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Foley ÉM, Slaney C, Donnelly NA, Kaser M, Ziegler L, Khandaker GM. A novel biomarker of interleukin 6 activity and clinical and cognitive outcomes in depression. Psychoneuroendocrinology 2024; 164:107008. [PMID: 38442505 DOI: 10.1016/j.psyneuen.2024.107008] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 02/05/2024] [Accepted: 02/26/2024] [Indexed: 03/07/2024]
Abstract
BACKGROUND Inflammatory cytokines like interleukin-6 (IL-6) are implicated in depression, but most studies have hitherto focused on circulating levels of IL-6 rather than its activity. IL-6 trans-signalling is thought to be responsible for most of the pathogenic effects of IL-6 and is implicated in autoimmune diseases like rheumatoid arthritis. We tested the association between a multi-protein-derived measure of IL-6 trans-signalling and clinical and cognitive outcomes in patients with depression. We hypothesised that this novel measure of IL-6 activity/bioavailability would be associated with clinical and cognitive measures previously reported to be associated with inflammation in depression. METHODS Using data from 86 patients with International Classification of Diseases-10 diagnosis of depression, we calculated a ratio score representing IL-6 activity/bioavailability using serum IL-6, soluble IL-6 receptor (sIL-6R), and soluble glycoprotein 130 levels. We tested the relationship of this novel biomarker with 12 cytokines using correlation analyses and with cognitive and clinical measures using multivariable linear regression, following z-transformation of all immune exposures. RESULTS The novel measure of IL-6 activity/bioavailability was correlated with IL-6 (r=0.42, P=0.03), C-reactive protein (CRP) (r=0.42, P=0.03), sIL-6R (r=0.91, P<0.01), and tumour necrosis factor alpha (r=0.43, P=0.03). The IL-6 activity/bioavailability measure was associated with higher somatic symptoms of depression (β=1.09; 95% CI 0.30, 1.88; PFDR=0.01), fatigue (β=4.34; 95% CI 1.26, 7.42; PFDR=0.03), depression severity (β=3.06; 95% CI 0.71, 5.40; P=0.02), poorer quality of life (β=-0.07; 95% CI -0.13, -0.01; PFDR=0.045), and decreased psychomotor speed (β=-5.46; 95% CI -9.09, -1.84; PFDR=0.01),. There was little evidence of associations with reaction time, anhedonia, anxiety, emotional perception and recall, executive function, and sustained attention (Ps>0.05). The effect estimates for the associations of the novel measure with depression outcomes were comparable to those for individual immune proteins (i.e., IL-6, CRP, sIL-6R). CONCLUSION A novel multi-protein-derived measure of IL-6 activity/bioavailability shows robust associations with various inflammation-related clinical and cognitive outcomes in depression and performs well in comparison to single inflammatory proteins. We need replication of these findings in other samples, experiments for mechanistic validity of this novel biomarker, and clinical studies to assess its usefulness as a marker of illness risk and prognosis.
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Affiliation(s)
- Éimear M Foley
- MRC Integrative Epidemiology Unit, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.
| | - Chloe Slaney
- MRC Integrative Epidemiology Unit, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Nicholas A Donnelly
- MRC Integrative Epidemiology Unit, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; Avon and Wiltshire Mental Health Partnership NHS Trust, Bristol, UK
| | - Muzaffer Kaser
- Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, UK; Department of Psychiatry, University of Cambridge, Cambridge, UK
| | - Louise Ziegler
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Golam M Khandaker
- MRC Integrative Epidemiology Unit, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; Avon and Wiltshire Mental Health Partnership NHS Trust, Bristol, UK; NIHR Bristol Biomedical Research Centre, Bristol, UK
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Chen QS, Bergman O, Ziegler L, Baldassarre D, Veglia F, Tremoli E, Strawbridge RJ, Gallo A, Pirro M, Smit AJ, Kurl S, Savonen K, Lind L, Eriksson P, Gigante B. A machine learning based approach to identify carotid subclinical atherosclerosis endotypes. Cardiovasc Res 2023; 119:2594-2606. [PMID: 37475157 PMCID: PMC10730242 DOI: 10.1093/cvr/cvad106] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 03/12/2023] [Accepted: 05/05/2023] [Indexed: 07/22/2023] Open
Abstract
AIMS To define endotypes of carotid subclinical atherosclerosis. METHODS AND RESULTS We integrated demographic, clinical, and molecular data (n = 124) with ultrasonographic carotid measurements from study participants in the IMPROVE cohort (n = 3340). We applied a neural network algorithm and hierarchical clustering to identify carotid atherosclerosis endotypes. A measure of carotid subclinical atherosclerosis, the c-IMTmean-max, was used to extract atherosclerosis-related features and SHapley Additive exPlanations (SHAP) to reveal endotypes. The association of endotypes with carotid ultrasonographic measurements at baseline, after 30 months, and with the 3-year atherosclerotic cardiovascular disease (ASCVD) risk was estimated by linear (β, SE) and Cox [hazard ratio (HR), 95% confidence interval (CI)] regression models. Crude estimates were adjusted by common cardiovascular risk factors, and baseline ultrasonographic measures. Improvement in ASCVD risk prediction was evaluated by C-statistic and by net reclassification improvement with reference to SCORE2, c-IMTmean-max, and presence of carotid plaques. An ensemble stacking model was used to predict endotypes in an independent validation cohort, the PIVUS (n = 1061). We identified four endotypes able to differentiate carotid atherosclerosis risk profiles from mild (endotype 1) to severe (endotype 4). SHAP identified endotype-shared variables (age, biological sex, and systolic blood pressure) and endotype-specific biomarkers. In the IMPROVE, as compared to endotype 1, endotype 4 associated with the thickest c-IMT at baseline (β, SE) 0.36 (0.014), the highest number of plaques 1.65 (0.075), the fastest c-IMT progression 0.06 (0.013), and the highest ASCVD risk (HR, 95% CI) (1.95, 1.18-3.23). Baseline and progression measures of carotid subclinical atherosclerosis and ASCVD risk were associated with the predicted endotypes in the PIVUS. Endotypes consistently improved measures of ASCVD risk discrimination and reclassification in both study populations. CONCLUSIONS We report four replicable subclinical carotid atherosclerosis-endotypes associated with progression of atherosclerosis and ASCVD risk in two independent populations. Our approach based on endotypes can be applied for precision medicine in ASCVD prevention.
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Affiliation(s)
- Qiao Sen Chen
- Division of Cardiovascular Medicine, Department of Medicine Solna, Karolinska Institutet, Solnavägen 30, 171 64 Stockholm, Sweden
| | - Otto Bergman
- Division of Cardiovascular Medicine, Department of Medicine Solna, Karolinska Institutet, Solnavägen 30, 171 64 Stockholm, Sweden
| | - Louise Ziegler
- Division of Medicine and Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Entrevägen 2, 182 88 Stockholm, Sweden
| | - Damiano Baldassarre
- Department of Medical Biotechnology and Translational Medicine, Università di Milano, Via Vanvitelli 32, 20133 Milan, Italy
- Centro Cardiologico Monzino, IRCCS, Via Carlo Parea 4, 20138 Milan, Italy
| | - Fabrizio Veglia
- Maria Cecilia Hospital, GVM Care & Research, Via Corriera 1, 48033 Cotignola (RA), Italy
| | - Elena Tremoli
- Maria Cecilia Hospital, GVM Care & Research, Via Corriera 1, 48033 Cotignola (RA), Italy
| | - Rona J Strawbridge
- Division of Cardiovascular Medicine, Department of Medicine Solna, Karolinska Institutet, Solnavägen 30, 171 64 Stockholm, Sweden
- Institute of Health and Wellbeing, University of Glasgow, Clarice Pears Building, 90 Byres Road, Glasgow G12 8TB, UK
- Health Data Research, Clarice Pears Building, 90 Byres Road, Glasgow G12 8TB, UK
| | - Antonio Gallo
- Lipidology and Cardiovascular Prevention Unit, Department of Nutrition, Sorbonne Université, INSERM UMR1166, APHP, Hôpital Pitié-Salpètriêre, 47 Boulevard de l´Hopital, 75013 Paris, France
| | - Matteo Pirro
- Internal Medicine, Angiology and Arteriosclerosis Diseases, Department of Medicine, University of Perugia, Piazzale Menghini 1, 06129 Perugia, Italy
| | - Andries J Smit
- Department of Medicine, University Medical Center Groningen, Groningen & Isala Clinics Zwolle, Dokter Spanjaardweg 29B, 8025 BT Groningen, the Netherlands
| | - Sudhir Kurl
- Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio Campus, Yliopistonranta 1 C, Canthia Building, B Wing, FI-70211 Kuopio, Finland
| | - Kai Savonen
- Kuopio Research Institute of Exercise Medicine, Haapaniementie 16, FI-70100 Kuopio, Finland
- Department of Clinical Physiology and Nuclear Medicine, Science Service Center, Kuopio University Hospital, Yliopsistonranta 1F, FI-70211 Kuopio, Finland
| | - Lars Lind
- Department of Medical Sciences, Uppsala University, Uppsala Science Park, Dag Hammarskjöldsv 10B, 752 37 Uppsala, Sweden
| | - Per Eriksson
- Division of Cardiovascular Medicine, Department of Medicine Solna, Karolinska Institutet, Solnavägen 30, 171 64 Stockholm, Sweden
| | - Bruna Gigante
- Division of Cardiovascular Medicine, Department of Medicine Solna, Karolinska Institutet, Solnavägen 30, 171 64 Stockholm, Sweden
- Department of Cardiology, Danderyd University Hospital, Entrevägen 2, 182 88 Stockholm, Sweden
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Grimm M, Seglias A, Ziegler L, Mademilov M, Isaeva E, Tynybekov K, Tilebalieva A, Osmonbaeva N, Furian M, Sooronbaev TM, Ulrich S, Bloch KE. Sleep apnea in school-age children living at high altitude. Pulmonology 2023; 29:385-391. [PMID: 36964122 DOI: 10.1016/j.pulmoe.2023.02.008] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 02/01/2023] [Accepted: 02/09/2023] [Indexed: 03/26/2023] Open
Abstract
INTRODUCTION Among adults, sleep apnea is more common in highlanders than in lowlanders. We evaluated the sleep apnea prevalence in children living at high altitude compared to age-matched low-altitude controls. METHODS Healthy children, 7-14 y of age, living at 2500-3800m in the Tien Shan mountains, Kyrgyzstan, were prospectively studied in a health post at 3250m. Healthy controls of similar age living at 700-800m were studied in a University Hospital at 760m in Bishkek. Assessments included respiratory sleep studies scored according to pediatric standards, clinical examination, medical history, and the pediatric sleep questionnaire (PSQ, range 0 to 1 with increasing symptoms). RESULTS In children living at high altitude (n = 37, 17 girls, median [quartiles] age 10.8y [9.6;13.0]), sleep studies revealed: mean nocturnal pulse oximetry 90% (89;91), oxygen desaturation index (ODI, >3% dips in pulse oximetry) 4.3/h (2.5;6.7), apnea/hypopnea index (AHI) total 1.7/h (1.0;3.6), central 1.6/h (1.0;3.3), PSQ 0.27 (0.18;0.45). In low-altitude controls (n=41, 17 girls, age 11.6y [9.5;13.0], between-groups comparison of age P=0.69) sleep studies revealed: pulse oximetry 97% (96;97), ODI 0.7/h (0.2;1.2), AHI total 0.4/h (0.1;1.0), central 0.3/h (0.1;0.7), PSQ 0.18 (0.14;0.31); P<0.05, all corresponding between-group comparisons. CONCLUSIONS In school-age children living at high altitude, nocturnal oxygen saturation was lower, and the total and central AHI were higher compared to children living at low altitude. The greater score of sleep symptoms in children residing at high altitude suggests a potential clinical relevance of the nocturnal hypoxemia and subtle sleep-related breathing disturbances.
