Integrated genomic surveillance enables tracing of person-to-person SARS-CoV-2 transmission chains during community transmission and reveals extensive onward transmission of travel-imported infections, Germany, June to July 2021

Background

Tracking person-to-person SARS-CoV-2 transmission in the population is important to understand the epidemiology of community transmission and may contribute to the containment of SARS-CoV-2. Neither contact tracing nor genomic surveillance alone, however, are typically sufficient to achieve this objective.

Aim

We demonstrate the successful application of the integrated genomic surveillance (IGS) system of the German city of Düsseldorf for tracing SARS-CoV-2 transmission chains in the population as well as detecting and investigating travel-associated SARS-CoV-2 infection clusters.

Methods

Genomic surveillance, phylogenetic analysis, and structured case interviews were integrated to elucidate two genetically defined clusters of SARS-CoV-2 isolates detected by IGS in Düsseldorf in July 2021.

Results

Cluster 1 (n = 67 Düsseldorf cases) and Cluster 2 (n = 36) were detected in a surveillance dataset of 518 high-quality SARS-CoV-2 genomes from Düsseldorf (53% of total cases, sampled mid-June to July 2021). Cluster 1 could be traced back to a complex pattern of transmission in nightlife venues following a putative importation by a SARS-CoV-2-infected return traveller (IP) in late June; 28 SARS-CoV-2 cases could be epidemiologically directly linked to IP. Supported by viral genome data from Spain, Cluster 2 was shown to represent multiple independent introduction events of a viral strain circulating in Catalonia and other European countries, followed by diffuse community transmission in Düsseldorf.

Conclusion

IGS enabled high-resolution tracing of SARS-CoV-2 transmission in an internationally connected city during community transmission and provided infection chain-level evidence of the downstream propagation of travel-imported SARS-CoV-2 cases.

Venous Thromboembolism Issues in Women

The lifetime risk of venous thromboembolism (VTE) is slightly higher in women than in men. There are several issues related to VTE that are unique to women. Combined hormonal contraceptives and pregnancy increase the risk of VTE in women of childbearing age, whereas hormone replacement therapy increases the VTE risk of postmenopausal women. Hereditary thrombophilia and risk factors such as older age, obesity, or smoking contribute to the risk increase. In women diagnosed with acute hormone-related VTE who are treated with oral anticoagulants, adequate contraception is mandatory to avoid unwanted pregnancies. According to current knowledge, hormonal contraception may be continued during anticoagulant therapy but must be switched to an estrogen-free contraception method at least 6 weeks before the termination of anticoagulation. VTE is also a major cause of maternal morbidity and mortality during pregnancy and the postpartum period. Currently, assisted reproduction technologies such as in vitro fertilization are widely used to treat couples affected by infertility. Complications of fertility treatment comprise VTE cases, especially in women with ovarian hyperstimulation syndrome. With this review, we intended to focus on VTE issues in women and summarize current evidence and guideline recommendations.

Effective high-throughput RT-qPCR screening for SARS-CoV-2 infections in children

Systematic SARS-CoV-2 testing is a valuable tool for infection control and surveillance. However, broad application of high sensitive RT-qPCR testing in children is often hampered due to unpleasant sample collection, limited RT-qPCR capacities and high costs. Here, we developed a high-throughput approach (‘Lolli-Method’) for SARS-CoV-2 detection in children, combining non-invasive sample collection with an RT-qPCR-pool testing strategy. SARS-CoV-2 infections were diagnosed with sensitivities of 100% and 93.9% when viral loads were >10⁶ copies/ml and >10³ copies/ml in corresponding Naso-/Oropharyngeal-swabs, respectively. For effective application of the Lolli-Method in schools and daycare facilities, SEIR-modeling indicated a preferred frequency of two tests per week. The developed test strategy was implemented in 3,700 schools and 698 daycare facilities in Germany, screening over 800,000 individuals twice per week. In a period of 3 months, 6,364 pool-RT-qPCRs tested positive (0.64%), ranging from 0.05% to 2.61% per week. Notably, infections correlated with local SARS-CoV-2 incidences and with a school social deprivation index. Moreover, in comparison with the alpha variant, statistical modeling revealed a 36.8% increase for multiple (≥2 children) infections per class following infections with the delta variant. We conclude that the Lolli-Method is a powerful tool for SARS-CoV-2 surveillance and can support infection control in schools and daycare facilities.

Dewald et al. combine a non-invasive sampling approach (Lolli-Test) with an RT qPCR-pool testing strategy to screen for SARS-CoV-2 infections in children and use the method for surveillance and infection control in > 4000 school and daycare settings.

Characterization of SARS-CoV-2 infection clusters based on integrated genomic surveillance, outbreak analysis and contact tracing in an urban setting

Background

Tracing of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission chains is still a major challenge for public health authorities, when incidental contacts are not recalled or are not perceived as potential risk contacts. Viral sequencing can address key questions about SARS-CoV-2 evolution and may support reconstruction of viral transmission networks by integration of molecular epidemiology into classical contact tracing.

Methods

In collaboration with local public health authorities, we set up an integrated system of genomic surveillance in an urban setting, combining a) viral surveillance sequencing, b) genetically based identification of infection clusters in the population, c) integration of public health authority contact tracing data, and d) a user-friendly dashboard application as a central data analysis platform.

Results

Application of the integrated system from August to December 2020 enabled a characterization of viral population structure, analysis of 4 outbreaks at a maximum care hospital, and genetically based identification of 5 putative population infection clusters, all of which were confirmed by contact tracing. The system contributed to the development of improved hospital infection control and prevention measures and enabled the identification of previously unrecognized transmission chains, involving a martial arts gym and establishing a link between the hospital to the local population.

Conclusions

Integrated systems of genomic surveillance could contribute to the monitoring and, potentially, improved management of SARS-CoV-2 transmission in the population.

Hormonal Contraception. Guideline of the DGGG, OEGGG and SGGG (S3 Level, AWMF Registry Number 015/015, January 2020)

Aims This is an official interdisciplinary guideline published and coordinated by the German Society for Gynecology and Obstetrics (DGGG), the Austrian Society for Gynecology and Obstetrics (OEGGG) and the Swiss Society for Gynecology and Obstetrics (SGGG). The guideline was developed for use in German-speaking regions and is backed by numerous professional societies and organizations. The aim of this guideline is to provide an evidence- and consensus-based overview of the diagnostic approach and the management of hormonal contraception based on a systematic evaluation of the relevant literature. Methods To compile this S3-guideline, a systematic search for evidence was carried out in PubMed and the Cochrane Library to adapt existing guidelines and identify relevant reviews and meta-analyses. A structured evaluation of the evidence was subsequently carried out on behalf of the Guidelines Commission of the DGGG, and a structured consensus was achieved based on consensus conferences attended by representative members from the different specialist societies and professions. Recommendations Evidence-based recommendations about the advice given to women requesting contraception were compiled. The guideline particularly focuses on prescribing contraceptives which are appropriate to women's individual needs, take account of her personal circumstances, and have few or no side effects.

