A Mortality Prediction Score for Patients With Veno-Venous Extracorporeal Membrane Oxygenation (VV-ECMO): The PREDICT VV-ECMO Score

Mortality prediction for patients with the severe acute respiratory distress syndrome (ARDS) supported with veno-venous extracorporeal membrane oxygenation (VV-ECMO) is challenging. Clinical variables at baseline and on day 3 after initiation of ECMO support of all patients treated from October 2010 through April 2020 were analyzed. Multivariate logistic regression analysis was used to identify score variables. Internal and external (Monza, Italy) validation was used to evaluate the predictive value of the model. Overall, 272 patients could be included for data analysis and creation of the PREDICT VV-ECMO score. The score comprises five parameters (age, lung fibrosis, immunosuppression, cumulative fluid balance, and ECMO sweep gas flow on day 3). Higher score values are associated with a higher probability of hospital death. The score showed favorable results in derivation and external validation cohorts (area under the receiver operating curve, AUC derivation cohort 0.76 [95% confidence interval, CI, 0.71-0.82] and AUC validation cohort 0.74 [95% CI, 0.67-0.82]). Four risk classes were defined: I ≤ 30, II 31-60, III 61-90, and IV ≥ 91 with a predicted mortality of 28.2%, 56.2%, 84.8%, and 96.1%, respectively. The PREDICT VV-ECMO score suggests favorable performance in predicting hospital mortality under ongoing ECMO support providing a sound basis for further evaluation in larger cohorts.

[Skull base surgery in the German DRG system-New categorization of important procedures]

Surgery of the skull base includes interventions between the nose or paranasal sinuses (anterior skull base) or ear/temporal bone (lateral skull base) and the intracranial space. As interventions at the anterior skull base almost exclusively involve complex pathologies in a demanding anatomical region, in many cases two experienced surgeons from different disciplines are required who should be experienced in operating together. The technical and time requirements are also considerable in many cases; however, for many procedures there are no specific skull base operational and procedural keys (OPS) codes that take the considerable personnel and structural effort into account. A change in the diagnosis-related groups (DRG) system, implemented since the beginning of 2023, now adjusts the remuneration of the abovementioned effort for malignant pathologies of the anterior and lateral skull base. The reallocation of procedures 5‑015.0/1/3/4 and 5‑016.0/2/4/6 results in a significant upgrade of anterior and lateral skull base surgery. Since the beginning of 2023 skull base surgery will no longer be charged under DRG D25C with a (former) relative weight of 1.893, but with DRG D25B with a current relative weight of 3.753 when a code of the aforementioned groups is used. Nevertheless, further adjustments are necessary, for example, in the available reconstructive steps in order to provide the Institute for the Remuneration System in Hospitals (InEK) with the most differentiated data possible on the procedural effort of the intervention and to achieve a more balanced distribution of the reimbursements of skull base surgery in the long term.

Propofol dose and efficacy of defibrillation testing during implantation of subcutaneous implantable cardioverter-defibrillators: A retrospective, single center cohort study

INTRODUCTION

Defibrillation testing (DFT) is recommended during subcutaneous implantable cardioverter-defibrillator (S-ICD) implantation. Previous studies analyzing the potential interference of propofol with defibrillation threshold are inconsistent. The purpose of this study was to analyze whether propofol affects DFT post S-ICD placement.

METHODS

All patients with S-ICD implantation between 01/2017 and 11/2020 at the University Heart Center Freiburg were retrospectively analyzed. Two groups were generated depending on the success of the first shock during DFT. Implantation characteristics and dose of anesthetics were analyzed.

RESULTS

In 12 of the included 80 (15%) patients, first shock during DFT failed. The absolute dose of propofol was significantly higher in patients with first shock failure (median 653 mg [IQR 503-855]) compared to patients with first shock termination (376 mg [200-600]; p = 0.027). Doses of opioids and midazolam as well as type of anesthesia did not differ between the groups. A multivariable binary logistic regression analysis confirmed an independent association of first shock termination and propofol dose (per 100 mg: OR 0.73 (95% CI: 0.56-0.95); p = 0.021).

CONCLUSION

There is an independent association of propofol dose and first shock failure in routine S-ICD defibrillation testing.

Annual hospital procedural volume and outcome in extracorporeal membrane oxygenation for respiratory failure

BACKGROUND

The hospital mortality of patients suffering from pulmonary failure requiring venovenous extracorporeal membrane oxygenation (V-V ECMO) or extracorporeal carbon dioxide removal (ECCO₂ R) is high. It is unclear whether outcome correlates with a hospital's annual procedural volume.

METHODS

Data on all V-V ECMO and ECCO₂ R cases treated from 2007 to 2019 was retrieved from the German Institute for Medical Documentation and Information. Comorbidities and outcomes were assessed by DRG, OPS, and ICD codes. The study population was divided into 5 groups depending on annual hospital V-V ECMO and ECCO₂ R volumes (<10 cases; 10-19 cases; 20-29 cases; 30-49 cases; ≥50 cases). Primary outcome was hospital mortality.

