Disease progression of heart failure in type 2 diabetes patients in Germany; a real world data analysis using health insurance claims data

 

Individuals with Type 2 Diabetes (T2D) show two- to four-fold increased risk of Heart failure (HF). Given the increasing T2D prevalence in Germany, researching the interaction of T2DM and HF is of high importance. HF still progresses rapidly. Left ventricular ejection fraction (LVEF) plays an important role in understanding disease progression. Commonly, LVEF is being distinguished into three categories: HF with preserved LVEF (HFpEF), HF with moderate reduced LVEF (HFmEF) and HF with reduced LVEF (HFrEF). In Germany there are no recent data on disease progression in HF especially according to LVEF categories. Purpose of this study is to a) measure how many T2DM patients acquire HF over two years; b) understand the progression of HF in these patients in a five-year follow-up; and c) visualize disease progression with Sankey plots.

We used insurance claims data from German Statutory Health Insurances (SHI). As LVEF category is not included in these data, a model was used to classify patients into HFrEF or HFpEF (with omitting the HFmEF category due to better statistical performance of a binary model). The model was derived from a set of 34 proxy variables (disease coding, interventions, drug prescriptions). Selection period for T2D patients is 2013. Inclusion period was 2014–2015, follow-up 2016–2020. Baseline characteristics include demographic data, disease stage, comorbidities, and risk factors. Follow-up criteria were MACE (including hospital admission) changes in LVEF category and mortality. 173,195 individuals with T2D were identified in 2013, median age 66 yrs. 6,725 (3.88% of the overall sample) developed HF in 2014 or 2015, median age 74 yrs. As Sankey plot visualizations show, 34.4% of the patients had MACE over the course of five years; 24.5% were still alive and 9.9% died from CV-death. Further 33% died of other causes. Myocardial infarct was the most common MACE, followed by stroke (32%), hospital admission for HF (28%) and CV death (7%). 40% of patients were never admitted to a hospital over the study period. Exploratory analyses identified 5,282 HFpEF patients (78.54%) and 1,443 HFrEF patients (21.46%). Survival after 5 years in HFpEF patients was 71%, in HFrEF patients 29%. After five years 3,430 (90%) surviving patients were still in HFpEF and 399 (10%) in HFrEF.

This analysis provides disease progression insights in T2D patients who developed HF in Germany. The sample is representative for the country and numbers can be extrapolated to the overall German SHI population. A significant number of patients die within 5 years of initial diagnosis. As echo diagrams are not available in German insurance claims, validity of the predicted LVEF cannot be assessed. Further research featuring real world LVEF score validation would be highly desirable. Beyond therapeutic care, digital solutions for closer monitoring of these patients may improve the outcome of these patients.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Sanofi

Increased functional connectivity in a population at risk of developing Parkinson's disease

BACKGROUND

While the concept of prodromal Parkinson's disease (PD) is well established, reliable markers for the diagnosis of this disease stage are still lacking. We investigated the functional connectivity of the putamina in a resting-state functional MRI analysis in persons with at least two prodromal factors for PD, which is considered a high risk for PD (HRPD) group, in comparison to PD patients and controls.

METHODS

We included 16 PD patients, 20 healthy controls and 20 HRPD subjects. Resting state echo planar images and anatomical T1-weighted images were acquired with a Siemens Prisma 3 T scanner. The computation of correlation maps of the left and the right putamen to the rest of the brain was done in a voxel-wise approach using the REST toolbox. Finally, group differences in the correlation maps were compared on voxel-level and summarized in cluster z-statistics.

RESULTS

Compared to both PD patients and healthy controls, the HRPD group showed higher functional connectivity of both putamina to brain regions involved in execution of motion and coordination (cerebellum, vermis, pre- and postcentral gyrus, supplementary motor area) as well as the planning of movement (precuneus, cuneus, superior medial frontal lobe).

CONCLUSIONS

Higher functional connectivity of the putamina of HRPD subjects to other brain regions involved in motor execution and planning may indicate a compensatory mechanism. Follow-up evaluation and independent longitudinal studies should test whether our results reflect a dynamic process associated with a prodromal PD state.

Bone conducted vibration is an effective stimulus for otolith testing in cochlear implant patients

BACKGROUND

Treatment with a cochlear implant (CI) poses the risk of inducing a behaviorally unmeasurable air-bone gap leading to false negative absence of cervical and ocular vestibular evoked myogenic potentials (cVEMPs, oVEMPs) to air conducted sound (ACS).

OBJECTIVE

To investigate VEMP response rates to ACS and bone conducted vibration (BCV) in CI patients and the applicability of the B81 transducer for BCV stimulation.

