Results of the performance verification of the CoaguChek XS system

BACKGROUND

This is the first paper reporting a performance verification study of a point-of-care (POC) monitor for prothrombin time (PT) testing according to the requirements given in chapter 8 of the International Organization for Standardization (ISO) 17593:2007 standard "Clinical laboratory testing and in vitro medical devices - Requirements for in vitro monitoring systems for self-testing of oral anticoagulant therapy". The monitor under investigation was the new CoaguChek XS system which is designed for use in patient self testing. Its detection principle is based on the amperometric measurement of the thrombin activity generated by starting the coagulation cascade using a recombinant human thromboplastin.

METHODS

The system performance verification study was performed at four study centers using venous and capillary blood samples on two test strip lots. Laboratory testing was performed from corresponding frozen plasma samples with six commercial thromboplastins. Samples from 73 normal donors and 297 patients on oral anticoagulation therapy were collected. Results were assessed using a refined data set of 260 subjects according to the ISO 17593:2007 standard.

RESULTS

Each of the two test strip lots met the acceptance criteria of ISO 17593:2007 versus all thromboplastins (bias -0.19 to 0.18 INR; >97% of data within accuracy limits). The coefficient of variation for imprecision of the PT determinations in INR ranged from 2.0% to 3.2% in venous, and from 2.9% to 4.0% in capillary blood testing. Capillary versus venous INR data showed agreement of results with regression lines equal to the line of identity.

CONCLUSION

The new system demonstrated a high level of trueness and accuracy, and low imprecision in INR testing. It can be concluded that the CoaguChek XS system complies with the requirements in chapter 8 of the ISO standard 17593:2007.

First case of successful allogeneic stem cell transplantation in an HIV-patient who acquired severe Aplastic Anemia

We report on the first successful allogeneic stem cell transplantation (SCT) in an HIV-infected patient with severe aplastic anemia (SAA) per- formed at a tertiary care institution. Highly active antiretroviral therapy (HAART) was administered until transplantation and restarted 34 days later with sustained virological response. The patient did however develop a rapid rise in HIV load during the interruption of HAART associated with an acute febrile illness. Due to the extended period between the onset of SAA until SCT, the posttransplant course was complicated by bacterial infections. Stage two skin GvHD, but no AIDS-defining opportunistic diseases were experienced. Neutrophils recovered to >0.5/nL on day +18 and the CD4 count reached 250/microL on day +71 and >500/microL on day +182. The patient is in good condition with an ECOG score of 0 twelve months after transplantation. This report demonstrates the feasibility of allogeneic stem cell transplantation in the HIV setting.

Clinical and cardiorespiratory effects of propofol in the spotted bamboo shark (Chylloscyllium plagiosum)

Sharks are important exhibit animals in aquariums and zoologic institutions worldwide. Although veterinarians are encountering these species more frequently in these institutions, our knowledge regarding safe restraint and anesthesia is limited. To date there have been only a few anecdotal reports or studies evaluating the effects of tricaine methane sulfonate (MS-222), ketamine hydrochloride, and tiletamine and zolazepam (Telazol) in sharks. The purpose of this study was to evaluate the clinical and cardiorespiratory effects of propofol in spotted bamboo sharks (Chylloscyllium plagiosum). Nine wild-caught adult female spotted bamboo sharks (mean weight 2.4 kg+/-SD 1.45 kg) were used in this study. Propofol (2.5 mg/kg) was administered over 30 sec via the caudal tail vein. Heart rate, respiratory rate, time to relaxation, escape response, loss of righting reflex, and response to noxious stimuli (fin pinch) were evaluated and recorded at baseline and 5, 10, 15, 30, 45, 60, and 75 min after propofol administration. A surgical plane of anesthesia was achieved when the shark lost its righting reflex, did not respond to noxious painful stimuli, and no longer resisted handling. The righting reflex was lost within 5 min of propofol administration, and a surgical plane of anesthesia was observed in all nine sharks. Heart rate (P = 0.5) and respiratory rate (P = 0.5) did not change significantly over time. The righting response returned within 60 min in 44% (4/9) of the sharks, 75 min in 22% (2/ 9) of the sharks, and over 200 min in 33% (3/9) of the sharks. All nine animals recovered uneventfully. Propofol provided a safe anesthetic event for spotted bamboo sharks.

