Patients with Heart Failure During and After Inpatient Cardiac Rehabilitation

Background

Heart failure is the third most fatal disease in Germany and generates considerable treatment costs. The multimodal program of inpatient rehabilitation can improve the symptoms and prognosis of these patients. At the present time, however, only few data are available on the effectiveness of rehabilitation for heart failure patients.

Methods

After receiving study approval from the ethics committee of the Saxony–Anhalt Medical Association, 200 patients with a primary or secondary diagnosis of heart failure were prospectively included in the study at Paracelsus-Harz-Clinic Bad Suderode, Quedlinburg, Germany. Baseline parameters such as age, gender, and BMI were documented. Outcome variables included NYHA classifications, quality of life, and mortality. For follow-up, the patients were contacted again by mail or phone after three and 12 months and, data on symptoms and serious events were recorded.

Results

The proportion of patients with a highly reduced ejection fraction (HFrEF) was 13.5%, with a midrange reduced ejection fraction (HFmrEF) 33%, and with preserved ejection fraction (HFpEF) 53.5%. The mean age was 64 ± 11.9 years, the proportion of women 24.1%. The effects of rehabilitation were documented by low overall mortality (no patient died during the stay, only 4% of the patients died in the 12-month follow-up) and an improvement in NYHA classification during and after the inpatient rehabilitation.

Conclusion

This monocentric study showed effects both for symptoms (improvement in NYHA classifications) and prognosis (overall mortality) after rehabilitation. These data reflect the effectiveness of multimodal rehabilitation and underscore the need for rehabilitation in patients diagnosed with heart failure after an acute event and hospital stay or who present with chronic deterioration.

Evaluation of the Aortopathy in the Ascending Aorta: The Novelty of Using Matrix-Assisted Laser Desorption/Ionization Imaging

PURPOSE

Histopathological evaluation presents conflicting reports regarding aortic abnormalities. The authors aim to present proof-of-concept study to explore the feasibility of matrix-assisted laser desorption/ionization imaging mass spectrometry (MALDI-IMS) in combination with histopathology for characterizing alterations in the aneurysmal ascending formalin-fixed paraffin-embedded (FFPE) aorta tissue.

EXPERIMENTAL DESIGN

The authors assess FFPE specimens from patients with a dilated aorta and bicuspid aortic valve (BAV), those with a standard tricuspid aortic valve (TAV), and those with Marfan syndrome (MFS) via histopathology and grade the conditions for elastic fiber fragmentation (EFF) and MALDI-IMS. The proteins using liquid chromatographic-mass spectrometry are identified and the results are confirmed by immunohistochemistry.

RESULTS

There is significant difference in terms of EFF between MFS and BAV, and TAV and BAV. Characteristic peptide signatures and m/z values in the EFF facilitate the characterization among the aortic specimens of BAV, MFS, and TAV. The m/z values from the aortic alpha smooth muscle actin and myosin heavy chains significantly increase in BAV compared with MFS and TAV. These findings are confirmed by immunohistochemistry.

CONCLUSION

The results represent a strategy that uses MALDI-IMS in combination with histopathology as promising approaches to characterize spatial alteration in the structure of the aneurysmal ascending aorta.

The current LDL-C target <1.4mmol/l of the ESC is achieved in less than 16% of patients with Coronary Heart Disease despite effective lipid-lowering therapy: data from the LLT-R registry

Background

In the current guideline of the ESC, in patients with very high cardiovascular risk such as coronary heart disease (CHD) a treatment target for LDL-C <1.4mmol/l and/or a halving of the initial value are defined. It is unclear whether these treatment targets are achievable with standard therapy including statins and/or ezetemibe.

Methods

The primary objective of this prospective, multi-centre register study was the question of the guidance-based adaptation and adherence to lipid-lowering therapy during and after a cardiac rehabilitation in 1,100 patients with CHD up to 12 months after discharge from the six rehabilitation clinics involved. Patients were included from 2016 to 2018.

Results

The median age of the 1,100 patients was 63.4±10.4 years, the mean BMI was 28.5±4.7kg/m2, and 24.1% of patients were female. 12.2% were active smokers, 91.6% reported dyslipoproteinemia, 33.9% suffered from diabetes mellitus and 86.5% from hypertension.

The majority of patients were included with the main indications NSTEMI (31.6%), STEMI (29.6%) and after CABG surgery (26.4%).

The proportion of patients treated with statins was more than 94% when admitted and discharged from the rehabilitation clinic, as well as in 3- and 12-months follow-ups.

Approximately 9% of patients were treated with ezetemibe at baseline. On discharge from the rehabilitation clinic 23% of patients were treated with ezetemibe, which remains stable at 3 and 12 months.

PCSK9 inhibitors were used in 0.1–0.3% of patients at all times.

The adjustment of LLT during three week cardiac rehabilitation resulted in median LDL-C values of 2.27mmol/l (1.80/2.84) at baseline, 1.97mmol/l (1.57/2.47) on discharge (p<0.001 compared to baseline), 1.94mmol/l (1.57/2.49) after three months and 1.94mmol/l (1.53/2.40) after 12 months.

The proportion of patients with LDL-C <1.4mmol/l was 9% at baseline, 15.7% on discharge (p<0.001 compared to baseline), 15.6% at three-month follow-up and 15.1% at 12-month follow-up (Figure 1).

Discussion

In the context of cardiac rehabilitation, an effective adjustment of LLT is carried out, which resulted in a significant reduction of LDL-C. However, despite a high percentage of patients on statins and ezetemibe, the proportion of patients in the new target range <1.4mmol/l was only achievable in a small percentage and the question arises whether these treatment targets can be achieved without additional administration of PCSK9 inhibitors in majority of patients with CHD.

