Molecular genetic screening after non-ischaemic sudden cardiac arrest and no overt cardiomyopathy in real life: A major tool for the aetiological diagnostic work-up

BACKGROUND

With the development of advanced sequencing techniques, genetic testing has emerged as a valuable tool for the work-up of non-ischaemic sudden cardiac arrest (SCA).

AIMS

To evaluate the effectiveness of genetic testing in patients with unexplained SCA, according to clinical phenotype.

METHODS

All patients who underwent molecular genetic testing for non-ischaemic SCA with no left ventricular cardiomyopathy between 2012 and 2021 in two French university hospitals were included.

RESULTS

Of 66 patients (mean age 36.7±11.9years, 54.5% men), 21 (31.8%; 95% confidence interval 22.4-45.3%) carried a genetic variant: eight (12.1%) had a pathogenic or likely pathogenic (P/LP) variant and 13 (19.7%) had a variant of uncertain significance (VUS). Among 37 patients (56.1%) with no phenotypic clues, genetic testing identified a P/LP variant in five (13.5%), mainly in RYR2 (n=3) and SCN5A (n=2), and a VUS in nine (24.3%). None of the nine patients with phenotypic evidence of channelopathies had P/LP variants, but two had VUS in RYR2 and NKX2.5. Among the 20 patients with suspected arrhythmogenic cardiomyopathy, three P/LP variants (15.0%) and two VUS (10.0%) were found in DSC2, PKP2, SCN5A and DSG2, TRPM4, respectively. Genetic testing was performed sooner after cardiac arrest (P<0.001) and results were obtained more rapidly (P=0.02) after versus before 2016.

CONCLUSION

This study highlights the utility of molecular genetic testing with a genetic variant of interest identified in one-third of patients with unexplained SCA. Genetic testing was beneficial even in patients without phenotypic clues, with one-fourth of patients carrying a P/LP variant that could have direct implications.

Titin copy number variations associated with dominant inherited phenotypes

BACKGROUND

Titinopathies are caused by mutations in the titin gene (TTN). Titin is the largest known human protein; its gene has the longest coding phase with 364 exons. Titinopathies are very complex neuromuscular pathologies due to the variable age of onset of symptoms, the great diversity of pathological and muscular impairment patterns (cardiac, skeletal muscle or mixed) and both autosomal dominant and recessive modes of transmission. Until now, only few CNVs in TTN have been reported without clear genotype-phenotype associations.

METHODS

Our study includes eight families with dominant titinopathies. We performed next-generation sequencing or comparative genomic hybridisation array analyses and found CNVs in the TTN gene. We characterised these CNVs by RNA sequencing (RNAseq) analyses in six patients' muscles and performed genotype-phenotype inheritance association study by combining the clinical and biological data of these eight families.

RESULTS

Seven deletion-type CNVs in the TTN gene were identified among these families. Genotype and RNAseq results showed that five deletions do not alter the reading frame and one is out-of-reading frame. The main phenotype identified was distal myopathy associated with contractures. The analysis of morphological, clinical and genetic data and imaging let us draw new genotype-phenotype associations of titinopathies.

CONCLUSION

Identifying TTN CNVs will further increase diagnostic sensitivity in these complex neuromuscular pathologies. Our cohort of patients enabled us to identify new deletion-type CNVs in the TTN gene, with unexpected autosomal dominant transmission. This is valuable in establishing new genotype-phenotype associations of titinopathies, mainly distal myopathy in most of the patients.

Type 3 long QT syndrome: Is the effectiveness of treatment with beta-blockers population-specific?

BACKGROUND

The efficacy of beta-blocker treatment in type 3 long QT syndrome (LQT3) remains debated.

OBJECTIVES

The purpose of this study was to test the hypothesis that beta-blocker use is associated with cardiac events (CEs) in a French cohort of LQT3 patients.

METHODS

All patients with a likely pathogenic/pathogenic variant in the SCN5A gene (linked to LQT3) were included and followed-up. Documented ventricular tachycardia/ventricular fibrillation, torsades de pointes, aborted cardiac arrest, sudden death, and appropriate shocks were considered as severe cardiac events (SCEs). CEs also included syncope.

RESULTS

We included 147 patients from 54 families carrying 23 variants. Six of the patients developed symptoms before the age of 1 year and were analyzed separately. The 141 remaining patients (52.5% male; median age at diagnosis 24.0 years) were followed-up for a median of 11 years. The probabilities of a CE and an SCE from birth to the age of 40 were 20.5% and 9.9%, respectively. QTc prolongation (hazard ratio [HR] 1.12 [1.0-1.2]; P = .005]) and proband status (HR 4.07 [1.9-8.9]; P <.001) were independently associated with the occurrence of CEs. Proband status (HR 8.13 [1.7-38.8]; P = .009) was found to be independently associated with SCEs, whereas QTc prolongation (HR 1.11 [1.0-1.3]; P = .108) did not reach statistical significance. The cumulative probability of the age at first CE/SCE was not lower in patients treated with a beta-blocker.

CONCLUSION

In agreement with the literature, proband status and lengthened QTc were associated with a higher risk of CEs. Our data do not show a protective effect of beta-blocker treatment.

Prevalence and phenotypes associated with ALPK3 null variants in a large French multicentric cohort: Confirming its involvement in hypertrophic cardiomyopathy

Biallelic disease-causing variants in the ALPK3 gene were first identified in children presenting with a severe cardiomyopathy. More recently, it was shown that carriers of heterozygous ALPK3 null variants are at risk of developing hypertrophic cardiomyopathy (HCM) with an adult onset. Since the number of reported ALPK3 patients is small, the mutational spectrum and clinical data are not fully described. In this multi-centric study, we described the molecular and clinical spectrum of a large cohort of ALPK3 patients. Genetic testing using targeted next generation sequencing was performed in 16 183 cardiomyopathy index cases. Thirty-six patients carried at least one null ALPK3 variant. The five paediatric patients carried two ALPK3 variants, all presented an HCM phenotype with severe outcomes (one transplantation, one heart failure and one cardiac arrest). The 31 adult patients carried heterozygous variants and the main phenotype was HCM (n = 26/31); including 15% (n = 4) presented with an apical or a concentric form of hypertrophy. Reporting a large cohort of ALPK3 patients, this collaborative work confirmed a strong association with HCM and suggesting his screening in the context of idiopathic HCM.