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Affiliation(s)
- M Grimm
- Department of Respiratory Medicine, University Hospital Zurich, Zurich, Switzerland; Swiss-Kyrgyz High Altitude Medicine and Research Initiative, Zurich, Switzerland; Swiss-Kyrgyz High Altitude Medicine and Research Initiative, Bishkek, Kyrgyz Republic
| | - A Seglias
- Department of Respiratory Medicine, University Hospital Zurich, Zurich, Switzerland; Swiss-Kyrgyz High Altitude Medicine and Research Initiative, Zurich, Switzerland; Swiss-Kyrgyz High Altitude Medicine and Research Initiative, Bishkek, Kyrgyz Republic
| | - L Ziegler
- Department of Respiratory Medicine, University Hospital Zurich, Zurich, Switzerland; Swiss-Kyrgyz High Altitude Medicine and Research Initiative, Zurich, Switzerland; Swiss-Kyrgyz High Altitude Medicine and Research Initiative, Bishkek, Kyrgyz Republic
| | - M Mademilov
- Department of Respiratory Medicine, National Center of Cardiology and Internal Medicine, Bishkek, Kyrgyz Republic; Swiss-Kyrgyz High Altitude Medicine and Research Initiative, Zurich, Switzerland; Swiss-Kyrgyz High Altitude Medicine and Research Initiative, Bishkek, Kyrgyz Republic
| | - E Isaeva
- National Center of Maternity and Childhood Care, Bishkek, Kyrgyz Republic; Swiss-Kyrgyz High Altitude Medicine and Research Initiative, Zurich, Switzerland; Swiss-Kyrgyz High Altitude Medicine and Research Initiative, Bishkek, Kyrgyz Republic
| | - K Tynybekov
- National Center of Maternity and Childhood Care, Bishkek, Kyrgyz Republic; Swiss-Kyrgyz High Altitude Medicine and Research Initiative, Zurich, Switzerland; Swiss-Kyrgyz High Altitude Medicine and Research Initiative, Bishkek, Kyrgyz Republic
| | - A Tilebalieva
- National Center of Maternity and Childhood Care, Bishkek, Kyrgyz Republic; Swiss-Kyrgyz High Altitude Medicine and Research Initiative, Zurich, Switzerland; Swiss-Kyrgyz High Altitude Medicine and Research Initiative, Bishkek, Kyrgyz Republic
| | - N Osmonbaeva
- National Center of Maternity and Childhood Care, Bishkek, Kyrgyz Republic; Swiss-Kyrgyz High Altitude Medicine and Research Initiative, Zurich, Switzerland; Swiss-Kyrgyz High Altitude Medicine and Research Initiative, Bishkek, Kyrgyz Republic
| | - M Furian
- Department of Respiratory Medicine, University Hospital Zurich, Zurich, Switzerland; Swiss-Kyrgyz High Altitude Medicine and Research Initiative, Zurich, Switzerland; Swiss-Kyrgyz High Altitude Medicine and Research Initiative, Bishkek, Kyrgyz Republic
| | - T M Sooronbaev
- Department of Respiratory Medicine, National Center of Cardiology and Internal Medicine, Bishkek, Kyrgyz Republic; Swiss-Kyrgyz High Altitude Medicine and Research Initiative, Zurich, Switzerland; Swiss-Kyrgyz High Altitude Medicine and Research Initiative, Bishkek, Kyrgyz Republic
| | - S Ulrich
- Department of Respiratory Medicine, University Hospital Zurich, Zurich, Switzerland; Swiss-Kyrgyz High Altitude Medicine and Research Initiative, Zurich, Switzerland; Swiss-Kyrgyz High Altitude Medicine and Research Initiative, Bishkek, Kyrgyz Republic
| | - K E Bloch
- Department of Respiratory Medicine, University Hospital Zurich, Zurich, Switzerland; Swiss-Kyrgyz High Altitude Medicine and Research Initiative, Zurich, Switzerland; Swiss-Kyrgyz High Altitude Medicine and Research Initiative, Bishkek, Kyrgyz Republic.
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Hess N, Hong Y, Ziegler L, Keebler M, Hickey G, Huston J, Mathier M, Kaczorowski D. Predictors of Transplantation and Waitlist Mortality Among Patients Listed for Combined Heart-Lung Transplantation: A Unos Registry Analysis. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.210] [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: 04/05/2023] Open
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Hess N, Hong Y, Ziegler L, Keebler M, Hickey G, Huston J, Mathier M, Kaczorowski D. Extracorporeal Membrane Oxygenation Bridging to Orthotopic Heart Transplantation: Updated Analysis Following the 2018 Allocation Change. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.049] [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: 04/05/2023] Open
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Hess N, Hong Y, Ziegler L, Keebler M, Huston J, Mathier M, Hickey G, Kaczorowski D. Right Ventricular Oversizing Mitigates Post-Transplant Mortality in Recipients with Pulmonary Hypertension. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.188] [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: 04/05/2023] Open
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Pini S, Bekker HL, Bennett M, Ziegler L. A Structured Intervention to Support Early Palliative Care Conversations for Oncology Patients - A Qualitative Feasibility Study. Clin Oncol (R Coll Radiol) 2022; 34:e515-e522. [PMID: 35659476 DOI: 10.1016/j.clon.2022.05.012] [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: 02/17/2022] [Revised: 04/11/2022] [Accepted: 05/16/2022] [Indexed: 01/31/2023]
Abstract
AIMS For patients with advanced cancer, early access to palliative care can have numerous psychosocial and disease management benefits. However, it can be difficult for clinicians to initiate these initial conversations about palliative care. The aim of the present study was to beta test an intervention to facilitate timely conversations about palliative care between patients and clinicians. MATERIALS AND METHODS The study reported forms one stage of a complex intervention development study following Medical Research Council guidance for developing complex interventions. Feasibility was explored from patient and clinician perspectives in an oncology outpatient setting. RESULTS Sixteen patients and 18 clinicians participated. Three phases of the intervention were assessed through patient and clinician interviews. The analysis produced three themes in each phase: (i) Preparation (patient preparedness; healthcare professionals' perspectives on palliative care; administration, data and communication); (ii) STEP consultation (defining perspectives on palliative care; how palliative care fits with the current treatment plan; permission to explore future care); (iii) Outcomes (changes in perspective and approaches to coping; opening the door to future conversations; referrals and involvement of palliative services). CONCLUSIONS The STEP intervention generated important early conversations about end-of-life care that may otherwise not have occurred. No patients regretted having the STEP consultation, which resulted in palliative care referrals for some. Others felt better informed about the support services available and better able to have further conversations. Participating clinicians found the structured conversation guide useful, as it acted as a prompt for areas to cover, as well as providing an explicit way to open discussion about difficult topics.
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Affiliation(s)
- S Pini
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK.
| | - H L Bekker
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - M Bennett
- Academic Unit of Palliative Care, University of Leeds, Leeds, UK
| | - L Ziegler
- Academic Unit of Palliative Care, University of Leeds, Leeds, UK
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Ziegler L, Lundström A, Havervall S, Thålin C, Gigante B. IL-6 signalling biomarkers in hospitalised patients with moderate to severe SARS-CoV-2 infection in a single centre study in Sweden. Cytokine 2022; 159:156020. [PMID: 36057230 PMCID: PMC9420722 DOI: 10.1016/j.cyto.2022.156020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 05/15/2022] [Accepted: 08/20/2022] [Indexed: 11/03/2022]
Abstract
Background Method Results Conclusion
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Ziegler L, Wallén H, Aspberg S, de Faire U, Gigante B. Correction: IL6 trans-signaling associates with ischemic stroke but not with atrial fibrillation. BMC Neurol 2022; 22:337. [PMID: 36071382 PMCID: PMC9450387 DOI: 10.1186/s12883-022-02831-x] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Louise Ziegler
- Department of Clinical Sciences Karolinska Institutet, Division of Internal Medicine, Danderyd Hospital, S-182 88, Stockholm, Sweden.
| | - Håkan Wallén
- Department of Clinical Sciences Karolinska Institutet, Division of Cardiovascular Medicine, Danderyd Hospital, Stockholm, Sweden
| | - Sara Aspberg
- Department of Clinical Sciences Karolinska Institutet, Division of Cardiovascular Medicine, Danderyd Hospital, Stockholm, Sweden
| | - Ulf de Faire
- Unit of Cardiovascular and Nutritional Epidemiology Karolinska Institutet, Stockholm, Sweden
| | - Bruna Gigante
- Cardiovascular Medicine Unit, Department of Medicine Karolinska Institutet, Stockholm, Sweden
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Abstract
Lower extremity artery disease (LEAD), a chronic condition with disturbed lower extremity circulation due to narrowing of the arteries, is predominantly caused by atherosclerosis and is associated with the presence of cardiovascular risk factors and an increased risk of cardiovascular events. LEAD is prevalent among older individuals and predicted to rise with the ageing population. In progressive disease, the patient experiences symptoms of ischaemia when walking and, in advanced critical limb-threatening ischaemia, even at rest. However, LEAD is asymptomatic in most patients, delaying diagnosis and treatment. In this setting, circulating biomarkers may facilitate earlier diagnosis in selected individuals. This review provides a broad overview of the circulating biomarkers investigated to date in relation to LEAD and discusses their usefulness in clinical practice.
