Botrytis hypersensitive response inducing protein 1 triggers noncanonical PTI to induce plant cell death

According to their lifestyle, plant pathogens are divided into biotrophic and necrotrophic organisms. Biotrophic pathogens exclusively nourish living host cells, whereas necrotrophic pathogens rapidly kill host cells and nourish cell walls and cell contents. To this end, the necrotrophic fungus Botrytis cinerea secretes large amounts of phytotoxic proteins and cell wall-degrading enzymes. However, the precise role of these proteins during infection is unknown. Here, we report on the identification and characterization of the previously unknown toxic protein hypersensitive response-inducing protein 1 (Hip1), which induces plant cell death. We found the adoption of a structurally conserved folded Alternaria alternata Alt a 1 protein structure to be a prerequisite for Hip1 to exert its necrosis-inducing activity in a host-specific manner. Localization and the induction of typical plant defense responses by Hip1 indicate recognition as a pathogen-associated molecular pattern at the plant plasma membrane. In contrast to other secreted toxic Botrytis proteins, the activity of Hip1 does not depend on the presence of the receptor-associated kinases BRI1-associated kinase 1 and suppressor of BIR1-1. Our results demonstrate that recognition of Hip1, even in the absence of obvious enzymatic or pore-forming activity, induces strong plant defense reactions eventually leading to plant cell death. Botrytis hip1 overexpression strains generated by CRISPR/Cas9 displayed enhanced infection, indicating the virulence-promoting potential of Hip1. Taken together, Hip1 induces a noncanonical defense response which might be a common feature of structurally conserved fungal proteins from the Alt a 1 family.

3,4-Bis(hydroxymethyl)hexane-1,6-diol-based maltosides (HDMs) for membrane-protein study: Importance of detergent rigidity-flexibility balance in protein stability

Detergents have been major contributors to membrane-protein structural study for decades. However, membrane proteins solubilized in conventional detergents tend to aggregate or denature over time. Stability of large eukaryotic membrane proteins with complex structures tends to be worse, necessitating development of novel detergents with improved properties. Here, we prepared a novel class of detergents, designated 3,4-bis(hydroxymethyl)hexane-1,6-diol-based maltosides (HDMs). When tested on three membrane proteins, including two G-protein-coupled receptors (GPCRs), the new detergents displayed significantly better behaviors compared with DDM. Moreover, the HDMs were superior or comparable to LMNG, an amphiphile widely used for GPCR structural study. An optimal balance of detergent rigidity vs. flexibility of the HDMs is likely responsible for their favorable behaviors toward membrane-protein stability. Thus, the current study not only introduces the HDMs, with significant potential for membrane-protein structural study, but also suggests a useful guideline for designing novel detergents for membrane-protein research.

A bioinspired glycopolymer for capturing membrane proteins in native-like lipid-bilayer nanodiscs

Amphiphilic copolymers that directly extract membrane proteins and lipids from cellular membranes to form nanodiscs combine the advantages of harsher membrane mimics with those of a native-like membrane environment. Among the few commercial polymers that are capable of forming nanodiscs, alternating diisobutylene/maleic acid (DIBMA) copolymers have gained considerable popularity as gentle and UV-transparent alternatives to aromatic polymers. However, their moderate hydrophobicities and high electric charge densities render all existing aliphatic copolymers rather inefficient under near-physiological conditions. Here, we introduce Glyco-DIBMA, a bioinspired glycopolymer that possesses increased hydrophobicity and reduced charge density but nevertheless retains excellent solubility in aqueous solutions. Glyco-DIBMA outperforms established aliphatic copolymers in that it solubilizes lipid vesicles of various compositions much more efficiently, thereby furnishing smaller, more narrowly distributed nanodiscs that preserve a bilayer architecture and exhibit rapid lipid exchange. We demonstrate the superior performance of Glyco-DIBMA in preparative and analytical applications by extracting a broad range of integral membrane proteins from cellular membranes and further by purifying a membrane-embedded voltage-gated K⁺ channel, which was fluorescently labeled and analyzed with the aid of microfluidic diffusional sizing (MDS) directly within native-like lipid-bilayer nanodiscs.

Exchange of a single amino acid residue in the cryptophyte phycobiliprotein lyase GtCPES expands its substrate specificity

Cryptophytes are among the few eukaryotes employing phycobiliproteins (PBP) for light harvesting during oxygenic photosynthesis. In contrast to cyanobacterial PBP that are organized in membrane-associated phycobilisomes, those from cryptophytes are soluble within the chloroplast thylakoid lumen. Their light-harvesting capacity is due to covalent linkage of several open-chain tetrapyrrole chromophores (phycobilins). Guillardia theta utilizes the PBP phycoerythrin 545 with 15,16-dihydrobiliverdin (DHBV) in addition to phycoerythrobilin (PEB) as chromophores. The assembly of PBPs in cryptophytes involves the action of PBP-lyases as shown for cyanobacterial PBP. PBP-lyases facilitate the attachment of the chromophore in the right configuration and stereochemistry. Here we present the functional characterization of the eukaryotic S-type PBP lyase GtCPES. We show GtCPES-mediated transfer and covalent attachment of PEB to the conserved Cys82 of the acceptor PBP β-subunit (PmCpeB) of Prochlorococcus marinus MED4. On the basis of the previously solved crystal structure, the GtCPES binding pocket was investigated using site-directed mutagenesis. Thereby, amino acid residues involved in phycobilin binding and transfer were identified. Interestingly, exchange of a single amino acid residue Met67 to Ala extended the substrate specificity to phycocyanobilin (PCB), most likely by enlarging the substrate-binding pocket. Variant GtCPES_M67A binds both PEB and PCB forming a stable, colored complex in vitro and produced in Escherichia coli. GtCPES_M67A is able to mediate PCB transfer to Cys82 of PmCpeB. Based on these findings, we postulate that this single amino acid residue has a crucial role for bilin binding specificity of S-type phycoerythrin lyases but additional factors regulate handover to the target protein.