Tau aggregation and progressive neuronal degeneration in the absence of changes in spine density and morphology after targeted expression of Alzheimer's disease-relevant tau constructs in organotypic hippocampal slices

Alzheimer's disease (AD) is characterized by progressive loss of neurons in selected brain regions, extracellular accumulations of amyloid beta, and intracellular fibrils containing hyperphosphorylated tau. Tau mutations in familial tauopathies confirmed a central role of tau pathology; however, the role of tau alteration and the sequence of tau-dependent neurodegeneration in AD remain elusive. Using Sindbis virus-mediated expression of AD-relevant tau constructs in hippocampal slices, we show that disease-like tau modifications affect tau phosphorylation at selected sites, induce Alz50/MC1-reactive pathological tau conformation, cause accumulation of insoluble tau, and induce region-specific neurodegeneration. Live imaging demonstrates that tau-dependent degeneration is associated with the development of a "ballooned" phenotype, a distinct feature of cell death. Spine density and morphology is not altered as judged from algorithm-based evaluation of dendritic spines, suggesting that synaptic integrity is remarkably stable against tau-dependent degeneration. The data provide evidence that tau-induced cell death involves apoptotic as well as nonapoptotic mechanisms. Furthermore, they demonstrate that targeted expression of tau in hippocampal slices provides a novel model to analyze tau modification and spatiotemporal dynamics of tau-dependent neurodegeneration in an authentic CNS environment.

Kinks, nodal bilayer splitting, and interband scattering in YBa2Cu3O(6+x)

We apply the new-generation angle-resolved photoemission spectroscopy methodology to the most widely studied cuprate superconductor YBa2Cu3O(6+x). Considering the nodal direction, we found noticeable renormalization effects known as kinks both in the quasiparticle dispersion and scattering rate, the bilayer splitting, and evidence for strong interband scattering--all the characteristic features of the nodal quasiparticles detected earlier in Bi2Sr2CaCu2O(8+delta). The typical energy scale and the doping dependence of the kinks clearly point to their intimate relation with the spin-1 resonance seen in the neutron scattering experiments. Our findings strongly suggest a universality of the electron dynamics in the bilayer superconducting cuprates and a dominating role of the spin fluctuations in the formation of the quasiparticles along the nodal direction.

Transradial stenting of the iliac artery: A case report

In this case report, stenting of the common iliac artery via the radial access route with 6 Fr equipment, including an extra long multipurpose catheter, is presented. Radial access avoids bleeding and ischemia that may complicate retrograde or crossover access to the iliac artery.

[Clinical presentation and management of the severe acute respiratory syndrome (SARS)]

BACKGROUND AND OBJECTIVE

In February 2003, a newly emerged infectious disease was described, the etiology of which was initially unknown. It is referred to under the term SARS. In the beginning, it spread in some regions South-East Asia. Import infections appeared in many other parts of the world. Based on the first cases in Germany, this report illustrates the clinical appearance, the diagnostic results and the management of this new disease.

PATIENTS AND METHODS

We analysed the data of two patients with SARS and one suspected patient. The results of radiological, laboratory, microbiological and physical examinations were abstracted and compared with the data obtained in other regions.

RESULTS

Two of the three patients under our care developed SARS disease. This is characterised by fever of sudden onset lasting for more than 5 days, rapidly changing consolidations in chest x-ray not affected by antimicrobial therapy, leuko-, lympho- as well as thrombopenia with a compromised pulmonary function later in the course. Close contacts with SARS patients does not regularly result in full development of the disease. Secretion of a coronavirus could be detected in respiratory samples during the febrile phase and in feces for a longer time. It is still an open question whether bedrest and antibiotic prophylaxis by themselves or an additional administration of ribavirin and corticosteroids can improve the outcome.

CONCLUSION

SARS is a new and highly contagious lung disease. It is crucial to be able to recognize the clinical appearance and the diagnostic features of this disease at an early stage, in order to prevent a further dissemination of the disease.

Measurement of spin-correlation parameters ANN, ASS, and ASL at 2.1 GeV in proton-proton elastic scattering

At the Cooler Synchrotron COSY/Jülich spin-correlation parameters in elastic proton-proton (pp) scattering have been measured with a 2.11 GeV polarized proton beam and a polarized hydrogen atomic beam target. We report results for A(NN), A(SS), and A(SL) for c.m. scattering angles between 30 degrees and 90 degrees. Our data on A(SS)--the first measurement of this observable above 800 MeV--clearly disagrees with predictions of available pp scattering phase-shift solutions while A(NN) and A(SL) are reproduced reasonably well. We show that in the direct reconstruction of the scattering amplitudes from the body of available pp elastic scattering data at 2.1 GeV the number of possible solutions is considerably reduced.

Pronounced in-plane anisotropy of phonon anomalies in YBa(2)Cu(3)O(6.6)

The dispersion of the Cu-O bond-stretching and bond-bending vibrations in YBa(2)Cu(3)O(6.6) has been studied by high resolution inelastic neutron scattering. While the behavior of the bond-bending vibrations can be well accounted for by a simple potential model, the bond-stretching vibrations show a highly anomalous behavior. The displacement pattern of the most anomalous phonons is in principle consistent with dynamic charge stripe formation. However, charge stripes would have to extend along the a axis and not the b axis as inferred from the magnetic fluctuations by Mook et al. [Nature (London) 404, 729 (2000)].

