New renal scars in children with severe VUR: a 10-year study of randomized treatment

The International Reflux Study in Children was set up to compare prospectively the outcome of medical or surgical management of children with grade III or IV vesicoureteral reflux and a history of symptomatic urinary tract infection. Development of new radiological scars was the main end point. Of the 306 children randomized, 302 (153 medical, 149 surgical) were available for radiological follow-up at 5 years. New scars had developed in 19 medically and 21 surgically treated children. Among 223 patients (113 medical, 110 surgical) who continued follow-up with urography at 10 years, only 2 further new scars developed. Overall, 47 new scars were acquired in 42 patients (20 medical, 22 surgical), 25 of them in children with unscarred kidneys at entry (13 medical, 12 surgical). New scars occurred mostly in children under 5 years of age and were observed more frequently in children with grade IV than grade III reflux. We conclude that with careful management, only a small proportion of children with severe reflux developed new scars and rarely after the first 5-year follow up period, and that there was no difference between children treated medically or surgically.The authors are the writing committee of the European arm of the International Reflux Study in Children. H. Olbing is deceased. Co-ordinating center, Essen, Germany: chairman H. Olbing, scientific co-ordinator T. Tamminen-Möbius, statistics H. Hirche, documentation H. Lax. Participating university hospitals and investigators: Bonn, Germany: R. Mallmann, D. Emons; Brussels, Belgium: M. Hall, A. Piepsz, C. Schulmann; Essen, Germany: H.J. Bachmann, W. Rascher, E. Brunier, C. Reiners, J. Behrendt, P. Mellin (deceased); Gothenburg, Sweden: U. Jodal, K. Hjälmås, E. Hanson, N. Nilsson, J. Bjure (deceased), R. Sixt; Hamburg, Germany: R. Busch, C. Montz; Helsinki, Finland: O. Koskimies, S. Wikström, E. Marttinen, A. Kivisaari, T. Korppi-Tommola; Oulu, Finland: J. Seppänen (deceased), N.P. Huttunen, U. Seppänen, J. Heikkilä; Stockholm, Sweden: A. Aperia, G. Löhr, P. Herin, U. Freyschuss, L. Blom, U. Erasmi, B. Söderborg. Consultants: I. Claesson, K.-D. Ebel, R.A. Lebowitz, K. Parkkulainen, J.M. Smellie, I. Wikstad, and J. Winberg (deceased)     

Questions about questions: cognitive survey of questionnaire development

OBJECTIVES: Traditional pretests are used in the development of survey items to identify technical and comprehension problems. Cognitive processes involved in answering survey questions are not the object of this kind of test. METHODS: Cognitive survey methods were used here to test a questionnaire screening for rehabilitation needs in people suffering from back pain. Essential techniques of cognitive testing (think-aloud, probing, confidence ratings) are outlined. We applied these techniques to 20 patients suffering from either acute or chronic back pain in order to test the survey. RESULTS: The main goal, i.e., identifying problems in item formulation by means of cognitive testing, was achieved. Almost one third of the survey questions were rephrased according to the results of the study. Some of the improvements of the questionnaire are illustrated. CONCLUSIONS: The increased effort required to perform cognitive testing as compared to traditional pretesting pays off. The two methods have specific pros and cons and cannot replace one another.     

Peritoneal dialysis in maple-syrup-urine disease: Studies on branched-chain amino and keto acids

We report biochemical data on a child with MSUD who underwent peritoneal dialysis for severe metabolic imbalance. In confirmation of earlier data, the BCKA/BCAA ratios in blood had been found to be fairly stable in this patient during long-term dietary therapy.The child became comatose at comparatively low levels of leucine and KICA (ca. 2 mM each). At this time the blood/cerebrospinal fluid ratio for BCAA's and BCKA's was markedly diminished. During peritoneal dialysis, peritoneal clearance was highest for KIVA, but less for MEVA and BCAA's (40–50% or urea clearance), and least for the allegedly most toxic metabolite, KICA. The differences for BCKA's may be due to their differential protein binding. Given these individual differences, 1.8 to 8.7 initial plasma volumes were cleared in 14h with 24.21 of dialysis fluid. In the same time, urinary excretion of BCAA's and BCKA's was much less efficient.The data are discussed with regard to the pathobiochemical significance of high tissue levels of branched chain acids. A quantitative comparison between peritoneal dialysis and exchange transfusion is not yet possible.Abbreviations BCAA's branched-chain -amino acids - BCKA's branched-chain -keto acids - KICA -keto-isocaproic acid - KIVA -keto-isovalerio acid - MEVA -keto--methyl-n-valeric acid - MSUD maple syrup urine disease With support of the Landesamt für Forschung des Ministeriums für Wissenschaft und Forschung des Landes Nordrhein-Westfalen. U.L. was supported by Deutsche Forschungsgemeinschaft, Bad Godesberg, G.F.R. (DFG La 201, Schwerpunkt Biochemische Humangenetik and SFB 33 Nervensystem und biologische Information)     

Vaccination of allogeneic haematopoietic stem cell transplant recipients: report from the international consensus conference on clinical practice in chronic GVHD

Patients lose protective immunity to vaccine-preventable diseases after haematopoietic stem cell transplantation (HSCT). Therefore, revaccination of HSCT recipients represents an important strategy for reducing morbidity and mortality associated with these infections. Since there is little consensus on vaccine recommendations and practices for allogeneic HSCT recipients with active chronic graft-versus-host disease (GVHD) the German-Austrian-Swiss-Consensus Conference on Clinical Practice in Chronic GVHD developed an immunization schedule with the aim to provide optimal patient care. The proposed vaccine recommendations include immunization against Haemophilus influenzae type b, pertussis, pneumococci, meningococci, tetanus, diphtheria, hepatitis A and B, measles, mumps and rubella, influenza, poliomyelitis, varicella-zoster virus, human papilloma virus, and tick-borne encephalitis with a particular focus on vaccination of patients with active chronic GVHD.     

