Burnout, emotional distress and sleep quality among Chinese psychiatric healthcare workers during the COVID-19 pandemic: a follow-up study

Background

Different from the very early stages of the COVID-19 pandemic, burnout and chronic mental health problems among health care workers (HCWs) has become a challenge. Research is lacking on the relationship between burnout, stress, emotional distress and sleep quality.

Methods

The Chinese center has been involved in the Cope-Corona project since the second survey (T2). Named after the project, a total of three cross-sectional surveys were distributed: T2 (February 16-20, 2021), T3 (May 10-14, 2022), and T4 (December 20-24, 2022). Burnout, depression, anxiety, sleep quality, workplace factors and individual resources were measured. Using the T4 data, we conducted structural equation model (SEM) to examine the mediating role of burnout in predicting emotional distress and sleep quality.

Results

96, 124, and 270 HCWs were enrolled at T2, T3, and T4, respectively. In line with the epidemic trends, the level of perceived COVID-19 related risks was significantly higher at T4, while the feeling of health and safety decreased significantly. At T4, the percentages of participants with clinically significant levels of depression and anxiety symptoms were 18.9% (51/270) and 9.3% (25/270), respectively, while 30.4% (82/270) of them reported poor or very poor sleep quality. According to the SEM, individual resources and workplace factors mainly had an indirect effect in predicting depression and anxiety via burnout. However, neither burnout nor stress was a mediator or predictor of sleep quality. Instead, individual resources, positive workplace factors, and younger age had a direct effect in predicting good sleep quality.

Conclusion

Measures designed to enhance workplace factors and individual resources should be implemented to improve psychosomatic wellbeing of HCWs.

Markers of oxidative stress during post-COVID-19 fatigue: a hypothesis-generating, exploratory pilot study on hospital employees

Introduction

Post-COVID-19 fatigue is common after recovery from COVID-19. Excess formation of reactive oxygen species (ROS) leading to oxidative stress-related mitochondrial dysfunction is referred to as a cause of these chronic fatigue-like symptoms. The present observational pilot study aimed to investigate a possible relationship between the course of ROS formation, subsequent oxidative stress, and post-COVID-19 fatigue.

Method

A total of 21 post-COVID-19 employees of the General Hospital Nuremberg suffering from fatigue-like symptoms were studied during their first consultation (T1: on average 3 months after recovery from COVID-19), which comprised an educational talk on post-COVID-19 symptomatology and individualized outpatient strategies to resume normal activity, and 8 weeks thereafter (T2). Fatigue severity was quantified using the Chalder Fatigue Scale together with a health survey (Patient Health Questionnaire) and self-report on wellbeing (12-Item Short-Form Health Survey). We measured whole blood superoxide anion (O 2 • - ) production rate (electron spin resonance, as a surrogate for ROS production) and oxidative stress-induced DNA strand breaks (single cell gel electrophoresis: "tail moment" in the "comet assay").

Results

Data are presented as mean ± SD or median (interquartile range) depending on the data distribution. Differences between T1 and T2 were tested using a paired Wilcoxon rank sign or t-test. Fatigue intensity decreased from 24 ± 5 at T1 to 18 ± 8 at T2 (p < 0.05), which coincided with reduced O 2 • - formation (from 239 ± 55 to 195 ± 59 nmol/s; p < 0.05) and attenuated DNA damage [tail moment from 0.67 (0.36-1.28) to 0.32 (0.23-0.71); p = 0.05].

Discussion

Our pilot study shows that post-COVID-19 fatigue coincides with (i) enhanced O 2 • - formation and oxidative stress, which are (ii) reduced with attenuation of fatigue symptoms.

Changes in hospital staff' mental health during the Covid‑19 pandemic: Longitudinal results from the international COPE-CORONA study

This longitudinal study aimed to explore anxiety and depressive symptoms, individual resources, and job demands in a multi-country sample of 612 healthcare workers (HCWs) during the COVID-19 pandemic. Two online surveys were distributed to HCWs in seven countries (Germany, Andorra, Ireland, Spain, Italy, Romania, Iran) during the first (May-October 2020, T1) and the second (February-April 2021, T2) phase of the pandemic, assessing sociodemographic characteristics, contact with COVID-19 patients, anxiety and depressive symptoms, self-compassion, sense of coherence, social support, risk perception, and health and safety at the workplace. HCWs reported a significant increase in depressive and anxiety symptoms. HCWs with high depressive or anxiety symptoms at T1 and T2 reported a history of mental illness and lower self-compassion and sense of coherence over time. Risk perception, self-compassion, sense of coherence, and social support were strong independent predictors of depressive and anxiety symptoms at T2, even after controlling for baseline depressive or anxiety symptoms and sociodemographic variables. These findings pointed out that HCWs during the COVID-19 outbreak experienced a high burden of psychological distress. The mental health and resilience of HCWs should be supported during disease outbreaks by instituting workplace interventions for psychological support.

Small volume bone marrow aspirates with high progenitor cell concentrations maximize cell therapy dose manufacture and substantially reduce donor hemoglobin loss

BACKGROUND

Bone marrow (BM) transplantation is a life-saving therapy for hematological diseases, and the BM harbors also highly useful (progenitor) cell types for novel cell therapies manufacture. Yet, the BM collection technique is not standardized.

METHODS

Benchmarking our collection efficiency to BM collections worldwide (N = 1248), we noted a great variability of total nucleated cell (TNC) yields in BM products (HPC-M) with superior performance of our center, where we have implemented a small volume aspirate policy. Thus, we next prospectively aimed to assess the impact of BM collection technique on HPC-M quality. For each BM collection (N = 20 donors), small volume (3 mL) and large volume (10 mL) BM aspirates were sampled at 3 time points and analyzed for cell composition.

RESULTS

Compared to large volume aspirates, small volume aspirates concentrated more TNCs, immune cells, platelets, hematopoietic stem/progenitor cells, mesenchymal stromal cells (MSCs), and endothelial progenitors. Inversely, the hemoglobin concentration was higher in large volume aspirates indicating more hemoglobin loss. Manufacturing and dosing scenarios showed that small volume aspirates save up to 42% BM volume and 44% hemoglobin for HPC-M donors. Moreover, MSC production efficiency can be increased by more than 150%.

CONCLUSIONS

We propose to consider small volume BM aspiration as standard technique for BM collection.

