Chronic hyperglycemia is associated with acute kidney injury in patients undergoing CABG surgery – a cohort study

Background Chronic hyperglycemia (CHG) with HbA1c as an indicator affects postoperative mortality and morbidity after coronary artery bypass grafting surgery (CABG). Acute kidney injury (AKI) is one of the frequent postoperative complications after CABG impacting short-and long-term outcomes. We investigated the association between CHG and postoperative incidence of AKI in CABG patients with and without history of diabetes mellitus (DM). Methods This cohort study consecutively enrolled patients undergoing CABG in 2009 at the department for cardiovascular surgery. CHG was defined as HbA1c ≥ 6.0 %. Patients with advanced chronic kidney disease (CKD) were excluded. The incidence of postoperative AKI and its association with CHG was analyzed by univariate and multivariate logistic regression modeling. Results Three-hundred-seven patients were analyzed. The incidence of AKI was 48.2 %. Patients with CHG (n = 165) were more likely to be female and had greater waist circumference as well as other comorbid conditions, such as smoking, history of DM, CKD, hypertension, pulmonary hypertension, and chronic obstructive pulmonary disease (all p ≤ 0.05). Preoperative eGFR, atrial fibrillation (AF), history of DM and CHG were associated with an increased risk of postoperative AKI in univariate analyses. In multivariate modelling, history of DM as well as preoperative eGFR and AF lost significance, while age, CHG and prolonged OP duration (p < 0.05) were independently associated with postoperative AKI. Conclusions Our results suggest that CHG defined on a single measurement of HbA1c ≥ 6.0 % was associated with the incidence of AKI after CABG. This finding might implicate that treatment decisions, including the selection of operative strategies, could be based on HbA1c measurement rather than on a recorded history of diabetes

Prevention of Hepatic Steatosis and Hepatic Insulin Resistance by Knockdown of cAMP Response Element-Binding Protein

SummaryIn patients with poorly controlled type 2 diabetes mellitus (T2DM), hepatic insulin resistance and increased gluconeogenesis contribute to fasting and postprandial hyperglycemia. Since cAMP response element-binding protein (CREB) is a key regulator of gluconeogenic gene expression, we hypothesized that decreasing hepatic CREB expression would reduce fasting hyperglycemia in rodent models of T2DM. In order to test this hypothesis, we used a CREB-specific antisense oligonucleotide (ASO) to knock down CREB expression in liver. CREB ASO treatment dramatically reduced fasting plasma glucose concentrations in ZDF rats, ob/ob mice, and an STZ-treated, high-fat-fed rat model of T2DM. Surprisingly, CREB ASO treatment also decreased plasma cholesterol and triglyceride concentrations, as well as hepatic triglyceride content, due to decreases in hepatic lipogenesis. These results suggest that CREB is an attractive therapeutic target for correcting both hepatic insulin resistance and dyslipidemia associated with nonalcoholic fatty liver disease (NAFLD) and T2DM

Medical and cardio-vascular emergency department visits during the COVID-19 pandemic in 2020: is there a collateral damage? A retrospective routine data analysis

Background In this retrospective routine data analysis, we investigate the number of emergency department (ED) consultations during the COVID-19 pandemic of 2020 in Germany compared to the previous year with a special focus on numbers of myocardial infarction and acute heart failure. Methods Aggregated case numbers for the two consecutive years 2019 and 2020 were obtained from 24 university hospitals and 9 non-university hospitals in Germany and assessed by age, gender, triage scores, disposition, care level and by ICD-10 codes including the tracer diagnoses myocardial infarction (I21) and heart failure (I50). Results A total of 2,216,627 ED consultations were analyzed, of which 1,178,470 occurred in 2019 and 1,038,157 in 2020. The median deviation in case numbers between 2019 and 2020 was - 14% [CI (- 11)-(- 16)]. After a marked drop in all cases in the first COVID-19 wave in spring 2020, case numbers normalized during the summer Thereafter starting in calendar week 39 case numbers constantly declined until the end of the year 2020. The decline in case numbers predominantly concerned younger [- 16%; CI (- 13)-(- 19)], less urgent [- 18%; CI (- 12)-(- 22)] and non-admitted cases [- 17%; CI (- 13)-(- 20)] in particular during the second wave. During the entire observation period admissions for chest pain [- 13%; CI (- 21)-2], myocardial infarction [- 2%; CI (- 9)-11] and heart failure [- 2%; CI (- 10)-6] were less affected and remained comparable to the previous year. Conclusions ED visits were noticeably reduced during both SARS-CoV-2 pandemic waves in Germany but cardiovascular diagnoses were less affected and no refractory increase was noted. However, long-term effects cannot be ruled out and need to be analysed in future studies. [GRAPHICS]