Self-Assembly of Protein-Containing Lipid-Bilayer Nanodiscs from Small-Molecule Amphiphiles

When membrane proteins are removed from their natural environment, the quality of the membrane-solubilizing agent used is critical for preserving their native structures and functions. Nanodiscs that retain a lipid-bilayer core around membrane proteins have attracted great attention because they offer a much more native-like environment than detergent micelles. Here, two small-molecule amphiphiles with diglucose headgroups and either a hydrocarbon or a fluorocarbon hydrophobic chain are shown to directly assemble lipids and membrane proteins to form native nanodiscs rather than mixed micelles. Self-assembly of nanodiscs of increasing complexity from both defined, artificial vesicles as well as complex, cellular membranes is demonstrated. A detailed investigation of bilayer integrity and membrane-protein activity in these nanodiscs reveals gentle effects on the encapsulated bilayer core. The fluorinated amphiphile appears particularly promising because its lipophobicity results in gentle, non-perturbing interactions with the nanoscale lipid bilayer. A sequential model of nanodisc self-assembly is proposed that proceeds through perforation of the original membrane followed by saturation and complete solubilization of the bilayer. On this basis, pseudophase diagrams are established for mixtures of lipids and nanodisc-forming diglucoside amphiphiles, and the latter are used for the extraction of a broad range of membrane proteins from cellular membranes.

Hybrid Fluorocarbon-Hydrocarbon Surfactants: Synthesis and Colloidal Characterization

Four double-tailed hybrid fluorocarbon-hydrocarbon (F-H) surfactants with a poly(ethylene glycol) (PEG) polar headgroup were synthesized. The hydrophobic scaffold consists of an amino acid core, onto which were grafted both fluorocarbon and hydrocarbon chains of different lengths. The PEG polar head was connected to the hydrophobic scaffold through a copper(I)-mediated click reaction. The four derivatives exhibit aqueous solubility >100 g/L and self-assemble into micellar aggregates with micromolar critical micellar concentration (CMC) values, as demonstrated by isothermal titration calorimetry (ITC), surface tension (ST) measurements, and steady-state fluorescence spectroscopy. The CMC value decreased by a factor of ∼6 for each additional pair of CH₂ groups, whereas a decrease by a factor of ∼2.5 was observed when the size of the PEG polar head was reduced from 2000 to 750 g/mol. Dynamic light scattering (DLS) showed unimodal micelle populations with hydrodynamic diameters of 10-15 nm, in agreement with results obtained from size-exclusion chromatography (SEC). The aggregation number increased with the hydrocarbon chain length but decreased with increasing PEG chain lengths. The combination in one molecular design of both low CMC and high water solubility makes these new surfactants promising systems for novel drug-delivery systems.

Maltose-Based Fluorinated Surfactants for Membrane-Protein Extraction and Stabilization

Two new surfactants, F₅OM and F₅DM, were designed as partially fluorinated analogues of n-dodecyl-β-D-maltoside (DDM). The micellization properties and the morphologies of the aggregates formed by the two surfactants in water and phosphate buffer were evaluated by NMR spectroscopy, surface tension measurement, isothermal titration calorimetry, dynamic light scattering, small-angle X-ray scattering, and analytical ultracentrifugation. As expected, the critical micellar concentration (cmc) was found to decrease with chain length of the fluorinated tail from 2.1-2.5 mM for F₅OM to 0.3-0.5 mM for F₅DM, and micellization was mainly entropy-driven at 25 °C. Close to their respective cmc, the micelle sizes were similar for both surfactants, that is, 7 and 13 nm for F₅OM and F₅DM, respectively, and both increased with concentration forming 4 nm diameter rods with maximum dimensions of 50 and 70 nm, respectively, at a surfactant concentration of ∼30 mM. The surfactants were found to readily solubilize lipid vesicles and extract membrane proteins directly from Escherichia coli membranes. They were found more efficient than the commercial fluorinated detergent F₆H₂OM over a broad range of concentrations (1-10 mM) and even better than DDM at low concentrations (1-5 mM). When transferred into the two new surfactants, the thermal stability of the proteins bacteriorhodopsin (bR) and FhuA was higher than in the presence of their solubilization detergents and similar to that in DDM; furthermore, bR was stable over several months. The membrane enzymes SpNOX and BmrA were not as active as in DDM micelles but similarly active as in F₆OM. Together, these findings indicate both extracting and stabilizing properties of the new maltose-based fluorinated surfactants, making them promising tools in MP applications.

Diastereomeric Cyclopentane-Based Maltosides (CPMs) as Tools for Membrane Protein Study

Amphiphilic agents, called detergents, are invaluable tools for studying membrane proteins. However, membrane proteins encapsulated by conventional head-to-tail detergents tend to denature or aggregate, necessitating the development of structurally distinct molecules with improved efficacy. Here, a novel class of diastereomeric detergents with a cyclopentane core unit, designated cyclopentane-based maltosides (CPMs), were prepared and evaluated for their ability to solubilize and stabilize several model membrane proteins. A couple of CPMs displayed enhanced behavior compared with the benchmark conventional detergent, n-dodecyl-β-d-maltoside (DDM), for all the tested membrane proteins including two G-protein-coupled receptors (GPCRs). Furthermore, CPM-C12 was notable for its ability to confer enhanced membrane protein stability compared with the previously developed conformationally rigid NBMs [J. Am. Chem. Soc. 2017, 139, 3072] and LMNG. The effect of the individual CPMs on protein stability varied depending on both the detergent configuration (cis/trans) and alkyl chain length, allowing us draw conclusions on the detergent structure-property-efficacy relationship. Thus, this study not only provides novel detergent tools useful for membrane protein research but also reports on structural features of the detergents critical for detergent efficacy in stabilizing membrane proteins.

