The total amount of CRP within the first 72 h after STEMI is crucial for the outcome

Background

The CAMI-1 study dealt with the depletion of CRP by apheresis in patients with acute myocardial infarction (AMI). CRP, the prototype human acute phase protein, has been known as a marker of poor prognosis in AMI and independently predicts 30-day mortality.

Methods

66 STEMI patients were enrolled following complete coronary revascularization (2–12 h after AMI). 32 patients received CRP apheresis, whereas 34 patients treated by standard protocols served as controls. CRP apheresis started 24±12 h and 48±12 h after onset of symptoms. A specific CRP adsorber removed ≤79% of the original CRP. 6000 ml of plasma was treated via peripheral venous access. Primary endpoint was myocardial infarction size as determined by Cardiac Magnetic Resonance Imaging (CMR) 3–9 days after STEMI.

Results

Aphereses sessions were well tolerated with no relevant side effects. The expected peak CRP level after AMI can be calculated precisely with 2–3 CRP quantifications during the first 24h after the onset of symptoms (CRP gradient). The regression coefficient for this analysis is 0.91. This mathematical step allows for the comparison of the CRP-apheresis group and the controls on the basis of their individual CRP gradients. The mean CRP gradient does not differ between both groups, whereas the mean area under the curve (AUC) of CRP within the first 72 h after AMI does. Thus, there was no bias in CRP kinetics between the two groups. The AUC of CRP is a significant indicator for infarct size (p=0.002), LVEF (p<0.001), circumferential strain (p<0.001), longitudinal strain (p=0.021). Therefore, the aphereses patients performed significantly better at all endpoints than the controls. The CRP apheresis significantly reduced myocardial damage by a reduction of the AUC of CRP. To our surprise, two apheresis patients had an infarct size of 0%.

Conclusions

For the first time we find an unequivocal association between myocardial infarct size and the AUC of CRP. The results show a significant beneficial effect of CRP apheresis on myocardial infarction size and wall motion. Selective CRP apheresis is now being further evaluated as a therapeutic approach in the treatment of acute myocardial infarction in a registry (CAMI registry).

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Pentracor GmbH

C-reactive protein increases myocardial damage after STEMI

Background

The CAMI-1 study dealt with the depletion of CRP by apheresis in patients with acute myocardial infarction (AMI). CRP, the prototype human acute phase protein, has been known as a marker of poor prognosis in AMI and independently predicts 30-day mortality.

Methods

66 STEMI patients were enrolled in the study following complete coronary revascularization (2–12 h after the onset of symptoms). 32 patients received CRP apheresis, whereas 34 patients treated by standard protocols served as controls. CRP apheresis started 24±12 h and 48±12 h after onset of symptoms. In case of a rapid increase in CRP plasma levels following the 2nd session, a 3rd session was carried out another 24 h later. A specific CRP adsorber removed up to 79% of the original CRP. In each apheresis session, 6000 ml of plasma was treated via peripheral venous access. Primary study endpoint was myocardial infarction size as determined by Cardiac Magnetic Resonance Imaging (CMR) 2–9 days after STEMI.

Results

Aphereses sessions were well tolerated with no relevant side effects. Peak CRP plasma levels after STEMI ranged from 9 to 279 mg/l. The expected peak CRP level after AMI can be calculated precisely with 2–3 CRP quantifications during the first 24 h after the onset of symptoms. The regression coefficient for this analysis is 0.91. This mathematical step allows for the comparison of the CRP-apheresis group and the controls on the basis of their individual CRP peak levels. The statistical evaluation shows that the CRP concentration is significantly associated with the damage (infarct size, LVEF, circumferential strain) in the controls. This association was lost in the aphereses patients: they performed significantly better at all endpoints (infarct size, LVEF, circumferential strain) than the controls. The CRP apheresis significantly reduced myocardial damage. To our surprise, two apheresis patients had an infarct size of 0%.

