Anti-BP180 autoantibody levels at diagnosis correlate with 1-year mortality rates in patients with bullous pemphigoid

BACKGROUND

Bullous pemphigoid (BP) is the most frequent autoimmune blistering disease mainly affecting elderly patients. Among several published risk factors, a recent post hoc analysis linked anti-BP180 autoantibodies (AABs) to fatal outcomes in BP. To date, this finding has not been confirmed independently.

OBJECTIVE

To investigate the potential of anti-BP180-AAB levels as a marker of prognosis and to identify a cut-off level indicative of an increased risk for early death. Secondly, to characterize parameters associated with mortality.

METHODS

Retrospective, single-centre study of BP patients diagnosed between 2001 and 2012. Analyses included epidemiological and patient- and disease-specific characteristics as well as immunological parameters at diagnosis and during follow-up. Standardized mortality ratios as well as uni- and multivariate regression analyses were calculated.

RESULTS

One hundred patients (56 women, 44 men) with a median age of 81 years (interquartile range 74-86) were followed up for a median of 775 days (interquartile range 162-1617). One-year mortality rates were 25.0% implying a 2.4-fold increased risk of death compared with the general population. High anti-BP180 autoantibody levels at diagnosis (CI₉₅ 1.30-2.89; P = 0.001), dementia (CI₉₅ 1.13-6.72; P =0.03), length of hospitalization (CI₉₅ 1.16-2.41; P = 0.01) and age (CI₉₅ 1.23-4.19; P = 0.009) correlated significantly with 1-year mortality. BP180-AAB concentrations of ≥61 U/mL characterized a subgroup of patients with a particular higher risk for early death compared with the general population (CI₉₅ 1.81-3.81; P < 0.0001).

CONCLUSION

In bullous pemphigoid, serum concentrations of BP180 autoantibodies at diagnosis could help to identify patients at risk for death within the first year after diagnosis (cut-off value 61 U/mL).

Tailored optical vector fields for ultrashort-pulse laser induced complex surface plasmon structuring

Precise tailoring of optical vector beams is demonstrated, shaping their focal electric fields and used to create complex laser micro-patterning on a metal surface. A Spatial Light Modulator (SLM) and a micro-structured S-waveplate were integrated with a picosecond laser system and employed to structure the vector fields into radial and azimuthal polarizations with and without a vortex phase wavefront as well as superposition states. Imprinting Laser Induced Periodic Surface Structures (LIPSS) elucidates the detailed vector fields around the focal region. In addition to clear azimuthal and radial plasmon surface structures, unique, variable logarithmic spiral micro-structures with a pitch Λ ∼1μm, not observed previously, were imprinted on the surface, confirming unambiguously the complex 2D focal electric fields. We show clearly also how the Orbital Angular Momentum(OAM) associated with a helical wavefront induces rotation of vector fields along the optic axis of a focusing lens and confirmed by the observed surface micro-structures.

Delay dynamics of semiconductor lasers with short external cavities: bifurcation scenarios and mechanisms

We present a comprehensive study of the emission dynamics of semiconductor lasers induced by delayed optical feedback from a short external cavity. Our analysis includes experiments, numerical modeling, and bifurcation analysis by means of computing unstable manifolds. This provides a unique overview and a detailed insight into the dynamics of this technologically important system and into the mechanisms leading to delayed feedback instabilities. By varying the external cavity phase, we find a cyclic scenario leading from stable intensity emission via periodic behavior to regular and irregular pulse packages, and finally back to stable emission. We reveal the underlying interplay of localized dynamics and global bifurcations.

Dynamics of semiconductor lasers subject to delayed optical feedback: the short cavity regime

We give experimental and numerical evidence for a new dynamical regime in the operation of semiconductor lasers subject to delayed optical feedback occurring for short delay times. This short cavity regime is dominated by a striking dynamical phenomenon: regular pulse packages forming a robust low-frequency state with underlying fast, regular intensity pulsations. We demonstrate that these regular pulse packages correspond to trajectories moving on global orbits comprising several destabilized fixed points within the complicated phase space structure of this delay system.

