[Lay version of the 2018 EULAR recommendations for physical activity in people with inflammatory arthritis and osteoarthritis : Translation into German and linguistic validation in German-speaking countries with people affected]

BACKGROUND

Physical activity and exercise are beneficial for people with rheumatic diseases; however, recommendations for the management of rheumatoid arthritis (RA), spondyloarthritis (SpA) and hip- and knee osteoarthritis (HOA/KOA) are usually unspecific with respect to mode and dose of exercise. This is why the 2018 EULAR recommendations for physical activity in people with inflammatory arthritis and osteoarthritis were formulated. The recommendations consist of 4 overarching principles and 10 recommendations. These were also published as a lay version in the English language.

AIM

Translation of the lay version into German and its linguistic validation in Austria, Germany and Switzerland.

METHODS

A professional translation was reviewed by the authors, including people with, RA, SpA, HOA/KOA from the three German-speaking countries, which provided a prefinal lay version. Subsequently, eight interviews with people with RA, SpA, HOA/KOA were conducted in each country to evaluate understandability, wording, completeness and feasibility of the prefinal lay version. Finally, the authors, i.e. those with RA, SpA, and osteoarthritis, anonymously rated their agreement to the final lay version on a 0-10 scale.

RESULTS

The professional translation was substantially revised by the authors and based on the interviews. Formulations were adapted to increase readability and understandability and specify statements. Comments that would have changed content or structure were not considered. Average agreement with the particular recommendations was between 10 (SD 0) and 7.6 (SD 1.67).

DISCUSSION

For people with RA/SpA/HOA/KOA the EULAR physical activity recommendations should be available in their mother language. The final German lay version is valid and accepted across all three German-speaking countries. Thus, the physical activity recommendations can be provided to people with rheumatic diseases in an understandable and feasible way.

Two phase I studies of BI 836880, a vascular endothelial growth factor/angiopoietin-2 inhibitor, administered once every 3 weeks or once weekly in patients with advanced solid tumors

BACKGROUND

BI 836880 is a humanized bispecific nanobody® that inhibits vascular endothelial growth factor and angiopoietin-2. Here, we report results from two phase I, nonrandomized, dose-escalation studies (NCT02674152 and NCT02689505; funded by Boehringer Ingelheim) evaluating BI 836880 in patients with confirmed locally advanced or metastatic solid tumors, refractory to standard therapy, or for which standard therapy was ineffective.

PATIENTS AND METHODS

Patients aged ≥18 years, with an Eastern Cooperative Oncology Group performance status of 0-2 and adequate organ function received escalating intravenous doses of BI 836880 once every 3 weeks (Q3W; Study 1336.1) or once weekly (QW; Study 1336.6). Primary objectives were maximum tolerated dose (MTD) and recommended phase II dose of BI 836880, based on dose-limiting toxicities (DLTs) during the first cycle.

RESULTS

Patients received one of five dosages of 40-1000 mg Q3W (29 patients) or 40-240 mg QW (24 patients). One DLT occurred with Q3W treatment [Grade (G) 3 pulmonary embolism (1000 mg)]. Five DLTs occurred in four patients treated QW [G2 proteinuria (120 mg); G3 hypertension (180 mg); G3 proteinuria and G3 hypertension (240 mg); and G4 respiratory distress (240 mg)]. All patients experienced adverse events, most commonly hypertension with Q3W treatment (89.7%; G3 41.4%), and asthenia with QW treatment (62.5%). Two patients treated Q3W (both 1000 mg) and three patients treated QW (120 mg, 2 patients; 180 mg, 1 patient) experienced partial response.

CONCLUSIONS

The MTD of BI 836880 was 720 mg Q3W and 180 mg QW. BI 836880 was generally manageable and demonstrated preliminary efficacy.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.govNCT02674152; https://clinicaltrials.gov/ct2/show/NCT02674152 and NCT02689505; https://clinicaltrials.gov/ct2/show/NCT02689505.

Properties of Liquid Crystal Injection Mouldings

The suitability of liquid crystal polymers for the injection moulding process was pointed out at the time of their discovery. However, up to now, it has been assumed that the unmodified liquid crystal polymers were less suited to processing by injection moulding due to their distinct anisotropies. The direction of developments in the application of liquid crystal polymers was done mainly in another direction. We, however, have been concerned for more than four years now with this subject [3, 4, 5], even when our practical experiments could not be as comprehensive as we would wish, due to the limited availability of the raw materials. We have also been able to use this time to develop CAE programs which support the constructor in the design of injection moulds, whereby these programs enable the flow process to be simulated and therefore enabling the orientation to be seen at every point in the injection moulded part [6]. This is naturally particularly important for those materials in which the orientation of the molecules plays such a large part for the respective properties, as these are caused by the direction of the flows in the flow process. A changed runner position causes other orientations. More details should therefore be reported about our investigations to date.

Clinical and metabolic aspects of continuous ambulatory peritoneal dialysis (CAPD)

Experience with CAPD in 14 patients, treated for periods of 2–10 months, is presented. Clinical and biochemical control of uremia appeared adequate in all patients except one. Control of extracellular volume and hypertension was easier with CAPD than with intermittent peritoneal dialysis (IPD). Nine episodes of peritonitis occurred in 5 patients (one peritonitis/8 patients months). Mean protein loss was 9.7 ± 2.7 g per day. In 6 patients on IPD oral glucose tolerance test resulted in a paradoxical rise of HGH, whereas this was not observed after 4 months of CAPD.

