Comprehensive clinical commissioning and validation of the RayStation treatment planning system for proton therapy with active scanning and passive treatment techniques.

PURPOSE: To commission the treatment planning system (TPS) RayStation for proton therapy including beam models for spot scanning and for uniform scanning. METHODS: Tests consist of procedures from ESTRO booklet number 7, the German DIN for constancy checks of TPSs, and extra tests checking the dose perturbation function. The dose distributions within patients were verified in silico by a comparison of 65 clinical treatment plans with the TPS XiO. Dose-volume parameters, dose differences, and three-dimensional gamma-indices serve as measures of similarity. The monthly constancy checks of Raystation have been automatized with a script. RESULTS: The basic functionality of the software complies with ESTRO booklet number 7. For a few features minor enhancements are suggested. The dose distribution in RayStation agrees with the calculation in XiO. This is supported by a gamma-index (3mm/3%) pass rate of >98.9% (median over 59 plans) for the volume within the 20% isodose line and a difference of <0.3% of V95 of the PTV (median over 59 plans). If spot scanning is used together with a range shifter, the dose level calculated by RayStation can be off by a few percent. CONCLUSIONS: RayStation can be used for the creation of clinical proton treatment plans. Compared to XiO RayStation has an improved modelling of the lateral dose fall-off in passively delivered fields. For spot scanning fields with range shifter blocks an empirical adjustment of monitor units is required. The computation of perturbed doses also allows the evaluation of the robustness of a treatment plan.

[Haemostatic management in postpartum haemorrhage : Nationwide survey in Germany]. / Gerinnungstherapie der peripartalen Hämorrhagie : Deutschlandweite Umfrage.

BACKGROUND: In order to ensure evidence-based haemostatic management of postpartum haemorrhage (PPH, blood loss >500 ml) consistent with guidelines appropriate structural conditions must be fulfilled regardless of different levels (1-3) in perinatal care. The aim of the survey was to identify differences in haemostatic management in PPH under consideration of the different levels of perinatal care in Germany. MATERIALS AND METHODS: An electronic questionnaire assessing the structural and therapeutic preconditions for haemostatic management was sent to 533 anaesthesiology departments serving obstetric units. RESULTS: A total of 156 (29 %) questionnaires returned from hospitals of all levels were analysed. PPH occur in all and increase with higher level hospitals (level 1 <5 PPH/year vs. 3 >30 PPH/year). The percentage of PPH requiring red blood cell (RBC) transfusion amounts to <25 % (all levels). A bleeding history (35 %, all levels), laboratory coagulation tests (29 %, all levels) as well as viscoelastic point-of-care coagulation tests (42 %, mainly level 3) are limited in their availability. Blood loss is usually estimated (99 %, all levels), not measured. Tranexamic acid (>80 %, all levels), fibrinogen (>60 %, all levels) and fresh frozen plasma (FFP) (30 %, level 2a) are first line therapeutics. In level 2b and 3 FFP is a second line therapeutic. RBC transfusion is indicated at haemoglobin <5-7 g/dl (57-69 %, all levels), while 15-29 % in level 3 did not base their decision to transfuse RBC on haemoglobin only. CONCLUSIONS: Guideline-consistent haemostatic management of PPH is provided in almost all hospitals independent of the perinatal care level. Deviances from guidelines (measuring blood loss, bleeding history of the patient) affect all levels of perinatal care in Germany.

Comparison of pathogenicity prediction tools on missense variants in RYR1 and CACNA1S associated with malignant hyperthermia.

BACKGROUND: Malignant hyperthermia (MH) is a pharmacogenetic disorder that has been linked to the skeletal muscle calcium release channel (RYR1) and the α1S subunit of the voltage-dependent L-type calcium channel (CACNA1S). Genomic DNA capture and next generation sequencing are becoming the preferred method to identify mutations in these genes. Bioinformatic pathogenicity prediction of identified variants may help to determine if these variants are in fact disease causing. METHODS: Eight pathogenicity prediction programmes freely available on the web were used to determine their ability to correctly predict the impact of a missense variant on RyR1 or dihydropyridine receptor (DHPR) protein function. We tested MH-causative variants, variants that had been shown to alter calcium release in cells, and common sequence variants in RYR1 and CACNA1S. RESULTS: None of the prediction programmes was able to identify all of the variants tested correctly as either 'damaging' (MH-causative variants, variants that had been shown to alter calcium release in cells) or as 'benign' (common sequence variants). The overall sensitivity of predictions ranged from 84% to 100% depending on the programme used, with specificity from 25% to 83%. CONCLUSIONS: In this study we determined the sensitivity and specificity of bioinformatic pathogenicity prediction tools for RYR1 and CACNA1S. We suggest that the prediction results should be treated with caution, as none of the programmes tested predicted all the variants correctly and should only be used in combination with other available data (functional assays, segregation analysis).

