TY - JOUR A1 - Tony, Hans-Peter A1 - Burmester, Gerd A1 - Schulze-Koops, Hendrik A1 - Grunke, Mathias A1 - Henes, Joerg A1 - Kötter, Ina A1 - Haas, Judith A1 - Unger, Leonore A1 - Lovric, Svjetlana A1 - Haubitz, Marion A1 - Fischer-Betz, Rebecca A1 - Chehab, Gamal A1 - Rubbert-Roth, Andrea A1 - Specker, Christof A1 - Weinerth, Jutta A1 - Holle, Julia A1 - Müller-Ladner, Ulf A1 - König, Ramona A1 - Fiehn, Christoph A1 - Burgwinkel, Philip A1 - Budde, Klemens A1 - Sörensen, Helmut A1 - Meurer, Michael A1 - Aringer, Martin A1 - Kieseier, Bernd A1 - Erfurt-Berge, Cornelia A1 - Sticherling, Michael A1 - Veelken, Roland A1 - Ziemann, Ulf A1 - Strutz, Frank A1 - von Wussow, Praxis A1 - Meier, Florian MP A1 - Hunzelmann, Nico A1 - Schmidt, Enno A1 - Bergner, Raoul A1 - Schwarting, Andreas A1 - Eming, Rüdiger A1 - Schwarz-Eywill, Michael A1 - Wassenberg, Siegfried A1 - Fleck, Martin A1 - Metzler, Claudia A1 - Zettl, Uwe A1 - Westphal, Jens A1 - Heitmann, Stefan A1 - Herzog, Anna L. A1 - Wiendl, Heinz A1 - Jakob, Waltraud A1 - Schmidt, Elvira A1 - Freivogel, Klaus A1 - Dörner, Thomas A1 - Hertl, Michael A1 - Stadler, Rudolf T1 - Safety and clinical outcomes of rituximab therapy in patients with different autoimmune diseases: experience from a national registry (GRAID) JF - Arthritis Research & Therapy N2 - Introduction: Evidence from a number of open-label, uncontrolled studies has suggested that rituximab may benefit patients with autoimmune diseases who are refractory to standard-of-care. The objective of this study was to evaluate the safety and clinical outcomes of rituximab in several standard-of-care-refractory autoimmune diseases (within rheumatology, nephrology, dermatology and neurology) other than rheumatoid arthritis or non-Hodgkin’s lymphoma in a real-life clinical setting. Methods: Patients who received rituximab having shown an inadequate response to standard-of-care had their safety and clinical outcomes data retrospectively analysed as part of the German Registry of Autoimmune Diseases. The main outcome measures were safety and clinical response, as judged at the discretion of the investigators. Results: A total of 370 patients (299 patient-years) with various autoimmune diseases (23.0% with systemic lupus erythematosus, 15.7% antineutrophil cytoplasmic antibody-associated granulomatous vasculitides, 15.1% multiple sclerosis and 10.0% pemphigus) from 42 centres received a mean dose of 2,440 mg of rituximab over a median (range) of 194 (180 to 1,407) days. The overall rate of serious infections was 5.3 per 100 patient-years during rituximab therapy. Opportunistic infections were infrequent across the whole study population, and mostly occurred in patients with systemic lupus erythematosus. There were 11 deaths (3.0% of patients) after rituximab treatment (mean 11.6 months after first infusion, range 0.8 to 31.3 months), with most of the deaths caused by infections. Overall (n = 293), 13.3% of patients showed no response, 45.1% showed a partial response and 41.6% showed a complete response. Responses were also reflected by reduced use of glucocorticoids and various immunosuppressives during rituximab therapy and follow-up compared with before rituximab. Rituximab generally had a positive effect on patient well-being (physician’s visual analogue scale; mean improvement from baseline of 12.1 mm) KW - GRAID Y1 - 2011 U6 - http://nbn-resolving.de/urn/resolver.pl?urn:nbn:de:bvb:20-opus-142856 VL - 13 IS - R75 ER - TY - THES A1 - König, Martin T1 - Stereoselektive Synthese verschiedener beta-Amino- und Microcos-Piperidinderivate : Versuche zur Totalsynthese von (+)-Microconin T1 - Stereoselective synthesis of beta-amino- and Microcos-piperidines : An approach to the total synthesis