The pharmacologic stability of 35-year old theophylline

The propensity to preserve and to hoard drugs over the years at home is a well-known phenomenon and offers the possibility for intentional and accidental drug poisoning in man. We report a case of acute theophylline poisoning in an 80-year old women after ingestion of 'Asthmo-Kranit', a 35-year old combined preparation containing theophylline and aminopyrine as the main ingredients. The patient developed the typical clinical picture of a symptomatic theophylline poisoning with flush, tremor, tachycardia, hyperventilation, hypotonia, and hyperglycaemia. The clinical course after treatment with beta-blockers was without complications. The determination of theophylline in tablets showed stability of 90% of the labelled amount of the drug 30 years beyond the expiration date. The case illustrates the prolonged shelf stability and pharmacological potency of some pharmaceuticals and points to the risk of long-outdated prescriptions. Physicians should primarily not underestimate drug toxicity in consequence of old-age pharmaceuticals.

Strong renormalization of phonon frequencies in Mg(1-x)Al(x)B2

The phonon spectrum of Mg(1-x)Al(x)B2 shows a strong dependence on the aluminum content x. This is experimentally demonstrated by both Raman and inelastic neutron scattering and theoretically predicted by first-principles calculations. The observed changes in the phonon spectrum are put into perspective with respect to the superconducting properties within this family of materials.

A novel thermoregulatory system maintains perioperative normothermia in children undergoing elective surgery

BACKGROUND

Body heat loss during anaesthesia may result in increased morbidity, particularly in high-risk populations such as children. To avoid hypothermia, a novel thermoregulatory system (Allon) was devised. We tested the safety and efficacy of this system in maintaining normothermia in children undergoing routine surgical procedures.

METHODS

The system consists of a computerized body, which receives continuous afferent data, i.e. core (rectal) temperature. These data are then compared with a preset temperature (37 degrees C) and a microprocessor heating/cooling unit warms/cools the temperature of circulating water in a garment that is specially designed to allow maximal coverage of body surface area, without impingement on the surgical field. Water temperature to the garment was limited to a maximum of 39.5 degrees C. Continuous perioperative monitoring of skin and rectal temperature, heart rate and blood pressure was performed. Postoperative shivering and adverse effects were also assessed.

RESULTS

The Allon system was used in 38 patients aged 3 months to 14 years undergoing surgery under general anaesthesia lasting more than 30 min. Fifty to 80% body surface area was covered by the garment. Mean operative and postoperative core temperatures were 36.9 +/- 0.5 degrees C and 36.7 +/- 0.5 degrees C, respectively. Intraoperative skin temperatures were maintained at 34.4 +/- 2.7 degrees C. The average core- to-periphery intraoperative gradient was 2.9 +/- 4.9 degrees C. Postoperative shivering was absent in 36 cases and mild in two cases. No device-related adverse effects were observed.

CONCLUSIONS

Perioperative thermoregulation using the Allon system is safe and effective in maintaining body temperature within a narrow range in children undergoing brief surgical procedures.

Assessing the quality of life in children with cystic fibrosis

Although patients with cystic fibrosis (CF) are experiencing increased longevity, it is unclear that improved quality of life (QoL) accompanies the greater quantity of life. This is especially true of children with CF where the burdens of treatment are substantial. Assessing QoL in such children is difficult, and only one instrument--the Quality of Well-Being (QWB) scale--seems to have been used extensively to assess QoL in children with CF. After thoroughly reviewing the literature, we surveyed the 113 certified CF centers in the United States about QoL assessment. With 84% responding, it was found that only 7 centers are assessing QoL--4 have been using the QWB instrument. Concurrently, we pilot tested the QWB instrument in children being followed longitudinally in the Wisconsin CF Neonatal Screening Project. Our results indicated that QWB scores reflecting QoL decreased as the number of respiratory infections increased, as the number of concurrent medical conditions increased, and as the number of different medications increased. However, we recognized problems with the assessed domains and data interpretation. In fact, the QWB instrument has limited sensitivity and responds more to the extent of physician-determined treatment than to QoL. There is a need for more QoL assessment and better instruments, particularly in young children with CF.

Adult-onset Leukoencephalopathy with vanishing white matter presenting with dementia

We report on a case of dementia and extensive cerebral white matter abnormalities seen on magnetic resonance-images which meet the criteria for leukoencephalopathy with vanishing white matter. This is an inherited condition that was first thought to occur only in children. Our patient shows that vanishing white matter should be considered in adult patients with early-onset dementia and extensive white matter changes seen on magnetic resonance images.

