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Much has been written about the patient-physician relationship over the years. This relationship is essential in maintaining trust in the complex arena of modern diagnostic techniques, treatment and prevention, including vaccines and vaccine safety. However, a great deal of this material was written from the viewpoint of clinicians and academics. The patient voice may be positive or negative, fragmented or complex. Information sources are weighed and treated differently, according to the value system and risk perceptions of the individual. In post-trust societies, when people have less confidence in health authorities, communication needs to be more than a paternalistic top-down process. Notions of empowerment and individual patient choice are becoming crucial in medical care. The 'voice of the patient', which includes healthy individuals receiving vaccines, needs to be heard, considered and addressed. With respect to childhood immunizations, this will be the voice of the parent or caregiver. The key to addressing any concerns could be to listen more and to develop a communication style that is trust-based and science-informed. Regulatory agencies are encouraging clinical and patient-reported outcomes research under the umbrella of personalized medicine, and this is an important step forward. This paper attempts to reflect the paradigm shift towards increasing attention to the patient voice in vaccination and vaccine safety. (C) 2016 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved.

Fusarium oxysporum was isolated twice from the blood culture of a 5-year-old boy with inoperable Wilms' tumour (stage IV) 4 weeks after a cytoreductive therapy with actinomycin D, vincristine and adriamycin. The child died 3 weeks after the first isolation of the fungus with signs of hepatic failure and consumptive coagulopathy. The importance of infection with Fusarium spp. in immunocompromised neutropenic patients and their pathogenetic role are discussed in the view of the literature.

Patienten, Arzte und Versicherungstrager werden immer wieder damit konfrontiert, sich mit Verfahren befassen zu mussen, deren Nutzen nach Meinung der Schulmedizin nicht oder nicht ausreichend belegt ist. Von besonderer Bedeutung sind diese Methoden fur Patienten mit Krebserkrankungen. Jeder onkologisch tatige Arzt muss daher mit der Problematik alternativer und komplementarer Therapien vertraut sein, um seine Patienten sachgerecht zu beraten und eine gemeinsame Entscheidung zu finden. Komplementare und alternative Verfahren werden nur selten in Forschung und Lehre des universitaren Bereichs einbezogen. Zu unterscheiden sind die Alternative Medizin und die Komplementare Medizin. In der angelsachsischen Literatur werden diese Begriffe meist gleichzeitig unter einem Begriff zusammengefasst: Complementary and Alternative Medicine (CAM). Die vorliegende Stellungnahme richtet sich an Arzte aller Fachrichtungen, die Krebspatienten beraten und behandeln. Fur eine Arzt-Patienten-Kommunikation in der Onkologie ist es masgeblich, die Verwendung von CAM aktiv anzusprechen und zu erreichen, dass der Patient den Arzt seines Vertrauens informiert, wenn er alternative oder komplementare Verfahren in Erwagung ziehen mochte. Wie in der Schulmedizin spielt auch bei diagnostischen und therapeutischen Verfahren der CAM die individuelle Aufklarung eine entscheidende Rolle. Sie sollte von einem Arzt im personlichen Gesprach erfolgen und auf dem neuesten Erkenntnisstand sein.

Die Padiatriecurricula in Munchen, Heidelberg, Freiburg und Berlin zeigen das gesamte mogliche Spektrum von einem traditionellen (Freiburg) bis zu einem kompletten Reformcurriculum (Modellstudiengang Berlin). Besondere Vorbedingungen bestanden in Munchen (Munich-Havard-Alliance) und Heidelberg (HeiCuMed). Alle Curricula basieren auf expliziten Lernzielen, setzen besondere Lehr- und Prufungsformen ein und weisen besondere, gut evaluierte Curriculumeigenschaften auf. Das Curriculum in Munchen ist problemorientiert gestaltet, zusatzliche Angebote sind ein Kommunikationstraining und ein Kinderreanimationskurs. In Heidelberg werden ein Kerncurriculum und ein Wahlpflichtteil angeboten. Besonders abgestimmt sind Lernziele, Unterrichtselemente und Prufungsformate (Constructive Alignment). In Freiburg wird von den Studierenden v. a. die personliche Bindung kleiner Gruppen an einen erfahrenen arztlichen Tutor gelobt. Das traditionelle Berliner Curriculum und der Modellstudiengang lassen am Beispiel Padiatrie erkennen, wie ein innovatives Curriculum mit Perspektive auf den europaischen Hochschulraum aussehen konnte, in dem auch fur die Medizin die Bologna-Kriterien gelten.

