Propofol versus midazolam sedation in patients with cardiogenic shock – an observational propensity-matched study

Introduction

Benzodiazepines are recommended as first line sedative agent in ventilated cardiogenic shock patients, although data regarding the optimal sedation strategy are sparse. On our cardiac ICU, midazolam was used as first line sedation until 2016, whereas soybean oil formulated propofol was used preferentially since 2017.

Purpose

The aim of this study was to investigate the hemodynamic effects of propofol versus midazolam sedation in our cardiogenic shock registry.

Methods

Mechanically ventilated patients suffering from cardiogenic shock were retrospectively enrolled from a cardiogenic shock registry. 174 patients treated predominantly with propofol were matched by propensity-score to 174 patients treated predominantly with midazolam.

Results

Catecholamine doses were similar on admission but significantly lower in the propofol group on days 1–4 of ICU stay (Figure 1). Mortality rate was 38% in the propofol and 52% in the midazolam group after 30 days (p=0.002, Figure 2). Rate of ≥BARC3 bleeding was significantly lower in the propofol group compared to the midazolam group (p=0.008). Age, gender, first lactate measured on ICU, first GFR measured on ICU, cardiac arrest, coaxial left ventricular assist device and sedation with midazolam were significantly associated with ICU mortality.

Conclusion

In this observational cohort study, sedation with propofol in comparison to midazolam was linked to a reduced dose of catecholamines, decreased mortality and bleeding rates for patients with cardiogenic shock. Based on this study and in contrast to current recommendations, propofol should be given consideration for sedation in cardiogenic shock patients.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Deutsche Forschungsgemeinschaft

Combined effect of acute altitude exposure and vigorous exercise on platelet activation

Exposure to high altitudes and exercise alters body's physiology and may cause acute cardiovascular events. Platelet activation is one of the key players in these events. Therefore, we investigated the effect of vigorous exercise at higher altitude (2650 m) on platelet aggregation and serum markers of platelet activation. 14 healthy subjects performed a step incremental ergometer test until exhaustion at the Environmental Research Station (UFS, 2650 m) at Zugspitze. Platelet aggregation and serum levels of endothelin-1, soluble p-selectin, platelet factor 4 and Chromogranin A were measured. Platelet activation was significantly enhanced after exercise at high altitude compared to measures immediately prior exercise. We detected significantly enhanced serum levels of endothelin-1 and soluble p-selectin whereas chromogranin A and platelet factor 4 remained unchanged. This effect might be due to increased endothelin-1 levels causing pulmonary vasoconstriction, rheological changes and direct platelet activation. This might be of clinical relevance, especially in patients with pre-existing diseases.

[Esophagotracheal and esophagobronchial fistulas]

Esophagobronchial and esophagotracheal fistulas are rare but complex diseases with a heterogeneous spectrum of underlying etiologies. Common causes are locally advanced tumors of the esophagus and larynx, traumatic perforation from the esophageal or tracheal side as well as postoperative fistulas. The management of esophagotracheal and esophagobronchial fistulas always involves different health care providers and in most cases patients require a multidisciplinary treatment on the intensive care unit. The therapeutic concept primarily depends on the underlying cause, localization and size of the fistula but decision making is also influenced by the severity of the course of sepsis and the extent of the respiratory dysfunction. Endoscopic management with esophageal and/or tracheobronchial stenting is the most common treatment. Surgical reconstructive procedures are predominantly reserved for patients with a treatment refractory fistula or a septic multiple organ failure. The prognosis is particularly influenced by the underlying disease.

A 6-month randomized, double-blind, placebo-controlled trial of weekly exenatide in adolescents with obesity

BACKGROUND

Pharmacological treatment options for adolescents with obesity are very limited. Glucagon-like-peptide-1 (GLP-1) receptor agonist could be a treatment option for adolescent obesity.