Ascending Si diffusion into growing GaN nanowires from the SiC/Si substrate: up to the solubility limit and beyond

We report a novel mechanism that allows the incorporation of Si into GaN nanowires up to and beyond the solubility limit. This mechanism is documented during the growth on vicinal (misoriented) SiC/Si hybrid substrates having the step bunches. Nanowires that are grown at these locations become heavily Si doped. Such high Si concentrations were verified by secondary-ion mass spectrometry. Photoluminescence data also point to very high carrier concentrations. Moreover, Raman spectroscopy together with quantum chemical modelling shows the build up of Si into Ga sites and indicates even the possibility of the formation of a Ga(Si)N solid solution. The microscopic mechanism responsible for heavy doping and even alloying is diffusion driven by the mechano-chemical effect, which allows for the extremely efficient injection of Si atoms into the nanowires from the step bunches at the vicinal SiC/Si substrates.

Fast and Robust Quantification of Detergent Micellization Thermodynamics from Isothermal Titration Calorimetry

Detergents are widely used in modern in vitro biochemistry and biophysics, in particular to aid the characterization of integral membrane proteins. An important characteristic of these chemicals in aqueous solutions is the concentration above which their molecular monomers self-associate to form micelles, termed the critical micellar concentration (CMC). Micelles are supramolecular assemblies arranged with the hydrophobic portions oriented inward and the hydrophilic head groups positioned outward to interact with the aqueous solvent. Knowledge of the CMC is not only of practical relevance but also of theoretical interest because it provides thermodynamic insights. Isothermal titration calorimetry (ITC) is a powerful method to determine CMCs, as it furnishes additional information on the enthalpy and entropy of micellization. Here we describe our extension of previous methods to determine CMCs and other thermodynamic parameters from ITC demicellization curves. The new algorithm, incorporated into the stand-alone software package D/STAIN, analyzes ITC demicellization curves by taking advantage of state-of-the-art thermogram-integration techniques and automatically providing rigorous confidence intervals on the refined parameters. As a demonstration of the software's capabilities, we undertook ITC experiments to determine the respective CMCs of n-octyl β-d-glucopyranoside (OG), n-dodecyl β-d-maltopyranoside (DDM), and lauryldimethylamine N-oxide (LDAO). Motivated by the fact that in vitro membrane protein studies often require additives such as precipitants (e.g., polyethylene glycol (PEG)), we also carried out ITC demicellization studies in the presence of PEG3350, finding in all cases that PEG had significant effects on the thermodynamics of detergent micellization.

Role of hole confinement in the recombination properties of InGaN quantum structures

We study the isolated contribution of hole localization for well-known charge carrier recombination properties observed in conventional, polar InGaN quantum wells (QWs). This involves the interplay of charge carrier localization and non-radiative transitions, a non-exponential decay of the emission and a specific temperature dependence of the emission, denoted as “s-shape”. We investigate two dimensional In_0.25Ga_0.75N QWs of single monolayer (ML) thickness, stacked in a superlattice with GaN barriers of 6, 12, 25 and 50 MLs. Our results are based on scanning and high-resolution transmission electron microscopy (STEM and HR-TEM), continuous-wave (CW) and time-resolved photoluminescence (TRPL) measurements as well as density functional theory (DFT) calculations. We show that the recombination processes in our structures are not affected by polarization fields and electron localization. Nevertheless, we observe all the aforementioned recombination properties typically found in standard polar InGaN quantum wells. Via decreasing the GaN barrier width to 6 MLs and below, the localization of holes in our QWs is strongly reduced. This enhances the influence of non-radiative recombination, resulting in a decreased lifetime of the emission, a weaker spectral dependence of the decay time and a reduced s-shape of the emission peak. These findings suggest that single exponential decay observed in non-polar QWs might be related to an increasing influence of non-radiative transitions.

Hydrogenated Diglucose Detergents for Membrane-Protein Extraction and Stabilization

We report herein the design and synthesis of a novel series of alkyl glycoside detergents consisting of a nonionic polar headgroup that comprises two glucose moieties in a branched arrangement (DG), onto which octane-, decane-, and dodecanethiols were grafted leading to ODG, DDG, and DDDG detergents, respectively. Micellization in aqueous solution was studied by isothermal titration calorimetry, ¹H NMR spectroscopy, and surface tensiometry. Critical micellar concentration values were found to decrease by a factor of ∼10 for each pair of methylene groups added to the alkyl chain, ranging from ∼0.05 to 9 mM for DDDG and ODG, respectively. Dynamic light scattering and analytical ultracentrifugation sedimentation velocity experiments were used to investigate the size and composition of the micellar aggregates, showing that the aggregation number significantly increased from ∼40 for ODG to ∼80 for DDDG. All new compounds were able to solubilize membrane proteins (MPs) from bacterial membranes, insect cells, as well as the Madin-Darby canine kidney cells. In particular, native human adenosine receptor (A2AR) and bacterial transporter (BmrA) were solubilized efficiently. Striking thermostability improvements of +13 and +8 °C were observed when ODG and DDG were, respectively, applied to wild-type and full-length A2AR. Taken together, this novel detergent series shows promising detergent potency for solubilization and stabilization of membrane proteins (MPs) and thus makes a valuable addition to the chemical toolbox available for extracting and handling these important but challenging MP targets.