of (+)-Microconine N2 - Das Ziel dieser Arbeit war es, eine im Arbeitskreis entwickelte Methode zur Darstellung von unterschiedlich substituierten -Aminopiperidinen zu etablieren und zu verifizieren, indem unser Konzept einer Tandemreaktion zum Einsatz kommen sollte. Diese Reaktionssequenz sollte anschließend zur Totalsynthese von Microconin, einem aus Microcos paniculata isoliertem Alkaloid, genutzt werden. Den ersten Schritt in Richtung -Aminopiperidinderivate machte die Veresterung von L-Pyroglutaminsäure. Nach der Reduktion des Methylesters erfolgte die Aktivierung der Hydroxyfunktion des Alkohols in Form des Tosylats. Die Azideinführung resultierte aus einer nucleophilen Substitutionsreaktion, anschließend daran wurde der Lactam-Stickstoff mit Boc2O und einer katalytischen Menge DMAP geschützt. Das Lactam ist durch den Elektronenakzeptor aktiviert, so dass die Ringöffnung zum Methylester unter sehr milden Bedingungen und ohne weiteren Reinigungsschritt erfolgen konnte. Die Aminofunktion musste mit einer zweiten Schutzgruppe blockiert werden, die anschließende selektive Reduktion mit DiBAl-H in trockenem Ether verlief problemlos und lieferte mit dem Aldehyd das Edukt für Olefinierungen mittels verschiedener Wittig-Reaktionen. Dafür wurden stabilisierte Phosphonate hergestellt und in einer HWE-Reaktion mit dem Aldehyd umgesetzt. Die resultierenden elektronenarmen Olefine gingen dann die intramolekulare Cycloaddition mit dem Azidsubstituenten ein und bauten so den Grundkörper der -Aminopiperidinderivate in einer Reaktionssequenz auf, die wir als Tandem Wittig-[3+2]-Cycloaddition bezeichnen. Die Bildung der primären Triazoline erfolgte stereoselektiv, die Geschwindigkeit der Cycloaddition hing sowohl vom konjugierten Olefinsubstituenten als auch vom vicinalen Substituenten der Azidfunktion ab. Die Konfigurationsbestimmung erfolgte mittels NMR-Spektroskopie durch Analyse der Kopplungskonstanten und NOE-Messungen. Die asymmetrische Induktion der Cycloaddition konnte direkt für die Stereochemie am Piperidinring genutzt werden, indem, nach basischer Triazolin/Diazoamin Isomerisierung, gleich das Diazoamin hydriert wurde. Die Hydrierung der vinylogen Urethane, den Produkten aus der rhodiumkatalysierten Stickstoffextrusion, lieferte ein Diastereomerengemisch, wobei das Verhältnis der Diastereomere hauptsächlich vom Substitutionsgrad des exocyclischen Amins abhängig war. Überraschenderweise fand beim Sulfontriazolin keine Isomerisierung zum Diazoamin statt, daher musste für die Darstellung der Sulfonylmethyl--aminopiperidine eine alternative Route über ein Ketosulfon beschritten werden. Die Synthese von Microconin begann mit der Desoxygenierung von L-Rhamnose durch die sog. Fischer-Zach-Reaktion. Das Rhamnal wurde in einer drei Stufen Eintopfreaktion erhalten und mittels Perlinhydrolyse in den offenkettigen Aldehyd umgewandelt. Die Aktivierung der Hydroxyfunktion als Mesylat resultierte in einer äußerst empfindlichen Verbindung, die nur durch Verwendung des Lindlar-Katalysators mit zufrieden stellenden Ergebnis zum aliphatischen Aldehyd reduziert werden konnte. Eine bimolekulare nucleophile Substitutionsreaktion lieferte bei der Azideinführung zur Schlüsselverbindung sowohl die benötigte funktionelle Gruppe als auch die benötigte Inversion der Konfiguration. Die Tandem HWE-[3+2]-Cycloadditions-Reaktion führte auch bei dem Sulfontriazolin in eine Sackgasse, weshalb wieder eine alternative Syntheseroute eingeschlagen werden musste. Ausgehend von derselben Schlüsselverbindung gelang dies durch eine zinnkatalysierte Umsetzung mit stabilisierten Diazomethan zum Ketosulfon. Der Aufbau des Piperidin-Heterocyclus konnte dann wieder über eine intramolekulare Imin-Bildung des intermediären