METHODS

Prospective experimental study including unilateral CI patients, measuring cVEMPs and oVEMPs to ACS and to BCV, comparing response rates, signed asymmetry ratios, latencies, and amplitudes.

RESULTS

Data of 13 CI patients (mean age 44±12 years) were analyzed. For the CI side, oVEMP and cVEMP response rates were significantly higher for BCV (77%cVEMP, 62%oVEMP) compared to ACS (23%cVEMP, 8%oVEMP). For the contralateral side, no difference between response rates to ACS (85%cVEMP, 69%oVEMP) and BCV (85%cVEMP, 77%oVEMP) was observed. Substantially higher asymmetries were observed for ACS (-88±23%for cVEMPs, -96±11%for oVEMPs) compared to BCV (-12±45%for cVEMPs, 4±74%for oVEMPs).

CONCLUSIONS

BCV is an effective stimulus for VEMP testing in CI patients. The B81 is a feasible stimulator.

A hydrothermal apparatus for x-ray absorption spectroscopy of hydrothermal fluids at DESY

We present a new autoclave that enables in situ characterization of hydrothermal fluids at high pressures and high temperatures at synchrotron x-ray radiation sources. The autoclave has been specifically designed to enable x-ray absorption spectroscopy in fluids with applications to mineral solubility and element speciation analysis in hydrothermal fluids in complex compositions. However, other applications, such as Raman spectroscopy, in high-pressure fluids are also possible with the autoclave. First experiments were run at pressures between 100 and 600 bars and at temperatures between 25 °C and 550 °C, and preliminary results on scheelite dissolution in fluids of different compositions show that the autoclave is well suited to study the behavior of ore-forming metals at P-T conditions relevant to the Earth's crust.

Novel experimental setup for megahertz X-ray diffraction in a diamond anvil cell at the High Energy Density (HED) instrument of the European X-ray Free-Electron Laser (EuXFEL)

The high-precision X-ray diffraction setup for work with diamond anvil cells (DACs) in interaction chamber 2 (IC2) of the High Energy Density instrument of the European X-ray Free-Electron Laser is described. This includes beamline optics, sample positioning and detector systems located in the multipurpose vacuum chamber. Concepts for pump-probe X-ray diffraction experiments in the DAC are described and their implementation demonstrated during the First User Community Assisted Commissioning experiment. X-ray heating and diffraction of Bi under pressure, obtained using 20 fs X-ray pulses at 17.8 keV and 2.2 MHz repetition, is illustrated through splitting of diffraction peaks, and interpreted employing finite element modeling of the sample chamber in the DAC.

Molecular MR-Imaging for Noninvasive Quantification of the Anti-Inflammatory Effect of Targeting Interleukin-1β in a Mouse Model of Aortic Aneurysm

Background:

Molecular-MRI is a promising imaging modality for the assessment of abdominal aortic aneurysms (AAAs). Interleukin-1β (IL-1β) represents a new therapeutic tool for AAA-treatment, since pro-inflammatory cytokines are key-mediators of inflammation. This study investigates the potential of molecular-MRI to evaluate therapeutic effects of an anti-IL-1β-therapy on AAA-formation in a mouse-model.

Methods:

Osmotic-minipumps were implanted in apolipoprotein-deficient-mice (N = 27). One group (Ang-II+01BSUR group, n = 9) was infused with angiotensin-II (Ang-II) for 4 weeks and received an anti-murine IL-1β-antibody (01BSUR) 3 times. One group (Ang-II-group, n = 9) was infused with Ang-II for 4 weeks but received no treatment. Control-group (n = 9) was infused with saline and received no treatment. MR-imaging was performed using an elastin-specific gadolinium-based-probe (0.2 mmol/kg).

Results:

Mice of the Ang-II+01BSUR-group showed a lower aortic-diameter compared to mice of the Ang-II-group and control mice (p < 0.05). Using the elastin-specific-probe, a significant decrease in elastin-destruction was observed in mice of the Ang-II+01BSUR-group. In vivo MR-measurements correlated well with histopathology (y = 0.34x-13.81, R² = 0.84, p < 0.05), ICP-MS (y = 0.02x+2.39; R² = 0.81, p < 0.05) and LA-ICP-MS. Immunofluorescence and western-blotting confirmed a reduced IL-1β-expression.

Conclusions:

Molecular-MRI enables the early visualization and quantification of the anti-inflammatory-effects of an IL-1β-inhibitor in a mouse-model of AAAs. Responders and non-responders could be identified early after the initiation of the therapy using molecular-MRI.