Zahlreiche Fakultaten weltweit setzen die Unterrichtsform des problemorientierten Lernens (POL) in ihren Curricula ein, bei der Studierende in Kleingruppen – ausgehend von einem konkreten Fall – Problemlosestrategien entwickeln. Hierbei wird nach definierten Arbeitsschritten, dem so genannten POL-Bogen, vorgegangen. Anders als beim klassischen Frontalunterricht vor grosem Auditorium lernen die Studierenden selbstverantwortlich und kontextgebunden, was zu einer besseren Verankerung des Wissens fuhren soll. Der Rolle des Tutors kommt eine besondere Bedeutung zu, denn er fungiert – anders als im klassischen universitaren Unterricht – als Moderator, der den inhaltlichen und gruppendynamischen Lernprozess begleitet und strukturiert.

BACKGROUND: Many drugs have been reported as being capable of inducing immune neutropenia, but the causative drug-dependent antibodies were rarely demonstrated. STUDY DESIGN AND METHODS: This report describes the results of serologic testing and treatment in two children with immune neutropenia related to cefotaxime and metamizole, respectively. Serum samples were tested in the presence and the absence of the drugs using the granulocyte agglutination test (GAT), the granulocyte immunofluorescence test (GIFT), and the monoclonal antibody-specific immobilization of granulocyte antigens (MAIGA) assay. RESULTS: The serum of one child contained cefotaxime-dependent antibodies that were detectable by the GAT and the MAIGA assay, but not by the GIFT. The serum of the other child gave positive reactions in the GAT and GIFT due to HLA antibodies and in the MAIGA assay only in the presence of metamizole. While cefotaxime-dependent antibody was directed against CD16, the metamizole antibody was directed against CD11b and CD35. The administration of granulocyte–colony-stimulating factor led to an abrupt increase in circulating neutrophils in both cases. CONCLUSION: The use of more than one technique is necessary for detection of drug-dependent antibodies against neutrophils, and early administration of granulocyte–colony-stimulating factor may result in fewer complications in these patients.

Childhood acute autoimmune thrombocytopenia is defined as a bleeding disorder in otherwise healthy children caused by transient destruction of platelets. It is benign, presenting mostly with skin purpura and minor bleeds. The diagnosis requires information about previous infections or immunizations, a physical examination looking for signs or symptoms for other causes of thrombocytopenia and a complete blood count with examination of the peripheral blood smear focusing on the number and morphology of platelets. Bone marrow examination is indicated only when in doubt and should be considered if prednisone therapy is planned. A threshold platelet count dividing high- and low-risk groups in immune thrombocytopenia (ITP) is not known because of problems with platelet counting in thrombocytopenia and the lack of clinical data. Immunoglobulins or glucocorticoids increase the platelet count, probably by blockage of the phagocytic monocyte-macrophage system. However, it is unclear whether this increase influences bleeding or mortality or whether the disadvantages of these medications might outweigh their benefits.

Objective To determine the impact of therapy on the reported health-related quality of life (HRQoL) in children with primary immune thrombocytopenia (ITP) using the Kids ITP tool (KIT). Design Secondary data analysis of the international and North American KIT validation studies. Results 217 children from 6 countries participated in the two studies. The majority of treatments occurred in children with newly diagnosed ITP. There was no statistical difference in age, platelet count and bleeding severity at presentation in those who physicians chose to treat or observe. Self-reported KIT scores did not differ between the two groups. The KIT parent-proxy scores were significantly worse for newly diagnosed children receiving treatment, especially following prednisone. Conclusions Treatment of ITP does not improve, and may worsen, the HRQoL of children with ITP as measured using the KIT.