German Patient Blood Management Network: effectiveness and safety analysis in 1.2 million patients

BACKGROUND

Patient Blood Management (PBM) is a patient-centred, systematic, evidence-based approach to improve patient outcomes by managing and preserving a patient's own blood whilst promoting patient safety and empowerment. The effectiveness and safety of PBM over a longer period have not yet been investigated.

METHODS

We performed a prospectively designed, multicentre follow-up study with non-inferiority design. Data were retrospectively extracted case-based from electronic hospital information systems. All in-hospital patients (≥18 yr) undergoing surgery and discharged between January 1, 2010 and December 31, 2019 were included in the analysis. The PBM programme focused on three domains: preoperative optimisation of haemoglobin concentrations, blood-sparing techniques, and guideline adherence/standardisation of allogeneic blood product transfusions. The outcomes were utilisation of blood products, composite endpoint of in-hospital mortality and postoperative complications (myocardial infarction/ischaemic stroke/acute renal failure with renal replacement therapy/sepsis/pneumonia), anaemia rate at admission and discharge, and hospital length of stay.

RESULTS

A total of 1 201 817 (pre-PBM: n=441 082 vs PBM: n=760 735) patients from 14 (five university/nine non-university) hospitals were analysed. Implementation of PBM resulted in a substantial reduction of red blood cell utilisation. The mean number of red blood cell units transfused per 1000 patients was 547 in the PBM cohort vs 635 in the pre-PBM cohort (relative reduction of 13.9%). The red blood cell transfusion rate was significantly lower (P<0.001) with odds ratio 0.86 (0.85-0.87). The composite endpoint was 5.8% in the PBM vs 5.6% in the pre-PBM cohort. The non-inferiority aim (safety of PBM) was achieved (P<0.001).

CONCLUSIONS

Analysis of >1 million surgical patients showed that the non-inferiority condition (safety of Patient Blood Management) was fulfilled, and PBM was superior with respect to red blood cell transfusion.

CLINICAL TRIAL REGISTRATION

NCT02147795.

Novel evidence that the ABO blood group shapes erythropoiesis and results in higher hematocrit for blood group B carriers

The ABO blood group (BG) system is of great importance for blood transfusion and organ transplantation. Since the same transcription factors (TFs) and microRNAs (miRNAs) govern the expression of ABO BG antigens and regulate erythropoiesis, we hypothesized functional connections between both processes. We found significantly higher hemoglobin and hematocrit values in BG B blood donors compared to BG A. Furthermore, we observed that erythropoiesis in BG B hematopoietic stem/progenitor cells (HSPCs) was accelerated compared to BG A HSPCs. Specifically, BG B HSPCs yielded more lineage-specific progenitors in a shorter time (B: 31.3 ± 2.2% vs. A: 22.5 ± 3.0%). Moreover, non-BG A individuals exhibited more terminally differentiated RBCs with higher enucleation rates containing more hemoglobin compared to BG A. Additionally, we detected increased levels of miRNA-215-5p and -182-5p and decreased expression of their target TFs RUNX1 and HES-1 mRNAs in erythroid BG B precursor cells compared to BG A. This highlights the important roles of these factors for the disappearance of differentiation-specific glycan antigens and the appearance of cancer-specific glycan antigens. Our work contributes to a deeper understanding of erythropoiesis gene regulatory networks and identifies its interference with BG-specific gene expression regulations particularly in diseases, where ABO BGs determine treatment susceptibility and disease progression.

Psychological correlates of perceived loneliness in college students before and during the COVID-19 stay-at-home period: a longitudinal study

BACKGROUND

Loneliness is increasingly acknowledged as a serious public health issue. This longitudinal study aimed to assess the extent to which psychological distress and alexithymia can predict loneliness among Italian college students before and one year after the COVID-19 outbreak.

METHODS

A convenience sample of 177 psychology college students were recruited. Loneliness (UCLA), alexithymia (TAS-20), anxiety symptoms (GAD-7), depressive symptoms (PHQ-9), and somatic symptoms (PHQ-15) were assessed before the COVID-19 outbreak and one year after the spread of COVID-19 worldwide.

RESULTS

After controlling for baseline loneliness, students with high levels of loneliness during lockdown showed worsening psychological distress and alexithymic traits over time. Suffering from depressive symptoms before COVID-19 and the aggravation of alexithymic traits independently predicted 41% of perceived loneliness during the COVID-19 outbreak.

CONCLUSIONS

College students with higher levels of depression and alexithymic traits both before and one year after the lockdown were more at risk of suffering from perceived loneliness and may constitute the target sample for psychological support and intervention.

Burnout among hospital staff during the COVID-19 pandemic: Longitudinal results from the international Cope-Corona survey study

OBJECTIVE

Long-term changes in burnout and its predictors in hospital staff during the COVID-19 pandemic were investigated in an international study.

METHODS

Two online surveys were distributed to hospital staff in seven countries (Germany, Andorra, Ireland, Spain, Italy, Romania, Iran) between May and October 2020 (T1) and between February and April 2021 (T2), using the following variables: Burnout (emotional exhaustion and depersonalization), job function, age, gender, and contact with COVID-19 patients; individual resources (self-compassion, sense of coherence, social support) and work-related resources and demands (support at the workplace, risk perception, health and safety at the workplace, altruistic acceptance of risk). Data were analyzed using linear mixed models repeated measures, controlled for age.

RESULTS

A total of 612 respondents were included (76% women). We found an increase in burnout from T1 to T2. Burnout was high among personnel with high contact with COVID-19 patients. Individual factors (self-compassion, sense of coherence) and work-related factors (support at the workplace, risk perception, health and safety at the workplace) showed associations with burnout. Low health and safety at the workplace at T1 was associated with an increase in emotional exhaustion at T2. Men showed an increase in depersonalization if they had much contact with COVID-19 patients.

CONCLUSION

Burnout represents a potential problematic consequence of occupational contact with COVID-19 patients. Special attention should be paid to this group in organizational health management. Self-compassion, sense of coherence, support at the workplace, risk perception, and health and safety at the workplace may be important starting points for interventions.

REGISTRATION

Müller, M. M. (2020, August 30). Cope-Corona: Identifying and strengthening personal resources of hospital staff to cope with the Corona pandemic. Open Science Foundation.

Workplace factors can predict the stress levels of healthcare workers during the COVID-19 pandemic: First interim results of a multicenter follow-up study

Background

Research is lacking on the long-term influence of workplace factors on the mental health of health care workers during the COVID-19 pandemic.