RESULTS

A total of 25,096 V-V ECMO and 3,607 ECCO₂ R cases were analyzed. V-V ECMO hospitals increased from 89 in 2007 to 214 in 2019. Hospitals handling <10 cases annually increased especially (64 in 2007 to 149 in 2019). V-V ECMO cases rose from 807 in 2007 to 2,597 in 2019. Over 50% were treated in hospitals handling ≥30 cases annually. Hospital mortality was independent of the annual hospital procedural volume (55.3%; 61.3%; 59.8%; 60.2%; 56.3%, respectively, p=0.287). We detected no differences when comparing hospitals handling <30 cases to those with ≥30 annually (p=0.659). The numbers of ECCO₂ R hospitals and cases has dropped since 2011 (287 in 2007 to 48 in 2019). No correlation between annual hospital procedural volume and hospital mortality was identified (p=0.914).

CONCLUSION

The number of hospitals treating patients requiring V-V ECMO and V-V ECMO cases rose from 2007 to 2019, while ECCO₂ R hospitals and their case numbers decreased. We detected no correlation between annual hospital V-V ECMO or ECCO₂ R volume and hospital mortality.

Carboxyhemoglobin (CO-Hb) Correlates with Hemolysis and Hospital Mortality in Extracorporeal Membrane Oxygenation: A Retrospective Registry

Background: Patients supported with extracorporeal membrane oxygenation (ECMO) may develop elevated carboxyhemoglobin (CO-Hb), a finding described in the context of hemolysis. Clinical relevance of elevated CO-Hb in ECMO is unclear. We therefore investigated the prognostic relevance of CO-Hb during ECMO support. Methods: Data derives from a retrospective single-center registry study. All ECMO patients in a medical ICU from October 2010 through December 2019 were considered. Peak arterial CO-Hb value during ECMO support and median CO-Hb values determined by point-of-care testing for distinct time intervals were determined. Groups were divided by CO-Hb (<2% or ≥2%). The primary endpoint was hospital survival. Results: A total of 729 patients with 59,694 CO-Hb values met the inclusion criteria. Median age (IQR) was 59 (48−68) years, 221/729 (30.3%) were female, and 278/729 (38.1%) survived until hospital discharge. Initial ECMO configuration was veno-arterial in 431/729 (59.1%) patients and veno-venous in 298/729 (40.9%) patients. Markers for hemolysis (lactate dehydrogenase, bilirubin, hemolysis index, and haptoglobin) all correlated significantly with higher CO-Hb (p < 0.001, respectively). Hospital survival was significantly higher in patients with CO-Hb < 2% compared to CO-Hb ≥ 2%, evaluating time periods 24−48 h (48.6% vs. 35.2%, p = 0.003), 48−72 h (51.5% vs. 36.8%, p = 0.003), or >72 h (56.9% vs. 31.1%, p < 0.001) after ECMO cannulation. Peak CO-Hb was independently associated with lower hospital survival after adjustment for confounders. Conclusions: In ECMO, CO-Hb correlates with hemolysis and hospital survival. If high CO-Hb measured should trigger a therapeutic intervention in order to reduce hemolysis has to be investigated in prospective trials.

Advantages of score-based delirium detection compared to a clinical delirium assessment-a retrospective, monocentric cohort study

Purpose

Delirium is an underdiagnosed complication on intensive care units (ICU). We hypothesized that a score-based delirium detection using the Nudesc score identifies more patients compared to a traditional diagnosis of delirium by ICU physicians.

Methods

In this retrospective study, all patients treated on a general medical ICU with 30 beds in a university hospital in 2019 were analyzed. Primary outcome was a documented physician diagnosis of delirium, or a delirium score ≥2 using the Nudesc.

Results

In 205/943 included patients (21.7%), delirium was diagnosed by ICU physicians compared to 438/943 (46.4%; ratio 2.1) by Nudesc≥2. Both assessments were independent predictors of ICU stay (p<0.01). The physician diagnosis however was no independent predictor of mortality (OR 0.98 (0.57–1.72); p = 0.989), in contrast to the score-based diagnosis (OR 2.31 (1.30–4.10); p = 0.004). Subgroup analysis showed that physicians underdiagnosed delirium in case of hypoactive delirium and delirium in patients with female gender and in patients with an age below 60 years.

Conclusion

Delirium in patients with hypoactive delirium, female patients and those below 60 years was underdiagnosed by physicians. The score-based delirium diagnosis detected delirium more frequently and correlated with ICU mortality and stay.