UNLABELLED The main objective of the multicenter study DAL-HD-87 was to evaluate for the involved-field irradiation a dose reduction by 5 Gy compared with the precursor studies HD-82 and HD-85. Moreover, the decisional strategy for selective laparotomy developed on the basis of retrospective analyses in study HD-82 was to be tested in a prospective design. Chemotherapy in group 1 (stages I, IIA) consisted in 2 OPA cycles (vincristine, prednisone, adriamycin). Group 2 (stages IIEA, IIB, IIIA) received 2 x OPA + 2 x COP(P), and group 3 (stages IIEB, IIIB, IV) 2 x OPPA (with procarbacine) + 4 x COP(P). For the subsequent radiotherapy, doses of 30, 25, and 20 Gy respectively were applied in the 3 groups. Fields with incomplete lymphoma regression were to receive an additional boost of 5-10 Gy. -Exploratory laparotomy was considered indicated in the event of abnormal findings in abdominal CT/ultrasonography and/or enlargement of lymph nodes at the pulmonary hilus. RESULTS From Dec. 1986 to Sept. 1990, 204 pts from 51 centres were enrolled in the study. 196 were evaluable. 109 pts (55.6%) were laparotomized, 58 (29.6%) splenectomized. The accuracy for the prediction of an abdominal involvement was 72.3% in case of abnormal findings in abdominal CT/ultrasound but only 36.4% in case of enlarged lymph nodes at the pulmonary hilus without abdominal abnormalities. 91.2% of the removed spleens were proven involved. -2 out of 196 pts suffered progression under treatment, and 22 relapsed (as of 1 Jan, 1994). 6 pts died, 4 of whom succumbed to Hodgkin's disease, and 2 to intercurrent infections. 2 pts in first remission developed a secondary malignancy, namely 1 malignant histiocytoma in radiation field and 1 ANLL. Another patient developed a thyroid carcinoma following salvage therapy for a relapse. The probabilities of event-free survival (EFS) and survival after 7 years are for the total group: 85% and 97%, in group 1: 84% and 99%, in group 2: 82% and 93%, and group 3: 89% and 95%. Comparison with the precursor studies HD-82 and HD-85 reveals that the dose reduction in radiotherapy has not affected the results. Differences in EFS are exclusively correlated with changes in chemotherapy.

The myelodysplastic syndromes (MDS) are a group of hematopoietic neoplasms characterized by ineffective hematopoiesis and a high risk of transformation in acute leukemia. Pathogenesis and clinical course of these disorders are heterogenous. MDS is unusual in childhood, and differential diagnosis is specially broad in this age group. Allogenic bone marrow transplantation is the treatment of choice. Therapy with hematopoietic growth factors can overcome the maturation defect of the malignant clone in some instances. Multicenter studies are necessary to accumulate sufficient data on pathogenesis, clinical course and treatment results of MDS in childhood.

Tumor directed cytotoxic therapy is one of the major challenges for the success of chemotherapy. In order to accomplish this goal in neuroblastoma, we rationally designed a prodrug of etoposide as substrate for tyrosine hydroxylase, a well established neuroblastoma associated enzyme. Here, we report synthesis and characterization of a 3,4 dihydroxy-phenyl carbamate derivative of etoposide. In order to demonstrate activation by tyrosine hydroxylase, the coding sequence of murine tyrosine hydroxylase was generated by reverse transcriptase-polymerase chain reaction from NXS2 neuroblastoma cells and cloned into the pRSET-A bacterial expression vector. The enzyme was expressed in Escherichia coli, characterized by Western blot and enzymatic activity was demonstrated by conversion of tyrosine into DOPA in the presence of cofactors using reversed phase high-performance liquid chromatography. Under these enzymatic conditions, we demonstrate conversion of 3,4 dihydroxy-phenyl carbamate prodrug into free etoposide. This effect was clearly mediated by the enzyme since bacteria transformed with the empty vector were ineffective of prodrug activation. Furthermore, tyrosine hydroxylase positive cells exposed to the etoposide prodrug were effectively killed in contrast to tyrosine hydroxylase negative controls. These findings demonstrate that etoposide can be designed as a prodrug substrate for tyrosine hydroxylase and thereby establish proof of concept for neuroblastoma directed enzyme prodrug therapy.

We present an 11-year-old girl with sensory and autonomic neurological dysfunction, and respiratory insufficiency caused by recurrent aspiration. The diagnosis of familial dysautonomia (FD) was confirmed by a missing axonal flare to histamine, miosis in response to conjunctival methacholine and homozygous polymorphic linked markers DS58(18) and DS159(7) on chromosome 9. Ashkenazi Jewish descent could not be ascertained by history. A variety of positive tests for autoantibodies were initially interpreted as evidence for systemic lupus erythematosus vs. overlap syndrome with pulmonary, cerebral, skin, and ocular involvement. The diagnosis of FD was delayed because of the rarity of this disorder in Germany (second case reported). We discuss possible explanations for the misleading immunological findings, including interference by antibodies binding to milk proteins used as blocking reagents in enzyme-linked immunoassays and circulating immune-complexes due to chronic aspiration pneumonitis.