Prevention of Venous Thromboembolism during Pregnancy and the Puerperium with a Special Focus on Women with Hereditary Thrombophilia or Prior VTE-Position Paper of the Working Group in Women's Health of the Society of Thrombosis and Haemostasis (GTH)

Venous thromboembolism (VTE) is a major cause of maternal morbidity during pregnancy and the postpartum period. Because there is a lack of adequate study data, management strategies for the prevention of VTE during pregnancy have mainly been deduced from case-control and observational studies and extrapolated from recommendations for non-pregnant patients. The decision for or against pharmacologic thromboprophylaxis must be made on an individual basis weighing the risk of VTE against the risk of adverse side effects such as severe bleeding complications. A comprehensive, multidisciplinary approach is often essential as the clinical scenario is made more complex by the specific obstetric context, especially in the peripartum period. As members of the Working Group in Women's Health of the Society of Thrombosis and Haemostasis (GTH), we summarize the evidence from the available literature and aim to establish a more uniform strategy for VTE risk assessment and thromboprophylaxis in pregnancy and the puerperium. In this document, we focus on women with hereditary thrombophilia, prior VTE and the use of anticoagulants that can safely be applied during pregnancy and the lactation period.

Relevance of a single dose of 270 μg/kg recombinant factor VIIa for the treatment of patients with haemophilia and inhibitors

Recombinant activated factor VII (rFVIIa; Novo Seven®) is, besides other indications, authorised for the treatment of bleeding episodes in patients with hereditary haemophilia A or B and inhibitors. Based on the results of three clinical studies, marketing authorisation was granted for the single dose of 270 μg/kg body weight rFVIIa for the treatment of mild-to-moderate bleeding episodes in patients with haemophilia A or B with inhibitors in March 2007. Thereupon, an expert group analysed the relevance of this additional treatment option for clinical routine. Compared with the repeated application of 90 μg/kg body weight rFVIIa, quality of life may be improved if the single dose of 270 μg/kg body weight rFVIIa reduces the number of injections. The single dose has a benefit for those patients who require several rFVIIa applications or who do not respond adequately to low doses. Moreover, patients with poor venous access or who fear injections or reject them (especially children) may benefit from the single dose. The prescription of 270 μg/kg body weight rFVIIa as a single dose instead of multiple dosing of 90 μg/kg body weight is basically an individual and indication-related decision.

Diagnose angeborener Störungen der Thrombozytenfunktion

Angeborene Störungen der Thrombozytenfunktion sind eine heterogene Gruppe von Erkrankungen, die oft erst bei Auftreten von Blutungen erkannt werden. Im klinischen Bereich haben sich nur wenige Methoden zur Diagnose und Klassifizierung von angeborenen Thrombozytenfunktionsstörungen bewährt. Für eine rationelle Diagnostik ist ein stufenweises Vorgehen empfehlenswert. Anamnese und klinische Untersuchung sind Grundvoraussetzungen. Das von-Willebrand-Syndrom und andere plasmatische Gerinnungsstörungen sollten vor einer spezifischen Thrombozytenfunktionsdiagnostik immer ausgeschlossen werden. Die Bestimmung von Zahl, Größe, Volumen (MPV) und Morphologie der Thrombozyten erlauben Rückschlüsse auf die zu Grunde liegende Störung.

Die PFA-100®-Verschlusszeit eignet sich als Screening zum Ausschluss schwerer Thrombozytenfunktionsstörungen. Die Aggrego metrie ermöglicht die Untersuchung zahlreicher Aspekte der Thrombozytenfunktion. Die Durchflusszytometrie ist zur Diagnose von Thrombasthenie Glanzmann, Bernard-Soulier- Syndrom und Freisetzungsstörungen geeignet. Molekulargenetische Untersuchungen können die Verdachtsdiagnose bestätigen oder zum Nachweis nicht beschriebener Defekte verwendet werden. Hier wird die ungekürzte Version der inter -disziplinären Leitlinie* präsentiert.

Prospective Analysis after Coronary-artery Bypass Grafting: Platelet GP IIIa Polymorphism (HPA-1b /PlA2) Is a Risk Factor for Bypass Occlusion, Myocardial Infarction, and Death

Recently, we have demonstrated that human platelet antigen 1b (HPA-1b or PlA2) is a hereditary risk factor for platelet thrombogenicity leading to premature myocardial infarction in preexisting coronary artery disease. However, HPA-1b does not represent a risk factor for coronary artery disease itself. The aim of our present study was to evaluate the role of HPA-1b on the outcome in patients after coronaryartery bypass surgery. We prospectively determined the HPA-1 genotype in 261 consecutive patients prior to saphenous-vein coronaryartery bypass grafting. The patients were followed for one year. Among patients with bypass occlusion, myocardial infarction, or death more than 30 days after surgery, the prevalence of HPA-1b was significantly higher than among patients without postoperative complications (60 percent, 6/10, vs. 24 percent, 58/241, p <0.05, odds ratio 4.7). Using a stepwise logistic regression analysis with the variables HPA1b, age, sex, body mass index, smoking (pack-years), hypertension, diabetes, cholesterol and triglyceride concentration, only HPA-1b had a significant association with bypass occlusion, myocardial infarction, or death after bypass surgery (p = 0.019, odds ratio 4.7). This study shows that HPA-1b is a hereditary risk factor for bypass occlusion, myocardial infarction, or death in patients after coronary-artery bypass surgery.

Polymorphism of Platelet Membrane Glycoprotein IIIa: Human Platelet Antigen 1b (HPA-1b/PlA2) Is an Inherited Risk Factor for Premature Myocardial Infarction in Coronary Artery Disease

Conflicting results of an association between the human platelet antigen 1b (HPA-1b or PlA2) allele and the risk of myocardial infarction and coronary artery disease have been reported. To assess the reason for this discrepancy, we determined the HPA-1 genotype in 298 men who had undergone coronary angiography, including 124 individuals with myocardial infarction, 83 individuals with coronary artery disease but no history of myocardial infarction, and 91 control patients. Among patients with acute or recent onset myocardial infarction (<1 year), the prevalence of HPA-1b was higher than among patients with coronary artery disease but without myocardial infarction (33 percent vs. 14 percent, p = 0.016). In patients under 60 years of age this difference was even more pronounced (45 percent vs. 15 percent, p = 0.003). Unlike conventional risk factors HPA-1b does not represent a risk factor for coronary artery disease itself but appears to be associated with increased platelet thrombogenicity.

Effect of hemostatic risk factors on the individual probability of thrombosis during pregnancy and the puerperium

In a retrospective study of 190 women with a first history of venous thromboembolism during pregnancy and the puerperium and 190 age-matched women with at least one prior pregnancy and no history of venous thromboembolism, the individual probability of thrombosis was determined. Assuming an overall risk of 1 in 1500 pregnancies, the probability of pregnancy-related thrombosis in carriers of homozygous factor V Leiden was 1 in 80 (odds ratio 20.6, p=0.005) and among carriers of combined heterozygous factor V Leiden and heterozygous G20210A mutation in the prothrombin gene 1 in 20 (odds ratio 88, p<0.001). The probability of thrombosis per pregnancy among women with elevated levels of factor VIII:C (>172 % activity) was 1 in 385 (odds ratio 4.5, p<0.001) and among those with increased levels of von Willebrand factor antigen (>190 %) 1 in 435 (odds ratio 4.0, p=0.002), independent of elevated factor VIII:C levels. The high prevalence of combined and homozygous defects of hemostatic components (21.6%) in patients as compared with normal women (0.86%) supports the concept that venous thromboembolism is a multicausal disorder.

