The burden in chronic prurigo: patients with chronic prurigo suffer more than patients with chronic pruritus on non-lesional skin: A comparative, retrospective, explorative statistical analysis of 4,484 patients in a real-world cohort

BACKGROUND

Chronic prurigo (CPG) is known as a high burdensome disease characterized by severe pruritus and multiple pruriginous lesions. Interestingly, the disease-specific burden is not well established and there are no data which compare the impact of CPG with chronic pruritus (CP) on non-lesional skin (CP-NL).

OBJECTIVES

To address this issue, we analysed datasets from 4484 patients with either CPG or CP-NL.

METHODS

Demographic medical data and additional information collected by validated patient reported outcome tools were analysed. The visual analogue scale and numerical rating scale (NRS) were used for assessing the pruritus intensity, the ItchyQoL for patients' quality of life, the Hospital Anxiety and Depression Scale and the Patient Needs Questionnaire' as a part of Patient Benefit Index for Pruritus for measuring the importance of 27 patient needs in terms of treatment goals. The Neuroderm questionnaire was used to assess the history of pruritus characteristics and the impact on sleep.

RESULTS

Patients with CPG suffered longer and with a higher intensity from pruritus [NRS worst the last 24 h, CPG 6.0 (4.0;8.0) vs. CP-NL 3.0 (5.0;7.0), P < 0.001]. In them, pruritus occurred more often and the whole day and night which led to more loss in sleeping hours [CPG 3.0 h (2.0;4.0) vs. CP-NL 2.0 h (1.0;4.0), P < 0.001]. Patients with CPG showed higher scores for depression [HADS-D, CPG 6.0 (3.0;10.0) vs. CP-NL 5.0 (2.0;8.0), P < 0.001], more impaired quality of life [ItchyQol; CPG: 72.6 (61.6;83.6) vs. CP-NL 59.4 (48.4;70.4), P < 0.001] and higher weighted needs in the predefined treatment goals.

DISCUSSION

Not only the presence of severe pruritus and pruriginous lesions but also sleep disorders and other mental symptoms may contribute to a higher burden in patients with CPG when compared with patients with CP-NL.

Central hemodynamic effects in patients with chronic coronary syndrome after long-term ivabradine therapy

Objectives

We sought to assess central hemodynamic effects in 23 patients (18 male, 5 female) with a resting heart rate (HR) of ≥70 beats per minute (bpm) and chronic coronary syndrome after long-term ivabradine therapy (6 months) by cardiac magnetic resonance (CMR).

Methods and results

In a cross-over design, all patients were treated with ivabradine (Iva, 7.5 mg bid) and placebo for 6 months each. CMR was performed three times (at baseline, after 6 and 12 months) to determine left ventricular (LV) function parameters, including end-diastolic and end-systolic volumes (EDVi, ESVi), stroke volume (SVi) and ejection fraction (EF) as well as volume-time curve (VTC) parameters, including peak ejection rate (PER), peak ejection time (PET), peak filling rate (PFR), peak filling time from ES (PFT), peak ejection rate normalized to EDV (PER/EDV) and peak filling rate normalized to EDV (PFR/EDV) for global LV function (systolic and diastolic) assessment. Flow measurements of the ascending aorta were performed with phase-contrast velocity imaging.

Treatment with Iva led to a HR reduction of 11.4 bpm (Iva 58.8±8.2 bpm vs placebo 70.2±8.3 bpm, p&lt;0.0001).There was no difference in LVEF (%) (Iva 57.4±11.2 vs placebo 53.0±10.9, p=0.18), EDVi or ESVi. SVi (ml/m2) remained comparatively unchanged after long-term treatment with Iva (Iva 40.6±9.6 vs placebo 35.7±8.8, p=0.08). VTC parameters reflecting systolic LV function (PER, PET) were unaffected by Iva, while both PFR and PFR/EDV were significantly increased (PFR/EDV (s-1) Iva 2.4±0.4 vs placebo 2.1±0.4, p=0.03). There was a trend to longer PFT during treatment with Iva, though not reaching statistical significance. Medium and maximum aortic flow were not affected by treatment with Iva, while mean velocity (cm/s) was significantly reduced (Iva 6.7±2.7 vs placebo 9.0±3.4, p=0.01). Aortic flow parameters were correlated to aortic distensibility (AD), as surrogate parameter for arterial stiffness. AD was significantly correlated to both aortic flow and flow velocity, whereby mean velocity showed the strongest correlation to AD (r=0.74 [0.61 to 0.83], p&lt;0.0001).