Autopsy Findings and Venous Thromboembolism in Patients With COVID-19: A Prospective Cohort Study

BACKGROUND

The new coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has caused more than 210 000 deaths worldwide. However, little is known about the causes of death and the virus's pathologic features.

OBJECTIVE

To validate and compare clinical findings with data from medical autopsy, virtual autopsy, and virologic tests.

DESIGN

Prospective cohort study.

SETTING

Autopsies performed at a single academic medical center, as mandated by the German federal state of Hamburg for patients dying with a polymerase chain reaction-confirmed diagnosis of COVID-19.

PATIENTS

The first 12 consecutive COVID-19-positive deaths.

MEASUREMENTS

Complete autopsy, including postmortem computed tomography and histopathologic and virologic analysis, was performed. Clinical data and medical course were evaluated.

RESULTS

Median patient age was 73 years (range, 52 to 87 years), 75% of patients were male, and death occurred in the hospital (n = 10) or outpatient sector (n = 2). Coronary heart disease and asthma or chronic obstructive pulmonary disease were the most common comorbid conditions (50% and 25%, respectively). Autopsy revealed deep venous thrombosis in 7 of 12 patients (58%) in whom venous thromboembolism was not suspected before death; pulmonary embolism was the direct cause of death in 4 patients. Postmortem computed tomography revealed reticular infiltration of the lungs with severe bilateral, dense consolidation, whereas histomorphologically diffuse alveolar damage was seen in 8 patients. In all patients, SARS-CoV-2 RNA was detected in the lung at high concentrations; viremia in 6 of 10 and 5 of 12 patients demonstrated high viral RNA titers in the liver, kidney, or heart.

LIMITATION

Limited sample size.

CONCLUSION

The high incidence of thromboembolic events suggests an important role of COVID-19-induced coagulopathy. Further studies are needed to investigate the molecular mechanism and overall clinical incidence of COVID-19-related death, as well as possible therapeutic interventions to reduce it.

PRIMARY FUNDING SOURCE

University Medical Center Hamburg-Eppendorf.

Salmonella Detection in Dried Milk Products by Motility Enrichment on Modified Semisolid Rappaport-Vassiliadis Medium: Collaborative Study

A collaborative study involving 19 laboratories was performed to validate motility enrichment on modified semisolid Rappaport-Vassiliadis (MSRV) medium for rapid detection of motile Salmonella in dried milk products. The MSRV method was compared with the AOAC culture method for detection of Salmonella in nonfat milk powder, whole milk powder, whey powder, casein powder, and butter milk powder. Samples were artificially inoculated with Salmonella at 2 levels of contamination. Un-inoculated control samples were included for each type of product. The sensitivity rates were 100% for the MSRV method and 99.0% for the AOAC culture method, while the specificity rate was 100.0% for both methods. Only for the samples of whey powder, which were inoculated with H2S negative S. tennessee, was there a significant difference in the proportion of samples positive by MSRV and the culture procedure. The MSRV method for detection of motileSalmonella in dried milk products has been adopted first action by AOAC INTERNATIONAL.

Multicolor femtosecond pump-probe system with single-electron sensitivity at low temperatures and high magnetic fields

We present an ultrafast spectroscopy system designed for temporal and spectral resolution of transient transmission changes after excitation of single electrons in solid-state quantum structures. The system is designed for optimum long-term stability, offering the option of hands-off operation over several days. Pump and probe pulses are generated in a versatile Er:fiber laser system where visible photon energies may be tuned independently from 1.90 eV to 2.51 eV in three parallel branches. Bandwidth-limited pulse durations between 100 fs and 10 ps are available. The solid-state quantum systems under investigation are mounted in a closed-cycle superconducting magnet cryostat providing temperatures down to 1.6 K and magnetic fields of up to 9 T. The free-standing cryomagnet is coupled to the laser system by means of a high-bandwidth active beam steering unit to eliminate residual low-frequency mechanical vibrations of the pulse tube coolers. High-NA objective lenses inside the sample chamber are employed for focusing femtosecond laser pulses onto the sample and recollection of the transmission signal. The transmitted probe light is dispersed in a grating monochromator equipped with a liquid nitrogen-cooled CCD camera, enabling a frame rate of 559 Hz. In order to eliminate spurious background effects due to low-frequency changes in the thermal equilibrium of the sample, we operate with a lock-in scheme where, instead of the pump amplitude, the pump-probe timing is modulated. This feature is provided without any mechanical action by an electro-optic timing unit inside the femtosecond Er:fiber system. The performance of the instrument is tested with spectrally resolved pump-probe measurements on a single negatively charged CdSe/ZnSe quantum dot under a magnetic field of 9 T. Selective initialization and readout of charge and spin states is carried out via two different femtosecond laser pulses. High-quality results on subpicosecond intraband relaxation dynamics after single-electron excitation motivate a broad variety of future experiments in ultrafast quantum optics and few-fermion quantum dynamics.