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Affiliation(s)
- Louise Ziegler
- Division of Internal Medicine, Department of Clinical Sciences, Karolinska Institute, Danderyd Hospital, Stockholm, Sweden
| | - Ulf Hedin
- Vascular Surgery Division, Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - Anders Gottsäter
- Department of Medicine, Lund University, Malmö, Sweden; Department of Medicine, Skåne University Hospital, Malmö, Sweden
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Miri Y, Leander K, Eriksson P, Gigante B, Ziegler L. Interleukin 6 trans-signalling and the risk of future cardiovascular events in men and women. Open Heart 2021; 8:openhrt-2021-001694. [PMID: 34635574 PMCID: PMC8506880 DOI: 10.1136/openhrt-2021-001694] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 09/23/2021] [Indexed: 11/25/2022] Open
Abstract
Objective Pro-inflammatory interleukin 6 (IL6) trans-signalling is associated with increased risk of cardiovascular events (CVEs). Whether this association exists for both sexes is, however, uncertain. Hence, we analysed the risk of CVE associated with IL6 trans-signalling in men and women and investigated if potential interaction between IL6 trans-signalling and sex affects the risk. Methods In a prospective cohort of 60-year-old men and women without cardiovascular disease (men=2039, women=2193), subjects were followed for 20 years. To assess the IL6 trans-signalling activity, the proportion between the active binary and inactive ternary IL6 complexes, the binary/ternary ratio (B/T ratio), was estimated. CVE (myocardial infarction, angina pectoris and ischaemic stroke, n=629) risk was analysed with Cox regression, presented as HRs with 95% CIs. B/T ratio was dichotomised, with levels >median representing IL6 trans-signalling. Interaction was analysed on the additive scale and expressed as the synergy index (S). Analyses were adjusted for cardiovascular risk factors. Results B/T ratio >median was associated with increased CVE risk in men (HR 1.63; 95% CI 1.32 to 2.01), but not in women (HR 1.21; 95% CI 0.93 to 1.57). There was a significant synergistic interaction (S=1.98; 95% CI 1.15 to 3.42) between the B/T ratio and male sex, the combination increasing the risk by 88%. Conclusions Our results suggest differential susceptibility to inflammation mediated by IL6 trans-signalling and subsequent CVE in men and women. The B/T ratio could be considered as a novel biomarker for cardiovascular risk in men, but not in women.
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Affiliation(s)
- Yasmin Miri
- Division of Cardiovascular Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Karin Leander
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Per Eriksson
- Division of Cardiovascular Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Bruna Gigante
- Division of Cardiovascular Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Louise Ziegler
- Department of Clinical Sciences Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
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Ziegler L, Gigante B. IL6 trans-signalling is associated with a higher risk of cardiovascular events in individuals with diabetes. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.2510] [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: 11/14/2022] Open
Abstract
Abstract
Background
Pro-inflammatory interleukin 6 (IL6) trans-signalling is associated with an increased risk of future cardiovascular events (CVE). Diabetes mellitus is a well-known risk factor for CVE but its relation to IL6 trans-signalling is not investigated.
Purpose
We aimed at analysing if the CVE risk associated with IL6 trans-signalling differed between individuals with/without diabetes.
Method
In a prospective cohort of 60-year-old men and women from our city (n=4232), 629 CVE (myocardial infarction, hospitalised angina pectoris and ischemic stroke) occurred during a 20-year follow-up. The risk of CVE associated with IL6 trans-signalling was assessed using the binary/ternary complex ratio (B/T ratio), a novel marker of IL6 trans-signalling derived from the serum molar concentrations of IL6 and the soluble IL6 receptors (sIL6R; sgp130). As a B/T ratio > median, mirroring active IL6 trans-signalling with a relative excess of the active binary IL6 complex in relation to the inactive ternary complex, previously was demonstrated to be associated with an increased CVE risk in this cohort we chose the same cut-off. The CVE risk was assessed by Cox proportional hazards models and described as hazard ratios (HR) with 95% confidence intervals (CI) in individuals with/without diabetes mellitus type 1 or 2 (n=114) defined as either self-reported, or fasting glucose >7.0 mmol/L in the baseline blood test. In the adjusted model, risk estimates were adjusted for the common cardiovascular risk factors. The additive interaction between IL6 trans-signalling and diabetes on the CVE risk was analysed using Cox regression and presented as Synergy index (S) with 95% CI where S > or <1 indicate presence of an interaction.
Result
There was a higher CVE risk associated with IL6 trans-signalling assessed by B/T ratio > median in individuals with diabetes (adjusted HR 3.42; 95% CI 1.60–7.29) compared to participants without (adjusted HR 1.36; 95% CI 1.15–1.60) and the interaction analysis suggested a presence of additive interaction between IL6 trans-signalling and diabetes on the CVE risk (adjusted S=5.23; 95% CI 0.93–29.26) as seen in Figure 1.
Conclusion
Individuals with diabetes mellitus have an increased risk of CVE associated with IL6 trans-signalling possibly in part due to an additive interaction between the two.
Funding Acknowledgement
Type of funding sources: Public Institution(s). Main funding source(s): The Stockholm County Council ALF projectStrategic research in Epidemiology at Karolinska Institutet Figure 1
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Affiliation(s)
- L Ziegler
- Danderyd University Hospital, Department of Clinical Sciences, Stockholm, Sweden
| | - B Gigante
- Karolinska Institute, Cardiovascular Medicine Unit, Department of Medicine, Stockholm, Sweden
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Lundström A, Ziegler L, Havervall S, Rudberg A, von Meijenfeldt F, Lisman T, Mackman N, Sandén P, Thålin C. Soluble angiotensin-converting enzyme 2 is transiently elevated in COVID-19 and correlates with specific inflammatory and endothelial markers. J Med Virol 2021; 93:5908-5916. [PMID: 34138483 PMCID: PMC8426677 DOI: 10.1002/jmv.27144] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 06/14/2021] [Indexed: 12/29/2022]
Abstract
The main entry receptor of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is angiotensin-converting enzyme 2 (ACE2). SARS-CoV-2 interactions with ACE2 may increase ectodomain shedding but consequences for the renin-angiotensin system and pathology in Coronavirus disease 2019 (COVID-19) remain unclear. We measured soluble ACE2 (sACE2) and sACE levels by enzyme-linked immunosorbent assay in 114 hospital-treated COVID-19 patients compared with 10 healthy controls; follow-up samples after four months were analyzed for 58 patients. Associations between sACE2 respectively sACE and risk factors for severe COVID-19, outcome, and inflammatory markers were investigated. Levels of sACE2 were higher in COVID-19 patients than in healthy controls, median 5.0 (interquartile range 2.8-11.8) ng/ml versus 1.4 (1.1-1.6) ng/ml, p < .0001. sACE2 was higher in men than women but was not affected by other risk factors for severe COVID-19. sACE2 decreased to 2.3 (1.6-3.9) ng/ml at follow-up, p < .0001, but remained higher than in healthy controls, p = .012. sACE was marginally lower during COVID-19 compared with at follow-up, 57 (45-70) ng/ml versus 72 (52-87) ng/ml, p = .008. Levels of sACE2 and sACE did not differ depending on survival or disease severity. sACE2 during COVID-19 correlated with von Willebrand factor, factor VIII and D-dimer, while sACE correlated with interleukin 6, tumor necrosis factor α, and plasminogen activator inhibitor 1. Conclusions: sACE2 was transiently elevated in COVID-19, likely due to increased shedding from infected cells. sACE2 and sACE during COVID-19 differed in correlations with markers of inflammation and endothelial dysfunction, suggesting release from different cell types and/or vascular beds.
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Affiliation(s)
- Annika Lundström
- Division of Neurology, Department of Clinical SciencesKarolinska Institutet Danderyd HospitalStockholmSweden
| | - Louise Ziegler
- Division of Internal Medicine, Department of Clinical SciencesKarolinska Institutet Danderyd HospitalStockholmSweden
| | - Sebastian Havervall
- Division of Internal Medicine, Department of Clinical SciencesKarolinska Institutet Danderyd HospitalStockholmSweden
| | - Ann‐Sofie Rudberg
- Division of Neurology, Department of Clinical SciencesKarolinska Institutet Danderyd HospitalStockholmSweden
| | - Fien von Meijenfeldt
- Surgical Research Laboratory, Department of SurgeryUniversity of Groningen, University Medical Center GroningenGroningenThe Netherlands
| | - Ton Lisman
- Surgical Research Laboratory, Department of SurgeryUniversity of Groningen, University Medical Center GroningenGroningenThe Netherlands
| | - Nigel Mackman
- Division of Hematology, Department of Medicine, UNC Blood Research CenterUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Per Sandén
- Division of Neurology, Department of Clinical SciencesKarolinska Institutet Danderyd HospitalStockholmSweden
| | - Charlotte Thålin
- Division of Internal Medicine, Department of Clinical SciencesKarolinska Institutet Danderyd HospitalStockholmSweden
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Ziegler L, Wallén H, Aspberg S, de Faire U, Gigante B. IL6 trans-signaling associates with ischemic stroke but not with atrial fibrillation. BMC Neurol 2021; 21:306. [PMID: 34372806 PMCID: PMC8351167 DOI: 10.1186/s12883-021-02321-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 04/11/2021] [Accepted: 07/07/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Pro-inflammatory processes underlie ischemic stroke, albeit it is largely unknown if they selectively associate with the risk of atherothrombotic or cardioembolic ischemic stroke. Here we analyze whether pro-inflammatory interleukin (IL) 6 trans-signaling, is associated with the risk of ischemic stroke and underlying atrial fibrillation (AF). METHODS During a 20-year follow-up, 203 incident ischemic strokes were recorded from national registers in the cohort of 60-year-old men and women from Stockholm (n = 4232). The risk of ischemic stroke associated with circulating IL6 trans-signaling, assessed by a ratio between the pro-inflammatory binary IL6:sIL6R complex and the inactive ternary IL6:sIL6R:sgp130 complex (B/T ratio), was estimated by Cox regression and expressed as hazard ratio (HR) with a 95% confidence interval (CI) in the presence or absence of AF. Risk estimates were adjusted for cardiovascular risk factors and anticoagulant treatment. In a secondary analysis, the association of IL6 trans-signaling with the risk of incident AF (n = 279) was analyzed. RESULTS B/T ratio > median was associated with increased risk of ischemic stroke in study participants without AF (adjusted HR 1.49; 95% CI 1.08-2.06), while an association could not be demonstrated in the presence of AF. Moreover, the B/T ratio was not associated with the risk of AF (HR 0.96; 95% CI 0.75-1.24). CONCLUSIONS Pro-inflammatory IL6 trans-signaling, estimated by the B/T ratio, is associated with ischemic stroke in individuals without AF. These findings suggest that the B/T ratio could be used to assess the risk of non-AF associated ischemic stroke.