Methods

We distributed two online surveys to health care workers between May and October 2020 (T1) and between February and April 2021 (T2). Perceived stress, coronavirus-related risks, and workplace factors were measured via self-report questionnaires at both time points. We conducted hierarchical linear regression to investigate the predictive factors for high stress.

Results

A total of 2,110 participants from seven countries and 4,240 participants from nine countries were enrolled at T1 and T2, respectively. Among them, 612 participated in both surveys. We called this cohort T1 + T2. High stress was reported in 53.8 and 61.6% of participants at T1 and T2, respectively. In cohort T1 + T2, compared with the baseline, the level of stress rose significantly (6.0 ± 2.9 vs. 6.4 ± 3.1), as did health/safety in the workplace (3.9 ± 0.8 vs. 4.2 ± 0.7). Unfortunately, we did not detect any significant difference concerning support in the workplace. Among all factors at baseline, being older than 35 [β (95% CI) = -0.92 (-1.45, -0.40)], support [-0.80 (-1.29, -0.32)], and health/safety in the workplace [-0.33 (-0.65, -0.01)] were independent protective factors, while a positive history of mental disorders [0.81 (0.26, 1.37)] and rejection in private life [0.86 (0.48, 1.25)] were risk factors for high stress at T2.

Conclusion

To relieve the high stress of health care workers, organizational-level approaches should be implemented, especially measures designed to enhance support, health/safety in the workplace, and to reduce the rejection of the public.

Psychiatric and Psychosomatic Consultation-Liaison Services in General Hospitals: A Systematic Review and Meta-Analysis of Effects on Symptoms of Depression and Anxiety

BACKGROUND

Psychiatric and psychosomatic consultation-liaison services (CL) are important providers of diagnosis and treatment for hospital patients with mental comorbidities and psychological burdens.

OBJECTIVE

To perform a systematic review and meta-analysis investigating the effects of CL on depression and anxiety.

METHODS

Following PRISMA guidelines, a systematic literature search was conducted until 2017. Included were published randomized controlled trials using CL interventions with adults in general hospitals, treatment as usual as control groups, and depression and/or anxiety as outcomes. Risk of bias was assessed using the Cochrane Risk of Bias Tool. Level of integration was assessed using the Standard Framework for Levels of Integrated Healthcare. Meta-analyses were performed using random effects models and meta-regression for moderator effects.

RESULTS

We included 38 studies (9,994 patients). Risk of bias was high in 17, unclear in 15, and low in 6 studies. Studies were grouped by type of intervention: brief interventions tailored to the patients (8), interventions based on specific treatment manuals (19), and integrated, collaborative care (11). Studies showed small to medium effects on depression and anxiety. Meta-analyses for depression yielded a small effect (d = -0.19, 95% CI: -0.30 to -0.09) in manual studies and a small effect (d = -0.33, 95% CI: -0.53 to -0.13) in integrated, collaborative care studies, the latter using mostly active control groups with the possibility of traditional consultation.

CONCLUSIONS

CL can provide a helpful first treatment for symptoms of depression and anxiety. Given that especially depressive symptoms in medically ill patients are long-lasting, the results underline the benefit of integrative approaches that respect the complexity of the illness.

Treatment Options in Hemophilia

BACKGROUND

Approximately 4550 persons were under treatment for hemophilia in Germany in 2017. The condition is currently treated with intravenous supplementa- tion of the missing clotting factor, either prophylactically or as needed. Newer treat- ment options rely on novel mechanisms of action.

METHODS

This review is based on pertinent publications retrieved by a selective search in MEDLINE/PubMed, as well as on expert opinions and the recommenda- tions of specialty societies.

RESULTS

Randomized controlled trials have shown that, in children aged 30 months to 6 years, prophylactic clotting-factor supplementation yields a markedly lower an- nual rate of hemorrhage than supplementation as needed: 3.27 (standard deviation [SD] 6.24) for the former vs. 17.69 (SD 9.25) for the latter. A similar large effect was seen in patients aged 12 to 50 years, with hemorrhage rates of 1.9 (SD 4.1) vs. 28.7 (SD 18.8). Clotting-factor preparations with longer half-lives make it possible to lessen the frequency of administration and to prevent subtherapeutic factor levels. A number of alternatives to clotting-factor supplementation have recently been approved or are currently being clinically tested. These new drugs are injected sub- cutaneously and have a longer half-life, possibly enabling better protection against bleeding than the current standard treatment. A further advantage of some of these drugs is that they can be given even in the presence of inhibitors to factor VIII. In addition, initial (phase I) clinical trials of gene therapy have been performed suc- cessfully for both hemophilia A and hemophilia B.

CONCLUSION

Now that new alternatives to classic supplementation therapy are be- coming available, pertinent treatment algorithms for patients with hemophilia will have to be developed. It is still unclear to what extent the new drugs might supplant clotting factor supplementation as the first line of treatment.

Spatial Attentional Selection Modulates Early Visual Stimulus Processing Independently of Visual Alpha Modulations

The capacity-limited human brain is constantly confronted with a huge amount of sensory information. Selective attention is needed for biasing neural processing towards relevant information and consequently allows meaningful interaction with the environment. Activity in the alpha-band has been proposed to be related to top-down modulation of neural inhibition and could thus represent a viable candidate to control the priority of stimulus processing. It is, however, unknown whether modulations in the alpha-band directly relate to changes in the sensory gain control of the early visual cortex. Here, we used a spatial cueing paradigm while simultaneously measuring ongoing alpha-band oscillations and steady-state visual evoked potentials (SSVEPs) as a marker of continuous early sensory processing in the human visual cortex. Thereby, the effects of spatial attention for both of these signals and their potential interactions were assessed. As expected, spatial attention modulated both alpha-band and SSVEP responses. However, their modulations were independent of each other and the corresponding activity profiles differed across task demands. Thus, our results challenge the view that modulations of alpha-band activity represent a mechanism that directly alters or controls sensory gain. The potential role of alpha-band oscillations beyond sensory processing will be discussed in light of the present results.

