Sequentially based analysis versus image based analysis of Intima Media Thickness in common carotid arteries studies - do major IMT studies underestimate the true relations for cardio- and cerebrovascular risk?

Background

Image-based B-mode ultrasound has gained popularity in major studies as a non-invasive method of measuring cardio- and cerebrovascular risk factors. However, none of the major studies appears to have paid sufficient attention to the variation in end diastolic wall process. By using sequentially based analyses (SBA) of Intima-Media Thickness (IMT), the general purpose of this study was to show that the current image based (ECG tracked) analysis (IBA) has some major variations and might underestimate the true relations for cardiovascular events and stroke for IMT measurement.

Method

The study group consisted of 2500 healthy male subjects aged between 35 to 55 years. 4 sequences (300 images) were analyzed per subject. 750,000 images were analysed throughout the course of this study.

Results

IBA showed significantly lower mean, maximal, and minimal values for IMT in CCA than for SBA. The correlation analysis between IBA and SBA with the cardio- and cerebrovascular risk factors showed a higher correlation of SBA for all risk factors. The Pearson coefficient was 0.81, p < 0.01, for SBA versus Framingham CHD risk level (FCRL) and 0.49, p = 0.01, for IBA versus FCRL.

Conclusion

IBA did not measure the true maximal values of the IMT in this study. Together with the correlation analysis, this indicates that IBA might underestimate the true relations for IMT and risk factors.

REMOVED: Comparing the reproducibility of intima-media thickness measurements using spectral analysis

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[Pharmacotherapy of elderly patients]

There is a complex interaction between age-driven changes in physiology and functional limitations in the elderly, which influences the pharmacokinetics, pharmacodynamics and management of drug therapy. Another frequent characteristic is multimorbidity, which results in polypharmacy and is a major cause of adverse drug reactions due to drug-drug interactions. Furthermore there are special risks in the elderly, which may alter the risk-benefit analysis of drug therapy and renal impairment, falls and delirium are of particular significance. These factors are discussed in detail and preventive strategies are given to optimize drug therapy in this population. Furthermore, the risks of frequently prescribed drugs and drugs bearing special risks in the elderly are outlined.

Loss-of-function mutations in the filaggrin gene: no contribution to disease susceptibility, but to autoantibody formation against citrullinated peptides in early rheumatoid arthritis

OBJECTIVES

Autoantibody formation to citrullinated (pro)filaggrin has proven to be a highly specific serological marker for rheumatoid arthritis (RA). To test the potential relevance of mutations of the filaggrin (FLG) gene for disease susceptibility and elicitation of humoural autoimmunity in RA, a case-control association study of three loss-of-function FLG variants was performed.

METHODS

DNA was obtained from 282 patients with early RA (mean disease duration: 6.5 months) and from 376 control individuals. Three loss-of-function variants of the FLG gene (*R501X, *2282del4 and *3702del1) were genotyped.

RESULTS

No significant differences in genotype frequencies were observed between control probands and the population of RA patients. The FLG*3702del1 allele was not identified in any of the patients nor controls, and none of the probands was homozygous or compound heterozygous. In the RA cohort, heterozygous carriers of either of the FLG variants exhibited a significantly elevated prevalence of autoantibodies to citrullinated peptides (CCP-2) (80%) compared to non-carriers (51.9%) (p = 0.018, odds ratio: 3.71 (1.20-11.46)).

CONCLUSIONS

The investigated FLG variants do not confer an overall risk for the development of RA. However, loss-of-function mutations in the FLG gene may contribute to the development of humoural autoimmunity, targeting citrullinated determinants in early RA.

