POS0170 EXPERIENCES WITH COVID-19 INFECTIONS IN GERMAN PEDIATRIC RHEUMATOLOGY CENTERS

Background

Although the risk for severe COVID-19 progression in children is low, this may be aggravated by the underlying disease and/or immunosuppressive drugs.

Objectives

We analyzed clinical data of COVID-19 cases among paediatric patients with rheumatic diseases reported to the BIKER registry.

Methods

The main task of the German BIKER (Biologics in Pediatric Rheumatology) registry is to monitor the safety of biologics therapies in JIA. After the onset of the COVID-19 pandemic, the survey was expanded with a standardized form to proactively interview all participating centers about the occurrence, presentation, and outcome of SARS-CoV-2- infections in children with rheumatic diseases. Interviews were conducted with 68 centers initially weekly and later biweekly.

Results

A total of 68 centres participated in the survey. Clinical data from 194 COVID-19 cases reported to the BIKER registry from 41 German and 1 Austrian pediatric rheumatology institutions between February 2020 and December 2021 were analyzed. Juvenile idiopathic arthritis (JIA, n=144) was the most common diagnosis followed by genetic autoinflammation (n=18; i.e. FMF, TRAPS, CAPS, HIDS, DADA2), systemic autoimmune diseases (n=11; i.e. SLE, dermatomyositis, vasculitis) and 16 with other rheumatic diseases (i.e. CRMO, Uveitis). 5 patients with no rheumatic disease were excluded. 104 (54%) patients were receiving conventional DMARDs, 81 (43%) received biologics, mainly TNF inhibitors (n=66 (35%)).

Of the 189 rheumatic patients with SARS-CoV2 infection, 123 (63%) were female. The mean age was 12.4+/-4.4 years in females and 13.2+/-4.1 in males. The duration of SARS-Co2 infection associated symptoms was 13.8+/-15.3 days (max. 113 days), in 35 (43%) patients they lasted for > 12 days. 46 (24%) were asymptomatic. Patients with autoinflammation and systemic autoimmunopathies reported more symptoms such as fever, head and throat ache. 4 patients only complained about dyspnea.

Only 3 patients were hospitalized and received Oxygen-supplementation. The only patients admitted to ICU, received ventilation but succumbed. This 3½-year-old patient, initially diagnosed with systemic JIA, developed fatal disease with intracranial edema and respiratory failure, as well as typical pulmonary texture changes. Prior to her SARS-CoV-2 infection, the patient was treated with MTX and low-dose steroids. Genetic testing revealed a so far unrecognized congenital immunodeficiency.

In the total JIA cohort, treatment with corticosteroids, conventional DMARDs, biologics or combinations did not influence the number of reported symptoms or the favorable outcome of the cohort. However, the duration of symptoms was lower in the TNF-treated cohort (10.4+/-6.4 days vs. 15.7 +/- 19.7 days). In the cohort with autoinflammation, fever was observed in 11 (61%). Those 6 who received IL-1-inhibitors did not show a different outcome than those 12 who did not. No case of PIMS/MISC in children with rheumatic diseases was reported.

Conclusion

Except for one patient with congenital immunodeficiency who died from her COVID-19 infection, no case of severe COVID-19 was reported in our cohort. At the time of infection, over 80% of patients in our cohort had been treated with conventional DMARDs and/or biologics. This did not appear to have a negative impact on the severity or outcome of SARS-CoV2 infection. Interestingly, no case of PIMS/MISC was observed.

Disclosure of Interests

Gerd Horneff Speakers bureau: Novartis, Pfizer, Janssen, Grant/research support from: Pfizer, Novartis, Roche, MSD, Frank Dressler Speakers bureau: Pfizer, Novartis, Abbvie, Paid instructor for: Advisory boards Novartis, Mylan, Daniel Windschall Speakers bureau: Pfizer, Novartis, Abbvie, MEDAC, Canon, Grant/research support from: Novartis, Pfizer, Sonja Mrusek: None declared, Toni Hospach: None declared, Alexander Kühn: None declared, Maria Haller: None declared, Philipp von Bismarck: None declared, Wolfgang Emminger: None declared, Peggy Ruehmer: None declared, Markus Hufnagel: None declared, Ariane Klein Speakers bureau: Novartis

POS0338 TRANSITION COMPETENCE IN YOUNG PEOPLE WITH JUVENILE IDIOPATHIC ARTHRITIS HAS IMPROVED OVER TIME

Background

In recent years, transition clinics have been set up at an increasing number of paediatric rheumatology sites in Germany to reduce identified deficits in the care of young people with rheumatic diseases1. In addition, the German Rheumatic Diseases League (Deutsche Rheuma-Liga, DRL), the largest self-help organisation in Germany, has been offering support services for young people in transition since 2016, including the interactive website www.mein-rheuma-wird-erwachsen.de.

Objectives

To assess the transition competence of young people with juvenile idiopathic arthritis (JIA) and their knowledge of self-help services.

Methods

Cross-sectional data of the National Paediatric Rheumatology Database (NPRD) from 2016 to 2020 were used to evaluate the health-related transition competence of young people with JIA aged ≥16 years. Health-related knowledge and health-care competence were assessed using a modified self-report instrument2 on a 4-point Likert scale as part of routine documentation in the NPRD. Young people were also asked about their information behaviour and knowledge of new support services. Linear mixed models were used to determine whether health-related transition competence changed between 2016 and 2020, adjusted for disease duration.

Results

During the years 2016 to 2020, between 1.908 to 2.536 patients with JIA aged ≥16 years were annually recorded in the NPRD from 56 to 61 paediatric rheumatology sites. The annual patient collectives comprised 34-39% oligoarthritis, 23-26% RF-negative or RF-positive polyarthritis and 22-27% enthesitis-related arthritis cases. In the years from 2016 to 2020, about one-third of patients had inactive disease (cJADAS-10≤1) and about 60% had no functional limitations (CHAQ=0).

