Outcomes and Prognostic Factors in Patients with Rheumatologic Diseases Admitted to the ICU

OBJECTIVE

To assess the outcomes in a large cohort of patients suffering from rheumatic diseases admitted to the ICU of a tertiary university medical center.

METHODS

A retrospective chart analysis was performed in 108 patients suffering from various rheumatic diseases and the outcomes, including morbidity and mortality, were assessed in relation to the underlying diseases, treatments and complications.

RESULTS

Overall, 48 patients with rheumatoid arthritis, five patients with spondyloarthritis, 14 patients with vasculitis, 30 patients with connective tissue diseases and 11 patients suffering from other rheumatologic conditions were admitted to the intensive care unit (ICU). The reasons for ICU admission included infection (30%), cardiovascular complications (22%), gastrointestinal problems (18%), endocrinological disorders (7%), neurological complications (2%) and others (3%). A total of 4% of the admitted patients required close monitoring and 14% suffered from acute exacerbation of the underlying rheumatic disease. The ICU mortality rate was 16%, whereas the overall hospital mortality rate was 20%. Fatal outcomes were related to exacerbation of the rheumatic disease in 14% of the patients, infectious complications in 46% of the patients and other reasons in 41% of the patients. An increased Apache II score, the need for mechanical ventilation, renal replacement therapy, treatment with vasopressor drugs and plasma exchange therapy were identified as risk factors for mortality.

CONCLUSION

The overall outcomes of critically ill patients with rheumatic diseases are impaired compared to that observed in other patient groups. However, there were no significant differences in outcomes between the different rheumatic disease groups or based on the use of immunosuppressive therapy in this study. An increased Apache II score, the need for mechanical ventilation, renal replacement therapy, treatment with vasopressor drugs and plasma exchange therapy were identified as risk factors for mortality.

Clinical characteristics and course of plantar vein thrombosis: a series of 22 cases

Objectives

To evaluate the clinical presentation and disease course of symptomatic plantar vein thrombosis.

Patients and methods

Patients with a first diagnosis of symptomatic plantar vein thrombosis at our institution were retrospectively identified from a prospectively maintained database. All patients underwent complete venous compression sonography extended to the plantar veins because of local symptoms at the sole of the foot. Clinical characteristics were obtained from the medical records.

Results

Between 2005 and 2013, 22 patients were diagnosed with a first episode of plantar vein thrombosis (64% women, mean age at diagnosis 58.2 years, range 32–79 years). All patients reported moderate to heavy pain of the sole of the foot. The lateral plantar veins (96%) were more frequently affected than the medial plantar veins (41%) and extension into the deep calf veins was common (27%). Half of the episodes were idiopathic, with subsequent diagnosis of occult malignancy in two of these patients. In seven patients (32%), plantar vein thrombosis occurred in association to physical strain to the foot. All patients were treated with anticoagulation. Symptomatic pulmonary embolism was not observed and during a mean follow up of 21 months, the post-thrombotic syndrome did not occur. However, recurrences were common (27%) and frequently again affected the plantar veins.

Conclusion

Plantar vein thrombosis should be considered as an important differential diagnosis of acute foot pain.

Verhaltensauffälligkeiten mit 9 Jahren zur Vorhersage von Schulproblemen im Alter von 11 und 15 Jahren

Verhaltensauffälligkeiten im Kindesalter stellen einen Risikofaktor für psychische Auffälligkeiten und verminderte schulische Leistungsfähigkeit dar. Die Studie untersucht, ob eine geringere Funktionalität im Grundschulalter die Auftretenswahrscheinlichkeit von Schulproblemen in der Adoleszenz erhöht. Fragebogendaten der 9-, 11- und 15-Jahres Nachuntersuchungen der MAS-Geburtskohorte (N=1314 Baselineerhebung bei Geburt; 47.9 % Mädchen, 52.1 % Jungen) werden ausgewertet. Erhoben werden Funktionalität auf den Dimensionen Psychisches Wohlergehen, Körperlicher Status, Soziale Beziehungen und Alltagsfunktionsfähigkeit zu 9 Jahren sowie das Vorkommen von Schulproblemen mit 11 und 15 Jahren. Eine geringere Funktionalität im Alter von 9 Jahren geht mit einer erhöhten Auftretenswahrscheinlichkeit von Schulproblemen mit 11 (adjustierte Odds Ratio [aOR]=3.53, 95 %Konfidenzintervall [KI] 2.20 – 5.66) und 15 Jahren (aOR=3.22, 95 %KI 1.85 – 5.62) einher. Diese Effekte zeigen sich deutlicher für Jungen als für Mädchen. Bereits Grundschulkinder können Einschränkungen in ihrer Funktionalität zeigen, welche über Jahre stabil zu bleiben scheinen und mit Schulproblemen in der Adoleszenz einhergehen können.