Conclusions

For the first time we find an unequivocal association between myocardial infarct size and the CRP concentration. This is in some respects a surprise, since the basic assumption in AMI is that the vascular occlusion leads to primary damage and the reperfusion to secondary damage, which would not have led one to expect such a clear dose-response relationship as that observed here. In addition, our results show a significant beneficial effect of CRP apheresis on myocardial infarction size and wall motion. Selective CRP apheresis is now being further evaluated as a therapeutic approach in the treatment of acute myocardial infarction in a registry (CAMI registry).

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Pentracor GmbH

Lipoprotein apheresis is an optimal therapeutic option to reduce increased Lp(a) levels

BACKGROUND

Lipoprotein(a) (Lp(a)) is a genetic risk factor for cardiovascular disease (CVD) and is associated with the induction and sustaining of atherosclerotic cardiovascular diseases (ASCVD). Since 2008 Lp(a) along with progressive CVD has been approved as an indication for regular lipoprotein apheresis (LA) in Germany. The German Lipoprotein Apheresis Registry (GLAR) has been initiated to provide statistical evidence for the assessment of extracorporeal procedures to treat dyslipidemia for both LDL-cholesterol (LDL-C) and Lp(a). The GLAR now allows prospective investigations over a 5-year period about annual incidence rates of cardiovascular events. Here Lp(a) patients (LDL-C < 100 mg/dl; Lp(a) > 60 mg/dl or >120 nmol/l) showed the same reduction of major coronary (83%) and non-coronary events (63%) as had been formerly shown in the Pro(a)LiFe study. However, Lp(a) is not only an apolipoprotein(a) (apo(a)) and LDL-C containing particle, which is covalently bound to a LDL-C core by a disulphide bridge. The composition of this particle, inter alia containing oxidized phospholipids, gives pro-atherosclerotic, pro-inflammatory, and pro-thrombotic properties, inducing atherosclerotic processes mainly in the arterial wall. However, recent investigations have shown that a reduction of inflammatory settings without LDL-C or Lp(a) reduction may reduce ASCVD events. Lipoprotein apheresis (LA) could not only reduce LDL-C and Lp(a) in parallel, but also different inflammatory and coagulation parameters. In summary lipoprotein apheresis is not only anti-atherosclerotic, but also anti-inflammatory and anti-thrombotic and therefore an ideal treatment option with respect to the shown reduction of major adverse coronary events (MACE) and major adverse non-coronary events (MANCE) by reducing Lp(a) levels.

Current insights into the German lipoprotein apheresis standard: PCSK9-inhibitors, lipoprotein apheresis or both?

According to current European guidelines, lipid lowering therapy for progressive cardiovascular disease including cardiovascular events has to be focused on a target level for LDL-C. In contrast for Lp(a) a threshold has to be defined with respect to the method of measurement. However, due to new lipid lowering drug developments like PCSK9-inhibitors (PCSK-9-I) a therapeutic algorithm for patients with severe hypercholesterolemia or isolated Lipoprotein(a)-hyperlipoproteinemia with progressive cardiovascular disease may be necessary to manage the use of PCSK9-I, lipoprotein apheresis (LA) or both. The therapeutic approach for patients with homozygous familial hypercholesterolemia is unambiguous: In addition to LA, in order to improve LDL-C reduction, PCSK9-I could be applied. In patients with heterozygous familial hypercholesterolemia, PCSK9-I is to be applied first. If in addition to a pronounced LDL-C elevation, cardiovascular complications exist or if imaging techniques documented atherosclerotic changes pre-disposing for a cardiovascular event while LDL-C reduction is insufficiently reduced (LDL-C > 100 mg/dl (2.6 mmol/l)), LA treatment should then be applied as last resort. In patients with elevated Lp(a) concentrations (Lp(a) > 60 mg/dl (>120 nmol/l)) and established cardiovascular disease, therapy should rely primarily on LA methods. If in addition to high Lp(a) levels insufficiently treated LDL-C concentrations (LDL-C > 100 mg/dl (2.6 mmol/l)) exist, in rare cases PCSK9-I can supplement the lipid lowering concept.