Aufbau und Auswertungen einer pathologisch-anatomischen Diagnosenkartei durch Computer-Einsatz

Das beschriebene System zur elektronischen Verarbeitung pathologisch-anatomischer Befunddaten ist im Verlaufe mehrerer Jahre aus einer Maschinenlochkartei hervorgegangen; es erfaßt zur Zeit etwa 23 000 Sektionsprotokolle aus 10 Jahren (1954—1963). Von entscheidender Bedeutung für das Auswertungsergebnis ist der Wert der eingegebenen Befunddaten, die mit allen Mitteln »gehärtet« werden müssen (Quantifizierung, pathohistologische, histochemische, bakteriologische und biochemische Zusatzuntersuchungen). Das im Computer zu lösende Problem muß exakt formuliert werden und ein Weg zur” Lösung vorgezeichnet werden. Die dafür notwendigen Routineprogramme und das speziell für Auswertungen von Sektionsprotokollen entworfene flexible Standardprogramm werden ausführlich beschrieben. Von sehr großer Bedeutung ist die Durchführung möglichst vieler automatischer Kontrollen auf formale und sachlogische Fehler. Mehrere große Auswertungen und zahlreiche kleine Untersuchungen, die mit Hilfe vorgedruckter Diagnosenverzeichnisse durchgeführt wurden, haben die Brauchbarkeit dieser pathologisch-anatomischen Diagnosenkartei erwiesen.

Befunddokumentation in der Pathologie: Erfahrungen mit einer Maschinenlochkartei

Die Dokumentation pathologisch-anatomischer Befunde (Obduktionen und Untersuchungen an Operationsmaterial) zeigt im deutschsprachigen Raum nicht die Fortschritte, die auf klinischem Gebiete zu verzeichnen sind. Die Gründe hierfür sind in den Eigenheiten des pathologisch - anatomischen Untersuchungsgutes zu suchen; insbesondere ist es die Fülle der auf ein Obduktionsprotokoll entfallenden Sachverhalte, die den Rahmen einer Lochkarte meist sprengen. Auch die bisher vorhandenen nationalen und internationalen Diagnosenschlüssel werden den besonderen Anliegen der pathologischen Anatomie nicht hinreichend gerecht.

Für die Erfassung der Obduktionsbefunde wurde daher ein eigener fünfstelliger Diagnosenschlüssel entwickelt. Das am Grazer Pathologischen Institut aufgebaute System der maschinellen Befunddokumentation wird kurz geschildert.

Computer in der Pathologie: Methodik und Erfahrungen nach Auswertung von 27000 Sektionsprotokollen

Beschreibung eines Befunddokumentationssystems, das als Ergebnis einer seit 3 Jahren durchgeführten elektronischen Verarbeitung von Sektionsdaten zur Zeit 27669 Sektionsfälle mit rund 350000 Diagnosen aus 13 Jahren (1952—1964) umfaßt. Diese Diagnosen werden routinemäßig ausgewertet und folgende Ergebnisse den Pathologen laufend zur Verfügung gestellt:

Eine Diagnosenkartei mit Diagnosen im Klartext und allen einschlägigen Fällen; eine Kinderdiagnosenund Todesursachenkartei j eine Auflistung aller Verkehrsund Arbeitsunfälle sowie schließlich der Sektionsfälle mit multiplen primären Malignomen und Spätrezidiven.

Neben diesen Standardauswertungen, die in mehreren Exemplaren im Institut aufliegen und jederzeit eine statistische Verwertung ohne maschinelle Hilfsmittel ermöglichen, können auch Sonderanfragen durch spezielle Programme beantwortet werden. Diese Programme ermöglichen das Auswerten von Fällen, die eine beliebige vorgegebene Kombination von Diagnosen und anderen Daten aufweisen oder nicht aufweisen. Die zutreffenden Fälle werden in übersichtlicher Form (nach Alter und Geschlecht geordnet) ausgedruckt. Bei Bedarf wird auch ein Altersdiagramm automatisch erstellt. Nach einer kurzen Darstellung der notwendigen vorbereitenden und auswertenden Programme folgen eine Diskussion der Fehler, ihrer Entstehung und Korrektur, sowie Angaben über den apparativen und zeitlichen Aufwand.

Das beschriebene Dokumentationssystem liefert dem anfragenden Arzt frei lesbare Diagnosentexte, so daß er keinerlei Entschlüsselung vorzunehmen hat. Auf Grund des entwickelten PATH-KWIC(KWIC = Key-Word in Context) Programms können sämtliche Diagnosen nach alphabetisch geordneten Stichworten’ (lexikographisch) ausgedruckt werden.

[Mental health in Bonaire - an inspiration for the Dutch New Mental Health Movement]

In 2010 the bes-islands in the Caribbean became a special municipality of the Netherlands. Healthcare was upgraded to match Dutch standards over a short period of time. With a population of 15,518 inhabitants in 2010 (19,408 in 2016), Bonaire received its own fact-team (flexible assertive community treatment). It subsequently became a unique experiment for the Dutch New Mental Health Movement.<br/> AIM: To describe the development of a modern mental health care system in a limited geographic area.<br/> METHOD: Site visitation, interviews and analysis of historical data sources.<br/> RESULTS: The local mental health team takes integral responsibility for all the mh care needs in Bonaire. There is no intricate diagnostic referral system. Consultation access lines are short. The team was able to dramatically reduce the need for hospitalization. Collaboration with the somatic hospital and general practitioners runs smoothly and the facilities offer complementary care. Societal integration is insured due to mental health professionals living interspersed in the neighborhood, the low threshold allowing them to respond to signals efficiently. There is a natural development of the following three domains of care: reduction of symptoms, societal participation and personal remission.<br/> CONCLUSION: Integrated mental health services in a geographically small area, as presented by the Dutch New Mental Health Movement, enables the possibility of recovery oriented care.