Over the years, the proportions of patients who rated their disease knowledge and health care competence as “very well” increased significantly in most areas. Although over time, no increase in numbers of patients seeking information about their disease outside of rheumatology consultations were recorded (2016: 22.8%; 2020: 20.9%), awareness of the DRL’s new website for young people with rheumatic diseases increased from 7.7% in 2016 to 26.9% in 2020. Compared to those who were unaware of the new website, those who knew about the website were more likely to have received care in rheumatology settings that offer transition clinics and were more likely to be girls (75% vs 65%), to attend high school (51% vs 46%) and to be slightly older (17.6 vs 17.1 years).

Conclusion

The transition competence of young people with JIA seems to have improved over the last five years. During this time, more transition services were made available for young people with rheumatic diseases. However, most young people are not yet aware of these services. Moreover, the effectiveness of the different measures/interventions has yet to be evaluated.

References

[1]Luque Ramos A et al. Semin Arthritis Rheum 2017;47:269-75.

[2]Herrmann-Garitz C et al. Gesundheitswesen 2017;79:491–6.

Table 1.

Health-related transition competence in JIA patients ≥16 years who participated in the NPRD

201620182020p (difference over time)PatientsN=2536N=2068N=1908Disease duration, years6.7±4.97.2±5.07.6±5.1DMARDs at documentation, %576263Disease-related knowledge (best answer “very well”), %N=1992N=1598N=1265name of illness3542420.001names of medicines5459560.717what medicines are for5054520.357who to contact in case of health problems5965650.015influence of smoking, drugs, and alcohol on disease4955540.002how to make a doctor’s appointment6868650.087which doctors are responsible after leaving paediatric care4246490.031Health-care competence (best answer “most of the time”), %N=1784N=1443N=1143inform my doctor of any unusual changes in my health6672690.038keep information about my illness8184840.281ask my own questions5156550.016answer the questions I am asked6973740.014take care of my health concerns and needs6671690.041attend the consultation alone5961610.599speak up for myself and say what I need6468680.537

Acknowledgements

The NPRD has been funded by the Federal Ministry of Health and the companies Abbvie, Chugai, ask, Novartis, Pfizer

Disclosure of Interests

Kirsten Minden Speakers bureau: Pfizer, Novartis, Consultant of: Pfizer, Novartis, Martina Niewerth: None declared, Susanne Schalm: None declared, Ivan Foeldvari: None declared, Johannes-Peter Haas: None declared, Gerd Horneff: None declared, Daniel Windschall Speakers bureau: Pfizer, Novartis, Abbvie, Medac, Sobi, Canon, Grant/research support from: Pfizer, Novartis, Abbvie, Medac, Sobi, Canon, Tilmann Kallinich: None declared, Frank Dressler: None declared, Frank Weller-Heinemann: None declared, Rainer Berendes: None declared, Toni Hospach Consultant of: SOBI, Novartis, Markus Hufnagel: None declared, Maria Haller: None declared, Sandra Hansmann: None declared, Jens Klotsche: None declared

POS1202 EXPERIENCE WITH COVID-19 IN GERMAN PAEDIATRIC RHEUMATOLOGY CENTRES

Background:

COVID-19 is a major challenge worldwide. Although the risk for a severe disease course is low among children with COVID-19, symptoms may be exacerbated by underlying disease and/or immunosuppressive medication. We analysed clinical data from COVID-19 cases in among pediatric patients with juvenile idiopathic arthritis (JIA) in Germany reported to the BIKER registry.

Objectives:

This is an analysis of clinical data for 56 COVID-19 cases reported to the German BIKER registry from 29 German pediatric rheumatology centers and clinics from February 2020 to January 2021.

Methods:

The major task of the German BIKER (Biologics in Paediatric Rheumatology) Registry is surveillance of biologics used in pediatric rheumatology patients. Following the start of the COVID-19 pandemic in Germany, a survey was established to proactively interview all participating centers regarding the occurrence, presentation and outcome of SARS-CoV-2-infected children with rheumatic diseases. Initially, the interviews were conducted in weekly intervals, later bi-weekly.

A standardized Adverse Event of Special Interest form was developed requesting biographic data, pre-treatment, current medication, data on clinical presentation, course, treatment and outcome of COVID-19 pediatric rheumatology patients.

Results:

In all, 56 patients with JIA and SARS-CoV-2 infection were reported (Table 1). Of these patients, 71% were 12 or more years old.

Table 1.

Patient characteristics. COVID-19 positive patients.

JIA patients, n=56n (%)Age 0-5 years / 6-11years / 12-18years3 (5.4) / 13 (23.2) / 40 (71.4)JIA category•Systemic JIA5 (8.9)•Oligoarthritis JIA9 (16)•Polyarticular JIA32 (57)•Enthesitis-related JIA2 (3.6)•Psoriatic JIA1 (1.8)•Unknown7 (12.5)Uveitis (concomitant)4 (7.1)Treatment•DMARD / MTX23/ 22 (41/39)•Biologics29 (52)•TNF inhibitors20 (36)•Tocilizumab5 (8.9)•Abatacept1 (1.8)•Anakinra1 (1.8)•Ustekinumab1 (1.8)•JAK inhibitors1 (1.8)•Steroids5 (8.9)Asymptomatic13 (23.2)Hospitalized/ICU/Ventilation/Death1/1/1/1 (1.8)

At the time of infection, 41% of the patients received conventional DMARDs and 52% received biologics (Table 1). Forty-four patients (79%) received either a conventional DMARD or a biologic. Most patients had a polyarticular course of their JIA (57%).

In 49 of the 56 cases (88%) COVID-19 was detected directly by PCR (n=46), by antigen test only (n=1) or an undisclosed method (n= 2). Six patients had detectable SARS-CoV2 antibodies and reported to have had typical symptoms. One patient tested negative but developed typical symptoms at approximately the same time a positive SARS-CoV-2 test was returned for a family member.

