Synthese organisch-anorganischer Hybridmaterialien in Mehrkomponenten-Lösungsmittelsystemen

Die Funktionalisierung anorganischer Nanopartikel stellt einen Schlüsselschritt in der Herstellung von Nanokompositen dar. Nanokomposite erzielen ein wachsendes Interesse im Bereich der Polymer- und der Materialwissenschaften, da die Kombination mehrerer Materialien mit unterschiedlichen Eigenschaften, wie etwa die Kombination anorganischer Nanopartikel mit Polymeren, große Synergieeffekte erhoffen lässt.rnrnDer Einbau anorganischer Nanopartikel in polymere Matrixmaterialien zur Verbesserung oder Einführung mechanischer, optischer oder magnetischer Eigenschaften von Polymeren bedarf allerdings der Modifizierung der Oberfläche des anorganischen Materials, um die für die positiven Synergieeffekte essentielle Kompatibilität zwischen Füllstoff und Matrix zu erreichen.rnrnEine Vielzahl anorganischer Partikel ist bereits als wässrige Dispersion erhältlich (SiO2, Al2O3, CeO2, ZrO2, ...). Mehrkomponenten- Lösungsmittelsysteme ermöglichen den Transfer dieser Partikel in eine unpolare Umgebung und gleichzeitig deren Funktionalisierung mit amphiphilen Copolymeren. Aufgrund der reversiblen Schaltbarkeit dieser Lösungsmittelsysteme zwischen einem einphasigen und zweiphasigen Zustand werden die zu Beginn in zwei nichtmischbaren Phasen vorliegenden Reaktionspartner durch Übergang in einen einphasigen Zustand unter homogenen Bedingungen in Kontakt gebracht und durch eine erneute Phasentrennung isoliert.rnEin weiterer Vorteil dieser Lösungsmittelsysteme ist deren Tolerierung funktioneller Gruppen in den verwendeten amphiphilen Copolymeren, welche nicht in Wechselwirkung mit der Partikeloberfläche stehen. Beispielsweise können Amine in den amphiphilen Copolymeren für die Wechselwirkung der funktionalisierten Partikel mit einer Polyurethanmatrix dienen, Alkine können mittels einer 1,3-dipolaren Cycloaddition umgesetzt werden oder aber perfluorierten Seitenketten in den Seitenketten der amphiphilen Copolymere die Kompatibilisierung der funktionalisierten Partikel mit einem perfluorierten Polymer gewährleisten.

Nonclassical crystallization of bivalent metal carbonates

Nichtklassische Kristallisationen tragen heutzutage einen entscheidenden Anteil zum Verständnis von Biomineralisationsprozessen und anspruchsvoller Morphogenese in vitro bei. Die vorliegende Dissertation stellt drei neue Vertreter nichtklassischer Kristallisationen vor, die während der Fällung von Calciumcarbonat und verwandten zweiwertigen Carbonaten auftreten.rn(a) Zum ersten Male wird eine Symmetrie-brechende Phasenselektion von Calciumcarbonat beschrieben, die auf einem subtilen Wechselspiel von verketteten Gleichgewichten basiert und deren Ursache letztendlich der paritätsverletzenden Energiedifferenz (PVED) zugeschrieben wird. rn(b) Die interkristalline Minoritätskomponente eines Mesokristalles, seien es z.B. eingeschlossenes Proteine oder polymere Additive, erfahren eine Morphogenese im Sinne einer Formpressung. Dieser bislang wenig beachtete Effekt in Mesokristallen wurde zur Herstellung von Nanoröhren eingesetzt, die aus verschiedensten Materialien bestehen können (z.B. Calciumcarbonat oder Cadmiumsulfid).rn(c) Das Hauptaugenmerk dieser Dissertation liegt auf dem Auftreten eines flüssig-amorphen Intermediates während der Metallcarbonat-Präzipitation. Durch diffusionskontrollierte und kontaktfreie Versuchsführung konnte die Existenz eines solchen nichtklassischen, flüssigen Intermediates, welches der kristallinen Phase bei neutralen pH vorangeht, sicher nachgewiesen werden. rn