Prävention unerwünschter Arzneimittelwirkungen bei älteren Patienten

Adverse drug reactions are among the most common adverse events and a significant cause of preventable morbidity and mortality. As multimorbidity and polypharmacy are frequent in this population, the elderly are at special risk for adverse drug events, although the calendar age has not been proved as independent risk factor in this context. In particular falls and delirium are clinically significant and typical adverse drug events in the elderly. In this review mechanisms and factors which determine adverse drug re actions are described, and possible strategies for an effective prevention are given. This covers pharmacokinetic, pharmacogenetic and pharmacodynamic aspects as well as factors influencing individual adherence to drug therapy. A significant portion of adverse drug reaction may be prevented by a thorough indication and prudent monitoring of pharmacotherapy. Also adherence to pharmacotherapy may be improved by tailored and individual means referring to the patient's needs and expectancies. In the elderly functional limitations such as reduced cognitive abilities, reduced visual acuity and impaired dexterity determine an ineffective pharmacotherapy and medication errors. Hereby these functional limitations are significant predictors of adverse drug events in the context of self-management of pharmacotherapy. Testing of functional abilities as provided in the geriatric assessment is helpful to identify these factors. Among altered pharmacokinetic factors in the elderly, reduced renal function is most important to avoid overdosage. Although a precise measurement of renal function is not possible in a bed-side manner, an estimation of actual renal function utilizing estimation-formulas should always take place.

Antileukoproteinase protects against hepatic inflammation, but not apoptosis in the response of D-galactosamine-sensitized mice to lipopolysaccharide

BACKGROUND AND PURPOSE

There is major evidence for the strong bi-directional interrelation of parenchymal cell apoptosis and leukocyte accumulation and inflammation in acute liver injury. Therefore, the aim of this in vivo study was to investigate the anti-apoptotic and anti-inflammatory potential of antileukoproteinase (ALP) in a murine model of acute liver failure.

EXPERIMENTAL APPROACH

C57BL/6J mice were given galactosamine (D-GalN) and E. coli lipopolysaccharide (LPS) followed by administration of saline or ALP. Besides survival rate, hepatic tissue damage and inflammatory response were analyzed by intravital fluorescence microscopy 6 hours after treatment. In addition, immunohistochemical analysis of NFkappaB-p65 and hepatocellular apoptosis, plasma levels of AST/ALT, TNF-alpha and IL-10 were determined.

KEY RESULTS

Administration of D-GalN/LPS provoked hepatic damage, including marked leukocyte recruitment and microvascular perfusion failure, as well as hepatocellular apoptosis and enzyme release. NFkappaB-p65 became increasingly detectable in hepatocellular nuclei, accompanied by a rise of TNF-alpha and IL-10 plasma levels. ALP markedly reduced intrahepatic leukocyte accumulation, nuclear translocation of NFkappaB and plasma levels of TNF-alpha and IL-10. Moreover, liver enzyme levels indicated the absence of necrotic parenchymal cell death. In contrast, ALP failed to block both apoptosis and caspase-3 levels and the mortality rate of ALP-treated animals was comparable to that of saline-treated mice.

CONCLUSIONS AND IMPLICATIONS

ALP could effectively prevent D-GalN/LPS-associated intrahepatic inflammatory responses by inhibition of NFkappaB activity, but not apoptosis-driven mortality. Thus, a protease-inactivating approach such as application of ALP seems to be inadequate in damaged liver where apoptosis represents the predominant mode of cell death.

[Current therapeutic strategy for rheumatoid arthritis]

The success of the treatment of rheumatoid arthritis depends primarily on early diagnosis. In most cases, basic therapy begins with methotrexate. Depending on the stage and course of the disease (radiographically detected early erosion and/or progression), basic immunosuppressive therapy can be combined or supplemented with cytokine antagonists. Furthermore, for specific indications, several alternative active substances (DMARD monotherapies) are available. Today the goal of therapy is always remission.

Classification of lactic acid bacteria with UV-resonance Raman spectroscopy

UV-resonance Raman spectroscopy is applied as a method for the identification of lactic acid bacteria from yogurt. Eight different strains of bacteria from Lactobacillus acidophilus, L. delbrueckii ssp. bulgaricus, and Streptococcus thermophilus were investigated. At an excitation wavelength of 244 nm signals from nucleic acids and proteins are selectively enhanced. Classification was accomplished using different chemometric methods. In a first attempt, the unsupervised methods hierarchical cluster analysis and principal component analysis were applied to investigate natural grouping in the data. In a second step the spectra were analyzed using several supervised methods: K-nearest neighbor classifier, nearest mean classifier, linear discriminant analysis, and support vector machines.