Symptoms were reported in 43 of the 56 patients (77%): fever n=15, rhinitis n=14, cough n=12, headache n=10, loss of sense of taste and/or smell n=9, pharyngitis n=8, fatigue n=5, musculoskeletal pain n=5, GI symptoms n=2 (abdominal pain n=1, diarrhoea n=1), dizziness n=3, encephalitis/seizure/respiratory failure/death n=1. Thirteen patients (23%) were asymptomatic.

A 3½ -year-old female patient initially diagnosed with systemic JIA developed intracranial oedema and respiratory failure. Her SARS-CoV2 PCR test was positive and pulmonary imaging displayed typical changes in lung texture. Before her SARS-CoV-2 infection, the patient was treated with methotrexate and low-dose steroids. Unfortunately, she died three days following hospital admission. Genetic testing revealed an inborn immunodeficiency. Except for this one patient, all other cases were treated as outpatients and no deaths were reported.

Conclusion:

Apart from one patient with an inborn immunodeficiency who died from her COVID-19 infection, no case of hospitalization or severe COVID-19 was reported in our cohort of JIA patients. At the time of COVID-19 diagnosis, nearly 80% of patients in our cohort had been treated with conventional DMARD and/or biologics. This seemed not to have a negative effect on severity or outcome of SARS-CoV2 infection.

Acknowledgements:

Thanks also for contributing Reports for this analysis to: Normi Brück, Frank Dressler, Ivan Foeldvari, Tilman Geikowski, Hermann Girschick, Johannes-Peter Haas, Tilmann Kallinich, Bernd-Ulrich Keck, Eggert Lilienthal, Anna-Hedrich Müller, Ulrich Neudorf, Nils Onken, Peggy Rühmer.

Disclosure of Interests:

None declared.

0582 Examining OSA Screening and Treatment for Individuals on a PTSD and Alcohol Disorder Residential Treatment Unit

Introduction

Obstructive sleep apnea (OSA) is highly co-occurring with both alcohol use disorder (AUD) and posttraumatic stress disorder (PTSD) and has been shown to interfere with both PTSD and AUD outcomes. However, OSA often goes undiagnosed and untreated in residential treatment facilities. Our study aimed to assess the feasibility of incorporating OSA screening and treatment onto a substance abuse residential rehabilitation treatment program (SARRTP). Further, we examine the relationship between adherence rates of CPAP on PTSD outcomes.

Methods

Participants were 35 consecutive veterans admitted to the SARRTP PTSD track who consented to screening. Veterans were on the unit for 4-6 weeks. OSA was diagnosed using Nox T3 recorders, a Type-3 portable OSA screener (using Apnea Hypopnea Index >= 5). Insomnia Severity Index and PTSD checklist were given at pre- and post-treatment.

Results

64.7% of Veterans screened positive for OSA. 11.8% were previously diagnosed with OSA, but did not use a CPAP machine; 17.6% were previously diagnosed and were using a CPAP machine; and 35.3% were newly diagnosed with OSA. Individuals with untreated OSA had significantly more days drinking in the last 30 days (M = 21.17 days, SD = 11.41) compared to no OSA/Treated OSA group (M = 8.82 days, SD = 10.92). There was no difference in change in PCL scores from baseline to post-treatment by the no-OSA/high compliance group and the low compliance group.

Conclusion

Taken together, OSA screening on the unit was accepted by the participants, feasible, and effective in diagnosing OSA. OSA screening and treatment should be considered as necessary on SUD and PTSD units. We did not find that OSA adherence predicted change in PTSD score, this is most likely due to veterans receiving their CPAP late into their stay on the unit. Future studies will need to examine OSA treatment on long term treatment outcomes.

Support: Support

This work is supported by UCSD Academic Senate Grant and a Veterans Affairs RR&D CDA (1lK2Rx002120-01) to Peter Colvonen.

Trauma related guilt cognitions partially mediate the relationship between PTSD symptom severity and functioning among returning combat veterans

Trauma related guilt, a distressing emotion associated with negative cognitions regarding one's actions or inaction during a traumatic event, is common among individuals with posttraumatic stress disorder (PTSD). We hypothesized that trauma related guilt cognitions would partially explain the relationship between PTSD symptom severity and functioning. The sample consisted of 254 combat veterans or active duty military personnel who served in Operation Enduring Freedom, Operation Iraqi Freedom or Operation New Dawn (OEF/OIF/OND) who consented to participate in a larger PTSD treatment study. Results revealed a significant relationship between PTSD severity and guilt cognitions (standardized β = 0.40), as well as PTSD and overall functioning (β = 0.49). Guilt cognitions (β's = 0.13 to 0.32) were significantly associated with nearly all domains of functioning, including overall functioning (β = 0.27), and partially explained the relationship between PTSD and functioning. This study lends support to the addition of guilt as a symptom of PTSD in the DSM-5 as it contributes significantly to functional impairment even when accounting for other symptoms of PTSD, although co-occurring mental health problems may also contribute to functional impairments associated with PTSD. Future studies are needed to investigate whether reductions in traumatic guilt are related to improved functional outcomes in PTSD treatments.

A Framework for (Tele-) Monitoring of the Rehabilitation Progress in Stroke Patients: eHealth 2015 Special Issue

BACKGROUND

Preservation of mobility in conjunction with an independent life style is one of the major goals of rehabilitation after stroke.

OBJECTIVES

The Rehab@Home framework shall support the continuation of rehabilitation at home.

METHODS

The framework consists of instrumented insoles, connected wirelessly to a 3G ready tablet PC, a server, and a web-interface for medical experts. The rehabilitation progress is estimated via automated analysis of movement data from standardized assessment tests which are designed according to the needs of stroke patients and executed via the tablet PC application.

RESULTS

The Rehab@Home framework's implementation is finished and ready for the field trial (at five patients' homes). Initial testing of the automated evaluation of the standardized mobility tests shows reproducible results.

CONCLUSIONS

Therefore it is assumed that the Rehab@Home framework is applicable as monitoring tool for the gait rehabilitation progress in stroke patients.