Figure 1

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): This study was supported by an unrestricted grant from Sanofi-Aventis Germany.

Risikostratifizierung des chronischen Koronarsyndroms – Empfehlungen zur Risikobewertung und Diagnostik im klinischen Alltag gemäß ESC-Leitlinie 2019

Die neue Leitlinie der European Society of Cardiology (ESC) von 2019 liefert neue Empfehlungen zum Umgang mit dem chronischen Koronarsyndrom (CCS, früher stabile koronare Herzerkrankung = KHK). In diesem Beitrag werden Methoden zur Bestimmung der Prätestwahrscheinlichkeit eines CCS und die relevanten diagnostischen Mittel vorgestellt, wie etwa die neuen Empfehlungen für die Stellung des Angio-CT und die Verwendung der Koronarangiografie. Ein besonderer Schwerpunkt dieses Beitrags liegt auf denjenigen Patientengruppen, die Ärzte und Pflegekräfte im klinischen Alltag vor besondere Herausforderungen stellen. Hierzu gehören Patienten mit atypischer oder fehlender Klinik, Patienten höheren Alters und Patientinnen. Für diese Gruppen werden gesonderte Empfehlungen formuliert.

[Health-Related Quality of Life in Patients with Non-Small Cell Lung Cancer before and after Surgery - a Comparison between Thoracotomy and Video-Assisted Thoracoscopic Surgery]

BACKGROUND

Earlier studies have proven that in patients with non-small cell lung cancer video-assisted thoracoscopic surgery is functionally superior to thoracotomy in terms of perioperative and postoperative complications. The objective of this work was to determine whether there is a difference in health-related quality of life (HRQoL) of patients with non-small cell lung cancer - compared to the German normal population - before and after surgery. Moreover, HRQoL after thoracotomy was compared to HRQoL after video-assisted thoracoscopic surgery (VATS).

MATERIAL AND METHODS

Based on retrospective data generated during a 7-year period (2010 - 2017), 327 patients with non-small cell lung cancer who underwent therapy were examined. Patients either underwent thoracotomy or video-assisted thoracoscopic surgery. 456 of short form 12 questionnaires were analysed. Via norm-based scoring, and physical and mental component summaries (PCS and MCS) were calculated before and 6, 12, and 24 months after treatment. Using t tests, potential differences in physical and mental component summaries were evaluated between patients and the German normal population as well as between patients after thoractomy and after VATS.

RESULTS

Up to 24 months after surgery, the physical dimension of HRQoL is significantly reduced, while the mental component summary does not significantly differ from the German population. Moreover, thoracotomy and VATS gave equivalent values for health-related quality of life.

CONCLUSION

With respect to health-related quality of life, thoracotomy and video-assisted thorascopic surgery are equivalent in the long term. But there was a trend to improvement with both summary scores that might indicate superiority of video-assisted thoracoscopic surgery.

Adherence To Lipid-Lowering Therapy In Patients With Coronary Heart Disease From The State Of Saxony-Anhalt, Germany

OBJECTIVES

Treatment with lipid-lowering therapy (LLT) such as statins, cholesterol absorption inhibitors, or PCSK9 inhibitors is of major importance for the survival of patients with atherosclerotic diseases, and adherence to LLT is essential for treatment success. The intention of this study was to investigate adherence to LLT in patients with coronary heart disease (CHD) in a 12-month follow-up period in Saxony-Anhalt, the state with the highest incidence and mortality for CHD in Germany.

PATIENTS AND METHODS

Data were taken from 542 hospitalized patients with angiographically documented CHD who were prospectively included in this study conducted in the Department of Medicine III of the University Clinics (Halle). We collected data concerning medication at discharge and after 3 and 12 months.

RESULTS

A total of 542 patients were included in this study. Mean age was 69.2 ± 11.8 years. In all, 68.8% were males, 165 (30.4%) were smokers, 39.7% suffered from diabetes, and 86.9% had arterial hypertension. The follow-up time of this study was 12 months. At discharge, 463 patients (85.4%) were being treated with a statin. After 3 months 409 (75.5%) and after 12 months, 395 patients (72.9%) were still on statin therapy, respectively. In total treatment, adherence for the statin medication decreased by 15.7% in 12 months. Kaplan-Meier analyses showed that survival, taken as freedom of death from any cause, decreased significantly if statin treatment was stopped (p=0.001). This was confirmed by multivariate Cox regression (HR 1.78, p=0.012). Ezetemibe was prescribed for 56 patients at discharge (10.3%). After 3 months, 40 patients (7.4%) were still taking ezetemibe. After 12 months, adherence to ezetemibe treatment decreased to 4.1% (22 patients).

CONCLUSION

During follow-up for 3 and 12 months, adherence for statin therapy decreased by 15.7% and for ezetemibe by 46.6%. Here, low adherence to statin therapy was associated with fatal outcome.

Primary Malignant Melanoma of the Small Bowel a Case Report and Review of the Literature

Although small bowel involvement by malignant melanoma is most frequently metastatic, a primary origin at this site has been reported in rare cases. The biological and clinical features of these cases have not yet been summarized. Here, another case of small bowel melanoma is described, and a review of the existing literature is given. An 81-year-old man presented with anemia and gastrointestinal bleeding. A tumor of the ileum was detected by video capsule endoscopy and removed by segment resection. Histological examination revealed a malignant melanoma of the ileum. Another primary site could be excluded by clinical and radiographic examination. The patient felt well five months after surgery.