Medical and cardio-vascular emergency department visits during the COVID-19 pandemic in 2020: is there a collateral damage? A retrospective routine data analysis

Background In this retrospective routine data analysis, we investigate the number of emergency department (ED) consultations during the COVID-19 pandemic of 2020 in Germany compared to the previous year with a special focus on numbers of myocardial infarction and acute heart failure. Methods Aggregated case numbers for the two consecutive years 2019 and 2020 were obtained from 24 university hospitals and 9 non-university hospitals in Germany and assessed by age, gender, triage scores, disposition, care level and by ICD-10 codes including the tracer diagnoses myocardial infarction (I21) and heart failure (I50). Results A total of 2,216,627 ED consultations were analyzed, of which 1,178,470 occurred in 2019 and 1,038,157 in 2020. The median deviation in case numbers between 2019 and 2020 was − 14% [CI (− 11)–(− 16)]. After a marked drop in all cases in the first COVID-19 wave in spring 2020, case numbers normalized during the summer. Thereafter starting in calendar week 39 case numbers constantly declined until the end of the year 2020. The decline in case numbers predominantly concerned younger [− 16%; CI (− 13)–(− 19)], less urgent [− 18%; CI (− 12)–(− 22)] and non-admitted cases [− 17%; CI (− 13)–(− 20)] in particular during the second wave. During the entire observation period admissions for chest pain [− 13%; CI (− 21)–2], myocardial infarction [− 2%; CI (− 9)–11] and heart failure [− 2%; CI (− 10)–6] were less affected and remained comparable to the previous year. Conclusions ED visits were noticeably reduced during both SARS-CoV-2 pandemic waves in Germany but cardiovascular diagnoses were less affected and no refractory increase was noted. However, long-term effects cannot be ruled out and need to be analysed in future studies. Graphical abstractOpen Access funding enabled and organized by Projekt DEAL.Charité - Universitätsmedizin Berlin (3093

Comprehensive Molecular Characterization of Pheochromocytoma and Paraganglioma

SummaryWe report a comprehensive molecular characterization of pheochromocytomas and paragangliomas (PCCs/PGLs), a rare tumor type. Multi-platform integration revealed that PCCs/PGLs are driven by diverse alterations affecting multiple genes and pathways. Pathogenic germline mutations occurred in eight PCC/PGL susceptibility genes. We identified CSDE1 as a somatically mutated driver gene, complementing four known drivers (HRAS, RET, EPAS1, and NF1). We also discovered fusion genes in PCCs/PGLs, involving MAML3, BRAF, NGFR, and NF1. Integrated analysis classified PCCs/PGLs into four molecularly defined groups: a kinase signaling subtype, a pseudohypoxia subtype, a Wnt-altered subtype, driven by MAML3 and CSDE1, and a cortical admixture subtype. Correlates of metastatic PCCs/PGLs included the MAML3 fusion gene. This integrated molecular characterization provides a comprehensive foundation for developing PCC/PGL precision medicine

Effect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial.

