[Flexible programs and advanced training for rheumatological patient education]. / Flexible Programme und Fortbildungen für die rheumatologische Patientenschulung.

In two research projects, rheumatological patient education programmes were updated. The first step was to develop an expert consented framework for all rheumatological patient education programmes. From this, curricula and working materials for rheumatoid arthritis (RA) and axial spondyloarthritis (AS) were derived and two exemplary patient education manuals developed. A randomized controlled trail was designed for the five-hour RA basic education program. Finally, existing train-the-trainer training courses were adapted for these patient education programmes.

[Multimorbidity in elderly rheumatic patients part 1]. / Multimorbidität bei älteren Rheumapatienten Teil 1.

An appropriate treatment of elderly rheumatic patients implements comprehensive diagnostics and exclusion diagnostics of e.g. coronary heart disease, osteoporosis, renal failure, diabetes mellitus type 2 and thyroid gland dysfunction. Furthermore, the complex disease situation might require the integration of other faculties or might be a reason for inpatient treatment. The complexity in the treatment of multimorbid elderly patients suffering from rheumatism not only rises with increasing age but also constitutes a considerable challenge due to existing incapacities and preceding as well as currently performed immunosuppressive therapies. The necessary treatment framework is outlined from the perspective of rheumatologists and geriatricians. Typical geriatric symptoms, such as malnutrition, immobility and frailty might be enhanced if multimorbidity is simultaneously present.

[Multimorbidity in elderly rheumatic patients part 2]. / Multimorbidität bei älteren Rheumapatienten Teil 2.

While diseases, such as cardiovascular diseases and osteoporosis in the elderly are categorized as comorbidities of rheumatoid arthritis, elderly rheumatic patients are often additionally affected by thyroid dysfunctions and diabetes mellitus type 2, so that the risk of multimorbidity (coexistence of at least two chronic and/or acute diseases) will increase significantly in elderly patients already suffering from systemic rheumatic diseases. Restricted cognition, adherence or compliance may additionally complicate the treatment of elderly rheumatic patients. Furthermore, the pharmacokinetics of the elderly is another challenging task. Referring to selected aspects of geriatric pharmacotherapy, the use of certain substance classes is described in this context.

Zygomycosis in a 13 year old girl with T-NHL.

We report the clinical and pathological findings of an unusual invasive fungal infection in a 13-year-old girl with T-NHL. The diagnosis of disseminated Zygomycosis was made four days after onset of clinical symptoms. Risk factors for Zygomycosis were prolonged neutropenia, corticosteroids, and steroid induced diabetes mellitus.

Inhibitor-Immunology-Study. Different HLA-types seem to be involved in the inhibitor development in haemophilia A.

UNLABELLED: The development of inhibitors is one of the most important complications of replacement therapy in haemophilia, affecting mortality and morbidity. Inhibitor development is based on complex immunological factors. Cytokines and their receptors, T-cell receptors, and the Major Histocompatibility Complex may play important roles in the development of inhibitors. Earlier studies showed non significant associations between HLA class and inhibitor development. Later studies found an increased risk of inhibitor development if there was a combination between certain factor VIII mutations and HLA antigens. We performed HLA typing in 50 patients with haemophilia A in an effort to find associations with inhibitor development. RESULTS: 25 patients had developed an inhibitor (11 low titre, 14 high titre), and 25 never had. In logistic regression analysis, HLA-A 34, DRB1 0405, DRB1 1301 seemed to be involved in inhibitor development and HLA-A 30, B 13, B15, B 57, Cw 12, DQB1 0303, DPB1 0201 protection against inhibitor development. In our patients, the HLA-associations with inhibitor development were different from those in previous publications.

[Risk factors for perioperative complications in renal surgery for Wilms' tumor]. / Risikofaktoren perioperativer Komplikationen in der Chirurgie des Wilms-Tumors.

