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Biomedical subjects

R Stocker

Publications and source records attributed to R Stocker.

At least 19 recordsLinked to original sources

Hypocretin-1 (orexin A) deficiency in acute traumatic brain injury.

Hypocretin-1 is involved in the regulation of the sleep-wake cycle. The authors prospectively assessed CSF hypocretin-1 levels in 44 consecutive patients with acute traumatic brain injury (TBI). Compared with controls, hypocretin-1 levels were abnormally lower in 95% of patients with moderate to severe TBI and in 97% of patients with posttraumatic brain CT changes. Hypocretin-1 deficiency after TBI may reflect hypothalamic damage and be linked with the frequent development of posttraumatic sleep-wake disorders.

Adolescent↗

Inhibition of lipoprotein lipid oxidation.

According to the oxidative modification hypothesis, antioxidants that inhibit the oxidation of low-density lipoprotein (LDL) are expected to attenuate atherosclerosis, yet not all antioxidants that inhibit LDL oxidation in vitro inhibit disease in animal models of atherosclerosis. As with animal studies, a benefit with dietary supplements of antioxidants in general and vitamin E in particular was anticipated in humans, yet the overall outcome of large, randomized controlled studies has been disappointing. However, in recent years it has become clear that the role of vitamin E in LDL oxidation and the relationship between in vitro and in vivo inhibition of LDL oxidation are more complex than previously appreciated, and that oxidative events in addition to LDL oxidation in the extracellular space need to be considered in the context of an antioxidant as a therapeutic drug against atherosclerosis. This review focuses on some of these complexities, proposes a novel method to assess in vitro 'oxidizability' of lipoprotein lipids, and summarizes the present situation of development of antioxidant compounds as drugs against atherosclerosis and related cardiovascular disorders.

Animals↗

New insights on oxidative stress in the artery wall.

Atherosclerosis and its resultant cardiovascular events represent a state of heightened oxidative stress that is commonly thought to contribute to atherogenesis. The aim of this review is to summarize the data linking oxidative events to the pathogenesis of atherosclerosis. Despite abundant data supporting the presence of lipid and protein oxidation in the vascular wall, the poor performance of antioxidant strategies in limiting either atherosclerosis or cardiovascular events from atherosclerosis remain a fundamental problem for implicating oxidative stress as pathophysiologically important. Direct evidence that oxidative stress in general, and the oxidative modification of low-density lipoprotein in particular, is both necessary and sufficient for atherosclerosis has been difficult to find. There are many potential reasons for this difficulty, not the least of which is our lack of sufficient knowledge delineating the precise molecular events that beget oxidative stress in the vessel wall, and the precise mediators involved. Further investigation elucidating these oxidative events are required to provide us with the tools to limit oxidative stress at its source and ameliorate all of its secondary phenomena. Only then will we know what components of atherosclerosis are directly due to oxidative stress.

Animals↗

Burden of illness imposed by severe sepsis in Switzerland.

OBJECTIVE: This study aims to determine the burden of illness imposed by severe sepsis in Switzerland by evaluating the direct and indirect patient-related costs for critically ill patients with severe sepsis. METHODS: In order to estimate the direct costs a retrospective analysis was undertaken using records from 61 adult patients treated in three intensive care units (ICUs) in three different University hospitals in Switzerland, in 2001. Resource use was determined by a bottom up approach and valued using centre-specific unit costs for medication, nutrition, blood products, disposables and official tariffs for laboratory and microbiology analysis, diagnostic services, and clinical procedures. By adding centre-specific personnel and basic bed (hotel) costs total direct costs in the ICU were calculated. Indirect costs resulting from unfitness for work, early retirement, and premature death were calculated using official Swiss statistics for the years 1998-2000. RESULTS: The mean total direct costs for a severely septic patient are CHF 41,790 (+/- 33,222 CHF) or CHF 3244 (+/- 757 CHF) per day. Nonsurvivors cause significantly higher costs than survivors (CHF 45,956 vs. CHF 37,759, p <0.001). The total intensive care costs in Switzerland due to severe sepsis amount to CHF 146-355 million. Indirect costs were estimated to range from CHF 347 to 844 million (predominantly due to premature death). Consequently the burden of illness of severe sepsis can be estimated to range from CHF 493 to 1199 million per year in Switzerland (1 CHF = 0.662 Euro in 2001). CONCLUSION: Patients suffering from severe sepsis in Switzerland have a high mortality rate and spend a prolonged time in the ICU, leading to high direct and indirect costs. Particularly productivity losses due to premature death represent a considerable burden to the Swiss society.

Adolescent↗

Lipid oxidation in atherogenesis: an overview.