Selective Intraportal Transplantation of DiI-marked Isolated Rat Hepatocytes

Transplantation of isolated hepatocytes is a promising alternative to orthotopic liver transplantation in experimental animal models with acute hepatic failure and hereditary enzyme defects. Conventional light microscopy identification of hepatocytes within recipient livers has been limited due to the inability to distinguish between donor and recipient liver cells. In this study, we labeled hepatocytes intracellularly with the fluorescent dye DiI-18 prior to selective intraportal or intrasplenic transplantation. Syngeneic LEW rat hepatocytes were isolated and 2 × 107 fluorescence-labeled cells were transplanted by intraportal infusion selectively into 2/3 of the recipient liver lobules to avoid lethal portal hypertension. Rats were sacrificed on postop days 1, 3, 5, 10, 20, and 40. Histological examination was performed using light and fluorescence microscopy counterstained by light green dye. The quantity of transplanted hepatocytes residing within the recipient liver was determined by FACS analysis after enzymatic digestion of the recipient liver lobules. Engrafted hepatocytes were identified in the periportal regions of transplanted liver lobules. The stained hepatocytes were retrieved up to 20 days postop using fluorescent microscopy. Using FACS analysis the number of labeled hepatocytes was found to diminish over time following transplantation from 2.1% on postop day 1 to 0.5% on day 10. Labeled hepatocytes transplanted into the spleen were retrieved in clusters up to 20 days postop (the last day of observation). Furthermore, the migration of labeled hepatocytes from spleen to liver parenchyma was observed following intrasplenic transplantation. However, after selective intraportal transplantation, only fluorescent debris was found in splenic and pulmonary tissue upon examination of various organs. This article describes the method of fluorescent labeling of rat hepatocytes and reports the feasibility and limitations of using DiI-18 as a marker.

Allogeneic Hepatocyte Transplantation Using FK 506

Hepatocyte transplantation is an intriguing alternative to orthotopic liver transplantation. While engraftment of syngeneic hepatocytes can be achieved with relative ease, engraftment of allogeneic hepatocytes has been far more complicated. We used FK 506 (Tacrolimus), a novel and highly efficient immunosuppressant, which has been reported to augment liver regeneration in rats. Recipients of isolated syngeneic (LEW) and allogeneic (Wistar F.) rat hepatocytes (major histocompatibility barrier) recieved different immunosuppressive regiments with FK 506 or Cyclosporine A (CsA). Mature syngeneic hepatocytes could be retrieved up to post op day 300 with the lowest number of hepatocytes on post op day 20. Following allogeneic transplantation, no mature hepatocytes could be identified after post op day 10, though ductular like structures within the spleen were found in FK 506 but not CsA-treated animals. The epithelial cells of ductular like structures exhibit cytological features of CK-19 positive cells. Our results suggest that under CsA or FK 506 immunosuppression long-term survival of mature allogeneic hepatocytes within the spleen cannot be achieved across a major histocompatibility barrier though FK 506 allows engraftment of allogeneic donor type ductular cells. Copyright © 1997 Elsevier Science Inc.

Localization of spatially distributed brain sources after a tensor-based preprocessing of interictal epileptic EEG data

This paper addresses the localization of spatially distributed sources from interictal epileptic electroencephalographic data after a tensor-based preprocessing. Justifying the Canonical Polyadic (CP) model of the space-time-frequency and space-time-wave-vector tensors is not an easy task when two or more extended sources have to be localized. On the other hand, the occurrence of several amplitude modulated spikes originating from the same epileptic region can be used to build a space-time-spike tensor from the EEG data. While the CP model of this tensor appears more justified, the exact computation of its loading matrices can be limited by the presence of highly correlated sources or/and a strong background noise. An efficient extended source localization scheme after the tensor-based preprocessing has then to be set up. Different strategies are thus investigated and compared on realistic simulated data: the "disk algorithm" using a precomputed dictionary of circular patches, a standardized Tikhonov regularization and a fused LASSO scheme.

[Noninvasive Mechanical Ventilation in Acute Respiratory Failure]

The non-invasive ventilation (NIV) is widespread in the clinical medicine and has attained meanwhile a high value in the clinical daily routine. The application of NIV reduces the length of ICU stay and hospitalization as well as mortality of patients with hypercapnic acute respiratory failure. Patients with acute respiratory failure in context of a cardiopulmonary edema should be treated in addition to necessary cardiological interventions with continuous positive airway pressure (CPAP) or NIV. In case of other forms of acute hypoxaemic respiratory failure it is recommended the application of NIV to be limited to mild forms of ARDS as the application of NIV in severe forms of ARDS is associated with higher rates of treatment failure and mortality. In weaning process from invasive ventilation the NIV reduces the risk of reintubation essentially in hypercapnic patients. A delayed intubation of patients with NIV failure leads to an increase of mortality and should therefore be avoided. With appropriate monitoring in intensive care NIV can also be successfully applied in pediatric patients with acute respiratory insufficiency. Furthermore NIV can be useful within palliative care for reduction of dyspnea and improving quality of life. The aim of the guideline update is, taking into account the growing scientific evidence, to outline the advantages as well as the limitations of NIV in the treatment of acute respiratory failure in daily clinical practice and in different indications.

