Lipoprotein(a)-an interdisciplinary challenge

Lipoprotein(a) (Lp(a)) is an internationally recognized atherogenic risk factor which is inherited and not changed by nutrition or physical activity. At present, only proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors may modestly decrease its concentration (but not in all patients)-leading to a certain decrease in cardiovascular events (CVE) in controlled studies. However, at present an elevation of Lp(a) is not a generally accepted indication for their use. More effective is lipoprotein apheresis (LA) therapy with respect to both lowering Lp(a) levels and reduction of CVE. In the future, an antisense oligonucleotide against apolipoprotein(a) will probably be available. Atherosclerosis in patients with an elevation of Lp(a) may affect several vessel regions (carotids, aorta, coronaries, leg arteries). Thus, Lp(a) should be measured in high-risk patients. These patients are usually cared for by their family doctors and by other specialists who should closely cooperate. Lipidologists should decide whether costly therapies like PCSK9 inhibitors or LA should be started. The main aim of current therapy is to optimize all other risk factors (LDL cholesterol, hypertension, diabetes mellitus, body weight, renal insufficiency). Patients should be regularly monitored (lab data, heart, arteries). This paper describes the duties of physicians of different specialties when caring for patients with high Lp(a) concentrations.

[Life-threatening bleeding from ileal conduit venous varices in a patient with portal hypertension]

Life-threatening bleeding from portosystemic varices is a feared complication of portal hypertension. Particularly, varices in atypical locations-so-called ectopic varices-pose a challenge for diagnosis and therapy. In the present article, we describe the case of a patient with liver cirrhosis and recurrent bleeding from an ileal conduit resulting from peristomal varicosis. The difficult and hence delayed diagnosis led to a life-threatening hemorrhage that was successfully treated with interventional radiological variceal embolization and TIPS (transjugular intrahepatic portosystemic shunt) implantation.

Hair cortisol and childhood trauma predict psychological therapy response in depression and anxiety disorders

OBJECTIVE

Around 30-50% of patients with depression and anxiety disorders fail to respond to standard psychological therapy. Given that cortisol affects cognition, patients with altered hypothalamic-pituitary-adrenal (HPA) axis functioning may benefit less from such treatments. To investigate this, reliable pretreatment cortisol measures are needed.

METHOD

N = 89 outpatients with depression and anxiety disorders were recruited before undergoing therapy within an Improving Access to Psychological Therapies (IAPT) service. Three-month hair cortisol was determined, and the Childhood Trauma Questionnaire was administered. Patients were classified as responders if they showed significant decreases in depression (>= 6 points on the Patient Health Questionnaire) or anxiety (>= 5 points on the Generalised Anxiety Disorder Scale).

RESULTS

Non-responders in terms of depression (57%) had lower pretreatment hair cortisol concentrations (P = 0.041) and reported more physical abuse (P = 0.024), sexual abuse (P = 0.010) and total trauma (P = 0.039) when compared to responders. Non-responders in terms of anxiety (48%) had lower pretreatment hair cortisol (P = 0.027), as well as higher levels of emotional abuse (P = 0.034), physical abuse (P = 0.042) and total trauma (P = 0.048).

CONCLUSION

If future research confirms hair cortisol to be a predictor of psychological therapy response, this may prove a useful clinical biomarker which identifies a subgroup requiring more intensive treatment.

Diurnal cortisol and alpha-amylase in the daily lives of older adults with vital exhaustion

OBJECTIVE

Vital exhaustion (VE) is characterised by unusual fatigue, increased irritability, and a feeling of demoralisation. It has been found a major risk factor for cardiovascular diseases, and one that is independent of subclinical or clinical manifestations of coronary heart disease or lifestyle-related risk factors. Stress-induced alterations in the hypothalamic-pituitary-adrenal (HPA) axis and sympathetic nervous system may mediate the link between VE and increased cardiovascular risk. However, no studies have yet assessed both systems simultaneously and in high-risk populations, such as older adults.

METHODS

A total of 72 older adults (34 women, mean age 61.7±7.3) who were free of any major physical or mental illnesses filled out the Maastricht Vital Exhaustion Questionnaire (MVEQ) and the Perceived Stress Scale (PSS). To determine cortisol and alpha-amylase, participants collected saliva samples upon awakening, +30min thereafter, and at 11am, 3pm, and 8pm.

RESULTS

Participants with higher VE reported lower perceived stress (β=-0.515, p<0.001). Individuals reporting higher VE also exhibited more diminished cortisol concentrations across the day, although only by trend (β=-0.218, p=0.092). There was no significant association between VE and diurnal alpha-amylase activity. Moreover, women had lower diurnal cortisol (β=-0.381, p=0.004) and alpha-amylase (β=-0.329, p=0.011) when compared to men.