Double-Blind, Randomized Comparison of Systemic Continuous Infusion of 0.25 Versus 0.50 mg/kg/24 h of Alteplase over 3 to 7 Days for Treatment of Deep Venous Thrombosis in Heparinized Patients: Results of the European Thrombolysis with rt-PA in Venous Thrombosis (ETTT) Trial

Thirty-two patients with acute, proximal-vein thrombosis were treated with heparin and alteplase (0.25 versus 0.5 mg/kg/24 h during 3-7 days) in a randomized, double-blind, multicenter, European (ETTT) trial. The treatment resulted in a decrease of the venographic Marder’s score from 18 (6-25) to 13 (2-24) units (median, range) in Group I (0.25 mg/kg/24 h, n = 15, median decrease 3.0, p = 0.32) and from 17.5 (3-33) to 15.5 (0-27) in Group II (0.5 mg/kg/24 h, n = 16, median decrease 4.0, p = 0.23). Comparison of the sequential venograms could be performed in 14 cases of Group I and in 15 cases in Group II. A minority of patients showed substantial partial recanalization of the initially obstructed veins on the control venogram (one in each treatment group) and most of the control venograms showed

Thus, the results of the ETTT trial show that the used low dosages of alteplase administered intravenously over 3-7 days in heparinized patients cannot be recommended as a treatment for patients with deep venous thrombosis of lower limbs and/or pelvis. Further studies are needed to define a more suitable dosage regimen of alteplase in this indication.

Endovascular stenting of a renal transplant vein

We describe successful endovascular stenting of a high-grade stenosis of a renal transplant vein in a 53-year old patient. Kidney transplantation had been performed due to IgA nephropathy and the patient had become symptomatic two months after uneventful recovery from operation.

Association of Cardiovascular Risk Factors with Pattern of Lower Limb Atherosclerosis in 2659 Patients Undergoing Angioplasty

OBJECTIVES

Aim of this study is to correlate distribution pattern of lower limb atherosclerosis with cardiovascular risk factor profile of patients with peripheral arterial occlusive disease (PAD).

PATIENTS AND METHODS

Analysis is based on a consecutive series of 2659 patients (1583 men, 1076 women, 70+/-11 years) with chronic PAD of atherosclerotic origin undergoing primary endovascular treatment of lower extremity arteries. Pattern of atherosclerosis was grouped into iliac (n=1166), femoropopliteal (n=2151) and infrageniculate (n=888) disease defined according to target lesions treated. A multivariable multinomial logistic regression analysis was performed to assess relation with age, gender and classical cardiovascular risk factors (diabetes mellitus, arterial hypertension, hypercholesterolemia, cigarette smoking) using femoropopliteal disease as reference.

RESULTS

Iliac disease was associated with younger age (RRR 0.95 per year of age, 95%-CI 0.94-0.96, p<0.001), male gender (RRR 1.32, 95%-CI 1.09-1.59, p=0.004) and cigarette smoking (RRR 2.02, 95%-CI 1.68-2.42, p<0.001). Infrageniculate disease was associated with higher age (RRR 1.02, 95%-CI 1.01-1.02, p<0.001), male gender (RRR 1.23, 95%-CI 1.06-1.41, p=0.005) and diabetes mellitus (RRR 1.68, 95%-CI 1.47-1.92, p<0.001). Hypercholesterolemia was less prevalent in patients with lesions below the knee (RRR 0.82, 95%-CI 0.71-0.94, p=0.006), whereas no distinct pattern was apparent related to arterial hypertension.

CONCLUSION

Clinical phenotype of peripheral atherosclerosis varies with prevalence of cardiovascular risk factors suggesting differences in mechanisms involved in iliac as compared with infrageniculate lesions. Identification of molecular mechanism might have influence on future therapeutic strategies in PAD patients.

Phlebödem und Lymphödem – das dicke Bein aus angiologischer Sicht

Periphere Ödeme sind durch Störungen des Gleichgewichts zwischen Filtration, Resorption und Lymphabfluss im Kapillarbereich bedingt. Wichtige Pathomechanismen sind die venöse Hypertonie sowie ein unzulänglicher Abtransport lymphpflichtiger Lasten. Sowohl die chronisch venöse Insuffizienz infolge Klappendegeneration als auch die akute Obstruktion im Rahmen einer tiefen Beinvenenthrombose führen zu venöser Hypertonie und somit zum Anstieg des Filtrationsdrucks in der Kapillare. Die venöse Hypertonie ist eine «Volkskrankheit» und Phlebödeme sind mit der häufigste Grund für eine Beinschwellung im klinischen Alltag. Primäre und sekundäre Lymphabflussstörungen sind ein weiterer wichtiger Grund für eine Dysbalance im ohnehin heiklen Flüssigkeitsgleichgewicht. Lymphödeme, an denen weltweit rund 140 Millionen Menschen leiden, werden dennoch oftmals nicht oder verspätet diagnostiziert.

Delay of dialysis in end-stage renal failure: Prospective study on percutaneous renal artery interventions

BACKGROUND

Renal artery stenosis (RAS) is a cause of end-stage renal failure. We studied the effect of percutaneous renal artery intervention (PRI) in patients with advanced, progressive disease at risk for renal failure, hypothesizing a beneficial effect.

METHODS

Thirty-nine primary and 14 secondary PRIs were performed on 28 patients with atherosclerotic RAS, serum creatinine >300 micromol/L, and progressive loss of renal function >/=1 year before PRI. Renal function and RA patency were prospectively followed for 12 months after primary and secondary PRI. The intervention's effect on the progressive loss of renal function was calculated by comparing reciprocal slopes of serum creatinine against time before and after PRI.

