[Pharmacological/pharmaceutical counseling in intensive care medicine]

Adequate pharmacotherapy in critically ill patients is challenging for many clinicians. Disease-related pathophysiological changes often lead to complex therapy strategies including many intensive care treatments (e.g. invasive ventilation, renal replacement therapy). These measures often influence drug prescribing and dosing. Therefore, in organ dysfunction such as renal and liver impairment reduced drug elimination has to be considered by adapting drug dosing towards elimination rates. Moreover, as intensive care medicine often includes the use of multiple drugs the risk for drug-drug interactions increases. The current article gives an overview about the complexity of individual pharmacotherapy in intensive care units whilst providing information for its clinical implementation.

[Adequate anti-infective treatment : Importance of individual dosing and application]

Sepsis-induced changes in pharmacokinetic parameters are a well-known problem in intensive care medicine. Dosing of antibiotics in this setting is therefore challenging. Alterations to the substance-specific kinetics of anti-infective substances have an effect on the distribution and excretion processes in the body. Increased clearance and an increased distribution volume (V_d) and particularly compromized organ function with reduced antibiotic elimination are often encountered in patients with sepsis. Renal replacement treatment, which is frequently used in intensive care medicine, represents a substantial intervention in this system. Current international guidelines recommend individualized dosing strategies and adaptation of doses according to measured serum levels and pharmacokinetic/pharmacodynamic (PK/PD) parameters as concepts to optimize anti-infective therapy in the critically ill. Likewise, the recommendation to adjust the administration form of beta-lactam antibiotics to prolonged or continuous infusion can be found increasingly more often in the literature. This article reviews the background of the individual dosing in intensive care patients and their applicability to the clinical routine.

New onset of diabetes after transplantation is associated with improved patient survival after liver transplantation due to confounding factor

BACKGROUND

The influence of NODAT on survival of liver transplant recipients has not been clarified. Therefore, we evaluated the effect of NODAT on survival in LT recipients.

METHODS

Data from 352 LT patients were totally analyzed. 97 patients with pretransplant diabetes mellitus were excluded, and 255 patients without diabetes mellitus at time of transplantation were included.

RESULTS

NODAT was diagnosed in 41 patients (16.1%). There was no difference in frequency of NODAT according to the etiology of liver cirrhosis. NODAT was associated with a higher body weight (p=0.004) and BMI (p=0.002) 5years after LT, but not with weight gain (p=0.201) or increase in BMI (p=0.335) 5years after LT. HbA1c 5years after LT was significantly higher in patients with NODAT (p=0.001), but mean HbA1c still remained lower than 6.5% (6.4(±1.2) %). Patients with NODAT showed better survival rates (log rank: p=0.002) compared to LT recipients without diabetes. According to all existing knowledge of diabetes mellitus (DM) better survival cannot be a direct effect of this disease. Our results are rather influenced by an not known confounding factor (possibly recovery from cachexia) associated with better survival and NODAT, while complications of NODAT will not appear during the relatively short postoperative time and observation period (mean follow up 6.08 (±2.67) years).

CONCLUSION

NODAT is frequently diagnosed in LT recipients and is associated with an improved 5year survival after LT due to a not exactly known confounding factor.

Thymic stromal lymphopoietin deficiency attenuates experimental autoimmune encephalomyelitis

In the present study we examined the role of thymic stromal lymphopoietin (TSLP) in experimental autoimmune encephalomyelitis (EAE). Here, we report that TSLP knock-out (KO) mice display a delayed onset of disease and an attenuated form of EAE. This delayed onset was accompanied by a reduced number of encephalitogenic T helper type 1 (Th1) cells in the central nervous system (CNS) of TSLP KO mice. In addition, CD4(+) and CD8(+) T cells from CNS of TSLP KO mice show a reduced activation status in comparison to wild-type mice. It is noteworthy that we could also show that lymph node cells from TSLP KO mice expanded less efficiently and that interleukin (IL)-6-, interferon (IFN)-γ and tumour necrosis factor (TNF)-α levels were reduced. Furthermore, CD3(+) T cells isolated in the preclinical phase from myelin oligodendrocyte glycoprotein peptide 35-55 (MOG(35-55))-immunized TSLP KO mice showed a reduced response after secondary exposure to MOG(35-55), indicating that differentiation of naive T cells into MOG(35-55)-specific effector and memory T cells was impaired in KO mice. The addition of recombinant TSLP enhanced T cell proliferation during MOG(35-55) restimulation, showing that T cells also respond directly to TSLP. In summary, these data demonstrate that expression of, and immune activation by, TSLP contributes significantly to the immunopathology of EAE.

