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Kohl SH, Schmidt-Lucke C. Clinical trials to go green-A sustainable argument for decentralised digital clinical trials. PLOS Digit Health 2023; 2:e0000366. [PMID: 37874796 PMCID: PMC10597501 DOI: 10.1371/journal.pdig.0000366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2023]
Affiliation(s)
- Simon H. Kohl
- MEDIACC GmbH, Sächsische Str. 70, 10707 Berlin, Germany
| | - Caroline Schmidt-Lucke
- MEDIACC GmbH, Sächsische Str. 70, 10707 Berlin, Germany
- Charité-Universitätsmedizin Berlin, Berlin, Germany
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Mengis N, Schmidt S, Ellermann A, Sobau C, Egloff C, Kreher MM, Ksoll K, Schmidt-Lucke C, Rippke JN. A Novel Sensor-Based Application for Home-Based Rehabilitation Can Objectively Measure Postoperative Outcomes following Anterior Cruciate Ligament Reconstruction. J Pers Med 2023; 13:1398. [PMID: 37763164 PMCID: PMC10532617 DOI: 10.3390/jpm13091398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 09/07/2023] [Accepted: 09/16/2023] [Indexed: 09/29/2023] Open
Abstract
In order to successfully implement individualized patient rehabilitation and home-based rehabilitation programs, the rehabilitation process should be objectifiable, monitorable and comprehensible. For this purpose, objective measurements are required in addition to subjective measurement tools. Thus, the aim of this prospective, single-center clinical trial is the clinical validation of an objective, digital medical device (DMD) during the rehabilitation after anterior cruciate ligament reconstruction (ACLR) with regards to an internationally accepted measurement tool. Sixty-seven patients planned for primary ACLR (70:30% male-female, aged 25 years [21-32], IKDC-SKF 47 [31-60], Tegner Activity Scale 6 [4-7], Lysholm Score 57 [42-72]) were included and received physical therapy and the DMD after surgery. For clinical validation, combined measures of range of motion (ROM), coordination, strength and agility were assessed using the DMD in addition to patient-reported outcome measures (PROMs) at three and six months after ACLR. Significant correlations were detected for ROM (rs = 0.36-0.46, p < 0.025) and strength/agility via the single-leg vertical jump (rs = 0.43, p = 0.011) and side hop test (rs = 0.37, p = 0.042), as well as for coordination via the Y-Balance test (rs = 0.58, p ≤ 0.0001) regarding the IKDC-SKF at three months. Additionally, DMD test results for coordination, strength and agility (Y-Balance test (rs = 0.50, p = 0.008), side hop test (rs = 0.54, p = 0.004) and single-leg vertical jump (rs = 0.44, p = 0.018)) correlate significantly with the IKDC-SKF at six months. No adverse events related to the use of the sensor-based application were reported. These findings confirm the clinical validity of a DMD to objectively quantify knee joint function for the first time. This will have further implications for clinical and therapeutic decision making, quality control and monitoring of rehabilitation measures as well as scientific research.
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Affiliation(s)
- Natalie Mengis
- Department of Orthopedic and Trauma Surgery, Kantonsspital Baselland, 4101 Bruderholz, Switzerland
- ARCUS Kliniken, Department of Sports Medicine, Rastatter Straße 17-19, 75175 Pforzheim, Germany; (S.S.); (A.E.); (C.S.); (J.-N.R.)
- Department of Orthopedic and Trauma Surgery, University Hospital Basel, Petersgraben 4/Spitalstrasse 21, 4031 Basel, Switzerland;
| | - Sebastian Schmidt
- ARCUS Kliniken, Department of Sports Medicine, Rastatter Straße 17-19, 75175 Pforzheim, Germany; (S.S.); (A.E.); (C.S.); (J.-N.R.)
- Department of Orthopedic Surgery, Vincentius-Diakonissen-Kliniken gAG, Steinhäuserstraße 18, 76135 Karlsruhe, Germany
| | - Andree Ellermann
- ARCUS Kliniken, Department of Sports Medicine, Rastatter Straße 17-19, 75175 Pforzheim, Germany; (S.S.); (A.E.); (C.S.); (J.-N.R.)
| | - Christian Sobau
- ARCUS Kliniken, Department of Sports Medicine, Rastatter Straße 17-19, 75175 Pforzheim, Germany; (S.S.); (A.E.); (C.S.); (J.-N.R.)
| | - Christian Egloff
- Department of Orthopedic and Trauma Surgery, University Hospital Basel, Petersgraben 4/Spitalstrasse 21, 4031 Basel, Switzerland;
| | - Mahli Megan Kreher
- MEDIACC, Medical-Academic Research Consultancy, 10713 Berlin, Germany; (M.M.K.); (C.S.-L.)
| | | | - Caroline Schmidt-Lucke
- MEDIACC, Medical-Academic Research Consultancy, 10713 Berlin, Germany; (M.M.K.); (C.S.-L.)
| | - Jules-Nikolaus Rippke
- ARCUS Kliniken, Department of Sports Medicine, Rastatter Straße 17-19, 75175 Pforzheim, Germany; (S.S.); (A.E.); (C.S.); (J.-N.R.)
- Department of Orthopedic and Trauma Surgery, University Hospital Basel, Petersgraben 4/Spitalstrasse 21, 4031 Basel, Switzerland;
- Department of Orthopedic and Trauma Surgery, KSA Spital Zofingen, Mühlethalstrasse 27, 4800 Zofingen, Switzerland
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Karaszewski W, Pekanovic A, Streich NA, Herbort M, Petersen W, Schmidt-Lucke C. Ultrasonography for quantitative assessment of knee joint effusions-useful tool for objective evaluation of rehabilitation progress? Int Orthop 2023; 47:955-961. [PMID: 36683051 DOI: 10.1007/s00264-023-05697-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 01/07/2023] [Indexed: 01/24/2023]
Abstract
PURPOSE We sought to externally validate ultrasonography (US) for quantification of suprapatellar effusion size to improve diagnosis and individualised rehabilitation strategies in knee rehabilitation after anterior cruciate ligament reconstruction (ACLR) surgery. METHODS US was performed on 35 patients as part of the ongoing CAMOPED study. Data were collected in ACLR and post surgery in defined intervals up to one year post-operation. The palpatory assessment was graded using the International Knee Documentation Committee (oIKDC). RESULTS In a total of 164 sonographies, a strong correlation between palpatory and US effusion (r = 0.83, p < 0.01) with lower deviations in US quantification compared to palpatory quantification Y = 1.15 + 0.15* x was seen. Threshold values could be determined for the detection of effusions by palpation and for the differentiation between mild and moderate/severe effusions (effusion depth: 2.6 mm and resp. 5.8 mm, respectively). CONCLUSIONS As demonstrated in this multicenter study, the size of suprapatellar effusions can be easily quantified with high accuracy using standardised bedside ultrasound. Especially in moderate to severe effusions, US provides a practical and reliable tool for outcome measurement superior to palpatory assessment with the goal of optimising individual recommendations during the rehabilitation course. Furthermore, for the first time, it has been possible to define sonographic threshold values for the detection of effusion and differentiation of mild vs. moderate/severe effusion by means of palpation.
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Affiliation(s)
- Willi Karaszewski
- MEDIACC (Medico-academic consultings), Berlin, Germany.,Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Ana Pekanovic
- MEDIACC (Medico-academic consultings), Berlin, Germany
| | | | - Mirco Herbort
- Orthopädische Chirurgie München, Munich, Germany.,Research Unit for Orthopaedic Sports Medicine and Injury Prevention (OSMI), Medical Informatics and Technology, Private University for Health Sciences, Innsbruck, Austria
| | | | - Caroline Schmidt-Lucke
- MEDIACC (Medico-academic consultings), Berlin, Germany. .,Charité-Universitätsmedizin Berlin, Berlin, Germany.
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Höher J, Lischke B, Petersen W, Mengis N, Niederer D, Stein T, Stoffels T, Prill R, Schmidt-Lucke C. Sensor-based telerehabilitation system increases patient adherence after knee surgery. PLOS Digit Health 2023; 2:e0000175. [PMID: 36812639 PMCID: PMC9937459 DOI: 10.1371/journal.pdig.0000175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 12/02/2022] [Indexed: 02/19/2023]
Abstract
OBJECTIVES Implementing evidence-based recommendations with the option of patient-individualised and situation-specific adaptations in telerehabilitation may increase adherence with improved clinical outcome. METHODS As part of a registry-embedded hybrid design (part 1), digital medical device (DMD)-usage in a home-based setting was analysed in a multinational registry. The DMD combines an inertial motion-sensor system with instructions for exercises and functional tests on smartphones. A prospective, single-blinded, patient-controlled, multicentre intervention study (DRKS00023857) compared implementation capacity of the DMD to standard physiotherapy (part 2). Usage patterns by health care providers (HCP) were assessed (part 3). RESULTS AND CONCLUSION Registry raw data (10,311 measurements) were analysed from 604 DMD-users, demonstrating clinically expected rehabilitation progression post knee injuries. DMD-users performed tests for range-of-motion, coordination and strength/speed enabling insight to stage-specific rehabilitation (χ2 = 44.9, p<0.001). Intention-to-treat-analysis (part 2) revealed DMD-users to have significantly higher adherence to the rehabilitation intervention compared to the matched patient-control-group (86% [77-91] vs. 74% [68-82], p<0.05). DMD-users performed recommended exercises at home with higher intensity (p<0.05). HCP used DMD for clinical decision making. No adverse events related to the DMD were reported. Adherence to standard therapy recommendations can be increased using novel high quality DMD with high potential to improve clinical rehabilitation outcome, enabling evidence-based telerehabilitation.