Long-term survival and health-related quality of life in patients with severe acute respiratory distress syndrome and veno-venous extracorporeal membrane oxygenation support

Background

There is limited information about the long-term outcome of patients suffering from acute respiratory distress syndrome (ARDS) supported with veno-venous extracorporeal membrane oxygenation (VV ECMO). Most studies focused on short- to mid-term follow-up. We aimed to investigate long-term survival and health-related quality of life (HRQL) in these patients.

Methods

We report retrospective data from a single-centre registry of patients with severe ARDS treated with VV ECMO at the Interdisciplinary Medical Intensive Care Unit at the Medical Centre, University of Freiburg, Germany, between 10/2010 and 06/2019. Follow-up data of all patients that survived the index hospitalisation were collected by telephone interviews from 02/2020 till 09/2020. Long-term survival, HRQL (Short-Form Health Survey-36 (SF-36), St. Georges Respiratory Questionnaire (SGRQ), Hospital Anxiety and Depression Scale (HADS)) and the return to work rate were documented.

Results

In total, 289 patients were treated with VV ECMO during the study period (median age 55 years, 67% males, hospital survival 45%). After a median duration of 3.9 years, follow-up assessment was complete in 94 of 129 hospital survivors (73%). Fifty-three patients completed the HRQL assessment. Hospital survivors showed a high 6- and 12-month survival rate (89% and 85%, respectively). Estimated survival rate of those discharged alive from ICU was 68.5% (95%-CI 56.9–80.1%) after 9.7 years. These patients reported high levels of HRQL (median SF-36 total score 73) and only few pulmonary (median SGRQ total score 19) and mental limitations (median HAD-D score 2 and HAD-A score 3). In total, 80% of the patients were able to resume employment.

Conclusion

This analysis of VV ECMO patients showed favourable long-term survival and high levels of HRQL suggesting promising prospects for VV ECMO survivors.

Graphical Abstract

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-021-03821-0.

Incidence and predictors of delirium on the intensive care unit after acute myocardial infarction, insight from a retrospective registry

OBJECTIVES

This study aimed to identify the incidence and potential risk factors for delirium after myocardial infarction (MI).

BACKGROUND

Delirium is a common complication on intensive care units. Data on incidence and especially on predictors of delirium in patients after acute MI are rare.

METHODS

In this retrospective study, all patients hospitalized for MI treated with coronary angiography in an university hospital in 2018 were included and analyzed. Onset of delirium within the first 5 days after MI was attributed to the MI and was defined by a Nursing Delirium screening scale (NuDesc) ≥2. This score is taken as part of daily care in every patient on intensive care unit three times a day by especially trained nurses.

RESULTS

A total of 624 patients with MI (age 68.5 ± 13.2 years, ST-elevation MI 41.6%, hospital mortality 3.2%) were included in the study. Delirium was detected in 10.9% of all patients. In the subgroup of patients with a stay on the intensive care unit (ICU) for more than 24 hr (n = 229), delirium was detected in 29.7%. Hospital and ICU stay were significantly longer in patients with delirium (p < .001). Delirium was an independent predictor of prolonged ICU-stay. Independent predictors of delirium were age, dementia, alcohol abuse, cardiac arrest, hypotension, and leucocytosis. Infarct size or presentation with ST-elevation were not associated with incidence of delirium.

CONCLUSION

Development of delirium is frequent after acute MI and prolongs hospitalization. Incidence of delirium is associated with clinical instability, preexisting comorbidity, and age rather than MI type or size.

Delirium in Critically Ill Patients with and without COVID-19-A Retrospective Analysis

BACKGROUND

Delirium complicating the course of Intensive care unit (ICU) therapy is a known driver of morbidity and mortality. It has been speculated that infection with the neurotrophic SARS-CoV-2 might promote delirium.

METHODS

Retrospective registry analysis including all patients treated at least 48 h on a medical intensive care unit. The primary endpoint was development of delirium as diagnosed by Nursing Delirium screening scale ≥2. Results were confirmed by propensity score matching.

RESULTS

542 patients were included. The primary endpoint was reached in 352/542 (64.9%) patients, without significant differences between COVID-19 patients and non-COVID-19 patients (51.4% and 65.9%, respectively, p = 0.07) and correlated with prolonged ICU stay in both groups. In a subgroup of patients with ICU stay >10 days delirium was significantly lower in COVID-19 patients (p ≤ 0.01). After adjustment for confounders, COVID-19 correlated independently with less ICU delirium (p ≤ 0.01). In the propensity score matched cohort, patients with COVID-19 had significantly lower delirium incidence compared to the matched control patients (p ≤ 0.01).

CONCLUSION

Delirium is frequent in critically ill patients with and without COVID-19 treated at an intensive care unit. Data suggests that COVID-19 itself is not a driver of delirium per se.