BACKGROUND: There is controversy about preoperative chemotherapy in the treatment of Wilms' tumor. The perioperative morbidity plays a key role in this discussion. Therefore, risk factors of perioperative complications were analysed in our series of patients with Wilms' tumor with a special focus on the effects of preoperative chemotherapy. PATIENTS AND METHODS: Case histories of 37 patients [mean age 3.9 (range: 0.6 - 14) years] were retrospectively analysed concerning follow-up, clinical and histopathological stage, size of the primary tumor, as well as duration and extent of preoperative chemotherapy. RESULTS: 35 patients underwent radical nephrectomy, 2 patients had organ-sparing surgery because of bilateral involvement. The mean maximal tumor diameter was 9.5 cm (range: 4 - 24 cm). 11/37 patients had no or shortened preoperative chemotherapy. 6/37 patients (16.2 %) had perioperative complications. There was one intraoperative tumor rupture, 4 small bowel obstructions, 1 pancreatitis. All complications occurred in patients of clinical stages III and IV, maximal tumor diameter > 10 cm after unusually extended operative procedures. 4 patients showed only poor response to preoperative chemotherapy. Patients with doxorubicin pre-treatment showed a higher risk of postoperative small bowel obstruction. CONCLUSIONS: The risk of perioperative complications was correlated with the local extent of the primary tumor and was higher with those requiring more extensive surgical interventions. The influence of preoperative chemotherapy on the complications rate is inconstant. Considering a good response of the primary tumor, the complication rate will be decreased. However, the comorbidity of more intense preoperative chemotherapy in patients of stage IV may contribute to a higher risk of surgical complications.

Molecular basis of recessive congenital methemoglobinemia, types I and II: Exon skipping and three novel missense mutations in the NADH-cytochrome b5 reductase (diaphorase 1) gene.

Hereditary methemoglobinemia due to reduced nicotin amide adenine dinucleotide (NADH)-cytochrome b5 reductase (b5r) deficiency is classified into an erythrocyte type (I) and a generalized type (II). We investigated the b5r gene of three unrelated patients with types I and II and found four novel mutations. The patient with type I was homozygous for a c.535 G-->A exchange in exon 6 (A179T). The patients with type II were found to be homozygous for a c.757 G-->A transition in exon 9 (V253M) and compound heterozygous for two mutations, respectively. One allele presented a c.379 A-->G transition (M127V). The second allele carried a sequence difference at the invariant 3' splice-acceptor dinucleotide of intron 4 (IVS4-2A-->G) resulting in skipping of exon 5. To characterize a possible effect of this mutation on RNA metabolism, poly(A)(+) RNA was analyzed by RT-PCR and sequencing. The results show that RNA is made from the allele harboring the 3'-splice site mutation. Furthermore, western blot analysis revealed a complete absence of immunologically detectable b5r in skin fibroblasts of this patient. The compound heterozygosity for the splice site and the missense mutations apparently caused hereditary methemoglobinemia type II in this patient. Hum Mutat 17:348, 2001.

Autoregulation of the gonadotropin-releasing hormone (GnRH) system during puberty: effects of antagonistic versus agonistic GnRH analogs in a female rat model.

To address whether gonadotropin-releasing hormone (GnRH) regulates its own expression and the expression of its receptor in the hypothalamus and ovary, we treated five groups of prepubertal/peripubertal female rats from postnatal days 25-36 with either the GnRH agonist triptorelin (TRIP) or the GnRH antagonist cetrorelix (CET), each 10 or 100 microgram/day, or a placebo. We compared their effects regarding pubertal development, serum gonadotropins and the expression of GnRH and GnRH-receptor in the hypothalamus, pituitary, ovary and uterus. Onset of puberty was determined by vaginal opening, and expression levels of GnRH and GnRH-receptor were determined using either quantitative real-time PCR or competitive RT-PCR. Onset of puberty was retarded by both analogs but CET (100 microgram/day) inhibited while TRIP (10 and 100 microgram/day) stimulated serum gonadotropins (P<0.05). The expression of GnRH in the preoptic area did not show significant differences among the treatment groups but ovarian GnRH mRNA levels were significantly stimulated by CET (100 microgram/day). GnRH mRNA could not be detected in the uterus by either real-time PCR or competetive RT-PCR. The GnRH-receptor expression in the hypothalamus (preoptic area and mediobasal hypothalamus) did not vary among any of the groups, whereas in the pituitary GnRH-receptor mRNA levels were stimulated by TRIP (10 microgram/day) but inhibited by CET (100 microgram/day). In contrast, in the ovary GnRH-receptor mRNA levels were inhibited by both TRIP (100 microgram/day) and CET (100 microgram/day). Interestingly, the GnRH-receptor was even expressed in the uterus where it was strongly stimulated by both CET and TRIP in a dose-related manner. This shows that in addition to their different pituitary effects, the GnRH analogs cetrorelix and triptorelin exert different actions at the hypothalamic, ovarian and uterine level. This study also demonstrates an organ-specific regulation of GnRH and GnRH-receptor gene expression which is likely part of a local autoregulatory system. We conclude that the ovarian and uterine effects of GnRH analogs must be considered in addition to their known pituitary effects when deciding which GnRH analog is most suitable for treating precocious puberty.

Induction of differentiation and tetraploidy by long-term treatment of C6 rat glioma cells with erucylphosphocholine.