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Affiliation(s)
- Louise Ziegler
- Department of Clinical Sciences Karolinska Institutet, Division of Internal Medicine, Danderyd Hospital, S-182 88, Stockholm, Sweden.
| | - Håkan Wallén
- Department of Clinical Sciences Karolinska Institutet, Division of Cardiovascular Medicine, Danderyd Hospital, Stockholm, Sweden
| | - Sara Aspberg
- Department of Clinical Sciences Karolinska Institutet, Division of Cardiovascular Medicine, Danderyd Hospital, Stockholm, Sweden
| | - Ulf de Faire
- Unit of Cardiovascular and Nutritional Epidemiology Karolinska Institutet, Stockholm, Sweden
| | - Bruna Gigante
- Cardiovascular Medicine Unit, Department of Medicine Karolinska Institutet, Stockholm, Sweden
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Ziegler L, Rieger M, Gueder G, Frantz S, Nordbeck P, Lengenfelder B, Buravezky L, Herrmann S. Even a low transmitral pressure gradient after transcatheter mitral valve repair leads to impaired dynamic performance and increased left atrial endsystolic volumes. Eur Heart J Cardiovasc Imaging 2021. [DOI: 10.1093/ehjci/jeaa356.201] [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: 11/14/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
INTRODUCTION
Transcatheter mitral valve repair (TMVR) was shown to be safe and improves outcome in patients with severe functional mitral regurgitation (MR). Mean transmitral pressure gradients (MVG) < 5.0 mmHg are generally tolerated after TMVR. However, the prognostic relevance of this arbitrary threshold remains unclear and dynamic changes during physical exercise are not well examined.
METHODS
From 2017 to 2019 48 patients with an indication for TMVR were prospectively enrolled in a single center study. The total physical capacity was measured by dynamic stress echocardiography on bicycle at baseline, before discharge and follow-up (FUP, mean (± SD) of 8.2 ± 1.4 months). Patients were classified into two groups: "MVG present" (MVG ≥ 2.5mmHg, measured by transesophageal echocardiography intraoperatively after TMVR) or "MVG absent". Between group differences were compared with a two-sided t-test. For association analysis the Pearson Product-Moment correlation coefficient was used.
RESULTS
48 with a mean (± SD) age of 72.8 ± 12.1 years were eligible for the analysis. There was no significant difference in baseline characteristics concerning the level of the EuroScore II or prevalence of atrial fibrillation, heart failure, cardiovascular risk factors, renal failure or cardiomyopathy and demographic characteristics as age and sex, respectively. Also, most of the standard morphological and functional echocardiographic parameters as well as modern speckle-tracking derived parameters were similar between the 2 groups. There was no difference in remaining mitral regurgitation regarding severity between the two groups (p = 1.00). While the left atrial end systolic volumes (LAESV) at baseline did not differ significantly between groups, patients with an increased MVG after clipping showed an increase in LAESV (plus 56.2 ± 33.6 ml), while the other group showed a decrease in mean value (minus 15.9 ± 42.1 ml; baseline vs FUP: p < 0.001).
Further performance in dynamic stress echocardiography was significantly better in patients without development of a gradient (increase in metabolic equivalent of task (METS) changes between FUP and baseline 1.05 vs 0.06, p = 0.014).
Most importantly, those patients who had a higher MVG after TMVR showed a significant increase in MVG already during stress-echo at baseline, compared to patients who didn´t develop a significant MVG after intervention (1.45 ± 1,08 mmHg vs. 0.67 ± 1,00 mmHg; p = 0.026).
CONCLUSION
After TMVR even a low MVG increase of > = 2.5mmHg is associated with impaired performance in dynamic stress echo and with enlargement of LAESV. Increase of MVG in stress echo at baseline may be suitable to identify patients at risk to develop pathological MVG.
Therefore, periprocedural caution to hemodynamic changes in MVG should always be given. Maybe a certain residual MR could be accepted before implanting an additional clip, knowing that already a MVG > 2,5 mmHg might have adverse effects.
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Affiliation(s)
- L Ziegler
- University Hospital Wuerzburg, Department of Internal Medicine I, Wuerzburg, Germany
| | - M Rieger
- University Hospital Augsburg, Medical Department I, Augsburg, Germany
| | - G Gueder
- University Hospital Wuerzburg, Medical Department I / Comprehensive Heart Failure Center, Wuerzburg, Germany
| | - S Frantz
- University Hospital Wuerzburg, Department of Internal Medicine I, Wuerzburg, Germany
| | - P Nordbeck
- University Hospital Wuerzburg, Department of Internal Medicine I, Wuerzburg, Germany
| | - B Lengenfelder
- University Hospital Wuerzburg, Department of Internal Medicine I, Wuerzburg, Germany
| | - L Buravezky
- University Hospital Wuerzburg, Department of Internal Medicine I, Wuerzburg, Germany
| | - S Herrmann
- University Hospital Wuerzburg, Department of Internal Medicine I, Wuerzburg, Germany
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Ziegler L, Lundqvist J, Dreij K, Wallén H, de Faire U, Paulsson-Berne G, Hedin U, Matic L, Gigante B. Expression of Interleukin 6 signaling receptors in carotid atherosclerosis. Vasc Med 2020; 26:3-10. [PMID: 33350884 PMCID: PMC7879223 DOI: 10.1177/1358863x20977662] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [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] [Indexed: 11/17/2022]
Abstract
Interleukin (IL) 6 contributes to atherosclerotic plaque development through IL6 membrane-bound (IL6R and gp130) and soluble (sIL6R and sgp130) receptors. We investigated IL6 receptor expression in carotid plaques and its correlation with circulating IL6 and soluble receptor levels. Plasma samples and carotid plaques were obtained from 78 patients in the Biobank of Karolinska Endarterectomies study. IL6, sIL6R, and sgp130 were measured in plasma and IL6, IL6R, sIL6R, GP130, and sGP130-RAPS (sGP130) gene expression assessed in carotid plaques. Correlations between plaque IL6 signaling gene expression and plasma levels were determined by Spearman’s correlation. Differences in plasma and gene expression levels between patients with (n = 53) and without (n = 25) a history of a cerebral event and statin-treated (n = 65) and non-treated (n = 11), were estimated by Kruskal–Wallis. IL6 and its receptors were all expressed in carotid plaques. There was a positive, borderline significant, moderate correlation between plasma IL6 and sIL6R and the respective gene expression levels (rho 0.23 and 0.22, both p = 0.05). IL6R expression was higher in patients with a history of a cerebrovascular event compared to those without (p = 0.007). Statin-treated had higher IL6R, sIL6R, and sGP130 expression levels and plasma sIL6R compared to non-treated patients (all p < 0.05). In conclusion, all components of the IL6 signaling pathways are expressed in carotid artery plaques and IL6 and sIL6R plasma levels correlate moderately with IL6 and sIL6R. Our data suggest that IL6 signaling in the circulation might mirror the system activity in the plaque, thus adding novel perspectives to the role of IL6 signaling in atherosclerosis.
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Affiliation(s)
- Louise Ziegler
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden.,Department of Medicine, Danderyd Hospital, Stockholm, Sweden
| | - Jasmin Lundqvist
- Cardiovascular Medicine Unit, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Kristian Dreij
- Unit of Biochemical Toxicology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Håkan Wallén
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden.,Department of Cardiology, Danderyd Hospital, Stockholm, Sweden
| | - Ulf de Faire
- Unit of Cardiovascular and Nutritional Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.,Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | | | - Ulf Hedin
- Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden.,Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Ljubica Matic
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Bruna Gigante
- Cardiovascular Medicine Unit, Department of Medicine, Karolinska Institutet, Stockholm, Sweden.,Department of Cardiology, Danderyd Hospital, Stockholm, Sweden
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Ziegler L, Wallen H, Aspberg S, De Faire U, Gigante B. IL6 trans-signalling associates with atherothrombotic but not with cardioembolic stroke. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.2365] [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: 11/14/2022] Open
Abstract
Abstract
Background
Pro-inflammatory processes underlie ischemic stroke, albeit it is largely unknown if they selectively associate with the risk of atherothrombotic and cardioembolic ischemic stroke. Here we analyse whether the pro-inflammatory interleukin (IL) 6 trans-signalling, associates with the risk of ischemic stroke and underlying atrial fibrillation (AF).
Method
During a 20-year follow-up, 203 incident ischemic strokes were recorded from national registers in the cohort of 60-year-old men and women from Stockholm (n=4232).
For each study participant, we have estimated the activity of the IL6 trans-signalling through the calculation of the ratio between the circulating pro-inflammatory binary IL6:sIL6R complex and the circulating inactive ternary IL6:sIL6R:sgp130 complex, the so called B/T ratio. An excess of the binary complex, mirrored by a high B/T ratio, is associated with an increased risk of cardiovascular events. The B/T ratio has been dichotomized at the median. The risk of ischemic stroke associated with B/T ratio > median was estimated by Cox regression and expressed as hazard ratio (HR) with a 95% confidence interval (CI) in the presence and absence of AF. Risk estimates were adjusted for cardiovascular risk factors and anticoagulant treatment. In a secondary analysis, the association of IL6 trans-signalling with the risk of incident AF (n=279) was analysed.
Results
B/T ratio >median was associated with the risk of ischemic stroke only in study participants without AF diagnosis (adjusted HR 1.49; 95% CI 1.08–2.06). No association was observed with ischemic stroke in study participants also diagnosed with AF. Moreover, the B/T ratio was not associated with the risk of AF (HR 0.96; 95% CI 0.75–1.24).
Conclusions
IL6 trans-signalling, estimated by the B/T ratio, is associated with atherothrombotic but not cardioembolic stroke. Consistently, the B/T ratio did not associate with the risk of incident AF. Our results support the relevance of IL6 trans-signalling in atherosclerosis related ischemic stroke.