Nano- und mikrostrukturierte organische Erkennungsstrukturen in Lipidmembranen

Im Rahmen dieser Arbeit wurden zunächst die ausgewählten Lipide anhand ihrer p-ArnIsothermen charakterisiert. Dabei zeigte sich, dass die flüssiganaloge Phase umso ausgeprägter ist, je größer die hydrophile Kopfgruppe des jeweiligen Lipids ist, so dass diese schon bei sehr großen Flächen miteinander wechselwirken. Außerdem wurde das Mischungsverhalten und die Domänenbildung binärer und ternärer Mischungen untersucht.rnDabei konnte im Fall der binären Mischungen der polymerisierbaren Lipide 1 und 2 mit dem perfluorierten Lipid 3 eine Phasenseparation beobachtet werden. Hierbei zeigte sich, dass sowohl die Form als auch die Größe der Domänen durch zwei Faktoren kontrolliert werden konnte, nämlich zum einen durch den Lateraldruck und zum anderen durch die molare Zusammensetzung der binären Mischung. Bei niedrigen Lateraldrücken (10 mN/m) warenrnfluorierte und nichtfluorierte Lipide in der homogenen flüssiganalogen Phase vollständig mischbar. Bei sehr hohen Lateraldrücken (30 mN/m) lag eine nahezu vollständige Entmischung vor, da das Lipid 1 hier schon vollständig auskristallisiert war. Im Fall der binären Mischung 2/3 konnte ein solches Verhalten nicht beobachtet werden, was an dem Phasenverhalten des Lipids 2 liegt. Aber auch hier lies sich die Domänenbildung sowohl überrnden Lateraldruck als auch über die Komposition der binären Mischung kontrollieren. Des Weiteren konnte gezeigt werden, dass die Monoschichten dieser beiden binären Mischungen durch photochemische Polymerisation stabilisiert werden können.rnDer Einfluss des Fluorierungsgrades auf das Phasenseparationsverhalten wurde anhand der binären Mischungen 1/6 und 1/8 untersucht. Es zeigte sich hier, dass sich auch hier in beiden Fällen die Domänenbildung sowohl über den Lateraldruck als auch über die Komposiion der Mischung steuern lies. Ein Vergleich der gefundenen Strukturen belegte darüber hinaus klare Unterschiede zwischen dem fluorierten und teilfluorierten Lipid. Denn in der binären Mischung 1/8 (perfluoriertes Lipid) konnte die hexagonale Grundstruktur, die zuvor schon inrnder binären Mischung 1/3 gefunden wurde, beobachtet werden. Demgegenüber hatten die kristallinen Domänen, die in der binären Mischung 1/6 (teilfluoriertes Lipid) beobachtet wurden, die hexagonale Grundform verloren. Hier wurden rundliche unförmige Domänen gefunden, die zudem deutlich kleiner waren als die bei der Mischung mit dem perfluorierten Lipid gefundenen Domänen. In den ternären Mischungen zeigte sich, dass diese ternären Mischungen eine ähnliche Phasenseparation zeigten wie die binäre Mischung 1/3. Die hier auftretenden kristallanalogen Domänen bestanden aus Lipid 1, wobei die umgebendernflüssiganaloge Matrix die beiden fluorierten Lipide enthielt. Deswegen war es von besonderer Bedeutung wie sich die beiden fluorierten Verbindungen untereinander verhalten würden.rnDazu wurden die p-A Isothermen der binären Mischung 3/5 ausgewertet und dabei zeigte sich, dass sich das Vakzinlipid, sofern der Anteil nicht höher ist als der des fluorierten Matrixlipides, in idealer Weise mit diesem mischt. Eine Untersuchung der Antigen-Antikörper Erkennung der binären Mischungen 3/5 zeigte, dass die Reaktion mit dem Antikörper umso effektiver war, je größer der Anteil des Vakzinlipids 5 war. Allerdings konnte hier kein linearer Zusammenhang gefunden werden. Stattdessen handelte es sich umrneine Sättigungskurve, da bereits ein Anteil an Lipid 5 von 42,2 mol% eine nur geringfügig schwächere Antikörperanbindung zeigte, als das reine Vakzinlipid.