Remediation of TENORM residues: risk communication in practice

Despite several decades of studies on the risk assessment and risk perception of ionising radiation, risk management of radioactive materials remains a challenging issue. This is also true for wastes containing technologically enhanced naturally occurring radioactive materials. The present work focuses on the underlying reasons for communication problems between experts and affected members of the public. Exploring the case of a German remediation site with residual radioactive contamination in a residential area, the experts' as well as the residents' perspectives were studied by conducting qualitative interviews. Our results indicate a variety of reasons for communication problems on different levels of risk management and risk communication: the regulatory, the communicative and the moral levels. In the observed case, four salient causes for problems in risk communication and risk management emerged: the mismatch in understanding the residents' values, the issue of risk communication in an unforeseen situation, the problem of the regulatory gap between radiation protection and soil protection in regard to legacies with naturally occurring radioactive material in Germany, and the challenge of communicating a highly complex scientific issue to non-scientists. Moreover, one (at least partial) solution could be seen: the introduction of an external mediator. The results indicate that coordination of different health and environment protection disciplines-in this case radiation protection relating to soil protection-is possible and urgently needed. The opportunity to put, at least natural, radioactive material in line with other conventional industrial materials should be taken.

FOLFIRINOX as first-line treatment for unresectable acinar cell carcinoma of the pancreas: a case report

Pancreatic acinar cell carcinoma (ACC) is a rare, aggressive variant of pancreatic ductal adenocarcinoma. Surgery is the only curative treatment option and protocols for palliative chemotherapies in this context are not standardized yet. We reported a 63-year-old white male patient who had painless jaundice, weight loss, elevated bilirubin, and a mass of the pancreatic head as well as liver metastasis. Core biopsy revealed the diagnosis of ACC. Therapy with FOLFIRINOX resulted in a significant decrease of the primary tumor and regressiveness of a liver metastasis after chemotherapy. Our report suggests that pancreatic ACC treated by FOLFIRINOX is well tolerated and might be superior to other single chemotherapies in this rare tumor disease.

Preoperative left ventricular hypertrophy is associated with reduced patient survival after liver transplantation

Left ventricular hypertrophy (LVH) has been described in the context of cirrhotic cardiomyopathy. The influence of LVH on survival of liver transplant (LT) recipients has not been clarified. Therefore, we evaluated the effect of LVH on survival in LT recipients. In total, data from 352 LT patients were analyzed. LVH was diagnosed by echocardiographic measurement of left ventricular wall thickness before LT. Patients were followed up for a mean of 4.2 yr. LVH was diagnosed in 135 (38.4%) patients. Patients with LVH had significantly more frequently male gender (p = 0.046), diastolic dysfunction (p < 0.001), and hepatocellular carcinoma (HCC; p = 0.004). Furthermore, LVH patients were older (p < 0.001) and had a higher body mass index (BMI; p = 0.001). There was no difference in frequency of arterial hypertension, pre-transplant diabetes mellitus, or etiology of liver cirrhosis. Patients without LVH had a better survival (log rank: p = 0.05) compared with LVH patients. In a multivariate Cox regression LVH (p = 0.031), end-stage renal disease (ESRD; p = 0.003) and lack of arterial hypertension (p = 0.004) but not MELD score (p = 0.885) were associated with poorer survival.

CONCLUSION

LVH is frequently diagnosed in patients on the waiting list and influences survival after LT.