Identification of single eukaryotic cells with micro-Raman spectroscopy

For a fast identification of eukaryotic cells such as yeast species without a cultivation step it should be possible to perform the investigation on only one single cell. Since yeasts as eukaryotes are heterogeneous and their Raman spectra are therefore dependent on the measuring position, one Raman spectra is not representative of the whole cell. In this contribution we demonstrate the application of average Raman spectra of a line scan over single yeast cells. These average spectra are used for classification with the help of a support vector machine.

Evidence for susceptibility determinant(s) to psoriasis vulgaris in or near PTPN22 in German patients

INTRODUCTION

Variant R620W of protein tyrosine phosphatase non-receptor type 22 (PTPN22) has consistently been reported as a susceptibility factor for several autoimmune diseases. We investigated its role in susceptibility to psoriasis, the relevance of possibly other disease-causing variants, and interdependency of the major risk factor for psoriasis at PSORS1.

METHODS

R620W was tested in a case-control study initially with 375 German patients and then with an enlarged sample of an additional 418 patients. Analyses were extended to linkage disequilibrium (LD) based haplotypes. Potential interaction between risk haplotypes of PTPN22 and the PSORS1 associated risk allele was tested by regression analysis. PTPN22 coding sequence was determined in 20 patients carrying the risk haplotype. Association and regression analysis were also performed in the extended case-control study.

RESULTS

R620W was not associated in either case-control study, while significant association (corrected for multiple testing) with one haplotype (C-4) of the LD block encompassing PTPN22 as well with another haplotype (B-3) within an adjacent telomeric LD block was detected. No evidence for interaction between risk haplotype C-4 and the PSORS1 associated risk allele was found. Sequencing excluded other coding variants within PTPN22 as a basis for association findings. Analysis of the extended study group confirmed association for haplotypes B-3 and C-4 and independence of risk haplotypes C-4 and PSORS1.

DISCUSSION

We exclude a major role of *620W in German psoriasis patients but suggest that other susceptibility determinant(s) within non-coding regions of PTPN22 or its proximity might exist acting independently of the major PSORS1 risk factor.

[Dysphagia after taking an acetaminophen-tablet during oral anticoagulation]

The bezoar is only one example for an urgent indication for endoscopic intervention during oral anticoagulation. Because of the lack of life-threatening indication the endoscopy often is delayed for 1 to 3 days until the International Normalized Ratio (INR) is nearly in normal range. As well as the application of unique guidelines on endoscopy during oral anticoagulation new future oral anticoagulants with lower half-life may help to shorten suffering of patients.

Bedside Estimation of the Glomerular Filtration Rate in Hospitalized Elderly Patients

AIMS

To evaluate the quality of bedside estimation of glomerular filtration rate (GFR) in hospitalized elderly patients.

METHODS

We evaluated common estimators of GFR in 29 women and 32 men aged 60 and older hospitalized in a geriatric ward: creatinine clearance (CCR), the Cockcroft-Gault formula (CG), the modification of diet in renal disease formula (MDRD), Baracskay formula (BAR), and a newly developed formula derived recently by us (GCM). Inulin clearance (CINU) was used to assess GFR. Exclusion criteria were mental illness and urinary incontinence.

RESULTS

According to Bland and Altman accuracy and precision of all estimators were low and there was an underestimation of actual GFR: CCR 38.9 ml/min; CG 39.7 ml/min; MDRD 19.8 ml/min; BAR 34.0 ml/min, and GCM: 24.7 ml/min. The accuracy and precision of all methods were even lower in patients with a GFR of >90 ml/min and in patients with diabetes. In receiver-operating characteristics (ROC analysis) all formulas were superior to serum creatinine and overall MDRD disclosed the best results in detecting both a GFR of <90 ml/min and <60 ml/min.

CONCLUSIONS

In general, estimation errors are large in an acute care setting. However, formula estimation is clearly superior to serum creatinine and CCR. MDRD gave the best results but may be replaced by the more simple CG and GCM formulas, whereas BAR was inferior.

Risk factors of worsening renal function in hospitalized elderly patients

BACKGROUND

Worsening renal function during hospital treatment is a substantial hazard, especially for elderly hospitalized patients. However, data concerning the prevalence and significance of potential risk factors is lacking.