Conclusion

Systolic LV function was unaffected by treatment with Iva, while the filling during diastole was significantly improved. While medium and maximum aortic flow were not affected by Iva, mean velocity was significantly reduced. Aortic distensibility as surrogate parameter for arterial stiffness was significantly correlated to aortic mean velocity. This study confirms the underlying physiological principle of the If-current inhibitor Ivabradine.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): This work was supported by the Deutsche Herzstiftung (German Heart Foundation) (F/14/11 to F.C.) and the Deutsche Forschungsgemeinschaft (DFG KFO 196 to U.L., S.H.S and M.B. and SFB TTR 219, S-01 to M.B.). The Saarland University Medical Center has received an unrestricted grant from Servier (France).

Scanning acoustic microscopy investigation of weld lines in injection-molded parts manufactured from industrial thermoplastic polymer

Scanning acoustic microscopy (SAM) is used to characterize welds in a thermoplastic polymer (ABS) manufactured by injection-molding, particularly at the locations of weld-lines known to form as unavoidable significant defects. Acoustic micrographs obtained at 420 MHz clearly resolve the weld lines with morphological deformations and microelastic heterogenity. This is also where terahertz (THz) measurements, carried out in support of the SAM study, reveal enhanced birefringence corresponding to the location of these lines enabling verification of the SAM results. Rayleigh surface acoustic waves (RSAW), quantified by V(z) curves (with defocusing distance of 85 μm), are found to propagate slower in regions close to the weld lines than in regions distant from these lines. The discrepancy of about 100 m/s in the velocity of RSAW indicates a large variation in the micro-elastic properties between areas close to and distant from the weld lines. The spatial variations in velocity (V_R) of RSAWs indicate anisotropic propagation of the differently polarized ultrasonic waves.

Introducing the CSP Analyzer: A novel Machine Learning-based application for automated analysis of two-dimensional NMR spectra in NMR fragment-based screening

NMR-based screening, especially fragment-based drug discovery is a valuable approach in early-stage drug discovery. Monitoring fragment-binding in protein-detected 2D NMR experiments requires analysis of hundreds of spectra to detect chemical shift perturbations (CSPs) in the presence of ligands screened. Computational tools are available that simplify the tracking of CSPs in 2D NMR spectra. However, to the best of our knowledge, an efficient automated tool for the assessment and binning of multiple spectra for ligand binding has not yet been described. We present a novel and fast approach for analysis of multiple 2D HSQC spectra based on machine-learning-driven statistical discrimination. The CSP Analyzer features a C# frontend interfaced to a Python ML classifier. The software allows rapid evaluation of 2D screening data from large number of spectra, reducing user-introduced bias in the evaluation. The CSP Analyzer software package is available on GitHub https://github.com/rubbs14/CSP-Analyzer/releases/tag/v1.0 under the GPL license 3.0 and is free to use for academic and commercial uses.

Cells Undergo Major Changes in the Quantity of Cytoplasmic Organelles after Uptake of Gold Nanoparticles with Biologically Relevant Surface Coatings