Funding Acknowledgement
Type of funding source: None
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Affiliation(s)
- L Ziegler
- Karolinska Institutet, Stockholm, Sweden
| | - H Wallen
- Karolinska Institutet, Stockholm, Sweden
| | - S Aspberg
- Karolinska Institutet, Stockholm, Sweden
| | - U De Faire
- Karolinska Institutet, Stockholm, Sweden
| | - B Gigante
- Karolinska Institutet, Stockholm, Sweden
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18
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Ziegler L, Gajulapuri A, Frumento P, Bonomi A, Wallén H, de Faire U, Rose-John S, Gigante B. Interleukin 6 trans-signalling and risk of future cardiovascular events. Cardiovasc Res 2020; 115:213-221. [PMID: 30052808 DOI: 10.1093/cvr/cvy191] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [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] [Received: 01/24/2018] [Accepted: 07/20/2018] [Indexed: 12/17/2022] Open
Abstract
Aims The pro-inflammatory response to interleukin 6 (IL6) trans-signalling in atherosclerosis is driven by the IL6 and soluble IL6 receptor (sIL6R) binary complex. The binary IL6:sIL6R complex is inactivated by sgp130 through the formation of the ternary IL6:sIL6R:sgp130 complex. The aim of this study was to investigate if IL6 trans-signalling, estimated by a ratio between the binary and ternary complexes, associates with the risk of future cardiovascular events (CVE) in a Swedish cohort of 60-year-old men and women (n = 4232). Methods and results Binary and ternary complex levels expressed in nanomol/Litre were derived from serum concentrations of IL6, sIL6R, and sgp130. Cox regression models were used to assess the risk of CVE (myocardial infarction, angina pectoris, and ischaemic stroke, n = 525), expressed as hazard ratio (HR) with 95% confidence interval (CI), associated with increasing circulating levels of the three molecules and with the binary/ternary complex ratio. Estimates were adjusted for the common cardiovascular (CV) risk factors. To assess the level of IL6-trans-signalling, we estimated the binary/ternary complex ratio and then analysed the association with CVE risk. A ratio higher than the median, representing a relative excess of the active binary complex was associated with increased CVE risk (adjusted HR 1.44, 95% CI 1.21-1.72). Conclusion The ratio between the functional moieties of IL6 trans-signalling, IL6:sIL6R, and IL6:sIL6R:sgp130, was associated with CVE risk indicating that it could be a promising marker of CV risk and possibly be used in selecting patients for anti-inflammatory therapy.
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Affiliation(s)
- Louise Ziegler
- Department of Clinical Science, Danderyd Hospital, S-182 88 Stockholm, Sweden
| | - Ashwini Gajulapuri
- Swetox, Academic Research Center for Chemicals, Health and Environment, Södertälje, Sweden
| | - Paolo Frumento
- Unit of Biostatistics at the Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Alice Bonomi
- Unit of Biostatistics, Centro Cardiologico Monzino, IRCCS, Milan, Italy.,Unit of Cardiovascular Epidemiology, Karolinska Institutet, Stockholm, Sweden
| | - Håkan Wallén
- Department of Clinical Science, Danderyd Hospital, S-182 88 Stockholm, Sweden
| | - Ulf de Faire
- Unit of Cardiovascular Epidemiology, Karolinska Institutet, Stockholm, Sweden
| | - Stefan Rose-John
- Department of Biochemistry, Christian-Albrechts-University, Kiel, Germany
| | - Bruna Gigante
- Department of Clinical Science, Danderyd Hospital, S-182 88 Stockholm, Sweden.,Unit of Cardiovascular Epidemiology, Karolinska Institutet, Stockholm, Sweden
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Ziegler L, Frumento P, Wallen H, De Faire U, Gigante B. P1519IL6 trans-signalling affects risk of cardiovascular events pre-eminently in men. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz748.0281] [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: 11/15/2022] Open
Abstract
Abstract
Background
Interleukin 6 (IL6) is a known cardiovascular risk marker. The pro-atherogenic effects of IL6 are mediated by the IL6 trans-signalling pathway via a binary complex of IL6 and the soluble IL6 receptor (IL6:sIL6R). The binary complex is however neutralised by the natural inhibitor, sgp130 when forming the ternary complex (IL6:sIL6R:sgp130). To assess the risk of cardiovascular events (CVE) with IL6 trans-signalling, a ratio between the active binary complex and the neutralised ternary complex was calculated. We recently demonstrated that high levels of the binary/ternary complex ratio (b/t ratio > the median) representing an excess of the active binary complex, was independently associated with a 44% increased risk of future CVE in subjects free of prevalent cardiovascular disease.
Purpose
In this study we aimed to analyse the risk of CVE and time to event associated with the b/t ratio in men and women separately.
Methods
In a cohort of 60 year old men and women from Stockholm, the molar concentrations of the binary and ternary IL6 complex were estimated at baseline. Subjects free of prevalent cardiovascular disease were followed through national registers to assess future CVE (myocardial infarction, hospitalised angina pectoris and ischemic stroke). During a 16 year follow-up, 525 first time CVEs were registered. The risk for CVE and time to CVE was calculated for men and women, separately. To evaluate the risk associated with IL6 trans-signalling, the b/t ratio dichotomised at the median was modelled in a Cox regression model and risk was expressed as hazard ratios (HR) with 95% confidence intervals (CI). In addition, analysis was performed using censored quantile regression that allows measuring the effect of covariates on different quantiles of the time to CVE.
Results
Approximately half of the population were men and 64% of the CVE occurred in men. The risk of CVE during follow-up was significantly higher in men with b/t ratio > median (HR 1.70; 95% CI 1.35–2.15), while no significant difference was found in women (HR 1.12; 95% CI 0.84–1.50). Consistently, quantile regression showed that, men with a b/t ratio > median suffered their CVEs at an earlier time point. The time at which 15% of the male population was observed to have experienced CVE was 5.6 years shorter (95% CI: 4.0–7.2) in the high b/t ratio group. In women there was no significant difference in time to CVE.
Conclusion
The risk of CVE and early events associated with IL6 trans-signalling estimated by a b/t ratio >median is significantly increased in men.
Acknowledgement/Funding
The Stockholm County Council ALF project, Strategic research in Epidemiology
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Affiliation(s)
- L Ziegler
- Karolinska Institute, Stockholm, Sweden
| | - P Frumento
- Karolinska Institute, Institute of Environmental Medicine, Stockholm, Sweden
| | - H Wallen
- Danderyd University Hospital, Department of Clinical Sciences, Stockholm, Sweden
| | - U De Faire
- Karolinska Institute, Institute of Environmental Medicine, Stockholm, Sweden
| | - B Gigante
- Karolinska Institute, Institute of Environmental Medicine, Stockholm, Sweden
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Ziegler L, Frumento P, Wallén H, de Faire U, Gigante B. The predictive role of interleukin 6 trans-signalling in middle-aged men and women at low-intermediate risk of cardiovascular events. Eur J Prev Cardiol 2019; 27:122-129. [DOI: 10.1177/2047487319869694] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Background Interleukin 6 trans-signalling is independently associated with the risk of cardiovascular events. The aim of this study was to investigate if interleukin 6 trans-signalling can identify individuals at risk for cardiovascular events (coronary artery disease and ischaemic stroke) among those at-low–intermediate risk. Methods In a cohort of 60-year-olds ( n = 4232, incident cardiovascular events n = 525), interleukin 6 trans-signalling was estimated by a ratio between the pro-inflammatory interleukin 6: soluble interleukin 6 receptor binary receptor complex and the inactivated interleukin 6: soluble interleukin 6 receptor: sgp130 ternary complex (B/T ratio). Risk associated with B/T ratio >median was investigated in individuals with low-density lipoprotein cholesterol ≤4.0 (mmol/l) and in those at low-intermediate risk according to the Framingham risk score (FRS) using Cox regression and expressed as hazard ratio and 95% confidence interval. Difference in time to event (years; 95% confidence interval) was analysed with quantile regression. The interaction between low-density lipoprotein cholesterol and B/T ratio was estimated on the additive scale. Incremental discriminatory value of the B/T ratio if low-density lipoprotein cholesterol ≤4.0 was compared to that of the FRS and interleukin 6. Results B/T ratio >median was associated with increased cardiovascular event risk when low-density lipoprotein cholesterol ≤4.0 (hazard ratio 1.59; 95% confidence interval 1.24–2.05) or FRS ≤ 10%, >10–≤20% (hazard ratio 1.27; 95% confidence interval 1.00–1.61 and hazard ratio 1.78; 95% confidence interval 1.36–2.34, respectively). B/T ratio >median and low-density lipoprotein cholesterol ≤4.0 were associated with early cardiovascular events, particularly ischaemic stroke. No interaction was observed between low-density lipoprotein cholesterol and the B/T ratio, both factors increasing cardiovascular event risk by 60%. In the presence of low-density lipoprotein cholesterol ≤4.0, the B/T ratio slightly improved discrimination measures. Conclusions Interleukin 6 trans-signalling increases cardiovascular event risk in middle-aged men and women otherwise classified at low-intermediate cardiovascular risk.
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Affiliation(s)
- Louise Ziegler
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Sweden
- Division of Internal Medicine, Danderyd Hospital, Sweden
| | | | - Håkan Wallén
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Sweden
- Division of Cardiovascular Medicine, Danderyd Hospital, Sweden
| | - Ulf de Faire
- Cardiovascular and Nutritional Epidemiology Unit, Karolinska Institutet, Sweden
| | - Bruna Gigante
- Department of Medicine, Cardiovascular Medicine Division, Karolinska Institutet, Sweden
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Modig K, Talbäck M, Ziegler L, Ahlbom A. Temporal trends in incidence, recurrence and prevalence of stroke in an era of ageing populations, a longitudinal study of the total Swedish population. BMC Geriatr 2019; 19:31. [PMID: 30717697 PMCID: PMC6360781 DOI: 10.1186/s12877-019-1050-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 01/25/2019] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Stroke incidence has declined during the past decades. Yet, there is a concern that an ageing population together with improved survival after stroke will result in a raised proportion of the population who have experienced a stroke, as well as increasing incidence rate of recurrent strokes, and, absolute numbers of strokes. The objectives of this study were to investigate how the age specific incidence rates of recurrent strokes have developed in relation to the incidence rates of first strokes and how the postponement in age look like, and to see how the prevalence proportion of stroke as well as the absolute number of incident strokes has changed over time. METHODS This study includes the total Swedish population born 1890-1954 living in Sweden from 1987. Stroke was identified through hospital admissions and deaths in national health registers (mandatory for all hospitals in Sweden). Age specific incidence rates were calculated for first, second, all recurrent, and all strokes for each calendar year between 1994 and 2014 for each age between 60 and 104 years. The proportion in the population with a history of stroke up to 7 years back in time was also calculated for different age groups and for different calendar years. RESULTS Not only the incidence rate of first stroke but also of recurrent strokes have declined. The declines are evident in all ages up to 90 years of age, but not in ages above 90 years. Despite improved survival in stroke, the prevalence proportion has declined over the period and was around 3% in 2014 (somewhat higher for men than women). Even incident cases of stroke in absolute number has declined. CONCLUSIONS Decreasing incidence rates of stroke have offset an increase in both absolute and relative numbers of stroke that otherwise would have taken place due to improved survival and an ageing population. The decline in stroke recurrence has been as strong as the decline in first strokes.