All-polymer photonic sensing platform based on whispering-gallery mode microgoblet lasers

We present an all-polymer photonic sensing platform based on whispering-gallery mode microgoblet lasers integrated into a microfluidic chip. The chip is entirely made from polymers, enabling the use of the devices as low-cost disposables. The microgoblet cavities feature quality factors exceeding 10(5) and are fabricated from poly(methyl methacrylate) (PMMA) using spin-coating, mask-based optical lithography, wet chemical etching, and thermal reflow. In contrast to silica-based microtoroid resonators, this approach replaces technically demanding vacuum-based dry etching and serial laser-based reflow techniques by solution-based processing and parallel thermal reflow. This enables scaling to large-area substrates, and hence significantly reduces device costs. Moreover, the resonators can be fabricated on arbitrary substrate materials, e.g., on transparent and flexible polymer foils. Doping the microgoblets with the organic dye pyrromethene 597 transforms the passive resonators into lasers. Devices have lasing thresholds below 0.6 nJ per pulse and can be efficiently pumped via free-space optics using a compact and low-cost green laser diode. We demonstrate that arrays of microgoblet lasers can be readily integrated into a state-of-the-art microfluidic chip replicated via injection moulding. In a proof-of-principle experiment, we show the viability of the lab-on-a-chip via refractometric sensing, demonstrating a bulk refractive index sensitivity (BRIS) of 10.56 nm per refractive index unit.

Farm Exposure as a Differential Risk Factor in ANCA-Associated Vasculitis

Objective

To investigate the association of farm exposure and the development of ANCA-associated vasculitis (AAV).

Methods

One hundred eighty-nine well defined patients with AAV (n = 119 with granulomatosis with polyangiitis [GPA], n = 48 with microscopic polyangiitis [MPA], n = 22 patients with eosinophilic granulomatosis with polyangiitis [EGPA]) and 190 controls (n = 119 patients with rheumatoid arthritis, n = 71 with large vessel vasculitis) were interrogated using a structured questionnaire. Factors investigated were occupation, farm exposure, contact to different livestock, participation in harvesting, residence next to a farm, MRSA status, and contact to domestic pets at disease onset or ever before. The odds ratio (OR) and 95% confidence interval [95%CI] were calculated for each item.

Results

Univariate analysis revealed a strong association of AAV with regular farm exposure; OR 3.44 [95%CI 1.43–8.27]. AAV was also associated with regular contact to cattle 4.30 (1.43–8.27), pigs 2.75 (1.12–6.75) and MRSA carriage 3.38 (1.11–10.3). This association was stronger in the subgroup of GPA patients. OR in this group for farm exposure was 4.97; [2.02–12.2], for cattle 6.71 [95% CI 2.19–20.7], for pigs 4.34 [1.75–10.9], and MRSA carriage 5.06 [1.62–15.8]). There was no significant association of MPA or EGPA with these parameters.

Conclusion

A significant association between farm exposure or farm animal exposure and AAV especially in the subgroup of patients with GPA has been identified. This suggests that these entities are distinct and have different triggers for the immune process.

The incidence of hypomagnesaemia following abdominal aortic aneurysm surgery

INTRODUCTION

Magnesium is important for cardiac function. Hypomagnesaemia is associated with a higher incidence of arrhythmias and poorer outcomes in cardiac surgery. No studies have investigated the incidence or impact of postoperative hypomagnesaemia after abdominal aortic aneurysm (AAA) surgery. We aim to assess the incidence of hypomagnesaemia after AAA repair in our population.

METHODS

Retrospective analysis was performed of patients who underwent elective AAA surgery at a single vascular centre. The last 110 patients undergoing open or endovascular AAA repair were identified. The hospital pathology system was used to identify the immediate postoperative serum magnesium levels as well as patient demographics and admission details. Hypomagnesaemia was defined as serum magnesium of <0.7 mmol/l.

RESULTS

A total of 211 patients were studied and there were 3 deaths. Of the patients included, 101 underwent open elective AAA repair and 110 underwent endovascular repair. In the elective open repair group, 73 patients (73%) were hypomagnesaemic. In the endovascular repair group, 35 (32%) had hypomagnesaemia. A t-test showed a statistically significant difference in hypomagnesaemia between the open and endovascular groups (p<0.001).

CONCLUSIONS

AAA surgery is associated with a high incidence of postoperative hypomagnesaemia, which is significantly greater among open repair patients. This is likely to have an effect on cardiac activity and lead to cardiac complications such as arrhythmias and poorer postoperative outcomes, especially in the open AAA repair subgroup. This stresses the importance of serum magnesium and cardiac monitoring in the postoperative phase. A prospective study is proposed to further investigate these findings, and their potential implications on perioperative morbidity and mortality.