Here, we use cryo soft X-ray tomography (cryo-SXT), which delivers 3D ultrastructural volumes of intact cells without chemical fixation or staining, to gain insight about nanoparticle uptake for nanomedicine. We initially used dendritic polyglycerol sulfate (dPGS) with potential diagnostic and therapeutic applications in inflammation. Although dPGS-coated gold nanoparticle (dPGS-AuNP) uptake followed a conventional endocytic/degradative pathway in human lung epithelial cell lines (A549), with cryo-SXT, we detected ∼5% of dPGS-AuNPs in the cytoplasm, a level undetectable by confocal light microscopy. We also observed ∼5% of dPGS-AuNPs in a rarely identified subcellular site, namely, lipid droplets, which are important for cellular energy metabolism. Finally, we also found substantial changes in the quantity of cytoplasmic organelles upon dPGS-AuNP uptake over the 1-6 h incubation period; the number of small vesicles and mitochondria significantly increased, and the number of multivesicular bodies and the number and volume of lipid droplets significantly decreased. Although nearly all organelle numbers at 6 h were still significantly different from controls, most appeared to be returning to normal levels. To test for generality, we also examined cells after uptake of gold nanoparticles coated with a different agent, polyethylenimine (PEI), used for nucleic acid delivery. PEI nanoparticles did not enter lipid droplets, but they induced similar, albeit less pronounced, changes in the quantity of cytoplasmic organelles. We confirmed these changes in organelle quantities for both nanoparticle coatings by confocal fluorescence microscopy. We suggest this cytoplasmic remodeling could reflect a more common cellular response to coated gold nanoparticle uptake.

[Is the discipline associated with self-confidence in handling rational antibiotic prescription? : Results from the MR2 study in German hospitals]

BACKGROUND

Besides public awareness and specialist knowledge and training of physicians, their self-confidence plays a key role for clinical decision-making in the respective area.

OBJECTIVE

This exploratory study investigated the influence of the discipline on differences in self-confidence in dealing with antibiotics and in the self-rated knowledge.

METHODS

In 2015 the multi-institutional reconnaissance of practice with multiresistant bacteria (MR2) questionnaire containing items on antibiotic prescription and multiresistant pathogens was sent out to 1061 physicians working in departments for internal medicine, general surgery, gynecology and obstetrics and urology. In 2017 a similar MR2 survey was sent to 1268 specialist and assistant physicians in anesthesiology in Germany. Besides demographic data 4 items on self-confidence in the use of antibiotic treatment and 11 items concerning self-rated knowledge about rational antibiotic therapy and multiresistant pathogens were included in the present analysis. Logistic regression analysis, the χ²-test and the Kruskal-Wallis test were used for statistical analysis of the influence of the discipline on these items.

RESULTS

The response rates were 43% (456 out of 1061) from the non-anesthetists and 56% (705 out of 1268) from the anesthetists. Of the non-anesthetists 44% and 57% of the anesthetists had had no advanced training on antibiotic stewardship during the year before the study. In the overall analysis anesthetists (mean±SD: 2.53±0.54) were significantly less self-confident about antibiotics than colleagues from other departments (internal medicine: 3.10±0.50, general surgery: 2.97±0.44, gynecology and obstetrics: 3.12±0.42 and urology: 3.15±0.44) in the unadjusted (all p<0.001) and adjusted comparison. The analysis of self-rated knowledge about rational antibiotic prescription showed similar results. Senior consultant status and advanced training in infectiology were significantly associated with self-confidence and self-rated knowledge about antibiotics.

CONCLUSION

Anesthetists showed significantly less self-confidence in dealing with antibiotics than colleagues from other disciplines. Advanced training on a rational prescription of antibiotics was associated with a greater self-confidence, so that the implementation of compulsory courses on rational antibiotic stewardship in the respective residency curriculum needs to be considered.

Risk detection in patients with obstructive sleep apnea syndrome based on cardiovascular time series analysis