Obesity in Youth with Type 1 Diabetes in Germany, Austria, and the United States

OBJECTIVE

To examine the current extent of the obesity problem in 2 large pediatric clinical registries in the US and Europe and to examine the hypotheses that increased body mass index (BMI) z-scores (BMIz) are associated with greater hemoglobin A1c (HbA1c) and increased frequency of severe hypoglycemia in youth with type 1 diabetes (T1D).

STUDY DESIGN

International (World Health Organization) and national (Centers for Disease Control and Prevention/German Health Interview and Examination Survey for Children and Adolescents) BMI references were used to calculate BMIz in participants (age 2-<18 years and ≥ 1 year duration of T1D) enrolled in the T1D Exchange (n = 11,435) and the Diabetes Prospective Follow-up (n = 21,501). Associations between BMIz and HbA1c and severe hypoglycemia were assessed.

RESULTS

Participants in both registries had median BMI values that were greater than international and their respective national reference values. BMIz was significantly greater in the T1D Exchange vs the Diabetes Prospective Follow-up (P < .001). After stratification by age-group, no differences in BMI between registries existed for children 2-5 years, but differences were confirmed for 6- to 9-, 10- to 13-, and 14- to 17-year age groups (all P < .001). Greater BMIz were significantly related to greater HbA1c levels and more frequent occurrence of severe hypoglycemia across the registries, although these associations may not be clinically relevant.

CONCLUSIONS

Excessive weight is a common problem in children with T1D in Germany and Austria and, especially, in the US. Our data suggest that obesity contributes to the challenges in achieving optimal glycemic control in children and adolescents with T1D.

Intradermal alpha1-antitrypsin therapy avoids fatal anaphylaxis, prevents type 1 diabetes and reverses hyperglycaemia in the NOD mouse model of the disease

AIMS/HYPOTHESIS

Human alpha1-antitrypsin (hAAT) gene therapy prevents type 1 diabetes in a NOD mouse model of diabetes. However, repeated i.p. injections of hAAT into NOD mice leads to fatal anaphylaxis. The aim of the study was to determine if an alternative route of administration avoids anaphylaxis and allows evaluation of hAAT's potential for diabetes prevention and reversal. We also sought to determine if the addition of granulocyte colony-stimulating factor (G-CSF), augments hAAT's capacity to prevent or reverse disease in the NOD mice.

METHODS

To evaluate hAAT pharmacokinetics, serum hAAT levels were monitored in NOD mice receiving a single dose (2 mg) of hAAT by i.p., s.c. or i.d. injection. For studies of type 1 diabetes prevention and reversal, mice received i.d. hAAT (2 mg/mouse/3 days) for 8 or 10 weeks or hAAT and G-CSF (i.p., 6 microg/day) for 6 weeks. Blood glucose determinations, glucose tolerance testing and insulin tolerance tests were performed.

RESULTS

Both i.p. and s.c. injections resulted in fatal anaphylaxis. The i.d. injection avoided anaphylaxis and i.d. injection of hAAT into 11-week-old NOD mice prevented disease (p = 0.005, AAT vs PBS at 40 weeks of age). Treatment of diabetic NOD mice with hAAT or hAAT plus G-CSF provided long-term (at least 100 days) reversal of diabetes in 50% of treated animals. G-CSF did not enhance the reversal rates of hAAT. Glucose tolerance and insulin levels were normalised in mice with hAAT prevention and reversal.

CONCLUSIONS/INTERPRETATION

Intradermal hAAT prevents and reverses disease in a NOD mouse model of type 1 diabetes without inducing anaphylaxis.

Loss of RAF kinase inhibitor protein is a somatic event in the pathogenesis of therapy-related acute myeloid leukemias with C-RAF germline mutations

We recently described oncogenic and anti-apoptotic C-RAF germline mutations in patients with therapy-related acute myeloid leukemia (t-AML). Activation of the RAF effector ERK was restricted to transformed cells, suggesting the requirement for cooperating events in leukemogenesis. Western blot analysis of blast cells from patients with C-RAF germline mutations revealed loss of the tumor and metastasis suppressor RAF kinase inhibitor protein (RKIP). Immunohistochemistry of the patients' primary tumors revealed normal RKIP expression levels, indicating that the loss of RKIP is a somatic, t-AML-specific event. In focus formation assays, the oncogenic potential of human mutant C-RAF was strongly influenced by expression levels of RKIP. Although the number of colonies formed by C-RAF(S427G) was significantly increased by RKIP silencing, the opposite was observed after RKIP overexpression. These results show that the loss of RKIP is a functional somatic event in carriers of C-RAF germline mutations, which contributes to the development of t-AML.

Dissoziativer Stupor als Ursache f�r postoperative Bewusstlosigkeit

A 31-year-old woman failed to awaken after an uneventful general anesthesia (propofol, alfentanil and 65% N2O in oxygen) for laparoscopic resection of an ovarian cyst. After the operation she was extubated and vital signs were stable. However, the patient remained unresponsive even to painful stimuli for about 2 h. Just before we performed a computed tomogram of the brain to exclude a cerebral lesion we noticed that she blinked. We hypothesized that unconsciousness was due to a dissociative stupor. After administration of sublingual lorazepam the patient woke up promptly and was alert and normal for the rest of the hospital stay. In conclusion, after exclusion of a pharmacological or organic cause for postoperative unconsciousness, dissociative stupor may be a reason for apparent coma after general anesthesia.

Recurrent fever as the only or predominant clinical sign in four dogs and one cat with congenital portosystemic vascular anomalies

Fever is not considered a typical clinical sign in animals with portosystemic vascular anomalies (PSVA). In a time period of 8 years, PSVA was diagnosed in 23 cases (20 dogs, 3 cats) at the Animal Hospital of the University of Zurich. Of these, recurrent fever was the only, the predominant or an early sign in 5 animals. Fever and associated unspecific clinical signs like lethargy, inappetence, and reluctance to move were present for weeks to months before the final diagnosis of PSVA was made. It was the lack of typical and well-known signs of PSVA that obscured and delayed the diagnosis. Therefore, PSVA should be included in the differential diagnosis of animals with fever of unknown origin (FUO).