Induction of differentiation represents a promising concept for chemotherapy of malignant gliomas, which are often refractory even to the combined treatment with surgery, irradiation and chemotherapy. Since anti-neoplastic alkylphosphocholines can induce differentiation of leukemic cell lines, the effects of the intravenously applicable alkylphosphocholine-derivative erucylphosphocholine (ErPC) on proliferation, morphology and differentiation of the rat glioma cell line C6 was examined in vitro. Short-term exposure to ErPC induced accumulation of the cells in the G2/M-phase of the cell cycle and apoptotic cell death. In contrast, continuous exposure of C6 rat glioma cells to sublethal ErPC doses (30 and 50 microM) caused both the formation of a slower growing tetraploid cell population and astrocytic differentiation. No resistance to in vivo obtainable ErPC concentrations was observed during this treatment. We conclude that ErPC-induced differentiation might be beneficial for a long-term adjuvant chemotherapy of low grade glioma.

Erucylphosphocholine, a novel antineoplastic ether lipid, blocks growth and induces apoptosis in brain tumor cell lines in vitro.

A potential benefit of alkylphosphocholines in brain tumor therapy was evaluated. The in vitro effects of the intravenously applicable erucylphosphocholine (ErPC) on proliferation, viability, morphology and cell cycle distribution of a rat glioma, four human astrocytoma/glioblastoma and a human medulloblastoma cell line were analyzed daily after continuous drug-exposure for up to six days. ErPC exerted strong cytostatic and direct cytotoxic effects on all cell lines tested at drug concentrations that are achieved in the rat brain after repeated intravenous injections of nontoxic drug doses. Concentrations of 70 microM (T98G, A172, 85HG66, 86HG39) and 110 microM (C6, D283 Med) led to complete cell death within 48-96 h. Particular characteristics of ErPC action are i) the accumulation of cells with a 4n DNA content corresponding to the G2/M-phase of the cell cycle, ii) the formation of two- and multinucleated cells and iii) the induction of apoptosis.

Erucylphosphocholine: pharmacokinetics, biodistribution and CNS-accumulation in the rat after intravenous administration.

The clinical use of alkylphosphocholines (APC) in cancer patients is restricted because of the high gastrointestinal toxicity and the need for oral administration. Therefore we evaluated the clinical pharmacology of erucylphosphocholine (ErPC), the first derivative of the APC family suitable for intravenous administration with strong antineoplastic activity, in vitro and in vivo in rats. The pharmacokinetic parameters after a single intravenous dose of 40 mg/kg were calculated using a two-compartment model: C(max) = 1.6 +/- 0.3 micromol/ml, T(1/2alpha) = 0.18 +/- 0.09 h, T(1/2beta) = 3.3 +/- 0.88 h, clearance = 9.7 +/- 1.2 ml/h, AUC = 2.5 +/- 0.3 micromol/ml per h and Vss = 40.4 +/- 7.9 ml. Biodistribution studies were performed after repeated ErPC administration at different doses. Intravenous injections of 20 mg/kg given at intervals of 48 h for up to 4 weeks were well tolerated. Neither clinical evaluation nor laboratory parameters (haematology and clinical chemistry) revealed toxic side effects. In contrast, higher doses of ErPC (40 mg/kg per 48 h) led to weight loss. After 2 and 4 weeks of therapy with 20 mg/kg per 48 h a high ErPC accumulation was found in the adrenal glands, small intestine and brain. The brain to serum concentration ratios averaged 2.1 after 2 weeks and 4.5 after 4 weeks. Significant leucocytosis and thrombocytosis were observed after 4 weeks of ErPC treatment. The findings suggest that ErPC is a suitable candidate for clinical trials. In particular, owing to the high accumulation in brain tissue, ErPC is a potential agent for chemotherapy against malignant brain tumours.

Ontogeny of the GNRH-, glutaminase- and glutamate decarboxylase-gene expression in the hypothalamus of female rats.

