Temporal trends, sex-differences and outcomes of patients hospitalized for heart failure in Germany

Background

Despite remarkable improvements in treatment of cardiovascular disease, heart failure (HF) is still characterized by a high mortality rate. Sex-specific differences in HF have been described, but underlying reasons are widely unexplored. Thus, we aimed to investigate sex differences of patients hospitalized for HF in a nationwide cohort.

Methods

The nationwide German inpatient sample (2005–2016) was used for this sex-specific analyses. Temporal trends on hospitalizations, mortality, and treatments were analyzed and independent predictors of adverse outcomes identified.

Results

The present analysis comprises 4,538,977 hospitalizations due to HF (52.0%women) in Germany (2005–2016). Although women were older (median 82 (IQR75–87) vs. 76 (69–82), P<0.001), coronary artery disease (CAD, 50.3% vs. 30.7%, P<0.001) was more prevalent in men, who were more often treated with PCI (3.4% vs. 1.4%, P<0.001) and implantable cardioverter-defibrillator (2.2% vs. 0.5%, P<0.001). In-hospital mortality was significantly lower in men than in women (8.9% vs. 10.2, P=0.001) and was reduced in patients who received PCI or implantation of an ICD.

While total numbers of hospitalizations between 2005 and 2016 increased in both men (β-estimate 7185.71 (95% CI 6502.23 to 7869.18), P<0.001) and women (β-estimate 5297.60 (95% CI 4557.37 to 6037.83), P<0.001) as well as almost all comorbid co-conditions, in-hospital mortality rate decreased more distinctly in women (β-estimate −0.41 (95% CI: −0.42 to −0.39), P<0.001) compared to men (β-estimate −0.29 (95% CI: −0.30 to −0.27), P<0.001).

Conclusions

Interventional treatments of HF were associated with improved outcomes and equally beneficial for both sexes. However, they were more often used in male HF patients, in which CAD is significantly more frequent than in female HF patients. This may explain the higher case fatality rate of HF in females.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): German Federal Ministry of Education and Research (BMBF)

Antibody reactivities to skeletal muscle proteins in a patient with lambda light chain secreting multiple myeloma, generalised amyloidosis and rhabdomyolysis

Rhabdomyolysis is a rare complication in haematological malignancies, and a diverse range of factors has been implicated in the etiology of the syndrome. In the present study we analysed muscle morphology and antibody reactivities to skeletal muscle proteins in a patient diagnosed with lambda (lambda) light chain-secreting multiple myeloma (MM) and amyloidosis, who developed a progressive rhabdomyolysis. The muscle tissue analysis showed focal amyloid depositions and a low degree of atrophy and inflammation. Antibody reactivities against muscle proteins of approximately 42, 51 and 66 kD, respectively, were present in the patient's serum. The antibody specificities were revealed by lambda light chain- or IgM-specific antibodies. The results indicate a possible etiologic link between antibody reactivities towards muscle proteins and muscle tissue disorder in a patient with the unique combination of rhabdomyolysis, amyloidosis and MM of the light chain type.

Thoracolumbar accessory penis: etiology, diagnosis, and management

Human sacral appendages have rarely been reported. We present a neonate with a thoracolumbar appendage resembling a penis, and discuss the nature of the anomaly and its diagnosis and management.

Diagnostic flexible peritoneoscopy: assessment of the contralateral internal inguinal ring during unilateral herniorrhaphy

BACKGROUND

Inguinal hernia is the most common pediatric surgical condition, with 75% of cases presenting unilaterally. No diagnostic study exists to determine preoperatively which children are at risk for subsequent contralateral hernia. The literature is not clear in advising whether surgeons should explore the contralateral side at the time of initial unilateral herniorrhaphy.

METHODS

Twenty-four patients presenting clinically with a unilateral hernia underwent flexible peritoneoscopy by isolation of the ipsilateral hernia sac and placement of a flexible cystoscope into the peritoneal cavity. After establishing a CO2 pneumoperitoneum, the contralateral side is checked for patency of the internal inguinal ring.

RESULTS

Our study found an open internal inguinal ring in 4 of 24 patients examined (16.7%). The other 20 patients were spared the usual routine contralateral exploration. An open contralateral internal inguinal ring was appreciated in two of nine (22.2%) left herniorrhaphy and 2 of 15 (13.3%) right herniorrhaphy patients. This technique requires an average of 4.5 minutes to perform. With 18-to 32-month follow-up, no hernias have developed on the contralateral side.