To perform a comparative analysis of 1) intravenous Ig (IVIG)-bound Fab fragments from a patient with autoimmune thrombocytopenia that had progressed to systemic lupus erythematosus (SLE) and 2) IVIG-selected Fabs from an SLE patient without thrombocytopenia.IVIG preparations have been successfully used to treat certain cases of autoimmune thrombocytopenia and SLE. Specific interactions of IVIG with the components of the immune system are not well characterized. To investigate these, we had previously cloned a large number of phage-displayed IgG Fab fragments, derived from 3 patients with autoimmune thrombocytopenia, that were specifically bound by IVIG molecules during panning. Many of these Fabs reacted with platelets. Sequencing revealed that the most frequently used VH germline gene segments of all IVIG-bound Fabs were 3-23 and 3-30/3-30.5. One patient's autoimmune thrombocytopenia had progressed to SLE. Using the same cloning and panning procedures, we performed a comparative analysis of this patient's IVIG-bound Fab fragments and the IVIG-selected Fabs from an SLE patient without thrombocytopenia.We observed an exclusive selection of antibodies derived from 3-23 and 3-30/3-30.5 germline segments. In contrast to the Fab fragments from the autoimmune thrombocytopenia patient who developed SLE, none of the IVIG-selected Fabs from the SLE patient without thrombocytopenia bound to thrombocytes.Our results suggest a preferential interaction of a subfraction of IVIG-representative of normal Ig repertoires-with antibodies and B cell receptors derived from these 2 gene segments. Importantly, these are the most frequently rearranged VH germline genes among human B cells. This kind of interaction is characteristic of a B cell superantigen, since light chains, antigen specificity, and the high variation in the third complementarity-determining region 3 showed little influence on the selection of 3-23- or 3-30/3-30.5-derived Fabs by IVIG. However, at least some of the contact residues on Fabs for IVIG appear to be different from those for staphylococcal protein A and human immunodeficiency virus gp 120. The IVIG-selected Fabs may now be used to clone antibodies representative of this IVIG subfraction to study their possible regulatory influence on the B cell repertoire during normal development and disease.

In search for a new therapeutic approach for metastasized renal cell carcinoma (RCC), we evaluated the cytotoxicity of a novel prodrug chemoimmunoconjugate with monoclonal antibody (mAb) 138H11 and the DNA-cleaving enediyne calicheamicin thetaI1 (Camtheta) in vitro and in vivo. Previously, mAb 138H11, produced against human renal gamma-glutamyltransferase, stained over 99% clear cell and papillary RCC on frozen sections, showing a membranous expression of the target antigen. In contrast, in normal kidneys gammaGT was restricted to the brush-border in the lumen of proximal tubules and not accessible to the circulation. Thus, human tumor-bearing kidneys perfused in an extra-corporeal system with 99mTc-138H11 revealed a high, specific uptake into the tumor. In this study, fluorescence-activated cell sorting analysis showed binding of mAb 138H11 to RCC cell lines, whereas squamous cell carcinoma lines, fibroblasts, and the murine RENCA were negative. XTT cell proliferation assays revealed efficient killing of the Caki-1 cell line by the 138H11-Camtheta conjugate using SPDP (EC50 = 5 x 10(-11) M) as a covalent linker. For in vivo testing, five groups of eight nude mice each were injected with 2.5 x 10(6) Caki-1 cells s.c. and treated with the following: (a) PBS; (b) 138H11; (c) Camtheta; (d) a mixture of 138H11 and Camtheta; and (e) 138H11-Camtheta conjugate. Treatment started on day 1 after tumor induction and was repeated three times. The data show a highly significant inhibition of tumor growth with the 138H11-Camtheta conjugate versus PBS (P = 0.004). Only mice treated with 138H11-Camtheta showed a tumor shrinkage to minimal residues. In a second experiment, lower doses of the 138H11-Camtheta conjugate were compared with an antineuroblastoma mAb (ch14.18), confirming targeted killing of RCC by the 138H11-Camtheta conjugate at tolerable toxicity in vivo. In conclusion, these combined results encourage further studies for targeted therapy of metastatic RCC with mAb 138H11 conjugates.

Beta-thalassaemia is inherited as an autosomal recessive trait in most families. Particular interest has recently been focused on the molecular pathology of the rare forms with a dominant mode of inheritance. The index patient and her mother, who are described in this report, displayed typical clinical and haematological features of beta-thalassaemia intermedia with significant ineffective erythropoiesis and additional peripheral haemolysis. Molecular analysis demonstrated a heterozygous genotype for a novel 6 bp (TGGTCT) deletion of the beta-globin gene involving codons 33-35. This deletion results in the removal of two valine residues from the beta-globin chain at position 33/34 (B15/B16) and the substitution of the tyrosine residue at position 35 (C1) by an aspartic acid (beta 33-35 [B15-C1] Val-Val-Tyr--0-0-Asp). According to the index patient's place of birth, this abnormal haemoglobin has been termed Hb Dresden. The stability of the variant and the normal beta-globin chains were similar during the incubation period of in vitro globin chain synthesis analysis. However, Hb Dresden is exquisitely unstable and cannot be detected in the peripheral blood by haemoglobin electrophoresis, high-performance liquid chromatography (HPLC) or isoelectric focusing. This instability can be explained by the vital structural role of the three affected amino acids that, in normal haemoglobin, establish a total of nine intermolecular bonds (five hydrophobic and four polar) at both the alpha1beta1 (alpha2beta2) and the alpha1beta2 (alpha2beta1) interface.