Obstructive sleep apnea represents the most common form of sleep-disordered breathing and has a high prevalence in patients with cardiovascular disease. Disturbed sleep is a potential risk factor for cardiovascular disorders such as arterial hypertension, cardiac ischemia, sudden cardiac death, and stroke. In this study we investigated polysomnographic records and analyzed the ECG, plethysmogram, respiration and SpO2 time series during wakefulness (WK), NREM, and REM sleep stages applying variability and coupling analyses methods. We enrolled 55 patients with obstructive sleep apnea syndrome (OSAS) and 29 healthy control subjects (CON: 45.9±14.9 years, 21 male) in this study. OSAS patients were subdivided into a low- and high-risk group (LR: 50.8±14.1 years, n=29, 21 male; HR: 57.2±13.4 years, n=26, 19 male) based on the Apnea-Hypopnea Index (AHI) (CON: 0-5 AHI, LR: 5-15 AHI, HR: >15 AHI). We could demonstrate the presence of an altered autonomic function in OSAS patients, differing from healthy controls. This altered autonomic function was mainly based on heart rate-, respiratory-, SpO2- and plethysmogram variability and their couplings. The discriminant analysis showed that the optimal set consisting of two autonomic indices revealed a high classification power (ACC=86.7%, AUC=90.3%, SENS=89.5% and SPEC=84.6%) when comparing low-risk and high-risk OSAS patients during WK. These results were slightly improved when analyzing REM sleep stages. Based on these results it seems to be possible to perform optimal risk stratification for OSAS patients based on autonomic indices. Based on our findings it is possible to differentiate between high-risk OSAS patient and low-risk OSAS patient at an early stage and in a promising manner allowing to set up therapy strategies for those patients in an early stage.

The German version of the Critical-Care Pain Observation Tool for critically ill adults : A prospective validation study

BACKGROUND

The implementation of the Critical-Care Pain Observation tool (CPOT) in intensive care units (ICU) has been associated with more frequent pain assessments, a reduced number of complications, and improved administration of analgesics and sedatives. So far no German translation exists. Translating this tool into foreign languages requires further validation testing.

OBJECTIVE

The aim of this prospective observational validation study was to translate the original version of the CPOT according to scientific principles for translation and to establish the validity and reliability of the German translation of CPOT for critically ill adult patients.

MATERIAL AND METHODS

A total of 292 cardiac surgery patients from 2 ICUs of 2 German university teaching hospitals were included (114 patients at center 1 and 178 patients at center 2). Of the included patients 22.6% were female and 76.4% were male with a mean age of 68.5 years ±9.3 SD. Pain was evaluated with the CPOT, the Bhavioral Pain Scale (BPS) and with the Numeric Rating scale (NRS) at three time points (1. intubated + sedated, 2. intubated + awake, 3. extubated + awake) at rest and during nociceptive stimulus (positioning). Assessments were made separately by trained physicians and nursing staff.

RESULTS

Good results for interrater reliability and internal consistency could be demonstrated (weighted Cohen's kappa of 0.73, Cronbach's coefficient alpha of 0.8). Spearman correlation between CPOT and NRS was moderate but significant. The receiver operating characteristic (ROC) analysis to obtain optimal thresholds of CPOT to detect pain revealed different results during rest and stimulus and in intubated and extubated patients.

CONCLUSION

The validated German CPOT translation is a reliable tool for pain assessment in cardiac ICU patients in the absence of patients' ability for self-reporting. The use of this German version of CPOT now allows a better international comparability of corresponding data in future studies.

Optical Nanosensing of Lipid Accumulation due to Enzyme Inhibition in Live Cells

Drugs that influence enzymes of lipid metabolism can cause pathological accumulation of lipids in animal cells. Here, gold nanoparticles, acting as nanosensors that deliver surface-enhanced Raman scattering (SERS) spectra from living cells provide molecular evidence of lipid accumulation in lysosomes after treatment of cultured cells with the three tricyclic antidepressants (TCA) desipramine, amitryptiline, and imipramine. The vibrational spectra elucidate to great detail and with very high sensitivity the composition of the drug-induced lipid accumulations, also observed in fixed samples by electron microscopy and X-ray nanotomography. The nanoprobes show that mostly sphingomyelin is accumulated in the lysosomes but also other lipids, in particular, cholesterol. The observation of sphingomyelin accumulation supports the impairment of the enzyme acid sphingomyelinase. The SERS data were analyzed by random forest based approaches, in particular, by minimal depth variable selection and surrogate minimal depth (SMD), shown here to be particularly useful machine learning tools for the analysis of the lipid signals that contribute only weakly to SERS spectra of cells. SMD is used for the identification of molecular colocalization and interactions of the drug molecules with lipid membranes and for discriminating between the biochemical effects of the three different TCA molecules, in agreement with their different activity. The spectra also indicate that the protein composition is significantly changed in cells treated with the drugs.

