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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.
Donor CD4\(^+\)Foxp3\(^+\) regulatory T cells (T reg cells) suppress graft-versus-host disease (GvHD) after allogeneic hematopoietic stem cell transplantation (HCT allo-HCT]). Current clinical study protocols rely on the ex vivo expansion of donor T reg cells and their infusion in high numbers. In this study, we present a novel strategy for inhibiting GvHD that is based on the in vivo expansion of recipient T reg cells before allo-HCT, exploiting the crucial role of tumor necrosis factor receptor 2 (TNFR2) in T reg cell biology. Expanding radiation-resistant host T reg cells in recipient mice using a mouse TNFR2-selective agonist before allo-HCT significantly prolonged survival and reduced GvHD severity in a TNFR2-and T reg cell-dependent manner. The beneficial effects of transplanted T cells against leukemia cells and infectious pathogens remained unaffected. A corresponding human TNFR2-specific agonist expanded human T reg cells in vitro. These observations indicate the potential of our strategy to protect allo-HCT patients from acute GvHD by expanding T reg cells via selective TNFR2 activation in vivo.
Background: Recently published results of quality of life (QoL) studies indicated different outcomes of palliative radiotherapy for brain metastases. This prospective multi-center QoL study of patients with brain metastases was designed to investigate which QoL domains improve or worsen after palliative radiotherapy and which might provide prognostic information.
Methods: From 01/2007-01/2009, n=151 patients with previously untreated brain metastases were recruited at 14 centers in Germany and Austria. Most patients (82 %) received whole-brain radiotherapy. QoL was measured with the EORTC-QLQ-C15-PAL and brain module BN20 before the start of radiotherapy and after 3 months.
Results: At 3 months, 88/142 (62 %) survived. Nine patients were not able to be followed up. 62 patients (70.5 % of 3-month survivors) completed the second set of questionnaires. Three months after the start of radiotherapy QoL deteriorated significantly in the areas of global QoL, physical function, fatigue, nausea, pain, appetite loss, hair loss, drowsiness, motor dysfunction, communication deficit and weakness of legs. Although the use of corticosteroid at 3 months could be reduced compared to pre-treatment (63 % vs. 37 %), the score for headaches remained stable. Initial QoL at the start of treatment was better in those alive than in those deceased at 3 months, significantly for physical function, motor dysfunction and the symptom scales fatigue, pain, appetite loss and weakness of legs. In a multivariate model, lower Karnofsky performance score, higher age and higher pain ratings before radiotherapy were prognostic of 3-month survival.
Conclusions: Moderate deterioration in several QoL domains was predominantly observed three months after start of palliative radiotherapy for brain metastases. Future studies will need to address the individual subjective benefit or burden from such treatment. Baseline QoL scores before palliative radiotherapy for brain metastases may contain prognostic information.
Background: Preservation of kidney function in newly diagnosed (ND) multiple myeloma (MM) helps to prevent excess toxicity. Patients (pts) from two prospective trials were analyzed, provided postinduction (PInd) restaging was performed. Pts received three cycles with bortezomib (btz), cyclophosphamide, and dexamethasone (dex; VCD) or btz, lenalidomide (len), and dex (VRd) or len, adriamycin, and dex (RAD). The minimum required estimated glomerular filtration rate (eGFR) was >30 mL/min. We analyzed the percent change of the renal function using the International Myeloma Working Group (IMWG) criteria and Kidney Disease: Improving Global Outcomes (KDIGO)-defined categories. Results: Seven hundred and seventy-two patients were eligible. Three hundred and fifty-six received VCD, 214 VRd, and 202 RAD. VCD patients had the best baseline eGFR. The proportion of pts with eGFR <45 mL/min decreased from 7.3% at baseline to 1.9% PInd (p < 0.0001). Thirty-seven point one percent of VCD versus 49% of VRd patients had a decrease of GFR (p = 0.0872). IMWG-defined “renal complete response (CRrenal)” was achieved in 17/25 (68%) pts after VCD, 12/19 (63%) after RAD, and 14/27 (52%) after VRd (p = 0.4747). Conclusions: Analyzing a large and representative newly diagnosed myeloma (NDMM) group, we found no difference in CRrenal that occurred independently from the myeloma response across the three regimens. A trend towards deterioration of the renal function with VRd versus VCD may be explained by a better pretreatment “renal fitness” in the latter group.
The vertebrate spinal cord is composed of billions of neurons and glia cells, which are formed in a highly coordinated manner during early neurogenesis. Specification of these cells at distinct positions along the dorsoventral (DV) axis of the developing spinal cord is controlled by a ventrally located signaling center, the medial floor plate (MFP). Currently, the origin and time frame of specification of this important organizer are not clear. During my PhD thesis, I have analyzed the function of the novel secreted growth factor Midkine-a (Mdka) in zebrafish. In higher vertebrates, mdk and the related factor pleiotrophin (ptn) are widely expressed during embryogenesis and are implicated in a variety of processes. The in-vivo function of both factors, however, is unclear, as knock-out mice show no embryonic phenotype. We have isolated two mdk co-orthologs, mdka and mdkb, and one single ptn gene in zebrafish. Molecular phylogenetic analyses have shown that these genes evolved after two large gene block duplications. In contrast to higher vertebrates, zebrafish mdk and ptn genes have undergone functional divergence, resulting in mostly non-redundant expression patterns and functions. I have shown by overexpression and knock-down analyses that Mdka is required for MFP formation during zebrafish neurulation. Unlike the previously known MFP inducing factors, mdka is not expressed within the embryonic shield or tailbud but is dynamically expressed in the paraxial mesoderm. I used epistatic and mutant analyses to show that Mdka acts independently from these factors. This indicates a novel mechanism of Mdka dependent MFP formation during zebrafish neurulation. To get insight into the signaling properties of zebrafish Mdka, the function of both Mdk proteins and the candidate receptor Anaplastic lymphoma kinase (Alk) have been compared. Knock-down of mdka and mdkb resulted in the same reduction of iridophores as in mutants deficient for Alk. This indicates that Alk could be a putative receptor of Mdks during zebrafish embryogenesis. In most vertebrate species a lateral floor plate (LFP) domain adjacent to the MFP has been defined. In higher vertebrates it has been shown that the LFP is located within the p3 domain, which forms V3 interneurons. It is unclear, how different cell types in this domain are organized during early embryogenesis. I have analyzed a novel homeobox gene in zebrafish, nkx2.2b, which is exclusively expressed in the LFP. Overexpression, mutant and inhibitor analyses showed that nkx2.2b is activated by Sonic hedgehog (Shh), but repressed by retinoids and the motoneuron-inducing factor Islet-1 (Isl1). I could show that in zebrafish LFP and p3 neuronal cells are located at the same level along the DV axis, but alternate along the anteroposterior (AP) axis. Moreover, these two different cell populations require different levels of HH signaling and nkx2.2 activities. This provides new insights into the structure of the vertebrate spinal cord and suggests a novel mechanism of neural patterning.