Novel pathogenic variants in SLCO2A1 causing autosomal dominant primary hypertrophic osteoarthropathy

Primary hypertrophic osteoarthropathy (PHO), or pachydermoperiostosis, is characterized by a clinical association including digital clubbing, periostosis and pachydermia. SLCO2A1 and HPGD genes are both responsible for PHO. The pathology is classically defined as an autosomal recessive disorder with clinical variability ranging from a mild to more severe phenotype. However, the hypothesis for an autosomal dominant form suggested for a long time was only demonstrated for the first time in 2021 for SLCO2A1. We aimed to detect a second pathogenic variant by a deep sequencing of the entire SLCO2A1 and HPGD genes, associated with functional transcription analysis in PHO patients harboring only one heterozygous variant. Among 10 PHO patients, 4 presented a single pathogenic or probably pathogenic novel variant in SLCO2A1 in heterozygous status (NM_005630.3: c.234+1G > A, c.1523_1524delCT, c.1625G > A and c.31delC), and the others carried homozygous pathogenic variants. For heterozygous forms, we found no additional pathogenic variant in HPGD or SLCO2A1. PHO can be a dominant form with age at disease onset later than that for the recessive form. This dominant form is not exceptional in young adults. In conclusion, both modes of inheritance of PHO explain the clinical variability and the difference in age at disease onset. Molecular analysis is especially required in the incomplete form to distinguish it from secondary hypertrophic osteoarthropathy.

Detailed cell-level analysis of sperm nuclear quality among the different hypo-osmotic swelling test (HOST) classes

PURPOSE

We studied the quality differences between the different hypo-osmotic swelling test (HOST) classes, as measured by criteria of DNA fragmentation, DNA decondensation, and nuclear architecture. The aim was to find particular HOST classes associated with good-quality metrics, which may be potentially used in ICSI (intra-cytoplasmic sperm injection).

METHODS

Ten patients from the Department of Reproductive Medicine at Tenon Hospital (Paris, France) were included. Their semen samples were collected and divided into two fractions: one was incubated in a hypo-osmotic solution as per HOST protocol and sorted by sperm morphology, and a second was incubated without undergoing the HOST protocol to serve as an unsorted baseline. Three parameters were assessed: DNA fragmentation (TUNEL assay), DNA decondensation (chromomycin A3 assay), and nuclear architecture (FISH, with telomeric and whole chromosome painting probes). The different HOST classes were evaluated for these three parameters, and statistical analysis was performed for each class versus the unsorted non-HOST-treated sperm. Results with p<0.05 were considered statistically significant.

RESULTS

For each of the parameters evaluated, we found significant differences between HOST-selected spermatozoa and non-selected spermatozoa. Overall, spermatozoa of HOST classes B and B+ exhibited the highest quality based on four metrics (low DNA fragmentation, low DNA decondensation, short inter-telomeric distance, and small chromosome 1 territory area), while spermatozoa of HOST classes A and G exhibited the poorest quality by these metrics.

CONCLUSION

In addition to their pathophysiological interest, our results open possibilities of sperm selection prior to ICSI, which may allow for optimization of reproductive outcomes in heretofore unstudied patient populations.

A novel deep intronic variant in ATP7B in five unrelated families affected by Wilson disease

BACKGROUND

Wilson disease is an autosomal recessive metabolic disorder resulting from accumulation of excess copper especially in the liver and brain. This disease is mainly characterized by hepatic disorders and less frequently by neuro-psychiatric disturbances. This recessive disease is due to mutation in ATP7B, which codes for an ATPase involved in copper-transport across the plasma membrane. Molecular diagnosis of WD is positive in approximately 98% of cases. Also, in few cases, WD patients present a single deleterious mutation (heterozygous) or no mutation after sanger and NGS standard sequencing analysis of ATP7B. Therefore, in these problematic WD cases, we hypothesized that deleterious mutations reside in intronic regions of ATP7B.

METHODS

Complete ATP7B gene was sequenced by Next Generation Sequencing including its promoter.

RESULTS

Five unrelated families with Wilson disease shared the same novel, deep intronic NG_008806.1 (ATP7B_v001):c.2866-1521G>A variant in ATP7B. Analysis of RNA transcripts from primary fibroblasts of one patient confirmed the deleterious impact of the intronic variant on splicing and its likely pathologic effect in this compound heterozygote.

CONCLUSION

This discovery of a novel intronic mutation in ATP7B has improved the molecular diagnosis of WD in the French patient cohort to greater than 98%. Thus, we recommend complete sequencing of ATP7B gene, including introns, as a molecular diagnostic approach in cases of clinically confirmed WD which lack pathogenic exon or promoter variants in one or both alleles.

Double chromosomal translocation in an infertile man: one-step FISH meiotic segregation analysis and reproductive prognosis

BACKGROUND

The prevalence of chromosomal translocations is 1/500 in the general population. While in the vast majority of cases, carriers have a normal phenotype; they can present with difficulty conceiving due to the presence of a proportion of unbalanced gametes as a consequence of abnormal chromosomal segregation during meiosis. Since complex translocations involve three or more chromosomes, meiotic segregation leads to a greater number of possible combinations which effectively complicate both their study and therapeutic care.

CASE PRESENTATION

We report on the case of a male carrier of a complex homogeneous double Robertsonian translocation: 44, XY, der(13;14)(q10;q10),der(21;22)(q10;q10). We studied his meiotic segregation by FISH on spermatozoa from the initial sample, as well as following discontinuous gradient centrifugation and after incubation in an hypo-osmotic solution.

CONCLUSION

We report a method to study in a simple single-step manner the meiotic segregation of double Robertsonian translocations in spermatozoa. Further, our results suggest that reproductive prognosis of affected individuals may be markedly improved by HOST-based sperm selection (HBSS).

E. coli bacteremia in comparison to K. pneumoniae bacteremia: influence of pathogen species and ESBL production on 7-day mortality

In a previous study, we demonstrated prolonged length of hospital stay in cases of extended-spectrum beta-lactamase (ESBL)-positive K. pneumoniae bacteremia compared to bacteremia cases due to E. coli (ESBL-positive and –negative) and ESBL-negative K. pneumoniae. The overall mortality was significantly higher in bacteremia cases resulting from ESBL-positive pathogens but also in K. pneumoniae cases disregarding ESBL-production. In order to examine whether pathogen species rather than multidrug resistance might affect mortality risk, we reanalyzed our dataset that includes 1.851 cases of bacteremia.