Physical and ecological effects of rehabilitating the geothermally influenced Waikite Wetland, New Zealand

Pressure to optimise land use and to maximise the economic viability of land has had a detrimental impact on wetlands worldwide. Rehabilitating wetlands has been identified by resource managers as increasingly important to enhance environmental values and restore ecosystem functions that may have been lost through developments effecting wetlands. This paper investigates rehabilitating a geothermally influenced wetland that had been drained and used for grazing stock. The Waikite Wetland (New Zealand) is a relatively unique wetland because the primary water source to the wetland has a significant geothermal water component. This results in the area hosting populations of rare flora and fauna that are significant to New Zealand. A range of management actions that included diverting a geothermal stream back into the wetland, blocking drains, pest control, weed control, native plantings, fencing and building a weir to increase water levels were used to rehabilitate the wetland. This was done to promote thermotolerant vegetation growth, restore wetland water levels and minimise pest plant species re-establishing while minimising the effects on geothermal surface features and allowing indigenous wetland vegetation to re-establish. Physical, chemical and vegetation monitoring show that management actions have increased thermotolerant vegetation growth in the wetland while having a small potential impact on geothermal discharges into the wetland. Increasing the water level in the wetland appears to be helping control plant pest species close to the weir, but has also made sensitive vegetation growing close to the waterways more susceptible to flooding caused by high-intensity rainfall events.

MR diffusion imaging and 1H spectroscopy in a child with medulloblastoma: A case report

We report on a child with a metastasising medulloblastoma which was assessed by MR diffusion imaging and 1H MR spectroscopy (MRS). Reduced mean apparent diffusion coefficients and a high amount of taurine could be demonstrated. This is the first reported case of high taurine in medulloblastoma in vivo and confirms earlier in vitro findings. It is suggested that the changes on diffusion imaging, possibly reflecting the small-cell histology of the tumour and high taurine in MRS, are indicative of medulloblastoma.

[Endoscopic mucosal resection (EMR) followed by radiofrequency ablation (RFA) in neoplastic Barrett's esophagus or Barrett early cancer is also economically superior to sole radical endoscopic resection]

INTRODUCTION

Neoplastic changes (mild or high grade intraepithelial neoplasia (L- or HGIEN) or early cancer) in Barrett esophagus are treated with various methods. This study compares clinical-economical aspects of sole stepwise radical endoscopic resection (SRER) against combination treatment with EMR (Endoscopic mucosal resection) and RFA (radiofrequency ablation).

MATERIAL AND METHODS

Based on clinical data from a randomized controlled trial 1 we developed an economic model for costs of treatment according to the German Hospital Remuneration System (G-DRG). Our calculating incorporated initial treatment costs and the cost of treating complications (both paid via G-DRG).

RESULTS

Medical and economically, the treatment with EMR + RFA advantages over sole SRER treatment 1. The successful complete resection or destruction of neoplastic intestinal metaplastic tissue is similar in both procedures. Acute complications (24 vs. 13 % in SRER EMR + RFA) and late complications (88 vs. 13 % in SRER EMR + RFA) are significantly more likely in sole SRER than in the EMR + RFA.

DISCUSSION

While SRER initially appears more cost-effective as a sole therapy, cost levels move significantly above EMR+RFA due to higher complication rates and following procedures costs. Overall, the costs of treatment was € 13 272.11 in the SRER group and € 11 389.33 in the EMR + RFA group. The EMR + RFA group thus achieved a cost advantage of € 1882.78. The study shows that the treatment of neoplastic Barrett esophagus with EMR + RFA is also appropriate in economic terms.

Exploration of the phase diagram of liquid water in the low-temperature metastable region using synthetic fluid inclusions

The paper presents experimental data of the low-temperature metastable region of liquid water to evaluate and improve theoretical models describing the p–V–T properties of water.

A rabbit humerus model of plating and nailing osteosynthesis with and without Staphylococcus aureus osteomyelitis

The local mechanical environment at a fracture is known to influence biological factors such as callus formation, immune cell recruitment and susceptibility to infection. Infection models incorporating a fracture are therefore required to evaluate prevention and treatment of infection after osteosynthesis. The aim of this study was to create humane, standardised and repeatable preclinical models of implant-related bone infection after osteosynthesis in the rabbit humerus. Custom-designed interlocked intramedullary nails and commercially available locking plates were subjected to biomechanical evaluation in cadaveric rabbit humeri; a 10-week in vivo healing study; a dose response study with Staphylococcus aureus over 4 weeks; and finally, a long-term infection of 10 weeks in the plate model.Outcome measures included biomechanical testing, radiography, histology, haematology and quantitative bacteriology. Both implants offered similar biomechanical stability in cadaveric bones, and when applied in the in vivo study, resulted in complete radiographic and histological healing and osteotomy closure within 10-weeks. As expected in the infection study, higher bacterial doses led to an increasing infection rate. In both infected groups, there was a complete lack of osteotomy closure at 4 weeks. C-reactive protein (CRP), lymphocyte: granulocyte ratio and weight loss were increased in infected animals receiving IM nails in comparison with non-inoculated equivalents, although this was less evident in the plate group. In the 10-week infection group, healing does not occur in the plated rabbits. We have successfully developed a rabbit model that is suitable for further studies, particularly those looking into preventative strategies for post-traumatic implant-related osteomyelitis.