Amino acid neurotransmitters like gamma-aminobutyric acid (GABA) and glutamate (GLU) are involved in the regulation of hypothalamic gonadotropin releasing hormone (GnRH) release. We investigated, whether there are changes of gene expression in the rat hypothalamus for GnRH, GnRH receptor, as well as glutaminase and glutamate decarboxylase, two enzymes regulating neurotransmitter concentrations of GLU and GABA in the brain during the ontogeny. After reverse transcription-polymerase chain reaction (RT-PCR) we used an ELISA method to quantify PCR products. In 15-day old animals high plasma luteinizing hormone (LH) levels with pronounced variations were found. In 25-day old animals LH values were low, whereas in 35-day old rats LH levels increased significantly indicating the reactivation of the GnRH-pulse generator at the beginning of puberty. In parallel to these changes, the mRNA levels of the GnRH receptor in the mediobasal hypothalamus were high at day 15, significantly lower at day 25 and again high at day 35 after birth (ELISA O.D. GnRH-R day 15: 0.46+/-0.07, day 25: 0.16+/-0.04, day 35: 0.36+/-0.04; p<0.01), but no changes of GnRH receptor gene expression were found in the preoptic area. The mRNA of GnRH in the preoptic area as well as mRNA levels of glutaminase and glutamate decarboxylase in the mediobasal hypothalamus and the preoptic area did not change during ontogeny. We conclude that hypothalamic GnRH receptors are involved in the characteristic changes of LH secretion patterns during sexual maturation. Major changes of GnRH receptor gene expression occurred in the mediobasal hypothalamus and correlated well with plasma LH levels, whereas hypothalamic mRNA levels of GnRH, glutaminase and glutamate decarboxylase did not change within the different age groups. Thus the activity of the GABA- and glutamatergic system during ontogeny may be regulated at the receptor or postreceptor level.

Reduction of gamma-aminobutyric acid-ergic neurotransmission as a putative mechanism of radiation induced activation of the gonadotropin releasing-hormone-pulse generator leading to precocious puberty in female rats.

Brain irradiation in prepubertal children with malignomas can cause precocious puberty. A selective cranial cobalt (Co(60))-irradiation technique has been developed in rats. In two experiments early juvenile (13-15 days old) female rats received a single dose of 5 Gy or sham irradiation. At pubertal age (post-natal days 33-34) irradiated rats had higher serum estradiol and luteinizing hormone levels. In experiment 1 irradiated rats had higher gonadotropin releasing-hormone (GnRH) mRNA levels in the preoptic area compared to controls (P<0.05). In experiment 2 the release rates of gamma-aminobutyric acid (GABA) in vitro from preoptic mediobasal hypothalamic areas of irradiated rats were significantly reduced after stimulation with the GABA(A) receptor agonist muscimol (maximum values 4607+/-804 vs. 7399+/-1048 pM in controls, mean+/-SEM, P<0.05). Radiation induced central precocious puberty might be caused by damage to inhibitory GABAergic neurons leading to premature activation of the GnRH-pulse generator.

Red cell pyruvate kinase deficiency: an optimised assay.

As a result of using a variety of assay techniques, rather different values for the rate of the pyruvate kinase (PK) reaction were obtained. Kinetic measurements performed with red cell PK using the stopped-flow as well as the "classical" spectrophotometric method demonstrated that only the initiation of the reaction with ADP yields reproducible results in the standard assay. Moreover, the influence of substrate concentrations, activator concentrations, ionic strength, buffer system, temperature and duration of preincubation were thoroughly investigated and were shown to play an important role. As a consequence of our kinetic measurements, a modified optimised assay composition together with new normal values for erythrocyte PK activity in haemolysate are presented. For better characterisation and comparability of PK variants, we suggest the use of the optimised assay composition described and that the reaction be initiated with ADP.

Erythrocyte pyruvate kinase- and glucose phosphate isomerase deficiency: perturbation of glycolysis by structural defects and functional alterations of defective enzymes and its relation to the clinical severity of chronic hemolytic anemia.

The pathogenesis of two metabolic disorders caused by enzyme defects in the red blood cell leading to hemolytic anemia, and in some cases of glucose phosphate isomerase (GPI) deficiency additionally to neurological impairment was investigated. Rheological studies were performed to determine the influence of a shortage of energy on the deformability of the erythrocytes. The functions of the enzymes were determined by studying the enzyme kinetics, the temperature dependence of the enzyme activity and the migration of the proteins in an electric field. A detailed molecular genetic analysis of the gene encoding for the given protein allowed the detection of mutations involving amino acid exchanges which cause alterations of the protein structure. For both enzyme deficiencies, a good correlation was found between the structural changes (usually caused by single point mutations in the gene), the altered function of the enzymes and the severity of the clinical picture. The exchange of amino acids close to either the active site or the regulatory domain results in a decreased turnover as well as an alteration of the regulatory properties of the enzymes; this usually leads to an increased severity of the disease. Increased concentrations of glucose-6-phosphate (G-6-P), found in all red blood cells of patients suffering from hemolytic anemia caused by pyruvate kinase (PK) and GPI deficiency, correlate well with the severity of the clinical picture, apparently reflecting the degree of the perturbation of glycolysis. This results in a lack of the energy donor adenosine triphosphate (ATP); this leads then to a destabilization of the red cell membrane which causes earlier lysis of the red blood cell, which in turn gives rise to hemolytic anemia of variable degrees. One patient with neurological symptoms has been studied so far biochemically and at the molecular genetic level. The point mutations found in this patient's GPI gene support the idea that GPI may have a neurological function in addition to its role in the carbohydrate metabolism; this is due to the presence of a monomeric sequence analogue called neuroleukin (NLK). The mutations apparently lead to the incorrect folding of this neurotrophic factor, and thus destroy the neurological activity.