RESULTS

Progression of renal failure slowed significantly following PRI. Mean (+/-SE) slopes of reciprocal serum creatinine values were: 6.69 +/- 0.97 L micromol(-1) day(-1) (x10(-6)) before and 6.76 +/- 3.03 L micromol(-1) day(-1) (x10(-6)) after PRI (P= 0.0007). Fifteen patients (53.5%) showed improvement or stabilization of progressive renal dysfunction. Out of 11 patients expected to become dialysis dependent within one year, 8 (72.7%) experienced an improvement in renal function sufficient to remain dialysis-free. Favorable outcome correlated with a lower creatinine level (P= 0.0137) and a more negative slope of progression (r= 0.49, P= 0.020) at entry. Mortality was 10.7%, and rate of local complications was 7.1%. Deterioration of renal function following PRI was suspected in 17.9% of patients.

CONCLUSION

PRI may improve renal function and ultimately delay dialysis in patients with advanced renal failure. Possible advantages must be weighed against the risk of renal failure advancement and high procedure-related complication rate.

Double-blind, randomized, controlled study on the efficacy and safety of a novel diclofenac epolamine gel formulated with lecithin for the treatment of sprains, strains and contusions

To evaluate the efficacy of the new diclofenac-N-(2-hydroxyethyl)-pyrrolidine gel formulated with lecithin (DHEP lecithin) compared with diclofenac-N-(2-hydroxyethyl)-pyrrolidine gel (DHEP gel) without lecithin in mild-to-moderate posttraumatic injuries (grade 1 ankle, knee and muscle injuries), a multicenter, double-blind, controlled study was carried out. A total of 100 patients were enrolled and randomly assigned to either DHEP lecithin (n = 52) or DHEP gel (n = 48) treatment. All patients concluded the treatment period except for five, who did not turn up to their respective investigational sites for the follow-up visits. According to an intention-to-treat approach, they were all included in the statistical analysis. As for the efficacy and safety analysis, the primary variable was "pain on movement" as measured by a Huskisson visual analog scale. During the first 3 days of treatment each group recorded a significant within-group decrease, but patients treated with DHEP lecithin showed a decrease in absolute value that was statistically greater than that obtained with DHEP gel (p = 0.025). At the end of the treatment period (day 10) the difference between groups was still statistically significant (p = 0.036). The statistical analysis of the secondary efficacy variables showed significant results in favor of DHEP lecithin treatment. These were superimposable on the results found for the primary variable. The global efficacy and tolerability judgments, reported either by patient or by physician, showed no statistical difference between treatment groups. Due to the presence of lecithin in the new gel formulation, DHEP lecithin showed a faster and significantly more marked therapeutic effect compared with that of DHEP gel.

Does infection affect amputation rate in chronic critical leg ischemia?

BACKGROUND

Aim was to analyze the association between local infection and amputation rate in patients with chronic critical limb ischemia (CLI) with or without successful revascularization.

PATIENTS AND METHODS

We performed a retrospective analysis of 56 consecutive patients with 57 critically ischemic legs seen at the University Hospital Bern. Patients with CLI were selected if ischemic lesions and follow-up of more than 2 months were documented. Infection was suggested when 2 of the following criterion were present: temperature > 37 degrees C, C-reactive protein > 50 mg/L, leukocytes > 10 x 10(3)/microliter ("2 of 3" criterion), or a putrid secretion was documented ("secretion" criterion).

RESULTS

In patients with successful revascularization (n = 39), there was a significant shift from 10.3% major to 33.3% minor amputations (Chi Square p value = 0.014) as compared to patients without or with failed revascularization (n = 18) with 44.4% and 11.1% (Chi Square p value = 0.008), respectively. An infection was suggested in 22 of 53 limbs (41.5%) according to the "2 of 3" criterion, and 30 of 57 limbs (52.6%) satisfying the "secretion" criterion. Both criteria, were significantly more common in patients undergoing amputation as compared to patients without amputation (p = 0.001). Multiple lesions were more common in patients with major amputations (p = 0.026).

CONCLUSION

Successful revascularization effectively reduces major amputations and leads to healing of ischemic ulcers. Secondary foot infections are frequent. Infections are associated with a significantly higher rate of minor and major amputations, also in patients with successful revascularization, and should be treated adequately as well as in time with antibiotics.

[Anticoagulation and antiaggregation in patients with peripheral arterial occlusive diseases]

Peripheral vascular occlusive disease (PAOD) is frequently seen in patients suffering from coronary heart or cerebrovascular disease and is, considered as a prognostic predictor for the morbidity and mortality of this patient group. Thus, secondary antithrombotic and antiplatelet prophylaxis in these patients is not limited to achievement of long-term patency of the revascularized or recanalized arterial segment, but plays as well a pivotal role for the prevention of myocardial infarction and stroke. Generally, claudicants as well as patients undergoing percutaneous transluminal angioplasty (PTA), supragenicular femoro-popliteal artificial bypass surgery, aortofemoral, iliaco-femoral unilateral bypass, or aortobifemoral Y-graft implantation with unimpaired arterial outflow are treated life-long with low dose acetylsalicylic acid (ASA) 75-250 mg. On the other hand, those undergoing axillo-femoral, femoro-femoral crossover, aorto-profundal or femoro-popliteal infragenicular and femoro-distal venous bypass surgery should be treated with vitamin K antagonists. The role of Clopidogrel in secondary prevention after peripheral revascularization and recanalization still needs to be defined.