Feasibility of a radiation dose conserving CT protocol for myocardial function assessment

OBJECTIVE

Assessment of myocardial function can be performed at higher noise levels than necessary for coronary arterial evaluation. We evaluated image quality and radiation exposure of a dose-conserving function-only acquisition vs retrospectively electrocardiogram(ECG)-gated coronary CTA with automatic tube current modulation.

METHODS

Of 26 patients who underwent clinically indicated coronary CTA for coronary and function evaluation, 13 (Group I) underwent prospectively ECG-triggered coronary CTA, followed by low-dose retrospectively ECG-gated scan for function (128-slice dual-source, 80 kVp; reference tube current, 100 mA; 8-mm-thick multiplanar reformatted reconstructions) performed either immediately (n = 6) or after 5- to 10-min delay for infarct assessment (n = 7). 13 corresponding controls (Group II) underwent retrospectively ECG-gated protocols (automatic tube potential selection with CARE kV/CARE Dose 4D; Siemens Healthcare, Forchheim, Germany) with aggressive dose modulation. Image quality assessment was performed on the six Group I subjects who underwent early post-contrast dedicated function scan and corresponding controls. Radiation exposure was based on dose-length product.

RESULTS

Contrast-to-noise ratio (CNR) was preserved throughout the cardiac cycle in Group I and varied according to dose modulation in Group II. Visual image quality indices were similar during end systole but were better in Group II at end diastole. Although the total radiation exposure was equivalent in Group I and Group II (284 vs 280 mGy cm), the median radiation exposure associated with only the dedicated function scan was 138 mGy cm (interquartile range, 116-203 mGy cm).

CONCLUSION

A low-dose retrospective ECG-gated protocol permits assessment of myocardial function at a median radiation exposure of 138 mGy cm and offers more consistent multiphase CNR vs traditional ECG-modulation protocols. This is useful for pure functional evaluation or as an adjunct to single-phase scan modes.

ADVANCES IN KNOWLEDGE

Radiation exposure can be limited with a tailored myocardial function CT protocol while maintaining preserved images.

Induction of inducible nitric oxide synthase (iNOS) expression by oxLDL inhibits macrophage derived foam cell migration

OBJECTIVE

Deletion of inducible nitric oxide synthase (iNOS) in apolipoprotein E knockout mice was shown to mitigate the extent of arteriosclerosis. Oxidized low density lipoprotein (oxLDL) inhibits macrophage migration and traps foam cells, possibly through a mechanism involving oxidative stress. Here, we addressed whether a reduction of iNOS-mediated oxidative stress remobilizes macrophage-derived foam cells and may reverse plaque formation.

METHODS

Migration of RAW264.7 cells and bone marrow cells was quantified using a modified Boyden chamber. iNOS expression, phalloidin staining, focal adhesion kinase phosphorylation, lipid peroxides, nitric oxide (NO) and reactive oxygen species (ROS) production were assessed.

RESULTS

oxLDL treatment significantly reduced cell migration compared to unstimulated cells (p < 0.05). This migratory arrest was reversed by co-incubation with a pharmacologic iNOS inhibitor 1400 W (p < 0.05) and iNOS-siRNA (p > 0.05). Furthermore, apoE/iNOS double knockout macrophages do not show migratory arrest in response to oxLDL uptake, compared to apoE knockout controls (p > 0.05). We documented significantly increased iNOS expression following oxLDL treatment and downregulation using 1400 W and small inhibitory RNA (siRNA). iNOS inhibition was associated with a reduction in NO and peroxynitrite (ONOO-)- and increased superoxide generation. Trolox treatment of RAW264.7 cells restored migration indicating that peroxynitrite mediated lipid peroxide formation is involved in the signaling pathway mediating cell arrest..

