Kriterien der Deutschen Gesellschaft für Kardiologie – Herz- und Kreislaufforschung für „Chest-Pain-Units“

The Chest Pain Unit (CPU) Task Force of the German Cardiac Society has elaborated prerequisites for a CPU certification program. To become a certified CPU, a facility must have 24-h cath lab capabilities, 24-h access to clinical chemistry, at least four intermediate care beds, and the capability for echocardiography, computed tomography (CT), magnetic resonance imaging (MRI) and abdominal ultrasound. The transfer time from the CPU to the cath lab should not exceed 15 minutes. The facility must demonstrate well-defined processes to evaluate moderate- and low-risk patients with chest pain that minimize unnecessary admissions and inappropriate discharges. This means that CPUs must have well-defined pathways when an acute coronary syndrome (ACS) patient arrives at their facility, including ST-segment elevation myocardial infarction (STEMI), non-STEMI (NSTEMI), unstable angina (UA) and low-risk patients. Nurses and doctors in the CPU should have education and training opportunities and undergo practice drills. Doctors should have a sound knowledge of echocardiography and intensive care medicine. The Chest Pain Unit must be headed by a cardiologist.     

The perfused rat lung as a model for studies on the formation of surfactant and the effect of Ambroxol on this process

The isolated perfused rat lung was used as a model to investigate the synthesis of surfactant phospholipids from various radioactive precursors and the effect of Ambroxol, a bronchial secretolyticum, on this process. Lungs were ventilated and perfused for periods up to 5 h without detectable development of pulmonary edema. The lungs remained metabolically stable during the entire period of perfusion. Both in whole lung tissue and in the surfactant fraction the radioactive substrates incorporated predominantly into phosphatidylcholine and phosphatidylglycerol. The degree of saturation of labelled phosphatidylcholines synthesized during perfusion with [Me-¹⁴C]choline, D [U-¹⁴C]glucose, [1(3)-³H]glycerol and [1-¹⁴C]palmitate was higher in surfactant than in whole lung tissue. A delayed incorporation into surfactant phospholipids was observed for all precursors. Under the conditions employed, glucose carbon was recovered mainly in the glycerol backbone of phosphatidylcholine and phosphatidylglycerol. Compared to glucose, glycerol appeared to be a minor substrate for lung lipid formation. If the lungs were perfused after pretreatment of the rats with Ambroxol on three consecutive days, the incorporation of labelled choline and glycerol into pulmonary phospholipids was found to be enhanced. This stimulation was more pronounced in the surfactant fraction than in whole lung tissue. The stimulatory effect on the formation of surfactant lipids was smaller after pretreatment of the animals with Ambroxol for one day. The results of the present study suggest that Ambroxol may specifically stimulate the synthesis of phospholipids in the alveolar type II cells and that the drug may not only affect the formation but also the secretion of surfactant lipids by these cells.     

Electrocortical processing of social signals of threat in combat-related post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) is characterized by avoidance, emotional numbing, increased arousal and hypervigilance for threat following a trauma. Thirty-three veterans (19 with PTSD, 14 without PTSD) who had experienced combat trauma while on deployment in Iraq and/or Afghanistan completed an emotional faces matching task while electroencephalography was recorded. Vertex positive potentials (VPPs) elicited by happy, angry and fearful faces were smaller in veterans with versus without PTSD. In addition, veterans with PTSD exhibited smaller late positive potentials (LPPs) to angry faces and greater intrusive symptoms predicted smaller LPPs to fearful faces in the PTSD group. Veterans with PTSD were also less accurate at identifying angry faces, and accuracy decreased in the PTSD group as hyperarousal symptoms increased. These findings show reduced early processing of emotional faces, irrespective of valence, and blunted prolonged processing of social signals of threat in conjunction with impaired perception for angry faces in PTSD.     

Aetiology of acute febrile illness in children in a high malaria transmission area in West Africa

ObjectivesAreas with declining malaria transmission in sub-Saharan Africa have recently witnessed important changes in the aetiology of childhood acute febrile illness (AFI). We describe the aetiology of AFI in a high malaria transmission area in rural Burkina Faso.MethodsIn a prospective hospital-based diagnostic study, children aged 3 months to 15 years with AFI were recruited and assessed using a systematic diagnostic protocol, including blood cultures, whole blood PCR on a selection of bacterial pathogens, malaria diagnostics and a multiplex PCR on nasopharyngeal swabs targeting 21 viral and 4 bacterial respiratory pathogens.ResultsA total of 589 children with AFI were enrolled from whom an infectious disease was considered in 575 cases. Acute respiratory tract infections, malaria and invasive bacterial infections (IBI) accounted for 179 (31.1%), 175 (30.4%) and 75 (13%) of AFI cases respectively; 16 (21.3%) of IBI cases also had malarial parasitaemia. A viral pathogen was demonstrated from the nasopharynx in 157 children (90.7%) with respiratory tract symptoms. Of all children with viral respiratory tract infections, 154 (92.4% received antibiotics, whereas no antibiotic was provided in 13 (17%) of IBI cases.ConclusionsViral respiratory infections are a common cause of childhood AFI in high malaria transmission areas, next to malaria and IBI. These findings highlight the importance of interventions to improve targeted treatment with antimicrobials. Most patients with viral infections received antibiotics unnecessarily, while a considerable number with IBI did not receive antibiotics.     