Autoimmune thyreoiditis in childhood--epidemiology, clinical and laboratory findings in 61 patients.

Autoimmune thyroiditis (AT) is the most common cause of nonendemic goiter and acquired hypothyroidism in children and adolescents. In 61 patients AT was diagnosed following clinical, ultrasonographic, biochemical and cytological examinations. Girls were more often affected than boys, the female/male ratio in our patients was 9:1. Clinically the vast majority of patients had a goiter. Approximately half of the patients were euthyroid (n = 29). In the other patients hyperthyrotropinaemia (n = 16), hypothyroidism (n = 9) and hyperthyroidism (n = 7) were evident. Thyroid microsomal and peroxidase antibodies were elevated in most of the patients, while thyroglobin antibodies were less frequently elevated. As AT without detectable thyroid antibodies can occur, a fine-needle aspiration cytology of the thyroid is important in nontypical cases. This type of cytologic examination should also be considered in patients with euthyroid nonendemic goiter, thyroid nodules and hyperthyroid goiter.

GnRH antagonist cetrorelix prevents sexual maturation of peripubertal male rats.

UNLABELLED: Gonadotropin releasing-hormone (GnRH) analogues contain amino acid substitutions of the native decapeptide. Depending on the substitutions, the analogues have GnRH agonistic or antagonistic properties. GnRH agonists are the established treatment in cases of central precocious puberty caused by premature activation of the hypothalamic GnRH pulse generator. Much less data exist on the use of GnRH antagonists to influence the onset of puberty. Using the GnRH antagonist cetrorelix we conducted a 5 day treatment of peripubertal male rats (cetrorelix group n=12, 100 microg/d intraperitoneally injected; placebo n=10, NaCl 0.9% intraperitoneally injected) from postnatal day 32 to 36 and decapitated on postnatal day 37 to investigate the effects on pubertal development, serum gonadotropin and testosterone levels as well as the GnRH release from explanted hypothalami. A control group of 5 male rats was added for hypothalamus superfusion experiments on day 25. We observed no progress of testicular development in the cetrorelix group. Cetrorelix injected rats had lower testicular weights (531+/-13 versus controls 819+/-25 mg, mean+/-SEM, p<0.0001). 12 h after the last injection testosterone levels were in the castrate range (serum testosterone, median controls: 1.7 ng/ml, median cetrorelix <0.30 ng/ml, p<0.001), and they showed lower serum LH and FSH compared to the same age placebo group. After decapitation the preoptic mediobasal hypothalamic area (POA/MBH) was dissected from 5 randomly selected rats from each treatment group and the release rates of GnRH were determined in superfusion experiments: The hypothalamic GnRH secretion was comparable in the CET and the same age placebo rats but significantly higher than in the 25 day old control group. CONCLUSION: The GnRH antagonist cetrorelix inhibits the pituitary-gonadal axis in peripubertal male rats and may be effective in treating central precocious puberty in males.

Erucylphosphocholine-induced apoptosis in chemoresistant glioblastoma cell lines: involvement of caspase activation and mitochondrial alterations.

Intrinsic chemoresistance constitutes a major problem in the therapy of malignant gliomas. In vitro experiments with four astrocytoma/glioblastoma (AC/GBM) cell lines revealed that the chemoresistance of two cell lines, A172 and T98G, to cisplatin and etoposide was due to resistance to drug-induced apoptosis. In contrast, all the AC/GBM cell lines tested were sensitive to treatment with the lipophilic ether lipid erucylphosphocholine, ErPC. ErPC-induced apoptosis was independent of wild-type p53-signaling and triggering of the CD95/CD95 ligand (CD95L) system. Inhibition of protein and RNA synthesis by cycloheximide and actinomycin D did not abrogate ErPC-induced apoptosis. However, expression of members of the bcl-2 protein family was modulated during ErPC treatment. Activation of caspase 3 and mitochondrial alterations were central to ErPC-induced apoptosis. We conclude that ErPC-induced activation of the mitochondrial pathway enables cell death in the chemoresistant AC/GBM cells.