Single-injection inulin clearance for routine measurement of glomerular filtration rate in cats

Glomerular filtration rate (GFR) was determined in 53 cats using an inulin single-injection method. Thirty healthy young adult cats were used to establish normal values. The procedure was also used in 23 cats that were either older than 10 years or had borderline serum creatinine levels. The total clearance was calculated from the decay of the serum inulin concentration after injection of 3000 mg/m(2)body surface area using a two-compartment model. Concomitant inulin and iohexol clearance in nine cats showed excellent correlation between the two methods. Calculated normal values for GFR in 30 healthy cats were 35.9-58.5 (median 46.0) ml/min/m(2)or 2.07-3.69 (median 2.72) ml/min/kg. A few cats with normal creatinine or blood urea nitrogen levels were detected as having reduced GFR and therefore being in a state of early renal dysfunction. The study indicates that single-injection inulin clearance is a valuable tool for routine GFR measurement in cats. An "inulin excretion test" using only one blood sample 3h after the administration of 3000 mg/m(2)body surface area could prove an attractive alternative for the assessment of renal function in daily practice.

How farmers in Switzerland perceive fertilizers from recycled anthropogenic nutrients (urine)

We studied acceptance of a urine-based fertilizer product using a mail survey of 467 Swiss farmers. We distinguished among four production types: organic or IP farming, and with or without vegetable production. Considering that the idea of urine-based fertilizers is new, acceptance among the answering farmers was surprisingly high, with 57% explicitly stating that they thought it was a good or very good idea, and 42% willing to purchase such a product. The farmers of different production types did not differ strongly in their attitude towards urine-based fertilizers. Especially IP and vegetable farmers, who purchased additional fertilizers anyway, seem willing to accept urine-based fertilizers, hereby preferring a grainy, odorless ammonium nitrate fertilizer. Absolutely essential is a hazard-free product: 30% of all farmers had concerns regarding micropollutants. Based on fertilizer data, we demonstrate an existing demand for the nutrients N, P, and K in Switzerland, which could be partially substituted by a recycled urine product. Finally, we discuss methodological requirements of social science surveys. To obtain representative data on an entire population in a mail survey, multiple contacts with respondents are necessary. We argue that information and participation of stakeholders at an early stage is essential for successful technology transfer.

Continuous cardiac output measurements do not agree with conventional bolus thermodilution cardiac output determination

PURPOSE

To evaluate the performance of two different continuous cardiac output monitoring systems based on the thermodilution principle in critically ill patients.

METHODS

Nineteen cardiac surgical patients were randomly assigned to continuous cardiac output monitoring using one of the two systems under study (group I, IntelliCath(TM) catheter, n=9; group II, Opti-Q(TM) catheter, n=10). Each patient was studied over a period of three hours. Conventional bolus thermodilution cardiac output measurements were carried out every 15 min leading to 13 measurements in each patient. The continuous cardiac output values were compared with the bolus thermodilution measurements. Bias (mean difference between continuous and bolus thermodilution) and precision (SD of differences) were calculated as a measure of agreement between the respective continuous method and conventional bolus thermodilution.

RESULTS

The range of measured cardiac outputs was 3.8-15.4 L*min(-1) (IntelliCath(TM)) and 3.5-8.3 L*min(-1) (OptiQ(TM)). Bias and precision was 0.06 +/- 0.76 L*min(-1) (IntelliCath(TM)) and -0.04 +/- 0.74 L*min(-1) (OptiQ(TM)), respectively. There was no difference in bias between the two systems (P=0.38). +/- 2 SD of the differences (i.e., 95% of the differences) did not fall within the predetermined limits of agreement of +/- 0.5 L*min(-1).

CONCLUSIONS

There was no difference between the two systems regarding the agreement with conventional bolus thermodilution as the standard. A discrepancy between bolus and continuous thermodilution cardiac output measurement techniques above the clinically acceptable limits suggest that they are not interchangeable.

Dynamic activation of K(ATP) channels in rhythmically active neurons

1. The respiratory centre within the brainstem is one of the most active neuronal networks that generates ongoing rhythmic activity. Stabilization of such vital activity requires efficient processes for activity-correlated adjustment of neuronal excitability. Recent investigations have shown that a regulatory factor coupling electrical activity with cell metabolism comprises ATP-dependent K(+) channels (K(ATP) channels), which continuously adjust the excitability of respiratory neurons during normoxia and increasingly during hypoxia. 2. We used the single-cell antisense RNA amplification-polymerase chain reaction (PCR) technique to demonstrate that respiratory neurons co-express the sulphonylurea receptor SUR1 with the Kir6.2 potassium channel protein. 3. Single channel measurements on rhythmically active inspiratory neurons of the brainstem slice preparation of newborn mice revealed that K(ATP) channels are periodically activated in synchrony with each respiratory cycle. 4. The Na(+)-K(+)-ATPase was inhibited with ouabain to demonstrate that oscillations of the channel open probability disappear, although respiratory activity persists for a longer time. Such findings indicate that K(ATP) channel open probability reflects activity-dependent fluctuations in the ATP concentration within submembrane domains. 5. We also examined the effects of extracellular [K(+)] and hypoxia. All changes in the respiratory rhythm (i.e. changes in cycle length and burst durations) affected the periodic fluctuations of K(ATP) channel activity. 6. The data indicate that K(ATP) channels continuously modulate central respiratory neurons and contribute to periodic adjustment of neuronal excitability. Such dynamic adjustment of channel activity operates over a high range of metabolic demands, starting below physiological conditions and extending into pathological situations of energy depletion.