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Affiliation(s)
- Jürgen Höher
- Sportsclinic Cologne, Cologne, Germany
- Department for Orthopedics and Sports Traumatology, Merheim Hospital Cologne, University of Witten-Herdecke, Germany
- * E-mail:
| | - Betty Lischke
- MEDIACC (Medico-academic Consultings), Berlin, Germany
| | | | | | - Daniel Niederer
- Department of Sports Medicine and Exercise Physiology, Institute of Occupational, Social and Environmental Medicine, Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Thomas Stein
- Department of Sports Medicine and Exercise Physiology, Institute of Occupational, Social and Environmental Medicine, Goethe-University Frankfurt, Frankfurt am Main, Germany
- SPORTHOLOGICUM Frankfurt—Center for Sport and Joint Injuries, Frankfurt am Main, Germany
| | - Thomas Stoffels
- OC Stadtmitte—Practice for Orthopedics & Surgery, Berlin, Germany
| | - Robert Prill
- Center of Orthopaedics and Traumatology, Brandenburg Medical School, University Hospital Brandenburg/Havel, Germany
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Mohammad J, Lischke B, Rheimann R, Haspel A, Habazettl H, Schmidt-Lucke A, Pekanovic A, Ochsenreither S, Keller U, Schmidt-Lucke C. Reduction of aerobic metabolism and increased microvascular perfusion during pressure-adjusted static compression as underlying mechanism with potential of preventing chemotherapy-induced neuropathy. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Chemotherapy (CTX)-induced neuropathy [CIPN] limits the maximal applicable dose. Static compression for prevention of CIPN is recommended by guidelines. The postulated underlying effect of reduced microvascular perfusion (MP), however, contradicts current knowledge of elegant in vivo studies.
We, thus tested the hypothesis of increased MP combined with reduction of aerobic metabolism in response to pressure-adjusted static compression (PSC) in CTX-induced endothelial damage (CIED).
Metabolic oxygen demand (dh), tissue oxygenation (StO2), oxygen supply (O2h) and microvascular perfusion (th) were measured with quantitative time-resolved near infra-red spectroscopy (NIRS) and temperature with thermography on upper extremities following standard procedures in healthy volunteers (n=12, 6 female; age 22±2), peripheral arterial disease patients (n=17, PAD; 75% male, age 68±9 years, 42%, positive controls) and CTX (n=22) with and without clinical CIPN (n=11 each, 46% male; age 64±11 years). Endothelial microvascular function was quantified during post-ischaemic reactive hyperaemia (PIRH). Resting muscle metabolism was quantified by dh during minute 1 of arterial occlusion. Perfusion was quantified by th during venous occlusion. PSC was applied with commercially available compression products and patented palmar pads for up to 90 minutes under standardised and controlled conditions.
PSC induces instant and constant fall of temperature (−4.8±0.8°C, p<0.05) and oxygen demand (−3.4±5.2μM, p<0.05). PSC lead to further reduction of tissue metabolism (O2h: −27±38%, dh: −27±38.2%, PIRH-AUC: −20±27%, p<0,05 each compared to without PSC). Oxygen supply increased time-dependently (O2h: 3.0±1.3 μM, p<0.001) as consequence of locally increased perfusion (19±45%, p<0.05) with subsequent rise of tissue oxygenation (StO2: 9.1±4.2, p<0.01) that continued beyond the PSC-duration, indicating a rather metabolic mechanism. This effect is accompanied by a significant similar, albeit lesser reaction on the control hand (p<0.05). PIRH was reduced in controls in response to PSC as a sign for reduced metabolism. In PAD, reaction to PSC was less pronounced and non-significant, reflecting effects of endothelial dysfunction. Patients with CTX with CIPN showed significant endothelial dysfunction compared to controls (StO2 downslope −7±2%, T95 (s) 13±5, PIRH-AUC 9±6, p<0.05 each) and to CTX without CIPN (p<0.05 each), like PAD.
For the first time, CIED as result of CTX comparable to atherosclerotic disease is shown. In contrast to previous assumptions of clinicians propagating compression therapy for prevention of CIPN, the results presented prove that not constriction of the products, but rather a combination of increased local perfusion and oxygen delivery in combination with mechanical effects on the low pressure system and reduced metabolism is induced by PSC. These findings open the field for well-designed RCTs to develop novel treatment options for CIPN targeting CIED.
Funding Acknowledgement
Type of funding sources: Private company. Main funding source(s): MEDIACC GmbH
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Affiliation(s)
- J Mohammad
- MEDIACC GmbH, Medico Academic Consulting , Berlin , Germany
| | - B Lischke
- MEDIACC GmbH, Medico Academic Consulting , Berlin , Germany
| | - R Rheimann
- MEDIACC GmbH, Medico Academic Consulting , Berlin , Germany
| | - A Haspel
- MEDIACC GmbH, Medico Academic Consulting , Berlin , Germany
| | - H Habazettl
- Charite - Campus Mitte (CCM) , Berlin , Germany
| | - A Schmidt-Lucke
- Practice for internal medicine medical practice , berlin , Germany
| | - A Pekanovic
- MEDIACC GmbH, Medico Academic Consulting , Berlin , Germany
| | - S Ochsenreither
- Charité-Universitätsmedizin Berlin, Dpt of Hematology, oncology and Tumor immunology , Berlin , Germany
| | - U Keller
- Charité-Universitätsmedizin Berlin, Dpt of Hematology, oncology and Tumor immunology , Berlin , Germany
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Pekanovic A, Strobl W, Hafkemeyer U, Kleine J, Bernius P, Burghardt R, Schmidt-Lucke C. Dynamic Standing Exercise Using the Innowalk Device in Patients with Genetic and Acquired Motor Impairments. J Rehabil Med 2022; 54:jrm00284. [PMID: 35362086 DOI: 10.2340/jrm.v54.23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE For individuals with motor impairments, dynamic standing has been proposed as an opportunity for regular daily physical activity. The aim of this study was to analyse patient characteristics, indications, intensity of usage, desired objectives and outcomes of dynamic standing in daily clinical practice in order to form the basis for research regarding this treatment option. SETTING Data were analysed from standardized questionnaires completed prospectively before supply of a home-based medical device for dynamic standing (Innowalk; Made for Movement GmbH, Langenhagen, Germany) and at the time of individual adaptations. PARTICIPANTS In a retrospective chart analysis, records of 46 patients (50% cerebral palsy; 50% diverse syndromes) were evaluated. INTERVENTION The Innowalk had been prescribed for either home-based use (n = 31), in therapeutic institutions (n = 8), or other settings (n = 7). Dynamic standing was performed for 10-30 min as a single session (n = 8) or for 20-60 min 11 [4-21] weeks in 36 patients. RESULTS Improvements were found for: passive assisted motion (79%), stimulation of intestinal functions (71%), body stability (64%), joint mobility (56%), secure means of allowing supine position (52%), and revision of abnormal motion patterns (48%). CONCLUSION Thus, this systematic approach shows usage patterns, indications, desired goals and clinical outcome of dynamic standing in daily clinical practice and forms the basis for the design of a prospective, randomized controlled trial.
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Schmidt-Lucke C, Käferle J, Rydh Berner BM, Ahlborg L, Hansen HM, Skjellvik Tollefsen U, Thon T, Damkjær Moen R, Pekanovic A, Tornberg ÅB, Lauruschkus K. Effect of assisted walking-movement in patients with genetic and acquired neuromuscular disorders with the motorised Innowalk device: an international case study meta-analysis. PeerJ 2019; 7:e7098. [PMID: 31249736 PMCID: PMC6587941 DOI: 10.7717/peerj.7098] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 05/08/2019] [Indexed: 12/31/2022] Open
Abstract
People with physical disabilities (PD) suffer from consequences due to lack of physical activity and consequently, are at increased risk of chronic diseases. We aimed to evaluate the ability of a motorised assistive device for dynamic standing with weight-bearing in addition to standard state-of-the-art therapy to improve clinical outcome in a meta-analysis of available studies. A total of 11 studies were identified from different European countries analysing the effect of the dynamic device Innowalk. Raw data of nine studies were pooled including a total of 31 patients observed between 2009 and 2017. Standardised questionnaires and physical outcomes were examined in this exploratory meta-analysis. We recorded patients' characteristics, duration, intensity, and location of usage as well as general clinical outcomes and improvement of passive range of motion (PROM). The analysed population consisted in 90% cases of patients younger than 18 years of age. Patients were severely disabled individuals (aged 8 (6-10) years; 58% male; 67% non-ambulatory, 86% cerebral palsy). A total of 94% used the Innowalk in a home-based or day-care setting. For nearly all individuals (94%), improvements were recorded for: walking or weight-bearing transfer (n = 13), control/strength of the trunk or head (n = 6), joint mobility (n = 14), sleep (n = 4 out of 6/67%), or muscle strength (n = 17), vital functions (n = 16), bowel function (n = 10), attention/orientation (n = 2). PROM of the hip (flexion, abduction, and adduction) significantly (p < 0.001 for multiple comparisons) increased after 1 month (p < 0.05 flexion, adduction) and further after 5 months (p < 0.05 each) in contrast (p < 0.05 each) to a control group with state-of-the-art therapy. Similarly, PROM showed a trend towards improvement in dorsal extension of the ankle (p = 0.07). In summary, this is the first report of a novel device with additional benefit to standard therapy for severe PD. These intriguing results warrant the planned prospective randomised controlled trial to prove the concept and mechanism of action of this device.