Autoimmune thrombocytopenic purpura (AITP) is a severe disease in children with a still unknown aetiology. It is not known why AITP can either be transient and self limiting or become chronic. The beneficial use of intravenous immunoglobulins (IVIG) in certain groups of AITP patients has been proven. It is, however, not clear how IVIG functions. To analyse patient-derived monoclonal IgG platelet autoantibodies that interact with IVIG in an anti-idiotypic manner, the combinatorial antibody phage display system was applied. From three different patients a large number of clones specifically reacting with IVIG molecules were derived. Many of these IVIG binders also reacted strongly with platelets in ELISA and FACS, in contrast to IVIG binders derived from a healthy individual. The heavy and light chain variable regions were sequenced and compared with each other and with databases. In all three AITP patients clones with a striking complementarity-determining region (CDR) sequence homology to each other and to many of the known anti-platelet antibodies were observed. Selected Fab-phages representing the characteristic variable regions that occurred in the investigated patients with AITP may now be used to clone potentially regulatory anti-idiotypes from healthy donors by phage display.

Many drugs have been reported as being capable of inducing immune neutropenia, but the causative drug-dependent antibodies were rarely demonstrated.This report describes the results of serologic testing and treatment in two children with immune neutropenia related to cefotaxime and metamizole, respectively. Serum samples were tested in the presence and the absence of the drugs using the granulocyte agglutination test (GAT), the granulocyte immunofluorescence test (GIFT), and the monoclonal antibody-specific immobilization of granulocyte antigens (MAIGA) assay.The serum of one child contained cefotaxime-dependent antibodies that were detectable by the GAT and the MAIGA assay, but not by the GIFT. The serum of the other child gave positive reactions in the GAT and GIFT due to HLA antibodies and in the MAIGA assay only in the presence of metamizole. While cefotaxime-dependent antibody was directed against CD16, the metamizole antibody was directed against CD11b and CD35. The administration of granulocyte-colony-stimulating factor led to an abrupt increase in circulating neutrophils in both cases.The use of more than one technique is necessary for detection of drug-dependent antibodies against neutrophils, and early administration of granulocyte-colony-stimulating factor may result in fewer complications in these patients.

Childhood acute autoimmune thrombocytopenia is defined as a bleeding disorder in otherwise healthy children caused by transient destruction of platelets. It is benign, presenting mostly with skin purpura and minor bleeds. The diagnosis requires information about previous infections or immunizations, a physical examination looking for signs or symptoms for other causes of thrombocytopenia and a complete blood count with examination of the peripheral blood smear focusing on the number and morphology of platelets. Bone marrow examination is indicated only when in doubt and should be considered if prednisone therapy is planned. A threshold platelet count dividing high- and low-risk groups in immune thrombocytopenia (ITP) is not known because of problems with platelet counting in thrombocytopenia and the lack of clinical data. Immunoglobulins or glucocorticoids increase the platelet count, probably by blockage of the phagocytic monocyte-macrophage system. However, it is unclear whether this increase influences bleeding or mortality or whether the disadvantages of these medications might outweigh their benefits.

Wahrend der intrauterinen Entwicklung und in der postnatalen Phase des Menschen werden verschiedene Perioden unterschieden: die Embryonalzeit bis zum Ende der 12. Schwangerschaftswoche, die Fetalzeit von der 13. bis zum Ende der 28. Schwangerschaftswoche, die Perinatalperiode, die von der 29. Schwangerschaftswoche bis zum Ende der ersten Wochen nach der Geburt des Kindes dauert, und das Neugeborenenalter von der Geburt des Kindes bis zum Ende des 1. Lebensmonats.