Current insights into the German Lipoprotein Apheresis Registry (GLAR) - Almost 5 years on

BACKGROUND

In recent years the Federal Joint Committee (G-BA), a paramount decision-making body of the German health care system required a reassessment of the approval of chronic lipoprotein apheresis therapy for regular reimbursement. Since 2005 an interdisciplinary German apheresis working group has been established by members of both German Societies of Nephrology. In 2009 the working group completed the indication for lipoprotein apheresis with respect to current cardiovascular guidelines and current scientific knowledge for the registry. In 2011 the German Lipoprotein Apheresis Registry (GLAR) was launched and data acquired over nearly 5 years can now be reported.

METHODS AND RESULTS

All data were collected and analyzed during the time period 2012-2015. Over this time interval, 68 German apheresis centers collected retrospective and prospective observational data of 1.283 patients undergoing lipoprotein apheresis (LA) treatment of high LDL-cholesterol (LDL-C) levels and/or high lipoprotein(a) (Lp(a)) levels suffering from progressive cardiovascular disease (CVD). A total of 15,167 documented LA treatments were investigated. All patients treated by LA exhibited a median LDL-C reduction rate of 68.6%, and a median Lp(a) reduction rate of 70.4%. Analogue to the Pro(a)LiFe pattern, patient data were analyzed and compared with respect to the incidence rate of coronary events (MACE) 1 and 2 years before the start of LA treatment (y-2 and y-1) and prospectively one year on LA treatment (y+1). During the first year of LA treatment a MACE reduction of 97% was be observed. In the years considered, LA treatment side effects occurred at a low rate (ca. 5%) and mainly comprised puncture problems.

CONCLUSIONS

For the first time data generated by the GLAR shows that LA lowers the incidence rate of cardiovascular events in patients with high LDL-C and/or high Lp(a) levels, progressive CVD and maximally tolerated lipid lowering medication. In addition LA treatments were found to be safe, exhibiting a low rate of side effects.

[Tryptophan immunoadsorption for multiple sclerosis and neuromyelitis optica: therapy option for acute relapses during pregnancy and breastfeeding]

BACKGROUND

Approximately 25 % of women with multiple sclerosis (MS) suffer clinically relevant relapses during pregnancy. Almost all disease-modifying drugs are contraindicated in pregnancy. High-dose glucocorticoids have some serious risks, especially within the first trimester. Tryptophan immunoadsorption (IA) provides a safe option to treat MS relapses during pregnancy.

OBJECTIVES

In this case series we describe for the first time the use of tryptophan IA for MS and neuromyelitis optica (NMO) relapses during pregnancy and breastfeeding.

PATIENTS AND METHODS

In this study a total of 9 patients were retrospectively analyzed of which 7 patients received IA treatment during pregnancy, 2 during breastfeeding and 4-6 tryptophan IA treatments were performed per patient with the single use tryptophan adsorber. Primary outcome was symptom improvement of the relapse.

RESULTS

In this study four patients with MS and one with NMO relapse during pregnancy were treated with IA without preceding glucocorticoid pulse therapy. The MS patients showed improvement in the expanded disability status scale (EDSS) by at least one point, the NMO patient showed significant improvement in visual acuity and two pregnant patients with steroid-refractory relapses showed clinically relevant improvement after IA. Of the patients two suffered from steroid-refractory relapses during breastfeeding and relapse symptoms improved in both cases after treatment with IA. All treatments were well tolerated and no serious adverse events occurred.

CONCLUSION

Tryptophan IA was found to be safe, well-tolerated and effective in the treatment of MS and NMO relapses during pregnancy and breastfeeding, sometimes without preceding glucocorticoid pulse therapy. A binding recommendation is limited without prospective clinical studies.

Temperature-induced reversal of magnetic interlayer exchange coupling

For epitaxial trilayers of the magnetic rare-earth metals Gd and Tb, exchange coupled through a nonmagnetic Y spacer layer, element-specific hysteresis loops were recorded by the x-ray magneto-optical Kerr effect at the rare-earth M5 thresholds. This allowed us to quantitatively determine the strength of interlayer exchange coupling (IEC). In addition to the expected oscillatory behavior as a function of spacer-layer thickness dY, a temperature-induced sign reversal of IEC was observed for constant dY, arising from magnetization-dependent electron reflectivities at the magnetic interfaces.