CONCLUSIONS

Here, we provide pharmacologic and genetic evidence that oxLDL induced iNOS expression inhibits macrophage-derived foam cell migration. Therefore, reduction of peroxynitrite and possibly lipid hydroperoxide levels in plaques represents a valuable therapeutic approach to reverse migratory arrest of macrophage-derived foam cells and to impair plaque formation.

Timed action of IL-27 protects from immunopathology while preserving defense in influenza

Infection with influenza virus can result in massive pulmonary infiltration and potentially fatal immunopathology. Understanding the endogenous mechanisms that control immunopathology could provide a key to novel adjunct therapies for this disease. Here we show that the cytokine IL-27 plays a crucial role in protection from exaggerated inflammation during influenza virus infection. Using Il-27ra^−/− mice, IL-27 was found to limit immunopathology, neutrophil accumulation, and dampened T_H1 or T_H17 responses via IL-10–dependent and -independent pathways. Accordingly, the absence of IL-27 signals resulted in a more severe disease course and in diminished survival without impacting viral loads. Consistent with the delayed expression of endogenous Il-27p28 during influenza, systemic treatment with recombinant IL-27 starting at the peak of virus load resulted in a major amelioration of lung pathology, strongly reduced leukocyte infiltration and improved survival without affecting viral clearance. In contrast, early application of IL-27 impaired virus clearance and worsened disease. These findings demonstrate the importance of IL-27 for the physiological control of immunopathology and the potential value of well-timed IL-27 application to treat life-threatening inflammation during lung infection.

Annual epidemics of influenza result in 3 to 5 million cases of severe illness and approximately 300,000 deaths around the world. Although most patients infected with normal circulating influenza A viruses recover from the illness, complications arise during infections with highly pathogenic strains of the virus, resulting in increased mortality associated with severe immunopathology and acute respiratory distress. Previous studies suggested a major contribution of the vigorous immune response to lung damage. How the immune system constrains the negative impact of inflammation might therefore be of significant importance for future therapies. Our study in a mouse model of influenza shows that the cytokine IL-27 plays a crucial role in survival by protecting against lung damage. Its actions include regulation of innate (neutrophil influx) and adaptive (inflammatory cytokine production of T cells) arms of immunity during the acute respiratory infection. The data also suggest a therapeutic potential of IL-27, as mice treated with recombinant cytokine at later stages of infection exhibited decreased immunopathology and showed improved survival. The findings uncover an important role of IL-27 in limiting the collateral damages of anti-viral immunity and provide initial evidence that these mechanisms might be exploited for the management of severe immunopathology after infection.

Respiratory diseases are associated with molar-incisor hypomineralizations

The objective of our study was to evaluate the association of molar-incisor hypomineralizations (MIHs) with prospectively collected potential causative factors from the first 4 years of life, e.g. respiratory diseases, breastfeeding, maternal smoking and parental education. A total of 692 children (10 years old) from the GINI birth cohort study participated. The dental examination included the registration of enamel hypomineralizations (EHs) according to the EAPD criteria. Children with EH were sub-categorized into those with at least one EH (MIH/1), those with a minimum of one EH on at least one first permanent molar (MIH/2) and those with EH on at least one first permanent molar and a permanent incisor (MIH/3). All relationships between causative factors and caries or MIH were evaluated using simple and multiple logistic regression analyses. EHs were observed in 37.9% (MIH/1), 14.7% (MIH/2) and 9.2% (MIH/3) of all subjects. After adjustment for confounding factors, 10-year-old children with at least one episode of respiratory disease had a significantly higher risk (2.48 times, adjusted OR) for the development of MIH/3. In case of breastfeeding, a non-significant association was observed. None of the tested factors was associated with either MIH/1 or MIH/2. Early respiratory diseases seem to be directly or indirectly related to MIH/3 only. The role of (systemic) medications used for treatment of these diseases needs to be investigated in future studies.

Lack of association between venous hemodynamics, venous morphology and the postthrombotic syndrome after upper extremity deep venous thrombosis

OBJECTIVES

To explore the association of the postthrombotic syndrome with venous hemodynamics and morphological abnormalities after upper extremity deep venous thrombosis.