Programmes for the management of preoperative anaemia: audit in ten European hospitals within the PaBloE (Patient Blood Management in Europe) Working Group

BACKGROUND AND OBJECTIVES

Preoperative anaemia is an independent risk factor for a higher morbidity and mortality, a longer hospitalization and increased perioperative transfusion rates. Managing preoperative anaemia is the first of three pillars of Patient Blood Management (PBM), a multidisciplinary concept to improve patient safety. While various studies provide medical information on (successful) anaemia treatment pathways, knowledge of organizational details of diagnosis and management of preoperative anaemia across Europe is scarce.

MATERIALS AND METHODS

To gain information on various aspects of preoperative anaemia management including organization, financing, diagnostics and treatment, we conducted a survey (74 questions) in ten hospitals from seven European nations within the PaBloE (Patient Blood Management in Europe) working group covering the year 2016.

RESULTS

Organization and activity in the field of preoperative anaemia management were heterogeneous in the participating hospitals. Almost all hospitals had pathways for managing preoperative anaemia in place, however, only two nations had national guidelines. In six of the ten participating hospitals, preoperative anaemia management was organized by anaesthetists. Diagnostics and treatment focused on iron deficiency anaemia which, in most hospitals, was corrected with intravenous iron.

CONCLUSION

Implementation and approaches of preoperative anaemia management vary across Europe with a primary focus on treating iron deficiency anaemia. Findings of this survey motivated the hospitals involved to critically evaluate their practice and may also help other hospitals interested in PBM to develop action plans for diagnosis and management of preoperative anaemia.

[Blood Transfusion: a Guide to Clinical Decision Making]

Nowadays, management of hemotherapy is regulated in Germany by the transfusion act and several guidelines while the transfusing physician is responsible for correct implementation at the bedside. Indications for blood products have to be carefully adapted to the patient's current clinical situation and pre-existing diseases have to be considered as well. Today, for most perioperative elective surgeries, evidence-based transfusion thresholds for packed red blood cell concentrates (RBC) have been defined and should be considered. Platelet concentrates (PC) have to be transfused in bleeding patients with thrombocytopenia or -pathy. In addition, PC are indicated prophylactically in clinically stable, not bleeding patients with a platelet trough count of less than 10/nl. Therapeutic plasma or fresh frozen plasma (FFP) is indicated for balanced substitution of coagulation factors, coagulation inhibitors and fibrinolysis factors in massive transfusion settings, where dilution of coagulation factors takes place. Plasma exchange in adults with thrombotic-thrombocytopenic purpura (TTP) or adult hemolytic-uremic syndrome (HUS) also requires FFP. In addition, FFP might be indicated, if no coagulation factor concentrate is available (e.g. FV deficiency). Adverse transfusion reactions are rare nowadays; however, hemolytic and allergic reactions are not too uncommon. For severe hemolytic transfusion reactions, in almost all cases, wrong blood in tube (WBIT) at the diagnostic bedside blood withdrawal or a mix-up of blood components before transfusion is causative. Massive transfusion situations require a proactive management, which includes RBC, FFP and potentially also PC and coagulation factor concentrates. Prior to elective surgery, anemic patients should be diagnosed and treated for the cause of their anemia, if possible.

Red blood cells treated with the amustaline (S-303) pathogen reduction system: a transfusion study in cardiac surgery

BACKGROUND

Nucleic acid-targeted pathogen inactivation technology using amustaline (S-303) and glutathione (GSH) was developed to reduce the risk of transfusion-transmitted infectious disease and transfusion-associated graft-versus-host disease with red blood cell (RBC) transfusion.

STUDY DESIGN AND METHODS

A randomized, double-blind, controlled study was performed to assess the in vitro characteristics of amustaline-treated RBCs (test) compared with conventional (control) RBCs and to evaluate safety and efficacy of transfusion during and after cardiac surgery. The primary device efficacy endpoint was the postproduction hemoglobin (Hb) content of RBCs. Exploratory clinical outcomes included renal and hepatic failure, the 6-minute walk test (a surrogate for cardiopulmonary function), adverse events (AEs), and the immune response to amustaline-treated RBCs.

RESULTS

A total of 774 RBC unis were produced. Mean treatment difference in Hb content was -2.27 g/unit (95% confidence interval, -2.61 to -1.92 g/unit), within the prespecified equivalence margins (±5 g/unit) to declare noninferiority. Amustaline-treated RBCs met European guidelines for Hb content, hematocrit, and hemolysis. Fifty-one (25 test and 26 control) patients received study RBCs. There were no significant differences in RBC usage or other clinical outcomes. Observed AEs were within the spectrum expected for patients of similar age undergoing cardiovascular surgery requiring RBCs transfusion. No patients exhibited an immune response specific to amustaline-treated RBCs.

CONCLUSION

Amustaline-treated RBCs demonstrated equivalence to control RBCs for Hb content, have appropriate characteristics for transfusion, and were well tolerated when transfused in support of acute anemia. Renal impairment was characterized as a potential efficacy endpoint for pivotal studies of RBC transfusion in cardiac surgery.

[Preoperative Preparation: Patient Blood Management - What is Optimal?]

Patient Blood Management (PBM) focusses on anemia management, the minimization of (unnecessary) iatrogenic blood loss and the exhaustion of natural tolerance to anemia with rational use of red blood cell transfusion. The focus of the current review article is now the preoperative phase with the following PBM components: management of anemia, pre-transfusion analytics and management of anticoagulants. Preoperative anemia is an independent risk factor for increased perioperative morbidity and mortality. In elective surgery, the causes of anemia should be diagnosed prior to surgery as early as possible, and if indicated, a specific treatment for treatable causes should be initiated. Preoperative pre-transfusion analytics should be performed by a step-wise approach depending on the transfusion probability (and the baseline hemoglobin) and current in-house data. Management of (oral) anticoagulants needs to consider an individual risk stratification for bleeding and thromboembolic events, should be initiated in the preoperative phase, and should specify whether the anticoagulant needs to be continued, stopped or bridged. Long-term success of the preoperative PBM program can only be guaranteed with clearly defined responsibilities in the preoperative PBM team, communication and training of all those involved in the process of care.

Transfusion of Packed Red Cells: Indications, Triggers and Adverse Events

BACKGROUND

About four million units of packed red cells are transfused in Germany every year. The safety of blood transfusions is further improved by modern production methods and molecular diagnostic techniques.

METHODS

This review is based on selected publications,including the German guidelines and regulations and the German Transfusion Act.