Sequence capture and massively parallel sequencing to detect mutations associated with malignant hyperthermia.

BACKGROUND: Malignant hyperthermia (MH) is a potentially fatal pharmacogenetic disorder in which intracellular calcium homeostasis in the skeletal muscle of susceptible individuals is disrupted upon exposure to halogenated anaesthetics. While MH is linked to the ryanodine receptor (RYR1) on chromosome 19 and the α1S subunit of the voltage-dependent L-type calcium channel (CACNA1S) on chromosome 1, mutations have been found in only 50-70% of patients, and subsequently, there is a need for a more powerful screening tool. METHODS: Genomic DNA capture and next-generation sequencing was used to screen 32 genes involved in excitation-contraction coupling, skeletal muscle calcium homeostasis, or immune response in two MH patients. Lymphoblastoid cell lines were used to functionally characterize candidate RYR1 mutations in one family. RESULTS: Sequence analysis revealed two putative causative mutations in RYR1 in one patient. Segregation analysis and functional analysis support a causative role of the detected variants. The amount of Ca(2+) released after stimulation with 4-chloro-m-cresol from B lymphocytes of the MH-susceptible patients in the family was significantly greater compared with that of Ca(2+) released from cells of an MH-negative family member. In the other patient, no causative mutations were identified in the 32 genes screened. CONCLUSIONS: In this study, we successfully demonstrate the use of genomic DNA capture and next-generation sequencing for identification of putative mutations causing MH. We also suggest that whole exome sequencing may be necessary to identify MH causing mutations in patients where no mutations in RYR1 and CACNA1S have been identified thus far.

Organization and expression of the Australian sheep blowfly (Lucilia cuprina) hsp23, hsp24, hsp70 and hsp83 genes.

In this study we report the isolation and characterization of a heat shock protein 70 (hsp70) gene, the hsp83 gene and two genes that encode small Hsps (Lchsp23 and Lchsp24) from the Australian sheep blowfly, Lucilia cuprina, a major agricultural pest. Phylogenetic analyses indicate that the LcHsp23 protein is the orthologue of Drosophila melanogaster Hsp23 and LcHsp24 is the orthologue of Sarcophaga crassipalpis Hsp23. Quantitative reverse-transcriptase PCR analysis showed that the basal level of Lchsp83 RNA is relatively high at all developmental stages and only moderately induced by heat shock. In contrast, Lchsp70 transcripts are present at low levels and strongly induced by heat shock at all stages. The basal levels of expression and degrees of heat induction of the Lchsp23 and Lchsp24 transcripts were more variable across the different developmental stages. Putative heat shock factor binding sites were identified in the Lchsp24, Lchsp70 and Lchsp83 gene promoters. The isolation of these hsp gene promoters will facilitate constitutive or conditional expression of a gene of interest in transgenic Lucilia.

Delayed treatment of delirium increases mortality rate in intensive care unit patients.

Delirium in the intensive care unit (ICU) is a serious complication associated with a poor outcome in critically ill patients. In this prospective observational study of the effect of a delay in delirium therapy on mortality rate, 418 ICU patients were regularly assessed using the Delirium Detection Score (DDS). The departmental standard required that if delirium was diagnosed (DDS >7), therapy should be started within 24 h. In total, 204 patients (48.8%) were delirious during their ICU stay. In 184 of the delirious patients (90.2%), therapy was started within 24 h; in 20 patients (9.8%), therapy was delayed. During their ICU stay, patients whose delirium treatment was delayed were more frequently mechanically ventilated, had more nosocomial infections (including pneumonia) and had a higher mortality rate than patients whose treatment was not delayed. Thus, it would appear that a delay in initiating delirium therapy in ICU patients was associated with increased mortality.

Increased arterial distensibility in postmenopausal hypertensive women with and without hormone replacement therapy after acute administration of the ACE inhibitor moexipril.