METHODS

Thirty-seven patients with a history of upper extremity deep venous thrombosis treated with anticoagulation alone underwent a single study visit (mean time after diagnosis: 44.4 ± 28.1 months). Presence and severity postthrombotic syndrome were classified according to the modified Villalta score. Venous volume and venous emptying were determined by strain-gauge plethysmography. The arm veins were assessed for postthrombotic abnormalities by ultrasonography. The relationship between postthrombotic syndrome and hemodynamic and morphological sequelae was evaluated using univariate significance tests and Spearman's correlation analysis.

RESULTS

Fifteen of 37 patients (40.5%) developed postthrombotic syndrome. Venous volume and venous emptying of the arm affected by upper extremity deep venous thrombosis did not correlate with the Villalta score (rho = 0.17 and 0.19; p = 0.31 and 0.25, respectively). Residual morphological abnormalities, as assessed by ultrasonography, did not differ significantly between patients with and without postthrombotic syndrome (77.3% vs. 86.7%, p = 0.68).

CONCLUSIONS

Postthrombotic syndrome after upper extremity deep venous thrombosis is not associated with venous hemodynamics or residual morphological abnormalities.

Urine of patients with acute kidney transplant rejection show high normetanephrine and decreased 2-hydroxyestrogens concentrations

BACKGROUND

A shift from anti- to proinflammatory steroid hormones has been observed in chronic inflammation. We tested the hypothesis that this shift occurs also in kidney transplant rejection together with a rise of urinary catecholamine degradation product concentrations as a consequence of locally produced cytokines, thus further promoting rejection.

METHODS

We examined 8 patients with an early rejection episode in the protocol biopsy ∼2 weeks, 9 with biopsy-proven rejection at 2-3 months, and 18 without rejection, both at 2 weeks and 3 months after transplantation. Metanephrine, normetanephrine, and 2- and 16-hydroxyestrogens concentrations were measured by EIA.

RESULTS

The median urinary concentrations of normetanephrine, but not metanephrine, were significantly higher in acute kidney transplant rejection in the first 2 weeks after transplantation (P < .05). During acute kidney transplant rejection at 2-3 months, but not in the first 2 weeks, after transplantation, 2-, but not 16-hydroxyestrogens, concentrations were significantly decreased (P < .05).

CONCLUSIONS

We demonstrated that the downstream product of noradrenaline conversion normetanephrine was elevated in kidney transplant rejection in the first weeks after transplantation. This change may promote rejection together with an important proinflammatory and mitogenic steroid hormone shift, which becomes increasingly relevant over time.

Is there a positive relationship between molar incisor hypomineralisations and the presence of dental caries?

OBJECTIVE

This epidemiological study aimed to compare the caries experience in 10-year-olds with and without molar incisor hypomineralisation (MIH).

METHODS

About 693 children from an ongoing birth cohort study (GINIplus10) were examined for caries lesions to determine the DMF index. Furthermore, enamel hypomineralisation (EH) was scored on all permanent teeth/surfaces, according to the criteria of the European Academy of Paediatric Dentistry. Children with EH were categorised into those with a minimum of one EH in the permanent dentition (MIH/1), with EH on at least one-first permanent molar (MIH/1A), on at least one-first permanent molar and permanent incisor (MIH/1B), and on other permanent teeth (MIH/1C).

RESULTS

The mean caries experience was 0.4 (SD 0.9) DMFT. Existence of MIH/1, MIH/1A, MIH/1B, and MIH/1C was determined in 36.5%, 14.7%, 9.4%, and 21.8% of all children. The corresponding DMFT values were the following: no MIH: 0.3 (SD 0.8); MIH/1: 0.5 (SD 0.9); MIH/1A: 0.5 (SD 0.9); MIH/1B: 0.4 (SD 0.9); and MIH/1C: 0.4 (SD 0.9) DMFT. No significant differences were found between all groups.

CONCLUSIONS

There was no relationship between the presence of EH/MIH and caries in 10-year-olds. A ratio of one EH-associated defect to two caries lesions indicates that both conditions are prevalent and influence the oral health status of 10-year-old children from Munich, Germany.