The main objective of the multicenter study DAL-HD-87 was to evaluate for the involved-field irradiation a dose reduction by 5 Gy compared with the precursor studies HD-82 and HD-85. Moreover, the decisional strategy for selective laparotomy developed on the basis of retrospective analyses in study HD-82 was to be tested in a prospective design. Chemotherapy in group 1 (stages I, IIA) consisted in 2 OPA cycles (vincristine, prednisone, adriamycin). Group 2 (stages IIEA, IIB, IIIA) received 2 x OPA + 2 x COP(P), and group 3 (stages IIEB, IIIB, IV) 2 x OPPA (with procarbacine) + 4 x COP(P). For the subsequent radiotherapy, doses of 30, 25, and 20 Gy respectively were applied in the 3 groups. Fields with incomplete lymphoma regression were to receive an additional boost of 5-10 Gy. -Exploratory laparotomy was considered indicated in the event of abnormal findings in abdominal CT/ultrasonography and/or enlargement of lymph nodes at the pulmonary hilus.From Dec. 1986 to Sept. 1990, 204 pts from 51 centres were enrolled in the study. 196 were evaluable. 109 pts (55.6%) were laparotomized, 58 (29.6%) splenectomized. The accuracy for the prediction of an abdominal involvement was 72.3% in case of abnormal findings in abdominal CT/ultrasound but only 36.4% in case of enlarged lymph nodes at the pulmonary hilus without abdominal abnormalities. 91.2% of the removed spleens were proven involved. -2 out of 196 pts suffered progression under treatment, and 22 relapsed (as of 1 Jan, 1994). 6 pts died, 4 of whom succumbed to Hodgkin's disease, and 2 to intercurrent infections. 2 pts in first remission developed a secondary malignancy, namely 1 malignant histiocytoma in radiation field and 1 ANLL. Another patient developed a thyroid carcinoma following salvage therapy for a relapse. The probabilities of event-free survival (EFS) and survival after 7 years are for the total group: 85% and 97%, in group 1: 84% and 99%, in group 2: 82% and 93%, and group 3: 89% and 95%. Comparison with the precursor studies HD-82 and HD-85 reveals that the dose reduction in radiotherapy has not affected the results. Differences in EFS are exclusively correlated with changes in chemotherapy.

The myelodysplastic syndromes (MDS) are a group of hematopoietic neoplasms characterized by ineffective hematopoiesis and a high risk of transformation in acute leukemia. Pathogenesis and clinical course of these disorders are heterogenous. MDS is unusual in childhood, and differential diagnosis is specially broad in this age group. Allogenic bone marrow transplantation is the treatment of choice. Therapy with hematopoietic growth factors can overcome the maturation defect of the malignant clone in some instances. Multicenter studies are necessary to accumulate sufficient data on pathogenesis, clinical course and treatment results of MDS in childhood.

Fusarium oxysporum was isolated twice from the blood culture of a 5-year-old boy with inoperable Wilms' tumour (stage IV) 4 weeks after a cytoreductive therapy with actinomycin D, vincristine and adriamycin. The child died 3 weeks after the first isolation of the fungus with signs of hepatic failure and consumptive coagulopathy. The importance of infection with Fusarium spp. in immunocompromised neutropenic patients and their pathogenetic role are discussed in the view of the literature.

Countercurrent elutriation is a powerful method for fast and gentle large-scale isolation of cells according to size and density. Current limitations of this approach are the suboptimal selectivity that is obtained and the fact that the total number of cells that can be separated per run is restricted. We describe a new separation chamber, which was calculated according to the hydrodynamic boundaries of the counterflow separation. In comparison to the chamber commonly in use, a fivefold higher cell number can be separated with this chamber at an increased separation selectivity. Furthermore the use of this chamber, which fits to the standard Beckman equipment, avoids large sampling volumes.

The characteristics of insulin receptor binding and structure and its proliferative and metabolic action in a human leukemic cell line was investigated during the cell cycle. Exponentially growing cells were separated by counterflow centrifugation which fractionates cells primarily on the basis of size into subpopulations representing G0/G1, S, and G2 + M cells. This method avoids disturbance of the cellular metabolism. After separation the cells showed a viability of at least 92%, underwent further proliferation, and remained morphologically unchanged, which was shown by electron microscopy. The cells could be enriched to 70-90% purity for G0/G1 phase and 50-60% purity for S and G2 + M phase, respectively, which was shown by DNA flow-cytometry. Specific binding of insulin could be demonstrated in G0/G1, S, and G2 + M enriched cells. Insulin binding sites decreased from 20-25,000 per cell in G0/G1 to 1-2,000 in S and increased to 30-50,000 in G2 + M. The affinity of insulin binding remained nearly constant during the cell cycle. The specificity of the insulin receptor could also be demonstrated by covalent crosslinking of the receptor to radiolabeled ligand in all enriched cell fractions. Glucose transport was stimulated by insulin independently of cell cycle. An increase to 140% of control was observed at an insulin concentration of 10 ng/ml. In contrast, glycogen synthesis could only be stimulated by insulin in the G0/G1 phase. An increase to 140% of control was already reached at 0.25 ng/ml insulin. Insulin in concentrations of 1 and 10 ng/ml stimulated the transit to S-phase in cycling, but not in resting, cells. The growth promoting action of insulin could be investigated by consecutive DNA analysis of the separated cells which had been stimulated by insulin.