Mechanochemical synthesis and characterisation of two new bismuth metal organic frameworks

Two metal organic structures composed of the ligands benzene-1,4-dicarboxylate and pyridine-2,5-dicarboxylate and bismuth cations are presented: (H₂Im)[Bi(1,4-bdc)₂] (1) and [Bi(pydc)(NO₃)₂(H₂O)₂]·H₂O (2) (bdc = benzenedicarboxylate, H₂Im = imidazole cation, pydc = pyridinedicarboxylate).

[Economic aspects of inpatient treatment for decompensated liver cirrhosis: a prospective study employing an evidence-based clinical pathway]

The introduction of the G-DRG reimbursement system has greatly increased the pressure to provide cost effective treatment in German hospitals. Reimbursement based on diagnosis-related groups, which requires stratification of costs incurred is still not sufficiently discriminating the disease severity and severity in relation to the intensive costs in gastroenterology. In a combined retrospective and prospective study at a tertial referral centre we investigated whether this also applies for decompensated liver cirrhosis. In 2006, 64 retrospective cases (age 57 ± 12.9; ♂ 69.2 %, ♀ 29.8 %) with decompensated liver cirrhosis (ICD code K76.4) were evaluated for their length of hospitalisation, reimbursement as well as Child and MELD scores. In 2008, 74 cases with decompensated liver cirrhosis were treated in a prospective study according to a standardised and evidence-based clinical pathway (age 57 ± 12.2; 73 % ♂, ♀ 27 %). Besides a trend in the reduction of length of hospital stay (retrospective: 13.6 ± 8.6, prospective 13.0 ± 7.2, p = 0.85) overall revenues from patients treated according to a evidence-based clinical pathway were lower than the calculated costs from the InEK matrix. Costs of medication as a percentage of reimbursement amount increased with increasing severity. In both years we could demonstrate an inverse correlation between daily reimbursement and disease severity which precluded cost coverage. For the cost-covering hospital treatment of patients with decompensated liver cirrhosis an adjustment of the DRG based on clinical severity scores such as Child-Pugh or MELD is warranted, if evidence-based treatment standards are to be kept.

Investigation of the best suture pattern to close a stuffed Christmas turkey

Instructions on how to debone and stuff a turkey are available, but what is the best way to close it up? A randomised trial involving 15 turkeys was performed in order to evaluate skin disruption scores and cosmetic outcomes following the use of different suture patterns. Turkeys were deboned, stuffed and cooked according to guidelines of the US Department of Agriculture Food Safety and Inspection Services. After stuffing, they were randomly assigned to one of five closure groups: simple continuous Lembert; simple continuous Cushing; simple continuous Utrecht; simple continuous; or staples. Turkeys were cooked at 180 °C for two hours ensuring core temperature reached 75 °C. Suture line integrity was evaluated after removal of the sutures and the cosmetic aspect was graded. Before cooking, the Utrecht pattern and skin staples offered the best cosmetic result. After removal of the sutures, the skin remained intact only in the stapled group. All other suture patterns disrupted the skin after removal of the sutures, rendering the turkey less cosmetically appealing for serving. Closure of a stuffed turkey was best performed using skin staples to achieve the best cosmetic results. Using this technique you will be able to impress family and friends at a Christmas dinner, and finally show them your surgical skills.

Are recommended phototherapy thresholds safe enough for extremely low birth weight (ELBW) infants? A report on 2 ELBW infants with kernicterus despite only moderate hyperbilirubinemia

Two extremely low birth weight (ELBW) infants developed characteristic signs of kernicterus at 4 and 8 months corrected age despite only moderate neonatal hyperbilirubinemia (peak serum bilirubin <10 g/dl) and phototherapy being applied according to current guidelines. Both girls were from twin pregnancies and had fetal complications (donor in a twin-twin transfusion syndrome and acardius-acranius malformation in the second twin, respectively), connatal anemia (initial hematocrit 30%), and mild acidosis after birth. They had been neurologically normal at discharge except for abnormal otoacustic emissions (OAE). At the time kernicterus was diagnosed, both infants were nearly deaf, showed severe psychomotor retardation with dystonic features and had marked bilateral hyperintensities in the globus pallidum on MRI. Based on these and similar cases from the literature, we question whether current phototherapy guidelines are appropriate for high-risk ELBW infants. Lower thresholds may be preferable, at least if additional risk factors, such as anemia, are present.