Platelet counts as a biomarker in ANCA-associated vasculitis

OBJECTIVES

To determine whether platelet (PLT) counts might serve as a biomarker to distinguish between active anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) and remission and also between active disease and systemic infection.

METHOD

PLTs were analysed before treatment in patients with AAV in the active state and in remission. PLTs were also analysed in AAV patients with acute infections. The results were correlated with clinical manifestations, the Birmingham Vasculitis Activity Score version 3 [BVAS(v.3)], and other laboratory findings [i.e. C-reactive protein (CRP), leucocytes, differential count, procalcitonin (PCT)]. Diagnostic accuracy was calculated with a receiver operating characteristic (ROC) curve.

RESULTS

PLT counts were significantly increased in 98 patients with AAV during the active disease state [median: 405 PLTs/nL; interquartile range (IQR) 288-504] compared to patients in remission (246 PLT/nL; IQR 214-289) (p < 0.001). We found a correlation of PLT counts in active disease with the BVAS(v.3) (r = 0.582, p < 0.001). In AAV patients with systemic infections (n = 37), PLT counts exhibited significantly lower values (226 PLT/nL; IQR 163-273) compared to patients with active disease (p < 0.001). In the ROC curve analysis, the area under the curve (AUC) of PLTs was significantly larger when distinguishing active disease from systemic infection (AUC 0.868) compared to leucocytes (AUC 0.590), CRP (AUC 0.522), or procalcitonin (AUC 0.515) (p < 0.001).

CONCLUSIONS

PLT counts were found to correlate with disease activity in AAV and thus may be used to represent immunological activity. In addition, PLT counts serve as a marker that can distinguish acute infection from active disease.

Untersuchungen über Funktionsstörungen der Blut-Hirnschranke bei Sauerstoffmangel und Kohlenoxydvergiftung mit dem neuen Schrankenindikator Astraviolett FF

Im Sauerstoffmangel (Unterdruck-Kammer) wird die Blut-Hirnschranke schon zu einem Zeitpunkt, an dem histologische Gewebsschädigungen noch nicht erkennbar sind, deutlich nachweisbar durchlässig. Diese sowie die durch CO bewirkte Durchlässigkeitssteigerung war mit dem bisher meist benutzten Schrankenindikator Trypanblau nicht zu beobachten. Astraviolett FF allein oder in Kombination mit Triphenyltetrazoliumchlorid (TTC) erwies sich als viel empfindlicherer Schrankenindikator.

EEG extended source localization: tensor-based vs. conventional methods

The localization of brain sources based on EEG measurements is a topic that has attracted a lot of attention in the last decades and many different source localization algorithms have been proposed. However, their performance is limited in the case of several simultaneously active brain regions and low signal-to-noise ratios. To overcome these problems, tensor-based preprocessing can be applied, which consists in constructing a space-time-frequency (STF) or space-time-wave-vector (STWV) tensor and decomposing it using the Canonical Polyadic (CP) decomposition. In this paper, we present a new algorithm for the accurate localization of extended sources based on the results of the tensor decomposition. Furthermore, we conduct a detailed study of the tensor-based preprocessing methods, including an analysis of their theoretical foundation, their computational complexity, and their performance for realistic simulated data in comparison to conventional source localization algorithms such as sLORETA, cortical LORETA (cLORETA), and 4-ExSo-MUSIC. Our objective consists, on the one hand, in demonstrating the gain in performance that can be achieved by tensor-based preprocessing, and, on the other hand, in pointing out the limits and drawbacks of this method. Finally, we validate the STF and STWV techniques on real measurements to demonstrate their usefulness for practical applications.

Association of extended interleukin-10 promoter haplotypes with disease susceptibility and manifestations in German patients with systemic lupus erythematosus

OBJECTIVES

Associations of interleukin-10 (IL-10) promoter single nucleotide polymorphisms (SNPs) and their haplotypes with systemic lupus erythematosus (SLE) are unclear. We extended the analysis of established proximal IL-10 promoter haplotypes to a more distal SNP with functional capacity.

METHODS

Two hundred and ten German caucasian SLE patients fulfilling the ACR criteria and 160 ethnically, age and sex matched controls were genotyped for IL-10 -2849 G > A, -1082 A > G, -819 T > C and -592 C > A. Haplotypes were reconstructed via a mathematical model, then allele and haplotype distributions were compared between patients and controls and patients with different disease manifestations.

RESULTS

We detected at -2849, -1082, -819 and -592 the four predominant haplotypes GGCC (22% in patients vs. 29% in controls), AGCC (24% vs. 21%), GACC (30% vs. 25%) and GATA (24% vs. 24%). GGCC was underrepresented in SLE patients, suggesting a protective effect (odds ratio (OR) 0.67, 95% confidence interval (CI) 0.48-0.94). AGCC was found significantly more frequently in patients with pathognomonic anti-dsDNA antibodies (26% vs. 15%; OR 1.98, 95% CI 1.04-3.75). As compared to patients with glomerulonephritis type V (WHO classification), the presumptive IL-10 high producer allele -2849 G was found significantly more often in patients with GN type III/IV (93% vs. 60%; OR 8.7, 95% CI 1.59-47.15).