Incidence, risk factors, and implemented prophylaxis of varicella zoster virus infection, including complicated varicella zoster virus and herpes simplex virus infections, in lenalidomide-treated multiple myeloma patients

In the era of high-dose chemotherapy and novel antimyeloma agents, the survival of multiple myeloma (MM) patients has substantially improved. Adverse effects, including infections, may however arise in the era of combination antimyeloma therapies. In general, MM patients have shown a risk of varicella zoster virus (VZV) infection of 1-4 %, increasing with bortezomib treatment or transplants, but whether immunomodulatory drugs also bear a risk of VZV/complicated herpes simplex virus (HSV) (e.g., VZV-encephalitis [VZV-E], disseminated VZV-infection [d-VZV-i], or conus-cauda syndrome [CCS]) has not been elucidated. We here assessed VZV, VZV-E, d-VZV-i, and CCS in 93 lenalidomide-treated MM patients, consecutively seen and treated in our department. Patients' data were analyzed via electronic medical record retrieval within our research data warehouse as described previously. Of the 93 MM patients receiving lenalidomide, 10 showed VZV or other complicated VZV/HSV infections. These VZV patients showed defined risk factors as meticulously assessed, including suppressed lymphocyte subsets, substantial cell-mediated immune defects, and compromised humoral immune response. Due to our findings-and in line with an aciclovir prophylaxis in bortezomib and stem cell transplant protocols-we introduced a routine aciclovir prophylaxis in our lenalidomide protocols in May 2012 to minimize adverse events and to avoid discontinuation of lenalidomide treatment. Since then, we have observed no case of VZV/complicated HSV infection. Based on our data, we encourage other centers to also focus on these observations, assess viral infections, and-in those centers facilitating a research data warehouse-advocate an analogue data review as an appropriate multicenter approach.

Influence of PEG in PEG-PLGA microspheres on particle properties and protein release

The aim of the present study was to compare different commercial available types of Poly(d,l-lactide-co-glycolide) (PLGA), multiblock copolymers of PLGA and polyethylene gylcol (PEG) as well as blends of PLGA and PEG regarding the preparation of microparticles and the release behavior of encapsulated protein. Microspheres were prepared by the solvent evaporation technique using the same conditions for each formulation. The encapsulation rate of bovine serum albumin (BSA) was unaffected by the different polymer types, and the mean was 79±4%. Microspheres composed of blends of PLGA and PEG showed a porous structure, a higher specific surface area, an inhomogenous distribution of protein and a higher release rate of BSA than microspheres consisting of PLGA, whereas the release profiles were the same. The specific surface area of microparticle formulations composed of diblock copolymers was the highest with 8.57±0.07m(2)/g emphasized by a highly porous, sponge-like structure. The triblock copolymer formulation revealed nearly spherical particles with a slightly uneven surface. Although the triblock copolymer consists of 10% PEG, the specific surface area was the lowest of all formulations. The rapid hydration due to PEG leads to a swollen matrix, which released the protein in a slow and continuous way.

Evaluation of the online-presence (homepage) of burn units/burn centers in Germany, Austria and Switzerland

PURPOSE

A successful online presence is an important key factor in the competition among hospitals today. However, little is known about the internet presence and the quality of websites of burn units on the World Wide Web. The aim was to assess the online presence of hospitals provided by specialized burn units in German speaking countries with a focus on the rate and the performance of actively run websites.

METHODS

A multicenter, observational, cross-sectional study was performed over a period of 1.5 month (October-December 2010). Forty-four burn units were assessed by using a previously generated criteria list. The list included 36 criteria with following topics: "research and teaching"; "patient care"; "clinical emphases", "general information"; "information brokerage".

RESULTS

Overall, the websites examined offered a good overview about their different online services with many multimedia-based elements included. All websites consisted of hyperlinks, general multimedia-based elements and information on means of communication with the hospital, respectively. In contrast, the quality of specific information for burn patients was relatively poor. With regard to the need of elderly people, the usability and the layout, the different websites offer a lot of options for future improvements.

CONCLUSION

Burn centers in Germany, Austria and Switzerland already consider the World Wide Web as an important tool for self-promotion and communication. The potential of burn center websites to function as a knowledge base for first aid as well as preventive measurements should be considered and realized in future web site designs.

Characterization of CD8+ T-cell response in acute and resolved hepatitis A virus infection

BACKGROUND & AIMS

In contrast to the infection with other hepatotropic viruses, hepatitis A virus (HAV) always causes acute self-limited hepatitis, although the role for virus-specific CD8 T cells in viral containment is unclear. Herein, we analyzed the T cell response in patients with acute hepatitis by utilizing a set of overlapping peptides and predicted HLA-A2 binders from the polyprotein.