Independent adjudicator assessments of platelet refractoriness and rFVIIa efficacy in bleeding episodes and surgeries from the multinational Glanzmann's thrombasthenia registry

Glanzmann's thrombasthenia (GT) is a rare congenital bleeding disorder associated with decreased platelet aggregation due to qualitative/quantitative deficiencies of the fibrinogen receptor. Severe bleeding episodes and perioperative bleeding are typically managed with platelet transfusions, although patients can develop anti-platelet antibodies or experience clinical refractoriness. The GT Registry (GTR) was established to collect efficacy/safety data on hemostatic treatments for GT, including recombinant factor VIIa (rFVIIa). At the request of the United States Food and Drug Administration, three hematology experts evaluated platelet refractoriness, antibody status, and rFVIIa efficacy data on a case-by-case basis to support a potential indication for rFVIIa in GT. Adjudication included 195 patients with 810 events (619 severe bleeding episodes, 192 surgeries), and a consensus algorithm was developed to describe adjudicators' coding of refractoriness and antibody status based on treatment patterns over time. Most rFVIIa-treated events were in patients without refractoriness or antibodies. Adjudicators rated most rFVIIa-treated bleeding episodes as successful (251/266, 94.4%; rFVIIa only, 101/109, 92.7%; rFVIIa ± platelets ± other agents, 150/157, 95.5%); efficacy was consistent in patients with platelet refractoriness ± antibodies (75/79, 94.9%), antibodies only (10/10, 100.0%), and neither/unknown (166/177, 93.8%). Adjudicators also rated most rFVIIa-treated surgeries as successful (159/160, 99.4%; rFVIIa only, 65/66, 98.5%; rFVIIa ± platelets ± other agents, 94/94, 100.0%); efficacy was consistent in patients with platelet refractoriness ± antibodies (69/70, 98.6%), antibodies only (24/24, 100.0%), and neither/unknown (66/66, 100.0%). Unblinding the adjudicators to investigator efficacy ratings changed few assessments. Doses of rFVIIa were narrowly distributed, regardless of other hemostatic agents used.

Perioperative intravenous immunoglobulin treatment in a patient with severe acquired von Willebrand syndrome: case report and review of the literature

Acquired von Willebrand syndrome may be related to plasma cell dyscrasia and can cause severe bleeding complications. Treatment, for example, with intravenous immunoglobulins may be indicated in selected cases. Physicians treating plasma cell dyscrasia have to be aware of bleeding complications in these patients, and clarification is necessary.

Diagnosis of pregnancy-associated venous thromboembolism - position paper of the Working Group in Women’s Health of the Society of Thrombosis and Haemostasis (GTH)

Abstract. Pregnancy and the postpartum period are associated with an increased risk of venous thromboembolism (VTE). Over the past decade, new diagnostic algorithms have been established, combining clinical probability, laboratory testing and imaging studies for the diagnosis of deep vein thrombosis (DVT) and pulmonary embolism (PE) in the non-pregnant population. However, there is no such generally accepted algorithm for the diagnosis of pregnancy-associated VTE. Studies establishing clinical prediction rules have excluded pregnant women, and prediction scores currently in use have not been prospectively validated in pregnancy or during the postpartum period. D-dimers physiologically increase throughout pregnancy and peak at delivery, so a negative D-dimer test result, based on the reference values of non-pregnant subjects, becomes unlikely in the second and third trimesters. Imaging studies therefore play a major role in confirming suspected DVT or PE in pregnant women. Major concerns have been raised against radiologic imaging because of foetal radiation exposure, and doubts about the diagnostic value of ultrasound techniques in attempting to exclude isolated iliac vein thrombosis grow stronger as pregnancy progresses. As members of the Working Group in Women’s Health of the Society of Thrombosis and Haemostasis (GTH), we summarise evidence from the available literature and aim to establish a more uniform strategy for diagnosing pregnancy-associated VTE.

Treatment of pregnancy-associated venous thromboembolism - position paper from the Working Group in Women’s Health of the Society of Thrombosis and Haemostasis (GTH)

Abstract. Venous thromboembolism (VTE) is a major cause of maternal morbidity during pregnancy and the postpartum period. However, because there is a lack of adequate study data, management strategies for pregnancy-associated VTE must be deduced from observational stu-dies and extrapolated from recommendations for non-pregnant patients. In this review, the members of the Working Group in Women’s Health of the Society of Thrombosis and Haemostasis (GTH) have summarised the evidence that is currently available in the literature to provide a practical approach for treating pregnancy-associated VTE. Because heparins do not cross the placenta, weight-adjusted therapeutic-dose low molecular weight heparin (LMWH) is the anticoagulant treatment of choice in cases of acute VTE during pregnancy. No differences between once and twice daily LMWH dosing regimens have been reported, but twice daily dosing seems to be advisable, at least peripartally. It remains unclear whether determining dose adjustments according to factor Xa activities during pregnancy provides any benefit. Management of delivery deserves attention and mainly depends on the time interval between the diagnosis of VTE and the expected delivery date. In particular, if VTE manifests at term, delivery should be attended by an experienced multidisciplinary team. In lactating women, an overlapping switch from LMWH to warfarin is possible. Anticoagulation should be continued for at least 6 weeks postpartum or for a minimum period of 3 months. Although recommendations are provided for the treatment of pregnancy-associated VTE, there is an urgent need for well-designed prospective studies that compare different management strategies and define the optimal duration and intensity of anticoagulant treatment.

Platelet function analyzer (PFA-100) as a useful tool for the prediction of transfusion requirements during aortic valve replacement

BACKGROUND

Shear stress-induced hemostatic abnormalities, particularly loss of the hemostatically most competent, highest molecular weight von Willebrand factor multimers, are common in patients with aortic valve stenosis. Although controversially discussed, these hemostatic defects might be associated with an increased risk of bleeding during aortic valve replacement. Since the determination of closure times with a platelet function analyzer is sensitive for the detection of defects of primary hemostasis including shear stress-induced von Willebrand factor abnormalities, this study was performed to evaluate a method to predict intraoperative transfusion requirements in this setting.

METHODS

Fifty patients (mean age ± SD: 68 ± 9 years, range 40-85 years) admitted for aortic valve replacement were enrolled in the study. Closure times of epinephrine/collagen and ADP/collagen cartridges were determined with a platelet function analyzer in the absence of antiplatelet agents. Results were compared to those obtained in healthy individuals without medication. The probability that a patient would require a transfusion of packed red cells (RBC) and fresh frozen plasma (FFP) was calculated for each obtained closure time using a multiple regression model.

RESULTS

Compared to controls, patients undergoing aortic valve replacement had a significantly higher incidence of prolonged closure in the platelet function analyzer. The prolonged closure time of both epinephrine/collagen and ADP/collagen cartridges was significantly correlated with intraoperative transfusion of RBC, but not FFP.

CONCLUSIONS

In patients undergoing aortic valve replacement, prolongation of closure times as determined by a platelet function analyzer is frequently observed, indicating the presence of shear stress-induced defects of primary hemostasis. Since the prolongation of closure times is significantly correlated to the probability of intraoperative transfusion, this method might offer a significant contribution to the preoperative risk stratification of patients.