X-ray tomography shows the varying three-dimensional morphology of gold nanoaggregates in the cellular ultrastructure

The processing of nanoparticles inside eukaryotic cells is a key step in many wanted and unwanted nano-bio-interactions. In order to understand the effects and functions of the intracellular aggregates that are formed, their properties and their interaction with the biological matrix must be characterized. High quality synchrotron soft X-ray tomography (SXT) data were obtained from cells containing gold nanoparticles that are commonly applied as tools for optical probing or drug delivery. 3D volume rendering of both cellular organelles and the nanoparticle aggregates of different sizes in the intact cells of two cell lines reveals variation in localization, size, shape and density of the intracellular gold nanoaggregates. The dependence of such variation on incubation time and cell type, as well as on the influence of pre-aggregation of primary nanoparticles is shown. The SXT results provide a detailed picture of intracellular aggregation and will improve the design of safe and efficient nanoparticle platforms for biomedical use.

Soft X-ray nanoscale imaging using a sub-pixel resolution charge coupled device (CCD) camera

A sub-pixel 16 bit charge coupled device camera featuring superresolution for the soft X-ray regime is presented. Superresolution images (SRIs) are reconstructed from a set of 4 × 4 individual low-resolution images that are recorded for different sub-pixel shifts of the detector. SRIs have a 1.3 times higher resolution than individual low-resolution images which is close to the maximum achievable enhancement factor of about 1.5 in the X-ray regime under ideal conditions. To characterize this camera and demonstrate its potential, an X-ray microscope setup is used to image different objects at different photon energies.

Position Statement: Linear prurigo is a subtype of chronic prurigo

BACKGROUND

Chronic prurigo (CPG) is a distinct disease characterized by chronic pruritus, history and/or signs of prolonged scratching and multiple pruriginous lesions. It may present with various clinical manifestations, including papules, nodules, plaques or umbilicated lesions. Some patients with chronic pruritus show pruriginous linear and scaring scratch lesions (LSSL) and it is unclear whether these lesions belong to the spectrum of CPG.

OBJECTIVE

To achieve a consensus on the classification of pruriginous LSSL and establish criteria to differentiate them from similar appearing conditions of different nature.

METHODS

Members of the Task Force Pruritus (TFP) of the European Academy of Dermatology and Venereology participated in the consensus conference, discussing representative clinical cases. Using the Delphi method, consensus was reached when ≥75% of members agreed on a statement.

RESULTS

Twenty-one members of the TFP with voting rights participated in the meeting. It was consented that LSSL occurs due to chronic pruritus and prolonged scratching, and share common pathophysiological mechanisms with CPG. LSSL were thus considered as belonging to the spectrum of CPG and the term 'linear prurigo' was chosen to describe this manifestation.

CONCLUSION

Considering linear prurigo as belonging to the spectrum of CPG has important clinical implications, since both the diagnostic and therapeutic approach of these patients should be performed as recommended for CPG. Importantly, linear prurigo should be differentiated from self-inflicted skin lesions as factitious disorders or skin picking syndromes. In the latter, artificial manipulation rather than pruritus itself leads to the development of cutaneous lesions, which can show clinical similarities to linear prurigo.

Relations between a standardized experimental stressor and cutaneous sensory function in patients with chronic pruritus and healthy controls: an experimental case-control study

Background

While chronic pruritus (CP) is a frequent symptom, many aspects of its underlying pathophysiological mechanisms still need elucidation. Research on sensory cutaneous function and on the influence of stress has been conducted mainly in patients with atopic dermatitis but is lacking for patients with CP.

Objective

To assess whether a standardized social stressor influences cutaneous sensory function in patients with CP in comparison with healthy controls (HC).

Methods

Case–control study; 33 CP and 30 HC were submitted to the standardized quantitative sensory testing protocol before and after the Trier Social Stress Test and 1 h later. Intraepidermal nerve fibre density (IENFD) was determined.