Amins mit dem Keton erzielt werden. Die diastereoselektive Hydrierung verlief unter Wasserstoffaddition von der sterisch weniger gehinderten -Seite und Ausbildung des all cis Substitutionsmusters. Nach dem erfolgreichen Aufbau des Heterocyclus mussten noch die beiden Heteroatome methyliert werden. Dabei wurden die besten Ergebnisse am Ringstickstoff mit der reduktiven Aminierung erzielt. Bei der anschließenden Abspaltung der Acetylgruppe zeigte sich erstmals, dass das Substitutionsmuster am Piperidinring nicht konfigurationsstabil war, da neben dem erwarteten Alkohol auch das Diastereomer isoliert wurde. Die genaue Ursache für die Epimerisierung nach der N-Methylierung konnte nicht geklärt werden. Die Einführung des Methoxy-Substituenten am Grundkörper erfolgte über eine Williamsonschen Ethersynthese. Bei den Versuchen zur Kupplung des Grundkörpers mit der Seitenkette 2,4-Nonadienal erwies sich der Zusatz von HMPT als förderlich. Weiterhin konnte die Ausbeute an -Hydroxysulfonen durch das Erwärmen der Reaktionsmischung gesteigert werden. In den Folgeschritten der Julia-Olefinierung blieben die Versuche zur Ausbildung der dreifach ungesättigten Struktureinheit in der Seitenkette des isolierten Naturstoffs jedoch erfolglos. N2 - The aim of this work was to establish and verify a route to differently substituted and easy modifiable -amino piperidines using the tandem reaction concept established in our work group. This concept should then be used for the total synthesis of Microconin (3), an alkaloid of Microcos paniculata. In the first step to -amino piperidines L-pyroglutamic acid was converted to its methyl ester according to a modified literature procedure. The reduction of the ester was followed by the activation of the alcohol as its tosylate. The incorporation of azide was achieved by nucleophilic substitution and the lactam moiety was protected using Boc2O and a catalytic amount of DMAP. Protection by an electron acceptor activates the lactam functional group so ring opening with methoxide occurred smoothly at room temperature to yield the azidoester without further purification. The amino function had to be blocked by introduction of a second protecting group, selective reduction in anhydrous ether employing DiBAl-H performed without surprise and resulted in the aldehyde as starting material for olefinations by Wittig type reactions. Several stabilised phosphonates were synthesised and reacted with the aldehyde in the HWE-reaction. The electron poor olefins underwent intramolecular azide cycloaddition building up the -amino piperidine scaffold in a sequence we call tandem Wittig-[3+2]-Cycloaddition. The primary triazoline formation is often diastereoselective whereas the reaction rate depends on the conjugated olefine substituent as well as on stereoelectronic effects caused by the vicinal azido functional group. The resulting configuration was determined by NMR-spectroscopy using analysis of coupling constants and NOESY-techniques. Asymmetric induction in the cycloaddition can be utilised in the piperidine heterocycle after basic triazolin/diazoamine isomerisation and subsequent hydrogenation of the diazo compound. Hydrogenation of the vinylogous urethanes, products of the Rhodium mediated extrusion of nitrogen, lead to a diastereomeric mixture, whereas the diastereomeric ratio depended mostly on the substitution grade of the exocyclic amine. Surprisingly, the isomerisation of sulphono triazoline to the corresponding diazo amin did not happen, so an alternative approach over a ketosulphone to the sulfonylmethyl -amino piperidines had to be found. The synthesis of micrconine started with the deoxygenation of L-rhamnose in a Fischer-Zach reaction. The rhamnal was