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Background
Diabetes mellitus (DM) is the leading cause of end-stage renal disease. Little is known about practice patterns of anti-diabetic therapy in the presence of chronic kidney disease (CKD) and correlates with glycaemic control. We therefore aimed to analyze current antidiabetic treatment and correlates of metabolic control in a large contemporary prospective cohort of patients with diabetes and CKD.
Methods
The German Chronic Kidney Disease (GCKD) study enrolled 5217 patients aged 18–74 years with an estimated glomerular filtration rate (eGFR) between 30–60 mL/min/1.73 m2 or proteinuria >0.5 g/d. The use of diet prescription, oral anti-diabetic medication, and insulin was assessed at baseline. HbA1c, measured centrally, was the main outcome measure.
Results
At baseline, DM was present in 1842 patients (35 %) and the median HbA1C was 7.0 % (25th–75th percentile: 6.8–7.9 %), equalling 53 mmol/mol (51, 63); 24.2 % of patients received dietary treatment only, 25.5 % oral antidiabetic drugs but not insulin, 8.4 % oral antidiabetic drugs with insulin, and 41.8 % insulin alone. Metformin was used by 18.8 %. Factors associated with an HbA1C level >7.0 % (53 mmol/mol) were higher BMI (OR = 1.04 per increase of 1 kg/m2, 95 % CI 1.02–1.06), hemoglobin (OR = 1.11 per increase of 1 g/dL, 95 % CI 1.04–1.18), treatment with insulin alone (OR = 5.63, 95 % CI 4.26–7.45) or in combination with oral antidiabetic agents (OR = 4.23, 95 % CI 2.77–6.46) but not monotherapy with metformin, DPP-4 inhibitors, or glinides.
Conclusions
Within the GCKD cohort of patients with CKD stage 3 or overt proteinuria, antidiabetic treatment patterns were highly variable with a remarkably high proportion of more than 50 % receiving insulin-based therapies. Metabolic control was overall satisfactory, but insulin use was associated with higher HbA1C levels.
Background
Reliable central venous access (CVC) is essential for hematology–oncology patients since frequent puncture of peripheral veins—e.g., for chemotherapy, antibiotic administration, repeated blood sampling, and monitoring—can cause unacceptable pain and psychological trauma, as well as severe side effects in cases of extravasation of chemotherapy drugs. However, CVC lines still carry major risk factors, including thrombosis, infection (e.g., entry site, tunnel, and luminal infections), and catheter dislocation, leakage, or breakage.
Methods
Here we performed a retrospective database analysis to determine the incidence of CVC-associated thrombosis in a single-center cohort of 448 pediatric oncologic patients, and to analyze whether any subgroup of patients was at increased risk and thus might benefit from prophylactic anticoagulation.
Results
Of the 448 patients, 269 consecutive patients received a CVC, and 55 of these 269 patients (20%) also had a thrombosis. Of these 55 patients, 43 had at least one CVC-associated thrombosis (total number of CVC-associated thrombosis: n = 52). Among all patients, the median duration of CVC exposure was 464 days. Regarding exposure time, no significant difference was found between patients with and without CVC-associated thrombosis. Subclavia catheters and advanced tumor stages seem to be the main risk factors for the development of CVC-associated thrombosis, whereas pharmacologic prophylaxis did not seem to have a relevant impact on the rate of thrombosis.
Conclusions
We conclude that pediatric surgeons and oncologists should pay close attention to ensuring optimal and accurate CVC placement, as this appears the most effective tool to minimize CVC-associated complications.
Quantenchemische Untersuchungen von Umgebungseinflüssen bei offen- und geschlossenschaligen Systemen
(2022)
In dieser Dissertation werden die Umgebungseinflüsse auf die strukturellen und elektronischen Eigenschaften von verschiedenen offen- und geschlossenschaligen Systemen mittels quantenchemischer Methoden berechnet.