CONCLUSION

Our data confirm that the complexity of the IL-10 promoter evokes the need for a meticulous analysis of its haplotypic structure in order to specify disease associations, particularly under functional aspects, thereby shedding light on the pathophysiology of SLE.

The influence of Castanhão reservoir on nutrient and suspended matter transport during rainy season in the ephemeral Jaguaribe river (CE, Brazil)

Measurements of nutrient and suspended matter concentrations and loads entering and leaving the Castanhão reservoir during the rainy season were carried out to assess the influence of this large reservoir on land-sea fluvial transport in the ephemeral Jaguaribe river basin. Spatial variation indicated statistically significant attenuation of concentrations only for total phosphorous and suspended matter across the reservoir. Strong retention of nutrients and suspended matter loads by the reservoir was observed with average trapping efficiency of 89% for dissolved silicon, 98% of soluble reactive phosphorus, 71% for ammonium, 87% for total nitrogen, 98% for total phosphorus and 97% for suspended matter compared to the reservoir inflow. The dam operational procedure defined by the ephemeral conditions of the river reduced water releases compared to reservoir inflow and induced strong retention of nutrient and suspended matter loads within the reservoir when fluvial transfer occurs in this semiarid watershed.

A stem cell-like gene expression signature associates with inferior outcomes and a distinct microRNA expression profile in adults with primary cytogenetically normal acute myeloid leukemia

Acute myeloid leukemia (AML) is hypothesized to be sustained by self-renewing leukemia stem cells (LSCs). Recently, gene expression signatures (GES) from functionally defined AML LSC populations were reported, and expression of a 'core enriched' (CE) GES, representing 44 genes activated in LCSs, conferred shorter survival in cytogenetically normal (CN) AML. The prognostic impact of the CE GES in the context of other molecular markers, including gene mutations and microRNA (miR) expression alterations, is unknown and its clinical utility is unclear. We studied associations of the CE GES with known molecular prognosticators, miR expression profiles, and outcomes in 364 well-characterized CN-AML patients. A high CE score (CE(high)) associated with FLT3-internal tandem duplication, WT1 and RUNX1 mutations, wild-type CEBPA and TET2, and high ERG, BAALC and miR-155 expression. CE(high) patients had a lower complete remission (CR) rate (P=0.003) and shorter disease-free (DFS, P<0.001) and overall survival (OS, P<0.001) than CE(low) patients. These associations persisted in multivariable analyses adjusting for other prognosticators (CR, P=0.02; DFS, P<0.001; and OS, P<0.001). CE(high) status was accompanied by a characteristic miR expression signature. Fifteen miRs were upregulated in both younger and older CE(high) patients, including miRs relevant for stem cell function. Our results support the clinical relevance of LSCs and improve risk stratification in AML.

[Value of one-stage surgical treatment of diffuse peritonitis (relaparotomy on demand): a single-center analysis]

BACKGROUND

Despite modern surgical and intensive-care concepts, diffuse peritonitis remains a major source of high morbidity and mortality. The aim of this study was to critically evaluate the value of relaparotomy on demand (ROD) for patients with diffuse peritonitis.

PATIENTS AND RESULTS

In a retrospective analysis, the clinical course of 231 patients with diffuse peritonitis was analysed. The mean Mannheim Peritonitis Index (MPI) was 25.3. Overall lethality in this cohort was 14.3 %. In 214 patients, source control was successful during the index operation, and these patients were treated according to an on-demand strategy. For 178 of these patients, there was no demand for a relaparotomy, whereas 36 of these patients required further surgical interventions. Lethality for these subgroups was 9 % (no relaparotomy) and 27 % (relaparotomy), respectively.

CONCLUSIONS

This retrospective analysis confirms that an on-demand strategy is reasonable and feasible after successful source control and lavage. However, it still remains of clinical importance to identify parameters that may assist in selecting those patients who require a relaparotomy.

A novel extracorporeal CO(2) removal system: results of a pilot study of hypercapnic respiratory failure in patients with COPD

BACKGROUND

Hypercapnic respiratory failure in patients with COPD frequently requires mechanical ventilatory support. Extracorporeal CO2 removal (ECCO2R) techniques have not been systematically evaluated in these patients.

METHODS

This is a pilot study of a novel ECCO2R device that utilizes a single venous catheter with high CO2 removal rates at low blood flows. Twenty hypercapnic patients with COPD received ECCO2R. Group 1 (n = 7) consisted of patients receiving noninvasive ventilation with a high likelihood of requiring invasive ventilation, group 2 (n = 2) consisted of patients who could not be weaned from noninvasive ventilation, and group 3 (n = 11) consisted of patients on invasive ventilation who had failed attempts to wean.

RESULTS

The device was well tolerated, with complications and rates similar to those seen with central venous catheterization. Blood flow through the system was 430.5 ± 73.7 mL/min, and ECCO2R was 82.5 ± 15.6 mL/min and did not change significantly with time. Invasive ventilation was avoided in all patients in group 1 and both patients in group 2 were weaned; PaCO2 decreased significantly (P < .003) with application of the device from 78.9 ± 16.8 mm Hg to 65.9 ± 11.5 mm Hg. In group 3, three patients were weaned, while the level of invasive ventilatory support was reduced in three patients. One patient in group 3 died due to a retroperitoneal bleed following catheterization.