synthesised in a three step one pot reaction and the ring was opened by Perlin hydrolysis to the aldehyde. Activation of the hydroxyl function as a mesylate resulted in a very unstable compound, witch could only be reduced to the aliphatic aldehyde with sufficient results using the Lindlar catalyst. A bimoleculare nucleophilic substitution reaction of mesylate by azide led to the key intermediate with the necessary inversion of configuration. The tandem Wittig-[3+2]-Cycloaddition led with the sulphon triazoline in a dead end road. Therefore, an alternative synthetic route had to be found again. Starting from the key intermediate, the solution was a tin catalysed reaction with stabilised diazomethane leading to the ketosulphone. The construction of the heterocyclic piperidine core could then be accomplished by an intramoleculare imine formation of the amine intermediate with the ketone. Addition of hydrogen in the diastereoselective hydrogenation took place from the less hindered  face and resulted in an all cis configuration of the molecule. After successful creation of the heterocyclic frame, both hetero atoms had to be methylated. Best results at the ring nitrogen gave reductive aminations. That the substitution pattern of the piperidine heterocycle was configurationally unstable was observed the first time at the following deacetylation by isolating the diastereomeric alcohol besides the desired. The exact reason for the epimerisation after N-methylation could not be evaluated. The last step to the heterocyclic scaffold was the introduction of the methoxy function by a variant of the Williamson ether synthesis. In the coupling reactions of the piperidine core with the side chain unit 2,4-nonadienal the addition of HMPA proofed to be very effective. The yield of -hydroxysulphones could be further improved by slowly warming of the reaction mixture to room temperature. The following steps of the Julia-Olefination to build up the olefinic substructure in the side chain of the isolated natural compound remained without success. KW - Stereoselektive Synthese KW - Tandem-Reaktion KW - Wittig-Reaktion KW - Piperidinderivate KW - Dipolare Cycloaddition KW - Piperidinalkaloide KW - Konformationsanalyse KW - Sulfonyldiazomethan KW - Ketosulfon KW - stereoselective synthesis KW - Wittig-reaction KW - piperidines KW - piperidin alcaloids KW - conformational anylysis Y1 - 2009 U6 - http://nbn-resolving.de/urn/resolver.pl?urn:nbn:de:bvb:20-opus-40040 ER - TY - JOUR A1 - Meder, Lydia A1 - König, Katharina A1 - Ozretić, Luka A1 - Schultheis, Anne M. A1 - Ueckeroth, Frank A1 - Ade, Carsten P. A1 - Albus, Kerstin A1 - Boehm, Diana A1 - Rommerscheidt-Fuss, Ursula A1 - Florin, Alexandra A1 - Buhl, Theresa A1 - Hartmann, Wolfgang A1 - Wolf, Jürgen A1 - Merkelbach-Bruse, Sabine A1 - Eilers, Martin A1 - Perner, Sven A1 - Heukamp, Lukas C. A1 - Buettner, Reinhard T1 - NOTCH, ASCL1, p53 and RB alterations define an alternative pathway driving neuroendocrine and small cell lung carcinomas JF - International Journal of Cancer N2 - Small cell lung cancers (SCLCs) and extrapulmonary small cell cancers (SCCs) are very aggressive tumors arising de novo as primary small cell cancer with characteristic genetic lesions in RB1 and TP53. Based on murine models, neuroendocrine stem cells of the terminal bronchioli have been postulated as the cellular origin of primary SCLC. However, both in lung and many other organs, combined small cell/non-small cell tumors and secondary transitions from non-small cell carcinomas upon cancer therapy to neuroendocrine and small cell tumors occur. We define features of "small cell-ness" based on neuroendocrine markers, characteristic RB1 and TP53 mutations and small cell