CONCLUSION

Diagnostic flexible peritoneoscopy is safe, quick, simple, and could be used to evaluate the contralateral internal inguinal ring in unilateral pediatric herniorrhaphy patients.

Testicular sperm extraction for nonobstructive azoospermia: results of a multibiopsy approach with optimized tissue dispersion

OBJECTIVES

Testicular sperm extraction (TESE) is an effective procedure to retrieve sperm from some men with nonobstructive azoospermia (NOA). To optimize treatment effectiveness, we have reviewed our experience with TESE for NOA to better understand technical factors needed for sperm retrieval and lead to an optimized approach to TESE.

METHODS

Eighty-one men with confirmed NOA underwent attempted TESE using an open technique under optical magnification. Each testis sample was dispersed and examined in the operating room. Sequential biopsy attempts were made until sperm were visualized or until further biopsies were thought to jeopardize testicular blood flow. In 20 patients, standard biopsy and initial mechanical dispersion of the seminiferous tubules were compared with the passage of tissue through a 24-gauge angiocatheter after initial dispersion to quantitate spermatozoal yield.

RESULTS

Overall, 47 (58%) of 81 patients who underwent TESE had direct intraoperative visualization of spermatozoa. The average number of biopsy attempts for all patients was 8.9 and for patients with sperm isolated 6.4 (P = 0.002). Passage of the testicular tissue suspension through a 24-gauge angiocatheter increased sperm retrieval in matched tissue specimens from 83,000 to 390,000 or 470% over that achieved with standard dispersion alone (P = 0.005). An initial, substantive tissue biopsy revealed sperm in only 23 (28%) of 81 patients. Using this approach with sequential biopsies under optical magnification, no patient had evidence of testis injury or devascularization.

CONCLUSIONS

Because multiple TESE procedures can cause transient and permanent alterations in testicular function, it is imperative to perform TESE as safely and as efficiently as possible. We suggest that open TESE with optical magnification provides a safe method of retrieving sperm. A single biopsy for extraction is inadequate to detect spermatozoa for men with NOA. Use of the needle dispersion technique with passage of testicular tissue through an angiocatheter enhances detection of sperm and could potentially reduce the need for subsequent biopsies. An algorithm to minimize biopsies and allow sperm retrieval is presented.

Use of a free bladder mucosal graft for simple repair of vesicovaginal fistulae

The aim of this paper is to describe a simple, fast, and effective method for repair of difficult vesicovaginal fistulae by means of a free bladder mucosal graft. Six patients with high, large, multiple, or recurrent vesicovaginal fistulae were treated using a free bladder mucosal graft. Three patients underwent "early" repair (less than 3 months from time of injury) and 3 "late" repair (more than 6 months from time of injury). Via a suprapubic cystotomy, the mucosa of the fistulous tract was debrided without any attempt to excise the tract or close the bladder or vaginal defects. A free bladder mucosal graft was harvested from an unaffected portion of the bladder and placed over the fistulous tract, and mucosal approximation was made using interrupted 5-0 chromic stay sutures. The donor urothelial defect was allowed to re-epithelialize. A Foley catheter, suprapubic tube, and vaginal packing were left in place. Five patients noted an immediate result, with no evidence of leakage, and the suprapubic tube was removed by week 3. One patient required prolonged catheter drainage, and the tube was successfully removed by week 6. This patient had undergone irradiation. All patients remain dry at follow-up, which ranges from 2 to 6 years. We describe a simple and effective method for transabdominal vesicovaginal fistula repair, involving minimal mobilization, decreased dissection, and no need for rotational or interposition flaps, obviating the need to open the peritoneum. A free bladder mucosal graft can be used regardless of the individual anatomy or proximity to the ureteral orifices, because it can easily be tailored. This technique represents an important repair of difficult, recurrent, or multiple vesicovaginal fistulae.

Ha-ras oncogene expression abrogates a pH dependent endonuclease activity of apoptosis in normal rat kidney cells