Chaos synchronization and spontaneous symmetry-breaking in symmetrically delay-coupled semiconductor lasers

We present experimental and numerical investigations of the dynamics of two device-identical, optically coupled semiconductor lasers exhibiting a delay in the coupling. Our results give evidence for subnanosecond coupling-induced synchronized chaotic dynamics in conjunction with a spontaneous symmetry-breaking: we find a well-defined time lag between the dynamics of the two lasers, and an asymmetric physical role of the subsystems. We demonstrate that the leading laser synchronizes its lagging counterpart, whereas the synchronized lagging laser drives the coupling-induced instabilities.

Statistical properties of low-frequency fluctuations during single-mode operation in distributed-feedback lasers: experiments and modeling

Extensive experimental and numerical investigations of feedback-induced instabilities in single-mode distributed-feedback lasers are presented that confirm the basic assumptions of the Lang-Kobayashi model. We give experimental evidence of the occurrence of low-frequency fluctuation (LFF), alternation between LFF and stable emission, and coherence collapse during single-mode operation of the laser. We have obtained quantitative agreement between modeling and experiment in long-time statistical investigations of the time intervals between subsequent LFF dropouts. In particular, we show that even the dependence of the dynamics on the injection current, which results in a scaling law, is quantitatively identical in modeling and experiment.

Life-cycle analysis of depot versus rehabilitation manual wheelchairs

The proper selection of a wheelchair requires making several critical decisions, not the least of which is what type of wheelchair is appropriate. The International Organization for Standards (ISO) continues to develop and refine wheelchair standards. Standards allow the objective comparison of products from various sources, permitting consumers or clinicians to assess wheelchairs with which they are not familiar by comparing test results. This study consisted of three components: 1) the comparison of fatigue test results with a planar ANSI/RESNA test dummy to a HERL contoured test dummy; 2) the comparison of fatigue test results for common depot versus common rehabilitation manual wheelchairs; and 3) the comparison of fatigue test results for manual rehabilitation wheelchairs with solid 8-inch casters versus those with pneumatic 8-inch casters. Rehabilitation wheelchairs lasted on average 13.2 times longer than the depot wheelchairs. Both types, tested with the standard ISO-ANSI/RESNA dummy, lasted on average 2.1 times longer than those wheelchairs tested using the contoured dummy. The three rehabilitation wheelchairs equipped with 8-inch pneumatic casters lasted on average 3.2 times longer than the 6 rehabilitation wheelchairs equipped with solid 8-inch casters. The depot wheelchairs cost about 3.4 times as much to operate per cycle or per meter than the rehabilitation wheelchairs. The rehabilitation wheelchairs tended to experience component failures, while the depot wheelchairs tended to experience frame failures. Our testing indicates that the tests in the ISO-ANSI/RESNA standards can relate design features to fatigue test results and durability. Rehabilitation wheelchairs tend to use higher quality materials and better manufacturing practices, and they provide greater mobility for wheelchair users. Purchasers and prescribers of wheelchairs should consider the life-cycle cost and not just the purchase price for wheelchairs.

[The relevance of CDT (carbohydrate-deficient transferrin). Preoperative diagnosis of chronic alcohol abuse in intensive care patients following elective tumor resection]