Only 18 cases of primary small bowel melanoma (including the present one) have been reported to date. A literature review reveals that this rare neoplasm is associated with a slight predilection for the male gender, a predilection for the ileum and a poor prognosis.

Prognosis of patients with pulmonary embolism after rehabilitation

INTRODUCTION

Pulmonary embolism (PE) is a life-threatening disease; in Germany, therefore, rehabilitation after PE is recommended in patients with intermediate- and high-risk PE. However, no prospective data on PE after inpatient rehabilitation have been published so far.

PATIENTS AND METHODS

For this monocentric study, 70 patients with PE were prospectively recruited between November 2013 and November 2014 after giving written informed consent. This study was approved by the ethics committee of the Medical Association of Saxony-Anhalt. Inclusion criteria were as follows: age ≥18 years and a stay at the Paracelsus-Harz Clinic in Bad Suderode, Germany, with the main indication of PE. During the hospital stay, history-relevant medical data and diagnostic findings were collected and documented. Furthermore, we recorded whether patients were rehospitalized or died during the treatment period in the rehabilitation clinic or during the 12-month follow-up.

RESULTS

The mean age was 64.5 ± 13.0 years, the mean body mass index (BMI) was 30.4 ± 6.0 kg/m2, and 54.3% were women. During rehabilitation, two patients (3.9%) were transferred to a primary care hospital; no patient died. However, four patients died (5.7%) in the 12-month follow-up period. A total of 20 patients were hospitalized in the 12-month follow-up period (hospitalization rate during the 12-month follow-up period: 28.6%). Of these 20 patients, one patient was rehospitalized with a newly diagnosed PE (1.4%) and two patients were rehospitalized for bleeding events (2.8%).

CONCLUSION

PE is a life-threatening disease, and therefore it seems reasonable to recommend rehabilitation at least in patients with an intermediate- or high-risk PE. In this study, death and other serious event rates were low during the in-hospital rehabilitation and in the 12-month follow-up period, which underlined the safety and importance of a standardized rehabilitation program after survived PE.

A New Approach to Phenotyping Disseminated Tumor Cells: Methodological advances and Clinical Implications

At the time of primary therapy (surgery, systemic chemotherapy and/or radiation), disseminated tumor cells in the bone marrow can be found in almost one-third of patients with cancer of the breast, ovary, esophagus, stomach, colon, and other solid tumors. Whereas the prognostic impact of the mere presence of these cells is still a matter of debate, it has been shown that expression of tumor-associated antigens in disseminated tumor cells is linked to more aggressive disease. Therefore, further characterization of disseminated tumor cells at the protein and gene level has become increasingly important. To date, the most common detection method for disseminated tumor cells in the bone marrow is an immunocytochemical approach using cytokeratin-directed antibodies for detection of epithelial cells and the APAAP system for their visualization. We have established a new double immunofluorescence technique enabling simultaneous detection, phenotyping, and antigen quantification of disseminated tumor cells. Mononuclear cells from bone marrow are enriched by Ficoll gradient centrifugation and cytospins are prepared. Double immunofluorescence is performed using antibodies against cytokeratins 8/18/19 (mAb A45B/B3) and the uPA receptor CD87 (pAb HU277). CD87 expression is recorded by confocal laser scanning microscopy (CLSM) using fluorescence labeled latex beads as the reference; staining intensities of all the scans are then summed and quantified (extended focus). This protocol, originally designed for disseminated tumor cells in bone marrow, can also be applied to disseminated tumor cells in blood, to leukapheresis cells or to cells present in malignant ascites or other malignant effusions. The tumor cells detected may be used for gene and mRNA analyses. Furthermore, disseminated tumor cells also represent interesting targets for clinical studies on patient prognosis or prediction of therapy response as well as for specific tumor-biological therapies.

Preoperative assessment of relative pulmonary lobar perfusion fraction in lung cancer patients

Preoperative quantification of (relative) pulmonary lobar perfusion fraction using scintigraphy is established in predicting lung function after pulmonary surgery. Aim was to develop an easy and truly anatomical method for relative pulmonary lobar perfusion fraction quantification using SPECT/CT and to compare results with those from planar analyses in lung cancer patients. Patients, methods: 36 patients with operable lung cancer, borderline lung function referred to pre-operative quantification. Perfusion SPECT-data were acquired p.i. of 163±9 MBq 99mTc-MAA, subsequent low-dose-CT (SymbiaT, Siemens). Iterative Flash3D-reconstruction, manual 3D segmentation of all lobes using PMOD. VOI transfer to coregistered perfusion SPECTdata, calculation of lobar fractions. Modelbased calculation of relative lobar fractions based on planar data, analysis of planar vs. 3D results using t-test. Results: Significant differences (p<0.05) between the results from 3D method and planar imaging were found for right upper and middle lobe and both lower lobes. Maximum differences ranged from 10.9% (left upper lobe) to 22.9% (right upper lobe). Conclusions: Relative pulmonary lobar perfusion fraction can easily be obtained by an anatomically driven 3D quantification. Results yielded by this method and the traditional planar approach differed greatly, possibly affecting eligibility for lung surgery in individual patients. Considering these results a 3D approach should be used whenever possible.

Relationship between the Handball-Specific Complex-Test and Intermittent Field Test performance in professional players

BACKGROUND

We investigated the relationship between the Handball Complex-Test (HBCT) and two selected field performance tests (the repeated sprint ability [RSA], and the Yo-Yo Intermittent Recovery Test) in elite handball players.