Importance: Evidence regarding corticosteroid use for severe coronavirus disease 2019 (COVID-19) is limited. Objective: To determine whether hydrocortisone improves outcome for patients with severe COVID-19. Design, Setting, and Participants: An ongoing adaptive platform trial testing multiple interventions within multiple therapeutic domains, for example, antiviral agents, corticosteroids, or immunoglobulin. Between March 9 and June 17, 2020, 614 adult patients with suspected or confirmed COVID-19 were enrolled and randomized within at least 1 domain following admission to an intensive care unit (ICU) for respiratory or cardiovascular organ support at 121 sites in 8 countries. Of these, 403 were randomized to open-label interventions within the corticosteroid domain. The domain was halted after results from another trial were released. Follow-up ended August 12, 2020. Interventions: The corticosteroid domain randomized participants to a fixed 7-day course of intravenous hydrocortisone (50 mg or 100 mg every 6 hours) (n = 143), a shock-dependent course (50 mg every 6 hours when shock was clinically evident) (n = 152), or no hydrocortisone (n = 108). Main Outcomes and Measures: The primary end point was organ support-free days (days alive and free of ICU-based respiratory or cardiovascular support) within 21 days, where patients who died were assigned -1 day. The primary analysis was a bayesian cumulative logistic model that included all patients enrolled with severe COVID-19, adjusting for age, sex, site, region, time, assignment to interventions within other domains, and domain and intervention eligibility. Superiority was defined as the posterior probability of an odds ratio greater than 1 (threshold for trial conclusion of superiority >99%). Results: After excluding 19 participants who withdrew consent, there were 384 patients (mean age, 60 years; 29% female) randomized to the fixed-dose (n = 137), shock-dependent (n = 146), and no (n = 101) hydrocortisone groups; 379 (99%) completed the study and were included in the analysis. The mean age for the 3 groups ranged between 59.5 and 60.4 years; most patients were male (range, 70.6%-71.5%); mean body mass index ranged between 29.7 and 30.9; and patients receiving mechanical ventilation ranged between 50.0% and 63.5%. For the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively, the median organ support-free days were 0 (IQR, -1 to 15), 0 (IQR, -1 to 13), and 0 (-1 to 11) days (composed of 30%, 26%, and 33% mortality rates and 11.5, 9.5, and 6 median organ support-free days among survivors). The median adjusted odds ratio and bayesian probability of superiority were 1.43 (95% credible interval, 0.91-2.27) and 93% for fixed-dose hydrocortisone, respectively, and were 1.22 (95% credible interval, 0.76-1.94) and 80% for shock-dependent hydrocortisone compared with no hydrocortisone. Serious adverse events were reported in 4 (3%), 5 (3%), and 1 (1%) patients in the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively. Conclusions and Relevance: Among patients with severe COVID-19, treatment with a 7-day fixed-dose course of hydrocortisone or shock-dependent dosing of hydrocortisone, compared with no hydrocortisone, resulted in 93% and 80% probabilities of superiority with regard to the odds of improvement in organ support-free days within 21 days. However, the trial was stopped early and no treatment strategy met prespecified criteria for statistical superiority, precluding definitive conclusions. Trial Registration: ClinicalTrials.gov Identifier: NCT02735707

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

Development of enzymatical and immunohistochemical assays of phytanoyl-CoA hydroxylase in CHO-cells.