RESULTS

Packed red blood cells are transfused to prevent tissue hypoxia. As the clinical manifestations of anemia are nonspecific, the indication for transfusion is based on surrogate parameters, such as the hemoglobin (Hb) concentration, in addition to clinical criteria. For patients with unimpaired cardiopulmonary and vascular function, transfusion is generally indicated at hemoglobin values of 6 g/dL (3.7 mmol/L) or less. Randomized controlled trials have shown that a restrictive transfusion strategy (trigger: Hb 7-8 g/dL) in certain patient groups is as effective as a more liberal strategy (trigger: Hb about 10 g/dL). The most frequent causes for transfusion errors are lack of informed consent, lack of identity checking and/or AB0 identity testing, and the drawing of blood samples in unlabelled tubes.

CONCLUSION

Overtransfusion, undertransfusion, as well as other transfusion errors can be markedly reduced by means of appropriate organizational measures and training.

[Cost analysis of patient blood management]

BACKGROUND

Patient blood management (PBM) is a multidisciplinary approach focusing on the diagnosis and treatment of preoperative anaemia, the minimisation of blood loss, and the optimisation of the patient-specific anaemia reserve to improve clinical outcomes. Economic aspects of PBM have not yet been sufficiently analysed.

OBJECTIVES

The aim of this study is to analyse the costs associated with the clinical principles of PBM and the project costs associated with the implementation of a PBM program from an institutional perspective.

MATERIALS AND METHODS

Patient-related costs of materials and services were analysed at the University Hospital Frankfurt for 2013. Personnel costs of all major processes were quantified based on the time required to perform each step. Furthermore, general project costs of the implementation phase were determined.

RESULTS

Direct costs of transfusing a single unit of red blood cells can be calculated to a minimum of €147.43. PBM-associated costs varied depending on individual patient requirements. The following costs per patient were calculated: diagnosis of preoperative anaemia €48.69-123.88; treatment of preoperative anaemia (including iron-deficiency anaemia and megaloblastic anaemia) €12.61-127.99; minimising perioperative blood loss (including point-of-care diagnostics, coagulation management and cell salvage) €3.39-1,901.81; and costs associated with the optimisation of the tolerance to anaemia (including patient monitoring and volume therapy) €28.62. General project costs associated with the implementation of PBM were €24,998.24.

CONCLUSIONS

PBM combines various alternatives to the transfusion of red blood cells and improves clinical outcome. Costs of PBM vary from institution to institution and depend on the extent to which different aspects of PBM have been implemented. The quantification of costs associated with PBM is essential in order to assess the economic impact of PBM, and thereby, to efficiently re-allocate health care resources. Costs were determined at a single university hospital. Thus, further analyses of both the costs of transfusion and the costs of PBM-principles will be necessary to evaluate the cost-effectiveness of PBM.

Moraxella catarrhalis induces CEACAM3-Syk-CARD9-dependent activation of human granulocytes

The human restricted pathogen Moraxella catarrhalis is an important causal agent for exacerbations in chronic obstructive lung disease in adults. In such patients, increased numbers of granulocytes are present in the airways, which correlate with bacteria-induced exacerbations and severity of the disease. Our study investigated whether the interaction of M. catarrhalis with the human granulocyte-specific carcinoembryonic antigen-related cell adhesion molecule (CEACAM)-3 is linked to NF-κB activation, resulting in chemokine production. Granulocytes from healthy donors and NB4 cells were infected with M. catarrhalis in the presence of different inhibitors, blocking antibodies and siRNA. The supernatants were analysed by enzyme-linked immunosorbent assay for chemokines. NF-κB activation was determined using a luciferase reporter gene assay and chromatin-immunoprecipitation. We found evidence that the specific engagement of CEACAM3 by M. catarrhalis ubiquitous surface protein A1 (UspA1) results in the activation of pro-inflammatory events, such as degranulation of neutrophils, ROS production and chemokine secretion. The interaction of UspA1 with CEACAM3 induced the activation of the NF-κB pathway via Syk and the CARD9 pathway and was dependent on the phosphorylation of the CEACAM3 ITAM-like motif. These findings suggest that the CEACAM3 signalling in neutrophils is able to specifically modulate airway inflammation caused by infection with M. catarrhalis.

A global RNA-seq-driven analysis of CHO host and production cell lines reveals distinct differential expression patterns of genes contributing to recombinant antibody glycosylation

Boehringer Ingelheim uses two CHO-DG44 lines for manufacturing biotherapeutics, BI-HEX-1 and BI-HEX-2, which produce distinct cell type-specific antibody glycosylation patterns. A recently established CHO-K1 descended host, BI-HEX-K1, generates antibodies with glycosylation profiles differing from CHO-DG44. Manufacturing process development is significantly influenced by these unique profiles. To investigate the underlying glycosylation related gene expression, we leveraged our CHO host and production cell RNA-seqtranscriptomics and product quality database together with the CHO-K1 genome. We observed that each BI-HEX host and antibody producing cell line has a unique gene expression fingerprint. CHO-DG44 cells only transcribe Fut10, Gfpt2 and ST8Sia6 when expressing antibodies. BI-HEX-K1 cells express ST8Sia6 at host cell level. We detected a link between BI-HEX-1/BI-HEX-2 antibody galactosylation and mannosylation and the gene expression of the B4galt gene family and genes controlling mannose processing. Furthermore, we found major differences between the CHO-DG44 and CHO-K1 lineages in the expression of sialyl transferases and enzymes synthesizing sialic acid precursors, providing a rationale for the lack of immunogenic NeuGc/NGNA synthesis in CHO. Our study highlights the value of systems biotechnology to understand glycoprotein synthesis and product glycoprofiles. Such data improve future production clone selection and process development strategies for better steering of biotherapeutic product quality.

Patient blood management implementation strategies and their effect on physicians' risk perception, clinical knowledge and perioperative practice - the frankfurt experience

INTRODUCTION

A multicomponent, evidence-based and interdisciplinary Patient Blood Management (PBM) program was introduced at the University Hospital Frankfurt in July 2013. The implementation strategy included practical and tactical components aimed to increase knowledge on the risks of preoperative anemia, to standardize hemotherapy, and to facilitate PBM components.

METHODS

This article analyzes barriers to PBM implementation and outlines a strategy to introduce and manifest PBM. The effects in Frankfurt were measured in a before and after questionnaire study distributed among groups of physicians immediately before and 1 year after PBM implementation.