CONCLUSIONS

This single-catheter, low-flow ECCO2R system provided clinically useful levels of CO2 removal in these patients with COPD. The system appears to be a potentially valuable additional modality for the treatment of hypercapnic respiratory failure.

Central nervous system involvement in adults with epidemic hemolytic uremic syndrome

Hemolytic uremic syndrome is a multisystem disorder that is caused by infection with Shiga-toxin-producing Escherichia coli. HUS affects mainly children and is rare among adults. This retrospective case series analyzes clinical signs and MR imaging findings of 11 adult patients with HUS associated nervous system involvement during the epidemic EHEC outbreak in northern Europe with its epicenter in Hamburg in May 2011. The most prevalent imaging finding was symmetric pointy vasogenic edema of the brain stem in the acute and subacute phases of the disease (n = 5). One patient exhibited additional symmetric mesiotemporal signal changes mimicking limbic encephalitis. Two patients developed subcortical patchy lesions, and 4 subjects did not present with any signal changes. Remarkably, territorial ischemia, signs of hemorrhage, or blood-brain barrier disruption have not been detected. While brain stem lesions were transient and normalized with clinical recovery, supratentorial lesions did not resolve completely at 2-month follow-up examination.

Analysis of sleep fragmentation and sleep structure in patients with sleep apnea and normal volunteers

Sleep disorders have a high prevalence. Sleep disorders are recognized first by the complaint of nonrestorative sleep. A quantification of the disorder is done by the investigation in a sleep laboratory. The investigation in the sleep laboratory examines the EEG, EOG and EMG to derive sleep stages. This is a labor intensive sleep scoring after the polysomnography investigation. Usually the time course of the sleep stages is quantified in terms of percentages of stages related to total sleep time and the latencies for the individual stages. The additional feature of transitions between sleep stages and the disruption of sleep, which corresponds to periods of wakefulness during sleep are not evaluated systematically. We have evaluated these transitions using a statistical approach. We have detected systematic differences in the distributions o sleep stages and wake states during sleep. This differences were investigates in normal subjects and patients with sleep apnea. Then these differences were investigated in different species. The difference in the distributions can be explained only by fundamentally different regulation of sleep and wakefulness.

Kosten einer leitliniengerechten Versorgung von Hepatitis-B-Patienten in Deutschland

Leitliniengerechte Versorgungskosten sind bisher nur für wenige Krankheiten berechnet worden. Auch für volkswirtschaftlich bedeutende Infektionserkrankungen, wie die infektiösen Hepatitiden und HIV, gibt es keine Untersuchungen. Auf der Basis der aktuellen S3-Leitlinie − Prophylaxe, Diagnostik und Therapie der Hepatitis-B-Virus-Infektion − von 2011 wurden für die Patientengruppen HBsAg-Träger, Immuntolerante und die chronischen Hepatitis-B-Patienten mit und ohne Zirrhose die Kosten für eine leitliniengerechte Basisdiagnostik, Monitoring und Therapie errechnet. Das Modell wurde auf einen Zeitraum von 5 Jahren bezogen. Bei den Untersuchungskosten fallen die virologische Diagnostik und die bildgebenden Verfahren ins Gewicht. Hauptkostenfaktor ist aber die Therapie mit Interferon oder Polymeraseinhibitoren. Auch unter der Annahme, das nur 25 % der Infizierten erfasst werden, belaufen sich die 5-Jahres-Gesamtkosten in Deutschland auf über 2,5 Mrd. €. Damit ist die chronische Hepatitis B eine Erkrankung mit hohen Versorgungskosten. Ziel einer leitliniengerechten Versorgung ist die Verhinderung der Leberzirrhose mit ihren Komplikationen sowie des Leberzellkarzinoms. Eine konsequente Schutzimpfung gegen Hepatitis B als Prophylaxe scheint unter der Betrachtung der Versorgungskosten volkswirtschaftlich rational.

[MRI findings delay the diagnosis of nasopharyngeal carcinoma]

This report concerns a 55-year-old female patient who presented with headache, dry right eye and dry nose on the right side. After 5 months magnetic resonance imaging (MRI) was carried out but no pathological findings were diagnosed. Right-sided facial pain appeared 6 months later and a second MRI was carried out but only fluid retention in the right mastoid was diagnosed. After a further 8 months paresis of the right abducent nerve occurred and a computed tomography (CT) scan of the petrous bone showed extensive destruction of the apex of the petrous pyramid. Subsequently a third MRI revealed a tumor of about 5 cm in diameter in the right pterygopalatine fossa which was also retrospectively visible in the first MRI with a size of approximately 3 cm and in the second MRI with 4 cm in diameter. The histological examination after biopsy resulted in the diagnosis of a nasopharyngeal carcinoma and radiochemotherapy was initiated. The patient died 9 months later. The relatives of the patient applied to the arbitration board for medical liability which requested expert opinions in neuroradiology and otorhinolaryngology. The board came to the conclusion that the claims for damages against the radiologist who had made the three MRIs were well-founded and recommended an extrajudicial settlement.