Association of genotypes of thrombin-activatable fibrinolysis inhibitors with thrombotic microangiopathies--a pilot study

BACKGROUND

Thrombotic microangiopathies are characterized by microvascular thrombosis, consequently leading to microangiopathic haemolytic anaemia, thrombocytopenia and organ dysfunction. Although recent research has elucidated the pathogenesis of these rare thrombotic disorders to some extent, the determinants contributing to the manifestation remain rather unclear in the majority of affected patients.

METHOD

In the present pilot study, we used a case-control design, enrolling 40 patients [mean age (+/-SD) 35+/-11 years] with a history of thrombotic microangiopathy and 689 control subjects to evaluate the association of gene polymorphisms of the thrombin-activatable fibrinolysis inhibitor (TAFI) with the manifestation of these rare thrombotic disorders. These polymorphisms are major determinants of TAFI plasma levels that were found to modulate the onset of venous and arterial thrombosis.

RESULTS

As a result of our study, the prevalence of the GG genotype (adjusted OR 2.58; 95% CI 0.9-6.1, P=0.044) and the G allele (adjusted OR 2.2; 95% CI 1.2-4.2, P=0.017) of the C1542G polymorphism was significantly higher in patients with a history of thrombotic microangiopathy compared with controls. A higher prevalence of the GG genotype of the TAFI G505A polymorphism was also observed, but this association was not statistically significant (adjusted OR 4.97, CI 0.7-36.7, P=0.12). Considering the established genotype-phenotype associations, our observation suggests that lower TAFI plasma levels are associated with an increased risk for the manifestation of thrombotic microangiopathies. A diminished inactivation of C3a and C5a-also known from haemolytic uraemic syndrome (HUS) associated with factor H deficiency-might be the most likely explanation.

CONCLUSIONS

The results of our pilot study indicate that the GG genotype of the C1542G polymorphism of TAFI displays risk factors for the manifestation of thrombotic microangiopathies. Our observation provides a rationale to assess genotype-phenotype relations by determination of TAFI plasma levels in various stages of disease in patients suffering from these rare thrombotic disorders.

Freehand three-dimensional assessment of left ventricular volumes and ejection fraction with ultrasound contrast agent LK565

AIMS

Accurate assessment of left ventricular function by determining left ventricular volumes and ejection fraction is important in evaluating the prognoses of patients with heart failure. Two-dimensional (2D) echocardiography suffers from low correlation with reference methods like ventriculography. Three-dimensionally (3D) assessed data have been proved to have better conformity. Endocardial border delineation remains a problem, however, especially in patients with suboptimal recordings. Few data exist on 3D-echocardiographic volumetry with ultrasound contrast agents (UCAs). We evaluated the second-generation UCA LK565 for its boundary-tracing capacities in freehand 3D echocardiography in a phase II clinical trial. Safety and efficacy of the novel contrast agent were also evaluated.

METHODS AND RESULTS

Forty patients between the age of 42 and 77 were included in this trial. Left ventricular end-systolic and -diastolic volume (LVESV, LVEDV) and ejection fraction (EF) were determined by either 2D or 3D freehand second harmonic echocardiography with and without use of LK565. Parameters were compared statistically with ventriculography performed in 35 patients. Immune response to LK565 was evaluated by analysing phagocytosis capacity and kinetics of inflammatory cytokines (TNF-alpha, IL-4, IL-10, IFN-gamma). Patients were monitored for adverse events up to 72 h after application of the UCA. Calculated values for left ventricular volumes and ejection fraction correlated best for freehand 3D echocardiography in combination with LK565 (r=0.92 for LVEDV; r=0.96 for LVESV; r=0.94 for EF). Excellent left ventricular contrast enhancement was achieved for approximately 8 min. A reversible saturation of phagocytosis capacity for monocytes and neutrophils set in with a maximum peak at 6h. No significant increase in cytokine expression was observed.

CONCLUSION

LK565 improves feasibility of endocardial border delineation in 3D echocardiography, leading to better correlation of left ventricular volumetry with reference methods. Efficacy and safety of LK565 are equivalent to those of conventional UCAs.

Glanzmann’s Thrombasthenia Treatment: A Prospective Observational Registry on the Use of Recombinant Human Activated Factor VII and Other Hemostatic Agents

Glanzmann's thrombasthenia (GT) is a rare congenital bleeding disorder caused by deficiency or dysfunction of platelet surface glycoprotein (GP) IIb/IIIa receptor. Platelet transfusion is the standard treatment for bleeding that remains non-responsive to conservative measures, and for surgical coverage. Platelet transfusions, however, may result in the development of antibodies to GPIIb/IIIa and/or human leukocyte antigen (HLA), rendering further transfusions ineffective. Recombinant human activated factor VII (rFVIIa; NovoSeven/Niastase [Canada], Novo Nordisk, Bagsvaerd, Denmark) has documented efficacy in GT patients, and is approved in the European Union for the treatment of GT patients with platelet antibodies and platelet refractoriness. However, there are insufficient data to determine the optimal rFVIIa regimen (eg, for major surgery) or to allow thorough safety evaluation (eg, thrombotic risk). A post-marketing, prospective, observational, multinational registry has been developed to collect data on the efficacy and safety of rFVIIa in the treatment and prevention of bleeding in GT patients with platelet antibodies or platelet refractoriness. Patients treated with other hemostatic agents or rFVIIa to avoid the development of antibodies against GPIIb/IIIa will also be reported. Standardized data will be collected using a customized internet-based (www.glanzmann-reg.org) data collection tool. Data collection will begin in 2005 and continue for up to 6 years. Patients of all ages from any country are eligible for inclusion.

p53 codon 72 polymorphic variants, loss of allele-specific transcription, and human papilloma virus 16 and/or 18 E6 messenger RNA expression in squamous cell carcinomas of the head and neck

A polymorphism at codon 72 of the human tumor suppressor p53 determines translation into either arginine or proline. Yet, the impact of this amino acid variability on the risk to develop malignant tumors, particularly carcinomas associated with human papilloma virus (HPV) infections, remains unresolved because of contradictory results. To address a potential correlation between the different genotypes and the manifestation of squamous cell carcinomas of the head and neck (SCCHN), we determined the p53 codon 72 in 193 healthy subjects and 122 unselected SCCHN with known HPV status. Furthermore, loss of allele-specific transcription was analyzed in p53 codon 72 heterozygous (Arg/Pro) SCCHN and correlated with HPV 16 and/or 18 E6 transcript expression. We found a moderately increased risk (odds ratio, 1.86; 95% confidence interval, 1.0-3.3) for individuals with germ line heterozygosity to develop SCC of the pharynx. On the other hand, p53 codon 72 polymorphic variants, most notably the Arg/Arg genotype, showed no association with the presence of HPV 16 and/or 18 E6 transcript. Moreover, there was no evidence for HPV-driven selection in SCCHN with allele-specific loss of transcription. Our data suggest that the p53 codon 72 polymorphism has a minor impact on the development of SCCHN.

p53 Codon 72 Polymorphic Variants, Loss of Allele-Specific Transcription, and Human Papilloma Virus 16 and/or 18 E6 Messenger RNA Expression in Squamous Cell Carcinomas of the Head and Neck