METHODS

Nineteen handball players (age: 25.7±5.1 years) were drawn from the First Professional German League. The HBCT consists of four activity series (AS): agility parcours, defensive action, sprint (10 m, 20 m) and throw-on-goal parcours; these activities were completed twice, with five active pauses of 30-35 s, and a follow-up of recovery over the subsequent 10 minutes. The RSA comprised 6 x (15+15 m) sprints starting every 20 s; scoring noted best time (RSAbest), total time (RSATT) and decrement (RSAdec). In the Yo-Yo Intermittent Recover, we recorded the total distance covered (TD). Heart rates (HR) were recorded throughout and recovery was assessed for measurements immediately post-test (R0) and 10 minutes after completing the test (R10).

RESULTS

A strong correlation was found between HBCT and fastest 10 m and 20 m RSA sprint times (r=0.811, r=0.815, respectively). Also, the HBCT total 10 m and 20 m sprint times showed a strong positive association with RSATT (r=0.70; r=0.63, respectively), and the RSA heart rate post-test was strongly correlated with the HBCT heart rate after round two (r=0.865).

CONCLUSIONS

Data from the match-specific HBCT Test shows a strong positive association with other more generic intermittent field test measurements. These observations support the validity of using the generic tests to monitor current fitness and responses to training in team handball players.

Relative Expression of 1,25-Dihydroxyvitamin D3 Receptor, Vitamin D 1α-Hydroxylase, Vitamin D 24-Hydroxylase, and Vitamin D 25-Hydroxylase in Endometriosis and Gynecologic Cancers

The authors demonstrate expression of the vitamin D receptor (VDR) and its hydroxylases in the endometrium and ovaries of women with and without endometriosis and endometrial or ovarian cancer. Immunohistochemistry showed strong staining of the VDR in endometriosis and endometrial cancer, with the most intense staining in epithelial cells. The VDR mRNA was significantly increased in patients with endometrial and ovarian cancer compared to the control group. There was a significantly higher 1 alpha-hydroxylase expression in the endometrium of patients with endometriosis compared to healthy controls. The observed differences in VDR and 1 alpha -hydroxylase mRNA levels were maintained at the protein level. The authors found no differences in 25-OH vitamin D levels between the serum of patients with endometriosis (25.7 +/- 2.1 ng/mL, n = 46) and healthy controls (22.6 +/- 2.0 ng/mL, n = 33, P = .31). They hypothesize that vitamin D might influence the local activity of immune cells and cytokines thought to play important pathogenic roles in the development and maintenance of endometriosis.

Anthropometric and physical performance characteristics of professional handball players: influence of playing position

BACKGROUND

The aims of the study were to examine the anthropometric and physical performance characteristics of professional handball players classified by playing position.

METHODS

Twenty-one competitors (age: 25.2±5.1 years) were categorized as backs, pivots, wings or goalkeepers. Measures included anthropometrics (body height and mass), scores on the Yo-Yo Intermittent Recovery Test (total distance covered, TD), repeated-sprint ability (6 repetitions of 2x15-m shuttle sprints with recording of best time for a single trial, RSAbest) and performance on a complex handball test (HBKT) of throw slap (TS) and throw jump (TJ) with and without precision.

RESULTS

The anthropometric data revealed a significantly lower body height for wings and pivots than for goalkeepers. Wings, pivots and goalkeepers were significantly shorter than backs, but had a similar BMI. The TD was greater for the wings (2.400 m) than for backs (1.832 m) and pivots (2.067m). Wings also achieved a better RSAbest (5.41 s) than backs (5.68 s) or pivots (5.82 s). Body height was significantly related to throw slap (TS) and jump (JT) (r=0.53, P<0.01; r=0.51, P<0.01 respectively). No significant difference (P=0.675; η2=0.009) was seen between JT with precision and JT without precision.

CONCLUSIONS

Substantial differences of body build and physical performance between playing positions underline the importance of a careful assignment of such positions and the development of position-specific training for professional handball players by modifying both intermittent aerobic and anaerobic endurance components of training sessions.

[How Valid is the Performance Diagnostic in Soccer?]

BACKGROUND

Assessments of physical and physiological performance tests in soccer sports are still unspecific yet. There is also a lack of scientific validation using those as a "golden standard". Concerning match performance a large deficit also exist in sports and medical science.

OBJECTIVE

The aim and purpose of this multicentric and prospective diagnostic study was to evaluate the validity of current established and recommended diagnostic tests for endurance and match performance (golden standard: real time of playing) in soccer.

MATERIALS AND METHODS

In a prospective study protocol two German soccer teams from the fourth (n = 22) and third (n = 24) national league first underwent different tests of performance and diagnostics ahead of the competition season (tapping, drop jump, counter movement jump, speed dribbling, treadmill running test). Afterwards, match performance of each athlete was assessed by real time of playing (as a surrogate parameter) during the half season (14 and 25 matches). We finally compared test parameters with the match performance in a linear regression analysis.

RESULTS

Our analysis showed no statistical relevant relationship between test parameters and match performance (r(2) < 0.10). Only the assessment in maximum of relative oxygen uptake during the treadmill test for endurance was associated with a higher amount of variance (12%).

CONCLUSIONS

According to the study results there is no relevant and valid correlation between current established diagnostic tests in soccer sport and sport-specific performance. The time of real engagement during a match might be associated with a quality of performance for the single athlete. Therefore, the assessment of this match activity is the most important parameter for improving diagnostic tests in soccer. The existence of a "golden standard" is essential for validation of any tests and parameters and the development of new specific assessments. At the moment, physical performance tests have no scientific evidence in soccer sports.