RESULTS

142 clinicians completed the questionnaire in July 2013 and 101 clinicians in August 2014. Absolute certainty that the treatment of preoperative anemia favorably influences morbidity and mortality rose from 25 to 37%. Transfusion behavior seems to have been affected: In 2014, 56% of clinicians stated that they clinically reassess the patient and analyze hemoglobin following each single red blood cell unit compared to only 38% stating this in 2013.

CONCLUSION

These results show that our implementation strategy was effective in changing physicians' risk perception, attitude, and knowledge on PBM principles. Our experience highlights key success factors for the implementation of a comprehensive PBM program.

[Patient blood management--How does it work in practice?--the interdisciplinary cooperation]

Patient blood management (PBM), as a multidisciplinary, evidence-based treatment concept for reducing anemia and blood losses, should be realized in individual hospitals after local adaptation according to the available facilities.The implementation of a PBM program in clinical institutions will be a challenging but in every case worthwhile task. The local facilities may be insufficient to fulfill the training requirements of a large group of different personnel. Accordingly, sustained support by the hospital's management with provision of the necessary resources for personnel and materials is essential. The formation of the core PBM team, in our case consisting initially of anaesthesiologists, surgeons, internists and transfusion medicine specialists as well as - the particularly important - motivated nursing personnel, is one of the most pressing and primary tasks in the establishment of a PBM project.It is also extremely important to firmly anchor the PBM project permanently within the hospital. Possible steps and details for this purpose are presented and discussed in terms of value and weighting by the authors on the basis of their actual experience in Frankfurt University Hospital.

[Management of extended blood loss and massive transfusion]

In patients suffering from massive bleeding, transfusion of allogenic blood products (red blood cells, fresh frozen plasma and platelets) and the application of other hemostatic therapy in form of coagulation factor concentrates represent therapeutic approaches to optimize hemostasis and to restore and assure tissue oxygenation. In accordance to the "Helsinki declaration on patient safety" of the European Society of Anaesthesiology, this review article describes a clinical practice guideline for the treatment of patients requiring massive transfusion that was implemented at the University hospital Frankfurt in 2013. Our guideline may be used as a template for other institutions.

[Blood--a special resource]

Haemotherapy is an integral part of modern high-tech medicine. Without supportive care including red blood cell (RBC), platelet concentrate (PC) and fresh frozen plasma (FFP) transfusion, invasive therapies such as high-dose chemotherapy regimens for haematological and solid malignancies, haematopoietic stem cell (HSC) and solid organ transplantation as well as major surgery and modern trauma management would not be possible. In this article we describe the current state of haemotherapy, the risk of adverse effects and risk minimization measures, specifically focussing on haemolytic transfusion reactions (HTR), transfusion-related lung injury (TRALI) and transfusion-transmitted infections (TTI). Aided by the introduction of NAT technology for blood component screening, the residual risk of transfusion transmitted infections was reduced to 1:10.8 million for HCV, to 1:4.3 million for HIV-1, and to 1:360,000 for HBV for blood products of the German Red Cross Blood Service.

Perioperative Red Blood Cell Transfusion: Harmful or Beneficial to the Patient?

Although the transfusion of red blood cells (RBCs) is safer than ever regarding infections, it is still associated with several adverse reactions and therefore should only be used on the basis of evidence-based triggers. However, prevention of RBC transfusion and subsequent substitution of blood losses with acellular solutions will inevitably result in dilutional anemia. Acute dilutional anemia can be compensated by the body over a wide range of hemoglobin concentrations without a critical restriction of tissue oxygenation. On the other hand, chronic anemia is known to be a potent cause of morbidity and mortality. As a consequence, the impact of perioperative anemia on mortality is difficult to describe, because anemia, as well as the transfusion of RBCs, can influence the clinical outcome. The resulting 'Gordian knot' cannot be cut easily, and this circumstance forces clinical physicians to make a daily trade-off between transfusion-associated and anemia-associated risks. This review focuses on the physiology of oxygen transport, the hazards of acute anemia, the hazards of RBC transfusion, and the literature putting these problems into perspective.

First Observations of Mycosphaerella pini on Scots Pine in Finland

Red band needle blight of pines caused by Mycosphaerella pini (anamorph Dothistroma septosporum) has recently been recorded on Scots pine (Pinus sylvestris) at 14 rural districts in southern and central Finland. Scots pine is the most common and commercially most important tree species in Finland. Red bands with aggregations of conidial stromata on otherwise brown attached needles were frequently encountered on saplings and young trees in dense stands and sporadically on lower twigs of mature trees within 2 m of the ground. These symptoms and signs, typical for M. pini (1), were also observed on needles of P. contorta and P. cembra, which occur in Finland in low frequency. Symptoms of red band needle blight and abundant conidial stromata were found in March and April of 2008 after a mild and rainy winter. After this time, the frequency at which fresh acervuli were observed decreased. Conidia were isolated after squeezing conidial stromata into a drop of sterile water and rinsing out the drop onto water agar from where single conidia were picked up from under the microscope with a modified Pasteur pipette. The conidia were hyaline, smooth, thin walled, filiform, 2.0 to 2.7 (2.4) μm wide, and 15 to 37 (29.4) μm long. Germination of the conidia on water agar was 100%. The cultures grew slowly and reached a diameter of 4 to 10 mm within 3 weeks on modified orange serum agar (2) at 20°C and abundantly produced conidia. Complete sequences of the internal transcribed spacer (ITS) region including the 5.8S rRNA gene were obtained for three isolates from different rural districts: Hartola (61°34'N, 26°01'E), Kangasniemi (61°59'N, 26°39'E), and Suonenjoki (62°37'N, 27°07'E). These sequences are deposited in GenBank with Accession Nos. EU834294, EU834295, and EU834296 and are identical to each other and to more than 50 M. pini sequences in GenBank, including those of several Estonian and Austrian isolates. These isolates are deposited in the culture collection of the Finnish Forest Research Institute with identifiers Dot1, Dot2, and Dot8. Symptoms were reproduced after inoculation of 1-year-old Scots pine seedlings growing in seedling trays with 115 cm³ cavities. A conidial suspension (5 to 6·× 10³ conidia ml^-1) was prepared from two single-conidial cultures (Dot10 and Dot15), combined, and sprayed during July 2008 onto 192 seedlings until needles looked completely wet. Sixty-four seedlings were sprayed with distilled water as a control treatment. Seedlings were incubated outdoors in Suonenjoki and covered with a transparent plastic hood for the first 5 days after inoculation. The first symptoms (brown segments and red bands on needles) appeared on inoculated seedlings 1 month later, and conidial stromata appeared after another 2 to 4 weeks. M. pini was reisolated from the acervuli of 10 sample needles. Three months after inoculation, all inoculated seedlings showed symptoms while all noninoculated seedlings were healthy. It is possible that M. pini has spread recently from the south since it was identified for the first time in Estonia 2 years earlier (3). Although the Gulf of Finland separates Finnish pine forests from Estonian pine forests by approximately 50 to 100 km, spores may have been aerially disseminated over this distance. Alternatively, introduction of M. pini to Finland may have occurred on imported seedlings. References: (1) Anonymous. OEPP/EPPO Bull. 35, 303, 2005. (2) M. Hanso and R. Drenkhan. Plant Pathol. 57:170, 2008. (3) M. M. Müller et al. Mycol. Res. 98:593, 1994.

