bed rest and / or obesity as well as the thrombophilic defects are considerable factors for an increased risk of deep vein thrombosis (DVT) and pulmonary embolism (PE). Compared to unfractionated heparins (UFHs) prophylactic treatment relies mainly on low molecular weight heparins (LMWHs) which safety is now well established in pregnant women. In view of their multiple side effects oral anticoagulants such as cumarine or aspirin are contraindicated or of subordinate importance. The procedures to exclude DVT follow the usual diagnostic algorithms considering maximum radiation protection in case of further apparative diagnostics. Although there are reported good experiences with LMWHs in the treatment of DVT, UFHs are still the preferred drugs in this clinical condition. Insufficient heparin treatment or impending postthrombotic complications may be reasons for additional therapies like thrombolysis or operative thrombectomy.

Contractile reactivity of human myometrium in isolated non-pregnant uteri.

BACKGROUND: Perfusion of the isolated uterus has been shown to be a feasible experimental system for studies of the human endometrium and myometrium. Utilizing our established experimental perfusion model we perfused 20 uteri for 27 h and investigated the contractile reactivity of the myometrium in response to 17beta-estradiol (E2) and oxytocin (OT). METHODS: Uteri of group A (n = 4) were stimulated with OT; group B (n = 4) was treated continuously with E2; group C (n = 4) received both E2 and OT for 27 h; group D (n = 4) was perfused for 27 h with E2 with the addition of OT for the last 3 h of the experiment; group E (n = 4) as control group remained without any treatment. The pressure and duration of uterine contractions were recorded during the entire perfusion period using intramural and endoluminal pressure catheters. RESULTS: Compared to the other treatment groups and controls, the most effective myometrial activity was achieved in group D during the OT stimulation period. No relevant myometrial activity was detected in the control group. CONCLUSIONS: Continuous E2 treatment, with the addition of OT for the last 3 h of the 27 h perfusion period, led to the most pronounced uterotonic effects in the presented experimental condition.

Parametrial and rectovaginal adenocarcinoma arising from endometriosis.

Malignant extragonadal tumors arising from endometriosis are rare. We report on two cases. A 41-year-old gravida 1, para 1 (G1P1), with adenocarcinoma of the right parametrium arising from endometriosis and a 51-year-old G1P1 with endometriosis-associated rectovaginal adenocarcinoma were treated. Treatment included radical surgery plus radiation therapy. While the former patient was doing well 2 years after the primary diagnosis, the latter suffered a local pelvic recurrence 2 years later. Although there are no randomized controlled studies, radical surgery followed by radiation therapy seems generally to be the treatment of choice. The analysis of PTEN in various forms of endometriosis and its malignant transformation may help in understanding the early steps of tumorigenesis.

[ENZIAN-score, a classification of deep infiltrating endometriosis]. / ENZIAN-Score, eine Klassifikation der tief infiltrierenden Endometriose.

The ENZIAN-Score is presented as a new instrument to classify the deep infiltrating endometriosis. Especially the retroperitoneal part of the severe endometriosis is focussed on. In analogy to an oncological staging four different stages are pronounced. The localisation and the expansion of the endometriosis nodule was indicated to different subgroups. The still used rAFS-score is of no clinical evidence, as we pointed out in a retrospective study of our patients with severe intestinal endometriosis.

Is a third proton-conducting pathway operative in bacterial cytochrome c oxidase?

Despite the existence of several three-dimensional structures of cytochrome c oxidases, a detailed understanding of pathways involved in proton movements through the complex remains largely elusive. Next to the two well-established pathways (termed D and K), an additional proton-conducting network ('H-channel') has been proposed for the beef heart enzyme. Yet, our recent mutational studies on corresponding residues of the Paracoccus denitrificans cytochrome c oxidase provide no clues that such a pathway operates in the prokaryotic enzyme.

Mayer-von Rokitansky-Küster-Hauser syndrome in association with a hitherto undescribed variant of the Holt-Oram syndrome with an aorto-pulmonary window.