Outcomes of female and male patients suffering from coronary artery disease: A nation-wide registry of patients admitted as emergency

Presentation and mortality of coronary artery disease (CAD) substantially differs in both sexes. Most of the existing data analyzing sex differences is older than 10 years and mostly was retrieved in clinical trials, which are potentially structured with a bias against the inclusion of women, leading to a potential selection-bias. Meanwhile, with better diagnostic and therapeutic options, actual data analyzing sex differences in emergency CAD patients is rare.Data on all emergency case numbers with CAD diagnosis in Germany 2017 was retrieved from the German Institute for Medical Documentation and Information. DRG, OPS, and ICD codes were used to determine comorbidities, in-hospital course, and outcome. Competing risk regression analysis for in-hospital mortality was performed analyzing age, European System for Cardiac Operative Risk Evaluation (EuroSCORE), severity of CAD, clinical presentation type and sex.264,742 patients were included. Female patients were older and had more comorbidities. Three-vessel CAD was significantly less present in female patients (36.5% vs 47.5%; P < .001). After adjusting for age, EuroSCORE and severity of CAD, female sex was an independent predictor of lower in-hospital mortality (subdistribution hazard ratio [sHR] 0.94, 95% CI: 0.90-0.98, P = .002) in the whole cohort and in non-ST-segment elevation myocardial infarction (NSTEMI) patients (sHR 0.85, 95% CI: 0.79-0.92, P < .001), whereas in ST-segment elevation myocardial infarction (STEMI) patients, female sex was associated with a higher in-hospital mortality (sHR 1.07, 95% CI: 1.01-1.14, P = .029).In all patients admitted as emergency with CAD diagnosis and in all NSTEMI patients, female sex is protective, whereas in STEMI patients, females show a higher in-hospital mortality risk.

The impact of transcatheter aortic valve implantation planning and procedure on acute and chronic renal failure

BACKGROUND

Severe aortic valve stenosis inhibits renal perfusion, thereby potentially worsening renal function, in particular in elderly patients most often assigned to transcatheter aortic valve implantation (TAVI). Pre-TAVI diagnostics and the procedure itself may adversely impact renal function, however renal perfusion and function may also improve post-procedure. This study aimed to clarify the impact of TAVI planning and procedure on kidney function METHODS: In this retrospective study, kidney function of patients who underwent transfemoral TAVI at a tertiary university hospital between 2016 and 2019 was analyzed. The present study investigated kidney function at baseline, after computed tomography (CT) was performed for evaluation of TAVI, after TAVI, at discharge and at follow-up.

RESULTS

Among 366 patients, the prevalence of acute kidney injury (AKI) was 14.5% after TAVI. Independent predictors of AKI were arterial hypertension, baseline creatinine, AKI post CT and coronary intervention during pre-procedural diagnostics. At discharge and follow-up, 2.1% and 3.4%, respectively had sustained relevant impairment of kidney function (defined as creatinine/baseline creatinine > 1.5 or renal replacement therapy). Patients with known chronic kidney disease showed no higher rates of short- and long-term impairment, but higher rates of improvement of renal function after TAVI.

CONCLUSIONS

In most cases TAVI does not worsen renal function. A sustained impairment after TAVI was found in only a few cases. This was independent of reduced baseline kidney function. Transfemoral TAVI can thus be planned and performed even in patients with higher stages of chronic kidney disease.

Admission blood glucose level and outcome in patients requiring venoarterial extracorporeal membrane oxygenation

Background

Patients with cardiogenic shock or cardiac arrest undergoing venoarterial extracorporeal membrane oxygenation (V-A ECMO) frequently present with blood glucose levels out of normal range. The clinical relevance of such findings in the context of V-A ECMO is unknown. We therefore investigated the prognostic relevance of blood glucose at time of cannulation for V-A ECMO.

Methods

We conducted a single-center retrospective registry study. All patients receiving V-A ECMO from October 2010 to January 2020 were included if blood glucose level at time of cannulation were documented. Patients were divided in five groups according to the initial blood glucose level ranging from hypoglycemic (< 80 mg/dl), normoglycemic (80–140 mg/dl), to mild (141-240 mg/dl), moderate (241–400 mg/dl), and severe (> 400 mg/dl) hyperglycemia, respectively. Clinical presentation, arterial blood gas analysis, and survival were compared between the groups.

Results

392 patients met inclusion criteria. Median age was 62 years (51.5–70.0), SAPS II at admission was 54 (43.5–63.0), and 108/392 (27.6%) were female. 131/392 were discharged alive (hospital survival 33.4%). At time of cannulation, survivors had higher pH, hemoglobin, calcium, bicarbonate but lower potassium and lactate levels compared to non-survivors (all p < 0.01). Outcome of patients diagnosed with particularly high (> 400 mg/dl) and low (< 80 mg/dl) blood glucose at time of V-A ECMO cannulation, respectively, was worse compared to patients with normoglycemic, mildly or moderately elevated values (p = 0.02). Glucose was independently associated with poor outcome after adjustment for other predictors of survival and persisted in all investigated subgroups.