Progress toward the development and testing of source reconstruction methods for NIF neutron imaging

Development of analysis techniques for neutron imaging at the National Ignition Facility is an important and difficult task for the detailed understanding of high-neutron yield inertial confinement fusion implosions. Once developed, these methods must provide accurate images of the hot and cold fuels so that information about the implosion, such as symmetry and areal density, can be extracted. One method under development involves the numerical inversion of the pinhole image using knowledge of neutron transport through the pinhole aperture from Monte Carlo simulations. In this article we present results of source reconstructions based on simulated images that test the methods effectiveness with regard to pinhole misalignment.

Visual adaptation to convexity in macaque area V4

Aftereffects are perceptual illusions caused by visual adaptation to one or more stimulus attribute, such as orientation, motion, or shape. Neurophysiological studies seeking to understand the basis of visual adaptation have observed firing rate reduction and changes in tuning of stimulus-selective neurons following periods of prolonged visual stimulation. In the domain of shape, recent psychophysical work has shown that adaptation to a convex pattern induces a subsequently seen rectangle to appear slightly concave. In the present study, we investigate the possible contribution of V4 neurons of rhesus monkeys, which are thought to be involved in the coding of convexity, to shape-specific adaptation. Visually responsive neurons were monitored during the brief presentation of simple shapes varying in their convexity level. Each test presentation was preceded by either a blank period or several seconds of adaptation to a convex or concave stimulus, presented in two different sizes. Adaptation consistently shifted the tuning of neurons away from the convex or concave adapter, including shifting response to the neutral rectangle in the direction of the opposite convexity. This repulsive shift resembled the known perceptual distortion associated with adaptation to such stimuli. In addition, adaptation caused a nonspecific response decrease, as well as a specific decrease for repeated stimuli. The latter effects were observed whether or not the adapting and test stimuli matched closely in their size. Taken together, these results provide evidence for shape-specific adaptation of neurons in area V4, which may contribute to the perception of the convexity aftereffect.

Reorganization of the cerebro-cerebellar network of language production in patients with congenital left-hemispheric brain lesions

Patients with congenital lesions of the left cerebral hemisphere may reorganize language functions into the right hemisphere. In these patients, language production is represented homotopically to the left-hemispheric language areas. We studied cerebellar activation in five patients with congenital lesions of the left cerebral hemisphere to assess if the language network is reorganized completely in these patients, i.e. including also cerebellar language functions. As compared to a group of controls matched for age, sex, and verbal IQ, the patients recruited an area not in the right but in the left cerebellar hemisphere. The extent of laterality of the cerebellar activation correlated significantly with the laterality of the frontal activation. We suggest that the developing brain reacts to early focal lesions in the left hemisphere with a mirror-image organization of the entire cerebro-cerebellar network engaged in speech production.

[Comparative in vitro analysis of vacuum plasma-sprayed titanium implants--evaluation of OPG, Osteokalzin and AP expression]

INTRODUCTION

The purpose of this study was to evaluate the influence of different surface topographies on the expression of bone cell-associated proteins, such as osteoprotegerin (OPG), osteocalcin and alkaline phosphatase (AP), and the production of the extracellular matrix (ECM) in vitro. Another aspect was the question as to whether a hydroxyapatite (HA) coating offers additional advantages. Vacuum plasma-sprayed (VPS) pure titanium was used to generate different surface topographies.

MATERIALS AND METHODS

The in vitro response of human bone marrow cells to VPS implants (porosity ranging from 25 to 50%, pore size ranging from 50 to 200 microm and roughness ranging from 0.191 to 0.547 mm) and cancellous structured titanium (cs-Ti) as a reference material (55% porosity, pore size of 500 microm, roughness 0.836 mm) were compared. The expression of bone cell-associated proteins, such as OPG, osteocalcin and alkaline phosphatase (AP), was evaluated. Scanning electron microscopy (SEM) was used to judge the production of ECM.

RESULTS

All implant materials induced the release of OPG, osteocalcin and AP. Significant differences were evident between the cs-Ti and the different VPS-Ti surface structures. There was no difference in the response between the VPS-Ti surfaces. SEM showed a dense and increased production of ECM on the VPS-Ti surfaces. An additional HA coating caused a faster production of ECM and higher levels of OPG.

CONCLUSIONS

The in vitro data presented here demonstrate the superiority of VPS-Ti surfaces over cs-Ti, which is already in clinical use. Differences between the VPS-Ti surfaces were not evident. Presumably, VPS-Ti surfaces offer good prerequisites for a successful integration of the implant in the surrounding tissue. An additional HA coating could influence these events positively.