Ein Kernpunkt umfasst die Untersuchung von verdreht angeordneten, biradikalischen Diborylalkenen, welche eine ungesättigte C2R2-Brücke (R = Et, Me) besitzen und durch cyclische (Alkyl)(amino)carbene (CAACs) stabilisiert werden. Quantenchemische Berechnungen zeigen, dass hauptsächlich sterische Effekte für die Ausbildung einer verdrehten Molekülanordnung verantwortlich sind, während bei geringen sterischen Wechselwirkungen (R = H) die Delokalisationseffekte überwiegen, wodurch eine planare Struktur begünstigt wird. Die Bevorzugung einer offenschaligen Singulettkonfiguration anstelle eines Tripletts ist auf den großen Energieunterschied der beiden einfach besetzten Molekülorbitale zurückzuführen. Durch die Berechnung der Lösungsmitteleffekte mithilfe von polarisierbaren Kontinuumsmodellen kann gefolgert werden, dass mit zunehmender statischer Dielektrizitätskonstante eine planare und geschlossenschalige Struktur stärker stabilisiert wird als eine verdrehte Anordnung.
Ein weiteres Thema dieser Dissertation befasst sich mit der quantenchemischen Analyse eines makrozyklischen Perylenbisimid-Trimersystems, welches eingebettet in einer Polymethylmethacrylat-Matrix bei Temperaturen nahe dem absoluten Nullpunkt eine Lokalisierung der ersten drei angeregten Zustände zeigt. Quantenchemische Vakuumberechnungen ergeben, dass unabhängig von der gegenseitigen geometrischen Orientierung der drei Perylenbisimid-Chromophore der Übergang vom Grundzustand in den S1-Zustand verboten ist und dass die ersten drei angeregten Zustände delokalisiert vorliegen. Mithilfe von expliziten Lösungsmittelmodellen kann jedoch gezeigt werden, dass das Auftreten dieser Lokalisierungen auf eine inhomogene Polymethylmethacrylat-Umgebung zurückzuführen ist, die zu einem Symmetriebruch und somit zu einer Zunahme der Oszillatorstärke für S1 und der Lokalisierungsgrade für S1, S2 und S3 führt.
Darüber hinaus wird der Lösungsmitteleinfluss auf die angeregten Zustände des Azulens mittels impliziter und expliziter Lösungsmittelmodelle berechnet. Bei einer Erhöhung der dynamischen Dielektrizitätskonstante im impliziten Modell nehmen die Anregungsenergien der vertikalen Singulettzustände ab, wobei der Effekt mit steigender Oszillatorstärke zunimmt. Die Auswirkung der statischen Dielektrizitätskonstante auf die Anregungsenergien ist dagegen deutlich schwächer ausgeprägt. Im expliziten Modell bewirkt das Lösungsmittel ebenfalls eine Abnahme der Anregungsenergie des hellen Singulettzustands, wenn auch in geringerem Umfang als im impliziten Modell.
Als letztes Thema wird der Inhibitionsmechanismus der Cysteinprotease Rhodesain durch zwei modifizierte 1,4-Naphthoquinone untersucht. Während beide Naphthoquinone an der 2-Position eine Dipeptideinheit aufweisen, besitzen sie an der 3-Position entweder einen Nitril- oder Chloridsubstituenten. Zwar erfolgt bei beiden Derivaten die Inhibition über einen kovalent-reversiblen Mechanismus, jedoch verläuft die Hemmung im Falle des Nitrilderivats erheblich effektiver. Die quantenchemischen Berechnungen eines vereinfachten Modells zeigen, dass die Cysteineinheit (HS-R) bevorzugt in einer exothermen und reversiblen Additionsreaktion an die elektronenarme C-C-Doppelbindung der Naphthoquinone anlagert. Dabei werden kleinere Reaktionsenergien für die Reaktion des Chlorderivats als für die Reaktion des Nitrilderivats erhalten. Durch die Berücksichtigung von Wasser in einem impliziten Lösungsmittelmodell kommt es bei fast allen Reaktionsprodukten zu einer Energiezunahme, die bei der Reaktion des Nitrilderivats stärker ausfällt als bei der Reaktion des Chlorderivats.