Impact of sex differences on outcomes in patients with non-valvular atrial fibrillation undergoing left atrial appendage closure: A single-center experience

Female patients affected by non-valvular atrial fibrillation (NVAF) have a higher risk of stroke compared with male patients. Left atrial appendage (LAA) closure has been demonstrated as a reasonable alternative to warfarin therapy for stroke prevention in patients with NVAF. However, the impact of sex-related differences on outcomes in patients undergoing LAA closure (LAAC) remains unclear. Our study investigated the differences in LAAC efficacy and safety endpoints between sexes. 387 consecutive patients undergoing WATCHMAN device implantation were enrolled and stratified by sex. Baseline clinical characteristics, procedural data, severe peri-procedural complications and long-term outcomes were compared between men and women. Measurements of LAA width and depth, device implantation success rate, and the frequency of severe peri-procedural complications were comparable between the two groups. After an average follow-up length of two years post LAAC, no significant differences were observed in the risks for composite thromboembolic events (P = 0.096), major bleeding (P = 0.129), and combined primary (co-primary) efficacy events (P = 0.231) between sexes, but the risk of all-cause death decreased significantly in women compared with men (P = 0.045). After performing propensity matching adjustment for residual confounders, the sex-related differences in the cumulative ratio of freedom from all-cause death did not reach statistical significance (P = 0.062), as was also observed with the cumulative ratio of freedom from composite thromboembolic events (P = 0.104), major bleeding (P = 0.134), and co-primary efficacy events (P = 0.241). The observed annual rate of thromboembolic events was significantly decreased by 67.1% (P < 0.01) and 52.5% (P < 0.05) and the observed annual rate of bleeding was reduced by 33.6% (P < 0.05) and 43.5% (P < 0.05) in men and women when compared with the predicted risk based on CHA₂DS₂VASc score and HAS-BLED score, respectively. LAAC can be considered as an effective and safe strategy in preventing thromboembolic events and decreasing bleeding risks in NVAF patients, regardless of sex. LAAC appears to normalize the sex-specific differences in NVAF patients both in terms of safety and efficacy.     

Participation and Life Satisfaction in Aged People with Spinal Cord Injury: Does Age at Onset Make a Difference?

Background:

Few studies have reported on outcomes in samples of elderly people with SCI and the impact of the age at onset of SCI is unclear.

Objective:

To study levels of participation and life satisfaction in individuals with SCI aged 65 years or older and to analyze differences in participation and life satisfaction scores between individuals injured before or after 50 years of age.

Methods:

This cross-sectional survey included 128 individuals with SCI who were at least 65 years old. Age at onset was dichotomized as <50 or ≥50 years of age. Participation was measured with the Frequency scale of the Utrecht Scale for Evaluation-Participation, and life satisfaction was measured with 5 items of the World Health Organization Quality of Life abbreviated form.

Results:

Participants who were injured before 50 years of age showed similar levels of functional status and numbers of secondary health conditions but higher participation and life satisfaction scores compared to participants injured at older age. In the multiple regression analysis of participation, lower current age, higher education, and having paraplegia were significant independent determinants of increased participation (explained variance, 25.7%). In the regression analysis of life satisfaction, lower age at onset and higher education were significant independent determinants of higher life satisfaction (explained variance, 15.3%).

