Peter Heusser

Detection of circulating tumor cells in blood of metastatic breast cancer patients using a combination of cytokeratin and EpCAM antibodies

BackgroundCirculating tumor cells (CTCs) are detectable in peripheral blood of metastatic breast cancer patients (MBC). In this paper we evaluate a new CTC separation method based on a combination of anti-EpCAM- and anti-cytokeratin magnetic cell separation with the aim to improve CTC detection with low target antigen densities.MethodsBlood samples of healthy donors spiked with breast cancer cell line HCC1937 were used to determine accuracy and precision of the method. 10 healthy subjects were examined to evaluate specificity. CTC counts in 59 patients with MBC were measured to evaluate the prognostic value on overall survival.ResultsRegression analysis of numbers of recovered vs. spiked HCC1937 cells yielded a coefficient of determination of R2 = 0.957. The average percentage of cell recovery was 84%. The average within-run coefficient of variation for spiking of 185, 85 and 30 cells was 14%. For spiking of 10 cells the within-run CV was 30%. No CTCs were detected in blood of 10 healthy subjects examined.A standard threshold of 5 CTC/7.5 ml blood as a cut-off point between risk groups led to a highly significant prognostic marker (p < 0.001). To assess the prognostic value of medium CTC levels we additionally considered a low (CTC-L: 0 CTC), a medium (CTC-M: 1–4 CTC) and a high risk group (CTC-H: ≥5 CTC). The effect of this CTC-LMH marker on overall survival was significant as well (p < 0.001). A log-ratio test performed to compare the model with 3 vs. the model with 2 risk groups rejected the model with 2 risk groups (p = 0.026). For CTC as a count variable, we propose an offset reciprocal transformation 1/(1 + x) for overall survival prediction (p < 0.001).ConclusionsWe show that our CTC detection method is feasible and leads to accurate and reliable results. Our data suggest that a refined differentiation between patients with different CTC levels is reasonable.

Towards non-reductionistic medical anthropology, medical education and practitioner–patient-interaction: The example of Anthroposophic Medicine

OBJECTIVE To develop the hypothesis that reductionism in medical anthropology, professional education and health care influences empathy development, communication and patient satisfaction. METHOD We identified relevant literature and reviewed the material in a structured essay. We reflected our hypothesis by applying it to Anthroposophic Medicine (AM), an example of holistic theory and practice. RESULTS Reductionism in medical anthropology such as in conventional medicine seems to lead to a less empathetic and less communicative health care culture than holism such as in CAM disciplines. However, reductionism can be transformed into a systemic, multi-perspective holistic view, when the emergent properties of the physical, living, psychic, spiritual and social levels of human existence and the causal relations between them are more carefully accounted for in epistemology, medical anthropology and professional education. This is shown by the example of AM and its possible benefits for communication with and satisfaction of patients. CONCLUSION A non-reductionistic understanding of the human being may improve communication with patients and enhance patient benefit and satisfaction. PRACTICE IMPLICATIONS Interdisciplinary qualitative and quantitative studies are warranted to test this hypothesis and to understand the complex relations between epistemology, medical anthropology, education, health care delivery and benefit for patients.

Tumour cell derived effects on monocyte/macrophage polarization and function and modulatory potential of Viscum album lipophilic extract in vitro

BackgroundMacrophages are highly versatile cells that play an important role in tumour microenvironment. Tumour associated macrophages (TAMs) have been linked to both, good or bad prognosis of several cancer types depending on their number, composition and polarization. Viscum album lipophilic extract (VALE) contains several pentacyclic triterpenes known to modulate the activity of monocytes and other immune cells and to exhibit anticancer properties. In our in vitro study, we investigated the effect of tumour cell lines on macrophage polarization and monocyte chemotactic transmigration and examined the modulatory potential of VALE and its predominant triterpene oleanolic acid (OA).MethodsHuman peripheral blood monocytes were differentiated into monocyte derived macrophages (MDM) using M-CSF and polarized into M1 by IFN-γ and LPS and into M2 macrophages by IL-4 and IL-13 or by co-culture with two different tumour cell lines. Polarized macrophages were subsequently treated with VALE or OA. Phenotypic markers and cytokines were assessed by flow cytometry and immunoanalysis. Migration of human peripheral blood monocytes induced by monocyte chemotactic protein-1 (MCP-1) or supernatants of different tumour cell lines under the influence of VALE or OA was measured in a chemotaxis transmigration assay.ResultsIn vitro polarized M1 and M2 type macrophages revealed specific phenotypic patterns and tumour cell co-cultured MDM displayed ambiguous phenotypes with M1 as well as M2 associated markers. VALE and OA showed modest influence on cell surface marker profile and cytokine expression of tumour cell co-cultured macrophages. All tumour cell supernatants markedly enhanced the migratory activity of monocytes. VALE and OA significantly inhibited MCP-1 induced monocyte transmigration, whereas monocyte migration initiated by tumour cell derived supernatants was not affected.ConclusionsIn our study we reconfirmed that co-culture with different tumour cell lines can result in a mixed macrophage phenotype with M1 as well as M2 patterns, a finding that is important for a better understanding of tumour microenvironment functions. Moreover, we demonstrated that VALE shows slight immunomodulatory effects on tumour cell co-cultured macrophages and modulates monocyte chemotactic transmigration in vitro, indicating promising possibilities of triterpenes from Viscum album L. to contribute in a multimodal concept of anti-cancer therapy in future. Our data contribute to an understanding of monocyte function and macrophage polarization in vitro and of the possibility to influence their behaviour by triterpene containing mistletoe extracts.