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Affiliation(s)
- Caroline Schmidt-Lucke
- Charité University Berlin, Berlin, Germany.,Medico-academic Consultings, Berlin, Germany
| | | | - Britt-Marie Rydh Berner
- Department of Rehabilitation Medicine Stockholm, Danderyd University Hospital, Stockholm, Sweden
| | - Lotta Ahlborg
- Department of Rehabilitation Medicine Stockholm, Danderyd University Hospital, Stockholm, Sweden
| | | | | | - Tonje Thon
- Municipality of Porsgrunn, Posgrunn, Norway
| | | | | | - Åsa B Tornberg
- Department of Health Sciences, Faculty of Medicine, Lund University, Lund, Sweden
| | - Katarina Lauruschkus
- Department of Health Sciences, Faculty of Medicine, Lund University, Lund, Sweden
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Schmidt-Lucke C, Zobel T, Escher F, Tschöpe C, Lassner D, Kühl U, Gubbe K, Volk HD, Schultheiss HP. Human Parvovirus B19 (B19V) Up-regulates CXCR4 Surface Expression of Circulating Angiogenic Cells: Implications for Cardiac Ischemia in B19V Cardiomyopathy. J Infect Dis 2019; 217:456-465. [PMID: 28961998 DOI: 10.1093/infdis/jix309] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 07/04/2017] [Indexed: 01/09/2023] Open
Abstract
Background Human parvovirus B19 (B19V) infection and damage of circulating angiogenic cells (CAC) results in dysfunctional endogenous vascular repair (DEVR) with secondary end-organ damage. Trafficking of CAC is regulated by SDF-1α and the respective receptor CXCR4. We thus tested the hypothesis of a deregulated CXCR4/SDF-1α axis in symptomatic B19V-cardiomyopathy. Methods CAC were infected in vitro with B19V and transfected with B19V-components. Read-out were: CXCR4-expression and migratory capacity at increasing doses of SDF-1α. In 31 patients with chronic B19V-cardiomyopathy compared to 20 controls read-outs were from blood: migratory capacity, CXCR4 expression on CAC, serum SDF-1α; from cardiac biopsies: SDF-1α mRNA, HIF-1α mRNA, microvascular density, resident cardiac stem cells (CSC), transcardiac gradients of CAC. Results In vitro B19V-infected CAC showed up-regulation of surface CXCR4 with increased migratory capacity further enhanced by elevated SDF-1α concentrations. Overexpression of the B19V capsid protein VP2 was associated with this effect. Chronic B19V-cardiomyopathy patients showed increased numbers of ischaemia mobilised CAC but DEVR as well as diminished numbers of CAC after transcardiac passage. Cardiac microvascular density and CSC were significantly reduced in B19V-cardiomyopathy. Conclusions We thus conclude that B19V infection has a direct VP2-mediated negative impact on trafficking of CAC in the presence of impaired cardiac regeneration.
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Affiliation(s)
- Caroline Schmidt-Lucke
- Department of Cardiology and Pneumology, Charité-University Medicine.,Berlin-Brandenburg Center for Regenerative Therapies, Charité-University Medicine.,Medico-academic Consultings (MEDIACC)
| | - Thomas Zobel
- Department of Cardiology and Pneumology, Charité-University Medicine
| | - Felicitas Escher
- Department of Cardiology and Pneumology, Charité-University Medicine.,Institut für Kardiale Diagnostik und Therapie, Berlin
| | - Carsten Tschöpe
- Department of Cardiology and Pneumology, Charité-University Medicine.,Berlin-Brandenburg Center for Regenerative Therapies, Charité-University Medicine
| | - Dirk Lassner
- Institut für Kardiale Diagnostik und Therapie, Berlin
| | - Uwe Kühl
- Department of Cardiology and Pneumology, Charité-University Medicine
| | - Knut Gubbe
- Institute of Transfusion Medicine and Immunohematology, German Red Cross, Plauen
| | - Hans-Dieter Volk
- Berlin-Brandenburg Center for Regenerative Therapies, Charité-University Medicine.,Institute of Medical Immunology, Charité-University Medicine, Berlin, Germany
| | - Heinz-Peter Schultheiss
- Department of Cardiology and Pneumology, Charité-University Medicine.,Institut für Kardiale Diagnostik und Therapie, Berlin
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von Seck P, Sander FM, Lanzendorf L, von Seck S, Schmidt-Lucke A, Zielonka M, Schmidt-Lucke C. Persistent weight loss with a non-invasive novel medical device to change eating behaviour in obese individuals with high-risk cardiovascular risk profile. PLoS One 2017; 12:e0174528. [PMID: 28403206 PMCID: PMC5389612 DOI: 10.1371/journal.pone.0174528] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 03/07/2017] [Indexed: 12/27/2022] Open
Abstract
In evidence-based weight-loss programs weight regain is common after an initial weight reduction. Eating slowly significantly lowers meal energy intake and hunger ratings. Despite this knowledge, obese individuals do not implement this behaviour. We, thus tested the hypothesis of changing eating behaviour with an intra-oral medical device leading to constant weight reduction in overweight and obesity. Six obese patients (6 men, age 56 ± 14, BMI 29 ± 2 kg / m2) with increased CVRF profile were included in this prospective study. All patients had been treated for obesity during the last 10 years in a single centre and had at least 3 frustrate evidence-based diets. Patients received a novel non-invasive intra-oral medical device to slow eating time. Further advice included not to count calories, to avoid any other form of diet, to take their time with their meals, and to eat whatever they liked. This device was used only during meals for the first 4 to 8 weeks for a total of 88 [20–160] hours. Follow-up period was 23 [15–38] months. During this period, patients lost 11% [5–20%] (p<0.001) of their initial weight. At 12 months, all patients had lost >5%, and 67% (4/6) achieved a >10% bodyweight loss. In the course of the study, altered eating patterns were observed. There were no complications with the medical device. Of note, all patients continued to lose weight after the initial intervention period (p<0.001) and none of them had weight regain. With this medical device, overweight and obese patients with a history of previously frustrating attempts to lose weight achieved a significant and sustained weight loss over two years. These results warrant the ongoing prospective randomised controlled trial to prove concept and mechanism of action. Trial registration: German Clinical Trials Register DRKS00011357
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Affiliation(s)
| | | | - Leon Lanzendorf
- Department of Health Care Management, Technical University Berlin, Berlin, Germany
| | | | - André Schmidt-Lucke
- Department of Internal Medicine, Hygiea Hospital and Medical Practice, Berlin, Germany
| | | | - Caroline Schmidt-Lucke
- Charité University Berlin, Berlin, Germany
- Medico-academic Consultings, Berlin, Germany
- * E-mail:
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Schmidt-Lucke C, Zobel T, Schrepfer S, Kuhl U, Wang D, Klingel K, Becher PM, Fechner H, Pozzuto T, Van Linthout S, Lassner D, Spillmann F, Escher F, Holinski S, Volk HD, Schultheiss HP, Tschope C. Impaired Endothelial Regeneration Through Human Parvovirus B19-Infected Circulating Angiogenic Cells in Patients With Cardiomyopathy. J Infect Dis 2015; 212:1070-81. [PMID: 25805750 DOI: 10.1093/infdis/jiv178] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Accepted: 02/26/2015] [Indexed: 11/13/2022] Open
Abstract
Human parvovirus B19 (B19V) is a common pathogen in microvascular disease and cardiomyopathy, owing to infection of endothelial cells. B19V replication, however, is almost restricted to erythroid progenitor cells (ErPCs). Endothelial regeneration attributable to bone marrow-derived circulating angiogenic cells (CACs) is a prerequisite for organ function. Because of many similarities of ErPCs and CACs, we hypothesized that B19V is a perpetrator of impaired endogenous endothelial regeneration. B19V DNA and messenger RNA from endomyocardial biopsy specimens, bone marrow specimens, and circulating progenitor cells were quantified by polymerase chain reaction analysis. The highest B19V DNA concentrations were found in CD34(+)KDR(+) cells from 17 patients with chronic B19V-associated cardiomyopathy. B19V replication intermediates could be detected in nearly half of the patients. Furthermore, chronic B19V infection was associated with impaired endothelial regenerative capacity. B19V infection of CACs in vitro resulted in expression of transcripts encoding B19V proteins. The capsid protein VP1 was identified as a novel inducer of apoptosis, as were nonstructural proteins. Inhibition studies identified so-called death receptor signaling with activation of caspase-8 and caspase-10 to be responsible for apoptosis induction. B19V causally impaired endothelial regeneration with spreading of B19V in CACs in an animal model in vivo. We thus conclude that B19V infection and damage to CACs result in dysfunctional endogenous vascular repair, supporting the emergence of primary bone marrow disease with secondary end-organ damage.