CONCLUSIONS

Our findings provide initial evidence for psychosocial stress to be linked to VE in older adults, while evidence for HPA alterations remains tentative. Future research is warranted to determine whether VE related hypocortisolaemia represents a specific stage of the stress adaptation process that may put individuals at risk for incident cardiovascular diseases.

Biotransformation and detoxification of selenite by microbial biogenesis of selenium-sulfur nanoparticles

This study combines the interaction between the toxic oxyanions selenite and selenate and the plant growth promoting bacterium Azospirillum brasilense with a comprehensive characterization of the formed selenium particles. As selenium is an essential trace element, but also toxic in high concentrations, its state of occurrence in nature is of major concern. Growth of the bacterium was affected by selenite (1-5mM) only, observable as a prolonged growth lag-phase of 3days. Subsequently, selenite reduction occurred under aerobic conditions resulting in extracellularly formed insoluble Se⁰ particles. Complementary studies by microscopic and spectroscopic techniques revealed the particles to be homogeneous and stable Se_8-nS_n structured spheres with an average size of 400nm and highly negative surface charge of -18mV in the neutral pH range. As this is the first study showing Azospirillum brasilense being able to biotransform selenite to selenium particles containing a certain amount of sulfur, even if environmental waters supplemented with selenite were used, they may significantly contribute to the biogeochemical cycling of both elements in soil as well as to their soil-plant transfer. Therefore, microbial biotransformation of selenite under certain circumstances may be used for various bio-remediation and bio-technological applications.

DMSA-scintigraphy in paediatrics: Is the evaluation of the geometric mean necessary for the calculation of the differential renal function?

For assessment of differential renal function (PF) by means of static renal scintigraphy with Tc-99m-dimer-captosuccinic acid (DMSA) the calculation of the geometric mean of counts from the anterior and posterior view is recommended. Aim of this retrospective study was to find out, if the anterior view is necessary to receive an accurate differential renal function by calculating the geometric mean compared to calculating PF using the counts of the posterior view only. Methods: 164 DMSA-scans of 151 children (86 f, 65 m) aged 16 d to 16 a (4.7 ± 3.9 a) were reviewed. The scans were performed using a dual head gamma camera (Picker Prism 2000 XP, low energy ultra high resolution collimator, matrix 256 x 256,300 kcts/view, Zoom: 1.6-2.0). Background corrected values from both kidneys anterior and posterior were obtained. Using region of interest technique PF was calculated using the counts of the dorsal view and compared with the calculated geometric mean [SQR(Ctsdors x Ctsventr]. Results: The differential function of the right kidney was significantly less when compared to the calculation of the geometric mean (p<0.01). The mean difference between the PFgeom and the PFdors was 1.5 ± 1.4%. A difference > 5% (5.0-9.5%) was obtained in only 6/164 scans (3.7%). Three of 6 patients presented with an underestimated PFdors due to dystopic kidneys on the left side in 2 patients and on the right side in one patient. The other 3 patients with a difference >5% did not show any renal abnormality. Conclusion: The calculation of the PF from the posterior view only will give an underestimated value of the right kidney compared to the calculation of the geometric mean. This effect is not relevant for the calculation of the differntial renal function in orthotopic kidneys, so that in these cases the anterior view is not necesssary. However, geometric mean calculation to obtain reliable values for differential renal function should be applied in cases with an obvious anatomical abnormality.

Age-dependent physiological dynamics in acid-base balance, electrolytes, and blood metabolites in growing goats

There is a paucity of published data reporting acid-base equilibrium in goats, and no information is available on how the acid-base complexity changes when suckling goat kids become ruminants. The aims of this study were to evaluate young healthy goats for age-related changes in serum proteins, metabolites, and electrolytes; differences in results when the Henderson-Hasselbalch equation or strong ion approaches were used were also assessed. To assess biological variability and reproducibility, two consecutive long-term studies, each lasting from the 6th to 56th week of life (wl), were performed in 15 (Study 1) and 10 (Study 2) animals. Blood gas analysis, serum biochemical analysis, and electrophoresis were performed on venous blood, and acid-base information was obtained using the traditional Henderson-Hasselbalch approach, Stewart's strong ion model, and Constable's simplified strong ion model. In all goats within the first 4-5 months, serum concentrations of glucose, l-lactate, and inorganic phosphate decreased significantly, while serum concentrations of total protein, albumin, and gamma globulin increased. Consequently, nonvolatile weak acids (A_{tot Alb} and A_{tot TP}) increased. At the end of this 'adaptation period', i.e. when milk was replaced by purely plant-based food, significantly lower bicarbonate and base excess values were accompanied by blood pH that shifted towards acidosis. Electrolytes (Na⁺, K⁺, Ca²⁺, and Cl^-), anion gap, strong ion difference, and strong ion gap did not show age-dependent trends. In conclusion, somatic growth and development of gastro-intestinal fermentation in growing goats act as complex sources of physiological variability on acid-base equilibrium that was not reflected by the Henderson-Hasselbalch equation only.