In der vorliegenden Arbeit wurde nach Wegen gesucht, den Import peroxisomaler Matrixproteine, der über ein peroxisomales Targeting Signal Typ 2 gesteuert wird, zu messen. Es war vorgesehen, in erster Linie einen enzymchemischen Nachweis zu etablieren, da diese Methode den Vorteil einer Quantifizierbarkeit der Aktivität der gemessenen Enzyme bietet und somit Rückschlüsse auf den Grad einer Beeinträchtigung des Importes zulassen würden. Von dem Test wurde eine Sensitivität gefordert, die eine Messung auch in Homogenaten kultivierter Zellen, insbesondere von CHO-Zellen, erlaubt. Dieses war deswegen gefordert, weil der Test zur Charakterisierung induzierter CHO-Zell-Mutanten eingesetzt werden sollte, die die Merkmale eines PTS 2-Import-Defektes aufweisen. Dieser Nachweis sollte durch eine Messung der Phytanoyl-CoA-Hydroxylase erfolgen. Dieses Enzym ist eines von drei derzeit bekannten Proteinen, die eine PTS 2 besitzen und über diesen Weg importiert werden. Das Substrat für die Hydroxylase war als Phytansäure mit einer 2,3-3H-Markierung in der Arbeitsgruppe vorrätig und wurde für den Test zum CoA-Thioester chemisch umgesetzt. Nach erfolgter enzymatischer Umsetzung von Phytonoyl-CoA zu a-Hydroxyphytanoyl-CoA durch die Hydroxylase waren dann sowohl Edukt wie auch das Produkt durch eine radioaktive Markierung gekennzeichnet und konnten nach einer dünnschicht-chromatographischen Trennung über Kieselgel durch einem Radiodünnschichtscanner nachgewiesen werden. Zunächst wurde mit Hilfe von Homogenaten aus Rattenlebergewebe ein bereits beschriebenes Verfahren zur Messung der Phytanoyl-CoA-Hydroxylase optimiert. Es stellte sich jedoch heraus, daß die Sensitivität dieses Testes nicht hoch genug ist, um die Hydroxylase-Aktivität in Homogenaten kultivierter CHO-Zellen zu messen. An dieser Stelle wurde die Etablierung eines immunchemischen Nachweises begonnen. Hierzu sollten Antikörper gegen die Hydroxylase des chinesischen Zwerghamsters, des Ursprungsorganismus der CHO-Zellen, generiert werden. Eine Reinigung des Enzyms kam nicht in Betracht, weil die Hamster nicht im Labortierhandel erhältlich waren. Folglich musste die cDNA der Hydroxylase aus einer Hamster-cDNA-Bank kloniert werden, nachdem sie durch ihre bekannten Homologe aus Mensch und Maus identifizierbar war. In den verfügbaren cDNA-Banken fand sich keine vollständige Sequenz, so daß mit einer partiellen Sequenz ohne 5´-Ende weitergearbeitet werden musste. Es bot sich im Institut die Möglichkeit, aus dieser Sequenz Pepetide zu bestimmen, die mit hoher Wahrscheinlichkeit stark immunogen wirken. Solche Peptide wurden synthetisiert und nach Koppelung an Trägerproteine neuseeländischen weißen Kaninchen geimpft. Im Elisa wies das Antiserum zum Zeitpunkt seiner Gewinnung einen Titer von etwa 1:10000 auf, zeigte aber im Westernblot neben einer starken Detektion in Laufweite der Hydroxylase auch eine unspezifische Anfärbung der Proben. In der nun durchgeführten Affinitätsreinigung des Antiserums über einer mit den antigenen Peptiden beladenen Säule tauchte das Problem auf, daß die Antikörper so fest binden, daß sie von ihren Antigenen nicht mehr ohne dentaturierende Bedingungen zu lösen waren. Für die weitere Arbeit sollte sich nun eine affinitätschromatographische Reinigung über Peptide, die den Antikörper mit geringerer Avidität binden, anschließen, so daß nach Trennung der Immunkomplexe native Antikörper isoliert werden könnten. Hierzu wäre ein Epitop-mapping wünschenswert, damit auf dieser Grundlage Peptide mit den geforderten Eigenschaften synthetisiert werden können.The aim of the present work was to establish methods for studying the import of peroxisomal matrix proteins that are imported via the peroxisomal targeting signal type 2 (PTS-2). Initially, an enzymatical approach was preferred, because this would allow quantification of the enzyme activity and thus estimation of the degree of any impairment. With a test sensitive enough to measure the activity of the enzyme in homogenates of cultivated cells, especially of CHO-cells, it should be possible to characterize mutant CHO-cells with a defect of the PTS-2-mediated import. Phytanoyl-CoA hydroxylase was chosen as one of three known enzymes that are imported via PTS-2. The substrate [2,3-3H]phytanic acid, was available in the laboratory and was chemically converted to the CoA thioester. After enzymatic conversion of phytanoyl-CoA to hydroxyphytanoyl-CoA, both substrate and product were radioactively labeled and could be quantified by a TLC scanner after separation by thin layer chromatography. Attempts to optimize established assay procedures for measuring the hydroxylase in rat liver homogenates, however, failed because the sensitivity of the test could not be increased sufficiently to measure the much lower hydroxylase activity in homogenates of cultivated CHO-cells. Therefore, an immunohistochemical approach was pursued. Purification of the hamster enzyme was considered impractical because it would have been very difficult to obtain a sufficient number of the animals. Instead, it was planned to isolate the cDNA coding for the hamster enzyme from a Chinese hamster cDNA bank and to express the required amounts of the recombinant enzyme in E. coli. Starting from the rat paralogue, it was indeed possible to identify several clones with partial sequences but none of them contained the 5‘ terminus, so that expression of the enzyme was not possible. Within the amino acid sequence derived from the cDNA sequence information, sequences with predicted high immunogenicities were identified and the correspond-ing peptides were synthesized. After binding the peptides either to BSA or to keyhole limpet hemocyanin, these were injected into new zealand white rabbits. The titers achieved were approx. 1:10000, as estimated by ELISA, but Western blot analysis revealed a substantial amount of non-specific cross-reaction, making purification of the antibodies necessary. Affinity chromatography with the same peptides immobi-lized on a solid matrix gave unsatisfactory results, presumably because, owing to their high avidity, the antibodies could only be eluted under very harsh conditions, leading to their denaturation. It is now planned to conduct an epitope mapping of the binding sequence of the antibodies and to synthesize new peptides which are bound with lower affinity, which should make their purification easier