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Affiliation(s)
- Caroline Schmidt-Lucke
- Department of Cardiology and Pneumology Berlin-Brandenburg Center for Regenerative Therapies Medico-Academic Consultings
| | | | - Sonja Schrepfer
- Transplant and Stem Cell Immunobiology Laboratory, University Heart Center Hamburg
| | - Uwe Kuhl
- Department of Cardiology and Pneumology
| | - Dong Wang
- Transplant and Stem Cell Immunobiology Laboratory, University Heart Center Hamburg
| | - Karin Klingel
- Department of Molecular Pathology, Institute of Pathology, Tübingen, Germany
| | | | - Henry Fechner
- Department of Cardiology and Pneumology Institute for Biotechnology, University of Technology
| | | | | | | | | | | | | | - Hans-Dieter Volk
- Institute of Medical Immunology, Charité-Universitätsmedizin Berlin-Brandenburg Center for Regenerative Therapies
| | | | - Carsten Tschope
- Department of Cardiology and Pneumology Berlin-Brandenburg Center for Regenerative Therapies Deutsches Zentrum für Herz-Kreislauf-Forschung, Berlin
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Bobbert P, Weikert U, Schmidt-Lucke C, Skurk C, Meyer A, Steffens D, Schultheiss HP, Rauch U. Platelet activation and thrombus formation relates to the presence of myocardial inflammation in patients with cardiomyopathy. J Cardiol 2014; 63:379-84. [DOI: 10.1016/j.jjcc.2013.09.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2013] [Revised: 08/06/2013] [Accepted: 09/18/2013] [Indexed: 11/28/2022]
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Van Linthout S, Savvatis K, Miteva K, Peng J, Ringe J, Warstat K, Schmidt-Lucke C, Sittinger M, Schultheiss HP, Tschöpe C. ‘Mesenchymal stem cells improve murine acute coxsackievirus B3-induced myocarditis’ [Eur Heart J 2011;32(17):2168-2178, doi:10.1093/eurheartj/ehq467]. Eur Heart J 2013. [DOI: 10.1093/eurheartj/eht012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Pozzuto T, von Kietzell K, Bock T, Schmidt-Lucke C, Poller W, Zobel T, Lassner D, Zeichhardt H, Weger S, Fechner H. Transactivation of human parvovirus B19 gene expression in endothelial cells by adenoviral helper functions. Virology 2011; 411:50-64. [PMID: 21236463 DOI: 10.1016/j.virol.2010.12.019] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2010] [Revised: 12/06/2010] [Accepted: 12/13/2010] [Indexed: 12/15/2022]
Abstract
Human parvovirus B19 (B19V) DNA is highly prevalent in endothelial cells lining up intramyocardial arterioles and postcapillary venules of patients with chronic myocarditis and cardiomyopathies. We addressed the question of a possible stimulation of B19V gene expression in endothelial cells by infection with adenoviruses. Adenovirus infection led to a strong augmentation of B19V structural and nonstructural proteins in individual endothelial cells infected with B19V or transfected with an infectious B19V genome. Transactivation was mostly mediated at the level of transcription and not due to adenovirus-mediated induction of second-strand synthesis from the single-stranded parvoviral genome. The main adenoviral functions required were E1A and E4orf6, which displayed synergistic effects. Furthermore, a limited B19V genome replication could be demonstrated in endothelial cells and adenovirus infection induced the appearance of putative dimeric replication intermediates. Thus the almost complete block in B19V gene expression seen in endothelial cells can be abrogated by infection with other viruses.
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Affiliation(s)
- Tanja Pozzuto
- Department of Cardiology and Pneumology, Campus Benjamin Franklin, Charité-University Medicine Berlin, Hindenburgdamm 30, 12200 Berlin, Germany.
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Van Linthout S, Savvatis K, Miteva K, Peng J, Ringe J, Warstat K, Schmidt-Lucke C, Sittinger M, Schultheiss HP, Tschöpe C. Mesenchymal stem cells improve murine acute coxsackievirus B3-induced myocarditis. Eur Heart J 2010; 32:2168-78. [PMID: 21183501 PMCID: PMC3164101 DOI: 10.1093/eurheartj/ehq467] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Aims Coxsackievirus B3 (CVB3)-induced myocarditis, initially considered a sole immune-mediated disease, also results from a direct CVB3-mediated injury of the cardiomyocytes. Mesenchymal stem cells (MSCs) have, besides immunomodulatory, also anti-apoptotic features. In view of clinical translation, we first analysed whether MSCs can be infected by CVB3. Next, we explored whether and how MSCs could reduce the direct CVB3-mediated cardiomyocyte injury and viral progeny release, in vitro, in the absence of immune cells. Finally, we investigated whether MSC application could improve murine acute CVB3-induced myocarditis. Methods and results Phase contrast pictures and MTS viability assay demonstrated that MSCs did not suffer from CVB3 infection 4–12–24–48 h after CVB3 infection. Coxsackievirus B3 RNA copy number decreased in this time frame, suggesting that no CVB3 replication took place. Co-culture of MSCs with CVB3-infected HL-1 cardiomyocytes resulted in a reduction of CVB3-induced HL-1 apoptosis, oxidative stress, intracellular viral particle production, and viral progeny release in a nitric oxide (NO)-dependent manner. Moreover, MSCs required priming via interferon-γ (IFN-γ) to exert their protective effects. In vivo, MSC application improved the contractility and relaxation parameters in CVB3-induced myocarditis, which was paralleled with a reduction in cardiac apoptosis, cardiomyocyte damage, left ventricular tumour necrosis factor-α mRNA expression, and cardiac mononuclear cell activation. Mesenchymal stem cells reduced the CVB3-induced CD4− and CD8− T cell activation in an NO-dependent way and required IFN-γ priming. Conclusion We conclude that MSCs improve murine acute CVB3-induced myocarditis via their anti-apoptotic and immunomodulatory properties, which occur in an NO-dependent manner and require priming via IFN-γ.
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Affiliation(s)
- S Van Linthout
- Berlin-Brandenburg Center for Regenerative Therapies, Charité-University Medicine Berlin, Campus Virchow, Berlin, Germany
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Schmidt-Lucke C, Fichtlscherer S, Aicher A, Tschöpe C, Schultheiss HP, Zeiher AM, Dimmeler S. Quantification of circulating endothelial progenitor cells using the modified ISHAGE protocol. PLoS One 2010; 5:e13790. [PMID: 21072182 PMCID: PMC2972200 DOI: 10.1371/journal.pone.0013790] [Citation(s) in RCA: 111] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2010] [Accepted: 08/29/2010] [Indexed: 01/01/2023] Open
Abstract
AIMS Circulating endothelial progenitor cells (EPC), involved in endothelial regeneration, neovascularisation, and determination of prognosis in cardiovascular disease can be characterised with functional assays or using immunofluorescence and flow cytometry. Combinations of markers, including CD34+KDR+ or CD133+KDR+, are used. This approach, however may not consider all characteristics of EPC. The lack of a standardised protocol with regards to reagents and gating strategies may account for the widespread inter-laboratory variations in quantification of EPC. We, therefore developed a novel protocol adapted from the standardised so-called ISHAGE protocol for enumeration of haematopoietic stem cells to enable comparison of clinical and laboratory data. METHODS AND RESULTS In 25 control subjects, 65 patients with coronary artery disease (CAD; 40 stable CAD, 25 acute coronary syndrome/acute myocardial infarction (ACS)), EPC were quantified using the following approach: Whole blood was incubated with CD45, KDR, and CD34. The ISHAGE sequential strategy was used, and finally, CD45(dim)CD34(+) cells were quantified for KDR. A minimum of 100 CD34(+) events were collected. For comparison, CD45(+)CD34(+) and CD45(-)CD34(+) were analysed simultaneously. The number of CD45(dim)CD34(+)KDR(+) cells only were significantly higher in healthy controls compared to patients with CAD or ACS (p = 0.005 each, p<0.001 for trend). An inverse correlation of CD45(dim)CD34(+)KDR(+) with disease activity (r = -0.475, p<0.001) was confirmed. Only CD45(dim)CD34(+)KDR(+) correlated inversely with the number of diseased coronaries (r = -0.344; p<0.005). In a second study, a 4-week de-novo treatment of atorvastatin in stable CAD evoked an increase only of CD45(dim)CD34(+)KDR(+) EPC (p<0.05). CD45(+)CD34(+)KDR(+) and CD45(-)CD34(+)KDR(+) were indifferent between the three groups. CONCLUSION Our newly established protocol adopted from the standardised ISHAGE protocol achieved higher accuracy in EPC enumeration confirming previous findings with respect to the correlation of EPC with disease activity and the increase of EPC during statin therapy. The data of this study show the CD45(dim) fraction to harbour EPC.
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Affiliation(s)
- Caroline Schmidt-Lucke
- Department of Molecular Cardiology, Internal Medicine III, J.W. Goethe University, Frankfurt, Germany.