Effects of Homeopathic Arsenicum Album, Nosode, and Gibberellic Acid Preparations on the Growth Rate of Arsenic-Impaired Duckweed (Lemna gibba L.)

This study evaluated the effects of homeopathically potentized Arsenicum album, nosode, and gibberellic acid in a bioassay with arsenic-stressed duckweed (Lemna gibba L.). The test substances were applied in nine potency levels (17x, 18x, 21x–24x, 28x, 30x, 33x) and compared with controls (unsuccussed and succussed water) regarding their influence on the plant’s growth rate. Duckweed was stressed with arsenic(V) for 48 h. Afterwards, plants grew in either potentized substances or water controls for 6 days. Growth rates of frond (leaf) area and frond number were determined with a computerized image analysis system for different time intervals (days 0–2, 2–6, 0–6). Five independent experiments were evaluated for each test substance. Additionally, five water control experiments were analyzed to investigate the stability of the experimental setup (systematic negative control experiments). All experiments were randomized and blinded. The test system exhibited a low coefficient of variation (≈1%). Unsuccussed and succussed water did not result in any significant differences in duckweed growth rate. Data from the control and treatment groups were pooled to increase statistical power. Growth rates for days 0–2 were not influenced by any homeopathic preparation. Growth rates for days 2–6 increased after application of potentized Arsenicum album regarding both frond area (p < 0.001) and frond number (p < 0.001), and by application of potentized nosode (frond area growth rate only, p < 0.01). Potencies of gibberellic acid did not influence duckweed growth rate. The systematic negative control experiments did not yield any significant effects. Thus, false-positive results can be excluded with high certainty. To conclude, the test system with L. gibba impaired by arsenic(V) was stable and reliable. It yielded evidence for specific effects of homeopathic Arsenicum album preparations and it will provide a valuable tool for future experiments that aim at revealing the mode of action of homeopathic preparations. It may also be useful to investigate the influence of external factors (e.g., heat, electromagnetic radiation) on the effects of homeopathic preparations.

Immunomodulatory and Clinical Effects of viscum album (iscador M and Iscador P) in Children with Recurrent Respiratory Infections as a Result of the Chernobyl Nuclear Accident

&NA; Ninety-two children 5 to 14 years of age living in areas exposed to the radioactive fallout from Chernobyl with recurrent respiratory infections (RRIs) were treated after randomization with either Viscum album praeparatum mali or pini (Iscador M or P). The dosage was two subcutaneous injections a week for 5 weeks with individual doses of 0.001 mg to 1.0 mg. Both Viscum album preparations were effective in significantly reducing clinical symptoms. One year after a single treatment course, the frequency of RRI relapses decreased by 78% and 73%, respectively. Immunomodulatory effects were assessed by investigation of lymphocyte subsets, natural killer (NK) cell activity, phagocytic and oxidative activity of polymorphonuclear leukocytes, and antiviral activity of serum before and 1 week after treatment. Viscum album therapy resulted in normalization of initial immune indices either below or above the normal ranges. High levels of antiviral activity before treatment were significantly decreased by Viscum album mali. Viscum album treatment should be studied further in children with RRI.

Effects of Lipophilic Extract of Viscum album L. and Oleanolic Acid on Migratory Activity of NIH/3T3 Fibroblasts and on HaCat Keratinocytes

Viscum album L. lipophilic extract (VALE) contains pharmacologically active pentacyclic triterpenes that are known to exhibit immunomodulatory, antitumor, and wound healing activity. Preliminary clinical observations indicate that VALE was able to influence cutaneous wound healing in vivo. The objective of this study was to investigate wound closure related properties of VALE in vitro. As measured in a wound healing assay, VALE and its predominant triterpene oleanolic acid (OA) significantly and dose dependently promoted the migration of NIH/3T3 fibroblasts in vitro, thereby leading to an enhanced wound closure. Compared to the negative control, maximal stimulation by 26.1% and 26.2%, respectively, was attained with 10 μg/mL VALE and 1 μg/mL OA. Stimulation of proliferation in NIH/3T3 fibroblasts by VALE and OA could be excluded. At higher concentrations both substances affected proliferation and viability of NIH/3T3 fibroblasts and HaCat keratinocytes. In the toxic range of concentrations of VALE and OA, migration of NIH/3T3 fibroblasts was suppressed. The extent of the stimulatory effect on cell migration of VALE quite closely corresponded to the effect expected by the concentrations of OA contained in the crude extract VALE. These data support the casual observation that Viscum album L. lipophilic extract might modulate wound healing related processes in vivo.