The 'oxidation theory' for atherosclerosis proposes that lipid and/or protein oxidation products are responsible for lesion formation/development. The major target for oxidation is suggested to be intimal low-density lipoprotein. This idea was stimulated by the pro-atherogenic properties of in vitro oxidized lipoproteins, such as stimulation of chemotaxis and sterol accumulation in macrophages, adhesion molecule expression on endothelial cells and apoptosis of several cell types. It was supported by detection of oxidation products in lesion lipoproteins, although these are (in general) less heavily oxidized and their biological activity is less rigorously defined than for their in vitro oxidized counterparts. Lesion lipids contain products generated by both enzymic and non-enzymic oxidation reactions; the majority are generated non-enzymically. The type and source of oxidant involved has been the subject of much speculation and is not resolved. The oxidation theory predicts that appropriate antioxidants will protect against atherosclerosis. Vitamin E has been used in several animal and human studies, but to date has shown little evidence of anti-atherosclerotic potential. However, lack of knowledge of the oxidant(s) driving lesion oxidation and the complexity of the anti- and pro-oxidant properties of vitamin E may explain its disappointing track record to date. These subjects require more rigorous study before the oxidation theory can be fairly tested.

Animals↗

Extubation after breathing trials with automatic tube compensation, T-tube, or pressure support ventilation.

BACKGROUND: Automatic tube compensation (ATC) is a new option to compensate for the pressure drop across the endotracheal or tracheostomy tube (ETT), especially during ventilator-assisted spontaneous breathing. While several benefits of this mode have so far been documented, ATC has not yet been used to predict whether the ETT could be safely removed at the end of weaning, from mechanical ventilation. METHODS: We undertook a systematic trial using a randomized block design. During a 2-year period, all eligible patients of a medical intensive care unit were treated with ATC, conventional pressure support ventilation (PSV, 5 cmH2O), or T-tube for 2-h. Tolerance of the breathing trial served as a basis for the decision to remove the endotracheal tube. Extubation failure was considered if reintubation was necessary or if the patient required non-invasive ventilatory assistance (both within 48 h). RESULTS AND CONCLUSIONS: After the inclusion of 90 patients (30 per group) we did not observe significant differences between the modes. Twelve patients failed the initial weaning trial. However, half of the patients who appeared to fail the spontaneous breathing trial on the T-tube, PSV, or both, were successfully extubated after a succeeding trial with ATC. Extubation was thus withheld from four and three of these patients while breathing with PSV or the T-tube, respectively, but to any patient breathing with ATC. It seems that ATC can be used as an alternative mode during the final phase of weaning from mechanical ventilation. Furthermore, this study may promote a larger multicenter trial on weaning with ATC compared with standard modes.

Device Removal↗

First clinical experience with Molecular Adsorbent Recirculating System (MARS) in six patients with severe acute on chronic liver failure.

UNLABELLED: Despite recent advances in general supportive care, the mortality rate of patients with severe liver insufficiency remains high. Recently a new artificial liver support system MARS has been used for selective removal of albumin-bound toxins. AIM: To assess the safety and efficacy of MARS treatment in patients with acute on chronic liver disease (n = 5) or liver failure after extended hepatic resection (n = 1). DESIGN/PATIENTS: Six patients, aged 34-58 years, with severe liver insufficiency (mean MELD-score 31 (range 24-35)) were treated one to 16 times with the MARS system. At baseline three patients were intubated, three were encephalopathic (HE) and three had multifactorial kidney failure requiring kidney replacement therapy. RESULTS AND CONCLUSION: In all the patients MARS treatment significantly reduced the serum bilirubin levels. In three patients encephalopathy improved. In two patients the extracorporeal treatment precipitated a disseminated intravascular coagulation with clinically significant bleeding. Bridging to liver transplantation was possible in one patient, the other five patients died 30 days (2-74 days) after starting MARS therapy. Our case series shows that MARS treatment in general can be safely performed in patients with severe liver disease. However, in patients with an activated clotting system severe bleeding complication can be triggered and MARS treatment should be used very cautiously in these situations. MARS seems to be a promising new treatment option for patients with acute on chronic liver failure. However, carefully conducted randomized controlled trials are necessary to define its potential place in the treatment of patients with severe liver disease.

Acute Disease↗

Late oesophageal perforation after intraoperative transoesophageal echocardiography.

Serious haemodynamic instability occurred during emergency surgery for a perforated duodenal ulcer in a 72-year-old man with acute myocardial infarction. Intraoperative transoesophageal echocardiography was crucial for diagnosis of the location of myocardial infarction in the right ventricle and the subsequent haemodynamic management. Postoperatively, a thrombus in the right coronary artery was removed by coronary angiography. The patient's trachea was extubated on the fourth postoperative day. Another 4 days later a leak in the lower oesophagus was suspected because of pleural empyema, and verified. The patient's trachea had to be re-intubated and an oesophageal stent was inserted. The patient was discharged, fully recovered, 2 months after the operation.