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Schmidt-Lucke C, Spillmann F, Bock T, Kühl U, Van Linthout S, Schultheiss HP, Tschöpe C. Interferon beta modulates endothelial damage in patients with cardiac persistence of human parvovirus b19 infection. J Infect Dis 2010; 201:936-945. [PMID: 20158391 DOI: 10.1086/650700] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/09/2023] Open
Abstract
BACKGROUND In a phase 1 study, we investigated whether interferon beta reduced endothelial damage in patients with cardiac persistence of human parvovirus B19 (B19V) infection. METHODS AND RESULTS In vitro, B19V infected cultivated endothelial cells (ECs), which led to a reduction in their viability (P = .007). Interferon beta suppressed B19V replication by 63% (P = .008) in ECs and increased their viability (P = .021). Circulating mature apoptotic ECs (CMAECs [CD45(-)CD146(+) cells expressing von Willebrand factor and annexin V]) and circulating progenitor cells (CPCs [CD34(+)KDR(+) cells]) were quantified by flow cytometry in 9 symptomatic patients with cardiac B19V infection before and after 6 months of interferon beta therapy (16 MU) and were compared to levels in 9 healthy control subjects. Endothelial dysfunction was measured using flow-mediated dilatation of the forearm. Patients with B19V persistence had significantly higher (P = .04) levels of CMAECs than did control subjects, which normalized after treatment (mean +/- standard deviation, 0.06% +/-0.08% vs 0.01% +/- 0.006%; P = .008). Similar improvement was shown for flow-mediated dilatation (P = .04) in the treatment group only (P = .017 for the comparison with untreated patients with B19V persistence n = 5). There were significantly higher numbers of CPCs in patients with B19V persistence before therapy (mean +/- standard deviation, 0.04% +/- 0.05% vs 0.01% +/- 0.004%; P = .02; than in control subjects, which normalized after treatment (P = .03). CONCLUSION Thus, we present (for the first time, to our knowledge) a modulation of virally induced chronic endothelial damage-specifically, EC apoptosis and endothelial regeneration.
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Affiliation(s)
- Caroline Schmidt-Lucke
- Department of Cardiology and Pneumology, Charité-University Medicine Berlin, Campus Benjamin Franklin, Berlin, Germany.
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Schmidt-Lucke C, Fichtlscherer S, Rössig L, Kämper U, Dimmeler S. Improvement of endothelial damage and regeneration indexes in patients with coronary artery disease after 4 weeks of statin therapy. Atherosclerosis 2010; 211:249-54. [PMID: 20211468 DOI: 10.1016/j.atherosclerosis.2010.02.007] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2009] [Revised: 01/22/2010] [Accepted: 02/04/2010] [Indexed: 02/04/2023]
Abstract
BACKGROUND In patients with coronary artery disease (CAD), higher numbers of circulating endothelial progenitor cells (EPC) favourably influence clinical outcome. Controversially, increased apoptosis of endothelial cells (EC) may reflect vascular damage. Statins have been shown to improve vascular damage and enhance EPC function and numbers. The availability of ezetimibe, a potent novel cholesterol absorption inhibitor, allows to distinguish between lipid-lowering and pleiotropic properties of statins. METHODS AND FINDINGS 43 patients with CAD were assigned to receive either: de novo atorvastatin (group A; n=17), ezetimibe as add-on to chronic statin therapy (group B; n=14), or dose escalation of atorvastatin (group C; n=12) over 4 weeks. Circulating apoptotic EC (CD45-CD146+vWF+Annexin-V+) and EPC (CD34+KDR+) were quantified using flow cytometry. LDL cholesterol levels were significantly reduced in all treatment arms. Both statin groups, group A and group C, showed significantly reduced circulating apoptotic EC by 50% each (p<0.01). On the other hand, there was a significant doubling in the numbers of circulating EPC in group A and group C (p<0.005, each). Consequently, the endothelial damage-index calculated from numbers of circulating apoptotic mature EC related to EPC numbers, was improved in group A by 79% (p<0.01) and in group C by 70% (p<0.05). In contrast, sole LDL reduction by ezetimibe exerted no effect on any of the different circulating endothelial cell types. CONCLUSION Thus, the improvement in numbers of EPC and reduction of mature apoptotic EC after 4 weeks of statin therapy, document a novel pleiotropic effect of statin therapy in patients with CAD.
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Schädlich PK, Schmidt-Lucke C, Huppertz E, Lehmacher W, Nixdorff U, Stellbrink C, Brecht JG. Economic evaluation of enoxaparin for anticoagulation in early cardioversion of persisting nonvalvular atrial fibrillation: a statutory health insurance perspective from Germany. Am J Cardiovasc Drugs 2007; 7:199-217. [PMID: 17610347 DOI: 10.2165/00129784-200707030-00006] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
OBJECTIVE To estimate, from the perspective of Statutory Health Insurance (SHI, third-party payer) in Germany, the economic consequences of using the subcutaneous low-molecular-weight heparin (LMWH) enoxaparin instead of intravenous unfractionated heparin followed by oral phenprocoumon (UFH/PPC) for anticoagulation in patients undergoing transesophageal echocardiography (TEE)-guided early electrical cardioversion (ECV) of persisting nonvalvular atrial fibrillation (AF) without intracardiac clot. DESIGN AND SETTING The incremental cost for the enoxaparin-based regimen versus the UFH/PPC-based regimen was chosen as the target variable. A decision-analytic model considering the in- and outpatient sectors was used to quantify the target variable. Resource use during in- and outpatient treatment was taken from the Anticoagulation in Cardioversion using Enoxaparin (ACE) trial and from expert interviews with cardiologists in Germany in order to reflect the day-to-day conditions of clinical practice. Costs were given by SHI expenses for inpatient treatment and for medical services, drugs, disposables, and laboratory tests during outpatient treatment. These costs were determined by multiplying utilized resource items by the price or tariff of each item based on German healthcare regulations for the reference period of 2003/2004. According to the ACE trial, the evaluation encompassed 28 (26-30) treatment days with two consecutive phases. Phase I with 5 (3-12) days comprised diagnostics, start of anticoagulation, and ECV. Phase II with the remaining days consisted of continued anticoagulation and patient monitoring. The dosage of enoxaparin was 1 mg/kg bodyweight twice daily in treatment phase I followed by 40 mg twice daily with a bodyweight <65 kg or 60 mg twice daily with a BW > or =65 kg in treatment phase II. The daily dosages of UFH by continuous infusion and overlapping PPC were adjusted to an International Normalized Ratio of 2.0-3.0 in treatment phase I followed by 2.25mg PPC once daily in treatment phase II. Patients with any comorbidity and complication level (CCL) and those with low comorbidity and complications expected to occur in rare cases only (low-risk patients) were analyzed separately. In each base-case analysis, exclusively point estimates of all respective model parameters were applied. MAIN OUTCOME MEASURES AND RESULTS There were savings of 339 euro and 579 euro per patient receiving the enoxaparin-based regimen versus the UFH/PPC-based regimen in the case of patients with any CCL and of low-risk patients, respectively (1 euro approximate, equals $US1.25; first quarter 2004 values). In comprehensive sensitivity analyzes, the robustness of the model and its results was shown. First, the impact of the model parameters on the target variable for each patient group was quantified in a deterministic model. Secondly, the dependency of the target variable on random variables was described for each patient group using Monte Carlo simulation. Irrespective of the patient group, the cost weight and the base rate of hospitals for inpatient ECV in phase I turned out to have the greatest impact on the savings obtained by the enoxaparin-based regimen. In the case of patients with any CCL, this impact was about 1.4-fold of that of the probability of enoxaparin patients undergoing outpatient ECV in phase I. In the case of low-risk patients, the impact of the cost weight and the base rate of hospitals for inpatient ECV in phase I was about 4.1-fold of that of the price of enoxaparin 60 mg prefilled syringes in the outpatient sector. In 79% and 93% of 10,000 simulated comparisons each versus the UFH/PPC-based regimen, there were savings obtained by the enoxaparin-based regimen in patients with any CCL and in low-risk patients, respectively. CONCLUSIONS Results of this evaluation showed that an enoxaparin-based regimen for TEE-guided ECV of AF in patients without intracardiac clot offers SHI in Germany a considerable saving potential when used instead of an UFH/PPC-based regimen.
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Affiliation(s)
- Peter K Schädlich
- InForMed GmbH - Outcomes Research and Health Economics, Ingolstadt, Germany.
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Abstract
Non-ST elevation acute coronary syndrome (NSTE-ACS) refers to a cardiovascular disorder characterized by intracoronary thrombus formation on a disrupted atherosclerotic plaque with partial or transient occlusion. Generation of thrombin resulting from exposure of collagen leads to activation of platelets and conversion of fibrinogen to fibrin, thus forming a platelet-rich thrombus. The main therapeutic objective is to protect the patient from thrombotic complications, independent of the choice of antithrombotic agents. The management of NSTE myocardial infarction (MI) is constantly evolving. For primarily conservative strategy, enoxaparin has been proven superior to unfractioned heparin (UFH). With early invasive strategy providing better clinical outcome compared with conservative strategy, the effectiveness of enoxaparin in reducing death and MI rates is now being reconsidered in the era of poly-pharmacotherapy, early percutaneous coronary interventions and drug eluting stents. Bleeding complications can be minimized by avoiding cross-over from UFH to enoxaparin or vice versa, or by reducing the dosage of enoxaparin. We review the studies of enoxaparin and discuss its current role in the contemporary treatment of NSTE-ACS.
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Affiliation(s)
- Caroline Schmidt-Lucke
- Charité Medical University Berlin, Campus Benjamin Franklin, Dept. of Cardiology and Pulmology, Germany.