Diffusion-weighted magnetic resonance imaging of treatment-associated changes in recurrent and residual medulloblastoma: preliminary observations in three children

PURPOSE

To emphasize a possible role of magnetic resonance (MR) diffusion-weighted imaging (DWI) for lesion conspicuity and detection of treatment effects in children with medulloblastoma.

MATERIAL AND METHODS

Three children with medulloblastoma (two residual and one recurrent) were examined repetitively by MR diffusion-weighted imaging. Regional assessment of the apparent diffusion coefficient (ADC) was done for tumorous lesions and periventricular white matter appearing normal on standard MR images.

RESULTS

All lesions were clearly visible on DWI. In the case of recurrent tumor, on one scan, DWI showed lesions that were not seen on contrast-enhanced MRI. Increase (41%) of ADC was seen in one lesion, which subsequently responded completely to treatment over 27 months' follow-up. Intermediate increases (23-26%) of ADC were found with partial therapy response in three lesions. In contrast, a decrease (-11%) of ADC in two lesions was seen with tumor progression.

CONCLUSION

These observations may suggest a role for DWI in early detection of metastatic disease and treatment monitoring of medulloblastoma, warranting a formal study.

The diallelic locus encoding the minor histocompatibility antigen HA-1 is evolutionarily conserved

The polymorphic minor histocompatibility antigen HA-1 induces powerful T-cell alloreactivities with important consequences for graft-vs-tumor activity and development of graft-vs-host disease in patients after human leukocyte antigen-matched stem-cell transplantation (SCT). In view of possible translational animal studies, we analyzed the evolutionary conservation of the diallelic HA-1 locus in four mammalian species. Our results show that rodents do not encode the HA-1(H) allele, neither show polymorphism in this position on the HA-1 gene. Contrariwise, the HA-1(H) allele is present in non-human primate species and dogs. Interestingly, both the HA-1(H) T-cell epitope and its non-immunogenic counterpart HA-1(R) are present in the latter species. Thus, the HA-1 allelic polymorphism is conserved in evolution in primates and dogs.

[Maillard reaction products in food as pro-inflammatory and pro-arteriosclerotic factors of degenerative diseases]

Heating of food induces the formation of Maillard reaction products (MRPs) caused by the reaction of reducing sugars with proteins or amino acids. Analogous reactions occur in the human body, eventually forming "Advanced Glycation Endproducts" (AGEs). AGEs accumulate in aging tissues accelerating degenerative-inflammatory and proliferative processes. MRPs present in food can also directly cause inflammatory processes in the intestines and, once absorbed, would support and reinforce any inflammatory and degenerative process occurring in the body. The contribution of AGEs (and additional MRPs) in the development of diabetic complications as well as nephropathy, neuropathy, micro- and macroangiopathies is now well established. Which of the MRPs or AGEs in particular induce these cellular processes is currently unknown. Thus the exact knowledge of the chemical structures of the MRPs could help to minimize the formation of "harmful MRPs" that occur due to heating in food processing. Because MRPs play a decisive role in the successful marketing of edibles due to their characteristics as flavor components, it is important to increase the amount of innocuous and palatable MRPs, and minimize signal active pro-inflammatory MRPs by the use of defined preparation methods. It is practicable to use low-priced immunological methods for the quantitative determination of specific MRPs or AGEs. In the medical area, the knowledge of the signal active MRP/AGE structures provides the opportunity to measure their concentrations in body fluids and tissues and thus determine their influence on inflammatory and age-related degenerative processes (e. g., late diabetic complications, arteriosclerosis, degeneration of neurons). From a clinical perspective, the application of RAGE antagonists after an appropriate chemical diagnosis could be effective in supporting the treatment of affected patient groups, especially older diabetic and dialysis patients.

[Ocular changes in tropical malaria with cerebral involvement--results from the Blantyre Malaria Project]

INTRODUCTION

Malaria is a tropical disease causing an estimated 300 million infections and one million deaths per year. In sub-Saharan Africa, most infections are due to Plasmodium falciparum. The hallmark of the clinical syndrome of cerebral malaria is coma, and the associated mortality rate, even in appropriately treated patients, is 15 - 50 %. Funduscopy plays a major role for the ophthalmologist in the differential diagnosis because of the characteristic changes.

METHODS

To date more than 1000 children who satisfied the standard clinical case definition of cerebral malaria were admitted to the Blantyre Malaria Project (Malawi, Africa) for inpatient treatment and examined using indirect ophthalmoscopy through fully dilated pupils. The gender distribution was homogeneous and the children were between 2 and 14 years old. The optic nerve head, central and peripheral retina and central and peripheral vessels were described and photographed using a hand-held fundus camera (KOWA).