Aged↗

Correlation between intima-to-media ratio, apolipoprotein B-100, myeloperoxidase, and hypochlorite-oxidized proteins in human atherosclerosis.

The oxidative modification of low-density lipoprotein (LDL) is thought to contribute to atherogenesis, and there is evidence that oxidants derived from myeloperoxidase (MPO) contribute to such oxidative damage. Using human iliac arteries we investigated the relationship between lesion stage indicated by the intima-to-media (I/M) ratio and the presence of apolipoprotein B-100 (apoB, a marker for LDL), MPO, and hypochlorite (HOCl)-oxidized proteins identified by immunohistochemistry in the intima, media, and adventitia. More staining for apoB, MPO, and HOCl-oxidized proteins was observed in diseased than healthy vessels. Diseased segments also stained more for the three parameters than healthy segments in the same diseased vessel, highlighting the variability that can occur within a single cross-section of a vessel. However, significant positive correlation between I/M ratio and positive staining for apoB, MPO, and HOCl-oxidized proteins in different segments of individual arteries were apparent in segments with an I/M ratio of > 1.8. Also, the overall extent of intimal staining for apoB, MPO, and HOCl-oxidized proteins increased with increasing I/M ratio. In addition, the extent of apoB staining was greater and appeared at comparatively lower I/M ratios than that of MPO and HOCl-oxidized proteins. Our results support a contribution to atherogenesis of all three parameters assessed, although MPO and HOCl-oxidized proteins appear to participate in the disease process at a later stage than apoB.

Adult↗

Effect of vitamin E on aortic lipid oxidation and intimal proliferation after arterial injury in cholesterol-fed rabbits.

Oxidized low-density lipoproteins (LDL) are implicated in atherosclerosis. However, large-scale intervention studies designed to test whether antioxidants, such as vitamin E, can ameliorate cardiovascular disease have generated ambivalent results. This may relate to the fact that the mechanism whereby lipid oxidation is initiated in vivo is unknown and the lack of direct evidence for a deficiency of antioxidants in atherosclerotic lesions. Further, there is little evidence to suggest that vitamin E acts as an antioxidant for lipid peroxidation in vivo. Here we tested the antioxidant effect of dietary vitamin E (alpha-tocopherol) supplementation on intimal proliferation and lipid oxidation in balloon-injured, hypercholesterolemic rabbits. alpha-Tocopherol supplementation increased vascular content of alpha-tocopherol over 30-fold compared to nonsupplemented and alpha-tocopherol-deficient chows. Balloon injury resulted in oxidized lipid deposition in the aorta. Maximum levels of primary lipid oxidation products, measured as hydroperoxides of esterified lipid (LOOH) and oxidized linoleate (HODE), were 0.22 and 1.10 nmol/mg, representing 0.21 and 0.39% of the precursor molecule, respectively. Secondary lipid oxidation products, measured as oxysterols, were maximal at 5.60 nmol/mg or 1.48% of the precursor compound. Vascular HODE and oxysterols were significantly reduced by vitamin E supplementation. However, the intima/media ratio of aortic vessels increased with vitamin E supplementation, suggesting that the antioxidant promoted intimal proliferation. Thus, the study demonstrates a dissociation of aortic lipid oxidation and lesion development, and suggests that vitamin E does not prevent lesion development in this animal model.

Angioplasty, Balloon↗

ATP-binding cassette transporter A1 mediates cellular secretion of alpha-tocopherol.

Alpha-tocopherol (alpha-TOH) is associated with plasma lipoproteins and accumulates in cell membranes throughout the body, suggesting that lipoproteins play a role in transporting alpha-TOH between tissues. Here we show that secretion of alpha-TOH from cultured cells is mediated in part by ABCA1, an ATP-binding cassette protein that transports cellular cholesterol and phospholipids to lipid-poor high density lipoprotein (HDL) apolipoproteins such as apoA-I. Treatment of human fibroblasts and murine RAW264 macrophages with cholesterol and/or 8-bromo-cyclic AMP, which induces ABCA1 expression, enhanced apoA-I-mediated alpha-TOH efflux. ApoA-I lacked the ability to remove alpha-TOH from Tangier disease fibroblasts that have a nonfunctional ABCA1. BHK cells that lack an active ABCA1 pathway markedly increased secretion of alpha-TOH to apoA-I when forced to express ABCA1. ABCA1 also mediated a fraction of the alpha-TOH efflux promoted by lipid-containing HDL particles, indicating that HDL promotes alpha-TOH efflux by both ABCA1-dependent and -independent processes. Exposing apoA-I to ABCA1-expressing cells did not enhance its ability to remove alpha-TOH from cells lacking ABCA1, consistent with this transporter participating directly in the translocation of alpha-TOH to apolipoproteins. These studies provide evidence that ABCA1 mediates secretion of cellular alpha-TOH into the HDL metabolic pathway, a process that may facilitate vitamin transport between tissues and influence lipid oxidation.