METHODS

A set of 11 predicted peptides from the HAV polyprotein, identified as potential binders, were synthesized. Peripheral blood mononuclear cells (PBMCs) from patients were tested for IFNγ secretion after stimulation with these peptides and ex vivo with HLA-A2 tetramers. Phenotyping was carried out by staining with the activation marker CD38 and the memory marker CD127.

RESULTS

Eight out of 11 predicted HLA-A2 binders showed a high binding affinity and five of them were recognized by CD8+ T cells from patients with hepatitis A. There were significant differences in the magnitude of the responses to these five peptides. One was reproducibly immunodominant and the only one detectable ex vivo by tetramer staining of CD8+ T cells. These cells have an activated phenotype (CD38hi CD127lo) during acute infection. Three additional epitopes were identified in HLA-A2 negative patients, most likely representing epitopes restricted by other HLA-class I-alleles (HLA-A11, B35, B40).

CONCLUSIONS

Patients with acute hepatitis A have a strong multi-specific T cell response detected by ICS. With the tetramer carrying the dominant HLA-A2 epitope, HAV-specific and activated CD8+ T cells could be detected ex vivo. This first description of the HAV specific CTL-epitopes will allow future studies on strength, breadth, and kinetics of the T-cell response in hepatitis A.

Raster microdiffraction with synchrotron radiation of hydrated biopolymers with nanometre step-resolution: case study of starch granules

X-ray radiation damage propagation is explored for hydrated starch granules in order to reduce the step resolution in raster-microdiffraction experiments to the nanometre range. Radiation damage was induced by synchrotron radiation microbeams of 5, 1 and 0.3 µm size with ∼0.1 nm wavelength in B-type potato, Canna edulis and Phajus grandifolius starch granules. A total loss of crystallinity of granules immersed in water was found at a dose of ∼1.3 photons nm(-3). The temperature dependence of radiation damage suggests that primary radiation damage prevails up to about 120 K while secondary radiation damage becomes effective at higher temperatures. Primary radiation damage remains confined to the beam track at 100 K. Propagation of radiation damage beyond the beam track at room temperature is assumed to be due to reactive species generated principally by water radiolysis induced by photoelectrons. By careful dose selection during data collection, raster scans with 500 nm step-resolution could be performed for granules immersed in water.

Modulation of mu opioid receptor desensitization in peripheral sensory neurons by phosphoinositide 3-kinase gamma

G protein-coupled opioid receptors undergo desensitization after prolonged agonist exposure. Recent in vitro studies of mu-opioid receptor (MOR) signaling revealed an involvement of phosphoinositide 3-kinases (PI3K) in agonist-induced MOR desensitization. Here we document a specific role of the G protein-coupled class IB isoform PI3Kgamma in MOR desensitization in mice and isolated sensory neurons. The tail-withdrawal nociception assay evidenced a compromised morphine-induced tolerance of PI3Kgamma-deficient mice compared to wild-type animals. Consistent with a role of PI3Kgamma in MOR signaling, PI3Kgamma was expressed in a subgroup of small-diameter dorsal root ganglia (DRG) along with MOR and the transient receptor potential vanilloid type 1 (TRPV1) receptor. In isolated DRG acute stimulation of MOR blocked voltage-gated calcium currents (VGCC) in both wild-type and PI3Kgamma-deficient DRG neurons. By contrast, following long-term opioid administration the attenuating effect of MOR was strongly compromised in wild-type DRG but not in PI3Kgamma-deficient DRG. Our results uncover PI3Kgamma as an essential modulator of long-term MOR desensitization and tolerance development induced by chronic opioid treatment in sensory neurons.

The measles situation in Austria: a rapid risk assessment by an ECDC team and the outcome of an international meeting in Vienna, Austria

For the last three years, Austria has been considered a low-moderate incidence country (< 1/100,000/year) for measles [1] and the last significant measles outbreak occurred in 2003 involving 64 cases [2].