The increase of alcoholism-related problems is associated with vital postoperative clinical complications in chronic alcohol abusers. In particular, the alcohol withdrawal syndrome (AWS) may provoke potentially life-threatening complications in alcohol-dependent patients. Hence, a precise diagnosis of alcohol dependence is mandatory preoperatively, requiring an extensive case history using alcoholism-associated questionnaires. Additional new biological markers for detecting alcoholism could improve the accuracy of preoperative diagnosis. Carbohydrate-deficient transferrin (CDT) reflects increased alcohol consumption. The aim of our interdisciplinary study was to investigate whether the validity of the preoperative diagnosis of chronic alcohol abuse might be improved by measuring CDT. METHODS. A total of 45 patients from the departments of Otorhinolaryngology, Maxillofacial Surgery, and Abdominal and Thoracic Surgery were included in our prospective clinical study. Patients underwent resection of malignant oral, pharyngeal, laryngeal, or oesophageal tumours and were transferred to the intensive care unit for postoperative management. Routine preoperative history, examinations, and laboratory tests including GGT, MCV, ASAT, and ALAT, were supplemented by a specific alcohol-related questionnaire and CDT measurement. The patients were categorised in four groups based on history and the questionnaire: continuously abstinent subjects; sober subjects for at least 7 days; chronic abusers; and dependent subjects. CDT was separated by isocratic anion exchange chromatography and quantified by turbidimetric determination. Statistical analysis was performed by the Kruskal-Wallis test. RESULTS. Preoperatively, 21 patients were at major risk for alcoholism-related complications: 12 were chronic abusers and 9 were diagnosed as dependent. CDT was significantly increased in both groups, and was pathologically elevated in 16 of the 21 patients. Sampling occurred significantly long after the last alcohol intake in the 5 patients with normal CDT values (median: 6.0 days; range: 2-12 days) compared with the 16 with pathologically elevated CDT levels (median: 1.0 day; range: 0-4 days; P = 0.002). The sensitivity of CDT elevation was 16 out of 24 (76%), the specificity 16 out of 16 (100%). Sixteen patients had no previous history of alcohol consumption (sober for at least 7 days) and 8 were definitely abstinent. Both of these groups had normal CDT values. CONCLUSIONS. CDT was a sensitive and specific marker for chronic alcohol consumption in our patient population. Since CDT is a state marker, repeated determinations might be useful to estimate a patient's drinking habits. The combination of CDT and an alcohol-related questionnaire was reliable for detecting alcohol-dependent patients preoperatively.

[The role of clonidine in anesthesia]

For decades the adrenergic alpha2 agonist clonidine has been considered to be one of the classical, centrally acting antihypertensive agents. In addition to its antihypertensive and sympathicolytic effects, in recent studies clonidine has been demonstrated to be an effective sedative and analgesic and to reduce the amount of anaesthetic agents required. Therefore, a reconsideration of possible new indications for clonidine in clinical anaesthesiology seems to be justified. This paper presents the pharmacological basis for treatment with clonidine and reviews the extensive literature on its clinical indications in anaesthesia. Clonidine apparently produces its sedative and anaesthetic-sparing effects by stimulation of centrally located alpha2 adrenoceptors. Analgesia seems to be mediated mainly by activation of alpha2 adrenoceptors in the dorsal horn of the spinal cord. Considering its clinical indications, clonidine is often used as a supplement in the treatment of alcohol withdrawal syndromes. Future indications for clonidine may be the treatment of postoperative shivering and chronic pain management. Administration of clonidine in combination with a local anaesthetic prolongs analgesia and motor blockade. Its use in premedication and postoperative pain management may be limited by its principal effects of hypotension and bradycardia. In future, cardiovascular side effects may be minimized if all the subtypes of alpha2 adrenoceptors, their distribution within the central nervous system, and their specific action are clearly defined. This could result in a detailed therapeutic index of more selective and potent alpha2 agonists.

[Prophylaxis of alcohol withdrawal syndrome in prolonged oral and maxillofacial surgery procedures]

Alcohol-addicted patients have a high risk of intercurrent complications during the postoperative period. In addition to the predisposition for infection, alcohol withdrawal syndrome is potentially life-threatening in these patients. However, this concerns only addicts, and definite preoperative diagnosis of addiction therefore is a crucial parameter in assessing the postoperative risks. In our department, 40% of maxillofacial tumor patients with a history of alcohol abuse were assessed as alcohol-addicted according to a complex diagnosis scheme. In these patients, postoperative withdrawal syndrome prophylaxis with continuous, low-dose alcohol infusion is indicated after exclusion of contraindications. If prophylaxis is impossible and differential diagnosis has confirmed a withdrawal syndrome, therapy must take into account the patient's symptoms and the latest neurobiochemical findings on withdrawal-related imbalances in neuronal transmitter systems.