Soft X-ray excited colour-centre luminescence and XANES studies of calcium oxide

In this study, we show that colour centres can be produced by irradiating calcium oxide with soft X-rays from a synchrotron radiation source. Using the X-ray excited optical luminescence (XEOL) technique, two colour centres, F-centre, and F+-centre can be identified. These colour centres emit photons at characteristic wavelengths. In addition, by performing time-resolved XEOL (TRXEOL), we are able to reveal timing and decay characteristics of the colour centres. We also present X-ray absorption near-edge structure (XANES) spectra collected across oxygen K-edge, calcium L3,2-edge, and calcium K-edge. Experimental results are compared with density functional theory (DFT) calculations.Key words: calcium oxide, colour centre, synchrotron, X-ray excited optical luminescence, X-ray absorption near-edge structure.

Electronic structures of CdSe nanocrystals — An X-ray absorption near-edge structure (XANES) investigation

CdSe nanocrystals (NCs), capped with trioctylphosphine oxide and 1-octadecanamine, have been synthesized with colloidal methods. Both UV–vis absorption and photoluminescence spectra show that the prepared nanostructures exhibit a quantum confinement effect. X-ray absorption near–edge structure (XANES) at Se K-edge recorded in fluorescence yield mode have been carried out on these NCs, with different size and capping ligands to gain insight into how their electronic structures are affected by the NC size and chemical properties of the ligands. The results indicate that XANES are sensitive to both the NC size and the nature of the capping ligands. The whiteline intensity in XANES spectra can be related to the photoluminescence properties of these NCs.Key words: CdSe nanocrystals, capping ligands, X-ray absorption near-edge structure, UV–vis spectroscopy, photoluminescence.

Time-Resolved X-ray Excited Optical Luminescence from Tris(2-phenyl bipyridine)iridium

Time-resolved X-ray Excited Optical Luminescence (TRXEOL) has been developed to investigate the optical properties of a green organometallic phosphor, tris(2-phenyl pyridine)iridium, Ir(ppy)3. Using time-gated measurements, we find that the characteristic luminescence band from a neat Ir(ppy)3 film is composed of a fast channel at approximately 534 nm and a slower channel at approximately 580 nm. The implication of this study and the applicability of the technique in the study of light emitting materials are noted.

Synthesis and Synchrotron Light-Induced Luminescence of ZnO Nanostructures: Nanowires, Nanoneedles, Nanoflowers, and Tubular Whiskers

ZnO nanostructures, including single-crystal nanowires, nanoneedles, nanoflowers, and tubular whiskers, have been fabricated at a modestly low temperature of 550 degrees C via the oxidation of metallic Zn powder without a metal catalyst. Specific ZnO nanostructures can be obtained at a specific temperature zone in the furnace depending on the temperature and the pressure of oxygen. Scanning electron microscopy (SEM), high-resolution transmission electron microscopy (HRTEM), and X-ray diffraction (XRD) studies show that ZnO nanostructures thus prepared are single crystals with a wurtzite structure. X-ray excited optical luminescence (XEOL) from the ZnO nanostructures show noticeable morphology-dependent luminescence. Specifically, ZnO nanowires of around 15 nm in diameter emit the strongest green light. The morphology of these nanostructures, their XEOL, and the implication of the results will be discussed.

X-ray magneto-optics in lanthanides

Magneto-optical methods in the visible light regime generally lack element specificity, which has become a considerable shortcoming in research on advanced heteromagnetic systems. Using circularly polarized soft x rays tuned to a 4d-4f core-level transition of a lanthanide element, the specularly reflected x-ray intensity changes proportionally to the magnetization of this element and, e.g., hystereses are easily measured element specifically. In contrast to the case of visible light, temperature dependent 4d-4f magneto-optical signals are not influenced by the thermal lattice expansion.