A polymorphism at codon 72 of the human tumor suppressor p53 determines translation into either arginine or proline. Yet, the impact of this amino acid variability on the risk to develop malignant tumors, particularly carcinomas associated with human papilloma virus (HPV) infections, remains unresolved because of contradictory results. To address a potential correlation between the different genotypes and the manifestation of squamous cell carcinomas of the head and neck (SCCHN), we determined the p53 codon 72 in 193 healthy subjects and 122 unselected SCCHN with known HPV status. Furthermore, loss of allele-specific transcription was analyzed in p53 codon 72 heterozygous (Arg/Pro) SCCHN and correlated with HPV 16 and/or 18 E6 transcript expression. We found a moderately increased risk (odds ratio, 1.86; 95% confidence interval, 1.0-3.3) for individuals with germ line heterozygosity to develop SCC of the pharynx. On the other hand, p53 codon 72 polymorphic variants, most notably the Arg/Arg genotype, showed no association with the presence of HPV 16 and/or 18 E6 transcript. Moreover, there was no evidence for HPV-driven selection in SCCHN with allele-specific loss of transcription. Our data suggest that the p53 codon 72 polymorphism has a minor impact on the development of SCCHN.

G-protein beta 3 subunit 825 CC genotype is associated with unexplained (functional) dyspepsia

BACKGROUND & AIMS

In patients with functional dyspepsia, altered alpha-adrenoreceptor function and depression are prevalent, features that are linked to a G-protein beta 3 (GNB3) subunit gene polymorphism (C825T). We aimed to assess the association of specific G-protein beta 3 subunit genotypes with functional dyspepsia.

METHODS

In study A, abdominal symptoms were assessed in 67 patients with unexplained, upper abdominal symptoms and 259 consecutive blood donors with and without abdominal symptoms. In study B, a further 56 patients with functional dyspepsia and 112 age- and sex-matched healthy controls from a blood donor population study were evaluated. Genomic DNA was isolated from buccal swabs and genotyping of the C825T polymorphisms was performed by polymerase chain reaction and restriction analysis.

RESULTS

In the blood donors with no abdominal symptoms in study A (controls, n = 161), genotype distribution was 17 TT, 77 TC, and 67 CC. In blood donors and patients with unexplained abdominal symptoms, genotype distribution was 22 TT, 54 TC, and 89 CC (P = 0.007 vs. controls). In study B, the genotype distribution in functional dyspepsia patients was 4 TT, 18 CT, and 34 CC compared with 4 TT, 62 CT, and 46 CC in the controls (P < 0.02). Combining studies A and B, the odds ratio (OR) adjusted for age and sex for upper abdominal symptoms associated with the CC genotype was 2.2 (95% confidence interval [CI]: 1.4-3.3), compared with subjects with TC and TT genotype carrying an allele.

CONCLUSIONS

Homozygous GNB3 825C carrier status is associated with unexplained predominantly upper abdominal symptoms.

[X-ray contrast media Melitrast-300 and Melitrast-270 in cardiological diagnosis]

The aim of this study was the evaluation of safety and cardiologic efficacy of the non-ionic contrast agent Iosarcol (Melitrast), a contrast agent with low protein affinity in two different iodine concentrations. One hundred patients were prospectively randomized to receive either Melitrast-270 or Melitrast-300 for left heart ventriculography and coronary angiography. Clinical evaluation, blood pressure and pulse measurement were performed and an electrocardiogram was recorded before and after contrast application and the diagnostic efficacy using a score was evaluated. In three patients side effects could be observed 2 hours after the application (vertigo, sickness, sweating). Melitrast in both concentrations led to a good contrast during ventriculography and coronary angiography which could not be differentiated by two experienced observers. Thus a lower iodine concentration and by this a lower viscosity seems to favour Melitrast-270 for invasive cardiologic diagnosis.

[Secondary splenic rupture after thrombolysis for acute myocardial infarction]

Secondary splenic rupture after thrombolysis for acute myocardial infarction. HISTORY AND ADMISSION FINDINGS: A 67-year-old male patient was admitted with acute chest pain and signs of an acute anterior myocardial infarction in the ECG. The usual contraindications were excluded and after a systemic lysis with rt-PA the ECG-alterations as well as the symptoms of angina resolved completely. 2 hours later the patient developed an acute abdomen with a severe circulatory shock. INVESTIGATIONS: On ultrasound and CT a massive intraabdominal bleeding was found. TREATMENT AND COURSE: Emergency laparotomy revealed a splenic rupture. Retrospectively, 6 weeks before admission, the patient had fallen from a ladder to his left side. This is a rare case of a secondary splenic rupture during thrombolysis for acute myocardial infarction. 2 weeks later the patient developed rein-farction with angiographically shown two vessel disease. After angioplasty of the ramus interventricularis anterior (RIVA) he was stable. CONCLUSIONS: Intravenous thrombolysis in case of acute myocardial infarction is the method of choice. In the past a great number of patients were excluded from thrombolysis because of an extensive interpretation of contraindications. The aim to reach an alteration in this use may not risk health of patients by insufficient history.

Association of NAD(P)H: quinone oxidoreductase 1 (NQO1) C609T polymorphism with esophageal squamous cell carcinoma in a German Caucasian and a northern Chinese population

NAD(P)H: quinone oxidoreductase 1 (NQO1) is an antioxidant enzyme, important in the detoxification of environmental carcinogens. A single base substitution (C --> T) polymorphism at nucleotide 609 (null-allele) of NQO1 gene impairs stability and function of the NQO1 protein. To investigate the association of this NQO1 polymorphism with susceptibility to esophageal squamous cell carcinoma (ESCC), the NQO1 C609T genotypes were determined by PCR-RFLP analysis in 450 patients with ESCC (257 German Caucasians and 193 northern Chinese) and 393 unrelated healthy controls (252 German Caucasians and 141 northern Chinese). Additionally, NQO1 protein expression was determined by immunohistochemistry in a subset of 74 ESCC (50 German, 24 Chinese). A significant difference in NQO1 C609T genotype distribution was observed between Caucasian healthy controls (C/C, 73.4%; C/T, 25.0%; T/T, 1.6%) and Chinese healthy controls (C/C, 34.0%; C/T, 49.7%; T/T, 16.3%) (chi(2) = 68.40, P < 0.001). The NQO1 T/T genotype significantly increased the risk for developing ESCC in both Caucasian subjects (OR = 4.62, 95% CI = 1.54-13.86) and Chinese subjects (OR = 1.81, 95% CI = 1.04-3.15), compared with the combined C/C and C/T genotypes. In Chinese subjects, this increased susceptibility was pronounced in patients with family history of upper gastrointestinal cancers (OR = 2.18, 95% CI = 1.14-4.17). Immunohistochemical analysis showed NQO1 protein expression in 53 carcinomas, whereas 21 carcinomas were negative. Negativity for NQO1 expression correlated strongly with the NQO1 genotype, being present in 8.6% of cases with C/C, 22.2% of cases with C/T and 100% of cases with T/T genotype (chi(2) = 16.60, P < 0.001). In summary, the association of the NQO1 C609T polymorphism with ESCC in genetically distinct populations makes a strong argument for its importance in carcinogenesis of ESCC in the German Caucasian and the northern Chinese population.

