Arterial blood pressure during early sepsis and outcome

OBJECTIVE: To evaluate the association between arterial blood pressure (ABP) during the first 24 h and mortality in sepsis. DESIGN: Retrospective cohort study. SETTING: Multidisciplinary intensive care unit (ICU). PATIENTS AND PARTICIPANTS: A total of 274 septic patients. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Hemodynamic, and laboratory parameters were extracted from a PDMS database. The hourly time integral of ABP drops below clinically relevant systolic arterial pressure (SAP), mean arterial pressure (MAP), and mean perfusion pressure (MPP = MAP - central venous pressure) levels was calculated for the first 24 h after ICU admission and compared with 28-day-mortality. Binary and linear regression models (adjusted for SAPS II as a measure of disease severity), and a receiver operating characteristic (ROC) analysis were applied. The areas under the ROC curve were largest for the hourly time integrals of ABP drops below MAP 60 mmHg (0.779 vs. 0.764 for ABP drops below MAP 55 mmHg; P < or = 0.01) and MPP 45 mmHg. No association between the hourly time integrals of ABP drops below certain SAP levels and mortality was detected. One or more episodes of MAP < 60 mmHg increased the risk of death by 2.96 (CI 95%, 1.06-10.36, P = 0.04). The area under the ROC curve to predict the need for renal replacement therapy was highest for the hourly time integral of ABP drops below MAP 75 mmHg. CONCLUSIONS: A MAP level > or = 60 mmHg may be as safe as higher MAP levels during the first 24 h of ICU therapy in septic patients. A higher MAP may be required to maintain kidney function.

A 20-day period standing oscillation in the northern winter stratosphere

Observations of the ozone profile by a ground-based microwave radiometer in Switzerland indicate a dominant 20-day oscillation in stratospheric ozone, possibly related to oscillations of the polar vortex edge during winter. For further understanding of the nature of the 20-day oscillation, the ozone data set of ERA Interim meteorological reanalysis is analyzed at the latitude belt of 47.5° N and in the time from 1979 to 2010. Spectral analysis of ozone time series at 7 hPa indicates that the 20-day oscillation is maximal at two locations: 7.5° E, 47.5° N and 60° E, 47.5° N. Composites of the stream function are derived for different phases of the 20-day oscillation of stratospheric ozone at 7 hPa in the Northern Hemisphere. The streamline at Ψ = −2 × 107 m2 s−1 is in the vicinity of the polar vortex edge. The other streamline at Ψ = 4 × 107 m2 s1 surrounds the Aleutian anticyclone and goes to the subtropics. The composites show 20-day period standing oscillations at the polar vortex edge and in the subtropics above Northern Africa, India, and China. The 20-day period standing oscillation above Aral Sea and India is correlated to the strength of the Aleutian anticyclone.

Cholesterol transporters in lactating and nonlactating human mammary tissue

In mammals milk is the principal nutrient for neonates at birth. The basic milk composition is similar between different mammals, but the content of individual constituents such as lipids may differ significantly from one species to another. The milk fat fraction is mainly composed of triglycerides which account for more than 95% of the lipids found in human and bovine milk. Though sterols and in particular cholesterol, the predominant milk sterol, represent less than 0.5% of the total milk lipid fraction, they are of ultimate importance for biological processes such as the formation of biological membranes or as precursors for steroid hormone synthesis. Cholesterol found in milk originates either from blood uptake or from local synthesis. This chapter provides an overview of cholesterol exchanges between the blood, the mammary tissue and the milk. The current knowledge on the expression, localization and function of candidate cholesterol transporters in mammary tissues of human, murine and bovine origin is summarized. Different mechanisms of how cholesterol can be transferred via the mammary tissue into milk, and which active cholesterol transporters are likely to play a role in this process will be discussed.

Multicentre validation of the Geneva Risk Score for hospitalised medical patients at risk of venous thromboembolism. Explicit ASsessment of Thromboembolic RIsk and Prophylaxis for Medical PATients in SwitzErland (ESTIMATE).