A panel of different B-cell malignancies representing various stages of B-cell differentiation were analyzed for the expression of an antigen labeled by the monoclonal antibody FMC7 and of tartrate-resistant acid phosphatase (TracP) activity. The FMC7 antigen and TracP were not found on early immature pre B-cell proliferations, appeared at early and intermediate B-cell stages, reached their peak of expression in terms of both incidence of positivity and staining intensity at the late B cell stage (as represented by hairy cell leukemia) and were lost at the B-cell/plasma cell transition. Although detected at similar stages of B-cell differentiation, FMC7 and TracP appear to be independently expressed and were not related to a particular Ig class. The simultaneous detection of FMC7 and TracP represents a distinguishing parameter for the identification of hairy cell leukemia.

A cell clone of erythroleukemic mouse cells transformed by the spleen focus forming virus (SFFV) was adapted to growth in serum-free medium. The cells show induced erythroid differentiation if dimethylsulfoxide (DMSO) and iron are added to the serum-free medium. No serum constituents or macromolecules are required for induced differentiation. Serum enhances the capacity of the cells to differentiate. Erythropoietin is ineffective in promoting erythroid differentiation or an increased rate of cell division. Transferrin is not necessary for transport of iron into these cells.

Bei 4 Patienten mit saure Phosphatase-positiver akuter Leukamie besasen nahezu alle Blasten Zelloberflachenmerkmale von T-Lymphocyten (spontane Rosttenbildung mit Hammelerythrocyten). B-Lymphocyten-Merkmale (Oberflachenimmunglobulin) wurde auf den Blasten dieser Patienten nicht nachgewiesen. Bei 3 der 4 Patienten lies sich rontgenologisch ein Tumor des vorderen Mediastinum nachweisen, der mit groser Wahrscheinlichkeit vom Thymus ausging.

Subclassification of acute lymphocytic leukemias in childhood by multiple marker analysis has proven the heterogeneity of this disease and this methodology has led to a better understanding of the cell-biological basis of ALL. Enzyme markers have become important tools in multiple marker analysis. This is especially true for TdT, purine metabolic enzymes, hexosaminidase I, acid phosphatase and carboxylic esterases. In spite of sophisticated methods and encouraging results multiple marker analysis has not been totally satisfactory in defining patients at risk. The same is true for a risk score established by clinical data. More efforts in the future are necessary for combining multiple marker analysis, cytogenetics, proliferation characteristics, basic clinical findings and the final outcome of the disease in these patients. Beyond that this kind of leukemia research will help to clarify the pathobiological basis of human leukemia and to develop new specific therapeutic modalities.

The cyclic chemotherapy scheme OS I/75 was tried in 6 patients with newly diagnosed osteosarcoma and in 3 patients with secondary metastases. The treatment consists of high dose methotrexate, followed by citrovorum-factor rescue, doxorubicine (Adriblastin) and cyclophosphamide (Endoxan). All 6 primary patients are in a continuous remission of 6+ to 21+ months (median 12+ months). The length of remission in the patients with metastases is 5.5+ and 8+ months. The haematological side effects led to an average prolongation of the cycle by 11 days in a planned cycle duration of 42 days. However, they were readily manageable. Among the other side effects two cases of Adriblastin myocardiopathy are remarkable which became apparent after methotrexate and ifosfamide. In order to improve possibilities for treatment regional centralisation of patient care and interdisciplinary and supraregional cooperation of treatment centres are necessary. A prospective treatment programme has been developed for the Federal Republic of Germany and Austria.

This report summarises the current knowledge regarding the clinical utility of biochemical enzyme markers for both diagnostic and therapeutic purposes in acute leukaemia. The enzymes studied most extensively in this field are terminal deoxynucleotidyl transferase, adenosine deaminase, 5'-nucleotidase, purine nucleoside phosphorylase, and acid phosphatase, esterase, hexosaminidase isoenzymes. For each enzyme, the quantitative and qualitative characteristics in various immunologically defined subclasses of acute leukaemia are described. The quantitative evaluation of enzyme activities represents an adjunctive classification technique which should be incorporated into the multivariate analysis, the "multiple marker analysis." By qualitative characterisation pronounced heterogeneity of leukaemia subsets is uncovered. The application of 2'-deoxycoformycin, a specific inhibitor of adenosine deaminase, and the potential usefulness of two other enzymes as targets for treatment with selective agents is discussed. The concept that gene products expressed at certain developmental stages of normal cells can similarly be detected in leukaemic cells (which therefore seem to be "frozen" or "arrested" at this particular maturation/differentiation stage) is supported by the results obtained in enzyme studies. Besides their practical clinical importance for classification and treatment of acute leukaemias, biochemical enzyme markers constitute a valuable research tool to disclose biological properties of leukaemic cells.