Evaluation of clinical tests to assess perfusion in chronic critical limb ischemia

BACKGROUND

Evaluation of macro- and microcirculatory tests to confirm diagnosis, and recognize perfusion changes in chronic critical limb ischemia (CLI).

PATIENTS AND METHODS

Forty-two consecutive patients with CLI examined at the University Hospital Bern, with 21 included in this prospective follow-up analysis. Patients underwent serial clinical examinations, and assessment of the macro- (ankle arterial pressure [AP], great toe pressure [TP], oscillography) and microcirculation (transcutaneous partial oxygen pressure [tcPO2] recumbent, sitting, O2-inhalation; capillary microscopy) at baseline, 6 weeks after revascularization (group 1; [n = 11]), or after 10 weeks in patients unsuitable for revascularization (group 2; [n = 10]). Clinical improvement was considered to indicate increased perfusion.

RESULTS

Eleven patients with revascularization (11/11), and 2 without revascularization (2/10) showed clinical improvement. AP measurements were not reliable or feasible in 9 (43%), TP in 4 patients (19%), respectively. All measurable pressures were in accordance to clinical course. Oszillography gave a moderate perception of perfusion changes. Baseline tcPO2 levels were critical (< 30 mmHg) in all 21 patients, whereas follow-up gave poor correlation with the clinical course. Reliability to detect perfusion changes increased by adding provocation manoeuvers in patients with clinical improvement (39% [5/13] recumbent, 77% [10/13] sitting, 85% [11/13] O2-inhalation). Capillary microscopy revealed a relevant pathology at the forefoot level in all patients with feasible examinations (18/21), and significant improvements according to the clinical course in 92% of patients (12/13).

CONCLUSIONS

TP measurements represented most reliable test to confirm diagnosis and disclose improved perfusion in CLI. TcPO2 measurements in recumbent position gave unreliable results, improved by provocation manoeuvers. Capillary microscopy was reliable, but time consuming and limited by anatomical restrictions.

Recombinant tissue plasminogen activator versus urokinase for local thrombolysis of femoropopliteal occlusions: a prospective, randomized multicenter trial

PURPOSE

To report the outcome of a prospective, randomized, open multicenter trial comparing (1) the effects of local thrombolysis with recombinant tissue plasminogen activator (rtPA) or urokinase (UK) and (2) 2 administration techniques.

METHODS

Two hundred thirty-four patients with thromboembolic occlusions in 223 native femoral or popliteal arteries (95%) and 11 bypass grafts (5%) were randomized to rtPA (n = 124) or UK (n = 110) administered either through an endhole catheter (Hess technique) in 81 patients or a microporous balloon catheter (Schneider technique) in 153 patients. When lysis was incomplete, additional catheter interventions were applied to achieve patency. Results were analyzed by fluoroscopy during intervention and by angiography evaluated by independent experts blinded to the methods applied.

RESULTS

The only significant difference between rtPA and UK was found at the end of lysis using the Hess technique. Complete reperfusion (TIMI grade 3) was produced in 60% of patients by rtPA versus 37% by UK (p = 0.045). By both techniques TIMI grade 3 was achieved in 62% with rtPA and in 50% with UK (p = 0.18). Independent of delivery technique, thrombolytic agent, or additional catheter interventions, TIMI grade 3 was achieved in 81% and angiographic patency in 88%. Primary patency at 6 months was 66%, which was increased by secondary interventions to 75%. Major amputations were performed in 6%, all in patients with initial Fontaine stage III/IV ischemia.

CONCLUSIONS

With local thrombolysis alone, rtPA appears to be more effective than UK; however, additional catheter interventions further improved patency, abolishing the difference between the lytic agents.

Effects of exercise training program on functional capacity and quality of life in patients with peripheral arterial occlusive disease. Evaluation of a pilot project

BACKGROUND

In patients with peripheral arterial occlusive disease (PAOD) stage II, exercise training seems to be important to reduce symptoms and improve functional capacity. We evaluated the effects of an out-patient treatment program on walking distance (standardized treadmill testing), training exercise capacity, and disease specific quality of life (PAVK-86 questionnaire).

METHODS AND RESULTS

Thirty-one patients aged 70 +/- 2 with intermittent claudicatio in stage IIa/IIb according to Fontaine (n = 18/13) underwent a supervised 12 week exercise training and education outpatient program. During course of intervention, patients demonstrated improvements in pain-free training walking distance (p < 0.001) and repetitions of tiptoe standing (p < 0.05). In standardized treadmill testing, pain-free walking distance was improved by 182% (129 +/- 19 m-->364 +/- 53 m; p < 0.001), and maximum walking distance by 76% (311 +/- 42 m-->546 +/- 63 m; p < 0.01). Before training, mean subscale scores of the PAVK-86 demonstrated distinct impairments concerning pain and functional status. After 12 weeks of intervention, with exception of the subscale complaints, all dimensions of quality of life assessed have improved significantly. The highest effect size was observed for the subscales pain, mood, and functional status. Improvement in the subscale anxiety and pain-free walking distance (treadmill test) correlated significantly (r = 0.46) as well as improvement in the subscale mood and maximum walking distance (r = 0.45).

CONCLUSION

In patients with PAOD stage II considerable effects on functional capacity and important dimensions of quality of life can be achieved by a short exercise and education program.

Treatment of renal artery fibromuscular dysplasia with balloon angioplasty: a prospective follow-up study

OBJECTIVES

to assess restenosis rates and blood pressure response after percutaneous transluminal renal angioplasty (PTRA) in patients treated for fibromuscular dysplastic renal artery stenosis.