METHODS

All patients admitted during a 6-month observation period to a department of general internal medicine and geriatrics were enrolled. Patients <65 yrs old were excluded. Data was assessed using a retrospective analysis of patient charts; 343/583 charts provided sufficient data for the analysis. Renal function was estimated by the Cockcroft and Gault formula. Worsening renal function was defined as a decline to <66.7% of the initial value. Laboratory values at admission (serum albumin, sodium and potassium), activities of daily living at admission (ADL-score), established medical diagnosis and medication prior to and during in-patient treatment were included in the analysis of potential risk factors.

RESULTS

Renal function worsened in 6.1% of patients included. Risk factors were prescription of loop diuretics, trimethoprim/sulfamethoxazole or non-steroidal antiphlogistics during hospitalization. Hypernatremia, lower serum albumin and lower ADL-score at admission also demonstrated an association with a decline in renal function. However, an established diagnosis of heart failure, diabetes and hypertension were not predictive.

CONCLUSION

Reduced physiological resources to maintain fluid and sodium balance are more predictive for worsening renal function than medical diagnosis alone. ADL-score and serum albumin could help further to identify patients at risk. Non-steroidal antiphlogistics are still frequently prescribed during in-patient treatment, although they are significant risk factors for renal function decline.

Micro-Raman spectroscopic identification of bacterial cells of the genus Staphylococcus and dependence on their cultivation conditions

Microbial contamination is not only a medical problem, but also plays a large role in pharmaceutical clean room production and food processing technology. Therefore many techniques were developed to achieve differentiation and identification of microorganisms. Among these methods vibrational spectroscopic techniques (IR, Raman and SERS) are useful tools because of their rapidity and sensitivity. Recently we have shown that micro-Raman spectroscopy in combination with a support vector machine is an extremely capable approach for a fast and reliable, non-destructive online identification of single bacteria belonging to different genera. In order to simulate different environmental conditions we analyzed in this contribution different Staphylococcus strains with varying cultivation conditions in order to evaluate our method with a reliable dataset. First, micro-Raman spectra of the bulk material and single bacterial cells that were grown under the same conditions were recorded and used separately for a distinct chemotaxonomic classification of the strains. Furthermore Raman spectra were recorded from single bacterial cells that were cultured under various conditions to study the influence of cultivation on the discrimination ability. This dataset was analyzed both with a hierarchical cluster analysis (HCA) and a support vector machine (SVM).

Lack of genetic association of the three more common polymorphisms of CARD15 with psoriatic arthritis and psoriasis in a German cohort

OBJECTIVE

To determine whether the three common independent sequence variants of the putative pleiotropic non-MHC autoimmune gene CARD15 influence disease susceptibility in large German cohorts of patients with psoriatic arthritis and psoriasis vulgaris, before and after stratification to HLA-C.

METHODS

DNA was obtained from 375 patients with psoriatic arthritis, 281 patients with psoriasis vulgaris without joint involvement, and 376 controls. The three variants of the CARD15 gene (R702W, G908R, leu1007fsinsC), and two single nucleotide polymorphisms of the HCR gene (HCR-325, HCR-2327) for HLA-C stratification were genotyped using allelic discrimination Taqman assays.

RESULTS

No significant differences in genotype frequencies were observed between controls and either the psoriatic arthritis or the psoriasis vulgaris patient population, even after stratification to HLA-C in both patient cohorts, or to the type of joint involvement within the psoriatic arthritis group.

CONCLUSIONS

The lack of genetic association between the most common Crohn's disease alleles of the CARD15 gene and psoriatic joint disease on large cohorts of white patients does not support a recently claimed role for CARD15 as the first non-MHC susceptibility gene in the pathogenesis of psoriatic arthritis, but confirms and extends previous studies in the case of psoriasis vulgaris.