We report on the association of Mayer-von Rokitansky-Küster-Hauser syndrome (MRKHS) with a unique form of Holt-Oram syndrome (HOS) with an aorto-pulmonary window. A 24-year-old Turkish woman was referred to our hospital because of primary amenorrhoea. Both her vagina and uterus were absent, and the diagnosis of MRKHS was established. Laparoscopic creation of a neovagina by the modified Vecchietti technique was performed. A rare congenital malformation of the heart, namely an aorto-pulmonary window, had required cardiac surgery when the patient was a 6-month-old infant. This cardiac malformation plus associated upper limb anomalies led to the clinical diagnosis of HOS. To the best of our knowledge, this is only the second report in the scientific literature on the concurrence of MRKHS and HOS, and the first published case of HOS with an aorto-pulmonary window as the cardiac malformation.

Oxytocin receptor gene expression of estrogen-stimulated human myometrium in extracorporeally perfused non-pregnant uteri.

Oxytocin (OT) and the oxytocin receptor (OTR) seem to be less important for uterine contractility-associated disorders of the non-pregnant uterus compared to the pregnant uterus. In the present study, we investigated the mutual dependence of OTR, OT and 17beta-estradiol (E(2)) with regard to the localization of OTR in the non-pregnant uterus. Utilizing our established model for extracorporeal perfusion of the human uterus, we perfused 15 human uteri for 27 h under physiological conditions without oestradiol (group A, n = 5) or with high E(2) stimulation (group B, n = 5) followed by OT stimulation for both groups during the last 3 h of the experiment. Negative controls (n = 5) remained in perfusions for 27 h without any further hormone treatment. Gene expression of the myometrial OTR in both groups was compared using reverse transcriptase triple primer PCR. Stimulation with E(2) and OT led to significantly higher OTR gene expression than stimulation with OT alone. We also showed that concentrations of OTR transcripts increase from the lower uterine segment to the uterine fundus. However, maximum OTR levels of the uterine fundus in group B did not reach concentrations of specimens of third trimester of pregnancy which were used as positive controls. We conclude that our experimental model simulates a situation similiarly to the stimulated non-pregnant uterus in the therapeutic concepts of assisted reproduction. The data presented demonstrate that the dynamics of OTR expression can be modulated by stimulation with E(2) and OT, not only in the pregnant but also in the non-pregnant uterus.

Terminal ileitis with sealed perforation--a rare complication of intestinal endometriosis: case report and short review of the literature.

INTRODUCTION: Perforation is a rare complication of intestinal endometriosis. We report on a 38-year-old patient with previously known rectovaginal and ileocecal endometriosis who was referred with an acute abdomen. CASE REPORT: On abdominal plain film an ileus of small intestine was diagnosed. The patient had fever, and the C-reactive protein was markedly increased. Upon emergency laparotomy an acute terminal ileitis with omentum-sealed perforation and a stenosis of the anterior wall of the rectum due to endometriosis were found. Partial resection of the ileum with end-to-end anastomosis, appendectomy, and short segmental rectum resection were performed. The postoperative course was uneventful. Histological examination corroborated the intraoperative diagnosis of fistulas, perforation and deep ulceration of the intestine consistent with transmural endometriosis. DISCUSSION: For proper care of these patients excellent cooperation between gynecologists and general surgeons is desirable. A short review of the literature concerning intestinal endometriosis is given.

[Information technology in gynecological oncology today]. / Die aktuellen IT-Systeme in der gynäkologischen Onkologie.

Information technology has been integrated in gynecological oncology treatment. Therefore, new software has been established in hospitals and out-patient clinics. A German law concerning data collection in oncology has attempted to unify different strategies. All intentions to establish new documentation systems for tumor diseases need a standardized basic data set. Nevertheless, local governmental health organizations are not yet prepared to implement a global information system such as prenatal and perinatal care databases. Financial support and political work is therefore needed.