RESULTS

The spectrum and severity of findings of the ocular fundus in children with CM include the following distinct entities: haemorrhages (with and without a white centre), cotton wool spots, papilloedema, retinal whitening and retinal vessel abnormalities that may appear to be orange or white. Most of the retinal haemorrhages (in 40 %) have white centres and resemble Roth spots. Cotton wool spots were seen in only 5 %. Papilloedema was also not commonly seen (8 %) but is a poor prognostic sign. Retinal whitening (in 50 %) is seen more commonly at the posterior pole than in the periphery. 20 % of patients show retinal vessel abnormalities that may be orange or white in colour.

CONCLUSION

Ocular fundus changes in CM can be detected by the ophthalmologist using simple means and are decisive for the prognosis and timely therapy for this potentially lethal disease.

1H-MRS alterations in the cerebellum of patients with familial hemiplegic migraine type 1

BACKGROUND

About 20% of patients with familial hemiplegic migraine (FHM) develop progressive cerebellar signs. Genetic studies have established an association with mutations in the CACNA1A gene. However, the mechanisms underlying cerebellar involvement are largely unknown.

OBJECTIVE

To use proton MR spectroscopy (1H-MRS) to investigate metabolic alterations in the cerebellum as well as cortical regions known to be involved in the propagation of migraine aura.

METHODS

Fifteen CACNA1A mutation carriers from three FHM families and 17 healthy control subjects were studied. Eleven patients had clinical signs of cerebellar involvement. LCModel fits were used to estimate absolute concentrations of N-acetyl aspartate (NAA), myo-inositol (mI), glutamate (Glu), choline-containing compounds, total creatine, and lactate in the superior cerebellar vermis (SCV), parietal cortex, and occipital cortex. To control for atrophy effects, automated image segmentation was performed using SPM99. The brain parenchyma fraction (BPF) was determined for all three regions.

RESULTS

Compared with controls, the brain parenchyma fraction (BPF), NAA, and Glu were significantly reduced and mI was significantly elevated in the SCV of patients with FHM. In contrast, no metabolite alterations were found in supratentorial regions. BPF and NAA in the SCV significantly correlated with cerebellar scores, in particular, gait ataxia.

CONCLUSIONS

The findings suggest that there is a regionally distinct neuronal impairment in the superior cerebellar vermis that exceeds macroscopic tissue loss. Correlations with clinical scores emphasize the functional relevance of localized atrophy (brain parenchyma fraction) and N-acetyl aspartate levels. These measures may be useful to monitor disease progression. The observed reduction in glutamate may in part reflect impaired glutamatergic neurotransmission.

Histomorphometrische Evaluation poröser Titanprobenkörper anhand eines computergestützten Bildanalysesystems / Histomorphometric evaluation of bone ingrowth of porous titanium by a computer-assisted analyzing system

The objective of this study was to evaluate the bone ingrowth of a new vacuum plasma sprayed titanium surface (vps-ti) in comparison to cs-titanium implants in a göttinger minipig model. Fifteen göttinger minipigs each received the two implants, vacuum plasma sprayed titanium with a porosity of 50% and a pore size of 200 microm (vps-ti) and an implant with a similar porosity but a different pore size 500 microm (cs-ti), at the proximal femur metaphysis by press-fit technique. The pigs were euthanized at three different postsurgical periods: 4, 8 and 12 weeks. Each femur was harvested and qualitative (macroscopic and microscopic) and quantitative (histomorphometric) histological analysis was done on histological slides. The results indicated that there was a difference in bone ingrowth between the two implants, whereas the bone ingrowth of vps-ti was superior to cs-ti after 4 and 8 weeks healing time. 12 weeks post implantationem no statistiscal difference was evident. The pore size of 200 microm seemed superior to a pore size of 500 microm. Whether or not these effects lead to a better mechanical stability remains unanswered.

Escherichia coli-nitroreductase suicide gene control of human telomerase reverse transcriptase-transduced minor histocompatibility antigen-specific cytotoxic T cells

Adoptive immunotherapy with ex vivo generated cytotoxic T lymphocytes (CTLs) is applied for the treatment of leukemia relapses or viral infections after allogeneic stem cell transplantation. A common problem of adoptive immunotherapy strategies is the ex vivo expansion of the generated T cells to sufficient numbers. CTLs can be efficiently expanded by ectopic expression of the human telomerase gene (hTert). However, hTert transduction may also increase the chance for malignant transformation. Therefore, we explored the feasibility of suicide gene control of ex vivo generated CTLs expanded through the ectopic expression of hTert. To this end, we compared the efficacy of the new Escherichia coli-nitroreductase (E. coli-Ntr) suicide gene with the well-known herpes simplex virus-thymidine kinase (HSV-Tk). Introduction of hTert provided the transduced CTLs with a distinct growth advantage over the nontransduced CTLs. The hTert-E. coli-Ntr double-transduced CTLs retained their antigen-specific functions. Treatment of hTert-E. coli-Ntr double-transduced CTLs with metronidazole significantly inhibited the proliferation to a similar extent to the treatment of hTert-HSV-Tk double-transduced CTLs with ganciclovir. This is the first application of the E. coli-nitroreductase gene for the elimination of human T cells with metronidazole.