OBJECTIVE

To investigate the effect of exenatide extended release on body mass index (BMI)-SDS as primary outcome, and glucose metabolism, cardiometabolic risk factors, liver steatosis, and other BMI metrics as secondary outcomes, and its safety and tolerability in adolescents with obesity.

METHODS

Six-month, randomized, double-blinded, parallel, placebo-controlled clinical trial in patients (n = 44, 10-18 years, females n = 22) with BMI-SDS > 2.0 or age-adapted-BMI > 30 kg/m² according to WHO were included. Patients received lifestyle intervention and were randomized to exenatide extended release 2 mg (n = 22) or placebo (n = 22) subcutaneous injections given once weekly. Oral glucose tolerance tests (OGTT) were conducted at the beginning and end of the intervention.

RESULTS

Exenatide reduced (P < .05) BMI-SDS (-0.09; -0.18, 0.00), % BMI 95th percentile (-2.9%; -5.4, -0.3), weight (-3 kg; -5.8, -0.1), waist circumference (-3.2 cm; -5.8, -0.7), subcutaneous adipose tissue (-552 cm³ ; -989, -114), 2-hour-glucose during OGTT (-15.3 mg/dL; -27.5, -3.1), total cholesterol (11.6 mg/dL; -21.7, -1.5), and BMI (-0.83 kg/m² ; -1.68, 0.01) without significant change in liver fat content (-1.36; -3.12, 0.4; P = .06) in comparison to placebo. Safety and tolerability profiles were comparable to placebo with the exception of mild adverse events being more frequent in exenatide-treated patients.

CONCLUSIONS

Treatment of adolescents with severe obesity with extended-release exenatide is generally well tolerated and leads to a modest reduction in BMI metrics and improvement in glucose tolerance and cholesterol. The study indicates that the treatment provides additional beneficial effects beyond BMI reduction for the patient group.

P4400Heart rate variability in supporters of the German national football team during FIFA world cup 2018

Objective

It is well known that emotional stress can trigger cardiovascular events. Although several studies have confirmed this relationship during big sport events, the underlying mechanisms are less well understood. Therefore, we aimed to analyse parameters of the cardiac autonomous nervous system during FIFA World Cup 2018.

Methods

We performed a high-resolution digital electrocardiography (ECG) in healthy supporters of the German national football team watching the final group stage match of FIFA World Cup 2018 between Germany and South Korea. As control, ECG recordings were performed watching a group stage match of another group without involvement of the German team (Japan against Poland). We analysed standard parameters of heart rate variability (HRV). Further, we analyzed the number of admissions to Chest Pain Units (CPUs) and Stroke Units (SUs) in Munich at the day of the German match (June 27th, 2018) and at predefined control periods.

Results

All measured HRV parameters (SDNN, RMSSD, LF and HF) were significantly lower during the match involving the German national football team compared to the control match (SDNN: 76.7 (67.4–83.9) versus 82.9 (72.5–96.5) ms, p<0.05; RMSSD: 32.0 (27.7–33.3) versus 41.3 (31.4–49.19 ms, p<0.05; LF: 1442 (1182–1637) versus 2000 (1563–2238) ms2, p<0.05; HF: 206 (158–259) versus 376 (242–417), p<0.05). Regarding the LF/HF ratio, there was no significant difference. The admission rate on CPUs and SUs was numerically higher at the day of the German match compared to the control days and compared to the predefined control period (40.8% higher).

Conclusion

Emotional stress during important football matches results in a dysbalance of the cardiac autonomous nerve system. These findings might provide a link to increased cardiovascular events during emotional stress.

Maternal insulin resistance, triglycerides and cord blood insulin are not determinants of offspring growth and adiposity up to 5 years: a follow-up study

AIMS

Metabolic dysregulation in utero may influence fetal metabolism and early growth. We previously investigated relationships between maternal indices of glucose homeostasis and triglycerides as well as cord blood insulin with offspring anthropometry up to 2 years. The aim of this analysis was to follow these relationships up to the age of 5 years.