Darstellung von fluorierten Amphiphilen zur Modifikation von Grenzflächeneigenschaften

Die vorliegende Arbeit behandelt die Darstellung von neuen fluorierten Amphiphilen in Hinblick auf deren spätere Anwendung zur Modifikation von flüssig-gasförmigen, flüssig-flüssigen und flüssig-festen Grenzflächen. Jedes der drei Themengebiete richtete sich an eine andere Grenzfläche. Die erste Aufgabe wurde mit der Darstellung und Charakterisierung von Fluortensiden kurzen Perfluoralkyl-Ketten erfüllt, welche als möglichen umweltfreundlichen Ersatz für die Derivate der langkettigen Perfluoroktancarbonsäure und Perfluoroktansulfonsäure Anwendung finden. Es wurden Fluortenside entwickelt, welche die Oberflächenspannung von Wasser auf bis zu 18 mN/m absenken können. Der zweite Fokus lag auf der Stabilisierung einer fluorierten Emulsion, die sich für die carbo-kationische Polymerisationen eignete. Im Rahmen der Arbeit wurde das neue Blockcopolymer Poly(isobutylen-b-pentafluorstyrol) dargestellt. Neben der Homopolymerisation von Isobutylen zur PIB-Partikelsynthese wurde die Eignung des Stabilisator-Emulsionssystems durch die Darstellung von hart-weichen PS-PIB-Hybridpartikeln erfolgreich verfolgt. Dazu wurde die Synthese von quervernetzten PS-Kernpartikeln und der anschließenden Umhüllung durch PIB in einem weiteren Schritt. Im dritten Teil wurde die Adsorption von amphiphilen Fluorpolymeren zur Solvophobierung von rauen anorganischen Oberflächen untersucht. Es konnten sowohl superhydrophobe als auch superoleophobe Eigenschaften erzielt werden.

Significance of the Deformation History within the Hinge Zone of the Pennsylvania Salient, Appalachian Mountains

Two competing models exist for the formation of the Pennsylvania salient, a widely studied area of pronounced curvature in the Appalachian mountain belt. The viability of these models can be tested by compiling and analyzing the patterns of structures within the general hinge zone of the Pennsylvania salient. One end-member model suggests a NW-directed maximum shortening direction and no rotation through time in the culmination. An alternative model requires a two-phase development of the culmination involving NNW-directed maximum shortening overprinted by WNW-directed maximum shortening. Structural analysis at 22 locations throughout the Valley and Ridge and southern Appalachian Plateau Provinces of Pennsylvania are used to constrain orientations of the maximum shortening direction and establish whether these orientations have rotated during progressive deformation in the Pennsylvania salient's hinge. Outcrops of Paleozoic sedimentary rocks contain several orders of folds, conjugate faults, steeply dipping strike-slip faults, joints, conjugate en echelon gash vein arrays, spaced cleavage, and grain-scale finite strain indicators. This suite of structures records a complex deformation history similar to the Bear Valley sequence of progressive deformation. The available structural data from the Juniata culmination do not show a consistent temporal rotation of shortening directions and generally indicate uniform,

Causal Inference in Observational Studies with Outcome-Dependent Sampling

In this paper, we consider estimation of the causal effect of a treatment on an outcome from observational data collected in two phases. In the first phase, a simple random sample of individuals are drawn from a population. On these individuals, information is obtained on treatment, outcome, and a few low-dimensional confounders. These individuals are then stratified according to these factors. In the second phase, a random sub-sample of individuals are drawn from each stratum, with known, stratum-specific selection probabilities. On these individuals, a rich set of confounding factors are collected. In this setting, we introduce four estimators: (1) simple inverse weighted, (2) locally efficient, (3) doubly robust and (4)enriched inverse weighted. We evaluate the finite-sample performance of these estimators in a simulation study. We also use our methodology to estimate the causal effect of trauma care on in-hospital mortality using data from the National Study of Cost and Outcomes of Trauma.

Influence of oxygen therapy on glucose-lactate metabolism after diffuse brain injury

OBJECT: Severe traumatic brain injury (TBI) imposes a huge metabolic load on brain tissue, which can be summarized initially as a state of hypermetabolism and hyperglycolysis. In experiments O2 consumption has been shown to increase early after trauma, especially in the presence of high lactate levels and forced O2 availability. In recent clinical studies the effect of increasing O2 availability on brain metabolism has been analyzed. By their nature, however, clinical trauma models suffer from a heterogeneous injury distribution. The aim of this study was to analyze, in a standardized diffuse brain injury model, the effect of increasing the fraction of inspired O2 on brain glucose and lactate levels, and to compare this effect with the metabolism of the noninjured sham-operated brain. METHODS: A diffuse severe TBI model developed by Foda and Maramarou, et al., in which a 420-g weight is dropped from a height of 2 m was used in this study. Forty-one male Wistar rats each weighing approximately 300 g were included. Anesthesized rats were monitored by placing a femoral arterial line for blood pressure and blood was drawn for a blood gas analysis. Two time periods were defined: Period A was defined as preinjury and Period B as postinjury. During Period B two levels of fraction of inspired oxygen (FiO2) were studied: air (FiO2 0.21) and oxygen (FiO2 1). Four groups were studied including sham-operated animals: air-air-sham (AAS); air-O2-sham (AOS); air-air-trauma (AAT); and air-O2-trauma (AOT). In six rats the effect of increasing the FiO2 on serum glucose and lactate was analyzed. During Period B lactate values in the brain determined using microdialysis were significantly lower (p < 0.05) in the AOT group than in the AAT group and glucose values in the brain determined using microdialysis were significantly higher (p < 0.04). No differences were demonstrated in the other groups. Increasing the FiO2 had no significant effect on the serum levels of glucose and lactate. CONCLUSIONS: Increasing the FiO2 influences dialysate glucose and lactate levels in injured brain tissue. Using an FiO2 of 1 influences brain metabolism in such a way that lactate is significantly reduced and glucose significantly increased. No changes in dialysate glucose and lactate values were found in the noninjured brain.