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Affiliation(s)
- Karin Modig
- Institute of Environmental Medicine, Unit of Epidemiology, Karolinska Institutet, Box 210, SE-171 77 Stockholm, Sweden
| | - Mats Talbäck
- Institute of Environmental Medicine, Unit of Epidemiology, Karolinska Institutet, Stockholm, Sweden
| | - Louise Ziegler
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Anders Ahlbom
- Institute of Environmental Medicine, Unit of Epidemiology, Karolinska Institutet, Stockholm, Sweden
- Centre for Occupational and Environmental Medicine, Stockholm County Council, Stockholm, Sweden
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Ziegler L, Möller Palau-Ribes F, Enderlein D, Herbst W, Schmidt L, Lierz M. Mycoplasma hafezii sp. nov., isolated from the trachea of a peregrine falcon (Falco peregrinus). Int J Syst Evol Microbiol 2019; 69:773-777. [PMID: 30707094 DOI: 10.1099/ijsem.0.003235] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Mycoplasma species are well known pathogens in avian medicine, especially in poultry. However, several Mycoplasma species have been regularly found in the respiratory tract of birds of prey which seem to be commensals in these bird species. In previous studies, an unknown Mycoplasma species which caused false positive results in a Mycoplasma meleagridis-specific PCR, was isolated from a tracheal swab of a clinically healthy, captive, adult peregrine falcon (Falco peregrinus). The isolate appeared in typical fried-egg-shaped colonies on SP4 agar plates and was dependent on sterol for growth. Acid was produced from glucose, but no arginine or urea was hydrolysed. The temperature range for growth was 28-44 °C, with an optimum at 37 °C. Strain M26T was serologically distinct from all species of the genus Mycoplasma with 16S rRNA gene sequence similarity ≥94 %. Biochemical, serological and molecular biological properties demonstrate that this organism represents a novel species of the genus Mycoplasma, for which the name Mycoplasma hafezii sp. nov. is proposed; the type strain is M26T (NCTC 13928, DSM 27652).
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Affiliation(s)
- L Ziegler
- 1Clinic for Birds, Reptiles, Amphibians and Fish, Justus Liebig University, Giessen, Germany
| | - F Möller Palau-Ribes
- 1Clinic for Birds, Reptiles, Amphibians and Fish, Justus Liebig University, Giessen, Germany
| | - D Enderlein
- 1Clinic for Birds, Reptiles, Amphibians and Fish, Justus Liebig University, Giessen, Germany
| | - W Herbst
- 2Institute of Hygiene and Infectious Diseases of Animals, Justus Liebig University, Giessen, Germany
| | - L Schmidt
- 1Clinic for Birds, Reptiles, Amphibians and Fish, Justus Liebig University, Giessen, Germany
| | - M Lierz
- 1Clinic for Birds, Reptiles, Amphibians and Fish, Justus Liebig University, Giessen, Germany
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Ziegler L, Lundqvist J, Perisic L, Gajulapuri A, Dreij K, Frumento P, Paulsson-Berne G, Wallen H, De Faire U, Hedin U, Gigante B. P2625The soluble IL6 receptor and ischemic cerebrovascular disease. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy565.p2625] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- L Ziegler
- Danderyd University Hospital, Department of Clinical Sciences, Stockholm, Sweden
| | - J Lundqvist
- Karolinska Institute, Institute of Environmental Medicine, Stockholm, Sweden
| | - L Perisic
- Karolinska Institutet, Department of Molecular Medicine and Surgery, Stockholm, Sweden
| | - A Gajulapuri
- Karolinska Institute, Institute of Environmental Medicine, Stockholm, Sweden
| | - K Dreij
- Karolinska Institute, Institute of Environmental Medicine, Stockholm, Sweden
| | - P Frumento
- Karolinska Institute, Institute of Environmental Medicine, Stockholm, Sweden
| | | | - H Wallen
- Danderyd University Hospital, Department of Clinical Sciences, Stockholm, Sweden
| | - U De Faire
- Karolinska Institute, Institute of Environmental Medicine, Stockholm, Sweden
| | - U Hedin
- Karolinska Institutet, Department of Molecular Medicine and Surgery, Stockholm, Sweden
| | - B Gigante
- Karolinska Institute, Institute of Environmental Medicine, Stockholm, Sweden
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Sommer A, Ziegler L, Plewnia C. P25. Time specific neuronal activation and its association with cognitive control over emotions. Clin Neurophysiol 2018. [DOI: 10.1016/j.clinph.2018.04.667] [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: 10/28/2022]
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25
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Modig K, Ahlbom A, Talback M, Ziegler L. Incidence, recurrence and prevalence of stroke in an ageing population. Rev Epidemiol Sante Publique 2018. [DOI: 10.1016/j.respe.2018.05.352] [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: 10/28/2022] Open
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26
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Curland N, Gethöffer F, van Neer A, Ziegler L, Heffels-Redmann U, Lierz M, Baumgärtner W, Wohlsein P, Völker I, Lapp S, Bello A, Pfankuche VM, Braune S, Runge M, Moss A, Rautenschlein S, Jung A, Teske L, Strube C, Schulz J, Bodewes R, Osterhaus ADME, Siebert U. Investigation into diseases in free-ranging ring-necked pheasants ( Phasianus colchicus) in northwestern Germany during population decline with special reference to infectious pathogens. EUR J WILDLIFE RES 2018; 64:12. [PMID: 32214944 PMCID: PMC7087779 DOI: 10.1007/s10344-018-1173-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [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: 05/08/2017] [Revised: 11/06/2017] [Accepted: 01/19/2018] [Indexed: 11/29/2022]
Abstract
The population of ring-necked pheasants (Phasianus colchicus) is decreasing all over Germany since the years 2008/2009. Besides impacts of habitat changes caused by current rates of land conversion, climatic influences or predators, a contribution of infectious pathogens needs also to be considered. Infectious and non-infectious diseases in free-living populations of ring-necked pheasants have been scarcely investigated so far. In the present study, carcasses of 258 deceased free-ranging pheasants of different age groups, predominantly adult pheasants, collected over a period of 4 years in the states of Lower Saxony, North Rhine–Westphalia and Schleswig-Holstein, were examined pathomorphologically, parasitologically, virologically and bacteriologically, with a focus set on infectious pathogens. A periocular and perinasal dermatitis of unknown origin was present in 62.3% of the pheasants. Additional alterations included protozoal cysts in the skeletal musculature (19.0%), hepatitis (21.7%), enteritis (18.7%), gastritis (12.6%), and pneumonia (11.7%). In single cases, neoplasms (2.6%) and mycobacteriosis (1.7%) occurred. Further findings included identification of coronaviral DNA from trachea or caecal tonsils (16.8%), siadenoviral DNA (7.6%), avian metapneumoviral RNA (6.6%), and infectious bursal disease viral RNA (3.7%). Polymerase chain reaction (PCR) on herpesvirus, avian influenza virus (AIV), paramyxovirus type 1 (PMV-1), avian encephalomyelitis virus (AEV), and chlamydia were negative. Based on the present results, there is no indication of a specific pathogen as a sole cause for population decline in adult pheasants. However, an infectious disease can still not be completely excluded as it may only affect reproduction effectivity or a certain age group of pheasants (e.g., chicks) which were not presented in the study.
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Affiliation(s)
- N Curland
- 1Institute for Terrestrial and Aquatic Wildlife Research, University of Veterinary Medicine Hannover, Foundation, Bischofsholer Damm 15, 30173 Hannover, Germany
| | - F Gethöffer
- 1Institute for Terrestrial and Aquatic Wildlife Research, University of Veterinary Medicine Hannover, Foundation, Bischofsholer Damm 15, 30173 Hannover, Germany
| | - A van Neer
- 1Institute for Terrestrial and Aquatic Wildlife Research, University of Veterinary Medicine Hannover, Foundation, Bischofsholer Damm 15, 30173 Hannover, Germany
| | - L Ziegler
- 2Clinic for Birds, Reptiles, Amphibians and Fish, Justus Liebig University Giessen, Frankfurter Strasse 91, 35321 Giessen, Germany
| | - U Heffels-Redmann
- 2Clinic for Birds, Reptiles, Amphibians and Fish, Justus Liebig University Giessen, Frankfurter Strasse 91, 35321 Giessen, Germany
| | - M Lierz
- 2Clinic for Birds, Reptiles, Amphibians and Fish, Justus Liebig University Giessen, Frankfurter Strasse 91, 35321 Giessen, Germany
| | - W Baumgärtner
- 3Department of Pathology, University of Veterinary Medicine Hannover, Foundation, Buenteweg 17, 30559 Hannover, Germany
| | - P Wohlsein
- 3Department of Pathology, University of Veterinary Medicine Hannover, Foundation, Buenteweg 17, 30559 Hannover, Germany
| | - I Völker
- 3Department of Pathology, University of Veterinary Medicine Hannover, Foundation, Buenteweg 17, 30559 Hannover, Germany
| | - S Lapp
- 3Department of Pathology, University of Veterinary Medicine Hannover, Foundation, Buenteweg 17, 30559 Hannover, Germany
| | - A Bello
- 3Department of Pathology, University of Veterinary Medicine Hannover, Foundation, Buenteweg 17, 30559 Hannover, Germany
| | - V M Pfankuche
- 3Department of Pathology, University of Veterinary Medicine Hannover, Foundation, Buenteweg 17, 30559 Hannover, Germany
| | - S Braune
- 4Lower Saxony State Office for Consumer Protection and Food Safety (LAVES), Food and Veterinary Institute Braunschweig/Hannover, Eintrachtweg 17, 30173 Hannover, Germany
| | - M Runge
- 4Lower Saxony State Office for Consumer Protection and Food Safety (LAVES), Food and Veterinary Institute Braunschweig/Hannover, Eintrachtweg 17, 30173 Hannover, Germany
| | - A Moss
- 5Lower Saxony State Office for Consumer Protection and Food Safety (LAVES), Food and Veterinary Institute Oldenburg, Philosophenweg 38, 26121 Oldenburg, Germany
| | - S Rautenschlein
- 6Clinic for Poultry, University of Veterinary Medicine Hannover, Foundation, Buenteweg 17, 30559 Hannover, Germany
| | - A Jung
- 6Clinic for Poultry, University of Veterinary Medicine Hannover, Foundation, Buenteweg 17, 30559 Hannover, Germany
| | - L Teske
- 6Clinic for Poultry, University of Veterinary Medicine Hannover, Foundation, Buenteweg 17, 30559 Hannover, Germany
| | - C Strube
- 7Institute for Parasitology, Center for Infection Medicine, University of Veterinary Medicine Hannover, Foundation, Buenteweg 17, 30559 Hannover, Germany
| | - J Schulz
- 8Institute for Animal Hygiene, Animal Welfare and Farm Animal Behaviour, University of Veterinary Medicine Hannover, Foundation, Bischofsholer Damm 15, 30173 Hannover, Germany
| | - R Bodewes
- Department of Viroscience, Erasmus MC, P.O. Box 2040, Ee1726, 3000 CA Rotterdam, The Netherlands
| | - A D M E Osterhaus
- 10Research Center for Emerging Infections and Zoonoses, University of Veterinary Medicine Hannover, Foundation, Buenteweg 17, 30559 Hannover, Germany
| | - U Siebert
- 1Institute for Terrestrial and Aquatic Wildlife Research, University of Veterinary Medicine Hannover, Foundation, Bischofsholer Damm 15, 30173 Hannover, Germany
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Funcke S, Ziegler L, Lierz M, Wüst E, Paries S. Endoscopic assisted orchiectomy in Herman’s tortoises (Testudo hermanni sp.). Tierarztl Prax Ausg K 2018; 42:383-9. [DOI: 10.15654/tpk-131089] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Accepted: 04/14/2014] [Indexed: 11/13/2022]
Abstract
SummaryObjective: Male tortoises in captivity are often aggressive against other males or females, in particular during mating season related to hormonal influences (testosterone). Castration in males is the treatment of choice in many vertebrate species. A novel technique of minimal invasive castration is presented for Herman’s tortoises (Testudo hermanni).Material and methods: The procedure was performed in ten mature males. An endoscope (2.7 mm/30° angled) was inserted into a prefemoral incision on each side. The testicle was resected after ligation of the gubernaculum testis and the spermatic cord using hemoclips.Results: Each testicle could be removed in approximately 20 minutes. Complications like hemorrhage or damage of adjacent tissue did not occur and all animals recovered uneventfully.Conclusions and clinical relevance: Using the bilateral prefemoral entrance offers an alternative option for orchiectomy in Herman’s tortoises without dissection of the shell. Thus complications like hemorrhage or impaired wound healing followed by sequestration of the bone flap are prevented. Because of the anatomical settings and the risk of tissue damage and time consumption, a unilateral approach is not recommended. Fasting the animals is necessary due to the voluminous gastrointestinal tract of this herbivorous tortoise and emptying the urinary bladder provides more space for manipulations in the coelomic cavity and prevents clipping and cutting of adjacent organs. The magnification via the endoscope is beneficial for orientation in the coelomic cavity, which is formed by the extremely convex carapace. Without this equipment it is challenging to visualize the dorsocaudally located gonads through the relatively small incision and the inserted instruments might block the view at the surgical field. Administration of hemoclips achieved a good hemostasis and the testicles could be resected without major blood loss. The described technique is a gentle method for resection of the testicles in this species and can be adapted to other European tortoise species of equal size.