P-hydroxy-norephedrine as a possible mediator causing the reduction of oral intake of D-amphetamine in rats

In rats D-amphetamine is predominantly metabolized by hydroxylation to p-hydroxy-norephedrine (p-HNE); in guinea pigs, however, by deamination to benzoic acid. After 2-3 days on dosages of 1 mg/kg per day and more rats begin to reduce their oral intake of the stimulant whereas guinea pigs do not. In the present study we examined the hypothesis that the formation of p-HNE in the CNS is partially responsible for this aversion. To determine the elimination of D-amphetamine and the increase in p-HNE, groups of male Wistar rats were given various doses (0.5-5 mg/kg per day) of D-amphetamine in their drinking water intragastrically and intravenously. D-Amphetamine in the brain was determined by radioimmunoassay, p-HNE by high performance liquid chromatography followed by electrochemical detection. In contrast to the concentration of D-amphetamine, the p-HNE-content is independent of the route of administration; after oral treatment it showed a linear increase. The results reveal that p-HNE induces the aversion to the stimulant and that the ratio of D-amphetamine to its metabolite determines the onset of this aversion. No p-HNE was found in the brain of guinea pigs. Guinea pigs do not show any aversion to drinking D-amphetamine solutions, even in high dosages.

[Postoperative peritonitis. Patients, causes, therapy, prognosis]

1. The most frequent causes of postoperative peritonitis are circumscribed abscesses, the postoperative ileus and the anastomotic leakage or breakdown of the digestive suture. 2. The mortality is 33%; procedures in upper abdominal surgery are accompanied by higher mortality than in colorectal surgery in cases of postoperative peritonitis. 3. The most frequent cause of death after reoperation is the generalized sepsis. 4. A mixed flora of spores are found in most cases; obligate anaerobic spores are found mostly after colorectal procedures, while typical "hospitalized spores" were present equally after all surgical treatment in abdomen. 5. Method of treatment is: early surgical reintervention, systemic application of antibiotics, peritoneal lavage in generalized peritonitis, sufficient drainage in local peritonitis and the open-wound-treatment of the abdominal cavage in severe forms.

[Diagnostic and therapeutic aspects of gastroduodenal Crohn disease]

The duodenum or the stomach were involved in 20 (11%) of 177 patients with Crohn's disease. Four patients had no symptoms in the upper gastrointestinal tract, in ten patients pains and gastric disorders recurred. Six patients had severe symptoms caused by stenosis of the stomach or duodenum. The endoscopical and histological findings correlated to the severity of the symptoms. Early pathological changes were identified only by gastroscopy. We have little experience of the medical treatment of Crohn's disease of the duodenum or the stomach. A bypass procedure (gastrojejunostomy combined wih proximal-gastric vagotomy (PGV)) is indicated in all cases of severe gastric or duodenal stenosis.

[Modified cardiomyotomy using Rapant's method - guaranteed prevention of esophageal reflux in the operative therapy of achalasia?]

13 patients of 23 who had been treated for achalasia by a modified esophagomyotomy were reexamined by objective assessment of esophageal function with special regard to the problems mentioned above. Pull-through-manometry displayed a decrease of resting tonicity from 37 to 8 mm Hg. In the reflux-provocation-test all patients had a normal test result. In endoscopy normal histological findings raised 70% preoperatively to 83% postoperatively. The esophageal diameter was reduced in 11 of 13 patients. No patient had symptoms to suggest the presence of reflux and relapse.

Gastro-oesophageal reflux: an aetiological factor for bleeding in oesophageal varices?

The precipitating factor in bleeding oesophageal varices is unknown. To investigate this problem 10 patients who had bled from oesophageal varices were examined by manometry, pH monitoring and gastroscopy to determine whether gastro-oesophageal reflux occurred. No evidence for reflux was found. These results, together with previously published reports, cast doubt on peptic oesophagitis or reflux as an aetiological factor in the initiation of oesophageal variceal bleeding.

[Esophageal myoplicature in the treatment of decompensated achalasia]

Heller's cardiomyotomy or one of the modifications are not sufficient in the third stage of achalasia. Additional surgery is required for reversion of the dilated and elongated esophagus. Two patients with third-grade achalasia were treated by cardiomyotomy in combined with esophagomyoplication and followed up for one year. The results were evaluated clinically, radiologically, manometrically, pH-metrically, and endoscopically. We concluded that esophagomyoplication satisfactorily completes cardiomyotomy in cases of third-grade achalasia.