Generation of coherent radiation in the vacuum ultraviolet using randomly quasi-phase-matched strontium tetraborate

Tunable coherent radiation is generated in the vacuum ultraviolet down to 121 nm using random quasi-phase matching in strontium tetraborate, the shortest wavelength ever produced with a second-order nonlinear optical process in a solid-state material. Relevant properties of this radiation, the nonlinear process, and the nonlinear crystal are investigated.

2,4,6-Triphenylphosphinine and 2,4,6-triphenylposphabarrelene revisited: synthesis, reactivity and coordination chemistry

Important aspects of the synthesis, reactivity and coordination chemistry of 2,4,6-triphenylphosphinine and 2,4,6-triphenylphosphabarrelene have been revisited.

High-average-power, 50-fs parametric amplifier front-end at 1.55 μm

An average-power-scalable, two-stage optical parametric chirped pulse amplifier is presented providing 90-μJ signal pulses at 1.55 μm and 45-μJ idler pulses at 3.1 μm at a repetition rate of 100 kHz. The signal pulses were recompressible to within a few percent of their ~50-fs Fourier limit in anti-reflection coated fused silica at negligible losses. The overall energy conversion efficiency from the 1030-nm pump to the recompressed signal reached 19%, significantly reducing the cost per watt of pump power compared to similar systems. The two-stage source will serve as the front-end of a three-stage system permitting the development of novel experimental strategies towards laser-based imaging of molecular structures and chemical reactivity.

Rehabilitation in Patients With Coronary Heart Disease: Participation and Its Effect on Prognosis

BACKGROUND

In Germany, rehabilitation is considered to be indicated after an acute hospital stay for the treatment of a severe cardiac condition. In comparative studies, at least 51% of German hospital patients with coronary heart disease (CHD) who were entitled to rehabilitative measures actually took part n rehabilitation.

METHODS

We examined data on 1910 patients with CHD who took part in two prospective cohort studies at the University Hospital of Halle (Saale) in the years 2007-2011. We contacted these patients again with a questionnaire to determine which ones had undergone rehabilitation. For patients who died before we could contact them, the attempt was made to obtain the dates and causes of death from the local authorities. The primary endpoint of was overall mortality.

RESULTS

The median duration of follow-up was 136 ± 71 weeks. 727 patients (38.1%) had applied for rehabilitation during their acute hospitalization, but only 552 patients (28.9%) actually underwent it. Patients who did not undergo rehabilitation were older than those who did (68.6 ± 10.3 vs. 64.9 ± 10.5 years) and suffered more commonly from diabetes (41.3% vs. 33.7%; p = 0.002), arterial hypertension (89.2% vs. 85.3%; p = 0.017), and peripheral arterial occlusive disease (15.3% vs. 9.8%; p = 0.002). There were more smokers in the rehabilitation group. Kaplan-Meier analysis and multivariate Cox regression analysis both showed that the patients who underwent rehabilitation had lower mortality (hazard ratio 0.067, 95% confidence interval 0.025-0.180, p < 0.001).

CONCLUSION

Rehabilitation for cardiac patients was associated with lower mortality. Fewer patients underwent rehabilitation in this study than in other, comparable studies. Those who did not were older and had a greater burden of accompanying disease.

Feasibility and safety of rehabilitation after venous thromboembolism

BACKGROUND

Venous thromboembolism is a life-threatening disease. In survivors, different degrees of functional complaints need to be restored or prevented (eg, post-thrombotic syndrome, pulmonary hypertension). Therefore, rehabilitation after venous thromboembolism is recommended in Germany. However, a structured rehabilitation program has not been defined for this indication. Here, we present the experience of a single rehabilitation center.

METHODS

Data from consecutive pulmonary embolism (PE) patients who were referred for a 3-week inpatient rehabilitation program from 2006 to 2014 were retrospectively evaluated.

RESULTS

In all, 422 patients were identified. The mean age was 63.9±13.5 years, the mean body mass index (BMI) was 30.6±6.2 kg/m2, and 51.9% were female. Deep vein thrombosis according to PE was known for 55.5% of all patients. We applied a wide range of therapeutic interventions such as bicycle training with monitored heart rate in 86.7%, respiratory training in 82.5%, aquatic therapy/swimming in 40.1%, and medical training therapy in 14.9% of all patients. Adverse events (AEs) occurred in 57 patients during the 3-week rehabilitation period. The most common AEs were cold (n=6), diarrhea (n=5), and infection of the upper or lower respiratory tract that was treated with antibiotics (n=5). However, three patients under anticoagulation therapy suffered from bleeding, which was clinically relevant in one. Four patients (0.9%) had to be transferred to a primary care hospital for non-PE-associated reasons (acute coronary syndrome, pharyngeal abscess, and acute abdominal problems). No influence of any of the physical activity interventions on the incidence of any AE was found.

CONCLUSION

Since PE is a life-threatening disease, it seems reasonable to recommend rehabilitation at least in PE patients with an intermediate or high risk. It is shown for the first time in this study that a standard rehabilitation program after PE is safe. However, efficacy and safety in the long term need to be studied prospectively.