Conclusion

Arterial blood glucose at time of V-A ECMO cannulation predicts in-hospital survival of patients with cardiac shock or after ECPR. Whether dysglycemia represents a potential therapeutic target requires further evaluation in prospective studies.

Graphical Abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s00392-021-01862-7.

Impact of pulse pressure on clinical outcome in extracorporeal cardiopulmonary resuscitation (eCPR) patients

BACKGROUND

Hemodynamic response to successful extracorporeal cardiopulmonary resuscitation (eCPR) is not uniform. Pulse pressure (PP) as a correlate for myocardial damage or recovery from it, might be a valuable tool to estimate the outcome of these patients.

METHODS

We report retrospective data of a single-centre registry of eCPR patients, treated at the Interdisciplinary Medical Intensive Care Unit at the Medical Centre, University of Freiburg, Germany, between 01/2017 and 01/2020. The association between PP of the first 10 days after eCPR and hospital survival was investigated. Moreover, patients were divided into three groups according to their PP [low (0-9 mmHg), mid (10-29 mmHg) and high (≥ 30 mmHg)] at each time point.

RESULTS

One hundred forty-three patients (age 63 years, 74.1% male, 40% OHCA, average low flow time 49 min) were analysed. Overall hospital survival rate was 28%. A low PP both early after eCPR (after 1, 3, 6 and 12 h) and after day 1 to day 8 was associated with reduced hospital survival. At each time point (1 h to day 5) the classification of patients into a low, mid and high PP group was able to categorize the patients for a low (5-20%), moderate (20-40%) and high (50-70%) survival rate. A multivariable analysis showed that the mean PP of the first 24 h was an independent predictor for survival (p = 0.008).

CONCLUSION

In this analysis, PP occurred to be a valuable parameter to estimate survival and maybe support clinical decision making in the further course of patients after eCPR.

Outcome of acute respiratory distress syndrome requiring extracorporeal membrane oxygenation in Covid-19 or influenza: A single-center registry study

Veno‐venous extracorporeal membrane oxygenation (V‐V ECMO) is used to sustain blood oxygenation and decarboxylation in severe acute respiratory distress syndrome (ARDS). It is under debate if V‐V ECMO is as appropriate for coronavirus disease 2019 (Covid‐19) ARDS as it is for influenza. In this retrospective study, we analyzed all patients with confirmed SARS‐CoV‐2 or influenza A/B infection, ARDS and V‐V ECMO, treated at our medical intensive care unit (ICU) between October 2010 and June 2020. Baseline and procedural characteristics as well as survival 30 days after ECMO cannulation were analyzed. A total of 62 V‐V ECMO patients were included (15 with Covid‐19 and 47 with influenza). Both groups had similar baseline characteristics at cannulation. Thirty days after ECMO cannulation, 13.3% of all patients with Covid‐19 were discharged alive from our ICU compared to 44.7% with influenza (P = .03). Patients with Covid‐19 had fewer ECMO‐free days (0 (0‐9.7) days vs. 13.2 (0‐22.1) days; P = .05). Cumulative incidences of 30‐day‐survival showed no significant differences (48.6% in Covid‐19 patients, 63.7% in influenza patients; P = .23). ICU treatment duration was significantly longer in ARDS patients with V‐V ECMO for Covid‐19 compared to influenza. Thirty‐day mortality was higher in Covid‐19, but not significant.

Interruption of classic CD40L-CD40 signalling but not of the novel CD40L-Mac-1 interaction limits arterial neointima formation in mice

The co-stimulatory immune molecule CD40L figures prominently in a variety of inflammatory conditions including arterial disease. Recently, we made the surprising finding that CD40L mediates atherogenesis independently of its classic receptor CD40 via a novel interaction with the leukocyte integrin Mac-1. Here, we hypothesised that selective blockade of the CD40L-Mac-1 interaction may also retard restenosis. We induced neointima formation in C57/BL6 mice by ligation of the left carotid artery. Mice were randomised to daily intraperitoneal injections of either cM7, a small peptide selectively inhibiting the CD40L-Mac-1 interaction, scM7, a scrambled control peptide, or saline for 28 days. Interestingly, cM7-treated mice developed neointima of similar size compared with mice receiving the control peptide or saline as assessed by computer-assisted analysis of histological cross sections. These data demonstrate that the CD40L-Mac-1 interaction is not required for the development of restenosis. In contrast, CD40-deficient mice subjected to carotid ligation in parallel, developed significantly reduced neointimal lesions compared with respective wild-type controls (2872 ± 843 µm² vs 35469 ± 11870 µm²). Flow cytometry in CD40-deficient mice revealed reduced formation of platelet-granulocyte and platelet-inflammatory monocyte-aggregates. In vitro, supernatants of CD40-deficient platelet-leukocyte aggregates attenuated proliferation and increased apoptosis of smooth muscle cells. Unlike in the setting of atherosclerosis, CD40L mediates neointima formation via its classic receptor CD40 rather than via its recently described novel interaction with Mac-1. Therefore, selective targeting of CD40L-Mac-1 binding does not appear to be a favorable strategy to fight restenosis.