Integrative medical education: Educational strategies and preliminary evaluation of the Integrated Curriculum for Anthroposophic Medicine (ICURAM)

OBJECTIVES the development and preliminary evaluation of a new medical program aimed at educating students in patient-centered integrative care and developing appropriate educational strategies. METHODS The Integrated Curriculum for Anthroposophic Medicine (ICURAM) was developed with modules on anthroposophic medicine integrated into the full 6 years of the regular medical curriculum. The educational strategy is the ESPRI(2)T approach, combining Exploratory learning, Supported participation, Patient-based learning, Reflective practice, Integrated learning, an Integrative approach and Team-based learning. The student participation, assessed based on the number of credit points earned per year (ctp/year) through the ICURAM (1 ctp=30 h workload), served as a preliminary indicator of student interest. RESULTS Of the 412 55%medical students participated in the program: 16% full participation (≥ 4 ctp/year), 18% partial participation (1-3.99 ctp/year) and 22% occasional participation (0.25-0.99 ctp/year). The amount of additional workload taken on by students was between 7.8h/year for occasional participants, 33 h/year for partial participants and 84 h/year for full participants. CONCLUSION More than half of medical students were willing to invest a significant amount of additional time in the optional program. PRACTICE IMPLICATIONS An integrative medical curriculum with a student-centered educational strategy seems to be of interest to most medical students.

Investigation of Arsenic-Stressed Yeast (Saccharomyces cerevisiae) as a Bioassay in Homeopathic Basic Research

This study investigated the response of arsenic-stressed yeast (Saccharomyces cerevisiae) towards homeopathically potentized Arsenicum album, a duckweed nosode, and gibberellic acid. The three test substances were applied in five potency levels (17x, 18x, 24x, 28x, 30x) and compared to controls (unsuccussed and succussed water) with respect to influencing specific growth parameters. Five independent experiments were evaluated for each test substance. Additionally, five water control experiments were analyzed to investigate the stability of the experimental setup (systematic negative control experiments). All experiments were randomized and blinded. Yeast grew in microplates over a period of 38 h in either potentized substances or water controls with 250 mg/l arsenic(V) added over the entire cultivation period. Yeasts growth kinetics (slope, Et50, and yield) were measured photometrically. The test system exhibited a low coefficient of variation (slope 1.2%, Et50 0.3%, yield 2.7%). Succussed water did not induce any significant differences compared to unsuccussed water. Data from the control and treatment groups were both pooled to increase statistical power. In this study with yeast, no significant effects were found for any outcome parameter or any homeopathic treatment. Since in parallel experiments arsenic-stressed duckweed showed highly significant effects after application of potentized Arsenicum album and duckweed nosode preparations from the same batch as used in the present study, some specific properties of this experimental setup with yeast must be responsible for the lacking response.

Immunomodulatory actions of Viscum album (Iscador) in children with recurrent respiratory disease as a result of the Chernobyl nuclear accident

Summary To determine the clinical and immunological effects of Iscador in children suffering from recurrent respiratory disease as a result of the Chernobyl nuclear accident, a non-randomized, placebo-controlled trial was carried out at a specialist paediatric setting in Kiev. Twice-weekly injections of saline for 3 weeks were followed by twice-weekly injections of Iscador for 3 weeks. The outcome measures were clinical symptoms, counts of main lymphocyte subsets, PHA-lymphocyte response, NK activity and phagocytosis. Improvements in clinical and many immunological parameters were seen after treatment with Iscador, but not with placebo. Iscador appears to improve clinical symptoms and markers of immune function in children suffering recurrent respiratory disease after Chernobyl.

Watchful waiting or induction of labour – a matter of informed choice: identification, analysis and critical appraisal of decision aids and patient information regarding care options for women with uncomplicated singleton late and post term pregnancies: a review

BackgroundDecision-making during pregnancy regarding different options of care can be difficult, particularly when risks of intervention versus no intervention for mother and baby are unclear. Unbiased information and support for decision making may be beneficial in these situations. The management of normal pregnancies at and beyond term is an example of such a situation. In order to determine the need to develop an evidence-based decision aid this paper searches, analyses and appraises patient decision aids and patient information leaflets regarding care options in cases of late term and post-term pregnancies, including complementary and alternative medicine (CAM).MethodsA literature search was carried out in a variety of lay and medical databases. Inclusion criteria: written information related to uncomplicated singleton pregnancies and targeted at lay people. Analysis and appraisal of included material by means of quality criteria was set up based on the International Patient Decision Aid Standards accounting for evidence-basing of CAM options.ResultsInclusion of two decision aids and eleven leaflets from four decision aids and sixteen leaflets. One decision aid met the quality criteria almost completely, the other one only insufficiently despite providing some helpful information. Only one leaflet is of good quality, but cannot substitute a decision aid.ConclusionsThere is an urgent need for the design of an evidence-based decision aid of good quality for late-term or post-term pregnancy, particularly in German language.