Two-Center Experience in the Endovascular Treatment of Ruptured and Unruptured Intracranial Aneurysms Using the WEB Device: A Retrospective Analysis

BACKGROUND AND PURPOSE

The safety and efficacy of the Woven EndoBridge (WEB) device for the treatment of cerebral aneurysms has been investigated in several studies. Our objective was to report the experience of 2 neurovascular centers with the WEB device in the treatment of broad-based intracranial aneurysms, including the technical feasibility and safety as well as short- and midterm angiographic and clinical follow-up-results.

MATERIALS AND METHODS

We performed a retrospective analysis of all ruptured and unruptured aneurysms treated with a WEB device (WEB Single-Layer and Single-Layer Sphere) between August 2014 and February 2017. Primary outcome measures included the feasibility of implantation and the angiographic outcome. Secondary outcome measures included the clinical outcome at discharge and procedural complications.

RESULTS

One hundred two aneurysms in 101 patients, including 37 (36.3%) ruptured aneurysms, were treated with the WEB device. Implantation was successful in 98 (96.1%) aneurysms. Additional devices (stents/coils) were necessary in 15.3% (15/98) of aneurysms. Procedural complications occurred in 4.9% (5/102). Of these, 4 were thromboembolic events and 1 was an intraprocedural rupture. Angiographic follow-up at 3 and 12 months was available for 79.6% (78/98) and 50.0% (49/98) of all aneurysms to date, respectively, showing a sufficient aneurysm occlusion in 80.7% (63/78) at 3 months and 77.6% (38/49) at 12 months. Delayed aneurysm ruptures have not been observed during the follow-up period to date.

CONCLUSIONS

The WEB device offers a safe and effective treatment option for broad-based intracranial aneurysms without the need for dual antiplatelet therapy.

Estimating the long-term functional burden of osteoporosis-related fractures

Although fractures are associated with short-term reductions in functional status, there is limited information on longer-term burden of fracture. This study documents evidence of an association between fractures and significant declines and functional health and activities that persist but attenuate beyond two years.

INTRODUCTION

Although fractures are associated with short-term reductions in functional status and may have other short-term effects on healthcare utilization (hospitalization and follow-up care), there is limited information on long-term burden of fracture beyond 12 to 24 months post-fracture. Analysis of the long-term health burden can inform policymakers, health care practitioners, and payers.

METHODS

We acquired a data set containing the 1992-2012 Health and Retirement Survey data linked to the same individuals' Medicare claims. Fracture cases (n = 745) were matched to non-fracture controls using propensity scores matching. A regression-adjusted difference-in-difference (DD) approach was used to compare the change in functional status measures from baseline to two post-fracture periods for fracture cases relative to the change over the same time periods for matched controls. Self-reported measures of functional status were examined: limitations to activities of daily living (ADLs), limitations to instrumental activities of daily living (IADLs), a mobility index, a gross motor skills index, a fine motor skills index, and self-reported general health status.

RESULTS

Fracture cases reported increases in limitations to ADLs, difficulties with mobility, difficulties with gross motor skills, and difficulties with fine motor skills in each HRS collection period (the survey is administered every 2 years) following the fracture or index date (thus up to two years later) than matched controls (all p values < 0.05). The magnitude of these effects diminished in the second post-fracture wave (two to four years after fracture/index date), but they were still statistically significant.

CONCLUSIONS

Results suggest that fractures are associated with significant declines in some measures of functional activities up to two years following the fracture. The effects persist beyond two years but are smaller in magnitude.

Stereochemistry and biological activity of chlorinated lipids: a study of danicalipin A and selected diastereomers

The syntheses of (+)-16-epi- and (+)-11,15-di-epi-danicalipin A (2 and 3) are reported. The conformations of the parent diols 5 and 6 as well as the corresponding disulfates 2 and 3 were determined on the basis of J-based configuration analysis and supported by calculations. The impact of configuration on membrane permeability in Gram-negative bacteria and mammalian cell lines was assessed as well as cytotoxicity. Although diastereomer 2 showed similar behavior to natural (+)-danicalipin A (1), strikingly, the more flexible C11,C15-epimer 3 had no effect on permeability and proved equally or more toxic towards multiple cell lines.