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Schmidt-Lucke C, Aicher A, Romagnani P, Gareis B, Romagnani S, Zeiher AM, Dimmeler S. Specific recruitment of CD4+CD25++ regulatory T cells into the allograft in heart transplant recipients. Am J Physiol Heart Circ Physiol 2007; 292:H2425-31. [PMID: 17237241 DOI: 10.1152/ajpheart.01197.2006] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Regulatory T cells (T(reg)) migrate into allografts and induce tolerance of the graft. Immunosuppressive T(reg) are found among CD4+CD25++ T cells and specifically express the forkhead/winged transcription factor FOXP3. We hypothesized that activated T cells and T(reg) might modulate the ongoing inflammation of the cardiac allograft (CA) and that the chronic inflammatory environment might influence the balance between these distinct cell types. We therefore quantified levels of activated T cells and CD4+CD25++ T(reg) in the cardiac and systemic circulation in heart transplant recipients. To determine the influence of the allograft passage on these cells, transcardiac gradients were evaluated in CA recipients (n = 22) compared with controls (n = 18). Systemic levels of circulating T(reg) were significantly lower in CA recipients (8.9 +/- 1.3 microl) compared with controls (15.8 +/- 1.6 microl; P = 0.002). Similarly, the proportion of T(reg) related to the total leukocyte number was significantly lower in CA recipients (P < 0.01). In contrast, systemic levels of circulating activated CD4+ T cells and of circulating plasmacytoid dendritic cells were similar in both groups. In transplant patients, numbers of T(reg) significantly decreased during transcardiac passage (3.0 +/- 0.3 to 2.4 +/- 0.3% of CD4+ T cells, P < 0.01), and FOXP3+ T cells invaded into the allograft. In contrast, numbers of activated CD4+ T cells increased during passage through the allograft, even in the presence of effective immunosuppression. In conclusion, numbers of circulating immunosuppressive T(reg) are reduced in transplant recipients. Recruitment of T(reg) into the cardiac allograft during transcoronary passage may induce graft tolerance during subclinical inflammation potentially influencing allograft vasculopathy.
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Affiliation(s)
- Caroline Schmidt-Lucke
- Department of Internal Medicine III, Division of Cardiology, J. W. Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
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Schulze F, Lenzen H, Hanefeld C, Bartling A, Osterziel KJ, Goudeva L, Schmidt-Lucke C, Kusus M, Maas R, Schwedhelm E, Strödter D, Simon BC, Mügge A, Daniel WG, Tillmanns H, Maisch B, Streichert T, Böger RH. Asymmetric dimethylarginine is an independent risk factor for coronary heart disease: results from the multicenter Coronary Artery Risk Determination investigating the Influence of ADMA Concentration (CARDIAC) study. Am Heart J 2006; 152:493.e1-8. [PMID: 16923419 DOI: 10.1016/j.ahj.2006.06.005] [Citation(s) in RCA: 135] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2006] [Accepted: 06/11/2006] [Indexed: 11/30/2022]
Abstract
BACKGROUND Asymmetric dimethylarginine (ADMA) plasma levels have been shown to be elevated in diseases related to endothelial dysfunction such as hypertension, hyperlipidemia, diabetes mellitus, and others. It has been shown that ADMA predicts cardiovascular mortality in patients who have coronary heart disease (CHD). However, the question whether ADMA is an independent risk factor for CHD still remains unresolved. METHODS The CARDIAC study is a multicenter case-control study, designed to detect differences in ADMA plasma levels between patients with CHD and controls from the general population. We included in our analysis 131 cases and 131 controls, matched for age, sex, and body mass index. RESULTS We found that cases had higher ADMA plasma levels than controls (0.70 micromol/L [0.59-0.87 micromol/L] vs 0.60 micromol/L [0.54-0.69 micromol/L], P < .001). To evaluate the predictive power of ADMA regarding CHD, we calculated 2 multivariate logistic regression models including laboratory parameters and traditional risk factors. The odds ratio for ADMA in the multivariate model including the laboratory characteristics was 2.59 (1.61-4.17; P < .001); the odds ratio for the multivariate model including other risk factors was 6.04 (2.56-14.25; P < .001) for the third tertile (>0.72 micromol/L) versus the first (<0.58 micromol/L). CONCLUSIONS We conclude from the results of our study that ADMA is an independent risk factor for CHD.
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Affiliation(s)
- Friedrich Schulze
- Clinical Pharmacology Unit, Institute of Experimental and Clinical Pharmacology, Center of Experimental Medicine, University Hospital Hamburg-Eppendorf, Hamburg, Germany.
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Fichtlscherer S, Schmidt-Lucke C, Bojunga S, Rössig L, Heeschen C, Dimmeler S, Zeiher AM. Differential effects of short-term lipid lowering with ezetimibe and statins on endothelial function in patients with CAD: clinical evidence for 'pleiotropic' functions of statin therapy. Eur Heart J 2006; 27:1182-90. [PMID: 16621868 DOI: 10.1093/eurheartj/ehi881] [Citation(s) in RCA: 100] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
AIMS Statin therapy is associated with improved endothelial vasodilator function. The clinical availability of ezetimibe, a potent novel cholesterol absorption inhibitor, enables to differentiate lipid-lowering effects from potential non-lipid-lowering (pleiotropic) mechanisms of statins. METHODS AND RESULTS Forearm blood flow (FBF) responses to acetylcholine (ACH) and sodium nitroprusside (SNP) were measured by venous occlusion plethysmography in four prospectively defined groups of patients with stable coronary artery disease (CAD) before and after 4 weeks of lipid-lowering therapy. Group A (n=15): de novo monotherapy with 10 mg/day ezetimibe; Group B (n=15): 10 mg/day ezetimibe as an add-on to chronic simvastatin therapy with 20 mg/day; Group C (n=15): dose escalation from chronic 10 to 40 mg/day atorvastatin; and Group D (n=15): de novo monotherapy with 40 mg/day atorvastatin. After 4 weeks of therapy, LDL cholesterol levels were significantly reduced in all four groups. Neither ezetimibe monotherapy (Group A) nor ezetimibe combined with 20 mg simvastatin (Group B) was associated with an increase in ACH-mediated FBF responses after 4 weeks. In contrast, dose escalation of atorvastatin from 10 to 40 mg/day (Group C) or de novo therapy with 40 mg atorvastatin/day (Group D) was associated with a significant increase in ACH-mediated FBF responses (P<0.013). CONCLUSION Thus, both statins and ezetimibe effectively lower LDL-levels within 4 weeks of therapy. However, only statin therapy is associated with improved endothelial vasodilator function, disclosing the relevance of pleiotropic effects of statins during short-term treatment of patients with CAD.
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Affiliation(s)
- Stephan Fichtlscherer
- Department of Internal Medicine III, Division of Cardiology, Johann W. Goethe-University Frankfurt, Theodor Stern Kai 7, D-60590 Frankfurt, Germany.
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Taneva E, Borucki K, Wiens L, Makarova R, Schmidt-Lucke C, Luley C, Westphal S. Early effects on endothelial function of atorvastatin 40 mg twice daily and its withdrawal. Am J Cardiol 2006; 97:1002-6. [PMID: 16563905 DOI: 10.1016/j.amjcard.2005.10.032] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2005] [Revised: 10/12/2005] [Accepted: 10/12/2005] [Indexed: 01/05/2023]
Abstract
Combined hyperlipidemia is associated with endothelial dysfunction. Atorvastatin has lipid-lowering and pleiotropic properties, including a protective effect on endothelial function. This study investigated the short- and medium-term effects of therapy with atorvastatin and of its discontinuation on lipid lowering and endothelial function. In 33 patients with combined hyperlipidemia who had been randomized and treated for 6 weeks with 40 mg of atorvastatin twice daily (n = 23) or placebo (n = 10), fasting lipid levels and flow-mediated dilation (FMD) of the brachial artery were measured at baseline, after 12 hours, 1 week, and 6 weeks during therapy, and 36 hours after discontinuation of therapy. Thereafter, all patients received 20 mg/day of atorvastatin for another 6 weeks. In the atorvastatin group, low-density lipoprotein cholesterol was decreased by 30% and 46% after 1 and 6 weeks, respectively (p <0.0001 for the 2 comparisons). In patients who already showed an impaired FMD at the beginning of the study (n = 15), atorvastatin caused a significant improvement in FMD, from 2.6% at baseline to 4.0% and 6.3% after 1 and 6 weeks, respectively (p <0.05 and <0.001). Thirty-six hours after withdrawal of atorvastatin, the FMD in this group decreased again to 2.8% (p <0.05), whereas low-density lipoprotein cholesterol level remained unchanged. The 6 patients with normal FMD at baseline showed no improvement in FMD during therapy or any decrease after withdrawal of the drug. In conclusion, only patients with endothelial dysfunction profit from high-dose atorvastatin treatment. When the treatment is abruptly discontinued, the effect on FMD disappears in 36 hours.
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Affiliation(s)
- Elina Taneva
- Institute of Clinical Chemistry and Pathobiochemistry, Magdeburg University Hospital, Magdeburg, Germany.