Clinical aspects of symptomatic hyponatremia

Hyponatremia (HN) is a common condition, with a large number of etiologies and a complicated treatment. Although chronic HN has been shown to be a predictor of poor outcome, sodium-increasing treatments in chronic stable and asymptomatic HN have not proven to increase life expectancy. For symptomatic HN, in contrast, the necessity for urgent treatment has broadly been accepted to avoid the development of fatal cerebral edema. On the other hand, a too rapid increase of serum sodium in chronic HN may result in cerebral damage due to osmotic demyelinisation. Recently, administration of hypertonic saline bolus has been recommended as first-line treatment in patients with moderate-to-severe symptomatic HN. This approach is easy to memorize and holds the potential to greatly facilitate the initial treatment of symptomatic HN. First-line treatment of chronic HN is fluid restriction and if ineffective treatment with tolvaptan or in some patients other agents should be considered. A number of recommendations and guidelines have been published on HN. In the present review, the management of patients with HN in relation to everyday clinical practice is summarized with focus on the acute management

Modelling variations of emergency attendances using data on community mobility, climate and air pollution

Abstract Air pollution is associated with morbidity and mortality worldwide. We investigated the impact of improved air quality during the economic lockdown during the SARS-Cov2 pandemic on emergency room (ER) admissions in Germany. Weekly aggregated clinical data from 33 hospitals were collected in 2019 and 2020. Hourly concentrations of nitrogen and sulfur dioxide (NO2, SO2), carbon and nitrogen monoxide (CO, NO), ozone (O3) and particulate matter (PM10, PM2.5) measured by ground stations and meteorological data (ERA5) were selected from a 30 km radius around the corresponding ED. Mobility was assessed using aggregated cell phone data. A linear stepwise multiple regression model was used to predict ER admissions. The average weekly emergency numbers vary from 200 to over 1600 cases (total n = 2,216,217). The mean maximum decrease in caseload was 5 standard deviations. With the enforcement of the shutdown in March, the mobility index dropped by almost 40%. Of all air pollutants, NO2 has the strongest correlation with ER visits when averaged across all departments. Using a linear stepwise multiple regression model, 63% of the variation in ER visits is explained by the mobility index, but still 6% of the variation is explained by air quality and climate change