[Musculoskeletal biomechanics of the knee joint. Principles of preoperative planning for osteotomy and joint replacement]

The long-term clinical outcome of surgical interventions at the knee is dependent upon the quality of the restoration of normal function, together with moderate musculoskeletal loading conditions. In order to achieve this, it is essential to consider biomechanical knowledge during the planning and execution of the procedures. Until now, such knowledge has only been available in books and journal manuscripts and is merely considered during preoperative planning. Its transfer into the specific intraoperative situation is, however, primarily dependent upon the surgeon's skills and understanding. Mathematical models hold the potential to provide the surgeon with detailed, patient-specific information on the in vivo forces, as well as their spatial and temporal distribution. Their application in clinical routine, however, requires a comprehensive validation. Based on a model validated against patient data, it has been shown that - mainly as a result of the action of the muscles - both the tibiofemoral as well as the patellofemoral joints experience substantial mechanical loads even during normal activities of daily living. The calculations further indicate that malalignment at the knee in the frontal plane of more than approximately 4 degrees results in considerably increased forces across the tibiofemoral joint. The actual change in force to a given degree of malalignment might, however, vary greatly between subjects. In order to additionally determine the distribution of the forces in more detail, a sufficiently accurate model of knee joint kinematics is required. In combination with MR-based in vivo imaging techniques, new mathematical models offer the possibility to capture the individual characteristics of knee kinematics and might additionally allow the effect of muscle activity on joint kinematics to be considered. By implementing these technologies in preoperative planning and navigation systems, up-to-date biomechanical knowledge can be made available at the surgeons' fingertips. We propose that optimizing the biomechanical conditions through using these approaches will allow the long-term function of the replaced joint to be significantly enhanced.

A new model to predict in vivo human knee kinematics under physiological-like muscle activation

Although a number of approaches have attempted to model knee kinematics, rarely have they been validated against in vivo data in a larger subject cohort. Here, we assess the feasibility of four-bar linkage mechanisms in addressing knee kinematics and propose a new approach that is capable of accounting for lengthening characteristics of the ligaments, including possible laxity, as well as the internal/external rotation of the joint. MR scans of the knee joints of 12 healthy volunteers were taken at flexion angles of 0 degrees , 30 degrees and 90 degrees under both passive and active muscle conditions. By reconstructing the surfaces at each position, the accuracy of the four-bar linkage mechanism was assessed for every possible combination of points within each cruciate ligament attachment area. The specific set of parameters that minimized the deviation between the predictions and the in vivo pose was derived, producing a mean error of 1.8 and 2.5 on the medial and 1.7 and 2.4mm on the lateral side at 30 degrees and 90 degrees flexion, respectively, for passive motion, significantly improving on the models that did not consider internal/external rotation. For active flexion, mean medial errors were 3.3 and 4.7 mm and lateral errors 3.4 and 4.8 mm. Using this best parameter set, a generic predictive model was created and assessed against the known in vivo positions, producing a maximum average error of 4.9 mm at 90 degrees flexion. The accuracy achieved shows that kinematics may be accurately reconstructed for subject specific musculoskeletal models to allow a better understanding of the load distribution within the knee.

An esophagobronchial fistula caused by an unusual foreign body in the esophagus leading to mediastinitis with fatal outcome

An 8(10)/(12) year old girl with infantile cerebral paresis (ICP), severe mental retardation and seizure disorder was admitted to the intensive care unit (ICU) with clinical signs of aspiration and died ten days later. Final diagnosis was esophagobronchial fistula caused by a foreign body in the esophagus provoking aspiration pneumonia, mediastinitis and respiratory distress syndrome (ARDS). The foreign body was found to be part of a plastic toy. The clinical relevance of aspiration in mentally retarded children and the peculiar nature of the foreign body impacted in the esophagus in this case are discussed. We conclude that in cases of aspiration pneumonia in mentally retarded children the presence of unusual foreign bodies should be suspected.

Molecular epidemiology of West Nile Virus in humans

After the introduction of West Nile Virus into the United States of America in 1999 followed by annual WNV epidemics during the mosquito seasons and spreading of the virus from the East (New York; 1999) to the West of the U.S. (California; 2003/2004) there appeared the question of whether a similar scenario could happen in Europe, too. To be able to answer this question the German Ministry of Health decided to investigate the prevalence and incidence of WNV infections in German blood donors. First a test algorithm was established taking into account the high level of cross-reactivity between different flavivirus infections in serological test systems. AntiWNV-suspicious specimens were further investigated for their neutralisation capacity and by an antiWNV confirmation assay developed in-house. As a preliminary result of our studies a very low prevalence of WNV infections in healthy German blood donors was measured. Development of highly specific test systems is necessary for accurate and reliable differential diagnosis of flavivirus infections.