Accurate linear radiofrequency lesions guided by a nonfluoroscopic electroanatomic mapping method during atrial fibrillation

Catheter-based continuous linear lesions may become a curative procedure for AF. The accuracy of guiding the application of continuous RF lesions by a nonfluoroscopic mapping system (NFM) during AF in goats was tested. The NFM system (Carto) uses magnetic fields to determine, in real time, the location and orientation of a 7 Fr ablation catheter tip. AF was induced in nine goats by intravenous infusion of methacholine (3-4 microg x kg(-1) min(-1)) and burst pacing. The three-dimensional atrial geometry was reconstructed using the median location of the mapping catheter tip during 30 seconds when in contact with each endocardial site. Sequential RF energy (60 seconds in a temperature-controlled mode [60 degrees C]) was delivered along a predetermined path to create longitudinal lesions in both atria. Sites to which RF energy was applied were tagged on the NFM map, enabling the operator to accurately navigate the catheter tip to the adjacent sites. In all cases (n = 14) the location, shape, length, and continuity of the linear lesions on the electroanatomic maps highly correlated with the autopsy findings. Average line length on the reconstructed maps was 32.3+/-4.1 mm, which highly correlated (r = 0.98, P<.001) with the lesions created in the pathological specimen (31.7+/-3.9 mm). The NFM system can guide the application of RF linear lesions in a highly accurate manner during AF. Moreover, the ability to tag the ablation sites on the three-dimensional maps together with real-time monitoring of the ablation catheter tip location enables delivery of RF energy to create reproducible, continuous, longitudinal lesions without the use of fluoroscopy.

Three-dimensional electromechanical mapping: imaging in the operating room of the future

BACKGROUND

Three-dimensional electromechanical mapping has previously been shown to be a clinically important tool for cardiac imaging and intervention. We hypothesized that this technology may be beneficial as an intraoperative modality for assessing cardiac hemodynamics and viability during cardiac surgery. We report here the use of this technology as an imaging modality for intraoperative cardiac surgery.

METHODS

The tip of a locatable catheter connected to an endocardial mapping and navigating system is accurately localized while simultaneously recording local electrical and mechanical functions. Thus the three-dimensional geometry of the beating cardiac chamber is reconstructed in real time. The system was tested on 6 goats that underwent acute dynamic cardiomyoplasty and on 5 dogs that underwent left anterior descending (LAD) coronary artery ligation.

RESULTS

The electromechanical mapping system provided an accurate three-dimensional reconstruction of the beating left ventricle during cardiomyoplasty. After the wrapping procedure, significant end-diastolic area reduction was noted in the base and mid parts of the heart (948 +/- 194 mm2 vs 1245 +/- 33 mm2, p = 0.021; and 779 +/- 200 mm2 vs 1011 +/- 80 mm2, p = 0.016). The area of the cross-section of the apex did not change during the operation. Acute infarcted tissue was characterized 3 days after LAD ligation by concomitant deterioration in both electrical and mechanical function.

CONCLUSIONS

By providing both a clear view of the anatomical changes that occur during cardiac surgery, and an accurate assessment of tissue viability, electroanatomic mapping may serve as an important adjunct tool for imaging and analysis of the heart during cardiac surgery

Novel thermoregulation system for enhancing cardiac function and hemodynamics during coronary artery bypass graft surgery

BACKGROUND

Myocardial ischemia, arrhythmias, and coagulopathies are associated with postoperative hypothermia. This study assessed the efficacy of a novel thermoregulation system in alleviating these events during coronary artery bypass graft (CABG) surgery.

METHODS

Elective CABG surgery patients were randomized into either Allon thermoregulation (AT, n = 40) or routine thermal care (RTC, n = 20) groups in whom the maintenance of normothermia during the nonbypass phases of the operation was compared. The AT used patients' rectal temperature as reference data to monitor the maintenance of the water temperature circulating at 37 degrees C in a garment. Rectal temperature, patient hemodynamics, and cardiac-specific troponin I (cTnI) levels were assessed at the induction of anesthesia, 30 minutes into surgery, at discontinuation of bypass, end of surgery, and 2 hours postoperatively.

RESULTS

Body temperature was higher in the AT group compared to the RTC group at all five time points. Cardiac index (CI) (L/min) was higher in the AT group, 2.5 +/- 0.5, 2.6 +/- 0.5*, 3.2 +/- 0.6*, 3.3 +/- 0.5*, 3.1 +/- 0.7 at the respective time points, compared to the RTC group, 2.3 +/- 0.6, 2.1 +/- 0.2, 2.6 +/- 0.7, 2.7 +/- 0.7, 2.7 +/- 0.7 (*p < 0.05). Systemic vascular resistance (SVR) (dyne x s)/cm5) was consistently lower in the AT patients. Enzyme levels were elevated in both groups but were less so in the AT patients.

CONCLUSIONS

The AT system can efficiently maintain normothermia. The beneficial effects are expressed by reduced SVR, elevated CI, and lower levels of cTnI, which may show a possible attenuation of myocardial injury.