In pregnancy and neonatal period both mother and child are endangered by bleeding complications due to maternal idiopathic thrombocytopenic purpura. Obstetrical and perinatal management therefore must aim at increasing maternal and fetal platelet count. In our paper six patients in nine pregnancies are reported. Two of them (five pregnancies) were treated with corticosteroids, four of the patients were successfully treated with i.v. immunoglobulins (IgG). Longterm steroid application and splenectomy during pregnancy may be hazardous for mother and fetus. IgG i.v. administration in contrast offers a new and safe way to control maternal and fetal platelet counts during pregnancy, delivery and the neonatal period.

The mononuclear peripheral blood cells from eight patients with chronic myelocytic leukaemia (CML) were incubated in cell suspension culture in the presence of the phorbolester 12-O-tetradecanoylphorbol 13-acetate (TPA). TPA caused the treated cells to adhere and to acquire morphological and functional features characteristic of macrophage-like cells. Using isoelectric focusing distinct changes in the isoenzyme profiles of carboxylic esterase, acid phosphatase, hexosaminidase and lactate dehydrogenase were detected in the TPA-exposed cells. Besides an increase in the number and staining intensity of isoenzymes of all enzymes, TPA triggered the new expression of a monocyte-specific esterase isoenzyme isoenzyme and of the tartrate-resistant acid phosphatase isoenzyme. The latter two isoenzymes represent further parameters of the monocyte/macrophage complex. The results indicate that immature leukaemic cells arrested along the granulocytic cell axis retain the ability to transform to macrophages.

Enzyme marker analysis has become a valuable tool in leukemia research, especially as a part of the so-called multiple marker analysis which combines several disciplines for characterization of leukemia cells. In this study the qualitative activities of three enzyme markers were determined in leukemic cells from pediatric patients with acute leukemias: acid phosphatase (E.C. 3.1.3.2), carboxylic esterase (E.C. 3.1.1.1) and hexosaminidase (E.C. 3.2.1.30). The leukemia subtypes displayed different types of isoenzyme patterns. No additional isoenzyme was found that was not observed in normal blood cells, nor a single isoenzyme specific for a leukemia subtype. The biochemical profiles illustrated the existence of subsets in cALL, T-ALL and AML. The enzymologic polymorphism and the immunologic heterogeneity seen in leukemia subclasses have led together to an extended classification scheme of leukemias as well as to model schemes of normal hematopoietic cell differentiation. Despite former and constantly published assumptions there are still no specific markers of leukemia cells.

Isoelectric focusing analysis of esterase activity (E.C. 3.1.1.1.) has been carried out on polyacrylamide gel slabs of a variety of immunologically defined acute leukemia subtypes. Distinct isoenzyme bands and isoenzyme groups have been identified and characterized biochemically with regard to their features for substrate specificity, pH optimum and inhibition experiments. The esterase isoenzyme patterns permitted the distinction between acute myeloid and non-myeloid leukemias. Acute lymphocytic leukemias localized by their immunological profile along the T-cell axis exhibited a readily recognizable isoenzyme group (T group). Reproducible differences in isoenzyme patterns were observed in childhood common ALL which indicate that the immunologically determined entity cALL displays a clear heterogeneity with respect to biochemical profiles of enzyme markers. These results suggest that further combined biochemical and immunological characterization may significantly contribute to a better understanding of lymphopoietic and leukemic cell differentiation.

Enzymologic profiles of beta-hexosaminidase (N-acetyl-beta-D-glucosaminidase, E.C.3.2.1.30) were studied in cells from childhood acute leukemias and lymphomas. By analytical isoelectric focusing or disc electrophoresis the beta-hexosaminidase activity was separated into its components A, B, I and C. The isoenzyme patterns were correlated with immunologic cell surface marker characteristics found on the investigated leukemic cells. In all cases of T-ALL the beta-hexosaminidase forms A and B were observed, an enzyme pattern similar to that found in normal lymphocytes. Seven out of 11 cases with cALL, three of six cases with AML and one case of AUL displayed the intermediate component (Hex I). Marked heterogeneity within the immunologically classified subgroup cALL was reflected in different enzyme patterns of the cALL samples. These biochemical phenotypes may indicate the different maturation and differentiation status of cells expressing the same immunologic surface markers.