There is a need to validate risk assessment tools for hospitalised medical patients at risk of venous thromboembolism (VTE). We investigated whether a predefined cut-off of the Geneva Risk Score, as compared to the Padua Prediction Score, accurately distinguishes low-risk from high-risk patients regardless of the use of thromboprophylaxis. In the multicentre, prospective Explicit ASsessment of Thromboembolic RIsk and Prophylaxis for Medical PATients in SwitzErland (ESTIMATE) cohort study, 1,478 hospitalised medical patients were enrolled of whom 637 (43%) did not receive thromboprophylaxis. The primary endpoint was symptomatic VTE or VTE-related death at 90 days. The study is registered at ClinicalTrials.gov, number NCT01277536. According to the Geneva Risk Score, the cumulative rate of the primary endpoint was 3.2% (95% confidence interval [CI] 2.2-4.6%) in 962 high-risk vs 0.6% (95% CI 0.2-1.9%) in 516 low-risk patients (p=0.002); among patients without prophylaxis, this rate was 3.5% vs 0.8% (p=0.029), respectively. In comparison, the Padua Prediction Score yielded a cumulative rate of the primary endpoint of 3.5% (95% CI 2.3-5.3%) in 714 high-risk vs 1.1% (95% CI 0.6-2.3%) in 764 low-risk patients (p=0.002); among patients without prophylaxis, this rate was 3.2% vs 1.5% (p=0.130), respectively. Negative likelihood ratio was 0.28 (95% CI 0.10-0.83) for the Geneva Risk Score and 0.51 (95% CI 0.28-0.93) for the Padua Prediction Score. In conclusion, among hospitalised medical patients, the Geneva Risk Score predicted VTE and VTE-related mortality and compared favourably with the Padua Prediction Score, particularly for its accuracy to identify low-risk patients who do not require thromboprophylaxis.

Ultrasound-assisted thrombolysis for acute pulmonary embolism: a systematic review.

Pulmonary embolism remains a common and potentially life-threatening disease. For patients with intermediate- and high-risk pulmonary embolism, catheter-based revascularization therapy has emerged as potential alternative to systemic thrombolysis or surgical embolectomy. Ultrasound-assisted catheter-directed thrombolysis is a contemporary catheter-based technique and is the focus of the present review. Ultrasound-assisted catheter-directed thrombolysis is more effective in reversing right ventricular dysfunction and dilatation in comparison with anticoagulation alone in patients at intermediate risk. However, a direct comparison of ultrasound-assisted thrombolysis with systemic thrombolysis or surgical thrombectomy is not available. Ultrasound-assisted thrombolysis with initial intrapulmonary thrombolytic bolus may also be effective in high-risk patients, but evidence from randomized trials is not available. This review summarizes current data on ultrasound-assisted thrombolysis for acute pulmonary embolism.

Die prophylaktische Mastektomie: unnötige Hysterie oder nötige Vorsorge.

The prophylactic (risk-reducing) mastectomy is a world-wide recognized method for specifically treating the increased breast cancer risk in patients showing a BRCA1 and/or BRCA2 mutation as well as other patient groups at increased breast cancer risk. This option should be offered to all patients having the pertinent risk profile. Breast reconstruction is an integral part of the risk-reducing mastectomy procedure and all possible methods of breast reconstruction, especially autologous tissue reconstruction should be offered to all patients having a medical indication and desiring this surgical treatment. These patients are best managed in certified Breast Care Centres where the different medical and surgical specialists can address interdisciplinary all aspects of genetic counselling, preoperative counselling, mastectomy and reconstructive techniques as well as the necessary postoperative surveillance.

Die Rolle des Benefit-Finding für die Qualität der Anpassung an das Leben nach dem Spitzensport