Effect of prostaglandin E2, DL-cloprostenol, and prostaglandin E2 in combination with D-cloprostenol on uterine motility during diestrus in experimental cows

Prostaglandin F(2alpha) is used in dairy herd management because of its luteolytic properties and for its direct effect on the myometrium in cows diagnosed with endometritis. Prostaglandin E(2) has a contractile effect on the bovine uterus. In human medicine, prostaglandin E(2) is routinely used to maintain labor and to ripen the cervix. We hypothesized, that a combination of prostaglandin F(2alpha) and prostaglandin E(2) would provoke a long-lasting increase in intrauterine pressure (IUP) and uterine motility as compared to either prostaglandin group. Intrauterine pressure was recorded during the diestrus of eight lactating dairy cows using a transcervically placed intraluminal pressure microtransducer. After recording of physiologic uterine motility for 30min, prostaglandins (DL-cloprostenol, PGE(2), PGE(2) in combination with D-cloprostenol) or placebo were administered, followed by a 2h recording period. Significant differences were found for the area under the curve, the mean amplitude and the intrauterine pressure, whereas the number of pressure waves did not differ significantly among treatments. Peak values for area under the curve and mean amplitude were found during the first 15min for the combination of PGE(2) and D-cloprostenol. During the last 15min of the recording session, area under the curve and mean amplitude were increased only for the combination of PGE(2) and D-cloprostenol as compared to placebo. Although PGF(2alpha) and PGE(2) provoke an increase in intrauterine pressure, only their combination guarantees a significant effect over a 2h recording period.

Individuelle Beratung von Patienten mit Diabetes mellitus im Akutkrankenhaus

BACKGROUND

An increasing number of diagnostic procedures and shortened length of stay impede education for patients with diabetes mellitus attending an acute care unit. Therefore, an individualized approach to patient education may be more suitable.

PATIENTS AND METHODS

The educational needs of inpatients with diabetes attending a department of general internal medicine were analyzed using a structured 5- to 10-minute interview. Within a period of 4 months, all patients with diabetes mellitus referred to the IVth Medical Department (speciality: geriatrics) were screened. Screening took place close to the day of admission. Following the screening interview, the interviewer initiated an individualized diabetes education according to the patient's needs and resources. The screening interview covered clinical data, functional limitations and disabilities, diabetes complications, patient's competence and motivation for further education.

RESULTS

205 patients with diabetes were seen (prevalence: 30.0%). 24 of them were newly diagnosed (prevalence: 3.5%). Overall, the screening revealed remarkable heterogeneity in patients with diabetes mellitus. 45 patients with previously known diabetes denied any diabetes education prior to hospital admission. Shorter diabetes duration, cognitive impairment, and treatment without insulin were significant and independent risk factors for missing diabetes education. Only 17.4% of patients on an insulin regimen prior to hospital admission performed no monitoring of blood glucose at home. Most patients holding their own blood glucose monitoring device performed daily measurements. Finally, 119 lessons of individual diabetes education were initialized in 73 patients (incidence: 17.4% of all admitted patients).

CONCLUSION

Lack of education is common. As heterogeneity of patients with diabetes is striking, diabetes education has to be tailored to the individual needs and resources of the patients attending an acute care unit. Therefore, an individualized approach has proven to be suitable. In this context, a short structured interview is a useful tool for data assessment and scheduling of education lessons.

Todesverlangen?Ergebnisse einer Pilotstudie mit geriatrischen Akutpatienten

Desire for death when expressed by patients is extremely demanding to the geriatric team. In an acute geriatric setting with its high proportion of multi morbid patients, decisions about diagnostic and therapeutic measures as well as decisions about restrictions of therapy have vital consequences. In this context, what is the significance of expressions of desire for death? A growing amount of literature has reported about studies on such questions with terminally ill patients. Studies in the field of acute geriatrics are still missing. In the present explorative pilot study, data of ten patients in an acute geriatric setting were collected within a two-month period. Data comprise various dimensions of the expressions of desire for death, and variables of their medical psychiatric, psychological, and psycho-social context. The dimensions of duration, intensity, and concreteness could be differentiated within the expressions of desire for death. In addition, they were each correlated to different context variables. Intensity was associated with experiences of pain. Subjective well-being and social support were relevant to concreteness. Duration was correlated with depression, hopelessness, experienced stress, and functional health. Physical health did not play a significant role. This means that expressions of desire for death do not only occur in the context of extreme health problems. The study has identified differentiated starting points for better understanding the expressions of desire for death and for better intervention. Further study is necessary to confirm these findings within a longitudinal design.