Dynamics and kinematics of eruptive activity at Fuego volcano, Guatemala 2005-2009

Volcanoes are the surficial expressions of complex pathways that vent magma and gasses generated deep in the Earth. Geophysical data record at least the partial history of magma and gas movement in the conduit and venting to the atmosphere. This work focuses on developing a more comprehensive understanding of explosive degassing at Fuego volcano, Guatemala through observations and analysis of geophysical data collected in 2005 – 2009. A pattern of eruptive activity was observed during 2005 – 2007 and quantified with seismic and infrasound, satellite thermal and gas measurements, and lava flow lengths. Eruptive styles are related to variable magma flux and accumulation of gas. Explosive degassing was recorded on broadband seismic and infrasound sensors in 2008 and 2009. Explosion energy partitioning between the ground and the atmosphere shows an increase in acoustic energy from 2008 to 2009, indicating a shift toward increased gas pressure in the conduit. Very-long-period (VLP) seismic signals are associated with the strongest explosions recorded in 2009 and waveform modeling in the 10 – 30 s band produces a best-fit source location 300 m west and 300 m below the summit crater. The calculated moment tensor indicates a volumetric source, which is modeled as a dike feeding a SW-dipping (35°) sill. The sill is the dominant component and its projection to the surface nearly intersects the summit crater. The deformation history of the sill is interpreted as: 1) an initial inflation due to pressurization, followed by 2) a rapid deflation as overpressure is explosively release, and finally 3) a reinflation as fresh magma flows into the sill and degasses. Tilt signals are derived from the horizontal components of the seismometer and show repetitive inflation deflation cycles with a 20 minute period coincident with strong explosions. These cycles represent the pressurization of the shallow conduit and explosive venting of overpressure that develops beneath a partially crystallized plug of magma. The energy released during the strong explosions has allowed for imaging of Fuego’s shallow conduit, which appears to have migrated west of the summit crater. In summary, Fuego is becoming more gas charged and its summit centered vent is shifting to the west - serious hazard consequences are likely.

Virus purification, detection and removal

The biopharmaceutical industry has a growing demand and an increasing need to improve the current virus purification technologies, especially as more and more vaccines are produced from cell-culture derived virus particles. Downstream purification strategies can be expensive and account for 70% of the overall manufacturing costs. The economic pressure and purification processes can be particularly challenging when the virus to be purified is small, as in our model virus, porcine parvovirus (PPV). Our efforts are focused on designing an easy, economical, scalable and efficient system for virus purification, and we focused on aqueous two-phase systems. Industry acceptable standards for virus vaccine recovery can be as low as 30% due to demand of high final titer, virus transduction inhibitors and presence of empty or defective virus capsids as impurities. We have overcome these shortcomings by recovering a high 64% of infectious virus using an aqueous two-phase system. We used high molecular weight polymer and citrate salt to achieve a good yield and eliminated the major contaminant bovine serum albumin. Viruses are also studied for ensuring pure and safe drinking water. Low pressure microfiltrations are continuously being investigated for water filters as they allow high permeate flux and low fouling. Viruses such as PPV are small enough to pass through the microporous membranes. Control of viruses in water is crucial for public health and we have designed an affinity based membrane filter to capture virus. Nanofibers have a high surface to volume ratio providing a highly accessible surface area for virus adsorption. Chitosan an insoluble, biocompatible and biodegradable polymer was used for adsorbing trimer peptide WRW. About 0.2 μmoles of cysteine terminal WRW peptide was conjugated to amine terminal chitosan using maleimide conjugation chemistry. We achieved 90-99% virus removal from water adjusted to a neutral pH. The virus removal from affinity based chitosan was attributed to electrostatic and hydrophobic driven binding effect.