To investigate the role of oncogene expression in the resistance to tumor necrosis factor-alpha (TNF), we transfected the mutated T24-Ha-ras oncogene into the murine kidney cell line NRK and an alternative murine cell line C127 cells. The resulting transfectants, NRK-Ha and HC127, were assayed for TNF mediated cytotoxicity. Cellular cytotoxicity of 45% over 48 h occurred with the NRK cells. However, ras transfectant NRK-Ha cells demonstrated 0% cytotoxicity over the same period. Both C127 cells and the ras transfectant HC127 demonstrated 40% and 25% cytotoxicity, respectively, over 48 h when incubated with TNF. Furthermore, DNA isolated from NRK, C127, HC127, but not NRK-Ha cells revealed the presence of DNA fragmentation 'ladders' indicative of successful apoptosis when the cells were incubated with TNF. To determine the possible mechanism in which the ras oncogene may have protected the NRK-Ha cells from TNF mediated cytotoxicity and apoptosis, total nuclear endonucleases from the NRK cells and the ras transfectant NRK-Ha cells were isolated. We determined that the endonuclease activity in the NRK and the ras transfectant NRK-Ha cells was a pH dependent endonuclease. Significant degradation of the target DNA was observed only in pH 4-6 buffers containing the endonuclease. Furthermore, preliminary intracellular pH analysis suggested that while the NRK cells have an intracellular pH of 6.0, the ras transfectant NRK-Ha cells have an intracellular pH of 7.2 and may have abrogated its pH dependent endonuclease. Both the C127 cells and the ras transfectant HC127 cells did not express a pH dependent endonuclease but rather a Ca2+/Mg2+ dependent endonuclease. Furthermore, preliminary intracellular pH analysis suggested that both the C127 and HC127 cells have the same intracellular pH. Our results indicate that in normal rat kidney cells, ras oncogene transfection may cause a disruption in the endonuclease activation involved in apoptosis.

Ha-ras oncogene induction of invasion and metastasis is associated with the activation and redistribution of protease(s) in rat-kidney cells

To investigate the role of oncogenes in the development of metastatic ability, the Ha-ras oncogene was transfected into murine kidney cell line NRK and an alternative murine cell line C127 cells. The resulting transfectants, NRK-Ha and HC127, were assayed for their invasive capability in an in vitro invasion assay and compared with their parental cell lines. All transfected cells were demonstrated to express a 0.6 kb mRNA for the ras oncogene by Northern blot analysis. Using a modified Boyden chamber, we showed that the motile ability of the cell lines, transfected versus non-transfected, were not altered by the introduction of the Ha-ras oncogene. However, ras transfected NRK-Ha cells were able to penetrate and invade through an artificial basement membrane coated filter when compared with the non-transfected parental cell line. Neither the C127 cells nor its ras transfected HC127 cells were able to migrate or penetrate through an artificial basement membrane coated filter. Using immunoblot analyses, we determined that invasive NRK-Ha cells expressed a mature form of protease cathepsin B with a molecular weight between 25-28 kD. Furthermore, using subcellular fractionation and immunoblot, we localized this mature form of cathepsin B to the plasma membrane fraction of the invasive NRK-Ha cells. The plasma membrane fraction of invasive NRK-Ha cells was able to degrade basement membrane components such as fibronectin and the patterns seen were similar to those of purified cathepsin B degradation. Non-invasive NRK, C127 and HC127 cells had only the precursor form of cathepsin B with a molecular weight between 38-45 kD and were unable to degrade basement membrane components. We suggest that the presence and expression of the Ha-ras oncogene alone does not confer metastatic capability, but rather that the ras oncogene must signal specific intracellular redistribution of proteases such as cathepsin B in order to promote tumor cell invasiveness.

Dendritic morphology of central auditory neurons correlates with their tonotopic position

We have investigated the morphology of dendritic arbors in a central auditory nucleus, the lateral superior olive, of the Mongolian gerbil. Morphometric observations were obtained directly from Golgi-impregnated material by using a microcomputer-based three-dimensional data acquisition system. In particular, measurements were made to determine the dendritic arborization across each of three axes: the tonotopic axis, the rostrocaudal axis, and the isofrequency axis (i.e., perpendicular to the tonotopic axis). The tonotopic position of each cell was computed on the basis of a topographic map that has been constructed for the gerbil LSO (Sanes et al.: J. Comp. Neurol. 279:436-444, 1989). It was found that the span of a dendritic arbor along the tonotopic axis was directly correlated with the neuron's tonotopic position: Low frequency neurons had much broader arborizations than high frequency neurons. Moreover, the distribution of frequency bandwidths to which single LSO neurons responded showed a striking similarity to dendritic arborizations across the tonotopic axis. Lower frequency neurons responded to a larger number of octaves than higher frequency neurons. There was no correlation between tonotopic position and dendritic arborization in the isofrequency or rostrocaudal axis. Nor was there any correlation between frequency and total dendritic length, number of primary dendrites, or soma area. However, there was a small but significant difference between the primary dendrite diameter of low and high frequency neurons. Low frequency neurons had significantly greater diameters. These results suggest that the frequency selectivity of central auditory neurons may employ, as one morphological substrate, the distance over which their dendrites arborize along the tonotopic axis.