Clinical risk factors for deep venous thrombosis in pregnancy and the puerperium

Thromboembolic events are among the leading causes of maternal mortality. Mutations in the genes for clotting factors are known, but anamnestic factors can be found in a proportion of women with deep venous thromboses (DVT) during pregnancy and the puerperium. We here describe the clinical factors and pregnancy outcomes of such a group of 70 women who were all operated on for DVT. Highest risk is conferred by a familial history of clotting disease and by known mutations of the clotting factors. This might be used to target a high risk group for preventive treatment.

[A testing device for quality assurance of 3D-ultrasound equipment]

A test object for 3D-ultrasound (US) imaging equipment was constructed, that could be used for various purposes: For training of the correct technical setup procedures and practical handling of a 3D-US equipment, as well as for various quality assurance procedures. The size and volume of these structures were known precisely (+/- 0.1 mm resp. +/- 0.06 mL, respectively; smallest volume: 0.1 mL). The stability of the structures was in agreement with guideline IEC 854 and allowed to quantify exactly the imaging and measurement errors of size and volume measurements performed with commercial 3D-equipment. The test object is well suited to validate measured volume data, as well as to perform procedures of technical quality assurance in a reproducible manner.

Rationale and design of the LURIC study--a resource for functional genomics, pharmacogenomics and long-term prognosis of cardiovascular disease

BACKGROUND AND AIM

Coronary artery disease (CAD), arterial hypertension and Type 2 diabetes mellitus are common polygenetic disorders which have a major impact on public health. Disease prevalence and progression to cardiovascular complications, such as myocardial infarction (MI), stroke or heart failure, are the product of environment and gene interaction. The LUdwigshafen RIsk and Cardiovascular Health (LURIC) study aims to provide a well-defined resource for the study of environmental and genetic risk factors, and their interactions, and the study of functional relationships between gene variation and biochemical phenotype (functional genomics) or response to medication (pharmacogenomics). Long-term follow-up on clinical events will allow us to study the prognostic importance of common genetic variants (polymorphisms) and plasma biomarkers.

SETTING

Cardiology unit in tertiary care medical centre in south-west Germany.

STUDY DESIGN

Prospective cohort study of individuals with and without cardiovascular disease at baseline.

PATIENTS AND METHODS

LURIC is an ongoing prospective study of currently > 3300 individuals in whom the cardiovascular and metabolic phenotypes CAD, MI, dyslipidaemia, hypertension, metabolic syndrome and diabetes mellitus have been defined or ruled out using standardised methodologies in all study participants. Inclusion criteria for LURIC were: German ancestry (limitation of genetic heterogeneity) clinical stability (except for acute coronary syndromes [ACSs]) availability of a coronary angiogram (this inclusion criterium was waived for family members provided that they met all other inclusion and exclusion criteria) Exclusion criteria were: any acute illness other than ACSs any chronic disease where non-cardiac disease predominated a history of malignancy within the past five years. Exclusion criteria were pre-specified in order to minimise the impact of concomitant non-cardiovascular disease on intermediate biochemical phenotypes or on clinical prognosis (limitation of clinical heterogeneity). A standardised personal and family history questionnaire and an extensive laboratory work-up (including glucose tolerance testing in non-diabetics and objective assessment of smoking exposure by determination of cotinine plasma levels) was obtained from all individuals after informed consent. A total of 115 ml of fasting venous blood was sampled for the determination of a pre-specified wide range of intermediate biochemical phenotypes in serum, plasma or whole blood, for leukocyte DNA extraction and immortalisation of B-lymphocytes. Biochemical phenotypes measured included markers of endothelial dysfunction, inflammation, oxidative status, coagulation, lipid metabolism and flow cytometric surface receptor expression of lympho-, mono- and thrombocytes. In addition, multiple aliquots of blood samples were stored for future analyses.

RESULTS

A total of 3500 LURIC baseline measurements were performed in 3316 individuals between July 1997 and January 2000. The baseline examination was repeated within a median of 35 days in 5% of study participants (n = 166, including a third examination in 18 after a median of 69 days) for pharmacogenomic assessment of lipid-lowering therapy and for quality control purposes. A five-year follow-up on major clinical events (death, any cardiovascular event including MI, stroke and revascularisation, malignancy and any hospitalisation) is ongoing. The clinical phenotypes prevalent at baseline in the cohort of 2309 men (70%) with a mean age of 62 +/- 11 years and 1007 women (30%), mean age 65 +/- 10 years, were angiographically-documented CAD in 2567 (79%), MI in 1368 (41%), dyslipidaemia in 2050 (62%) with hypercholesterolaemia > or = 240 mg/dl (27%), hypertriglyceridaemia > or = 150 mg/dl (44%) and HDL-cholesterol < or = 35 mg/dl (38%) in individuals not treated with lipid-lowering agents, systemic hypertension in 1921 (58%), metabolic syndrome in 1591 (48%), Type 2 diabetes in 1063 (32%) and obesity defined by body mass index > or = 30 kg/m2 in 770 (23%). Control patients in whom CAD had been ruled out angiographically were five years younger than those with CAD (59 +/- 12 and 64 +/- 10 years, respectively; p < 0.001), twice as often females (48% compared to 25% females in the CAD group, p < 0.001) and had significantly less cardiovascular risk factors than individuals with CAD. The prevalence of specific cardiovascular risk subsets in LURIC, such as the elderly (> or = 75 years), was 375 (11%), while 213 (6%) were young adults (< 45 years) and 904 (27%) were postmenopausal women (90% of all females). A low risk status (< or = 1 out of the four traditional risk factors: dyslipidaemia, smoking, hypertension and diabetes mellitus) was identified in 314 (9%) individuals of the entire cohort (5% in CAD and 26% in controls, p < 0.001) and 97 (3%) carried none of the four risk factors (1% in CAD and 9% in controls, p < 0.001). (ABSTRACT TRUNCATED)

Angiotensinogen M235T polymorphism is associated with plasma angiotensinogen and cardiovascular disease

BACKGROUND

Genes encoding components of the renin-angiotensin system have been associated with elevated blood pressure (BP) and an increased risk of coronary artery disease. To explore the role of the angiotensinogen (AGT) gene in coronary atherosclerosis and thrombosis, we studied the effect of the AGT M235T gene variant on plasma AGT levels and BP in patients with coronary artery disease and in the subgroup of survivors of myocardial infarction as compared with angiographically defined control subjects.

METHODS AND RESULTS

This was a case-control study of 301 white male subjects examined at Frankfurt University medical center. Plasma AGT levels increased stepwise according to the number of T235 alleles present (no T235 allele, 14.8 +/- 3.9 nmol/L; 1 allele, 15.7 +/- 5.1 nmol/L; 2 alleles, 17.3 +/- 4.7 nmol/L; P =.006). In a multivariate model, circulating AGT emerged as the most important predictor of diastolic pressure (P =.001). In addition, AGT M235T gene polymorphism remained a significant predictor of diastolic BP in a multivariate model adjusted for age, body mass index, fasting glucose, apolipoprotein B, presence of coronary artery disease, and treatment with antihypertensive agents ( P <.05). Finally, homozygosity for T235 was associated with increased univariate risk of coronary artery disease and myocardial infarction (odds ratio estimates 1.5; 95% confidence intervals 1.1 to 2.1, P =.03, and 1.0 to 2.1, P =.05, respectively).