Lectin-mediated bioadhesion: preparation, stability and caco-2 binding of wheat germ agglutinin-functionalized Poly(D,L-lactic-co-glycolic acid)-microspheres

To take advantage of the cytoadhesive characteristics of Wheat germ agglutinin (WGA) for improved particulate drug delivery, the interaction between WGA-grafted poly(D,L-lactic-co-glycolic acid)-microspheres and Caco-2 monolayers was investigated using bovine serum albumin (BSA) or glycine coated microspheres as a control. Covalent immobilization of WGA by the carbodiimide/N-hydroxysuccinimide-method on 4 microm microspheres yielded a surface density of 9.67+/-1.21x10(6) molecules/particle, whereas 0.22+/-0.04x10(6) WGA-molecules were bound by physical adsorption. After storage for 21 days in HEPES-buffer and treatment of the particles with 5 M urea, 86% of covalently linked lectin was still attached to the particles. At 4 degrees C the Caco-2 binding rate of both, WGA- and BSA-modified particles increased with addition of increasing numbers of particles until saturation was reached at 38150+/-1740 (WGA) or 12066+/-1195 (BSA) microspheres bound/mm(2) Caco-2 monolayer. Inhibition of Caco-2 binding of WGA-functionalized microspheres by chitotriose indicated for specificity of the interaction. As observed by confocal laser scanning microscopy, the fluorescein-loading of the particles was accumulated intracellularly after incubation of Caco-2 monolayers with WGA-modified microspheres contrary to glycine-grafted microspheres. Additionally, in case of WGA-functionalized microspheres the amount of cell associated fluorescein was 200-fold higher than that of the free solution. In conclusion, WGA-modified microspheres are expected to enhance intestinal transport of incorporated drugs due to cytoadhesion provided by the lectin coating.

[Bipolar affective disorder and neuropsychiatric complications in a chronic course of thrombotic thrombocytopenic purpura. A case report]

A case report on a 43-year-old female patient with the longest chronic course of TTP known in the literature is presented. The results of comprehensive diagnostic investigations are described. In neuropsychiatric respect there exists a long standing bipolar affective disorder with a course showing a close association to this medical condition. This significant interaction is discussed in relation to the syndromal picture of the phasic bipolar psychosis and the various neuropsychiatric complications associated with recurrent cerebral thrombotic episodes.

[Successful treatment of atrial fibrillation by resection of a congenital aneurysm of the left heart atrium]

Atrial fibrillation occurred in a 27-year-old patient with a history of globular cardiac enlargement since childhood. Because of the probable causal relationship between the preexisting heart disease-which was supposed to be an enlargement of the left atrium-and the rhythm disturbance, we recommended a surgical intervention. Cardiac surgery revealed a congenital aneurysm of the left atrial appendage which could be resected without any complication. Postoperatively, atrial fibrillation had returned to regular sinus rhythm. The bad prognosis with a high risk of systemic embolism is the reason why early cardiac surgery should be performed after diagnosis of this rare anomaly (20 reported cases) of the left atrium.

[The interactional principle in individual and group psychotherapy]

We have shown that while on the one hand interactional psychotherapy is based on the nosology of psychoanalysis, in the realization of its methods and techniques it is nevertheless clearly distinguished from the standard approach of psychoanalysis. We developed this specific therapeutic procedure to meet the needs of patients with ego-pathological phenomena, more and more of whom are now turning to the analytic psychotherapist and in whom psychoanalysts are also showing a more and more intensive interest. This is demonstrated by the work of Kernberg (1978), Kohut (1971) and Blanck and Blanck (1978), as well as that of Fürstenau (1977) and König (1975) in the German-speaking world. We perceive the interactional psychotherapy that we have proposed (Heigl-Evers and Heigl, 1973 and 1979) as a therapy for ego-pathogenic phenomena. It is indicated in the case of patients with this type of disorder in a certain phase, usually the initial one. If a patient succeeds, with the help of this treatment, in developing an ego state roughly equivalent to what Freud referred in 1937 as the normal ego and which he considered to be a prerequisite for psychoanalytic therapy, then it should be possible to treat the conflict pathology which is also usually present in such patients, using the classical repertoire of psychoanalysis according to the principle of interpretation.