Acute exposure to air pollution particulate matter aggravates experimental myocardial infarction in mice by potentiating cytokine secretion from lung macrophages

Clinical, but not experimental evidence has suggested that air pollution particulate matter (PM) aggravates myocardial infarction (MI). Here, we aimed to describe mechanisms and consequences of PM exposure in an experimental model of MI. C57BL/6J mice were challenged with a PM surrogate (Residual Oil Fly Ash, ROFA) by intranasal installation before MI was induced by permanent ligation of the left anterior descending coronary artery. Histological analysis of the myocardium 7 days after MI demonstrated an increase in infarct area and enhanced inflammatory cell recruitment in ROFA-exposed mice. Mechanistically, ROFA exposure increased the levels of the circulating pro-inflammatory cytokines TNF-α, IL-6, and MCP-1, activated myeloid and endothelial cells, and enhanced leukocyte recruitment to the peritoneal cavity and the vascular endothelium. Notably, these effects on endothelial cells and circulating leukocytes could be reversed by neutralizing anti-TNF-α treatment. We identified alveolar macrophages as the primary source of elevated cytokine production after PM exposure. Accordingly, in vivo depletion of alveolar macrophages by intranasal clodronate attenuated inflammation and cell recruitment to infarcted tissue of ROFA-exposed mice. Taken together, our data demonstrate that exposure to environmental PM induces the release of inflammatory cytokines from alveolar macrophages which directly worsens the course of MI in mice. These findings uncover a novel link between air pollution PM exposure and inflammatory pathways, highlighting the importance of environmental factors in cardiovascular disease.

The role of biofilm infection in urology

In the process of endourological development a great variety of foreign bodies have been invented besides urinary catheters on which biofilm can be formed. Bacteria in the biofilm are less sensible to antibiotics. An additional problem of medical biomaterials in the urinary tract environment is the development of encrustation and consecutive obstruction. In this review, we tried to sum up the conditions where biofilm formation has a great impact on the development or maintenance of urological infections and on treatment success. Modification of the biomaterial surface seems to be the most promising prevention strategy for bacterial biofilms. Easier methods for diagnosing and quantifying biofilm infection, to develop more specific antimicrobial agents and ideal device surfaces would surely help the fight against biofilm formation.

Study of inflammatory responses to crocidolite and basalt wool in the rat lung

The subacute effects of crocidolite and basalt wool dusts were studied by nmeans of biochemical, morphological. and histological methods 1 and .3 mo after intrabronchial instillation. The cell count, protein and phospholipid contents, and lactate dehydrogenase (LDH) activity were determined in the bronchoalveolar lavage (BAL). Both types of fibers induced a prolonged inflammatory reaction in the lung. All the parameters studied in the experimental groups were more markedly elevated after 3 mo. Relative to the control, the protein and LDH values were increased three- to fivefold, the phospholipid content twofold, and the number of free cells in the BAL exceeded the control level up to ninefold. The inflammatory responses to crocidolite and basalt wool in the lung did not differ significantly. In spite of this, basalt wool is recoinmended as an asbestos substitute, as the use of this man-nade fiber may result in a significantly lower release of dust than that from crocidolite.

Steroid RU 486 inducible myogenesis by 10T1/2 fibroblastic mouse cells

For reconstruction or repair of damaged tissues, an artificially regulated switch from proliferation to differentiation would be of great advantage. To achieve conditional myogenesis, we expressed MyoD in mouse C3H 10T1/2 fibroblastic cells, using a gene regulation system based on the synthetic steroid RU 486. By stable co-transfection of a plasmid construct with the RU 486 dependent activator and an integrating inducible MyoD construct, a cell clone, designated 10T-RM, was obtained in which MyoD expression was stringently controlled by RU 486. 12 h after addition of 10 nM RU 486 to 10T-RM cells, saturation levels of MyoD mRNA were observed and >/=2 days later, mRNA for embryonal myosin heavy chain (MyHC(emb)) was abundant and mononucleated cells fused into myotubes.