[Economic Analysis of Treatment Courses for Patients Over the Age of 80 Years at a Surgical Maximum Care Centre]

BACKGROUND

The demographic change in Germany with an aging population and the resulting necessity of adequate surgical care for older patients was lately discussed with concern. One major aspect is the estimated higher treatment costs in the care of the elderly.

MATERIALS AND METHODS

InEK data from all cases of patients over the age of 80, who were treated and discharged from 2008 to 2012 as inpatients at the Department of General, Visceral, Vascular and Thoracic Surgery at the Charité - Universitätsmedizin Berlin, Campus Mitte, were analysed. Of a total of 13,612 patients 626 patients were over the age of 80. Their lengths of stay, mode of discharge and discharge management as well as costs and reimbursements according to the relevant diagnosis-related groups were analysed.

RESULTS

Cases of elderly patients amounted to a stable 5 % of all cases from 2008 until 2012. Their mean length of stay was 14 (median, 9), range, 1-129 days. 80 % of patients could be regularly discharged, 9 % died, 8 % were transferred to another hospital, 2 % discharged into a nursing home and 1 % into a rehabilitation centre. The elderly patients had a patient clinical complexity level of mean 2.84. Costs per day amounted to a mean 778 (median: 627) €, range: 306-7740 €, total costs to 10,686 (median: 5140) €, range: 368-186,059 €. The mean deficit was 491 (median: 176) € per patient, range: - 30,470-75,144 €. The discharge management was significantly different in comparison to patients under the age of 80 with respect to avoidance of discharge at the weekend.

CONCLUSION

Patients over the age of 80 are a relevant group in surgery. They have an increased perioperative risk, but patients should not be denied surgery solely because of their age. The perioperative management of the elderly has to be of maximum standardised quality. From an economic perspective it can be stated that elderly patients currently pose no exceptional financial risk to a surgical department, but contribute relevantly to the turnover, whereby special attention has to be paid to an early structured discharge management.

Bloodstream infection due to extended-spectrum beta-lactamase (ESBL)-positive K. pneumoniae and E. coli: an analysis of the disease burden in a large cohort

PURPOSE

The burden of extended-spectrum beta-lactamase (ESBL)-positive Enterobacteriaceae (ESBL-E) is growing worldwide. We aimed to determine the financial disease burden attributable to ESBL-positive species in cases of bloodstream infection (BSI) due to K. pneumoniae and E. coli.

METHODS

We conducted a cohort study on patients with BSI due to K. pneumoniae or E. coli between 2008 and 2011 in our institution. Data were collected on true hospital costs, length of stay (LOS), basic demographic parameters, underlying diseases as Charlson comorbidity index (CCI) and ESBL positivity of the pathogens. Multivariable regression analysis on hospital costs and length of stay was performed.

RESULTS

Overall we found 1,851 consecutive cases of ESBL-E BSI, 352 (19.0%) cases of K. pneumoniae BSI and 1,499 (81.0%) cases of E. coli BSI. Sixty-six of E. coli BSI (18.8%) and 178 of K. pneumoniae BSI (11.9%) cases were due to ESBL-positive isolates, respectively (p = 0.001). 830 (44.8%) cases were hospital-onset, 215 (61.1%) of the K. pneumoniae and 615 (41.0%) of the E. coli cases (p < 0.001). In-hospital mortality was overall 19.8, 25.0% in K. pneumoniae cases and 18.5% in E. coli cases (p = 0.006). Increased hospital costs and length of stay were significantly associated to BSI with ESBL-positive K. pneumoniae.

CONCLUSION

In contrast to BSI due to ESBL-positive E. coli, cases of ESBL-positive K. pneumoniae BSI were associated with significantly increased costs and length of stay. Infection prevention measures should differentiate between both pathogens.

Novel use of the wild species Cephalaria joppensis for silage preparation and its nutritive value for feeding lactating dairy cows

This study presents a novel method for use of the wild plant species Cephalaria joppensis (CJ) as agricultural forage for ruminants. Domesticated CJ tends to have higher crop mass yield per hectare than a commercial wheat variety (W) but is similar in in vitro dry matter (DM) digestibility. This study was composed of 3 experiments. Experiment 1 aimed to measure effects of ensiling CJ versus W in packed polyethylene-wrapped bales. Three types of ensiled bales were produced for each plant: 1) direct-cut CJ versus W packed solely; 2) direct-cut CJ versus W mixed as sole roughage source together with dietary ingredient and packed in bales to create CJ total mixed ration (CJ-TMR) or W-TMR; 3) CJ silage versus W silage mixed as one-third of dietary roughage source together with two-thirds sorghum (S) silage and additional dietary ingredients and packed in bales to create CJ-S-TMR or W-S-TMR. Data showed that packing and wrapping created anaerobic conditions within the 4 types of TMR bales while reducing pH (4.12 to 4.37). Dry matter loss during ensilage was higher for the 2 types of TMR containing W compared with CJ. Ensilage decreased soluble nitrate content as well as yeast and mold contamination, and the 4 types of TMR bales were characterized by a long outdoor shelf life (3 mo) and high stability under aerobic exposure. Experiment 2 aimed to measure the intake and digestibility by sheep of the 4 types of packed TMR after 90 d of ensiling. Data demonstrated higher voluntary intake of the CJ-TMR compared with the other TMR types. The CJ-TMR was characterized by higher digestibility of DM, crude protein, and neutral detergent fiber components compared with the CJ-S-TMR. Experiment 3 examined intake, digestibility, and milk production by 21 pairs of lactating cows individually fed CJ-S-TMR versus W-S-TMR. Similar intake (21.6 to 22.0 kg/d) and digestibility of DM and crude protein were observed in cows fed the 2 TMR types (68 to 69% and 66 to 68%, respectively). However, neutral detergent fiber and cellulose digestibility were slightly higher in the cows fed W-S-TMR and this was reflected in a small increase in their milk and energy-corrected milk yield (36.5 and 31.4 kg/cow per day, respectively) compared with cows fed CJ-S-TMR (35.5 and 30.4 kg/cow per day, respectively). Results demonstrate that direct-cut CJ used as is, or CJ silage can be included and ensiled in TMR bales for feeding productive ruminants as a substitute for wheat silage.