METHODS

Associations between maternal metabolic variables of glucose and lipid metabolism measured at 32 weeks' gestation and cord blood insulin with growth and body composition of 162 offspring aged 3-5 years were explored. Both indirect (i.e. body weight, BMI percentiles, sum of four skinfold thicknesses) and direct (i.e. ultrasonography, magnetic resonance imaging in a subgroup) measurement techniques were employed.

RESULTS

Maternal metabolic indices were largely unrelated to child body composition. Cord blood insulin was negatively associated with fat mass and lean body mass at 3 years in unadjusted analyses, and the sum of four skinfold thicknesses and body fat percentage in adjusted analyses, whereas the association with lean body mass was no longer observed. An inverse relationship between cord blood insulin and weight gain up to 5 years was observed in girls only with small effect sizes.

CONCLUSIONS

Results from this follow-up do not provide convincing evidence that these markers are independently related to offspring growth and adiposity in early childhood. Although cord blood insulin was weakly inversely related to weight gain in girls at 5 years, we cannot conclude that the observed changes in outcomes are clinically meaningful. (Clinical Trials Registry No: NCT00362089).

High resolution vs conventional esophageal manometry in the assessment of esophageal motor disorders in patients with non-cardiac chest pain

BACKGROUND

High-resolution esophageal manometry (HREM) has become a leading tool in the assessment of esophageal motor disorders, replacing conventional manometry. However, there is limited data about the contribution of HREM as compared with conventional manometry to the assessment of esophageal motor disorders in patients with non-cardiac chest pain (NCCP). The aim of the study was to compare the distribution of esophageal motor disorders in patients with NCCP using HREM as compared with conventional manometry and to determine if HREM improved diagnosis of these disorders.

METHODS

In this study, we included 300 consecutive patients with NCCP who underwent either HREM or conventional manometry over a period of 10 years. A total of 150 patients had conventional manometry and the other 150 patients HREM. The Chicago 3.0 classification and the Castell and Spechler classification were used to determine the esophageal motor disorder of NCCP patients undergoing HREM and conventional manometry, respectively.

KEY RESULTS

In both HREM and the conventional manometry groups, normal esophageal motility was the most frequent finding (47% and 36%; respectively, P = .054). Hypotensive lower esophageal sphincter was the most common motility disorder identified by conventional manometry (27.3%), while ineffective esophageal motility was the most common esophageal motor disorder identified by HREM (25.3%).

CONCLUSIONS & INFERENCES

There is a discrepancy in the type of esophageal motor disorders identified by HREM as compared with conventional manometry in NCCP patients. Hypotensive motility disorders are the most commonly diagnosed by both manometric techniques.

Collisional damping rates for electron plasma waves reassessed

Collisional damping of electron plasma waves, the primary damping for high phase velocity waves, is proportional to the electron-ion collision rate, ν_{ei,th}. Here, it is shown that the damping rate normalized to ν_{ei,th} depends on the charge state, Z, on the magnitude of ν_{ei,th} and the wave number k in contrast with the commonly used damping rate in plasma wave research. Only for weak collision rates in low-Z plasmas for which the electron self-collision rate is comparable to the electron-ion collision rate is the damping rate given by the commonly accepted value. The result presented here corrects the result presented in textbooks at least as early as 1973. The complete linear theory requires the inclusion of both electron-ion pitch-angle and electron-electron scattering, which itself contains contributions to both pitch-angle scattering and thermalization.

Longitudinal and Transverse Instability of Ion Acoustic Waves

Ion acoustic waves are found to be susceptible to at least two distinct decay processes. Which process dominates depends on the parameters. In the cases examined, the decay channel where daughter modes propagate parallel to the mother mode is found to dominate at larger amplitudes, while the decay channel where the daughter modes propagate at angles to the mother mode dominates at smaller amplitudes. Both decay processes may occur simultaneously and with onset thresholds below those suggested by fluid theory, resulting in the eventual multidimensional collapse of the mother mode to a turbulent state.