CONCLUSIONS

The significant relations observed between the AGT M235T variant, its protein product, and the cardiovascular disease phenotypes provide evidence for a possible role of elevated circulating AGT in the pathogenesis of coronary artery disease.

Recombinant growth hormone therapy in patients with ischemic cardiomyopathy : effects on hemodynamics, left ventricular function, and cardiopulmonary exercise capacity

BACKGROUND

We studied the effects of recombinant growth hormone (rhGH) on exercise capacity and cardiac function in patients with ischemic cardiomyopathy.

METHODS AND RESULTS

Seven patients (aged 55+/-9 years) with mild to moderate congestive heart failure (ejection fraction 31+/-4%) who were on standard therapy were included. The patients were studied at baseline, after 3 months of rhGH treatment, and 3 months after rhGH discontinuation. Cardiac function was assessed by exercise capacity, right heart catheterization at rest and after submaximal exercise, MRI, echocardiography, and Holter monitoring. When administered at a dose of 2 IU/d, rhGH doubled the serum concentration of insulin-like growth factor-I. rhGH improved clinical symptoms and exercise capacity significantly (New York Heart Association class 2.4+/-0.5 initially versus 1.4+/-0.5 at 3 months [mean+/-SD], P<0.05; VO2max 13.6+/-3.8 versus 17.4+/-5.4 mL. kg-1. min-1, P<0.05). Additionally, pulmonary capillary wedge pressures at rest and after submaximal exercise were reduced significantly. Cardiac output increased, particularly at rest (5.0+/-1.1 versus 5.8+/-1.3 L/min; P<0.05). Posterior wall thickness was increased (1.08+/-0.1 versus 1. 24+/-0.3 cm; P<0.05), and the end-diastolic and end-systolic volume indexes decreased significantly after rhGH treatment. There was no significant increase in left ventricular ejection fraction. The improvements were partially reversed 3 months after rhGH discontinuation.

CONCLUSIONS

The administration of rhGH for 3 months in patients with ischemic cardiomyopathy results in significant improvement in hemodynamics and clinical function. The attenuation of left ventricular remodeling persisted 3 months after discontinuation of treatment.

[Comparative studies of the rate of restenosis after implantation of Palmaz-Schatz and AVE-Micro stents]

Late results of interventional procedures utilizing coronary stents are largely determined by the rate of restenosis. So far few data are available addressing the effect of stent design, implantation pressure and morphologic factors on this crucial variable. Therefore we analyzed the coronary angiograms obtained in 259 patients before, immediately after and at 3 to 6 months following stent implantation for obstructive coronary disease. A total of 196 AVE-Micro-Stents and 142 Palmaz-Schatz-Stents were implanted into 307 stenoses. In 126 stenoses there were implanted only Palmaz-Schatz-Stents, in 170 only AVE-Micro-Stents and in 11 stenoses there were implanted Palmaz-Schatz- as well as Micro-Stents. Restenosis was defined as an over 50% stenosis at follow up. No significant difference was detected with regard to global restenosis rate at an average of 4 months following implantation (Palmaz-Schatz 33%, Micro-Stent 27%). If results were analyzed according to implantation pressure however, there was a significantly lower restenosis rate for AVE-Micro-Stents implanted with > 10 atm (17%) as compared to < or = 10 atm (35%, p < 0.02) and as compared to Palmaz-Schatz-Stents (34%, p < 0.02), which were also implanted with high pressure over 10 atm. In addition to implantation pressure, vessel segment and morphology of stenosis proved to be important determinants of late results. In this series of patients the AVE-Micro-Stent compared favourably to the Palmaz-Schatz-Stent not only with respect to a significantly lower restenosis rate, when implanted with pressures > 10 atm, but also with regard to its superior flexibility and handling characteristics.

[Polymer microparticles for right and left heart echocardiography and imaging myocardial perfusion after peripheral vein injection]

It is conceivable that a stable ultrasound contrast agent could be used for reproducible right and left heart echocardiography and myocardial visualization after intravenous injection. Microparticles from different polymers and preparation procedures were screened in six dogs leading to one superior agent with reproducible high quality echo contrast in doses of 1 mg/kg. This special agent is based on condensates of aspartic acid, ethanolamine and decanoic acid. Out of this material particles were formed with an average diameter of 2 micrometers. The easily suspendable particles were used for the following studies in a dose of 1 mg/kg intravenously in eight pigs. Maximal video intensity averaged 116 +/- 42 relative intensity units (IU) in the right, 137 +/- 42 IU in the left ventricle, 42 +/- 7 in the normally perfused and 11 +/- 2 in the hypoperfused myocardium after circumflex ligature. The area under the intensity curve was 1942 +/- 100 IUxs in the right, 2452 +/- 1291 IUxs in the left ventricle, 518 +/- 124 in the normally perfused and 202 +/- 94 in the hypoperfused myocardium after circumflex ligature. There was no change of heart rate, central arterial or pulmonary artery pressure during and after the injections. There was also no loss of echo intensity during the passage of contrast material through the heart due to systolic pressure. The described agent can be used for the opacification and ultrasonic visualization of the right and left heart as well as normally and hypoperfused myocardium without visible side-effects in animal studies.

[Comparison of NYHA classification with cardiopulmonary function in patients with chronic heart failure]

In this study a correlation was sought between the NYHA class, the results of cardiopulmonary exercise testing (CPX) and the ejection fraction (EF) measured by echocardiography and scintigraphy. Of 36 patients enrolled, CHF in 20 patients was due to CAD and in 16 patients due to DCM. The NYHA class was determined independently by two cardiologists who were blinded to the CPX, echocardiography or scintigraphy results. Sixteen patients were classified as class II and 20 as class III. As a control, 23 patients without cardiopulmonary disease were examined. The CPX was done according to a ramp protocol with continuous measurement of respiratory gases, maximal oxygen consumption (VO2-max) and oxygen consumption at the anaerobic threshold (VO2-AT). A correlation (p = 0.0425) between the NYHA classification and the Weber classification for VO2-AT was found. There was no correlation for VO2-max. VO2-AT was significantly higher in NYHA II patients as compared to NYHA III patients. No significant difference was seen in relation to the VO2-max. In comparison to the normal group, the VO2-AT and VO2-max were significantly lower in NYHA II and III patients. There was no significant correlation between VO2-AT and EF, VO2-max and EF, or between NYHA class and EF. During a 16-month follow-up period lethality was 8/14 patients with VO2-AT < 10 ml/kg/min. Although the NYHA classification provides a valid method for determining the prognosis of CHF patients, if feasible, the CPX examinations should be used to provide updates of the disease progress.