Changes in blood volume and hematocrit during acute preoperative volume loading with 5% albumin or 6% hetastarch solutions in patients before radical hysterectomy

BACKGROUND

The impact of acute preoperative volume loading with colloids on blood volume has not been investigated sufficiently.

METHODS

Before surgery, in 20 patients undergoing major gynecologic procedures, volume loading was performed during anesthesia by infusing approximately 20 ml/kg of colloid at a rate of 90 ml/min (group I: 5% albumin solution; group II: 6% hetastarch solution; n = 10 each). Plasma volume (indocyanine green dilution technique), erythrocyte volume (labeling erythrocytes with fluorescein), hematocrit, total protein, and hetastarch plasma concentrations (group II) were measured before and 30 min after the end of infusion.

RESULTS

More than 1,350 ml of colloid (approximately 50% of the baseline plasma volume) were infused within 15 min. Thirty minutes after the infusion had been completed, blood volume was only 524 +/- 328 ml (group I) and 603 +/- 314 ml (group II) higher than before volume loading. The large vessel hematocrit (measured by centrifugation) dropped more than the whole body hematocrit, which was derived from double-label measurements of blood volume.

CONCLUSIONS

The double-label measurements of blood volume performed showed that 30 min after the infusion of approximately 20 ml/kg of 5% albumin or 6% hetastarch solution (within 15 min), only mean 38 +/- 21% and 43 +/- 26%, respectively, of the volume applied remained in the intravascular space. Different, i.e., earlier or later, measuring points, different infusion volumes, infusion rates, plasma substitutes, or possibly different tracers for plasma volume measurement might lead to different results concerning the kinetics of fluid or colloid extravasation.

[The measurement of blood volume--state-of-the-art]

The term blood volume (BV) measurement can be understood as the exact volumetric definition of both components of blood, the red cell volume (RCV) and the plasma volume (PV) using tracer dilution methods. The tracer used to measure the RCV must be bound to the erythrocytes and for the PV to plasma proteins, in order to label the distribution space of each carrier (i.e. erythrocytes and albumin molecules). To differentiate this there are indirect methods to estimate the BV, such as measurement of the diastolic pressure or transoesophageal echocardiography, which will not be discussed here. Alterations in the RCV and PV cannot be routinely measured, or at most only roughly estimated by means of the haematocrit (Hc) or haemoglobin (Hb) concentration which can lead to serious errors when large changes have occurred. At present measurements of the RCV and PV are not carried out in routine clinical practice. The introduction of nonradioactive tracers with a faster elimination now renders possible a relatively exact measurement of both volumes under certain clinical situations, albeit with a high technical outlay. The RCV is measured using the tracer sodium fluorescein (SoF) and the PV with the dye indocyanine green (ICG). The RCV measurement seems to be suitable for certain clinical situations, such as characterization of the preoperative condition of a patient or quantification of surgical blood loss after an operation, because it is less invasive and has a high precision. However, the results of the RCV measurement can only be delivered after 1 h which makes it more suitable for clinically stable situations. In contrast the PV estimation is based on the measurement of the ICG concentration in the arterial bloodstream after a bolus injection of the dye in the central veins and is used more in intensive care because of the invasivity. The results can be obtained 5 min after injection of the dye and therefore even rapid changes in the PV can be monitored.

[Quantification of position-related errors in measurement of antetorsion of the femur with computerized tomography--introduction of a method for positional correction]

OBJECTIVE

To quantify the influence of patient positioning on the determination of collodiaphyseal (CCD) angle and femoral neck anteversion based on computed tomography. Description of a method for positional correction.

METHODS

We evaluated the CT scans of 84 femora from 77 patients, who received individually adapted prostheses. Projected as well as real anteversion and CCD angles were determined and corrected for positioning errors using a newly proposed mathematical method, and compared to other evaluation methods.

RESULTS AND CONCLUSIONS

We determined an average tilt of 4.2 degrees in the sagittal and of 9 degrees in the coronary plane, which correlated definitely with the deviations found in the graphical determination of the projected anteversion angle. This produced measurement errors of the projected anteversion angle of up to 10 degrees. Mathematically independent angles, such as projected anteversion and real CCD angle, showed only a weak correlation. This indicates also an anatomical independence of these angles.

Intrinsic optical signals in respiratory brain stem regions of mice: neurotransmitters, neuromodulators, and metabolic stress

In the rhythmic brain stem slice preparation, spontaneous respiratory activity is generated endogenously and can be recorded as output activity from hypoglossal XII rootlets. Here we combine these recordings with measurements of the intrinsic optical signal (IOS) of cells in the regions of the periambigual region and nucleus hypoglossus of the rhythmic slice preparation. The IOS, which reflects changes of infrared light transmittance and scattering, has been previously employed as an indirect sensor for activity-related changes in cell metabolism. The IOS is believed to be primarily caused by cell volume changes, but it has also been associated with other morphological changes such as dendritic beading during prolonged neuronal excitation or mitochondrial swelling. An increase of the extracellular K(+) concentration from 3 to 9 mM, as well as superfusion with hypotonic solution induced a marked increase of the IOS, whereas a decrease in extracellular K(+) or superfusion with hypertonic solution had the opposite effect. During tissue anoxia, elicited by superfusion of N(2)-gassed solution, the biphasic response of the respiratory activity was accompanied by a continuous rise in the IOS. On reoxygenation, the IOS returned to control levels. Cells located at the surface of the slice were observed to swell during periods of anoxia. The region of the nucleus hypoglossus exhibited faster and larger IOS changes than the periambigual region, which presumably reflects differences in sensitivities of these neurons to metabolic stress. To analyze the components of the hypoxic IOS response, we investigated the IOS after application of neurotransmitters known to be released in increasing amounts during hypoxia. Indeed, glutamate application induced an IOS increase, whereas adenosine slightly reduced the IOS. The IOS response to hypoxia was diminished after application of glutamate uptake blockers, indicating that glutamate contributes to the hypoxic IOS. Blockade of the Na(+)/K(+)-ATPase by ouabain did not provoke a hypoxia-like IOS change. The influences of K(ATP) channels were analyzed, because they contribute significantly to the modulation of neuronal excitability during hypoxia. IOS responses obtained during manipulation of K(ATP) channel activity could be explained only by implicating mitochondrial volume changes mediated by mitochondrial K(ATP) channels. In conclusion, the hypoxic IOS response can be interpreted as a result of cell and mitochondrial swelling. Cell swelling can be attributed to hypoxic release of neurotransmitters and neuromodulators and to inhibition of Na(+)/K(+)-pump activity.

