Leben mit Phenprocoumon — optimal versorgt? : Untersuchung der Qualität und Effektivität der Phenprocoumon-Therapie im ambulanten Sektor

In Deutschland wird zur oralen Vitamin-K-Antagonistentherapie überwiegend der Wirkstoff Phenprocoumon (PPC) eingesetzt und die meisten Patienten werden durch ihren Hausarzt betreut. In einer deskriptiven, nicht-interventionellen Studie wurde die Ist-Situation der Versorgung von PPC-Patienten im ambulanten Sektor untersucht. Ziel war es, die Qualität und Effektivität der bisherigen Standardtherapie zu evaluieren. In Anbetracht der Einführung der neuen oralen Antikoagulantien (NOAC) ist die Untersuchung der PPC-Therapie von besonderem Interesse. Dem „Throughput-Modell“ folgend sollten „Input“- und „Outcome“-Parameter analysiert werden. rnIn einer klinischen Studie wurden 50 ambulant behandelte Patienten mit PPC-Therapie jeweils über einen Zeitraum von 3 Jahren retrospektiv beobachtet. In 5 niedergelassenen Arztpraxen in Rheinland-Pfalz wurden dazu 10 Patienten pro Praxis rekrutiert. Anhand der Patientenakte wurde eine Dokumentenanalyse durchgeführt. Die Selbstmedikation wurde mit einem eigens erstellten Fragebogen erfasst. rnIm Studienkollektiv wurden im Median 3 Comorbiditäten ermittelt. Die mediane Wochendosis betrug 4,0 Tabletten à 3 mg PPC. Die Patienten wurden im Median mit weiteren 15 verschiedenen Wirkstoffen therapiert, einer davon wurde in Selbstmedikation eingenommen. Im gesamten Beobachtungszeitraum fanden pro Patient im Median 57 Arztbesuche statt, die durch die Phenprocoumon-Therapie bedingt waren. INR (International normalized ratio)-Messungen (Median 47) waren der häufigste Grund für die Arztbesuche, so dass ein 3-Wochen-Rhythmus vom Gesamtkollektiv zu 97% erreicht wurde. Die „stabile“ INR-Einstellung wurde im Median nach 94 Tagen erreicht. Die prozentuale Rate (INR (%)) für die Einhaltung des INR-Zielbereiches (ZSB) erreichte internationale Benchmark-Werte, was auf eine gute Versorgungsqualität hindeutete. Die genauere Analyse ergab jedoch große interindividuelle Schwankungen. Während der „stabilen“ INR-Einstellung wurden bessere Ergebnisse als im Gesamtbeobachtungszeitraum erzielt. Drei Patienten (6%) erreichten die „stabile“ INR-Einstellung innerhalb von 3 Jahren nie. Die Auswertung für den erweiterten ZSB (ZSB ± 0,2) ergab bessere INR (%)-Ergebnisse als für den ZSB. Die Zeit im INR-ZSB (TTR (%)) erreichte mit 75% höhere Werte als INR (%) im ZSB mit 70%. Tendenziell war das Patientenkollektiv eher unter- als übertherapiert (Median „Under-INR“ 18% bzw. „Over-INR“ 8%). Erkrankungen und Impfungen stellten die wichtigsten der zahlreichen Einflussfaktoren für INR-Shifts hin zu Werten außerhalb des ZSB dar. Patienten, die Comedikation mit hohem Interaktionspotential einnahmen, erreichten in den INR-Qualitätsindikatoren schlechtere Ergebnisse als Patienten ohne potentiell interagierende Comedikation (Mann-Whitney-U-Test; p-Wert=0,003 für TTR (%), p=0,008 für INR (%)). In Zeitintervallen der „stabilen“ INR-Einstellung war der Unterschied nur für TTR (%) auffällig (Mann-Whitney-U-Test; p=0,015). Für den erweiterten ZSB waren die Unterschiede bezüglich beider INR-Qualitätsindikatoren nicht auffällig. Insgesamt wurden 41 unerwünschte Ereignisse (UAW) beobachtet, davon 24 (59%) in der Phase der „stabilen“ INR-Einstellung (21 leichte Blutungen, 1 schwere Blutung, 2 thromboembolische Ereignisse (TE)). Je 4 leichte Blutungen (19%) wurden in einen möglichen bzw. sicheren kausalen Zusammenhang mit der VKA-Therapie gebracht, wenn ein Zeitintervall von 3 Tagen zwischen der INR-Messung und Auftreten der UAW geprüft wurde. Ein TE wurde als sicher kausal gewertet. Von insgesamt 5 Krankenhausaufenthalten waren 3 bzw. 2 durch Blutungen bzw. TE veranlasst. Des Weiteren wurde im 3-Tage-Zeitintervall für 4 INR-Shifts hin zu Werten außerhalb des ZSB eine Interaktion mit verordneter CM als in sicherem oder möglichem kausalen Zusammenhang bewertet. Bei 49% der beobachteten Grippeimpfungen wurde ein INR-Shift festgestellt, der in ca. 60% der Fälle zu einem subtherapeutischen INR-Wert führte. Insgesamt war das klinische Ergebnis nicht optimal. rnDas „Outcome“ in Form der gesundheitsbezogenen Lebensqualität (LQ) wurde retrospektiv-prospektiv mittels SF-36-Fragebogen ermittelt. Die Patienten zeigten gegenüber der Normalbevölkerung einen Verlust an LQ auf körperlicher Ebene bzw. einen Gewinn auf psychischer Ebene. Das humanistische Ergebnis erfüllte bzw. übertraf damit die Erwartungen. rnInsgesamt wiesen die Ergebnisse darauf hin, dass Qualität und Effektivität der Antikoagulationstherapie mit PPC im ambulanten Sektor weiterer Optimierung bedürfen. Mit intensivierten Betreuungsmodellen lässt sich ein besseres Outcome erzielen. rn