Tenascin expression and angiogenesis in breast cancers

The expression and the distribution of tenascin as well as the extent of blood vessel formation (angiogenesis) were investigated in 70 invasive human breast carcinomas. Formalin-fixed, paraffin-embedded specimens were stained with monoclonal antibody against tenascin-C (DAKO and Biogenex). Anti-CD31 antibody (Biogenex), an acknowledged marker of stromal angiogenesis, was used to detect endothelial cells. Tenascin immunostaining was positive in the tumours around the persisting normal ducts, around tumour-cell nests, in the neostroma, in some tumour cells, and it was found in or around vascular channels. Tumour vascularity was assessed by quantitative vascular grading (Chalkley point count) and was related to the localization and intensity of tenascin immunoreactivity. 19 tumours (27.1%) were scored as low, 35 (50%) as medium, and 16 (22.9%) as having a high vascular grade. The positive correlation between the vascular grade and the tenascin immunopositivity in tumour stroma was observed. Our results suggest that tenascin expression may be associated with endothelial cell activation and may play an important role in tumour angiogenesis.

[Comparative study for assessing quality of life of patients with exogenous sleep disorders (temporary sleep onset and sleep interruption disorders) treated with a hops-valarian preparation and a benzodiazepine drug]

This randomized, double-blind, controlled clinical trial in parallel group design demonstrated equivalent efficacy and tolerability of a hop-valerian preparation compared with a benzodiazepine preparation in patients suffering from sleep disorders according to DSM-IV criteria. Sleep quality, fitness and quality of life were determined by psychometric tests, psychopathologic scales and sleep-questionnaires at the beginning of the therapy, end of therapy (duration 2 weeks) and then 1 week after cessation of therapy. Patients' state of health (4-point scale) and medication tolerability (occurrence of adverse events) were documented. Using the following as parameters "Alphabetischer Durchstreichtest, Feinmotoriktest, Befindlichkeitsskala, Beschwerdeliste, Schlaffragebögen A and B" the differences between beginning and the end of the therapy were analyzed by simultaneous testing of the equality or superiority of the test preparation. The equivalence of both therapies according to sleep quality, fitness and quality of life was proven by a Mann-Whitney-Statistic of 0.50 with a lower boundary of the 95% confidence interval of 0.46. The patients' state of health improved during therapy while showing a deterioration after cessation with both preparations. Withdrawal symptoms, however, were documented with benzodiazepine. Only one adverse drug reaction was reported during this study, namely stomach complaints from both the test and reference medication. This study shows that the investigated hop-valerian preparation in the appropriate dose is a sensible alternative to benzodiazepine for the treatment of nonchronic and non-psychiatric sleep disorders.

[Anatomic variants of the internal carotid artery as differential parapharyngeal space-occupying lesions diagnosis]

Variations of the clinical course of the internal carotid artery are reported with an incidence of 15-40% in the literature. They mainly arise from degenerative lesions leading to elongation, slight coiling, and kinking of the vessel. Besides that, a sigmoid tortuosity represents an occasional congenital anomaly. This article reports two cases of tortuosity of the internal carotid artery which resulted in impressions of the pharyngeal wall and minor globus syndromes. The possibility of false diagnoses is demonstrated. The etiology and clinical significance of these variations are discussed in detail.

Deletion in the Z-line region of the titin gene in a baby hamster kidney cell line, BHK-21-Bi

The gene for titin, a 4MDa myofibrillar protein, was analysed in golden hamster DNAs from different sources, using human cDNA probes and PCR. In the DNA from the BHK-21-Bi subline of baby hamster kidney cells, extended sequences coding for Z-line associated domains were missing, indicating a deletion that renders titin non-functional. These sequences were present in the original BHK-21 line and in hamster DNAs. Our finding shows that, due to the absence of selective pressure on a gene's function, genomic deterioration can occur in a permanent cell line and can lead to a loss of overlapping DNA stretches in both autosomes.

Lack of cell-cycle-specific effects of recombinant tumor necrosis factor in vivo

Several in vitro studies have demonstrated that tumor cells arrested in the G2 and M phases of the cell cycle expressed an increased sensitivity to the tumor necrosis factor (TNF). The scope of the present study was to investigate whether this cycle dependence of TNF effects also exists in vivo. The experiments were performed by using the Lewis lung carcinoma (LLC), which had been allotransplanted to nude mice. In order to induce delays of the tumor cell cycle in G2, the animals were treated with etoposide (40 mg/kg body weight i.p.) or with local radiation (15 Gy), each increasing the G2 fraction of the LLC from 10% to 35% and 50% respectively. For combination therapy with recombinant (r)TNF, the tumor was transplanted to four groups of six mice each, one of them serving as a control group the others being treated either with a G2 inductor alone, with rTNF alone, or with rTNF and a G2 inductor combined. Administration of rTNF (125 or 250 micrograms/kg body weight i.v.) was always carried out 24 h after therapy with etoposide or radiation when the maximum of G2 accumulation had developed. The growth behavior of the treated tumors revealed that the response of the LLC to rTNF in vivo was not improved by pretreatment with a G2 inductor and, thus, obviously lacked cell-cycle specificity. It is supposed that direct interactions of TNF with the tumor cells, which are a basic requirement for cell-cycle-linked phenomena, play a minor role in the therapeutic outcome of the LLC under in vivo conditions.