Sources of synchronized induced Gamma-Band responses during a simple object recognition task: a replication study in human MEG

Natural stimuli are compiled of numerous features, which are cortically represented in dispersed structures. Synchronized oscillations in the Gamma-Band (>30 Hz; induced Gamma-Band Responses, iGBRs), are regarded as a plausible mechanism to re-integrate these regions into a meaningful cortical object representation. Using electroencephalography (EEG) it was demonstrated that the generators of iGBRs can be localized to temporal, parietal, posterior, and frontal areas. The present magnetoencephalogram (MEG) study intended to replicate these findings in order contribute to the ongoing debate regarding the possible functional difference of high-frequency signals as measured by both techniques. During a standard object recognition task we found an augmentation of the iGBR after the presentation of meaningful as opposed to meaningless stimuli at approximately 160-440 ms after stimulus onset. This peak was localized to inferior temporal gyri, superior parietal lobules and the right middle frontal gyrus. Importantly, most of these brain structures were significantly phase-locked to each other. The implications of these results are twofold: (1) they present further evidence for the view that iGBRs signify neuronal activity in a broadly distributed network during object recognition. (2) MEG is well suited to detect induced high-frequency oscillations with a very similar morphology as revealed by EEG recordings, thereby eliminating known problems with electroencephalographical methods (e.g. reference confounds). In contrast to the iGBR, the localization of event-related fields (ERFs) and evoked Gamma-Band Response (eGBRs) revealed generators in focal visual areas, and thus, seem to mirror early sensory processing.

Sustained spatial attention to vibration is mediated in primary somatosensory cortex

Focusing attention to a specific body location has been shown to improve processing of events presented at this body location. One important debate concerns the stage in the somatosensory pathway at which the neural response is modulated when one attends to a tactile stimulus. Previous studies focused on components of the somatosensory evoked potential to transient stimuli, and demonstrated an early cortical attentional modulation. The neural basis of sustained spatial stimulus processing with continuous stimulation remains, however, largely unexplored. A way to approach this topic is to present vibrating stimuli with different frequencies for several seconds simultaneously to different body locations while subjects have to attend to the one or the other location. The amplitude of the somatosensory steady-state evoked potential (SSSEP) elicited by these vibrating stimuli increases with attention. On the basis of 128 electrode recordings, we investigated the topographical distribution and the underlying cortical sources by means of a VARETA approach of this attentional amplitude modulation of the SSSEP. Sustained spatial attention was found to be mediated in primary somatosensory cortex with no differences in SSSEP amplitude topographies between attended and unattended body locations. These result patterns were seen as evidence for a low-level sensory gain control mechanism in tactile spatial attention.

Feature-selective attention enhances color signals in early visual areas of the human brain

We used an electrophysiological measure of selective stimulus processing (the steady-state visual evoked potential, SSVEP) to investigate feature-specific attention to color cues. Subjects viewed a display consisting of spatially intermingled red and blue dots that continually shifted their positions at random. The red and blue dots flickered at different frequencies and thereby elicited distinguishable SSVEP signals in the visual cortex. Paying attention selectively to either the red or blue dot population produced an enhanced amplitude of its frequency-tagged SSVEP, which was localized by source modeling to early levels of the visual cortex. A control experiment showed that this selection was based on color rather than flicker frequency cues. This signal amplification of attended color items provides an empirical basis for the rapid identification of feature conjunctions during visual search, as proposed by "guided search" models.

Responses of N-Terminal Pro-Brain Natriuretic Peptide (NT-proBNP) and Cardiac Troponin I (cTnI) to Competitive Endurance Exercise in Recreational Athletes

The present study was designed to investigate whether the stress of a half-marathon race can induce myocardial cell injury or left ventricular dysfunction in moderately trained runners of both gender, as assessed by post-race plasma concentrations of biochemical cardiac-specific markers and by quantitative echocardiographic measurements. We examined 12 male (mean+/-SD); age: 42.8+/-7.3 yr; height: 177.6+/-7.4 cm; body mass: 75.6+/-9.4 kg; BMI: 24.1+/-1.8 and 13 female (mean+/-SD); age: 39.0+/-6.5 yr; height: 164.6+/-6.2 cm; body mass: 58.4+/-9.8 kg; BMI: 21.5+/-3.4 recreational runners, who completed a half-marathon race. Blood samples were collected from each subject before the half-marathon race as well as 20 min and 2 h post-race and cardiac troponin I (cTnI) and N-terminal pro-brain natriuretic peptide (NT-proBNP) were measured. Quantitative echocardiographic analyses of wall dimensions and ejection fraction were also obtained from 14 of 25 subjects within 1 wk after the race. Both blood markers showed significant changes (p<0.05-0.001) over the time course of the three blood draws. A significant percentage of laboratory analytes analyzed in this study were outside the reference ranges and fulfilled conventional criteria for cardiac muscle damage. However, echocardiography within one week following the competition did not show any evidence that running a half-marathon competition damages the myocardium. Strenuous endurance exercise in middle-aged recreational runners induces a significant elevation of biochemical cardiac-specific markers, which may reflect transient subclinical myocardial damage, but can also reflect a physiological reparative or adaptive process.