Control of the long-range self-organization of polycyclic aromatic hydrocarbons for device applications

Electronic devices based on organic semiconductors have gained increased attention in nanotechnology, especially applicable to the field of field-effect transistors and photovoltaic. A promising class of materials in this reseach field are polycyclic aromatic hydrocarbons (PAHs). Alkyl substitution of these graphenes results in the selforganization into one-dimensional columnar superstructures and provides solubility and processibility. The nano-phase separation between the π-stacking aromatic cores and the disordered peripheral alkyl chains leads to the formation of thermotropic mesophases. Hexa-peri-hexabenzocoronenes (HBC), as an example for a PAH, exhibits some of the highest values for the charge carrier mobility for mesogens, which makes them promising candidates for electronic devices. Prerequisites for efficient charge carrier transport between electrodes are a high purity of the material to reduce possible trapping sites for charge carriers and a pronounced and defect-free, long-range order. Appropriate processing techniques are required to induce a high degree of aligned structures in the discotic material over macroscopic dimensions. Highly-ordered supramolecular structures of different discotics, in particular, of HBC derivatives have been obtained by solution processing using the zone-casting technique, zone-melting or simple extrusion. Simplicity and fabrication of highly oriented columnar structures over long-range are the most essential advantages of these zone-processing methods. A close relation between the molecular design, self-aggregation and the processing conditions has been revealed. The long-range order achieved by the zone-casting proved to be suitable for field effect transistors (FET).