Results

Mechanical pain sensitivity and mechanical detection thresholds were significantly higher in CP than in HC, and mechanical detection thresholds increased more in CP than in HC over the three measurements. In both groups, cold pain threshold increased and heat pain threshold decreased from before to after the stress test and remained constant 1 h later. Only in CP, almost all QST tests induced at least a small amount of pruritus, which was not significantly altered by the stress test. IENFD in pruritic skin was significantly reduced in CP when compared to healthy controls.

Conclusion

Peripheral thermal sensory function was not altered in CP despite reduced IENFD in lesional skin, but we could demonstrate central sensitization processes specifically in CP and influences of an acute stressor inducing more sensitivity to thermal pain in both groups.

Characterization of degeneration phenomena in lithium-ion batteries by combined microscopic techniques

The application of detector strategies in scanning electron microscopy (SEM) correlated with computer tomography (CT) and light microscopy (LM) delivered unique new insights in degeneration effects of lithium-ion batteries. There we exemplary studied reference, cycled and storage cells. High-resolution SEM permit to visualize a coating on top of the cathode material of the treated cells for the first time, which also connects the conductive additives and battery active material. This confirms the assumption of a solid permeable interface on top of the cathode. The detection of low-loss reflected backscattered electrons for energies beyond 3 keV increases the available spatial resolution for material contrast. This offered the opportunity to address the atomic number of precipitates in the nm range inside the coating to be above carbon and below Li_1-x(Ni_1/3Mn_1/3Co_1/3)O₂ (NMC). Applying voltage contrast enables to show the difference in electronic conductivity of plate-like features on top of the cycled cell anode, most likely lithium plating. Cross sectional images of the anode delivered a significant change of the surficial-area morphology for the treated cells with increasing porosity. Precipitates were detected on top of the separator foil. An increment in thickness of the entire treated cells by computer tomography was found, which can be explained by the alteration of the anode, separator and cathode.

From SOMDA to application - integration strategies in the OR.NET demonstration sites

The effective development and dissemination of the open integration for the next generation of operating rooms require a comprehensive testing environment. In this paper, we present the various challenges to be addressed in demonstration applications, and we discuss the implementation approach, the foci of the demonstration sites and the evaluation efforts. Overall, the demonstrator setups have proven the feasibility of the service-oriented medical device architecture (SOMDA) and real-time approaches with a large variety of example applications. The applications demonstrate the potentials of open device interoperability. The demonstrator implementations were technically evaluated as well as discussed with many clinicians from various disciplines. However, the evaluation is still an ongoing research at the demonstration sites. Technical evaluation focused on the properties of a network of medical devices, latencies in data transmission and stability. A careful evaluation of the SOMDA design decisions and implementations are essential to a safe and reliable interoperability of integrated medical devices and information technology (IT) system in the especially critical working environment. The clinical evaluation addressed the demands of future users and stakeholders, especially surgeons, anesthesiologists, scrub nurses and hospital operators. The opinions were carefully collected to gain further insights into the potential benefits of the technology and pitfalls in future work.

[Imaging and biopsy of soft tissue tumors]

Soft tissue tumors represent a special challenge in interdisciplinary cooperation. Malignant tumors require a multimodal therapy concept so that patient treatment in a specialized tumor center is recommended. The task of the surgeon in close cooperation with the radiologist is the resection of the tumor in sano with the required safety margin. The aim of diagnostic imaging is to describe the primary expansion of the tumor size and a possible tumor infiltration of adjacent compartments. The most important diagnostic imaging for this purpose is magnetic resonance imaging (MRI), especially T1-weighted fat-suppressed gadolinium-enhanced sequences. Together with T2-weighted sequences a reliable differentiation between necrosis and vital tumor tissue is possible, which enables a targeted biopsy of vital tumor tissue. For the differentiation between benign and malignant soft tissue tumors and for determination of histological differentation a core needle biopsy, either computer tomography-guided or under sonographic control and increasingly more by MRI guidance, is currently the gold standard in most tumor centers. A representative biopsy from vital tumor tissue leads to the diagnosis with a very high degree of certainty.