Conclusion:

Lower age at onset was associated with better participation and life satisfaction. This study did not reveal indications for worsening participation or life satisfaction due to an accelerated aging effect in this sample of persons with SCI.Key words: aged, aging, quality of life, rehabilitation outcome, spinal cord injuriesAging in the population of individuals with spinal cord injury (SCI) has 2 aspects: the average age at onset of SCI is increasing and people with SCI live on average longer than half a century ago. Age at onset of traumatic SCI has risen from 28.7 years in the 1970s to 40 years in the United States during the 2005-2009 period.¹ In other countries, a bimodal distribution of age at onset of traumatic SCI has emerged in recent years.² In the Netherlands, the median age at first admission to the acute hospital after traumatic SCI has increased to 62 years in 2010.³ People who are older at injury are more often victims of falls and have nontraumatic, incomplete, and cervical SCI more often than individuals who are injured at a younger age.³-⁵ They are more vulnerable than younger people and are at greater risk of death shortly after the onset of SCI.⁶ If they survive the acute phase, they are less often referred to specialized rehabilitation hospitals.³ If referred to a specialized center, elderly people with SCI may gain a similar rate of functional improvement⁷; but because older patients generally have lower functional scores at admission, they also show worse rehabilitation outcomes compared to people who are injured at a younger age.^4,8–10The life expectancy of the population with SCI has grown over the last 50 to 60 years.¹¹ Many people with a new SCI can expect to live another 30 to 40 years or more. However, this life expectancy has not grown in recent decades and is still clearly below that of the general population.¹¹ People with SCI are at risk of “accelerated aging” due to an inactive lifestyle and a greater risk of obesity, chronic inflammation, pressure ulcers, and pulmonary infections.^1,12Participation and quality of life in aged persons with SCI are influenced by a complex interaction of many factors associated with current chronologic age, age at injury, duration of injury, and age cohort effects. It has been suggested that increasing age and being of older age at onset of SCI are independently associated with worse outcomes and that longer time after SCI is associated with better adjustment, whereas the impact of age cohort effects on adjustment is unknown.^1,13–15 However, research into the impact of these health-related changes on participation and life satisfaction of aged people living with SCI is sparse, and associations with aging are often studied in samples that are well below retirement age.¹⁵Only 2 longitudinal projects in aging people with SCI are available. Krause and Bozard¹⁶ described 35-year longitudinal data of 64 individuals with SCI (mean age, 61.5 years; mean time since SCI, 41.4 years). The participants rated their overall adjustment significantly higher at follow-up than they did at the first assessment 35 years before (8.4 and 7.6 on a 0–10 scale, respectively). The participants, however, showed decreases in satisfaction with social life and participation indicators (visits with others, outings).¹⁶ Charlifue and Gerhart¹⁷ found in a large sample of people with long-standing SCI (mean age, 59 years; time since onset of SCI, 36 years at follow-up) a small but significant decline in community reintegration over a period of 10 years. Life satisfaction, however, remained stable over this time period.¹⁷It is still unclear how people aging with SCI differ from people who acquire SCI in later life.¹⁸ Given the same age, the accelerated aging hypothesis predicts that people injured at a younger age will be worse off. However, the reverse – higher age at injury is an independent predictor of worse functional outcomes – has also been shown.¹⁰ We therefore used data from earlier research with the following objectives: (a) to describe the levels of participation and life satisfaction in individuals with SCI aged 65 years or older, and (b) to analyze differences in participation and life satisfaction between individuals injured before 50 years of age or at or after 50 years of age.     

Placental expression of soluble fms-like tyrosine kinase 1 is increased in singletons and twin pregnancies with intrauterine growth restriction

OBJECTIVE: Intrauterine growth restriction (IUGR) is characterized by decreased placental perfusion. Low oxygen has been shown to increase soluble fms-like tyrosine kinase 1 (sFlt-1) expression in the human placenta. The objective of this study was to examine sFlt-1 expression in different types of IUGR pregnancies, including early-onset severe cases characterized by abnormal umbilical and uterine artery Doppler and discordant IUGR twins in which the normal cotwin represents the optimal control because both placentas share the same uterine environment. PATIENTS: Placentas from four subgroups were collected: early severe IUGR with umbilical artery absent end diastolic flow (n = 19), small for gestational age with normal uterine and umbilical artery Doppler (n = 11), severely growth-restricted dichorionic and monochorionic twins with abnormal umbilical artery Doppler (n = 9), preeclamptic twins (n = 3), and age-matched normal singletons (n = 19) and twin controls (n = 8). RESULTS: Expression of sFlt-1 mRNA and protein was significantly increased in IUGR placentas compared with small for gestational age and normal control placentas. sFlt-1 expression levels were also significantly greater in the small IUGR twin placentas from discordant twin pregnancies compared with the normal cotwin. In preeclamptic twins, sFlt-1 expression was increased in only one of the two placentas. CONCLUSIONS: Our results demonstrate that sFlt-1 expression is increased in severe IUGR placentas with abnormal umbilical artery Doppler of singletons and also in discordant IUGR twins. Reduced placental perfusion may contribute to the increased expression of sFlt-1 in IUGR pregnancies. Our data are compatible with differential sFlt-1 expression in placentas from discordant twins.