Selective Neurogenic Blockade and Perioperative Immune Reactivity in Patients Undergoing Lung Resection

OBJECTIVE: This double-blind, prospective, randomized, controlled trial examined the effects of thoracic epidural block and intravenous clonidine and opioid treatment on the postoperative Th1/Th2 cytokine ratio after lung surgery. The primary endpoint was the interferon γ (IFN-γ; Th1 cytokine)/interleukin 4 (IL-4; Th2 cytokine) ratio. Secondary endpoints were reductions in pain and incidence of pneumonia. METHODS: Sixty patients were randomized into three groups to receive remifentanil intravenously (remifentanil group, n = 20), remifentanil and clonidine intravenously (clonidine group, n = 20), or ropivacaine epidurally (ropivacaine group, n = 20). Pain was assessed using a numerical rating scale (NRS). Cytokines were measured using a cytometric bead array. RESULTS: Patients in the ropivacaine group (thoracic epidural block) had a significantly lower IFN-γ/IL-4 ratio at the end of surgery than those in the remifentanil group and clonidine group. There were no significant between-group differences in the IFN-γ/IL-4 ratio at other time-points. There were no differences in NRS scores at any time-point. No patient developed pneumonia. CONCLUSION: Intraoperative thoracic epidural block decreased the IFN-γ/IL-4 ratio immediately after lung surgery, indicating less inflammatory stimulation during surgery.

Volume therapy and cardiocircular function during hyperthermic intraperitoneal chemotherapy

BACKGROUND

Surgical cytoreduction and simultaneous hyperthermic intraoperative intraperitoneal chemotherapy (HIPEC) for peritoneal carcinomatosis is afflicted with a high incidence of postoperative complications. The knowledge of intraoperative volume therapy during surgery and chemotherapy is limited. On the other hand, the choice of a 'liberal' or 'restrictive' regimen of fluid administration has a deep impact on the postoperative morbidity. The aim of this observational trial was to report detailed data on volume replacement and cardiocircular function during the HIPEC procedure.

METHODS

Eighteen consecutive patients undergoing cytoreductive surgery and HIPEC for peritoneal carcinomatosis were enrolled. The intraoperative volume administration was observed as well as the postoperative morbidity and mortality. Cardiofunctional data were assessed by the invasive transthoracic thermodilution technique.

RESULTS

The study showed that large amounts of volume (1,240 ml h(-1); range: 810-1,570 ml h(-1)) are given during the HIPEC procedure to replace fluid loss and maintain a stable circulatory function. Signs of a hyperdynamic status during intraoperative intraperitoneal chemotherapy were not found.

CONCLUSIONS

During surgical cytoreduction and simultaneous HIPEC, large amounts of volume were administered. HIPEC in itself did not lead to an increased fluid requirement. Further prospective studies with larger populations are needed to investigate whether goal-oriented therapies and a restricted volume regimen can contribute to decrease the postoperative morbidity.

Should functional cardiac murmurs be diagnosed by auscultation or by Doppler echocardiography?

BACKGROUND

For many years, cardiac auscultation has been the only available method for distinguishing between functional and organic murmurs; however, a more reliable differential diagnosis can now be achieved with Doppler echocardiography. The question remains as to whether a Doppler echocardiogram needs to be routinely recorded in the presence of a heart murmur or whether the auscultatory diagnosis of a functional murmur is sufficient.

HYPOTHESIS

This prospective study attempts to answer this important question at a time when medical costs have to be curbed.

METHODS

The three cardiologists involved in this study saw 516 new patients in their private practice over a 10-month period; of these, 321 (63.6%) underwent Doppler echocardiography. All patients underwent careful auscultation prior to echocardiography. At the end of their examinations, the cardiologists noted whether they considered the murmur to be of functional or organic origin. Minimal mitral or aortic regurgitations of short duration and low velocity occurring on non-thickened valves were considered functional.

RESULTS

The results for cardiac auscultation and Doppler echocardiography were considered to be concordant, that is, both techniques diagnosed either a functional or organic murmur in 250 of 321 patients (77.9%). The results for cardiac auscultation and Doppler echocardiography showed a major discordance in just six cases (1.9%). All were mitral regurgitations of moderate severity.

CONCLUSION

The prevalence of cardiac murmurs in the general population is very high. As echocardiography currently represents a significant proportion of cardiac medical expenditure, it would be wise to limit the use of this technique to essential indications. This study confirms that both cardiac auscultation and Doppler echocardiography possess important limitations. Nevertheless, it also shows that well-trained cardiologists can identify the vast majority of functional murmurs on auscultation. Better training of nonspecialist physicians in cardiac auscultation may help in containing medical expenses.

["Fast-track" rehabilitation in thoracic surgery. First experiences with a multimodal, interdisciplinary, and proven perioperative treatment course]

OBJECTIVES

"Fast-track" rehabilitation is a multimodal perioperative treatment concept for accelerating postoperative recovery which has been already used successfully in visceral surgery. Of its use in thoracic surgery however, almost no data exist and the relevance of this concept for pulmonary operations is unknown.

PATIENTS AND METHODS

In this prospective study we examined a new perioperative fast-track treatment concept for thoracic surgery and evaluated the results. This program employs detailed information of patients, intensive perioperative respiratory therapy, thoracic peridural analgesia, forced mobilization, and an early start of postoperative normal food intake.

RESULTS

Fifty consecutive patients with benign or malignant diseases of the lung aged an average of 64 years (range 22-78) were operated on thoracoscopically (n=15) or with thoracotomy (n=35) and treated perioperatively using the fast-track program. All patients were mobilized beginning 4 h postoperatively and had normal food. The incidence of general postoperative complications was 0% in this study. Postoperative stay lasted 4.5 days (range 1.5-28.5). There was no increase in surgical complications, and 6% of the patients were readmitted. The patients' acceptance of this concept was high.

CONCLUSION

Fast-track rehabilitation resulted in a decreased rate of general complications and accelerated rehabilitation in thoracic surgery.