Magnetic resonance imaging guided corticosteroid injection of sacroiliac joints in patients with spondylarthropathy. Are multiple injections more beneficial?

Efficacy of a second magnetic resonance (MR) imaging guided corticosteroid injection of inflamed sacroiliac joints (SIJ) in patients with spondylarthropathy. Thirty-one patients received 50 injections in an outpatient basis. Fifteen of 31 patients who relapsed or were non-responders received a second injection. All had MR guided injection of 40 mg triamcinolone acetonide into SIJ using an open 0.2 Tesla unit. Twenty of 31 patients after the first injection, and 9 of 15 patients after the second injection reported subjective improvement, which lasted for a mean of 8.7+/-10.9 and 16.1+/-15.8 months for each group. Subchondral bone marrow edema resolved in 15 of 20 patients who reported subjective improvement, after the first injection. No complications occurred. MR guided steroid injection of SIJ is effective and safe. Since there is no exposure to radiation it could be performed many times. Repeated injections seem to be beneficial for primary non-responders and patients who relapsed.

Differenzialdiagnose einer papulösen Hauterkrankung des Neugeborenen: Pemphigoid gestationis

The clinical relevance of bullous skin diseases in newborns varies widely. We present the case of a preterm, 35 weeks of gestation, infant who was admitted to our hospital with skin lesions on face, thorax and plantae. There were no other pathological findings on clinical and neurological examinations. During another pregnancy the mother of the child had already suffered from pemphigoid gestationis. In the blood of the newborn complement-fixing auto-antibodies against BP180, the common antigen of pemphigoid gestationis and bullous pemphigoid, were detected. The skin lesions disappeared after a few days of local antiseptic therapy. Pemphigoid gestations is a rare autoimmune dermatosis in pregnancy. The frequency of skin lesions in newborns of mothers with pemphigoid gestationis is estimated to about 5 -- 10 %.

[Children: improving the prevention and early advancement in children with behavioral- and developmental disorders in the Ennepe-Ruhr District]

Developmental behavioural disorders in early childhood are a serious public health problem, because they signify a higher risk of social, regulatory and emotional impairment in later life. The public health office in Ennepe-Ruhr develops in cooperation with the communities a programme of health promotion for children and their families. An important motive is continually rising costs for supporting children with developmental problems. An element in the programme is a project of counselling mothers with babies and toddlers with excessive crying, serious sleep disorders and anxiety problems. This example of early intervention promises short-term relief, early identification of problem children and the strengthening of parental resources. A key issue is the introduction of a systematic evaluation of all communal funding for measures of support for preschool children. It shows that such measures start relatively late, and the coordination at community level is not always optimal. Some progress has been made, but criteria to measure the efficiency of current health promotion are still lacking. According to public health research early intervention for risk groups (single mothers, migrant families or families depending on public assistance) promises to give children and their families a better social and health perspective in life. It should be a primary health target for communities to develop evidence-based health programmes for children, focussing on mental and social well-being. Studies indicate that such interventions might have positive financial results.

Synaptic congenital myasthenic syndrome in three patients due to a novel missense mutation (T441A) of the COLQ gene

Congenital myasthenic syndromes (CMS) with deficiency of endplate acetylcholinesterase (AChE) are caused by mutations in the synapse specific collagenic tail subunit gene (COLQ) of AChE. We identified a novel missense mutation (T441A) homozygously in three CMS patients from two unrelated German families. The mutation is located in the C-terminal region of the ColQ protein, which initiates assembly of the triple helix, and is essential for insertion of the tail subunit into the basal lamina. Density gradient analysis of AChE extracted from muscle of one of the patients revealed the absence of asymmetric AChE. All patients were characterized by an onset of disease in childhood, exercise-induced proximal weakness, absence of ptosis and ophthalmoparesis, a decremental EMG response, and deterioration in response to anticholinesterase drugs. However, age at onset, disease progression, disease severity, and functional impairment varied considerably among the three patients. As adults, two siblings from one family experience only mild impairment, while the third patient requires a wheelchair for most of the day and assisted ventilation at night.