Effect of acquired cisplatin resistance on the response of a xenografted human hypopharynx carcinoma to concurrent radiochemotherapy with cisplatin

The optimum integration of chemotherapy and irradiation is of potential clinical significance in the treatment of advanced head and neck carcinomas. In the present study, the interaction of cis-diamminedichloroplatinum(II) (cisplatin) with fractionated radiotherapy was investigated in a human hypopharynx carcinoma and a cisplatin-resistant subline of this tumor, both growing in athymic mice. Two radiochemotherapy schedules which tested single as well as combined-modality treatments were applied. After therapy, the tumor sizes were measured three times per week in order to determine growth delay and treatment:control (T/C) ratios. The results revealed approximately additive effects of both agents in the parent hypopharynx carcinoma. In the resistant subline, such an interaction did not appear after treatment with any of the investigated schedules. However, a significant cross-resistance between cisplatin and radiation was detectable. It can be concluded that multiple courses of a platinum-based induction chemotherapy may be disadvantageous, since the treated tumors may develop drug resistance which obviously limits the effectiveness of a subsequent combined-modality approach.

[Housing for the elderly--results of an empirical study]

This empirical study is based on 285 standardized interviews with older people living in government-subsidized housing (sozialer Wohnungsbau). Housing conditions, especially contentment and perceived deficiencies are described. Additional remarks refer to the neighborhood relations. The high contentment, already known from former studies, is confirmed by the results. The findings indicate that steps towards an adaptation of housing conditions to possible needs of older people are not ranked very high. Beyond that, there seems to be a lack of information about the technical possibilities of improving the housing conditions, although older people want to live as long as possible in their current housing.

Influence of cisplatin on cell-cycle progression in xenografted human head and neck carcinomas

The scope of the present study was to examine whether the cytokinetic phenomena occurring in human tumors under the influence of cisplatin correlate with the response of the tumors to therapy with the drug. Therefore, three strains of heterotransplanted human head and neck carcinomas showing different degrees of sensitivity to cisplatin were investigated by flow cytometry at various intervals after a single administration of cisplatin at four different dose levels (3, 6, 9 or 12 mg/kg). Three types of cell-cycle alterations were observed that depended on the dose of cisplatin and the degree of drug sensitivity shown by the tumors investigated. The obviously weakest kind of tumor reaction was a delay in the G2 cell phase. This phenomenon also occurred in the case of non-responsiveness to therapy, whereby the growth, histological structure and mitotic activity of the tumors remained nearly unaltered after cisplatin treatment. With increasing cytotoxicity, additional accumulations of cells in the S phase and, finally, long-lasting blocks at the G1/S boundary were found. The latter phenomenon, which manifested at high dose levels used in sensitive tumors, was obviously irreversible, as it did not completely disappear until the tumor cells had died and been removed by immigrating macrophages. It was always accompanied by severe histological destruction, tumor cell necrotization, and marked depression of the mitotic index. Thus, the hindrance of cell traversal through the S phase obviously represents the main and significant cytokinetic event, which indicates a potent antitumor effect for cisplatin that leads to pronounced tumor regression. This finding supports the hypothesis that inhibition of DNA synthesis is the mechanism underlying the cytotoxicity of cisplatin.

Proliferation behavior of xenografted human tumors: a flow cytometric study

The proliferation behavior of three adenocarcinomas derived from the colon rectum, colon sigmoideum and the lung was pursued by flow cytophotometry between 0 h and 38 h after heterotransplantation to athymic mice. On principle, the same pattern of alterations was observed in the case of all three tumors, the time parameters slightly varying in dependence on growth velocity. At first, the number of intact tumor cells markedly decreased during 16-24 h after transplantation, being accompanied by an increase of cellular debris and an immigration of numerous host animal cells; the latter became the quantitatively preponderant portion of cells between days 2 and 8. On day 6, the tumor cell population began to proliferate. At first, the G1 peak rose, followed by the appearance of tumor cells in the S and (G2 + M) phases. Simulataneously, the relative portions of mouse cells and cellular debris diminished. Between days 14 and 30, when maximum rates of macroscopic growth of the heterotransplants were achieved, the cytokinetic features of the xenografts had stabilized and were characterized by the presence of a small portion of mouse cells and a prominent tumor cell population, most cells being in the G1 phase and a smaller number passing through the S and (G2 + M) phases. Beyond day 30, degeneration phenomena again occurred, which were reflected by a decay of mouse and tumor cell populations and a simultaneous increase of cell fragments. By cytokinetic means, the results of the present study reveal a multistep development of human tumors after heterotransplantation into nude mice, and confirm the importance of host-supplied cells for the removal of degenerated tumor cells and the induction of tumor cell proliferation. Moreover, the results show that a stable cytokinetic pattern is found only during the phase of macroscopic tumor growth and the following phase of steady state.