Atomic-scale characterization of diamond surfaces and fullerene self-assembly

In this thesis, elemental research towards the implantation of a diamond-based molecular quantum computer is presented. The approach followed requires linear alignment of endohedral fullerenes on the diamond C(100) surface in the vicinity of subsurface NV-centers. From this, four fundamental experimental challenges arise: 1) The well-controlled deposition of endohedral fullerenes on a diamond surface. 2) The creation of NV-centers in diamond close to the surface. 3) Preparation and characterization of atomically-flat diamondsurfaces. 4) Assembly of linear chains of endohedral fullerenes. First steps to overcome all these challenges were taken in the framework of this thesis. Therefore, a so-called “pulse injection” technique was implemented and tested in a UHV chamber that was custom-designed for this and further tasks. Pulse injection in principle allows for the deposition of molecules from solution onto a substrate and can therefore be used to deposit molecular species that are not stable to sublimation under UHV conditions, such as the endohedral fullerenes needed for a quantum register. Regarding the targeted creation of NV-centers, FIB experiments were carried out in cooperation with the group of Prof. Schmidt-Kaler (AG Quantum, Physics Department, Johannes Gutenberg-Universität Mainz). As an entry into this challenging task, argon cations were implanted into (111) surface-oriented CaF2 crystals. The resulting implantation spots on the surface were imaged and characterized using AFM. In this context, general relations between the impact of the ions on the surface and their valency or kinetic energy, respectively, could be established. The main part of this thesis, however, is constituted by NCAFM studies on both, bare and hydrogen-terminated diamond C(100) surfaces. In cooperation with the group of Prof. Dujardin (Molecular Nanoscience Group, ISMO, Université de Paris XI), clean and atomically-flat diamond surfaces were prepared by exposure of the substrate to a microwave hydrogen plasma. Subsequently, both surface modifications were imaged in high resolution with NC-AFM. In the process, both hydrogen atoms in the unit cell of the hydrogenated surface were resolved individually, which was not achieved in previous STM studies of this surface. The NC-AFM images also reveal, for the first time, atomic-resolution contrast on the clean, insulating diamond surface and provide real-space experimental evidence for a (2×1) surface reconstruction. With regard to the quantum computing concept, high-resolution NC-AFM imaging was also used to study the adsorption and self-assembly potential of two different kinds of fullerenes (C60 and C60F48) on aforementioned diamond surfaces. In case of the hydrogenated surface, particular attention was paid to the influence of charge transfer doping on the fullerene-substrate interaction and the morphology emerging from self-assembly. Finally, self-assembled C60 islands on the hydrogen-terminated diamond surface were subject to active manipulation by an NC-AFM tip. Two different kinds of tip-induced island growth modes have been induced and were presented. In conclusion, the results obtained provide fundamental informations mandatory for the realization of a molecular quantum computer. In the process it was shown that NC-AFM is, under proper circumstances, a very capable tool for imaging diamond surfaces with highest resolution, surpassing even what has been achieved with STM up to now. Particular attention was paid to the influence of transfer doping on the morphology of fullerenes on the hydrogenated diamond surface, revealing new possibilities for tailoring the self-assembly of molecules that have a high electron affinity.

Systematic functionalization of molecules for molecular self-assembly

This thesis describes the investigation of systematically varied organic molecules for use in molecular self-assembly processes. All experiments were performed using high-resolution non-contact atomic force microscopy under UHV conditions and at room temperature. Using this technique, three different approaches for influencing intermolecular and molecule-surface interaction on the insulating calcite(10.4) surface were investigated by imaging the structure formation at the molecular scale. I first demonstrated the functionalization of shape-persistent oligo(p-benzamide)s that was engineered by introducing different functional groups and investigating their effect on the structural formation on the sample surface. The molecular core was designed to provide significant electrostatic anchoring towards the surface, while at the same time maintaining the flexibility to fine-tune the resulting structure by adjusting the intermolecular cohesion energy. The success of this strategy is based on a clear separation of the molecule-substrate interaction from the molecule-molecule interaction. My results show that sufficient molecule-surface anchoring can be achieved without restricting the structural flexibility that is needed for the design of complex molecular systems. Three derivatives of terephthalic acid (TPA) were investigated in chapter 7. Here, the focus was on changing the adhesion to the calcite surface by introducing different anchor functionalities to the TPA backbone. For all observed molecules, the strong substrate templating effect results in molecular structures that are strictly oriented along the calcite main crystal directions. This templating is especially pronounced in the case of 2-ATPA where chain formation on the calcite surface is observed in contrast to the formation of molecular layers in the bulk. At the same time, the amino group of 2-ATPA proved an efficient anchor functionality, successfully stabilizing the molecular chains on the sample surface. These findings emphasizes, once again, the importance of balancing and fine-tuning molecule-molecule and molecule-surface interactions in order to achieve stable, yet structurally flexible molecular arrangements on the sample surface. In the last chapter, I showed how the intrinsic property of molecular chirality decisively influences the structure formation in molecular self-assembly. This effect is especially pronounced in the case of the chiral heptahelicene-2-carboxylic acid. Deposition of the enantiopure molecules results in the formation of homochiral islands on the sample surface which is in sharp contrast to the formation of uni-directional double rows upon deposition of the racemate onto the same surface. While it remained uncertain from these previous experiments whether the double rows are composed of hetero- or homochiral molecules, I could clearly answer that question here and demonstrate that the rows are of heterochiral origin. Chirality, thus, proves to be another important parameter to steer the intermolecular interaction on surfaces. Altogether, the results of this thesis demonstrate that, in order to successfully control the structure formation in molecular self-assembly, the correct combination of molecule and surface properties is crucial. This is of special importance when working on substrates that exhibit a strong influence on the structure formation, such as the calcite(10.4) surface. Through the systematic variation of functional groups several important parameters that influence the balance between molecule-surface and molecule-molecule interaction were identified here, and the results of this thesis can, thus, act as a guideline for the rational design of molecules for use in molecular self-assembly.