Men and women differ in their diurnal expression of monocyte peroxisome proliferator-activated receptor-α in the fed but not in the fasted state

Peroxisome proliferator-activated receptor-α (PPARα) plays a pivotal role in regulating metabolic response to fasting and is an inhibitor of inflammatory pathways in immune cells. It represents a therapeutic target for treatment of several diseases, mainly hyperlipidemia. To shed light on PPARα expression changes in response to fasting, young healthy male and female volunteers were fed or fasted for 24 hours. Monocytes were analyzed every 2 hours to compile both profiles of mRNA and protein expression of PPARα and its interactive partner, the circadian pacemaker brain and muscle aryl hydrocarbon receptor nuclear translocator like-1 (BMAL1). We found that women change their diurnal expression profiles of PPARα and BMAL1 when switching from the fed to the fasted state, whereas men do not. Interestingly, the PPARα and BMAL1 profiles of men and women in the fed state are different, whereas the profiles in the fasted state are virtually identical. The finding of diametrically opposite responses of male and female PPARα expression in the fed state might have practical implication in human medicine as PPARα activators like fibrates are used for the therapy of chronic lymphocytic leukemia, microvascular complications in diabetes, and kidney diseases.

Spectral fringes in non-phase-matched SHG and refinement of dispersion relations in the VUV

We consider second harmonic generation (SHG) of ultrashort pulses in the case of strong phase- and group-velocity mismatch. Spectral fringes appear in the second harmonic related to two delayed replicas of the fundamental pulse in the time domain. The fringe separation can be used to evaluate the group-velocity and refractive index of nonlinear crystals at extreme wavelengths. Experimental results with femtosecond pulses in SrB(4)O(7) (SBO) are used to refine the Sellmeier equation describing the n(c) refractive index down to 160 nm, essential for the use of this unique nonlinear crystal for random quasi-phase-matching in the VUV.

Evaluation of the prognostic role of tumor cell podoplanin expression in locally advanced squamous cell carcinoma of the head and neck

BACKGROUND AND PURPOSE

To investigate the potential prognostic role of tumor cell podoplanin expression in patients treated with resection followed by irradiation or chemoradiotherapy for locally advanced squamous cell carcinoma of the head and neck (SCCHN).

MATERIALS AND METHODS

Podoplanin expression (≤10 % versus > 10 %) and 12 other factors were evaluated in 160 patients for their association with locoregional control (LRC), metastases-free (MFS) and overall survival (OS). Other factors were age, gender, Eastern Cooperative Oncology Group (ECOG) performance status, preradiotherapy (pre-RT) hemoglobin level, tumor site, histological grading, T category, N category, American Joint Committee on Cancer (AJCC) stage, human papillomavirus (HPV) status, extent of resection and concurrent chemotherapy.

RESULTS

In multivariate analysis, ECOG performance status 0-1 (risk ratio, RR: 3.01; 95 % confidence interval, CI: 1.42-7.14; p = 0.003), pre-RT hemoglobin levels ≥ 7.45 mmol/l (12 g/dl; RR: 2.03; 95 % CI: 1.04-3.94; p = 0.038), oropharyngeal cancer (RR: 1.25; 95 % CI: 1.01-1.55; p = 0.038) and T category T1-2 (RR: 1.81; 95 % CI: 1.24-2.79; p = 0.002) were significantly associated with improved LRC. T category T1-2 (RR: 1.90; 95 % CI: 1.25-3.06; p = 0.002) and N category N0-2a (RR: 5.22; 95 % CI: 1.96-18.09; p < 0.001) were significantly associated with better MFS. Pre-RT hemoglobin levels ≥ 7.45 mmol/l (RR: 2.44; 95 % CI: 1.27-4.74; p = 0.007), T category T1-2 (RR: 1.97; 95 % CI: 1.36-3.04; p < 0.001) and N category N0-2a (RR: 2.87; 95 % CI: 1.37-6.61; p = 0.005) were significantly associated with improved OS. Podoplanin expression ≤ 10 % showed a trend towards improved OS on both univariate (p = 0.050) and multivariate analysis (RR: 1.86; 95 % CI: 0.96-3.59; p = 0.07).

CONCLUSION

Treatment outcomes were significantly associated with performance status, pre-RT hemoglobin level, tumor site and tumor stage. Tumor cell expression of podoplanin ≤ 10 % showed a trend towards improved OS when compared to podoplanin expression of > 10 %.

NMR Study of Molecular Dynamics in a D ho Columnar Mesophase

In this paper we report the first molecular dynamics study combining fast field-cycling and conven-tional NMR techniques in a thermotropic liquid crystal of discotic molecules exhibiting an ordered columnar hexagonal mesophase. Using the association of these techniques we obtained proton T1 data over a very large domain of Larmor frequencies (ω/2π from 500 Hz to 85 MHz). The proton spin-lattice relaxation results were analysed considering the structure of the mesophase and the types of movements which are expected to influence significantly the relaxation rate, namely local molecu-lar rotational reorientations, inter-columnar self-diffusion and collective movements corresponding to bending and compression of the columns. We verified that these mechanisms dominate the relaxation respectively for high, medium and low Larmor frequencies.

Dynamic Nuclear Polarization Experiments on 19F in Solutions and their Interpretation by the “Pulse Model” of Molecular Collisions

The dynamic fluorine polarization by the Overhauser effect has been studied at four different magnetic field values and at various temperatures in several fluorocarbon solutions. The importance of intermolecular contact couplings is very sensitively dependent on the chemical environment of the fluorine nuclei. The experimental data are interpreted in terms of the stochastic “pulse model” of molecular collisions derived in a preceding paper. The parameters of the model, such as the relative contribution of scalar couplings, the shape and the time scale of collision pulses and the correlation times of the molecular motion are given explicitly for six fluorocarbon solutions of free radicals.