Endocrine Alterations Associated with Extended Time Interval Between Estrus and Ovulation in High-Yield Dairy Cows

Short fertile half-lives of the male and female gametes in the female tract necessitate accurate timing of artificial insemination. We examined the possible association between extension of the estrus to ovulation (E-O) interval and alterations in concentrations of estradiol, progesterone, and the preovulatory LH surge before estrus and ovulation. High-yielding Holstein cows (n = 74 from a total of 106) were synchronized and were examined around the time of the subsequent estrus. They were observed continuously for estrual behavior. Blood samples were collected before and after estrus, and ultrasound checks for ovulation were made every 4 h. About three-quarters of the cows exhibited short (but normal) E-O intervals of 22 to 25 h (25%) or normal intervals of 25 to 30 h (47%); 17% of them displayed a long (but normal) E-O interval of 31 to 35 h, and about 10% exhibited a very long E-O interval of 35 to 50 h. Extended E-O interval comprised estrus-to-LH surge and LH surge-to-ovulation intervals that were both longer than normal. Pronounced changes in hormonal concentrations were noted before ovulation in the very long E-O interval group of cows: progesterone and estradiol concentrations were reduced, and the preovulatory LH peak surge was markedly less than in the other 3 groups. Postovulation progesterone concentrations during the midluteal phase were lesser in the very long and the long E-O interval groups compared with those in the short and normal interval groups. Season, parity, milk yield, and body condition did not affect the estrus to LH surge, LH surge to ovulation, and E-O intervals. The results indicate an association between preovulatory-reduced estradiol concentrations and a small preovulatory LH surge, on the one hand, and an extended E-O interval, on the other hand. Delayed ovulation could cause nonoptimal timing of AI, a less than normal preovulatory LH surge that may be associated with suboptimal maturation of the oocyte before ovulation, or reduced progesterone concentrations before and after ovulation. All may be factors associated with poor fertility in cows with a very long E-O interval.

Alpha-synuclein pathology of the spinal and peripheral autonomic nervous system in neurologically unimpaired elderly subjects

Studies on cases with incidental Lewy body disease (ILBD) suggest that alpha-synuclein (alphaSN) pathology of Parkinson's disease (PD) starts in lower brainstem nuclei and in the olfactory bulb. However, medullary structures as the induction site of alphaSN pathology have been questioned as large parts of the nervous system, including the spinal cord and the peripheral autonomic nervous system (PANS), have not been examined in ILBD. Thus, the time course of PD lesions in the spinal cord or PANS in relation to medullary lesions remains unknown. We collected 98 post mortem cases with no reference to PD-associated symptoms on clinical records. alphaSN pathology was found in the central nervous system, including the spinal cord, and in the PANS in 17 (17.3%) cases. alphaSN pathology was encountered in autonomic nuclei of the thoracic spinal cord, brainstem and olfactory nerves in 17/17, in sacral parasympathetic nuclei in 15/16, in the myenteric plexus of oesophagus in 14/17, in sympathetic ganglia in 14/17, and in the vagus nerve in 12/16 cases. In addition to the thoracic lateral horns, a high number of alphaSN lesions was also found in non-autonomic spinal cord nuclei. Considering supraspinal structures our cases corresponded roughly to the recently described sequential order of alphaSN involvement in PD. Our study indicates, however, that the autonomic nuclei of the spinal cord and the PANS belong to the most constantly and earliest affected regions next to medullary structures and the olfactory nerves. A larger cohort of ILBD cases will be needed to pinpoint the precise induction site of alphaSN pathology among these structures.

Die Aufgabe der Anästhesiologie bei der Umsetzung operativer „Fast track-Konzepte“

In the present study the "fast-track rehabilitation" protocol of the Charité university hospital for patients undergoing elective colonic resection is described. The underlying principles, clinical pathways and outcome data from 208 patients are shown. Particularly anesthesiological aspects of this multimodal approach, such as modified preoperative and postoperative fluid management, changed guidelines for preoperative fasting, effective analgetic therapy using epidural analgesia and avoiding high systemic doses of opioids, use of short-acting anesthetic agents, and maintenance of normothermia as well as normovolemia are presented and discussed. In comparison to outcome data before "fast-track rehabilitation" was established, the duration of postoperative hospital stay has been reduced from 12 to 5 days, the number of general complications (pneumonia, duodenal ulcer bleeding, urinary tract infection, cerebral, cardiac and renal dysfunction) decreased from 20% to 7%, whereas surgical complications remained constant at 17% (8% wound infections, 3% anastomotic insufficiency).

[Implementation of modern operating room management -- experiences made at an university hospital]

Caused by structural changes in health care the general need for cost control is evident for all hospitals. As operating room is one of the most cost-intensive sectors in a hospital, optimisation of workflow processes in this area is of particular interest for health care providers. While modern operating room management is established in several clinics yet, others are less prepared for economic challenges. Therefore, the operating room statute of the Charité university hospital useful for other hospitals to develop an own concept is presented. In addition, experiences made with implementation of new management structures are described and results obtained over the last 5 years are reported. Whereas the total number of operation procedures increased by 15 %, the operating room utilization increased more markedly in terms of time and cases. Summarizing the results, central operating room management has been proved to be an effective tool to increase the efficiency of workflow processes in the operating room.

Effects of GnRH administered to cows at the onset of estrus on timing of ovulation, endocrine responses, and conception

Two experiments examined effects of GnRH administered within 3 h after onset of estrus (OE) on ovulation and conception in dairy cows. In experiment 1, 46 cows received either saline, 250 microg of GnRH, or 10 microg of the GnRH analogue, Buserelin. Cows were observed for estrus, blood samples were collected, and ovulations were monitored by ultrasound. In controls, 76% of cows had intervals from estrus to ovulation of < or = 30 h and 24% had intervals > 30 h. Treatment with either GnRH or GnRH analogue (data combined) increased magnitude of LH surges and decreased intervals from estrus to LH surge or to ovulation. Treated cows all ovulated < or = 30 h after OE. Among control cows, plasma estradiol concentrations before estrus correlated positively with amplitudes of LH surges. Higher plasma progesterone was observed in the subsequent estrous cycle in GnRH-treated cows compared to control cows with delayed ovulations. Experiment 2 included 152 primiparous and 211 multiparous cows in summer and winter. Injection of GnRH analogue at OE increased conception rates (CR) from 41.3 to 55.5% across seasons. In summer, GnRH treatment increased CR from 35.1 to 51.6%. Across seasons, GnRH increased CR from 36.0 to 61.5% in cows with lower body condition at insemination and GnRH increased CR (63.2 vs. 42.2%) in primiparous cows compared to controls. Use of GnRH eliminated differences in CR for cows inseminated early or late relative to OE and increased CR in cows having postpartum reproductive disorders. In conclusion, GnRH at onset of estrus increased LH surges, prevented delayed ovulation, and may increase subsequent progesterone concentrations. Treatments with GnRH increased conception in primiparous cows, during summer, and in cows with lower body condition.