[Is there a characteristic constellation of findings in esophageal functional diagnosis after antireflux operations?]

The significance of the finding esophagitis (grade I) in 23 patients was evaluated by manometry, measurement of pH and acid clearance test 18 months after the antireflux procedure (Lortat-Jacob). The provocation of pathological reflux was impossible (reflux provocation test). The acid clearance test demonstrated a low grade delay of the emptying rate. From these results it is supposed that the antiflux procedure only produces a pressure barrier but not a digestive sphincter. According to the pressure barrier in the functional analysis of the esophagus, three typical findings appeared: esophagitis (grade I), normal pH-monitoring, and delayed acid clearance.

[Clinical and endoscopic radiologic results after transduodenal papilloplasty (author's transl)]

The study comprises 56 patients, who underwent transduodenal papilloplasty. More than 15% were symptom-free at least 4 years following surgery. All the symptoms the patients suffered from were nonspecific and the pathological findings of the blood samples were not correlated with the width of the orificium of the papilla of Vater or the diameter of the common bile duct. In 49 patients the ERCP was performed. In 48 cases the retrograde cholangiography was successful, in 1 case only the retrograde pancreatography was possible. In all patients we found normal efflux of contrastmedium out of the papilla. Bile stones, one localized in the common bile duct and the other in the cyst remnant were the most important findings. The diameters of the common bile ducts varied considerably and were not dependent on the velocity of the efflux of the contrast medium. Contrary to the observations of other authors, in only 15% of our patients free air bubbles were found in the bile tree. Peripapillary diverticula of the duodenum were detected in 15% of our patients, but did not lead to compression or obstruction of the common bile duct. Even without histologic examination of the liver, we believe that a broad papilloplasty of the papilla prevents an ascending cholangitis or other related complications.

[Surgical papillotomy, endoscopic-manometric and clinical results (author's transl)]

4--9 years after transduodenal papillotomy an endoscopic-manometric and clinical control of the surgical result was done in 49 patients. The pressure difference of common bile duct and duodenum was of great interest. There existed a correlation between the pressure difference and other parameters so far, as air was frequently seen in those patients without pressure gradient between common bile duct and duodenum. Pathological activity of gamma-GT and a decrease of Prothrombine-time was found after a high pressure difference. It may be possible that anatomical variations of the biliary system and the duodenum have some importance for the formation of stones.

Effects of somatostatin and human gastrin I on the lower esophageal sphincter in man

The influence of gastrin and somatostatin on the lower esophageal sphincter was investigated in a total of ten metabolically healthy volunteers and one patient with Zollinger-Ellison syndrome. It could be shown that only unphysiologically high concentrations of gastrin produce a rise in pressure in the lower esophageal sphincter, while somatostatin has neither an effect on the lower esophageal sphincter pressure, nor is it able to inhibit the pharmacological effect of exogenic gastrin administration. The results of this study demonstrate that normal levels of serum gastrin do not seem to have much effect of resting LES pressure, nor does somatostatin. (Gastrin, in fact, in pharmacologic dosage does have an effecton the tonicity of the lower esophageal sphincter.)

Extended somatostatin treatment of a patient with bleeding ulcer

The results of a 67 hour cyclic somatostatin continuous infusion in a patient with a bleeding ulcer are reported. The subject was a 65 year old male with very heavy gastrointestinal bleeding on the 9th postoperative day following a high BI-resection. Endoscopy revealed the bleeding to be caused by two residual ulcers in the area of the anastomosis. Somatostatin treatment led to an immediate cessation of the bleeding after 1 hour. Gastric secretion as well as gastrin, insulin and growth hormone levels were significantly inhibited by somatostatin. Endoscopy at the end of the treatment period showed two ulcers in the process of healing. The raised blood glucose levels caused by somatostatin were easily controlled with max. 14 IU cristalline insulin daily. Except for dryness in the mouth, no adverse side effects were apparent. There was no evidence from laboratory investigations of hemostatic defects or bleeding tendency in the patient.