Kernresonanzuntersuchung der Molekülrotation und Selbstdiffusion in festem Benzol: T1ϱ-Spektroskopie/ Nuclear Magnetic Resonance Investigation of Molecular Rotation and Diffusion in Solid Benzene: T1ϱ-Spectroscopy

We have extended previous NMR investigations of the molecular motion in solid benzene to lower proton spin Larmor frequencies using the rotating frame (T1ϱ) technique. The new data show two relaxation mechanisms, namely the well-known rotation of the benzene rings around their sixfold axis and, additionally, the self-diffusion by vacancies. The rotation and diffusion was analyzed by computer optimization of the relaxation models of Haeberlen and Torrey, respectively. The parameters of rotation are essentially consistent with results derived recently from high-frequency T1 measurements. The diffusion parameters are in agreement with preliminary low-frequency T1 measurements, but reveal a dramatic discrepancy by nearly 4 orders of magnitude with respect to tracer experiments of Fox and Sherwood. This behaviour is discussed in terms of correlation effects similar to those observed in plastic and liquid crystals.

Kernresonanzuntersuchung der Molekülrotation in festem Benzol: T1-Spektroskopie / Nuclear Magnetic Resonance Investigation of Molecular Rotation in Solid Benzene: T1-spectroscopy

We have extended Haeberlen’s and Maier’s NMR investigation of the molecular rotation in solid polycrystalline benzene (C6H6), performed in 1967 in the Larmor frequency range from 88 MHz to 22 MHz, to lower frequencies down to 4.4 MHz. In some cases monocrystalline samples were also studied. The extensive data show that the presently accepted model of purely uncorrected rotations of the benzene molecules around their sixfold axis has to be rejected. Instead, two results found, namely

- a slight increase of the rotational activation energy when approaching the melting point of benzene and

- the width of the T1 relaxation minima as a function of the reciprocal temperature suggest an additional relevance of correlated molecular motions, like e.g. the ‘gear-wheel mechanism’ first proposed by Cox. By appropriate modifications of Haeberlen’s theory, i.e. by assuming a rate equation with temperature dependent activation energy and by emphasizing the effect of simultaneous rotations of neighbouring rings compared with the purely statistical, uncorrelated case, we succeeded to describe the considered T1 measurements quantitatively.

Kernmagnetische Messungen von Selbstdiffusions-Koeffizienten in Wasser und Benzol bis zum kritischen Punkt

The most commonly used nuclear magnetic resonance spin-echo methods for determining selfdiffusion coefficients D are described; some experimental data are presented for protons in water and in benzene from room temperature up to the critical point. The results are interpreted in terms of the free-volume rate theory of MACEDO and LITOVITZ. The D-value of benzene may be described by a single activation energy. Water, however, shows such behavior only at high temperatures, thus demonstrating the strong influence of hydrogen bonding. The STOKES-EINSTEIN relation between diffusion coefficient and viscosity is well satisfied over that part of the temperature range where viscosity values are available.

NMR Investigation of Order Fluctuations, Self-Diffusion and Rotational Motions in the Nematic Liquid Crystal MBBA by T1-Relaxation Spectroscopy

We report on measurements of the proton spin T1 relaxation dispersion at various temperatures in the nematic phase of the liquid crystal MBBA in the Larmor frequency range from 2 kHz to 270 MHz, which exceeds previous studies by more than 3 orders of magnitude. The new results cannot be interpreted in terms of either order fluctuations or self-diffusion as recently proposed by Doane et al.1 and Blinc et al.2, respectively. Instead, the dispersion and its temperature dependence indicate the significance of at least three relaxation mechanisms, namely order fluctuations (OF), self-diffusion (SD) and rotation of the molecular ellipsoids about the short axis (R). The combined OF-SD-R model presented in this work allows a quantitative analysis of the experimental findings! The correlation times and activation energies of the three molecular reorientations evaluated from the T1 dispersion by means of a computer optimization procedure are in essential agreement with data provided by other spectroscopic methods [light scattering, tracer technique, dielectric relaxation], but differ from former NMR conclusions.

Kernmagnetische Messungen an einem linearen Polyäthylen I. Spin-Gitter-Relaxationszeit T1 und Linienform1

Die Spin-Gitter-Relaxationszeit T1 und die Form des Kernresonanzsignals der Protonen eines linearen Polyäthylens (Marlex 50, Typ 15) wurden mit einer Impulsapparatur bei 28 MHz zwischen —150°C und + 180°C untersucht. Die Ergebnisse an festem und geschmolzenem Polyäthylen lassen sich durch drei verschiedene Bewegungsformen der Polyäthylen-Moleküle erklären, die mit steigender Temperatur angeregt werden. Die Theorie von SOLOMON 2 wird dazu auf einige anisotrope Bewegungen angewandt.

Frequency Dependence of Proton Spin Relaxation in Liquid Crystalline PAA

We report on measurements of the Larmor frequency dependence of the proton spin relaxation time T1 in the nematic and isotropic phase of p-azoxyanisole (frequency range: 3.8 kHz ≦ ωL/2 π≦75 MHz) . In both cases our results clearly support the Pincus-Cahane mechanism of spin relaxation by order fluctuations ("ωL−½-law") and exclude the alternative translational dif­fusion model (“ωL+½-law”). For the isotropic phase it was possible to evaluate the correlation time τ of the liquid crystalline order fluctuations from the observed T1 dispersion. As a function of the deviation ⊿ν=ν-νc from the critical nematic-isotropic transition temperature, νc= (136± 0.5)°C, we found τ=2.71·10-7-⊿ν-0.25s .