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Schmidt-Lucke C, Paar WD, Stellbrink C, Nixdorff U, Hofmann T, Meurer J, Grewe R, Daniel WG, Hanrath P, Mügge A, Klein HU, Schmidt-Lucke JA. Quality of anticoagulation with unfractionated heparin plus phenprocoumon for the prevention of thromboembolic complications in cardioversion for non-valvular atrial fibrillation. Sub-analysis from the Anticoagulation in Cardioversion using Enoxaparin (ACE) trial. Thromb Res 2006; 119:27-34. [PMID: 16443257 DOI: 10.1016/j.thromres.2005.11.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2005] [Revised: 10/17/2005] [Accepted: 11/29/2005] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Anticoagulation in cardioversion for atrial fibrillation is performed using unfractionated heparin and oral anticoagulants. TEE-guided cardioversion, after achievement of therapeutic anticoagulation (1-3 days), may be an alternative to the traditional procedure (3-week anticoagulation followed by cardioversion). The quality of anticoagulation in atrial fibrillation has not been investigated in a randomised trial with TEE-guided cardioversion. We analysed respective data from the ACE trial on the quality of conventional anticoagulation, where most participating centres chose the TEE-guided approach. MATERIALS AND METHODS In a randomised, prospective, multicentre trial, we analysed the efficacy of unfractionated heparin plus phenprocoumon in 248 patients on an intention-to-treat basis. There were 2373 evaluable anticoagulation measurements (out of 2925 measurements) and 4 categories of anticoagulation quality (under-, target, over- and severe over-anticoagulation). Of patients with evaluable measurements, 88% received short-term anticoagulation (4 weeks) in TEE-guided cardioversion. RESULTS The median time to achieve therapeutic anticoagulation (aPTT> or =60 and <80 s or INR> or =2 and <3) was 3 days. Anticoagulation values were out of therapeutic range in 69.5% of measurements during 4- or 7-week follow-up, and never within therapeutic range in 10% of patients. Of the 15 primary endpoints observed (death, thromboembolism and major bleeding complications), only 3 were in patients with anticoagulation measurements within therapeutic range. CONCLUSIONS In this study setting, with predominance of 4 weeks anticoagulation in TEE-guided cardioversion for atrial fibrillation, therapeutic anticoagulation was reached within 3 days using conventional anticoagulation. Despite careful dose adjustments, anticoagulation was out of therapeutic range in almost 70% of total measurements and 80% of primary endpoints.
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Affiliation(s)
- Caroline Schmidt-Lucke
- Molecular Cardiology, JW Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany.
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Schmidt-Lucke C, Rössig L, Fichtlscherer S, Vasa M, Britten M, Kämper U, Dimmeler S, Zeiher AM. The First Prospective Human Evidence That Low Numbers of Circulating Endothelial Precursor Cells Predict Future Cardiovascular Events—Evidence of Defective Vascular Repair? J Am Soc Nephrol 2005; 16:3142-3145. [PMID: 37000933 DOI: 10.1681/01.asn.0000926764.84641.0f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
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Schmidt-Lucke C, Rössig L, Fichtlscherer S, Vasa M, Britten M, Kämper U, Dimmeler S, Zeiher AM. Reduced number of circulating endothelial progenitor cells predicts future cardiovascular events: proof of concept for the clinical importance of endogenous vascular repair. Circulation 2005; 111:2981-7. [PMID: 15927972 DOI: 10.1161/circulationaha.104.504340] [Citation(s) in RCA: 879] [Impact Index Per Article: 46.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND The maintenance of endothelial integrity plays a critical role in preventing atherosclerotic disease progression. Endothelial progenitor cells (EPCs) were experimentally shown to incorporate into sites of neovascularization and home to sites of endothelial denudation. Circulating EPCs may thus provide an endogenous repair mechanism to counteract ongoing risk factor-induced endothelial injury and to replace dysfunctional endothelium. METHODS AND RESULTS In 120 individuals (43 control subjects, 44 patients with stable coronary artery disease, and 33 patients with acute coronary syndromes), circulating EPCs were defined by the surface markers CD34+KDR+ and analyzed by flow cytometry. Cardiovascular events (cardiovascular death, unstable angina, myocardial infarction, PTCA, CABG, or ischemic stroke) served as outcome variables over a median follow-up period of 10 months. Patients suffering from cardiovascular events had significantly lower numbers of EPCs (P<0.05). Reduced numbers of EPCs were associated with a significantly higher incidence of cardiovascular events by Kaplan-Meier analysis (P=0.0009). By multivariate analysis, reduced EPC levels were a significant, independent predictor of poor prognosis, even after adjustment for traditional cardiovascular risk factors and disease activity (hazard ratio, 3.9; P<0.05). CONCLUSIONS Reduced levels of circulating EPCs independently predict atherosclerotic disease progression, thus supporting an important role for endogenous vascular repair to modulate the clinical course of coronary artery disease.
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Affiliation(s)
- Caroline Schmidt-Lucke
- Molecular Cardiology, Department of Medicine III, J.W. Goethe University, Frankfurt, Germany
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Schmidt-Lucke C, Belgore F, Reinhold D, Ansorge S, Klein HU, Schmidt-Lucke JA, Lip GYH. Soluble vascular endothelial growth factor, soluble VEGF receptor Flt-1 and endothelial function in healthy smokers. Int J Cardiol 2005; 100:207-12. [PMID: 15823626 DOI: 10.1016/j.ijcard.2004.05.046] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2004] [Revised: 04/28/2004] [Accepted: 05/05/2004] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To relate levels of vascular endothelial growth factor (VEGF) and its soluble receptor, sFlt-1, with endothelial function in healthy smokers. METHODS Plasma levels of VEGF and sFlt-1 were measured by ELISA in 22 healthy smokers and 22 matched healthy non-smoking controls, and compared to flow- (FMD) and acetylcholine-mediated (AMD) vasodilatation (endothelial-dependent) (EDV) and nitroglycerine-mediated (NMD) vasodilatation (endothelial-independent) of lower extremities were measured with plethysmography. RESULTS Smokers and controls had similar plasma VEGF levels, but sFlt-1 levels were lower in smokers than in controls (p<0.01). AMD was lower in smokers compared to controls (p<0.05), but FMD and NMD levels were similar. Smokers and controls with high AMD (>12 ml/100 ml tissue/min) had significantly lower plasma VEGF levels (p<0.001). An inverse correlation was found in both groups, between VEGF and AMD (smokers: r=-0.6, p<0.01; controls: r=-0.71, p<0.005) and with FMD (smokers: r=-0.56, p<0.05; controls: r=-0.58, p<0.005). There were no significant correlations between sFlt-1 with VEGF levels or endothelial-dependent dilatation. CONCLUSION In conclusion, healthy smokers demonstrate abnormal AMD, and an inverse correlation between plasma VEGF levels (but not sFlt-1) with indices of endothelial dysfunction (FMD and AMD) exists. VEGF, and not sFlt-1, may be related to the pathogenesis of endothelial dysfunction in healthy smoking individuals.
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Affiliation(s)
- Caroline Schmidt-Lucke
- Department of Internal Medicine, Division of Cardiology, Angiology and Pneumology, Otto-von-Guericke University, Magdeburg, Germany
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Stellbrink C, Nixdorff U, Hofmann T, Lehmacher W, Daniel WG, Hanrath P, Geller C, Mügge A, Sehnert W, Schmidt-Lucke C, Schmidt-Lucke JA. Use of subcutaneous enoxaparin compared to intravenous heparin and oral phenprocoumon in the setting of cardioversion--the ACE study (Anticoagulation in Cardioversion using Enoxaparin). ACTA ACUST UNITED AC 2004; 7:382-6. [PMID: 15071260 DOI: 10.1023/b:cepr.0000023145.54503.a2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The mode and duration of anticoagulation in the setting of cardioversion of atrial fibrillation-either with or without guidance by transesophageal echocardiography (TEE)-is still an unresolved issue. Oral anticoagulation with warfarin or phenprocoumon is frequently used but may be associated with an increased risk of bleeding complications or, conversely, episodes of undercoagulation. Moreover, it takes several days to reach full anticoagulation with oral compounds. This phase may be covered with intravenous heparin but this requires prolonged hospitalization. Low-molecular weight heparin is an attractive alternative as it not only provides a safe and predictable level of anticoagulation with few side effects but can also be administered safely on an outpatient basis. In addition, anticoagulation monitoring is usually unnecessary. The ACE study (Anticoagulation in Cardioversion using Enoxaparin) compared the safety and efficacy of subcutaneous enoxaparin with intravenous heparin/oral phenprocoumon before and after cardioversion (stratified to TEE guidance or no TEE guidance). This article summarizes the study rationale and design. The results will be published shortly.