Influence of treatment duration with a 600-mg dose of clopidogrel before percutaneous coronary revascularization

OBJECTIVES: We examined clinical outcomes in the Intracoronary Stenting and Antithrombotic Regimen-Rapid Early Action for Coronary Treatment (ISAR-REACT) trial based on the duration of pretreatment with a 600-mg loading dose of clopidogrel. BACKGROUND: The influence of the treatment duration with a 600-mg dose of clopidogrel before percutaneous coronary revascularization on early outcomes remains uncertain. METHODS: Among 2,159 patients with coronary disease who underwent percutaneous coronary intervention (PCI) in the ISAR-REACT trial, we examined clinical outcomes relative to the duration of pretreatment with a 600-mg dose of clopidogrel: (2 to 3 h, 3 to 6 h, 6 to 12 h, or >12 h). Patients were randomly assigned to adjunctive therapy with abciximab or placebo at the beginning of the study. The primary end point was a composite of death, myocardial infarction, or urgent revascularization within 30 days after randomization. RESULTS: No significant differences were observed between patient groups regarding the duration of pretreatment, irrespective of assignment to abciximab or placebo (p = 0.27 for interaction among abciximab/clopidogrel and placebo/clopidogrel treatment at each time interval). Occurrence of major bleeding also did not differ according to time of initial clopidogrel dosing. CONCLUSIONS: For low-to-intermediate risk patients treated with a 600-mg loading dose of clopidogrel before PCI, incremental clinical benefit within the first 30 days from durations of pretreatment >2 to 3 h was not evident.     

Overcoming compound interference in fluorescence polarization-based kinase assays using far-red tracers

Kinase-mediated phosphorylation of proteins is critical to the regulation of many biological processes, including cell growth, apoptosis, and differentiation. Because of the central role that kinases play in processes that can lead to disease states, the targeting of kinases with small-molecule inhibitors is a validated strategy for therapeutic intervention. Classic methods for assaying kinases include nonhomogenous enzyme-linked immunosorbent assays or scintillation-based formats using [gamma-(32)P]ATP. However, homogenous fluorescence-based assays have gained in popularity in recent years due to decreased costs in reagent usage through miniaturization, increased throughput, and avoidance of regulatory costs associated with the use of radiation. Whereas the readout signal from a nonhomogenous or radioactive assay is largely impervious to interferences from matrix components (such as library compounds), all homogenous fluorescent assay formats are subject to such interferences. Interference from intrinsically fluorescent compounds or from scattered light due to precipitated compounds can interfere with assays that depend on a fluorescence intensity (or fluorescence quenching), fluorescence resonance energy transfer, or fluorescence polarization-based readout. Because these interfering factors show a greater effect at lower wavelengths, one strategy to overcome such interferences is to develop fluorescent assays using longer wavelength (red-shifted) fluorescent probes. In this article, we describe the PanVera PolarScreen far-red fluorescence polarization assay format, which mitigates assay interference from autofluorescent compounds or scattered light through the use of a far-red tracer. The tracer shows substantially less interference from light scatter or autofluorescent library compounds than do fluorescein-based tracers, and gives rise to a larger assay window than the popular far-red fluorophore Cy5.     

The influence of glucocorticoid receptor single nucleotide polymorphisms on outcome after haematopoietic stem cell transplantation

Haematopoietic stem cell transplantation (HSCT) remains the only cure for most haematological malignancies, however, the mortality rate remains high. Complications after HSCT include relapse, graft versus host disease (GvHD), graft rejection and infection. Over the last few years several groups, have demonstrated that non‐HLA gene polymorphisms can be predictive of outcome after HSCT. Since the glucocorticoid cortisol is pivotal in the regulation of the immune system, we decided to examine single nucleotide polymorphisms (SNPs; rs6198, rs33388 and rs33389) within the glucocorticoid receptor (GR) and correlate with HSCT outcome. The training set consisted of patients (n = 458) who underwent HSCT for acute leukaemia between 1983 and 2005. In the recipients, the absence of the ACT haplotype and absence of the T allele of rs33388 were associated with decreased OS and the absence of the ACT haplotype, the absence of the T allele of rs33388 and the presence of the ATA haplotype were associated with increased risk of relapse. In addition, the presence of the ACT haplotype in the recipient showed a trend to be associated with increased risk of chronic graft versus host disease (cGvHD). The patients in this cohort received mainly myeloablative conditioning (n = 327). The SNPs in the glucocorticoid receptor were then investigated in a validation set (n = 251) of HSCT patients transplanted for acute leukaemia from 2006. This cohort contained significantly more patients that had received reduced intensity conditioning (RIC). Some of the results could be validated in these patients. However, contrary to the training set, the absence of the haplotype ACT in the donor in this cohort was associated with increased risk of cGvHD. Differences in the conditioning were shown to influence the results. These results are the first to associate GR SNPs with HSCT outcome and demonstrate the inherent problems of replicating SNP association studies in HSCT, due to different pre‐transplant regimens.