Seasonal differences in progesterone production by luteinized bovine thecal and granulosa cells

This study examined seasonal differences in progesterone (P4) production by granulosa cells (GC) and thecal cells (TC) that were luteinized in vitro during the winter or the summer; it also compared plasma P4 concentrations of lactating dairy cows in the two seasons. First-wave dominant follicles obtained from Holstein cows were dissected on day 6 of the cycle, GC and TC were separated, enzymatically dispersed, and cultured for 9 days in media containing 1% fetal calf serum, forskolin (10 micromol/mL) and insulin (2 microg/mL), to induce cell luteinization. All experimental procedures were identical and characteristics of the follicles were similar in the two seasons. During 9 days of culture, P4 production by luteinized GC was higher in winter than in summer, but the difference only tended to be significant. In contrast, luteinized TC produced three times as much P4 in winter as in summer (324 versus 100 ng/10(5)cells). In the in vivo experiment, P4 concentrations in plasma collected during entire estrous cycles in winter and summer were compared. The cows were, on average, at 70 days postpartum and yielded similar amounts of milk. Concentrations of progesterone in plasma were significantly higher in winter than in summer; during the mid-luteal phase the difference between the two seasons was 1.5 ng/mL. These results indicate that chronic effects of heat-stress are possibly carried over from an impaired follicle to an impaired corpus luteum (CL), and that luteinized TC are more susceptible to heat-stress than luteinized GC.

Self-awareness during the menopause

OBJECTIVE

The aim of the study was to test the hypothesis that body-image and self-esteem are major contributors to the severity of menopausal symptoms, and furthermore to measure the influence of hormonal therapy and postmenopausal oestrogen level on specific complaints such as vasomotor symptoms.

METHODS

For the random check 51 patients, aged 43-63 (x=53.8; s=4.4) of an independent medical institution for menopause referred to as 'Viennese ambulance' were questioned.

RESULTS

It turned out, that their attitude towards menopause was of major influence on the degree of specific symptoms (e.g. depression, misery, headache etc.)-women who had a negative attitude towards the menopause suffered much more from such symptoms than women who had a positive one. Moreover, women who were satisfied with their physical appearance experienced fewer troublesome symptoms. There was a significant association between high self-esteem and fewer menopausal symptoms. The higher the self-esteem, the lower the symptoms.

CONCLUSION

Women with a postmenopausal oestrogen level did not experience more menopausal symptoms than women with an average oestrogen level. Moreover, the symptoms were neither fewer nor more whether the women had undergone a hysterectomy or not whether they got hormonal treatment or not. That refutes the hypothesis, that the decrease of the oestrogen level during menopause is the main reason for the accompanying complaints.

NF-kappaB (p65/RelA) as a regulator of TNFalpha-mediated ML-1 cell differentiation

ML-1 human myeloblastic leukemia cells, suspended in serum-depleted medium, proliferate when the insulin-like growth factor-1 (IGF-1) and transferrin (Tf) are supplied, but differentiate to monocytes when these factors are replaced by the tumor necrosis factor-alpha (TNF-alpha). Induction of differentiation, but not of proliferation, involved the selective activation of diverse members of the NF-kappaB family of proteins. In differentiation-induced cells, NF-kappaB (p65) was translocated from the cytoplasm to the nucleus, whereas NF-kappaB (p75) remained localized to the cytoplasm. In contrast, NF-kappaB (p52) was present in the nuclei of proliferation- as well as of differentiation-induced ML-1 cells. The differentiation-specific translocation of NF-kappaB (p65) from the cytoplasm to the nucleus was mediated by an increase in the level of NIK, the NF-kappaB-inducing kinase which, through phosphorylation of IkappaB kinase alpha (Ikappakalpha), causes a decrease in the level of IkappaBalpha, allowing p65 to move from the cytoplasm to the nucleus. The p52/p65 heterodimer formed in the nucleus, bound specifically to the promoter of the tumor suppressor protein p53, effecting a 25 to 30-fold increase in the level of this protein. As we reported previously (Li et al, Cancer Res 1998; 58: 4282-4287), that increase led to the decreased expression of proliferating cell nuclear antigen (PCNA) and to the loss of proliferation-associated DNA synthesis. The ensuing uncoupling of growth from differentiation was followed by the initiation of the monocyte-specific differentiation program.

Effects of sevoflurane and propofol on pulmonary shunt fraction during one-lung ventilation for thoracic surgery

Forty patients requiring one-lung ventilation (OLV) for thoracic surgery were randomly assigned to receive propofol (4-6 mg kg(-1) h(-1)) or sevoflurane (1 MAC) for maintenance of anaesthesia. Three sets of measurements were taken: (i) after 30 min of two-lung ventilation (TLV), (ii) after 30 min of one-lung ventilation (OLV-1) in the supine position and (iii) during OLV in the lateral position (OLV-2) with the chest open and before surgical manipulation of the lung. There were no differences between groups in patient characteristics or preoperative condition. Increases in shunt fraction during OLV-1 were 17.4% and 17.2% (P=0.94), those during OLV-2 were 18.3% and 16.5% (P=0.59) for the propofol and sevoflurane group, respectively. Cardiac index and other haemodynamic and respiratory variables were similar for the two groups. We conclude that inhibition of hypoxic pulmonary vasoconstriction by sevoflurane may only account for small increases in shunt fraction and that much of the overall shunt fraction during OLV has other causes.

[Pneumomediastinum following drug abuse]

Pneumomediastinum is termed spontaneous when not associated with trauma or other identifiable pathological process. There are several reports of pneumomediastinum following narcotic drug inhalation or smoking while applying positive pressure. We describe a 37-year-old male drug addict, hospitalized after having being found unconscious with shortness of breath. CT scan demonstrated bilateral pneumonia with pneumomediastinum. After a day of mechanical ventilation he gradually recovered and the mediastinal air disappeared. Pneumomediastinum may occur in addicts but usually has no dangerous clinical consequences. If there is respiratory deterioration another cause should be sought.