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Schmidt-Lucke C, Reinhold D, Ansorge S, Klein HU, Schmidt-Lucke JA. Changes of plasma concentrations of soluble vascular cell adhesion molecule-1 and vascular endothelial growth factor after increased perfusion of lower extremities in humans. Endothelium 2004; 10:159-65. [PMID: 13129819 DOI: 10.1080/10623320390233472] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Shear stress modulates vascular structure and function through cytoskeletal remodeling and activation of signaling cascades. Elevated vascular endothelial growth factor (VEGF) concentrations are seen in atherosclerotic disease and after active increase of perfusion. Levels of soluble vascular cell adhesion molecule (sVCAM-1) are increased in atherosclerotic disease without strict correlation to disease progression. In vitro, increased shear stress induces a biphasic response of sVCAM-1. No data are available on in vivo downregulation of VEGF or sVCAM-1 in humans. In 24 healthy individuals, vascular function of lower extremities was assessed by plethysmography measuring flow-mediated dilation and through intra-arterial infusion of acetylcholine and nitroglycerine. Ten healthy individuals were challenged with cycle exercise testing. Cytokines were measured from citrate plasma from cubital and femoral vein blood. Plasma concentrations of VEGF and sVCAM-1 correlated with endothelium-dependent dilation. Two hours after acetylcholine-induced shear stress, plasma concentrations of sVCAM-1 levels were reduced by 31% (p <.001) locally and 18% (p <.05) systemically. Nitroglycerine produced similar local and systemic suppression (36% and 34%; p <.0001). Immediately after exercise, concentrations of sVCAM-1 increased with a significant decrease one hour later (-9%; p <.01). VEGF increased after infusion of nitroglycerine (+35%; p <.05) and dropped after 1 h of 30-min exercising (-31%, p <.05). This is the first study to show changes of sVCAM-1 in vivo. Changes of VEGF and sVCAM-1 in humans seem time, magnitude, and substance specific. Short acting suppression of VEGF and SVCAM-1 under physiological conditions may explain exercise-induced vascular protection and the lack of correlation of these cytokines with activity of atherosclerotic disease.
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Affiliation(s)
- Caroline Schmidt-Lucke
- Department of Internal Medicine, Division of Cardiology, Angiology and Pneumology, Otto-von-Guericke University, Magdeburg, Germany.
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Stellbrink C, Nixdorff U, Hofmann T, Lehmacher W, Daniel WG, Hanrath P, Geller C, Mügge A, Sehnert W, Schmidt-Lucke C, Schmidt-Lucke JA. Safety and Efficacy of Enoxaparin Compared With Unfractionated Heparin and Oral Anticoagulants for Prevention of Thromboembolic Complications in Cardioversion of Nonvalvular Atrial Fibrillation. Circulation 2004; 109:997-1003. [PMID: 14967716 DOI: 10.1161/01.cir.0000120509.64740.dc] [Citation(s) in RCA: 135] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Anticoagulation in cardioversion of atrial fibrillation is currently performed with unfractionated heparin (UFH) and oral anticoagulants, with or without guidance by transesophageal echocardiography (TEE). Low-molecular-weight heparins may reduce the risk of bleeding, may obviate the need for intravenous access, and do not require frequent anticoagulation monitoring.
Methods and Results—
In a randomized, prospective multicenter trial, we compared the safety and efficacy of enoxaparin administered subcutaneously with intravenous UFH followed by the oral anticoagulant phenprocoumon in 496 patients scheduled for cardioversion of atrial fibrillation of >48 hours’ and ≤1 year’s duration. Patients were stratified to cardioversion with (n=431) and without (n=65) guidance by TEE. The study aimed to demonstrate noninferiority of enoxaparin compared with UFH+phenprocoumon with regard to the incidence of embolic events, all-cause death, and major bleeding complications. Secondary end points included successful cardioversion, maintenance of sinus rhythm until study end, and minor bleeding complications. Of 496 randomized patients, 428 were analyzed per protocol. Enoxaparin was noninferior to UFH+phenprocoumon with regard to the incidence of the composite primary end point in a per-protocol analysis (7 of 216 patients versus 12 of 212 patients, respectively;
P
=0.016) and in an intention-to-treat analysis (7 of 248 patients versus 12 of 248 patients, respectively;
P
=0.013). There was no significant difference between the 2 groups in the number of patients reverted to sinus rhythm.
Conclusions—
Enoxaparin is noninferior to UFH+phenprocoumon for prevention of ischemic and embolic events, bleeding complications, and death in TEE-guided cardioversion of atrial fibrillation. Its easier application and more stable anticoagulation may make it the preferred drug for initiation of anticoagulation in this setting.
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Affiliation(s)
- Christoph Stellbrink
- Medizinische Klinik I, Rheinisch-Westfälische Technische Hochschule Aachen, Aachen, Germany.
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Abolmaali ND, Britten MB, Schmidt-Lucke C, Rössig L, Kämper U, Schächinger V, Vogl TJ. Korrelation der Arterioskleroseaktivität mit der MRT der Aortenwand bei KHK-Patienten. ROFO-FORTSCHR RONTG 2004. [DOI: 10.1055/s-2004-827842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Abstract
The role of low frequency flowmotion in physiological or pathophysiological settings is unclear. We performed various series of experiments in young anesthetized New Zealand white (NZW) rabbits. Many animals exhibited flowmotion during control conditions. However, they very often seemed to be in unstable physiological conditions, and our preset inclusion criteria (as to arterial pressure and blood gases) were frequently not met.Therefore, in a first series, we correlated these systematically with the incidence of flowmotion. Eleven of 35 anesthetized rabbits, subjected to extensive surgery, showed flowmotion with a median frequency of 1.5 cpm and a relative "amplitude" of 32%. Arterial pressure was 10 mmHg lower, bicarbonate, base-excess, and PCO(2) values and relative blood flow were also significantly lower compared to animals not exhibiting flowmotion. In a second series, we tested whether flowmotion could be induced by an isolated metabolic acidosis in animals meeting the inclusion criteria and not showing flowmotion at control. Here, flowmotion was induced in 9/10 cases (p < 0.01) 30 min after the start of an HCl-infusion. In a third study, we related the onset of flowmotion to the pressure/flow autoregulation curve. At locally reduced blood pressure all 23 rabbits exhibited flowmotion (p < 0,00001) in the gastrocnemius and the tenuissimus muscles, with maximum flowmotion at a locally reduced blood pressure of 30 mmHg; the LDF-flux level showing 67% of control flow.These results support the concept that low frequency periodic hemodynamics are a characteristic of pathophysiological conditions like hypoperfusion or acidosis rather than indicating a normal physiological state.
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Affiliation(s)
- Caroline Schmidt-Lucke
- Department of Medicine, Division of Vascular Medicine, Otto-von-Guericke University, Magdeburg, Germany
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Abstract
BACKGROUND As an alternative to manual pressure techniques new systems for achieving arterial hemostasis after cardiac catheterization were developed. Here we report about the diagnosis and therapy of femoral artery complications after use of the closure device Angio-Seal, consisting of an intraarterial anchor and extravascular collagen plug. PATIENTS AND METHODS Angio-Seal was deployed in 350 patients undergoing cardiac catheterization. Vascular investigations after device application consisted of ankle/brachial-pressure-index measurement, duplex sonography, and angiography. RESULTS Vascular complications occurred in 10 of 350 patients. In two patients complete occlusions of the superficial femoral artery required immediate vascular surgery. Stenoses of the superficial (five patients) and the common (three patients) femoral arteries were diagnosed in 8 cases. Of these 10 patients eight were obese, in 2 cases there was a further catheterization with Angio-Seal device application via the same femoral approach. Until now six patients underwent successful surgery: in 4 cases the whole Angio-Seal device was located intraarterially, there was 1 case of intima-dissection, and 1 case remained unclear due to a diagnostic delay of 7 months. In three patients with stenoses of the common femoral arteries without hemodynamic relevance no therapy was required. CONCLUSIONS Occlusions or stenoses of femoral arteries after use of Angio-Seal can be diagnosed easily by duplex sonography. All hemodynamic relevant complications (n = 7 of 350 [2%]) concerned a puncture of superficial femoral arteries. In these patients vascular surgery seems to be an adequate therapy.
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Affiliation(s)
- C Kirchhof
- Department of Medicine, Park-Krankenhaus Leipzig-Südost GmbH, Leipzig, Germany.
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Schmidt-Lucke C, Glattkowski-Schäfer G, Kirchhof C, von Bierbrauer A, Klein HU, Schmidt-Lucke JA. Incidence of cutaneous vasoactivity in patients with anemia and pulmonary hypoxia. VASA 2000; 29:112-5. [PMID: 10901088 DOI: 10.1024/0301-1526.29.2.112] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND In cutaneous laser Doppler flow (LDF)-recordings, various forms of flowmotion or vasoactivity can be observed. It is still a matter of dispute, whether flowmotion is a phenomenon of physiological or pathophysiological conditions. Therefore, we tested the hypothesis of increased vasoactivity being typical for patients with various degrees of acute and chronic anemia as well as with chronic obstructive pulmonary disease (COPD). PATIENTS AND METHODS We examined 12 healthy controls, 14 patients with COPD with a PO2 below 60 mmHg, 16 patients with chronic and 7 patients with acute anemia with an Hb below 12 g/dl. We used a simple LDF-technique on the dorsum of the forefoot. The regularity of blood flow frequencies was determined by calculation of the coefficient of variation. RESULTS Periods without vasoactivity (i.e. constant flow pattern) were 21% in normal controls, 7% in patients with COPD and 2% in patients with acute or chronic anemia. Mean frequencies in the four groups varied between 3.8 and 4.8 cpm, with significant changes only in the group with acute blood loss. However, vasoactivity was significantly more regular in the COPD- and anemia-groups as compared to normal controls, with coefficients of variation of 47.4% for controls, 31.8% for COPD- and 29.3% for chronic and 35.1% for acute anemia-patients. CONCLUSIONS The present paper shows that cutaneous vasoactivity is more regular in the three examined clinical entities of systemic tissue hypo-oxygenation, i.e. chronic and acute anemia and severe COPD as compared to healthy control subjects. Therefore, we hypothesize that increased vasoactivity constitutes a regulatory defense mechanism in cases of reduced oxygenation, by improving microcirculatory blood flow distribution.
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