The relationship between breast milk leptin and adiponectin with child body composition from 3 to 5 years: a follow-up study

BACKGROUND

Research indicates that breast milk contains bioactive components that influence metabolism in infancy and may play a role in the prevention of obesity in early childhood. In our initial study, 147 breastfeeding mother/child pairs were followed from birth to 2 years of age to examine the relationship between breast milk leptin and total adiponectin (collected at 6 weeks and 4 months postpartum) and infant body composition. Higher breast milk total adiponectin was related to greater fat mass and weight gain in children at 1 and 2 years of age, whereas leptin showed no association.

OBJECTIVES/METHODS

In this follow-up, we examined the relationship between both adipokines and children's body weight, body mass index percentiles, sum of four skin-folds, percentage of body fat, fat mass and lean body mass at 3, 4 and 5 years of age.

RESULTS

Breast milk adipokines were largely unrelated to child anthropometric measures.

CONCLUSION

Our results do not provide significant evidence that breast milk adipokines can predict adiposity in preschool children.

Impact of the n-6:n-3 long-chain PUFA ratio during pregnancy and lactation on offspring neurodevelopment: 5-year follow-up of a randomized controlled trial

BACKGROUND/OBJECTIVES

Evidence regarding the effect of n-3 long-chain polyunsaturated fatty acid (LCPUFA) supplementation during pregnancy on offspring's neurodevelopment is not conclusive.

SUBJECTS/METHODS

In this analysis, the effect of a reduced n-6:n-3 LCPUFA ratio in the diet of pregnant/lactating women (1.2 g n-3 LCPUFA together with an arachidonic acid (AA)-balanced diet between 15th wk of gestation-4 months postpartum vs control diet) on child neurodevelopment at 4 and 5 years of age was assessed. A child development inventory (CDI) questionnaire and a hand movement test measuring mirror movements (MMs) were applied and the association with cord blood LCPUFA concentrations examined.

RESULTS

CDI questionnaire data, which categorizes children as 'normal', 'borderline' or 'delayed' in different areas of development, showed no significant evidence between study groups at 4 (n=119) and 5 years (n=130) except for the area 'letters' at 5 years of age (P=0.043). Similarly, the results did not strongly support the hypothesis that the intervention has a beneficial effect on MMs (for example, at 5 years: dominant hand, fast: adjusted mean difference, -0.08 (-0.43, 0.26); P=0.631). Children exposed to higher cord blood concentrations of docosahexaenoic acid, eicosapentaenoic acid and AA, as well as a lower ratio of n-6:n-3 fatty acids appeared to show beneficial effects on MMs, but these results were largely not statistically significant.

CONCLUSIONS

Our results do not show clear benefits or harms of a change in the n-6:n-3 LCPUFA ratio during pregnancy on offspring's neurodevelopment at preschool age. Findings on cord blood LCPUFAs point to a potential influence on offspring development.

Soluble Vascular Cell Adhesion Molecule-1 (VCAM-1) as a Biomarker in the Mouse Model of Experimental Autoimmune Myocarditis (EAM)

Vascular cell adhesion molecule-1 (VCAM-1) is strongly upregulated in hearts of mice with coxsackie virus-induced as well as in patients with viral infection-triggered dilated cardiomyopathy. Nevertheless, the role of its soluble form as a biomarker in inflammatory heart diseases remains unclear. Therefore, we investigated whether plasma levels of soluble VCAM-1 (sVCAM-1) directly correlated with disease activity and progression of cardiac dysfunction in the mouse model of experimental autoimmune myocarditis (EAM). EAM was induced by immunization of BALB/c mice with heart-specific myosin-alpha heavy chain peptide together with complete Freund`s adjuvant. ELISA revealed strong expression of cardiac VCAM-1 (cVCAM-1) throughout the course of EAM in immunized mice compared to control animals. Furthermore, sVCAM-1 was elevated in the plasma of immunized compared to control mice at acute and chronic stages of the disease. sVCAM-1 did not correlate with the degree of acute cardiac inflammation analyzed by histology or cardiac cytokine expression investigated by ELISA. Nevertheless, heart to body weight ratio correlated significantly with sVCAM-1 at chronic stages of EAM. Cardiac systolic dysfunction studied with positron emission tomography indicated a weak relationship with sVCAM-1 at the chronic stage of the disease. Our data provide evidence that plasma levels of sVCAM-1 are elevated throughout all stages of the disease but showed no strong correlation with the severity of EAM.