The prevention of intrapartum HIV/AIDS transmission from mother to child

The transmission of HIV/AIDS from mother to child is the main cause of HIV/AIDS in children and child mortality. Two-thirds of children with HIV/AIDS are infected in the intrapartum period (Farley, 2000:1-2). Midwives, through effective practices, can lower the transmission of HIV/AIDS from mother to child in the intrapartum period. The aim of the study was to determine which preventive practices registered midwives in provincial labour wards in Bloemfontein, implement to lower the risk of mother to child transmission of HIV/AIDS and in doing so to lower child mortality. A descriptive research design was used. Fifty-one midwives completed questionnaires to determine what preventive practices are used. The study showed that most of the midwives did not implement the interventions that could lower the chances of HIV/Aids transmission from mother to child during the intrapartum period. Midwives therefore may not have a positive impact on child mortality. The researchers concluded that midwives do not implement the interventions mentioned in the study because of a lack of knowledge and skills. Of the midwives who completed questionnaires, 67% completed their training between 1990 and 2000. This lack of knowledge may be due to a lack in the curriculum of training institutions and of an up-to-date policy concerning the transmission of HIV/Aids in provincial institutions in Bloemfontein. It is recommended that all affordable interventions should be incorporated in the policy.

DRG-based cost analysis of inpatient conservative treatment of PAD stage III/IV

Hintergrund: In einer von der Deutschen Gesellschaft für Angiologie (DGA) und dem DRG Competence Center, München, durchgeführten prospektiven Studie wurde geprüft, ob die Kosten für eine konservative Behandlung von Patienten mit PAVK Stadium III/IV (DRG F65) im derzeitigen G-DRG-System adäquat abgebildet sind. Methode und Patienten: Im Zeitraum vom 1. September. bis 16. Dezember 2002 wurden an acht angiologischen Zentren in Deutschland insgesamt 704 Patienten mit der DRG F65 (periphere Gefäßerkrankungen) ausgewertet. Neben der Verweildauer im Krankenhaus wurden die Gesamtkosten (Kostenäquivalente) nach einer von der DRG Research Group der Universität Münster entwickelten Methodik berechnet. Darüber hinaus erfolgte ein Vergleich des Studienkollektivs mit einer von InEK veröffentlichten bundesdeutschen Kalkulationsstichprobe für die DRGs F65A/B. Ergebnisse: Es zeigte sich, dass konservativ behandelte Patienten mit einer PAVK Stadium III/IV (DRGs F65A/B) signifikant mehr Kosten verursachen (p < 0,001) und signifikant längere Verweildauern (p < 0,001) aufweisen als Patienten, die wegen anderer Gefäßerkrankungen ebenfalls in die DRG F65 eingruppiert wurden. Gleichzeitig wurde deutlich, dass angiologische Zentren doppelt so viele Patienten mit kritischer Extremitätenischämie behandeln, wie dies im bundesdeutschen Mittel der Fall ist. Die von InEK bislang veranschlagte Vergütung deckt nicht einmal die Hälfte der tatsächlich entstandenen Kosten für die konservative Therapie der PAVK Stadium III/IV. Schlussfolgerung: Um eine leistungsgerechte Vergütung zu gewährleisten, muss – wie von der DGA beantragt – eine neue Basis-DRG für Patienten mit PAVK Stadium III/IV gebildet werden. Andernfalls wird in Zukunft eine adäquate – den Leitlinien entsprechende – konservative Therapie dieser Patienten, die weder operativ noch interventionell behandelt werden können, nicht mehr möglich sein.

Normative pediatric brain data for spatial normalization and segmentation differs from standard adult data

Spatial normalization and morphological studies of pediatric brain imaging data based on adult reference data may not be appropriate due to the developmental differences between the two populations. In this study, we set out to create pediatric templates and a priori brain tissue data from a large collection of normal, healthy children to compare it to standard adult data available within a widely used imaging software solution (SPM99, WDOCN, London, UK). Employing four different processing strategies, we found considerable differences between our pediatric data and the adult data. We conclude that caution should be used when analyzing pediatric brain data using adult a priori information. To assess the effects of using pediatric a priori brain information, the data obtained in this study is available to the scientific community from our website (www.irc.cchmc.org).