METHODS

a prospective 12-month follow-up study of 27 patients with 31 treated renal artery stenosis. Follow-up assessment included colour-coded duplex sonography (CCD) of renal arteries, monitoring of blood pressure, antihypertensive medication, and creatinine measurements before discharge and at 3, 6, and 12 months. Primary end point was defined as a haemodynamically significant restenosis >60% assessed by CCD.

RESULTS

there was a cumulative 23% restenosis rate at 12 months. Arterial hypertension was cured or improved in 93% of patients immediately after the intervention and remained cured/improved in 74% of patients at 12 months of follow-up. Renal failure present in five patients before PTRA stabilised or improved in all patients.

CONCLUSION

although restenosis rate after PTRA in fibromuscular dysplasia is as high as in non-ostial atherosclerotic lesions, there remains a considerable higher therapeutic effect. Profound pressure response and recurrent arterial hypertension with restenosis support the high probability of a renovascular origin of arterial hypertension in this young and otherwise healthy population compared to patients with atherosclerotic renal artery lesions.

Recombinant tissue plasminogen activator versus urokinase for local thrombolysis of femoropopliteal occlusions: a prospective, randomized multicenter trial

PURPOSE

To report the outcome of a prospective, randomized, open multicenter trial comparing (1) the effects of local thrombolysis with recombinant tissue plasminogen activator (rtPA) or urokinase (UK) and (2) 2 administration techniques.

METHODS

Two hundred thirty-four patients with thromboembolic occlusions in 223 native femoral or popliteal arteries (95%) and 11 bypass grafts (5%) were randomized to rtPA (n = 124) or UK (n = 110) administered either through an endhole catheter (Hess technique) in 81 patients or a microporous balloon catheter (Schneider technique) in 153 patients. When lysis was incomplete, additional catheter interventions were applied to achieve patency. Results were analyzed by fluoroscopy during intervention and by angiography evaluated by independent experts blinded to the methods applied.

RESULTS

The only significant difference between rtPA and UK was found at the end of lysis using the Hess technique. Complete reperfusion (TIMI grade 3) was produced in 60% of patients by rtPA versus 37% by UK (p = 0.045). By both techniques TIMI grade 3 was achieved in 62% with rtPA and in 50% with UK (p = 0.18). Independent of delivery technique, thrombolytic agent, or additional catheter interventions, TIMI grade 3 was achieved in 81% and angiographic patency in 88%. Primary patency at 6 months was 66%, which was increased by secondary interventions to 75%. Major amputations were performed in 6%, all in patients with initial Fontaine stage III/IV ischemia.

CONCLUSIONS

With local thrombolysis alone, rtPA appears to be more effective than UK; however, additional catheter interventions further improved patency, abolishing the difference between the lytic agents.

Reisethrombose 2001

Anlässlich einer Tagung in Wien im Juni 2001 hat eine Gruppe von Experten aus Deutschland, der Schweiz und aus Österreich ein Dokument ausgearbeitet, in welchem eine Definition der Reisethrombose gegeben und Vorbeugemaßnahmen vorgeschlagen wurden, die an drei Risikogruppen angepasst sind.

[Treatment of peripheral arterial occlusive disease]

The choice of therapy for peripheral artery occlusive disease depends on functional stage, site and extent of vascular lesion, pathogenesis, and the individual needs of the patients. In stage I (according to Fontaine) the risk factors are sought and treated. In stage II walking exercise is the main pillar besides vasoactive drugs and secondary drug prevention. Transluminal angioplasty is recommended if vascular lesions are suitable (short stenoses or occlusions in iliac a/o femoro-popliteal arteries). Surgery may be performed in aorto-iliac arteries but only exceptionally in femoro-popliteal disease. In stage III/IV or chronic critical ischemia every possibility for revascularisation must be considered. In acute stages immediate therapy is necessary. In our hands catheter techniques (thrombolysis a/o aspiration) are the first line approach on the femoro-popliteal level while occlusions on aorto-iliac level are left to surgery.

Stent placement in ostial and nonostial atherosclerotic renal arterial stenoses: a prospective follow-up study

PURPOSE

To compare the results of balloon percutaneous transluminal renal angioplasty (PTRA) and stent placement in atherosclerotic ostial, proximal, and isolated truncal stenoses.

MATERIALS AND METHODS

Between January 1994 and April 1998 the authors prospectively followed up 163 consecutive patients with 200 atherosclerotic renal arterial lesions after primary PTRA or primary stent placement. Duplex ultrasonography was performed 1 day and 3, 6, and 12 months later.

RESULTS

The primary 12-month PTRA patency rates were 34% (21 of 33 atherosclerotic lesions) for ostial stenoses, 65% (20 of 60) for proximal stenoses, and 83% (five of 30) for truncal stenoses (chi(2) value, 15.63; P <.001). The corresponding stent patency rates were 80% (four of 21), 72% (nine of 34), and 66% (five of nine), respectively (chi(2) value, 4.11; not significant). Significant stent-related reduction in risk of restenosis was limited to the ostial stenoses (P =.002).

CONCLUSION

Renal arterial stent placement considerably improves patency in ostial stenoses, but compared with the technically successful PTRA, it does not significantly improve primary patency in proximal and isolated truncal renal arterial stenoses.

Percutaneous catheter thrombus aspiration for acute or subacute arterial occlusion of the legs: how much thrombolysis is needed?

OBJECTIVE

To evaluate the role of a combined percutaneous endovascular approach including thrombus aspiration, catheter thrombolysis, and percutaneous transluminal angioplasty (PTA) to treat acute and subacute occlusions of native leg arteries.

MATERIALS AND METHODS

Retrospective evaluation of the effectiveness and safety of this catheter therapy in 89 consecutive patients (93 legs) in a single centre.