Decreased tissue reaction to bioprosthetic heart valve material afterL-glutamic acid treatment. A morphological study

Degenerative alterations of two different glutaraldehyde (GA)-fixed bioprosthetic heart valve materials were investigated in subcutaneous rat implants: Bovine pericardium, prepared according to clinically used bioprosthetic heart valve material (BHV) was compared to alternatively preserved pericardium (APHV), which was fixed in GA and treated with L-glutamic acid. Following 63 days of subcutaneous implantation, calcification of APHV implants was significantly lower as compared to BHV implants (13 +/- 6 versus 158 +/- 18 micrograms Ca/mg dry weight tissue; p less than 0.05). In BHV implants ultrastructural investigations showed nucleation of plate-shaped hydroxyapatite crystals at the surface of collagen fibrils and in remnants of connective tissue cells; no signs of calcification could be detected in APHV implants. The time-course of the inflammatory reaction was determined by quantification of immunohistochemical stained mononuclear host-cells invading the implants. In both preparation groups inflammatory reaction reached maximum 42 days after implantation. However, infiltration rate of inflammatory cells was markedly decreased in APHVs as compared to BHVs (p less than 0.05).

Intracellular acidification by inhibition of the Na+/H+-exchanger leads to caspase-independent death of cerebellar granule neurons resembling paraptosis

Potassium withdrawal is commonly used to induce caspase-mediated apoptosis in cerebellar granule neurons in vitro. However, the underlying and cell death-initiating mechanisms are unknown. We firstly investigated potassium efflux through the outward delayed rectifier K+ current (Ik) as a potential mediator. However, tetraethylammoniumchloride, an inhibitor of Ik, was ineffective to block apoptosis after potassium withdrawal. Since potassium withdrawal reduced intracellular pH (pHi) from 7.4 to 7.2, we secondly investigated the effects of intracellular acidosis. To study intracellular acidosis in cerebellar granule neurons, we inhibited the Na+/H+ exchanger (NHE) with 4-isopropyl-3-methylsulfonylbenzoyl-guanidine methanesulfonate (HOE 642) and 5-(N-ethyl-N-isopropyl)-amiloride. Both inhibitors concentration-dependently induced cell death and potentiated cell death after potassium withdrawal. Although inhibition of the NHE induced cell death with morphological criteria of apoptosis in light and electron microscopy including chromatin condensation, positive TUNEL staining and cell shrinkage, no internucleosomal DNA cleavage or activation of caspases was detected. In contrast to potassium withdrawal-induced apoptosis, cell death induced by intracellular acidification was not prevented by insulin-like growth factor-1, cyclo-adenosine-monophosphate, caspase inhibitors and transfection with an adenovirus expressing Bcl-XL. However, cycloheximide protected cerebellar granule neurons from death induced by potassium withdrawal as well as from death after treatment with HOE 642. Therefore, the molecular mechanisms leading to cell death after acidification appear to be different from the mechanisms after potassium withdrawal and resemble the biochemical but not the morphological characteristics of paraptosis.

[Muscle cell proteins are selectively released into the blood stream by marathon running]

In 19 marathon runners of both sexes, plasma concentrations of total creatine kinase (CK) activity, CKMB mass, myoglobin and troponin I were determined before and immediately after the race. Total CK activity and myoglobin increased significantly in all runners and showed neither a correlation with the individual age of the runners nor with the time they needed to reach the goal. In 12 of the runners, CKMB mass increased during the race to a level suggesting myocardial necrosis. However, the runners did not show any detectable deterioration of cardiac function after the race. The appearance of considerable amounts of muscle proteins in plasma precipitated by the muscle strain during the race seems explained by damage of skeletal muscle detected by histological studies. These phenomena may also be a consequence of profoundly disturbed cellular permeability, perhaps due to a kind of local stunning of muscle tissue by prolonged muscular strain.

Sustained division of the attentional spotlight

By voluntarily directing attention to a specific region of a visual scene, we can improve our perception of stimuli at that location. This ability to focus attention upon specific zones of the visual field has been described metaphorically as a moveable spotlight or zoom lens that facilitates the processing of stimuli within its 'beam'. A long-standing controversy has centred on the question of whether the spotlight of spatial attention has a unitary beam or whether it can be divided flexibly to disparate locations. Evidence supporting the unitary spotlight view has come from numerous behavioural and electrophysiological studies. Recent experiments, however, indicate that the spotlight of spatial attention may be divided between non-contiguous zones of the visual field for very brief stimulus exposures (&<100 ms). Here we use an electrophysiological measure of attentional allocation (the steady-state visual evoked potential) to show that the spotlight may be divided between spatially separated locations (excluding interposed locations) over more extended time periods. This spotlight division appears to be accomplished at an early stage of visual-cortical processing.

Determination of fifteen nucleotides in cultured human mononuclear blood and umbilical vein endothelial cells by solvent generated ion-pair chromatography

The paper describes the development of a method for the determination of 15 nucleotides in cultured mononuclear blood and umbilical vein endothelial cell lysates by solvent generated ion-pair chromatography. The phase system is generated via a mobile phase of 100 mM phosphoric acid adjusted to pH 6.2 with triethylamine. Nucleotides are eluted by applying a linear magnesium ion gradient. The method is robust, highly reproducible and easily adaptable to other cell lysates and allows the separation and quantitation of the nucleotides with detection limits in the range from 17 (ADP) to 126 (CDP) pmol in 20-microl aliquots.

Endothelial cell compatibility of azithromycin and erythromycin

Phlebitis is a severe local adverse event related to the use of parenteral macrolides. In order to evaluate the effect of azithromycin and erythromycin on human venous endothelial cells, we set up an in vitro model. The intracellular levels of purine nucleotides, as adenosine 5'-triphosphate (ATP), adenosine 5'-diphosphate (ADP) and guanosine 5'-triphosphate (GTP), were measured by means of high-performance liquid chromatography. Incubation of cells with 2 mg/mL azithromycin and erythromycin resulted in a rapid decline of intracellular ATP from 12.5 +/- 0.9 nmol/million cells to 4.1 +/- 0.3 and 2.6 +/- 0.4 nmol/million cells, respectively, after 60 min. In addition, ADP was extensively depleted from 2.1 +/- 0.17 nmol/million cells to 0.8 +/- 0.09 and 0.8 +/- 0.13 nmol/million cells after 60 min. After exposure of 0.5 mg/mL azithromycin and erythromycin, no significant decline of intracellular high-energy phosphate levels occurred after 20 and 60 min. Based on these results, solutions of azithromycin and erythromycin may not be well tolerated and may cause local adverse reactions even if diluted according to the manufacturer's recommendation.