Diagnosis of coronary artery disease in patients with permanent cardiac pacemaker by dobutamine stress echocardiography or exercise thallium-201 myocardial tomography

This study evaluated the use of dobutamine stress echocardiography and exercise thallium-201 myocardial computed tomography (CT) in the diagnosis of coronary artery disease (CAD) in patients with permanent transvenous pacemaker with the electrode implanted in the right ventricle (RV). Twenty-nine consecutive patients with pacemaker underwent dobutamine stress echocardiography, exercise thallium-201 myocardial CT, and coronary arteriography over a period of 8 +/- 1 days. None of these patients had suffered a myocardial infarction (MI). The cardiac rhythm of every patient was electrically paced during echocardiography and tomography. Sixteen (55%) patients showed CAD on angiography (stenosis > or = 50% of the luminal diameter of a major epicardial vessel). The detection sensitivity for CAD was 94% for the tomography and 88% for the echocardiography (P = NS). The difference between the sensitivities of the two techniques in detecting CAD based on the affected coronary artery was not statistically significant. Of the 13 patients without CAD, tomography showed a positive result in nine cases, i.e., a specificity of 31%, whereas echocardiography showed a positive result in only one case, i.e., a specificity of 92% (P < 0. 01). Exercise thallium-201 myocardial computed tomography produces an increased rate of false-positive results in patients with permanent transvenous cardiac pacemaker (PCP) implanted in the right ventricle (RV). Dobutamine stress echocardiography can thus be used to reduce considerably the level of false-positive results in these patients and still retain a detection sensitivity for CAD equal to that of myocardial tomography.

Orthogonal leads for the measurement of QT dispersion: a comparison with conventional leads

To determine the characteristics of QT interval dispersion using orthogonal ECG leads with high paper speed (100 mm/s) and high voltage gain (10 cm/mV) as compared to conventional 12-lead ECG, we measured the QT dispersion in 57 patients at rest and directly after exercise using these two techniques. The measurements were repeated by the same observer and by an independent observer in 29 patients to assess reproducibility. QT dispersion was found to be significantly lower in orthogonal leads than standard lead tracings (24+/-20 ms versus 44+/-17 ms at rest, P<0.001; 29+/-21 ms versus 53+/-27 ms after exercise, P<0.001, respectively). The intrasubject and interobserver reproducibility was better for the orthogonal lead tracings, making this technique a potentially useful tool for future research.

Clinical study to investigate the predictive parameters for the onset of atrial fibrillation in patients with essential hypertension

BACKGROUND

The risk factors involved in the onset of atrial fibrillation (AF) are well known, but the predictive clinical and paraclinical parameters for the onset of AF in hypertensive patients have not been investigated specifically.

METHODS AND RESULTS

We retrospectively analyzed 97 consecutive patients with hypertension and no known history of AF or cardiovascular events who attended the cardiology outpatient clinic. The analysis was based on clinical data, the noninvasive ambulatory 24-hour measurement of blood pressure (AMBP), a standard 12-lead electrocardiogram, and a Doppler echocardiogram. After a mean follow-up of 25 +/- 3 months, 19 (19. 5%) patients had AF, 3 (15.8%) of whom had a cerebrovascular accident. The patients with AF were older than the others and their AMBP showed higher mean systolic diurnal and nocturnal blood pressures, though no differences in the clinical blood pressure readings were present. On the electrocardiogram, the maximum duration of the P wave and its dispersion were more prolonged in the patients with AF. On the Doppler echocardiogram, left ventricular mass and left atrial dimension were higher in the patients with AF, and the A-wave velocity of diastolic mitral flow was reduced in these patients. In the multivariate analysis, age (odds ratio 3.28, P <.001), diurnal systolic blood pressure (odds ratio 1.35, P <.01) and nocturnal systolic blood pressure (odds ratio 1.16, P <.01), maximum duration of the P wave (odds ratio 2.09, P <.01), dispersion of the P wave (odds ratio 2.52, P <.001), echocardiographic left ventricular mass (odds ratio 1.43, P <.01), left atrial dimension (odds ratio 2.81, P <.001), and velocity of the A wave (odds ratio 2. 24, P <.01) were independent predictors for the onset of AF. After correction for age, maximum duration of the P wave (odds ratio 1.34, P <.01), dispersion of the P wave (odds ratio 1.63, P <.001), and the velocity of the A wave (odds ratio 1.42, P <.01) remained independent predictors for the onset of AF.

CONCLUSIONS

In patients with hypertension, age and the level of diurnal and nocturnal systolic blood pressures measured by 24-hour AMBP are important independent predictors for the onset of AF. Independent of age, increases in left atrial dimension and left ventricular mass, prolongation of the maximum duration and dispersion of the P wave and reduced A-wave velocity are also predictors for the onset of AF.

Nutrition support in cancer

OBJECTIVES

To describe nutrition intervention strategies frequently used to support cancer patients experiencing malnutrition.

DATA SOURCES

Textbook chapters, database reports, and current related literature.

CONCLUSIONS

Clinicians have many options for providing nutrition support interventions for the cancer patient at risk for malnutrition. The most appropriate strategy for a patient should be based on a careful assessment of contributing factors with input from a multidisciplinary team.

IMPLICATIONS FOR NURSING PRACTICE

It is important for nurses to be knowledgeable about nutrition intervention options available to patients at various points along the cancer trajectory. Oncology nurses are in a key position to provide support to patients and families with regard to nutrition issues. Of paramount importance is their contribution to ongoing assessment of nutritional status and early and aggressive intervention to meet nutritional needs.

[Ambulatory management of patients after myocardial infarction]

After a myocardial infarction, the physician should evaluate if his patient has a high risk of complications. Main factors for prognosis are left ventricular systolic function, myocardial ischemia, ventricular arrhythmias and coronary anatomy. Treatment of symptoms and complications (angina, heart failure, ventricular arrhythmias) and drugs aimed at improving prognosis (beta-blockers, platelet inhibitors, angiotensin-converting enzyme inhibitors, estrogen) are discussed. Finally the importance of correcting risk factors is stressed with emphasis on the essential role of statins.

Should a regurgitant mitral valve be replaced simulataneously with a stenotic aortic valve?