Molecular characterization of a cellulase-negative mutant of Hypocrea jecorina

The "cbh2 activating element," CAE, consisting of two separate boxes (ATTGG = CCAAT and GTAATA, respectively) is essential for cellobiohydrolase II gene expression in the filamentous fungus Hypcrea jecorina. Here we report that cell-free extracts from a cellulase-negative mutant form CAE-protein complexes with higher mobility and lower binding-strength compared to the wild type. EMSA analysis demonstrated an increased mobility of the GTAATA-binding protein complex and, supported by in vivo footprinting, a lowered binding strength of the HAP2/3/5 proteins. However, the hap2/hap3/hap5 genes of the mutant are unaltered and transcribed normally. A nucleotide fragment of the cbh1 promoter containing a (GG)CTAATA motif without an adjacent CCAAT box is also bound by cell-free extracts of H. jecorina, and the protein-DNA complex of the mutant shows the characteristic increase in mobility. We conclude that this mutant is defective in the functional formation of the CAE-protein complexes but not in their binding to the target sequences itself.

Liver transplantation in primary biliary cirrhosis: risk assessment and 11-year follow-up

BACKGROUND/AIMS

Liver transplantation (LTx) is the only established treatment in patients with end-stage primary biliary cirrhosis (PBC). Although short-term survival after LTx in this group of patients is usually good, few data exist on the long-term survival. The optimal timing of transplantation is difficult. Thus, the aims of this study were to assess the long-term survival of patients with PBC after LTx and to identify potential predictive factors for a positive outcome.

METHODS

Survival of 28 patients with PBC who underwent LTx between 1985 and July 1999 in a single center was studied by Kaplan-Meier analysis and was compared to predicted survival without LTx using established prognostic models for PBC, the Mayo and European risk scores. Potential prognostic parameters obtained before LTx were tested for correlation to survival. Rates of bone fractures as markers of hepatic osteodystrophy were compared before and after LTx.

RESULTS

Median follow-up after LTx was 90 months with a maximum of 140 months. Actuarial survival of patients with PBC was 89% after 1, 5, and 10 years and was significantly better than estimated survival without LTx after 1-7 years as calculated by the Mayo and European risk scores. Of several parameters tested, only serum bilirubin and the prognostic scores, but no other liver function tests obtained immediately prior to transplantation were significantly correlated with survival after LTx. The duration of intensive care after LTx was not associated with any parameters obtained before LTx. Bone fractures were diagnosed in 43% of patients of whom the vast majority were osteopenic before LTx as determined by osteodensitometry.

CONCLUSION

Long-term survival of a well-defined group of patients with PBC was excellent after LTx and was inversely correlated with preoperative serum bilirubin levels as well as Mayo and European risk scores.

Pulmonary function and health-related quality of life in a sample of long-term survivors of the acute respiratory distress syndrome

OBJECTIVE

We performed a follow-up cohort analysis in order to delineate the correlation between pulmonary function (PF) and health-related quality of life (HRQL) in patients after ARDS.

DESIGN

Follow-up cohort study.

SETTING

A 20-bed ICU of a university teaching hospital.

PATIENTS

A cohort of 50 long-term survivors of ARDS.

MEASUREMENTS AND RESULTS

Measurements of PF (FVC, FEV1, TLC, D(LCO)) and HRQL (SF-36 Health Status Questionnaire) were made 5.5 years (median value) after discharge from the ICU. Impairments in PF (defined as PF results below 80% of the predicted value) were frequent but generally mild. Twenty patients had a single PF impairment (with limitations in FEV1/FVC ratio in 12 patients being the most common), four patients had two (with D(LCO) and FEV1/FVC ratio impairment the most common) and three patients had pathologic results in three PF tests (FEV1/FVC ratio, TLC and capillary pO2 during exercise in one case, FVC, TLC and capillary pO2 during exercise in the second patient and FVC, TLC and D(LCO) in the third). Compared to normal controls, survivors of ARDS showed impairments in all SF-36 health dimensions (p < 0.001). Patients with multiple (> 1) PF impairments described the lowest HRQL with major limitations in all SF-36 categories (p < 0.037) including physical and mental summary scores (36.5 vs 46.9, p = 0.037 and 31.3 vs 51.4, p = 0.003) when compared to patients with no or only one PF impairment.

CONCLUSIONS

Long-term survivors of ARDS have a significant reduction in HRQL and the presence of multiple PF impairments is associated with maximal decrements in HRQL.

Development of a knowledge-base for automatic monitoring of renal function of intensive care patients over time

Renal dysfunction is a major problem in the management of critically ill patients. Monitoring of renal parameters over time is a prerequisite for detection of any significant deterioration of kidney function. Thus, we developed a knowledge-base for the dynamic monitoring of renal function of critically ill patients. A database with renal parameters of 750 intensive care patients was analyzed for distribution of parameters within predefined intervals of the creatinine clearance. Additionally, a subgroup of 11 patients with (quite) normal renal function over 11 days was selected and the daily variability of renal parameters was analyzed. An interdisciplinary expert team selected a set of nine clinically relevant renal parameters and formulated, on the basis of the data analysis and the parameter set, eight definitions of renal function, which represent four levels of renal performance. These definitions were arranged into an hierarchical structure, considering only clinically relevant changes of renal function. A change from one functional state to another inside of 2 days indicates a relevant alteration of renal function. Monitoring of time courses can additionally be performed by statistical analysis of the daily variability of parameters and comparison with their 'normal' variability. Moreover, rules were established for the plausibility check of results and interpretations of single parameters and parameter sets formulated.