Die Lebensereignisforschung postuliert, dass die Anpassung an eine durch ein kritisches Ereignis veränderte Situation durch Benefit-Finding gefördert wird, indem Menschen Gewinnbringendes für ihr Leben erkennen (Filipp & Aymanns, 2010). Während in der frühen Forschung zum oft als kritisches Lebensereignis beschriebenen Karriereende im Spitzensport Benefit-Finding mitbedacht wurde, wird es in der aktuellen Forschung nur punktuell berücksichtigt (z.B. Curtis & Ennis, 1988, Wippert, 2011). Basierend auf dem Konzept Kritisches Lebensereignis (Filipp, 1995) untersucht die vorliegende Studie die Rolle des Benefit-Finding für die kurz-, mittel- und langfristige Qualität der Anpassung an das Karriereende. Methods: 290 Schweizer Spitzenathleten (Frauenanteil: 32.8%) aus 64 Sportarten wurden etwa 7.46 Jahre nach ihrem Karriereende mittels Fragebogen zum Benefit-Finding, Erleben des Karriereendes, zur Dauer und subjektiven Qualität der Anpassung an das Karriereende sowie zum psychischen Wohlbefinden befragt. Die Datenauswertung erfolgte mittels Strukturgleichungsmodellierung. Results: Das Modell zur Vorhersage der langfristigen Anpassungsqualität (psychische Wohlbefinden) an das Karriereende mit einer Varianzaufklärung von R2 = .26 passt recht gut zu den Daten (χ2 = 114.764, p ≤ .001, df = 56, CFI = .93, SRMR = .06, RMSEA = .06; AGFI = .91). Wie postuliert, hat das Ausmass von Benefit-Finding einen – über die kurz- und mittelfristige Anpassungsqualität (positive Emotionen, Anpassungsdauer und subjektive Anpassungsqualität) – vermittelten Effekt auf das psychische Wohlbefinden im Leben nach dem Spitzensport. Discussion/Conclusion: Das Konzept Kritisches Lebensereignis kristallisierte sich als zielführender Ansatz für die Analyse von zusammenwirkenden Faktoren hinsichtlich Qualität der Anpassung an das Leben nach dem Spitzensport heraus. Die Befunde indizieren, dass sportpsychologische Interventionen mit Fokus auf Benefit-Finding, zusammen mit anderen Elementen der gängigen Career-Assistance-Programme, kurzfristig für eine gelingende Transition und langfristig ein günstiges psychisches Wohlbefinden sinnvoll sind. References: Curtis, J. & Ennis, R. (1988). Negative consequences of leaving competitive sport? Comparative findings for former elite-level hockey players. Sociology of Sport Journal, 5, 87-106. Filipp, S.-H. (Hrsg.) (1995). Kritische Lebensereignisse (3. Aufl.). Weinheim: Beltz. Filipp, S.-H. & Aymanns, P. (2010). Kritische Lebensereignisse und Lebenskrisen. Vom Umgang mit den Schattenseiten des Lebens. Stuttgart: Kohlhammer. Wippert, P.-M. (2011). Kritische Lebensereignisse in Hochleistungsbiografien. Untersuchungen an Spitzensportlern, Tänzern und Musikern. Lengerich: Pabst.

The silent services of the world ocean

The most recent comprehensive assessment carried out by the Intergovernmental Panel on Climate Change has concluded that “Human influence on the climate system is clear,” a headline statement that was approved by all governments in consensus. This influence will have long-lasting consequences for ecosystems, and the resulting impacts will continue to be felt millennia from now. Although the terrestrial impacts of climate change are readily apparent now and have received widespread public attention, the effects of climate change on the oceans have been relatively invisible. However, the world ocean provides a number of crucial services that are of global significance, all of which come with an increasing price caused by human activities. This needs to be taken into account when considering adaptation to and mitigation of anthropogenic climate change.

Effects of dialysis modality on blood loss, bleeding complications and transfusion requirements in critically ill patients with dialysis-dependent acute renal failure.

Blood loss and bleeding complications may often be observed in critically ill patients on renal replacement therapies (RRT). Here we investigate procedural (i.e. RRT-related) and non-procedural blood loss as well as transfusion requirements in regard to the chosen mode of dialysis (i.e. intermittent haemodialysis [IHD] versus continuous veno-venous haemofiltration [CVVH]). Two hundred and fifty-two patients (122 CVVH, 159 male; aged 61.5±13.9 years) with dialysis-dependent acute renal failure were analysed in a sub-analysis of the prospective randomised controlled clinical trial-CONVINT-comparing IHD and CVVH. Bleeding complications including severity of bleeding and RRT-related blood loss were assessed. We observed that 3.6% of patients died related to severe bleeding episodes (between group P=0.94). Major all-cause bleeding complications were observed in 23% IHD versus 26% of CVVH group patients (P=0.95). Under CVVH, the rate of RRT-related blood loss events (57.4% versus 30.4%, P=0.01) and mean total blood volume lost was increased (222.3±291.9 versus 112.5±222.7 ml per patient, P <0.001). Overall, transfusion rates did not differ between the study groups. In patients with sepsis, transfusion rates of all blood products were significantly higher when compared to cardiogenic shock (all P <0.01) or other conditions. In conclusion, procedural and non-procedural blood loss may often be observed in critically ill patients on RRT. In CVVH-treated patients, procedural blood loss was increased but overall transfusion rates remained unchanged. Our data show that IHD and CVVH may be regarded as equivalent approaches in critically ill patients with dialysis-dependent acute renal failure in this regard.