Perioperative echocardiography-guided hemodynamic therapy in high-risk patients:a practical expert approach of hemodynamically focused echocardiography

The number of high-risk patients undergoing surgery is growing. To maintain adequate hemodynamic functioning as well as oxygen delivery to the vital organs (DO2) amongst this patient population, a rapid assessment of cardiac functioning is essential for the anesthesiologist. Pinpointing any underlying cardiovascular pathophysiology can be decisive to guide interventions in the intraoperative setting. Various techniques are available to monitor the hemodynamic status of the patient, however due to intrinsic limitations, many of these methods may not be able to directly identify the underlying cause of cardiovascular impairment. Hemodynamic focused echocardiography, as a rapid diagnostic method, offers an excellent opportunity to examine signs of filling impairment, cardiac preload, myocardial contractility and the function of the heart valves. We thus propose a 6-step-echocardiographic approach to assess high-risk patients in order to improve and maintain perioperative DO2. The summary of all echocardiographic based findings allows a differentiated assessment of the patient's cardiovascular function and can thus help guide a (patho)physiological-orientated and individualized hemodynamic therapy

Grondslagen voor hoogwaterbescherming

De bescherming tegen overstromingen is essentieel voor de leefbaarheid van Nederland. In de Waterwet zijn daarom normen voor waterkeringen vastgelegd. Waterschappen en Rijkswaterstaat zorgen er voor dat de primaire waterkeringen die zij beheren aan deze normen voldoen. Hiervoor zijn praktisch toepasbare, uniforme rekenwijzen nodig waarmee een oordeel over de veiligheid van een bestaande of nieuw te ontwerpen waterkering kan worden gegeven. Vanzelfsprekend is voldoende kennis en ervaring bij het toepassen van de rekenwijzen noodzakelijk. Delen van kennis en ervaringen tussen waterkeringbeheerders, kennisinstellingen en het bedrijfsleven is daarom essentieel. De te hanteren rekenwijzen en kennis staan in Voorschriften, Leidraden en Technische rapporten. Grondslagen voor hoogwaterbescherming beschrijft de achterliggende principes van de hoogwaterbescherming in Nederland. Aan bod komen thema’s als het omgaan met onzekerheden, het afleiden van technische eisen en verschillende aspecten die een rol spelen bij het ontwerpen van waterkeringen, de continue zorg voor hoogwaterbescherming en crisisbeheersing. Grondslagen voor hoogwaterbescherming is geschreven door het Expertise Netwerk Waterveiligheid (ENW), op verzoek van het ministerie van Infrastructuur en Milieu en vervangt het boek Grondslagen voor waterkeren uit 1998. Het ENW vertrouwt erop dat Grondslagen voor hoogwaterbescherming bijdraagt aan een beter begrip van het werk aan de bescherming tegen overstromingen in Nederland.TAW-EN

CD44 isoforms containing exon V3 are responsible for the presentation of heparin-binding growth factor

Glycosaminoglycan-modified isoforms of CD44 have been implicated in growth factor presentation at sites of inflammation. In the present study we show that COS cell transfectants expressing CD44 isoforms containing the alternatively spliced exon V3 are modified with heparan sulfate (HS). Binding studies with three HS-binding growth factors, basic-fibroblast growth factor (b-FGF), heparin binding-epidermal growth factor (HB-EGF), and amphiregulin, showed that the HS-modified CD44 isoforms are able to bind to b-FGF and HB-EGF, but not AR. b-FGF and HB-EGF binding to HS-modified CD44 was eliminated by pretreating the protein with heparitinase or by blocking with free heparin. HS-modified CD44 immunoprecipitated from keratinocytes, which express a CD44 isoform containing V3, also bound to b-FGF. We examined whether HS-modified CD44 isoforms were expressed by activated endothelial cells where they might present HS-binding growth factors to leukocytes during an inflammatory response. PCR and antibody-binding studies showed that activated cultured endothelial cells only express the CD44H isoform which does not contain any of the variably spliced exons including V3. Immunohistological studies with antibodies directed to CD44 extracellular domains encoded by the variably spliced exons showed that vascular endothelial cells in inflamed skin tissue sections do not express CD44 spliced variants. Keratinocytes, monocytes, and dendritic cells in the same specimens were found to express variably spliced CD44. 35SO4(-2)-labeling experiments demonstrated that activated cultured endothelial cells do not express detectable levels of chondroitin sulfate or HS-modified CD44. Our results suggest that one of the functions of CD44 isoforms expressing V3 is to bind and present a subset of HS-binding proteins. Furthermore, it is probable that HS-modified CD44 is involved in the presentation of HS-binding proteins by keratinocytes in inflamed skin. However, our data suggests that CD44 is not likely to be the proteoglycan principally involved in presenting HS-binding growth factors to leukocytes on the vascular cell wal