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Ziegler L, Gajulapuri A, Frumento P, Wallen H, De Faire U, Gigante B. 4159The soluble IL6 receptor as a predictor for early cardiovascular events. Eur Heart J 2017. [DOI: 10.1093/eurheartj/ehx504.4159] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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29
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Jarrett N, Scott I, Addington-Hall J, Amir Z, Brearley S, Hodges L, Richardson A, Sharpe M, Stamataki Z, Stark D, Siller C, Ziegler L, Foster C. Informing future research priorities into the psychological and social problems faced by cancer survivors: a rapid review and synthesis of the literature. Eur J Oncol Nurs 2013; 17:510-20. [PMID: 23619278 DOI: 10.1016/j.ejon.2013.03.003] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [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: 09/07/2012] [Revised: 03/04/2013] [Accepted: 03/08/2013] [Indexed: 12/24/2022]
Abstract
PURPOSE To establish what is known regarding the psychological and social problems faced by adult cancer survivors (people who are living with and beyond a diagnosis of cancer) and identify areas future research should address. METHOD A rapid search of published literature reviews held in electronic data bases was under taken. Inclusion and exclusion criteria, and removal of duplicated papers, reduced the initial number of papers from 4051 to 38. Twenty-two review papers were excluded on grounds of quality and 16 review papers were selected for appraisal. RESULTS The psychological and social problems for cancer survivors are identified as depression, anxiety, distress, fear of recurrence, social support/function, relationships and impact on family, and quality of life. A substantial minority of people surviving cancer experience depression, anxiety, and distress or fear associated with recurrence or follow up. There is some indication that social support is positively associated with better outcomes. Quality of life for survivors of cancer appears generally good for most people, but an important minority experience a reduction in quality of life, especially those with more advanced disease and reduced social and economic resources. The majority of research knowledge is based on women with breast cancer. The longer term implications of cancer survival have not been adequately explored. CONCLUSIONS Focussing well designed research in the identified areas where less is already known about the psychological and social impact of cancer survival is likely to have the greatest impact on the wellbeing of people surviving cancer.
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Affiliation(s)
- N Jarrett
- Faculty of Health Sciences, University of Southampton, Highfield, Southampton SO17 1BJ, UK.
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Absolom K, Hector C, Campbell L, Eng S, Taylor S, Takeuchi E, Warrington L, Ziegler L, Velikova G. Using the measure of patient centred communication to assess oncology consultations. BMJ Support Palliat Care 2011. [DOI: 10.1136/bmjspcare-2011-000020.59] [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: 11/03/2022]
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31
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Pennemann H, Dobra M, Zapf R, Ziegler L, Kolb G. Entwicklung eines Siebdruckverfahrens zur Katalysatorbeschichtung mikrostrukturierter Plattenwärmetauscher. CHEM-ING-TECH 2010. [DOI: 10.1002/cite.201050520] [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: 11/05/2022]
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32
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Ziegler L, Newell R, Stafford N, Lewin R. A literature review of head and neck cancer patients information needs, experiences and views regarding decision-making. Eur J Cancer Care (Engl) 2004; 13:119-26. [PMID: 15115467 DOI: 10.1111/j.1365-2354.2004.00449.x] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.2] [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: 11/29/2022]
Abstract
This study reviews the body of existing research undertaken to explore head and neck cancer patients experiences of treatment for surgery, their information needs and their views regarding decision-making. Patients who suffer head and neck cancers and undergo surgery often report considerable psychological distress and impaired social functioning. To optimize survival, the decision about what treatment option to follow is often made quickly, with little support in terms of counsel or the provision of information. It is suggested that there is inadequate previous work exploring the content and delivery of information required by patients, their experiences and their views regarding decision-making to guide appropriate clinical interventions. By assimilating and critiquing existing work in this review an appropriate focus for further research is likely to be determined. An electronic search of relevant databases was undertaken including Cinahl, Medline, Psychinfo, Assia, the Cochrane Library and British Nursing Index. In addition, a grey literature search was also undertaken by hand. The search strategy was developed using recommendations from the Centre for Reviews and Dissemination 'Guidance for Those Carrying Out or Commissioning Reviews' (CRD Report Number 4, 2001). There is significant psychosocial and other functional disturbance amongst survivors of head and neck cancer surgery. Improved information giving may play a part in determining these outcomes.
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Affiliation(s)
- L Ziegler
- School of Health Sciences, University of Bradford, Bradford, UK.
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Petit N, Ziegler L, Goux A. [Reduction of haemolysis rates using intravenous catheters with reduced capacity tubes]. Ann Biol Clin (Paris) 2002; 60:471-3. [PMID: 12147452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
Affiliation(s)
- N Petit
- Service d'accueil des urgences, Centre hospitalier Saint-Nicolas, 2, rue d'Anthouard, BP 713, 55107 Verdun cedex
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Abstract
There appear to be two modes of stereoscopic processing: a conventional linear operation that is dependent on correspondence between local luminance components in the two eyes' views, and a non-linear or second-order processing mode. This second mode may use disparity information provided by particular 'non-Fourier' features of the stimulus such as the contrast envelope. Preliminary results suggest that people who fail standard clinical stereotests are able to extract non-linear disparity information from Gabor stimuli [McColl & Mitchell, 1998. Vision Research, 38, 1889-1900]. Here we evaluate the status of the non-linear mechanism in such individuals by using two types of contrast enveloped stimuli, namely random line and Gabor micropatterns, in a task that requires near/far depth judgements [Ziegler & Hess, 1999. Vision Research, 39, 1491-1507]. Although our sample was small, three of our four subjects who had performed poorly on at least one standard clinical test of stereopsis could perform the task, as well as one 'stereoblind' subject who had failed all four standard clinical tests. The overall results suggest that individuals with stereoanomalies show a diversity of deficits, but some nevertheless can see depth using 'non-linear' mechanisms.
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Affiliation(s)
- S L McColl
- Department of Psychology, McGill University, Stewart Biological Sciences Building, 1205 Dr. Penfield Avenue, Montreal, Canada.
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Holland J, Hersh L, Bryhan M, Onyiriuka E, Ziegler L. Culture of human vascular endothelial cells on an RGD-containing synthetic peptide attached to a starch-coated polystyrene surface: comparison with fibronectin-coated tissue grade polystyrene. Biomaterials 1996; 17:2147-56. [PMID: 8922600 DOI: 10.1016/0142-9612(96)00028-2] [Citation(s) in RCA: 53] [Impact Index Per Article: 1.9] [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: 02/03/2023]
Abstract
A synthetic peptide, Gly-Arg-Gly-Asp-Ser-Pro-Lys (GRGDSPK), which includes the cell-adhesive region of fibronectin, Arg-Gly-Asp (RGD), was covalently bound to a dialdehyde starch (DAS) coating on a polymer surface by reductive amination. The GRGDSPK/DAS-coated surface was characterized by atomic force microscopy (AFM), X-ray photoelectron spectroscopy (XPS) and scanning electron microscopy (SEM). AFM and SEM revealed a uniform, roughened, textured surface, much more so than standard polymer or adhesive protein-coated polymer surfaces. XPS showed that GRGDSPK binding to DAS occurred in dose-dependent fashion in the 0-200 micrograms ml-1 GRGDSPK concentration range, with a plateau happening in the 200-400 micrograms ml-1 range. AFM revealed a uniform peptide layer on the DAS surface with a maximum separation distance of 50 nm between peptides. Angle-dependent XPS showed that the peptide is present in nearly constant amounts to at least 10 nm depth of the DAS coating. The attachment, spreading and growth properties of anchorage-dependent human umbilical vein endothelial cells (EC) on the GRGDSPK/DAS-coated polystyrene surface were compared with a standard fibronectin-coated polystyrene surface. EC adhesion, spreading and growth properties were similar for cells plated on polystyrene surfaces coated with fibronectin (5 micrograms cm-2) and GRGDSPK (25-50 micrograms ml-1)/DAS. In contrast, EC adhesion, spreading and growth performance significantly increased for cells plated on GRGDSPK (100-200 micrograms ml-1)/DAS compared with the fibronectin-coated surface. These findings support the conclusion that the GRGDSPK/DAS-coated surface can be substituted for an adhesive protein-coated surface in the culture of anchorage-dependent cells.