Mobilisation of haemopoietic stem cells in teriparatide-treated patients

Parathyroid hormone (PTH) is the predominant regulator of calcium/phosphate homeostasis in the human body. Beside this classical function, preclinical and clinical studies indicated a relevant role for PTH in mobilisation of bone marrow-derived cells into peripheral blood. In addition, recombinant PTH (teriparatide) was recently approved for the treatment of severe osteoporosis. Therefore, it was the aim of the present study to investigate the dynamics of haemopoietic stem cells and corresponding in peripheral blood of 13 patients with osteoporosis during treatment with teriparatide. We were able to show that administration of teriparatide is sufficient to mobilise haemopoietic stem cells into the bloodstream accompanied by an alteration of mobilising cytokines. In conclusion, teriparatide might be a useful tool in the context of stem cell mobilisation.

Automated sorting of polymer flakes: fluorescence labeling and development of a measurement system prototype

The extensive demand and use of plastics in modern life is associated with a significant economical impact and a serious ecological footprint. The production of plastics involves a high energy consumption and CO2 emission as well as the large need for (limited) fossil resources. Due to the high durability of plastics, large amounts of plastic garbage is mounting in overflowing landfills (plus 9.6 million tons in Europe in the year 2012) and plastic debris is floating in the world oceans or waste-to-energy combustion releases even more CO2 plus toxic substances (dioxins, heavy metals) to the atmosphere. The recycling of plastic products after their life cycle can obviously contribute a great deal to the reduction of the environmental and economical impacts. In order to produce high-quality recycling products, mono-fractional compositions of waste polymers are required. However, existing measurement technologies such as near infrared spectroscopy show limitations in the sorting of complex mixtures and different grades of polymers, especially when black plastics are involved. More recently invented technologies based on mid-infrared, Raman spectroscopy or laser-aided spectroscopy are still under development and expected to be rather expensive. A promising approach to put high sorting purities into practice is to label plastic resins with unique combinations of fluorescence markers (tracers). These are incorporated into virgin resins during the manufacturing process at the ppm (or sub ppm) concentration level, just large enough that the fluorescence emissions can be detected with sensitive instrumentation but neither affect the visual appearance nor the mechanical properties of the polymers. In this paper we present the prototype of a measurement and classification system that identifies polymer flakes (mill material of a few millimeters size) located on a conveyor belt in real time based on the emitted fluorescence of incorporated markers. Classification performance and throughput were experimentally quantified using 3 different types of polymers (Polyoxymethylene (POM), Polybutylenterephthalat (PBT) and Acrylonitrile Styrene Acrylate (ASA)) in colored and uncolored form. Overall, 12 classes of plastic flakes were investigated in this study, where 11 classes were labeled with unique binary combinations of 4 fluorescence markers and class 12 includes unlabeled plastic flakes of various colors. From approx. 68,000 investigated flakes it was found that the developed measurement prototype system achieves an average sensitivity (true positive rate) of 99.4% and a precision (positive predictive value) of 99.5%, while being able to handle up to approx. 1800 flakes per second.

Breast milk leptin and adiponectin in relation to infant body composition up to 2 years

BACKGROUND

Adipokines in breast milk have been associated with infant growth trajectories.

OBJECTIVE

We aimed to explore the relationship of leptin and adiponectin in breast milk with infant weight gain and body composition up to the age of 2 years.