Menopause and essential hypertension are associated with a decreased compliance and distensibility of the arteries. ACE inhibitors have been shown to improve arterial distensibility. Hormone replacement therapy (HRT), especially estrogens, could have a positive influence through their atheroprotective, vasodilative, and blood pressure-lowering effect. The vascular interactions of HRT and ACE inhibitors, like moexipril hydrochloride, have not been investigated so far. This trial was intended to assess the effect of combined sequential HRT for 25 days on acute changes in arterial distensibility after a single oral dose of 15 mg moexipril hydrochloride in postmenopausal women with borderline to mild essential hypertension. This study had a monocentric, randomized, parallel-group design, and was open for moexipril, and double-blind, and placebo-controlled for HRT. Assessment of arterial distensibility was by automatic noninvasive measurement of the carotid-femoral pulse wave velocity (PWV). The PWV and the pulse pressure decreased significantly after a single oral dose of 15 mg moexiprill. An influence of HRT on the changes in the PWV and pulse pressure could not be seen. The plasma concentrations of renin increased and of aldosterone decreased after moexipril administration. Arterial function improves after acute administration of 15 mg moexipril in postmenopausal women with mild to moderate essential hypertension. The changes in PWV and pulse pressure are of similar magnitude in women with and without HRT.

[Significance of left ventricular hypertrophy in primary hypertension and therapeutic modification by antihypertensive drugs]. / Die Bedeutung der linksventrikulären Hypertrophie (LVH) bei primärer Hypertonie und ihre therapeutische Beeinflussbarkeit durch antihypertensive Medikamente.

Left ventricular hypertrophy (LVH) is one of the major cardiovascular risk factors. Without treatment a concentric form with left ventricular dysfunction develops characteristically into an excentric form with progressive heart failure. Many pathogenetically important factors are known. Treatment is possible with life-style modification and nearly all first-line antihypertensive drugs. It should aim at prevention or permanent normalisation of an existing LVH.

Enhancement of glucose disposal in patients with type 2 diabetes by alpha-lipoic acid.

Insulin resistance of skeletal muscle glucose uptake is a prominent feature of Type II diabetes (NIDDM); therefore pharmacological interventions should aim to improve insulin sensitivity. Alpha-lipoic acid (CAS 62-46-4, thioctic acid, ALA), a natural occurring compound frequently used for treatment of diabetic polyneuropathy, enhances glucose utilization in various experimental models. To see whether this compound also augments insulin mediated glucose disposal in NIDDM, 13 patients received either ALA (1000 mg/Thioctacid/500 ml NaCl, n = 7) or vehicle only (500 ml NaCl, n = 6) during a glucose-clamp study. Both groups were comparable in age, body-mass index and duration of diabetes and had a similar degree of insulin resistance at baseline. Acute parenteral administration of ALA resulted in a significant increase of insulin-stimulated glucose disposal; metabolic clearance rate (MCR) for glucose rose by about 50% (3.76 ml/kg/min = pre vs. 5.82 ml/kg/min = post, p < 0.05), whereas the control group did not show any significant change (3.57 ml/kg/min = pre vs. 3.91 ml/kg/min = post). This is the first clinical study to show that alpha-lipoic acid increases insulin stimulated glucose disposal in NIDDM. The mode of action of ALA and its potential use as an antihyperglycemic agent require further investigation.

Crystallization and preliminary crystallographic data of purple acid phosphatase from red kidney bean.

Purple acid phosphatase from red kidney bean has been crystallized from ammonium sulfate solutions in the pH range from 3.5 to 5.5. The crystal form is tetragonal bipyramidal and the largest crystals grew up to 2.0 mm long. Systematic absences indicate one of the enantiomorphic space groups P4(1)2(1)2 (92) or P4(3)2(1)2 (96) with cell dimensions a = b = 104.1(1) A and c = 308.7(2) A. The asymmetric unit contains one dimer with Mr of 110,700, determined by ultraviolet-laser desorption mass spectrometry. The crystals, with a salt-free density of 1.12 g/cm3 and a water content of 67%, diffract to 3.5 A.

Transsynovial kinetics of indoprofen in patients with rheumatoid arthritis and cyclooxygenase-inhibition in vitro.

Twenty-four patients suffering from rheumatoid arthritis and requiring articular punctures were treated with 200 mg of indoprofen thrice daily for four days. The subjects were divided into four groups each of six patients. Following the last dose, blood and synovial fluid samples were taken simultaneously according to different time schedules. Maximum plasma levels of 17.5 micrograms/ml were observed after 2.5 h. Peak synovial fluid concentrations amounted to 8.1 micrograms/ml 4 h following the last dose. Elimination from synovial fluid occurred at 10.6 h compared to 9.3 h from plasma. Free synovial fluid levels of approximately 50 ng/ml are in the range of concentrations necessary for cyclooxygenase inhibition in mouse peritoneal macrophages.