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Affiliation(s)
- J Holland
- Department of Medicine, State University of New York Health Science Center, Syracuse 13210, USA
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Abstract
We have previously reported that the Wistar/Furth (W/Fu) rat strain is resistant to mineralocorticoid hypertension. In the current study, we have examined renal mRNA levels for mineralocorticoid receptor (MR), glucocorticoid receptor (GR), renin and Na+, K(+)-ATPase in response to treatment with mineralocorticoids. Uninephrectomized male Wistar (WI) and W/Fu rats were treated with aldosterone or deoxycorticosterone acetate (DOCA) and were given 1% NaCl to drink. Rats were sacrificed after 1, 3 or 7 days of treatment. Renal MR and ATPase mRNA levels were significantly reduced in aldosterone and DOCA-treated WI rats (e.g. MR was 30% on day 3 and ATPase was 50% of control on day 7 of aldosterone treatment). Unexpectedly, GR mRNA levels paralleled the changes in MR. In W/Fu rats the level of message was either unchanged or only moderately altered by this treatment. In vivo administration of the MR antagonist RU28318 or the GR antagonist RU38486 to WI rats for 4 days reduced renal mRNA levels for both subunits of ATPase. In the W/Fu rat, this treatment resulted in no change in the alpha subunit and an increase in the beta subunit of ATPase. In preliminary studies, we have determined that the W/Fu rat is also resistant to dexamethasone-induced hypertension. These studies suggest that altered MR- and GR-mediated mechanisms may contribute to the resistance of the W/Fu rat strain to steroid-induced hypertension.
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Affiliation(s)
- K Kayes
- Department of Biochemistry, University Buffalo, NY 14214, USA
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Waggenspack GA, Tabb DR, Tiruchelvam V, Ziegler L, Waltersdorff K. Three-dimensional localization of hepatic neoplasms with computer-generated scissurae recreated from axial CT and MR images. AJR Am J Roentgenol 1993; 160:307-9. [PMID: 8424339 DOI: 10.2214/ajr.160.2.8424339] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Schedel H, Buchner H, Ziegler L, Vogl T, Hilbertz T, Lissner J. [Pre- and postoperative NMR tomographic studies in avascular femur head necrosis]. ROFO-FORTSCHR RONTG 1992; 156:415-9. [PMID: 1596541 DOI: 10.1055/s-2008-1032912] [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: 12/27/2022]
Abstract
46 patients with avascular necrosis of the femoral head were examined by T2- and T1-weighted MR before and after infusion of Gd-DTPA. Both sides were involved in 12 cases. The classification was done according to Ficat. In early stages and in postoperative studies a correlation of signal intensity after infusion of Gd-DTPA and clinical symptoms was found. Hyperintensity of the avascular area or of the implanted material was assumed to be vascularised or vital components in 4 cases of Ficat I and in 15 postoperative studies. Contrariwise, we found in 5 patients with severe postoperative symptoms, low signal intensity areas due to avascular regions.
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Affiliation(s)
- H Schedel
- Radiologische Klinik und Poliklinik, Ludwig-Maximilians-Universität München
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39
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Vogl TJ, Balzer JO, Stemmler J, Egger J, Ziegler L, Schedel HK, Lissner J. [MR angiography in neuropediatric problems: the technic and the clinical results]. ROFO-FORTSCHR RONTG 1992; 156:112-9. [PMID: 1739767 DOI: 10.1055/s-2008-1032848] [Citation(s) in RCA: 5] [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: 12/28/2022]
Abstract
31 children aged between 6 months and 14 years with various neurovascular abnormalities were examined by MR angiography in a prospective study. In order to test the sensitivity and specificity of the MR results, these were compared in 8 cases with the findings of digital subtraction angiography or conventional angiography. In 24 patients arterial MR angiography was performed; in 17 these showed anomalies or abnormalities of the intracranial vascular system. In 7 patients venous MR angiography was performed and demonstrated the presence of sinus thrombosis in 6 of these. Comparison between MR angiography and DSA showed agreement in 7 cases; in one patient the degree of a stenosis was exaggerated by MR. The results of this study indicate that arterial and venous MR is of great value as an additional study in paediatric neurovascular problems.
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Affiliation(s)
- T J Vogl
- Radiologische Poliklinik, Universität München
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Schedel H, Vogl T, Reimers CD, Ziegler L, Scherer B, Hahn D, Habekost M. [Diagnosis of acute myositis. Magnetic resonance tomography with Gd-DTPA]. ROFO-FORTSCHR RONTG 1991; 155:370-2. [PMID: 1932732 DOI: 10.1055/s-2008-1033279] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Ziegler L, Hahn D, Hasenfratz G. Buchbesprechungen. J Mol Med (Berl) 1991. [DOI: 10.1007/bf01649055] [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: 11/28/2022]
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Rehbock J, Ziegler L, Schramm T, Maassen V. [Destructive bladder mole--follow-up by human chorionic gonadotropin (HCG), ultrasound and digital subtraction angiography (DSA)]. Geburtshilfe Frauenheilkd 1990; 50:893-5. [PMID: 2283017 DOI: 10.1055/s-2008-1026388] [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: 12/31/2022] Open
Abstract
A case report of a mola destruens is presented including the clinical monitoring and the therapeutical conclusions. Control parameters were the HCG, ultrasound and DSA. The DSA in a new and improved technique, provided helpful information during a critical phase of the disease, when changing from mono- to polychemotherapy was necessary. Furthermore, the excellent vascular mapping enables planning of radiological interventions. In case of tumour bleeding hysterectomy can be avoided by embolisation. There may thus be more time for conservative treatment by chemotherapy.
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Affiliation(s)
- J Rehbock
- I. Universitätsfrauenklinik, München
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Ziegler L, Hart H, Küffer G, Hahn D. [Digital sialography]. Digitale Bilddiagn 1990; 10:106-10. [PMID: 2085939] [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] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Sialography is at present performed either by the subtraction mode or conventional technique only. We utilised a high-resolution digital radiography system with a 1024 x 1024 matrix in 17 patients with diseases of the salivary glands. Digital subtraction ductography in lateral projection was followed by digital radiography in adequate projections. In that way advantages of both methods could be combined in one. Additional advantages are possibilities of storage and communication of the digital data.
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Affiliation(s)
- L Ziegler
- Radiologische Klinik, Universität München
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Abstract
In the genesis of ganglions synovial herniation is discussed with an existence of a valve mechanism which prevents the synovial fluid from returning into the joint space. Arthrography of the wrist was performed in 34 patients with suspicion of ganglions on the dorsal and volar aspect of the wrist. By injection of contrast medium in 6 cases directly into the ganglion no connection with the carpal joint cavity was seen. On the contrary, wrist arthrography with examination of the midcarpal and radiocarpal joint showed regularly a communication by a torturous narrow duct between the midcarpal joint and the dorsal ganglion and the radiocarpal joint and the volar ganglion. Other pathologic findings were seen, like tears of the scapholunate ligament and of the triangular fibrocartilage. The consequences for surgical therapy and conclusions for the aetiology of the ganglions are shown.
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Affiliation(s)
- L Ziegler
- Radiologische Klinik und Poliklinik, Universität München
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Ziegler L, Rehbock J, Hahn D, Küffer G. [Intra-arterial digital subtraction angiography in diagnosis and course control of an invasive hydatidiform mole]. Digitale Bilddiagn 1990; 10:59-61. [PMID: 2208917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- L Ziegler
- Radiologische Klinik, Universität München
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Lange M, Ziegler L, Hamburger C. [The importance of 111-indium marked leukocyte scintigraphy in inflammatory intracranial processes]. Neurochirurgia (Stuttg) 1989; 32:150-3. [PMID: 2507951 DOI: 10.1055/s-2008-1054025] [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] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
111-indium-labelled leukocyte scintigraphy used for testing inflammatory intracranial lesion delimitation in differential diagnosis, shows reliable results in 80% of the cases, whereas 10% demonstrate false-positive as well as false-negative results. Loss of time is caused by the 24 h waiting period for measurement, and because of supply problems. Due to these drawbacks, this method is of only limited help to the neurosurgeon in quickly finding safe pointers for determining the time of operation if inflammatory intracranial lesions are suspected. Hence, this method requires to be improved upon, or a new one should be developed.
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Affiliation(s)
- M Lange
- Neurochirurgische Klinik der Ludwig-Maximilians-Universität München
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Gagnerie F, Taillan B, Leyge JF, Jullien JP, Ghurgheguian B, Leloire P, Commandre F, Ziegler L. [Enthesopathy of familial hypophosphoremic malacia]. Presse Med 1987; 16:1285. [PMID: 2955390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
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Zalta AH, Karlin KM, Ziegler L, Zimmerman TJ. The effect of nitroglycerin ointment on the external ocular structures of rabbits. J Ocul Pharmacol 1985; 1:71-7. [PMID: 3939726 DOI: 10.1089/jop.1985.1.71] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The toxicity of three different transdermal nitroglycerin ointments on the external ocular structures of New Zealand White rabbits was investigated. Using a randomized, double-blind protocol, both eyes of four rabbits in each of four treatment groups received 3.75 mg of either Nitrol Ointment, Nitrong Ointment, Nitro-bid Ointment, or Lacri-lube Ointment twice a day for 21 days. The eyelids, palpebral and bulbar conjunctiva, cornea, anterior chamber, and iris were evaluated by slit lamp. Pupillary size was noted and intraocular pressure was measured with an applanation tonometer. All parameters were evaluated pretreatment and two hours after the last dose on treatment days 1, 8, 15, and 22. On days 8 and 15, all four treatment groups had evidence of mild conjunctival injection; however, only the three nitroglycerin groups had mild conjunctival chemosis. At day 22, all four treatment groups had no statistically significant evidence of toxicity to the eyelid, conjunctiva, and iris. Only Nitrong Ointment produced any corneal toxicity, a mild diffuse punctate keratopathy statistically significant only on day 22. In addition, the four treatment groups showed no change in pupil size and intraocular pressure. Transdermal nitroglycerin preparations were well tolerated by the external ocular structures of rabbits. Additional animal studies to evaluate the dosage and frequency effects on tolerance and intraocular pressure are indicated.
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Affiliation(s)
- A H Zalta
- University of Cincinnati Medical Center, Ohio
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