[Primary sclerosing cholangitis: conventional and quantitative liver function tests during long-term therapy with ursodeoxycholic acid]

Primary sclerosing cholangitis, a chronic cholestatic liver disease, frequently leads to an impairment of liver function. In nine men and two women, aged 23 to 57 years, we prospectively studied for three to six years the effect of treatment with ursodeoxycholic acid (UDCA) on liver function. 10 mg UDCA/kg bw significantly reduced serum activities of AP, gamma GT, AST and ALT for several years. After three years of treatment, however, serum concentration of bilirubin was higher than before therapy in eight out of eleven patients (1.8 +/- 0.8 versus 0.9 +/- 0.1 mg/dl; p = 0.01). Likewise, serum concentration of bilirubin was higher in eight out of nine patients after four years of treatment (1.3 +/- 0.3 versus 0.9 +/- 0.1 mg/dl; p = 0.03). In most cases, however, the increase was discrete. Parameters of synthetic liver function (coagulation, serum protein concentration, serum activity of cholinesterase) remained constant in the observation time. Quantitative liver function tests (galactose elimination capacity and indocyanine green half-life) also showed little variation in the observation time. We conclude that UDCA treatment significantly improves serum activities of liver enzymes for several years. Nevertheless, serum bilirubin concentration, believed to be of prognostic value in patients with PSC, seems to rise slowly over time. Serial determinations of galactose elimination capacity and indocyanine green halflife are not superior to conventional liver function tests in the timing of liver transplantation in the individual patient.

Liver function in patients with pulmonary emphysema due to severe alpha-1-antitrypsin deficiency (Pi ZZ)

Alpha 1-Antitrypsin deficiency predisposes to pulmonary emphysema, liver cirrhosis and hepatocellular carcinoma. Anecdotal evidence and a large autopsy study suggest that severe lung and liver disease rarely coexist in the same subject, but this has not been studied in patients. Therefore we investigated 27 patients with severe alpha 1-deficiency (Pi ZZ) and pulmonary emphysema for signs of liver disease and impaired hepatic function. A subgroup of 7 patients underwent quantitative liver function tests. On physical examination or ultrasonography, cirrhosis or tumor was not suspected in any patient. Conventional liver function tests were completely normal in 17 patients. Elevated serum activities of gamma-glutamyltranspeptidase and/or aminotransferases were seen in 10 patients. In some, the elevation was only marginal and in none more than twice normal. The serum bilirubin concentration and activity of alkaline phosphatase were increased in 1 patient. Serum protein, albumin, fibrinogen, antithrombin III, alpha 1-fetoprotein concentrations, serum activities of cholinesterase and glutamate dehydrogenase, activated partial thromboplastin time and prothrombin time were normal in all patients. The indocyanine green half-life was abnormal only in 1 of 6 patients, suggesting that hepatic blood flow was not impaired in the study group. However, the lidocaine half-life and galactose elimination capacity, parameters of hepatic metabolization, were impaired in 4 and 6 of 7 patients, respectively. We conclude that liver disease or impaired liver function is not a clinically relevant problem in most patients with pulmonary emphysema due to alpha 1-antitrypsin deficiency. But results of quantitative liver function tests, although performed in only a small group of patients, suggest that hepatic metabolization might be impaired even in those patients who present with pulmonary disease.

[Transthoracic and transesophageal follow-up in patients with left atrial thrombosis]

The embolic risk and changes of thrombus location and size were investigated in 29 consecutive patients with echocardiographically proven thrombi in the left atrium. Inclusion criteria were the visualization of a left atrial thrombus using transesophageal echocardiography. Transesophageal follow-up echocardiograms were performed at a mean period of 18 months. In this period 6 cases of embolism were observed at an interval of 20 days to 26 months after the detection of thrombus. Thus, the embolic rate was 14% per patient year. All patients received phenprocoumon (n = 4) or aspirin at the time of embolism. Furthermore, in two patients after cardiac thrombectomy left atrial thrombi were seen again although patients were treated with anticoagulants. On the other hand, in 12 patients (5 received oral anticoagulation, 2 received aspirin) thrombi completely resolved. It can be concluded from these data, that the majority of patients receiving anticoagulation profit from this therapy, however, a complete protection against arterial embolism or reoccurrence of thrombi cannot be reached. Left atrial spontaneous echo contrast was the only risk factor significantly associated with thromboembolism in patients with left atrial thrombi.

Influence of blood sampling from venipunctures and catheter systems on serial determinations of prothrombin activation fragment 1 + 2 and thrombin-antithrombin III complex

To evaluate the influence of different blood sampling techniques on test results of thrombin-antithrombin III complex (TAT) and prothrombin fragment 1 + 2 (F1 + 2) serial determinations were performed. In six groups of nonrandomized patients (ten patients each) the concentrations of the coagulation markers of blood samples from central catheters (internal jugular, caval, Shaldon, pulmonary artery) and peripheral cannulas (17G and 18G) were compared with those of blood samples obtained simultaneously from direct venipunctures of the contralateral arm. Medians and 25th-75th percentiles of TAT and F1 + 2 concentrations of plasmas obtained from central catheters were not different from those taken from venipunctures. When delta mean values (catheter - venipuncture) were calculated negative results were obtained, indicating lower concentrations measured from blood sampled through central catheters with the exception of blood that taken from Shaldon catheters. Only for TAT concentrations significantly were lower values measured in blood samples taken from internal jugular catheters when compared with blood samples obtained from direct venipunctures. Significantly higher TAT concentrations were determined in blood samples obtained from Shaldon catheters. For both coagulation markers correlations were found between concentrations in blood samples from central catheters and venipunctures. In blood samples taken from peripheral venous cannulas only F1 + 2 concentrations correlated with the concentrations found in samples from direct venipuncture. In contrast to F1 + 2, TAT concentrations measured from blood samples via peripheral cannulas were determined significantly higher than those taken from direct venipunctures.(ABSTRACT TRUNCATED AT 250 WORDS)

[Diastolic flow analysis of the left ventricle after myocardial infarct]

The diastolic function of the left ventricle was investigated in 12 normal young volunteers, 10 older volunteers, 10 patients without evidence of coronary artery disease, 26 patients with inferior wall and 19 patients with anterior wall infarction at eight locations of the total circumference of the left ventricle using pulsed wave Doppler. The ratio of early diastolic inflow (Vmax E) to the maximal velocity of atrial contraction (Vmax A) was determined. Furthermore, the delay between the end of electrical diastole until the end of the A-wave of the pulsed Doppler was measured. The results were compared with a clinically used marker of myocardial ischemia, treadmill exercise testing. The E/A ratio was 2.03 +/- 0.51 in normal volunteers, 1.16 +/- 0.41 in older volunteers, 1.41 +/- 0.59 in patients without evidence for coronary artery disease, 1.28 +/- 1.13 in patients with inferior and 1.08 +/- 0.41 in patients with anterior wall infarction (p = 0.020 ANOVA). The diastolic delay at the apex was 47.3 +/- 8.9 ms in normal volunteers, 78.3 +/- 8.3 ms in older volunteers, 79.1 +/- 13.7 ms in patients without coronary artery disease, 109.1 +/- 12 ms in patients with inferior and 169.5 +/- 18.8 ms in patients with anterior wall infarction (p = 0.000 ANOVA). There was a correlation between the latter parameter of delay and the amount of pathological wall segments at wall motion analysis (r = 0.61, p = 0.007). In two patients with anterior myocardial infarction (11%) with significant diastolic delay intraventricular thrombi developed consecutively.(ABSTRACT TRUNCATED AT 250 WORDS)