METHODS

Breast milk samples were collected from exclusively or partially breastfeeding mothers at 6 weeks (n = 152) and 4 months (n = 120) post-partum. Leptin and adiponectin were determined in skim breast milk and related to infant growth and fat mass assessed by skin-fold thickness measurements. A total of 118 infants were examined at 2 years.

RESULTS

The levels of both milk adipokines were slightly lower at 4 months compared with 6 weeks post-partum. Breast milk leptin was largely unrelated to infant anthropometric measures up to 2 years. Milk adiponectin tended to be inversely related to early infant anthropometry up to 4 months, but beyond was positively associated with weight gain and the sum of skin-folds up to 2 years.

CONCLUSIONS

Our results suggest that higher adiponectin levels in breast milk might be associated with greater weight gain and higher fat mass in the offspring up to 2 years.

Maternal insulin resistance, triglycerides and cord blood insulin in relation to post-natal weight trajectories and body composition in the offspring up to 2 years

AIMS

The intrauterine metabolic environment might have a programming effect on offspring body composition. We aimed to explore associations of maternal variables of glucose and lipid metabolism during pregnancy, as well as cord blood insulin, with infant growth and body composition up to 2 years post-partum.

METHODS

Data of pregnant women and their infants came from a randomized controlled trial designed to investigate the impact of nutritional fatty acids on adipose tissue development in the offspring. Of the 208 pregnant women enrolled, 118 infants were examined at 2 years. In the present analysis, maternal fasting plasma insulin, homeostasis model assessment of insulin resistance and serum triglycerides measured during pregnancy, as well as insulin in umbilical cord plasma, were related to infant growth and body composition assessed by skinfold thickness measurements and abdominal ultrasonography up to 2 years of age.

RESULTS

Maternal homeostasis model assessment of insulin resistance at the 32nd week of gestation was significantly inversely associated with infant lean body mass at birth, whereas the change in serum triglycerides during pregnancy was positively associated with ponderal index at 4 months, but not at later time points. Cord plasma insulin correlated positively with birthweight and neonatal fat mass and was inversely associated with body weight gain up to 2 years after multiple adjustments. Subsequent stratification by gender revealed that this relationship with weight gain was stronger, and significant only in girls.

CONCLUSIONS

Cord blood insulin is inversely associated with subsequent infant weight gain up to 2 years and this seems to be more pronounced in girls.

Kinetic simulations of the self-focusing and dissipation of finite-width electron plasma waves

Two-dimensional simulations, both Vlasov and particle-in-cell, are presented that show the evolution of the field and electron distribution of finite-width, nonlinear electron plasma waves. The intrinsically intertwined effects of self-focusing and dissipation of field energy caused by electron trapping are studied in simulated systems that are hundreds of wavelengths long in the transverse direction but only one wavelength long and periodic in the propagation direction. From various initial wave states, both the width at focus Δm relative to the initial width Δ0 and the maximum field amplitude at focus are shown to be a function of the growth rate of the transverse modulational instability γTPMI divided by the loss rate of field energy νE to electrons escaping the trapping region. With dissipation included, an amplitude threshold for self-focusing γTPMI/νE∼1 is found that supports the analysis of Rose [Phys. Plasmas 12, 012318 (2005)].

Kinetic theory and Vlasov simulation of nonlinear ion-acoustic waves in multi-ion species plasmas

The theory of damping and nonlinear frequency shifts from particles resonant with ion-acoustic waves (IAWs) is presented for multi-ion species plasma and compared to driven wave Vlasov simulations. Two distinct IAW modes may be supported in multi-ion species plasmas, broadly classified as fast and slow by their phase velocity relative to the constituent ion thermal velocities. In current fusion-relevant long pulse experiments, the ion to electron temperature ratio, T(i)/T(e), is expected to reach a level such that the least damped and thus more readily driven mode is the slow mode, with both linear and nonlinear properties that are shown to differ significantly from the fast mode. The lighter ion species of the slow mode is found to make no significant contribution to the IAW frequency shift despite typically being the dominant contributor to the Landau damping.