morphology. Furthermore, here we identify a pathway driving the pathogenesis of secondary SCLC involving inactivating NOTCH mutations, activation of the NOTCH target ASCL1 and canonical WNT-signaling in the context of mutual bi-allelic RB1 and TP53 lesions. Additionaly, we explored ASCL1 dependent RB inactivation by phosphorylation, which is reversible by CDK5 inhibition. We experimentally verify the NOTCH-ASCL1-RB-p53 signaling axis in vitro and validate its activation by genetic alterations in vivo. We analyzed clinical tumor samples including SCLC, SCC and pulmonary large cell neuroendocrine carcinomas and adenocarcinomas using amplicon-based Next Generation Sequencing, immunohistochemistry and fluorescence in situ hybridization. In conclusion, we identified a novel pathway underlying rare secondary SCLC which may drive small cell carcinomas in organs other than lung, as well. KW - lung cancer KW - small cell lung cancer KW - achaete-scute homolog 1 KW - neurogenic locus notch homolog KW - retinoblastoma protein Y1 - 2016 U6 - http://nbn-resolving.de/urn/resolver.pl?urn:nbn:de:bvb:20-opus-190853 VL - 138 IS - 4 ER - TY - JOUR A1 - Jobs, Alexander A1 - Vonthein, Reinhard A1 - König, Inke R. A1 - Schäfer, Jane A1 - Nauck, Matthias A1 - Haag, Svenja A1 - Fichera, Carlo Federico A1 - Stiermaier, Thomas A1 - Ledwoch, Jakob A1 - Schneider, Alisa A1 - Valentova, Miroslava A1 - von Haehling, Stephan A1 - Störk, Stefan A1 - Westermann, Dirk A1 - Lenz, Tobias A1 - Arnold, Natalie A1 - Edelmann, Frank A1 - Seppelt, Philipp A1 - Felix, Stephan A1 - Lutz, Matthias A1 - Hedwig, Felix A1 - Borggrefe, Martin A1 - Scherer, Clemens A1 - Desch, Steffen A1 - Thiele, Holger T1 - Inferior vena cava ultrasound in acute decompensated heart failure: design rationale of the CAVA‐ADHF‐DZHK10 trial JF - ESC Heart Failure N2 - Aims Treating patients with acute decompensated heart failure (ADHF) presenting with volume overload is a common task. However, optimal guidance of decongesting therapy and treatment targets are not well defined. The inferior vena cava (IVC) diameter and its collapsibility can be used to estimate right atrial pressure, which is a measure of right‐sided haemodynamic congestion. The CAVA‐ADHF‐DZHK10 trial is designed to test the hypothesis that ultrasound assessment of the IVC in addition to clinical assessment improves decongestion as compared with clinical assessment alone. Methods and results CAVA‐ADHF‐DZHK10 is a randomized, controlled, patient‐blinded, multicentre, parallel‐group trial randomly assigning 388 patients with ADHF to either decongesting therapy guided by ultrasound assessment of the IVC in addition to clinical assessment or clinical assessment alone. IVC ultrasound will be performed daily between baseline and hospital discharge in all patients. However, ultrasound results will only be reported to treating physicians in the intervention group. Treatment target is relief of congestion‐related signs and symptoms in both groups with the additional goal to reduce the IVC diameter ≤21 mm and increase IVC collapsibility >50% in the intervention group. The primary endpoint is change in N‐terminal pro‐brain natriuretic peptide from baseline to hospital discharge. Secondary endpoints evaluate feasibility, efficacy of decongestion on other scales, and the impact of the intervention on clinical endpoints. Conclusions CAVA‐ADHF‐DZHK10 will investigate whether IVC ultrasound supplementing clinical assessment improves decongestion in patients admitted for ADHF. KW - acute decompensated heart failure KW - inferior vena cava KW - congestion KW - NT‐proBNP KW - ultrasound Y1 - 2020 U6 - http://nbn-resolving.de/urn/resolver.pl?urn:nbn:de:bvb:20-opus-212692 VL - 7 IS - 3 SP - 973 EP - 983 ER -