[Acute kidney failure. Physiopathology--clinical diagnosis--therapy]

Acute renal failure (ARF) is characterized by an acute decrease in glomerular filtration rate (GFR). ARF complicates 4% to 23% of intensive care unit admissions, and is associated with a mortality of approximately 50% among critically ill patients. In the intensive care setting the term ARF is usually applied to acute tubular necrosis (ATN), a form of intrinsic ARF caused by ischemia or nephrotoxins. Pathophysiological mechanisms involved in the decline in GFR include tubular obstruction caused by detachment of tubular epithelial cells from the basement membrane and back-leak of glomerular filtrate as a consequence of disruption of the epithelial cell layer. Vascular mechanisms involved in the pathophysiology of ATN are vasoconstriction due to an imbalance between vasoconstrictive and vasodilatory mediators and vascular obstruction caused by cell aggregation. Currently, there is no real time method to monitor renal function comparable to the real time monitoring of blood pressure or arterial oxygen saturation. Urinary output does not reflect glomerular filtration which may be critically reduced despite normal urine volumes and creatinine clearance still provides the clinically most applicable estimate of GFR. Tubular function can be assessed using the fractional excretion of sodium or the ratio of urinary and serum osmolality; both parameters can be obtained from spot samples of urine and serum and no urinary sampling period is necessary. However, both parameters are strongly affected by the administration of loop diuretics and high fluid and sodium inputs which are common in the intensive care unit. We determined the day to day variability of creatinine clearance, fractional excretion of sodium and the urinary to serum osmolality ratio in critically ill patients without renal dysfunction (i.e. creatinine clearance in the normal range) and found differences of 16% for creatinine clearance, 79% for fractional excretion of sodium and 22% for urinary to serum osmolality ratio. Treatment of ARF is mainly supportive and there is no clinically accepted therapy that attenuates the course of ATN. Treatment of the underlying disease and renal replacement therapy are the main options for the treatment of patients with ARF. In critically ill patients continuous venovenous hemo(dia)filtration is the first choice because it provides more hemodynamic and metabolic stability than intermittent therapy. Acute life-threatening hyperkalemia is an indication for intermittent hemodialysis because of the higher efficacy of dialysis in the clearance of low molecular weight substances.

Beat-to-beat measurement of cardiac output by intravascular pulse contour analysis: a prospective criterion standard study in patients after cardiac surgery

OBJECTIVE

To evaluate the accuracy of a new pulse contour method of measuring cardiac output in critically ill patients.

DESIGN

A prospective criterion standard study.

SETTING

Cardiac surgery intensive care unit in a university hospital.

PARTICIPANTS

Nineteen cardiac surgery patients requiring intensive care treatment with pulmonary artery catheters after surgery.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The pulse contour cardiac output monitor uses transpulmonary bolus thermodilution measurements to calibrate the system. In each patient, the pulse contour cardiac output values were compared with conventional thermodilution. The method described by Bland and Altman and linear regression analysis were used for comparison. The mean difference (bias) +/- standard deviation of differences (precision) was 0.31 +/- 1.25 L/min for pulmonary bolus thermodilution cardiac output versus pulse contour cardiac output and 0.21 +/- 0.73 L/min for pulmonary bolus thermodilution cardiac output versus transpulmonary bolus thermodilution cardiac output. Linear regression (correlation) analyses were pulse contour cardiac output = 0.97 thermodilution + 0.53 (r = 0.88), and transpulmonary cardiac output = 0.87 thermodilution + 1.09 (r = 0.96). There was a small increase 60 minutes after recalibration but not a statistically significant difference between pulse contour cardiac output and pulmonary bolus thermodilution cardiac output (p = 0.52).

CONCLUSIONS

Bias and precision are acceptable, and the system provides results that agree with conventional thermodilution. This study demonstrates the clinical applicability of the pulse contour cardiac output monitoring system.

Changes in intravascular volume during acute normovolemic hemodilution and intraoperative retransfusion in patients with radical hysterectomy

BACKGROUND

Changes in blood volume during acute normovolemic hemodilution (ANH) and their consequences for the perioperative period have not been investigated sufficiently.

METHODS

In 15 patients undergoing radical hysterectomy, preoperative ANH to a hematocrit of 24% was performed using 5% albumin solution. Intraoperatively, saline 0.9% solution was used for volume substitution, and intraoperative retransfusion was started at a hematocrit of 20%. Plasma volume (indocyanine green dilution technique), hematocrit, and plasma protein concentration were measured before and after ANH, before retransfusion, and postoperatively. Red cell volume (labeling erythrocytes with fluorescein) was determined before and after ANH and postoperatively.

RESULTS

Mean normal plasma volumes (1,514 +/- 143 ml/m2) and reduced red cell volumes (707 +/- 79 ml/m2) were measured preoperatively. Blood (1,150 +/- 196 ml) was removed and replaced with 1,333 +/- 204 ml of colloid. Blood volume before and after ANH was equal and amounted to 3,740 ml. Intraoperatively, plasma volume did not increase until retransfusion despite infusing 3,389 +/- 1,021 ml of crystalloid (corrected for urine output) to compensate for an estimated surgical blood loss of 727 +/- 726 mi. Postoperatively, after retransfusion of all autologous blood, blood volume was 255 +/- 424 ml higher than preoperatively before ANH. Despite mean calculated blood loss of 1,256 +/- 892 ml, only one patient received allogeneic blood.

CONCLUSIONS

During ANH, normovolemia was exactly maintained. After surgical blood loss of 1,256 +/- 892 ml, crystalloid and colloid supplies of 5,752 +/- 1,462 ml and 1,667 +/- 548 ml, respectively, and complete intraoperative retransfusions of autologous blood in every patient, mean blood volume was 250 ml higher than preoperatively before ANH.