Stereoselective biotransformation of ketamine in equine liver and lung microsomes

Stereoselectivity has to be considered for pharmacodynamic and pharmacokinetic features of ketamine. Stereoselective biotransformation of ketamine was investigated in equine microsomes in vitro. Concentration curves were constructed over time, and enzyme activity was determined for different substrate concentrations using equine liver and lung microsomes. The concentrations of R/S-ketamine and R/S-norketamine were determined by enantioselective capillary electrophoresis. A two-phase model based on Hill kinetics was used to analyze the biotransformation of R/S-ketamine into R/S-norketamine and, in a second step, into R/S-downstream metabolites. In liver and lung microsomes, levels of R-ketamine exceeded those of S-ketamine at all time points and S-norketamine exceeded R-norketamine at time points below the maximum concentration. In liver and lung microsomes, significant differences in the enzyme velocity (V(max)) were observed between S- and R-norketamine formation and between V(max) of S-norketamine formation when S-ketamine was compared to S-ketamine of the racemate. Our investigations in microsomal reactions in vitro suggest that stereoselective ketamine biotransformation in horses occurs in the liver and the lung with a slower elimination of S-ketamine in the presence of R-ketamine. Scaling of the in vitro parameters to liver and lung organ clearances provided an excellent fit with previously published in vivo data and confirmed a lung first-pass effect.

Modifying peripheral IV catheters with side holes and side slits results in favorable changes in fluid dynamic properties during the injection of iodinated contrast material

OBJECTIVE: The purpose of this study was to compare a standard peripheral end-hole angiocatheter with those modified with side holes or side slits using experimental optical techniques to qualitatively compare the contrast material exit jets and using numeric techniques to provide flow visualization and quantitative comparisons. MATERIALS AND METHODS: A Schlieren imaging system was used to visualize the angiocatheter exit jet fluid dynamics at two different flow rates. Catheters were modified by drilling through-and-through side holes or by cutting slits into the catheters. A commercial computational fluid dynamics package was used to calculate numeric results for various vessel diameters and catheter orientations. RESULTS: Experimental images showed that modifying standard peripheral IV angiocatheters with side holes or side slits qualitatively changed the overall flow field and caused the exiting jet to become less well defined. Numeric calculations showed that the addition of side holes or slits resulted in a 9-30% reduction of the velocity of contrast material exiting the end hole of the angiocatheter. With the catheter tip directed obliquely to the wall, the maximum wall shear stress was always highest for the unmodified catheter and was always lowest for the four-side-slit catheter. CONCLUSION: Modified angiocatheters may have the potential to reduce extravasation events in patients by reducing vessel wall shear stress.

Concentration-dependent isoflurane effects on withdrawal reflexes in pigs and the role of the stimulation paradigm

In this prospective two-phase experimental trial, 10 pigs were anaesthetized twice with isoflurane only. In the first phase, the individual minimum alveolar concentration (MAC) was determined and in the second phase the effects on withdrawal reflexes of increasing end-tidal isoflurane concentrations (from 1.6% to 2.8%) were assessed. Single, 10 and 60 repeated electrical stimulations were used to evoke withdrawal reflexes which were recorded and quantified by electromyography. Recruitment curves for reflex amplitude for increasing stimulation intensities and isoflurane concentrations were constructed. Isoflurane MAC was 1.9+/-0.3%. Reflexes evoked by repeated stimulation were suppressed at isoflurane concentrations significantly higher than those which suppressed complex movements during MAC determination (P=0.014 and P=0.006 for 10 and 60 repeated stimuli respectively). Isoflurane up to 2.8% was still not able to abolish reflex activity evoked by repeated stimulations in all pigs. Single stimulation reflexes were suppressed at significantly lower concentrations than repeated stimulation reflexes (P=0.008 and P=0.004 for 10 and 60 repeated stimuli, respectively). Reflex amplitude was significantly correlated with isoflurane concentration (P<0.001, r=-0.85) independent of the individual MAC. The findings indicate that the level at which isoflurane suppresses withdrawal reflexes is dependent on the stimulation paradigm (single vs. repeated electrical stimulation), and there is limited value in expressing reflex withdrawal suppression in terms of MAC as purposeful and reflex movements are independently affected by isoflurane in individual animals.