RESULTS

Treatment was initially successful in 90% of legs. Mortality at 30 days was 8%, and at 12 months 19%. Amputation-free survival at 12 months was 78%. Aspiration alone was sufficient in 31% of cases, urokinase (mean dose 112 500+/-55 900 IU) was used in 22%, PTA was added in 69%. There was no major bleeding except for one false aneurysm treated by ultrasound-guided compression. Secondary interventions within 12 months were required in 30% of cases (14 endovascular, 16 open surgical procedures).

CONCLUSIONS

Catheter thrombus aspiration in combination with thrombolysis and/or PTA is highly effective. Only in a minority of patients are thrombolytics in modest doses necessary, and serious bleeding complications are rare. We recommend this procedure as first-line treatment for acute or subacute infrainguinal arterial occlusions.

[Progress in endovascular therapy of peripheral arteries]

Percutaneous transluminal angioplasty introduced by Grüntzig nearly 30 years ago, remains one of the most often performed treatment for peripheral artery disease. Aortoiliac stenoses as well as short femoropopliteal occlusions are particularly prone to PTA approach. Because catheter intervention is not only limited to balloon dilatation but offers a wide variety of treatment, endovascular treatment tends to replace the generic term PTA. Recent progress in this field extend far beyond imaging improvement. They comprise new revascularisation techniques and lesions that were formerly considered to be solely treatable by surgery become curable by endovascular approaches. Combined treatment associating thromboaspiration with embolectomy in case of acute or subacute infrainguinal occlusions as well as low dose infiltration thrombolysis with or without additional PTA represent now first choice therapeutic interventions. The manufacturing of stents or stent-grafts represents one of the greatest breakthrough in the field of endovascular interventions. Stents have significantly improved post PTA patency particularly in the suprainguinal location. Furthermore, stent-grafts represent an attractive alternative to bypass surgery in a selected population, to exclude aortic aneurysm, mainly below the renal arteries. The last but not the least of the progress in the management of patients with peripheral artery disease is the multidisciplinary approach of the vascular problems by the specialist involved in cardiovascular diseases.

Renal artery stenting following acute aortic dissection: implantation and follow-up

Two patients with renal artery involvement in type B dissection of the aorta were treated by percutaneous stent implantation. Both of them were hypertensive and showed increasing serum creatinine levels. After stent implantation in the renal arteries blood pressure and renal function improved, and the renal arteries were patent in duplex ultrasound 15 and 30 months after treatment respectively.

Influence of the ultrasound contrast agent Levovist on human nailfold capillary microcirculation

Little is known about the behavior of ultrasound contrast microbubbles in human capillaries. The evaluation of circulatory effects of echo contrast media may bring valuable information for the interpretation of echo contrast phenomena in the human myocardium. In 12 healthy volunteers (aged 31 +/- 6.7 years; five women), nailfold capillaries were examined by means of TV microscopy. The authors investigated acral microcirculation at rest and after local cold application with and without saccharide-based microbubbles (10 mL Levovist 300 mg/mL IV). The mean blood flow velocity at rest was 1.18 +/- 0.18 mm/s (mean value +/-1 SD) and 1.11 +/- 0.11 mm/s (mean value +/- 1 SD) after the injection of Levovist (ns). One minute after local cold exposure a decrease of the blood flow velocity by 61% before and by 75% after intravenous Levovist was found. In both groups the cold-induced decrease of blood flow velocity was statistically significant (p<0.01), whereas there was no significant difference in flow reaction between the two groups. No wall adhesion of blood cells or extravasation of contrast into the surrounding tissue was detected. After intravenous injection of a regular dose of saccharide-based microbubbles Levovist, no change of blood cell flow velocity and no wall adhesion or extravasation could be found at rest and after cold application in human nailfold capillaries. Since microcirculatory flow characteristics in the finger nailfold capillaries are not influenced by Levovist, it might be assumed also that myocardial blood flow behavior remains unchanged, so that this contrast agent may be used as a flow tracer for cardiac investigation.

The pole-pressure test: an easy alternative in patients with ischemic legs and incompressible arteries

BACKGROUND

Systolic ankle artery pressure measured classically by cuff-manometry and Doppler ultrasound in patients with severely ischemic legs may be falsely elevated because of impaired compressibility of the arteries. We evaluated a hydrostatic blood pressure or so-called pole pressure test by correlating the ankle artery pressure as well as tcpO2 with the pole pressure.

PATIENTS AND METHODS

We enrolled 29 patients (18 male, 11 female, 10 diabetics) with critical leg ischaemia. The pole pressure was obtained by elevating the leg, and measuring the height at which the Doppler signal disappears by means of a calibrated pole (recalculating cm H2O for mmHg). We used an 8 MHz cw-Doppler device. Only pole pressure values up to 70 cm H2O were included. In addition tcpO2 at 45 degrees C was recorded at the forefoot of the same leg.

RESULTS

When we included the values of the ten diabetic patients the pole pressure of 57.9 +/- 16.2 mmHg (mean +/- SD) was significantly lower by 40.7 mmHg than the ankle pressure of 98. +/- 38.4 mmHg, p < 0.0001 (paired t-test). Without the diabetics the difference was 33.7 mmHg. The correlation coefficient between pole pressure and ankle pressure was 0.546 including the patients with diabetes, and 0.609 excluding the diabetics. The correlation of tcpO2 with the pole pressure, however, was 0.624 regardless of the inclusion of diabetics, while that between tcpO2 and ankle pressure was only 0.250.

CONCLUSIONS

The pole pressure test is an easy, inexpensive and fast method providing a meaningful, quantitative measure independent of the compressibility of the arteries.