Mitral valve regurgitation frequently accompanies aortic valve stenosis. It has been suggested that mitral regurgitation improves after aortic valve replacement alone and that the mitral valve need not be replaced simultaneously Furthermore, mitral regurgitation associated with coronary artery disease, particularly in patients with poor left ventricular function, shows immediate improvement after coronary artery bypass grafting. We studied 60 consecutive patients with aortic stenosis and mitral regurgitation to determine the degree of improvement in mitral regurgitation after aortic valve replacement alone versus aortic valve replacement combined with coronary artery bypass grafting. Thirty-six of the patients had normal coronary arteries (Group 1); the other 24 had symptomatic coronary artery disease requiring bypass surgery (Group 2). Echocardiography was performed preoperatively, 1 week postoperatively, and at follow-up. In Group 1, left ventricular ejection fraction did not improve early or at 2.5 months postoperatively, but mitral regurgitation improved gradually during follow-up. In Group 2, mitral regurgitation showed improvement 1 week postoperatively (p < 0.001), and left ventricular ejection fraction was improved at 2.5 months. We conclude that patients with aortic valve stenosis and mild-to-severe mitral regurgitation, without echocardiographic signs of chordal or papillary muscle rupture and without coronary artery disease, should undergo aortic valve replacement alone. The mitral regurgitation will remain the same or improve. For patients with coexisting coronary artery disease, simultaneous aortic valve replacement and coronary artery bypass grafting are imperative; however, the mitral valve again requires no intervention, since mitral regurgitation improves significantly after the other 2 procedures.

Does nutritionist review of a self-administered food frequency questionnaire improve data quality?

OBJECTIVE

This study sought to evaluate the benefit of utilizing a nutritionist review of a self-administered food frequency questionnaire (FFQ), to determine whether accuracy could be improved beyond that produced by the self-administered questionnaire alone.

DESIGN

Participants randomized into a dietary intervention trial completed both a FFQ and a 4-day food record (FR) at baseline before entry into the intervention. The FFQ was self-administered, photocopied and then reviewed by a nutritionist who used additional probes to help complete the questionnaire. Both the versions before nutritionist review and after nutritionist review - were individually compared on specific nutrients to the FR by means, correlations and per cent agreement into quintiles.

SETTINGS AND SUBJECTS

Three hundred and twenty-four people, a subset of participants from the Polyp Prevention Trial - a randomized controlled trial examining the effect of a low-fat, high-fibre, high fruit and vegetable dietary pattern on the recurrence of adenomatous polyps - were recruited from clinical centres at the University of Utah, University of Buffalo, Memorial Sloan Kettering Cancer Center in New York and Kaiser Permanente Medical Program in Oakland.

RESULTS

Reviewing the FFQ increased correlations with the FR for every nutrient, and per cent agreement into quintiles for all nutrients except calcium. Energy was underestimated in both versions of the FFQ but to a lesser degree in the version with review.

CONCLUSIONS

One must further evaluate whether the increases seen with nutritionist review of the FFQ will enhance our ability to predict diet-disease relationships and whether it is cost-effective when participant burden and money spent utilizing trained personnel are considered.

Tumor suppressor proteins as regulators of cell differentiation

The products of the tumor suppressor genes are considered to function as specific inhibitors of tumor cell growth. In this communication, we present evidence to show that these proteins inhibit tumor cell proliferation by participating in the activation of tumor cell differentiation. The ML-1 human myeloblastic leukemia cells used in this study proliferate when treated with insulin-like growth factor I and transferrin but differentiate to monocytes when exposed to tumor necrosis factor alpha or transforming growth factor beta1, or to macrophage-like cells when treated with both these cytokines. Initiation of proliferation but not of differentiation was followed by a 20- to 25-fold increase in the nuclear level of the DNA polymerase-associated processivity factor PCNA and of the proliferation-specific transcription factor E2F1. In contrast, induction of differentiation but not of proliferation was followed by a 25- to 30-fold increase in the nuclear level of the tumor suppressor proteins p53 (wild type), pRb, and p130/Rb2 and of the p53-dependent cyclin kinase inhibitor p21/Cip1. p53 and p21/Cip1, respectively, inhibit the expression and activation of PCNA, whereas p130 and pRb, respectively, inhibit the expression and activation of E2F1. As a result, G1-S-associated DNA and mRNA synthesis is inhibited, growth uncoupled from differentiation, and maturation enabled to proceed. Where this function of the tumor suppressor proteins is impaired, the capacity for differentiation is lost, which leads to the sustained proliferation that is characteristic of the cancer cell.

[Symptomatic coronary disease associated with mitral insufficiency: surgical strategy]

In recent years coronary artery bypass grafting (CABG) has been extended to include patients with very low left ventricular ejection fractions (LVEF), also frequently with co-existing mild to moderate mitral valve regurgitation (MR). The question is, should MR be corrected simultaneously with a myocardial revascularization or not? Between January 1990 and December 1996, 82 patients with preoperative LVEF < or = 0.25 and echocardiographic evidence of co-existing MR without chordal or papillary muscle rupture (Grade I-28%, II-35%, III-32% and IV-5%) underwent primary CABG. None of them underwent simultaneous mitral valve surgery. The mean preoperative LVEF was 0.17 +/- 0.04 (0.10-0.25), mean PAP 43.8 +/- 15.9 mmHg. An average of 4.4 +/- 1.5 grafts/ patient were placed. The overall mortality was 3.7% (3/82). Transient postoperative low cardiac output syndrome occurred in 24 patients (29%). Thirty-two patients (39%) had no postoperative complications at all. Seventy-nine hospital survivors were followed up over a period of 18 months (6-48 months) on average. There was one death (8 months post-operatively) and 2 graft occlusions, not requiring redo surgery. At the end of follow up echocardiography showed that 45 patients had no MR at all and 28 patients had MR-Grade I, a total of 73 patients (94%). Five patients had Grade II-III MR, none of them requiring mitral valve surgery. All patients improved their NYHA functional class, from 3.5 +/- 0.7 to 1.8 +/- 0.5 and the LVEF from 0.17 +/- 0.04 to 0.46 +/- 0.08, p < 0.001. Moderate to severe co-existing MR (Grade II-IV) seems to normalize after the myocardial revascularization and should therefore not be surgically corrected at the primary operation, if there are no echocardiographic evidence of chordal or papillary muscle rupture. Peroperative control echocardiography is recommended.