Safety and tolerability of slow-release oral morphine versus methadone in the treatment of opioid dependence

Opioid substitution treatment (OST) for opioid dependence may be limited by adverse events (AEs). Increasing the range of therapeutic options optimizes outcomes and facilitates patient management. An international, multi-center, two-phase study investigated the efficacy and safety of slow-release oral morphine (SROM) versus methadone in patients receiving methadone therapy for opioid dependence. In phase 1 (two way cross-over, 11 weeks each period) patients were randomized to SROM or methadone oral solution. In phase 2 (25 weeks), patients continued treatment with SROM (group A) or switched from methadone to SROM (group B). In total, 211 out of 276 completed phase 1 and 198 entered phase 2 (n = 95 group A, n = 103 group B). Treatment with both SROM and methadone was well tolerated. However, the mean QTc-interval associated with methadone was significantly longer than that under SROM. Higher treatment satisfaction, fewer cravings for heroin, and lower mental stress were reported with SROM. This study adds a significant further weight of evidence that SROM is an effective and well tolerated long-term maintenance treatment for opioid dependence with a beneficial risk profile compared to methadone regarding cardiac effects and supports its clinical utility.

Poly(ethylene oxide)-b-poly(3-sulfopropyl methacrylate) block copolymers for calcium phosphate mineralization and biofilm inhibition.

Poly(ethylene oxide) (PEO) has long been used as an additive in toothpaste, partly because it reduces biofilm formation on teeth. It does not, however, reduce the formation of dental calculus or support the remineralization of dental enamel or dentine. The present article describes the synthesis of new block copolymers on the basis of PEO and poly(3-sulfopropyl methacrylate) blocks using atom transfer radical polymerization. The polymers have very large molecular weights (over 10(6) g/mol) and are highly water-soluble. They delay the precipitation of calcium phosphate from aqueous solution but, upon precipitation, lead to relatively monodisperse hydroxyapatite (HAP) spheres. Moreover, the polymers inhibit the bacterial colonization of human enamel by Streptococcus gordonii, a pioneer bacterium in oral biofilm formation, in vitro. The formation of well-defined HAP spheres suggests that a polymer-induced liquid precursor phase could be involved in the precipitation process. Moreover, the inhibition of bacterial adhesion suggests that the polymers could be utilized in caries prevention.

Adjuvant exemestane with ovarian suppression in premenopausal breast cancer.

BACKGROUND Adjuvant therapy with an aromatase inhibitor improves outcomes, as compared with tamoxifen, in postmenopausal women with hormone-receptor-positive breast cancer. METHODS In two phase 3 trials, we randomly assigned premenopausal women with hormone-receptor-positive early breast cancer to the aromatase inhibitor exemestane plus ovarian suppression or tamoxifen plus ovarian suppression for a period of 5 years. Suppression of ovarian estrogen production was achieved with the use of the gonadotropin-releasing-hormone agonist triptorelin, oophorectomy, or ovarian irradiation. The primary analysis combined data from 4690 patients in the two trials. RESULTS After a median follow-up of 68 months, disease-free survival at 5 years was 91.1% in the exemestane-ovarian suppression group and 87.3% in the tamoxifen-ovarian suppression group (hazard ratio for disease recurrence, second invasive cancer, or death, 0.72; 95% confidence interval [CI], 0.60 to 0.85; P<0.001). The rate of freedom from breast cancer at 5 years was 92.8% in the exemestane-ovarian suppression group, as compared with 88.8% in the tamoxifen-ovarian suppression group (hazard ratio for recurrence, 0.66; 95% CI, 0.55 to 0.80; P<0.001). With 194 deaths (4.1% of the patients), overall survival did not differ significantly between the two groups (hazard ratio for death in the exemestane-ovarian suppression group, 1.14; 95% CI, 0.86 to 1.51; P=0.37). Selected adverse events of grade 3 or 4 were reported for 30.6% of the patients in the exemestane-ovarian suppression group and 29.4% of those in the tamoxifen-ovarian suppression group, with profiles similar to those for postmenopausal women. CONCLUSIONS In premenopausal women with hormone-receptor-positive early breast cancer, adjuvant treatment with exemestane plus ovarian suppression, as compared with tamoxifen plus ovarian suppression, significantly reduced recurrence. (Funded by Pfizer and others; TEXT and SOFT ClinicalTrials.gov numbers, NCT00066703 and NCT00066690, respectively.).