Background: Although cardiovascular rehabilitation (CR) is well accepted in general, CR-attendance and delivery still considerably vary between the European countries. Moreover, clinical and prognostic effects of CR are not well established for a variety of cardiovascular diseases. Methods: The guidelines address all aspects of CR including indications, contents and delivery. By processing the guidelines, every step was externally supervised and moderated by independent members of the “Association of the Scientific Medical Societies in Germany” (AWMF). Four meta-analyses were performed to evaluate the prognostic effect of CR after acute coronary syndrome (ACS), after coronary bypass grafting (CABG), in patients with severe chronic systolic heart failure (HFrEF), and to define the effect of psychological interventions during CR. All other indications for CR-delivery were based on a predefined semi-structured literature search and recommendations were established by a formal consenting process including all medical societies involved in guideline generation. Results: Multidisciplinary CR is associated with a significant reduction in all-cause mortality in patients after ACS and after CABG, whereas HFrEF-patients (left ventricular ejection fraction <40%) especially benefit in terms of exercise capacity and health-related quality of life. Patients with other cardiovascular diseases also benefit from CR-participation, but the scientific evidence is less clear. There is increasing evidence that the beneficial effect of CR strongly depends on “treatment intensity” including medical supervision, treatment of cardiovascular risk factors, information and education, and a minimum of individually adapted exercise volume. Additional psychologic interventions should be performed on the basis of individual needs. Conclusions: These guidelines reinforce the substantial benefit of CR in specific clinical indications, but also describe remaining deficits in CR-delivery in clinical practice as well as in CR-science with respect to methodology and presentation.
Background
Data on the routine use of video-assisted laryngoscopy in peri-operative intubations are rather inconsistent and ambiguous, in part due to small populations and non-uniform outcome measures in past trials. Failed or prolonged intubation procedures are a reason for relevant morbidity and mortality. This study aims to determine whether video-assisted laryngoscopy (with both Macintosh-shaped and hyperangulated blades) is at least equal to the standard method of direct laryngoscopy with respect to the first-pass success rate. Furthermore, validated tools from the field of human factors will be applied to examine within-team communication and task load during this critical medical procedure.
Methods
In this randomized, controlled, three-armed parallel group design, multi-centre trial, a total of more than 2500 adult patients scheduled for perioperative endotracheal intubation will be randomized. In equally large arms, video-assisted laryngoscopy with a Macintosh-shaped or a hyperangulated blade will be compared to the standard of care (direct laryngoscopy with Macintosh blade). In a pre-defined hierarchical analysis, we will test the primary outcome for non-inferiority first. If this goal should be met, the design and projected statistical power also allow for subsequent testing for superiority of one of the interventions.
Various secondary outcomes will account for patient safety considerations as well as human factors interactions within the provider team and will allow for further exploratory data analysis and hypothesis generation.
Discussion
This randomized controlled trial will provide a solid base of data in a field where reliable evidence is of major clinical importance. With thousands of endotracheal intubations performed every day in operating rooms around the world, every bit of performance improvement translates into increased patient safety and comfort and may eventually prevent significant burden of disease. Therefore, we feel confident that a large trial has the potential to considerably benefit patients and anaesthetists alike.
Trial registration
ClincalTrials.gov NCT05228288.
Protocol version
1.1, November 15, 2021.
Atypical teratoid rhabdoid tumors (AT/RT) are characterized by mutations and subsequent inactivation of SMARCB1 (INI1, hSNF5), a predilection for very young children and an unfavorable outcome. The European Registry for rhabdoid tumors (EU‐RHAB) was established to generate a common European database and to establish a standardized treatment regimen as the basis for phase I/II trials. Thus, genetic analyses, neuropathologic and radiologic diagnoses, and a consensus treatment regimen were prospectively evaluated. From 2005 to 2009, 31 patients with AT/RT from four countries were recruited into the registry study Rhabdoid 2007 and treated with systemic and intraventricular chemotherapy. Eight patients received high‐dose chemotherapy, 23 radiotherapy, and 17 maintenance therapy. Reference evaluations were performed in 64% (genetic analyses, FISH, MLPA, sequencing) up to 97% (neuropathology, INI1 stain). Germ‐line mutations (GLM) were detected in 6/21 patients. Prolonged overall survival was associated with age above 3 years, radiotherapy and achievement of a complete remission. 6‐year overall and event‐free survival rates were 46% (±0.10) and 45% (±0.09), respectively. Serious adverse events and one treatment‐related death due to insufficiency of a ventriculo peritoneal shunt (VP‐shunt) and consecutive herniation were noted. Acquisition of standardized data including reference diagnosis and a standard treatment schedule improved data quality along with a survival benefit. Treatment was feasible with significant but manageable toxicity. Although our analysis is biased due to heterogeneous adherence to therapy, EU‐RHAB provides the best available basis for phase I/II clinical trials.