Skeletal muscle VO₂ kinetics from cardio-pulmonary measurements: assessing distortions through O₂ transport by means of stochastic work-rate signals and circulatory modelling

During non-steady-state exercise, dynamic changes in pulmonary oxygen uptake (VO₂pulm) are dissociated from skeletal muscle VO₂ (VO₂musc) by changes in lung and venous O₂ concentrations (CvO₂), and the dynamics and distribution of cardiac output (CO) between active muscle and remaining tissues (Qrem). Algorithms can compensate for fluctuations in lung O₂ stores, but the influences of CO and CvO₂ kinetics complicate estimation of VO₂musc from cardio-pulmonary measurements. We developed an algorithm to estimate VO₂musc kinetics from VO₂pulm and heart rate (HR) during exercise. 17 healthy volunteers (28 ± 7 years; 71 ± 12 kg; 7 females) performed incremental exercise using recumbent cycle ergometry (VO₂peak 52 ± 8 ml min(-1) kg(-1)). Participants completed a pseudo-random binary sequence (PRBS) test between 30 and 80 W. VO₂pulm and HR were measured, and CO was estimated from HR changes and steady-state stroke volume. VO₂musc was derived from a circulatory model and time series analyses, by solving for the unique combination of venous volume and the perfusion of non-exercising tissues that provided close to mono-exponential VO₂musc kinetics. Independent simulations showed that this approach recovered the VO₂musc time constant (τ) to within 7% (R(2) = 0.976). Estimates during PRBS were venous volume 2.96 ± 0.54 L; Qrem 3.63 ± 1.61 L min(-1); τHR 27 ± 11 s; τVO₂musc 33 ± 8 s; τVO₂pulm 43 ± 14 s; VO₂pulm time delay 19 ± 8 s. The combination of stochastic test signals, time series analyses, and a circulatory model permitted non-invasive estimates of VO₂musc kinetics. Large kinetic dissociations exist between muscular and pulmonary VO₂ during rapid exercise transients.

Comprehensive morphometric analysis of mononuclear cell infiltration during experimental renal allograft rejection

The role of specific subtypes of infiltrating cells in acute kidney allograft rejection is still not clear and was so far not examined by different analyzing methods under standardized conditions of an experimental kidney transplantation model. Immunohistochemical staining of CD3, CD20 and CD68 was performed in rat allografts, in syngeneically transplanted rats and in control rats with a test duration of 6 and 28 days. The detailed expression and localization of infiltrating cells were analyzed manually in different kidney compartments under light microscope and by the two different morphometric software programs. Data were correlated with the corresponding kidney function as well as with histopathological classification. The information provided by the morphometric software programs on the infiltration of the specific cell types after renal transplantation was in accordance with the manual analysis. Morphometric methods were solid to analyze reliably the induction of cellular infiltrates after renal transplantation. By manual analysis we could clearly demonstrate the detailed localization of the specific cell infiltrates in the different kidney compartments. Besides infiltration of CD3 and CD68 infiltrating cells, a robust infiltration of CD20 B-cells in allogeneically transplanted rats, even at early time points after transplantation was detected. Additionally an MHC class I expression could reliable be seen in allogeneically transplanted rats. The infiltration of B-cells and the reliable antigen presentation might act as a silent subclinical trigger for subsequent chronic rejection and premature graft loss.

Toll-like receptor 4 in experimental kidney transplantation: early mediator of endogenous danger signals

The role of toll-like receptors (TLRs) has been described in the pathogenesis of renal ischemia/reperfusion injury, but data on the expression and function of TLR4 during renal allograft damage are still scarce. We analyzed the expression of TLR4 in an experimental rat model 6 and 28 days after allogeneic kidney transplantation in comparison to control rats and rats after syngeneic transplantation. On day 6, a significant induction in TLR4 expression--restricted to the glomerular compartment--was found in acute rejecting allografts only. TLR4 expression strongly correlated with renal function, and TLR4 induction was accompanied by a significant increase in CC chemokine expression within the graft as well as in urinary CC chemokine excretion. TLR4 induction may be caused by an influx of macrophages as well as TLR4-expressing intrinsic renal cells. Fibrinogen deposition in renal allografts correlated with renal TLR4 expression and may act as a potent stimulator of chemokine release via TLR4 activation. This study provides, for the first time, data about the precise intrarenal localization and TLR4 induction after experimental kidney transplantation. It supports the hypothesis that local TLR4 activation by endogenous ligands may be one pathological link from unspecific primary allograft damage to subsequent chemokine release, infiltration and activation of immune cells leading to deterioration of renal function and induction of renal fibrosis.