Kernmagnetische Relaxation und Korrelation im System Wasser - Sauerstoff

The magnetic interaction between the electronic magnetic dipole moment of molecular oxygen dissolved in water and water protons has been investigated by measuring the nuclear magnetic proton relaxation times and their dependence upon oxygen pressure (10–2—200 at), upon the proton LARMOR frequency (0.45 — 160 Mc) and upon temperature (20°C—300°C). The results are interpreted in terms of microscopic correlation times. The dipolar interaction, which is dominant, appears to be modulated in time mainly by the correlation time τS of the 02 electron spin. At 25°C we obtain τS = (1 ± 0.4) · 10-11 sec for the O2 spin correlation time and d= 2.87 ± 0.15 Å for the effective distance of nearest approach between electron and proton spin. The value for the translational correlation time TD &gt; 1.3·10-11 sec at 25°C, somewhat larger than in pure water, might suggest a weak, short-lived bonding between O2 and H2O.

NMR Pulsed Field Gradient Study of Self-Diffusion in the Isotropic Phase of the Liquid Crystals MBBA and EBBA

In refinement of a previous study made by Hayward and Packer, the self-diffusion coefficients D of the nematogen liquid crystals MBBA and EBBA were remeasured in the isotropic phase by means of the NMR pulsed field gradient technique. In particular, the diffusion measurements were made for the first time at different Larmor frequencies. A comparison with results obtained recently on the same samples by NMR T1 relaxation analysis reveals a severe discrepancy. Since the gradient method gives results in essential agreement with optical spectroscopies, the observed discrepancy must be attributed to shortages of the relaxation analysis (incorrect models, insufficient experimental accuracy). It is also shown that D depends more strongly on the molecular weight m than m-1/2 .

Proton Spin Relaxation in Reentrant Nematic Cyano -biphenyl Liquid Crystals

The frequency dependence of the longitudinal proton spin relaxation time T1 was measured by field-cycling and standard NMR techniques in the nematic, smectic and reentrant nematic mesophases of the reentrant liquid crystal 6OCB-8OCB. The results clearly demonstrate that, in contrast to conclusions reported in the literature, the underlying relaxation mechanisms are the same for the nematic and reentrant nematic order, but different in the nematic and smectic phase. In particular, at low frequencies the nematic and reentrant samples reveal a square-root dispersion profile (T1,~ ν½) characteristic for nematic director fluctuations, whereas the smectic samples show a dissimilar and only very narrow dispersion step. It can be attributed to a linear relaxation time increase (T1 ~ v1) expected for smectic-type order fluctuations. The experimental data are described and discussed in terms of four molecular processes, namely nematic or smectic order fluctuations, self-diffusion, rotational motions, and a resonant proton nitrogen coupling.

NMR Study of Collective Motions and Bending Rigidity in Multilamellar System of Lipid and Surfactant Bilayers

The frequency dependence of the longitudinal proton spin relaxation time T1 was measured by field-cycling and standard NMR techniques at different temperatures in the liquid crystalline lamellar phases of bilayer systems, composed of lipids, nonionic surfactants, and lipid-surfactant mixtures. We show by our data analysis, comparing various motional models such as layer undulations (LUs) and relaxation by translational diffusion mediated reorientations (TR), that collective layer undulations with their typical T1~ν behaviour determine the low frequency T1 dispersion in both unoriented and glass plate-oriented bilayer systems. The angular dependence of the T1 dispersion for the oriented bilayer system supports these findings and provides a more critical analysis of the two dimensional self-diffusion than in unoriented samples. The evaluated fitting parameters of the LU model allows, together with the measured second moment of the proton NMR signal for the lipid, calculation of the bending rigidity ϰc for these bilayers at different levels of hydration. The obtained values of ϰc turn out to be too large compared with the literature. However, using recent LU models (B. Halle) which include the obvious couplings between neighbouring bilayers at low Larmor frequencies, the corrected ϰc of the fully hydrated membrane systems are comparable to those obtained from the standard videooptical experiments. Therefore proton spin relaxation measure-ments at low Larmor frequencies with the field-cycling technique are a suitable means to determine the bending rigidity ϰc of model membrane systems at low hydrations and of systems containing surfactants.

NMR Field-Cycling Study of Rotational Flow and Viscosity in Nematic Liquid Crystals

A proton NMR method is described which enables rotational flow and viscosity measurements of low molecular weight ṉematic ḻiquid c̱rystals (NLC's). This is achieved by an extension of the common NMR field-cycling technique, namely by fast electronic switching of both the external magnetic field direction and strength. In thermodynamic equilibrium, the director of an NLC with positive diamagnetic anisotropy (Δχ > 0) orients parallel to the external magnetic field. Thus a change of this direction causes a reorientation process of the molecules to align to the new equilib­rium, which in low viscous systems in contrast to polymer liquid crystals is rather fast and hence requires fast field switching. We have studied systematically this response as a function of the initial field rotation angle 90 relative to the director for some homologous NLC's of the n-alkyl-cyano-biphenyl (nCB) series. It is shown that there exists a critical angle θcr in such a way that for θo < θcr, however (e.g. in the case of 5 CB θcr is ≈ 85 degrees) the viscoelastic behaviour is more complicated because of a coupling between flow and director gradients. The analysis of the alignment process by the changes of the proton line spectra also allows to determine the Leslie viscosities α1, α2, α3, α4 + α5, and the average Frank elastic constant K̄ by a single measurement.