cAAC‐Stabilized 9,10‐diboraanthracenes—Acenes with Open‐Shell Singlet Biradical Ground States
(2020)
Narrow HOMO–LUMO gaps and high charge‐carrier mobilities make larger acenes potentially high‐efficient materials for organic electronic applications. The performance of such molecules was shown to significantly increase with increasing number of fused benzene rings. Bulk quantities, however, can only be obtained reliably for acenes up to heptacene. Theoretically, (oligo)acenes and (poly)acenes are predicted to have open‐shell singlet biradical and polyradical ground states, respectively, for which experimental evidence is still scarce. We have now been able to dramatically lower the HOMO–LUMO gap of acenes without the necessity of unfavorable elongation of their conjugated π system, by incorporating two boron atoms into the anthracene skeleton. Stabilizing the boron centers with cyclic (alkyl)(amino)carbenes gives neutral 9,10‐diboraanthracenes, which are shown to feature disjointed, open‐shell singlet biradical ground states.
The facile synthesis and detailed investigation of a class of highly potent protease inhibitors based on 1,4-naphthoquinones with a dipeptidic recognition motif (HN-l-Phe-l-Leu-OR) in the 2-position and an electron-withdrawing group (EWG) in the 3-position is presented. One of the compound representatives, namely the acid with EWG = CN and with R = H proved to be a highly potent rhodesain inhibitor with nanomolar affinity. The respective benzyl ester (R = Bn) was found to be hydrolyzed by the target enzyme itself yielding the free acid. Detailed kinetic and mass spectrometry studies revealed a reversible covalent binding mode. Theoretical calculations with different density functionals (DFT) as well as wavefunction-based approaches were performed to elucidate the mode of action.
Geringe HOMO-LUMO-Abstände und eine hohe Ladungsträgermobilität prädestinieren die höheren Acene für Anwendungen im Bereich der Organoelektronik. Die Leistungsfähigkeit derartiger Verbindungen steigt hierbei dramatisch mit der Anzahl anellierter Benzolringe. Größere Acenmengen sind synthetisch bisher jedoch nur für Acene bis Heptacen verlässlich zugänglich. Theoretischen Studien zufolge besitzen (Oligo)acene offenschalige Singulettbiradikal- und (Poly)acene polyradikalische Grundzustände. Eindeutige experimentelle Belege für diese Vorhersagen sind hingegen äußerst selten. Durch den Einbau von zwei Boratomen in das Anthracengrundgerüst konnten wir den HOMO-LUMO-Abstand von Acenen dramatisch verringern und zwar ohne die Notwendigkeit einer Ausweitung des konjugierten π-Systems. Stabilisierung der Borzentren durch cyclische (Alkyl)(amino)carbene lieferte hierbei neutrale 9,10-Diboraanthracene mit disjunkten, offenschaligen Singulettbiradikal-Grundzuständen.
Background: Scientific guidelines have been developed to update and harmonize exercise based cardiac rehabilitation (ebCR) in German speaking countries. Key recommendations for ebCR indications have recently been published in part 1 of this journal. The present part 2 updates the evidence with respect to contents and delivery of ebCR in clinical practice, focusing on exercise training (ET), psychological interventions (PI), patient education (PE). In addition, special patients' groups and new developments, such as telemedical (Tele) or home-based ebCR, are discussed as well. Methods: Generation of evidence and search of literature have been described in part 1. Results: Well documented evidence confirms the prognostic significance of ET in patients with coronary artery disease. Positive clinical effects of ET are described in patients with congestive heart failure, heart valve surgery or intervention, adults with congenital heart disease, and peripheral arterial disease. Specific recommendations for risk stratification and adequate exercise prescription for continuous-, interval-, and strength training are given in detail. PI when added to ebCR did not show significant positive effects in general. There was a positive trend towards reduction in depressive symptoms for “distress management” and “lifestyle changes”. PE is able to increase patients’ knowledge and motivation, as well as behavior changes, regarding physical activity, dietary habits, and smoking cessation. The evidence for distinct ebCR programs in special patients’ groups is less clear. Studies on Tele-CR predominantly included low-risk patients. Hence, it is questionable, whether clinical results derived from studies in conventional ebCR may be transferred to Tele-CR. Conclusions: ET is the cornerstone of ebCR. Additional PI should be included, adjusted to the needs of the individual patient. PE is able to promote patients self-management, empowerment, and motivation. Diversity-sensitive structures should be established to interact with the needs of special patient groups and gender issues. Tele-CR should be further investigated as a valuable tool to implement ebCR more widely and effectively.