8-Bromo Cyclic Adenosine Monophosphate↗

Reaction of human myoglobin and peroxynitrite: characterizing biomarkers for myoglobin-derived oxidative stress.

Mixtures of human myoglobin (Mb) (or the Y103F variant of human Mb), authentic peroxynitrite (ONOO(-), ONOO(-):protein 2 mol/mol), and 5,5-dimethyl-1-pyrroline-N-oxide (DMPO) gave radicals adducts at cysteine-110 (DMPO-C110) that are detected directly by electron paramagnetic magnetic spectroscopy (EPR). DMPO-C110 was detected exclusively over a range of DMPO concentrations (DMPO:protein ratios 25-100 mol/mol). Treatment of human Mb (or Y103F Mb) with the ONOO(-) generator 5-amino-3-(4-morpholinyl)-1,2,3-oxadiazolium (SIN-1) chloride (ONOO(-):protein 5 mol/mol) yielded a cross-linked Mb dimer as judged by SDS-PAGE analyses. Addition of DMPO or carbonate effectively eliminated the cross-linked product. Mass analyses of samples containing human Mb (or Y103F Mb), carbonate, and ONOO(-) indicated that nitration occurs exclusively at Y103. Thus, reaction of human Mb and ONOO(-) yields specific products that depend on the presence or absence of physiological concentrations of carbonate. These products may serve as biomarkers for the participation of Mb-derived radicals in the oxidative damage associated with myocardial reperfusion injury.

Biomarkers↗

Antioxidants inhibit indoleamine 2,3-dioxygenase in IFN-gamma-activated human macrophages: posttranslational regulation by pyrrolidine dithiocarbamate.

Induction of the heme-containing indoleamine 2,3-dioxygenase (IDO) by IFN-gamma is implicated in anti-microbial and pro-inflammatory activities of human macrophages. Antioxidants can modulate the expression of immune and inflammatory genes, and pyrrolidine dithiocarbamate (PDTC) is a frequently used antioxidant to inhibit the transcription factor NF-kappaB. Here we show that IFN-gamma treatment of human monocyte-derived macrophages (hMDMs) increased the proportion of oxidized glutathione. PDTC attenuated this increase and inhibited IDO activity, although it increased IDO protein expression and did not affect IDO mRNA expression and enzyme activity directly. Other antioxidants, 2-ME, ebselen, and t-butyl hydroquinone, inhibited IDO protein expression. Similar to PDTC, the heme biosynthesis inhibitor succinylacetone (SA) and the iron-chelator pyridoxal isonicotinoyl hydrazone inhibited cellular IDO activity without affecting protein expression, whereas addition of hemin or the heme precursor delta-aminolevulinic acid increased IDO activity. Also, incubation of IFN-gamma-activated hMDM with delta-[(14)C]-aminolevulinic acid resulted in the incorporation of label into immunoprecipitated IDO, a process inhibited by PDTC and SA. Furthermore, supplementation of lysates from PDTC- or SA-treated hMDM with hemin fully restored IDO activity to control levels, and hemin also reversed the inhibitory action of SA but not PDTC in intact cells. Together these results establish a requirement for de novo heme synthesis for IDO activity in IFN-gamma-activated hMDM. They show that, similar to other pro-inflammatory proteins, the activity of IDO is modulated by antioxidants though in the case of PDTC this takes place posttranslationally, in part by limiting the availability of heme for the formation of holo-IDO.

Antioxidants↗

Improved results after lung transplantation--analysis of factors.

Better recipient selection, sophisticated postoperative surveillance and new immunosuppressive and anti-infective regimens can improve the results of lung transplantation. We compared the results of lung transplants performed between 1992 and 1996 (early period; 47) and between 1997 and 2000 (recent period; 46) in a cohort study to assess which factors influenced survival. Estimates of relative hazards were adjusted for possible confounding effects with the use of Cox regression analysis. Overall 2-year survival was 70%. Survival by this time was significantly better in the recent period (82% vs. 60%; p = 0.0093). Acute rejection episodes and death due to BOS were less frequent in the recent period. There were no technical failures, and the cumulative incidence of BOS was low (34% at 5 years). The beneficial effect of the transplantation date 1997 or later at a hazard ratio of 0.33 (95% CI, 0.13-0.84) was materially changed only by the adjustment for ganciclovir prophylaxis (0.50; 95% CI, 0.09-2.91) and immunosuppression with mycophenolate mofetil (0.80; 95% CI, 0.27-2.36). After adjustment for both ganciclovir and mycophenolate mofetil, the beneficial time period effect was completely removed (1.24; 95% CI, 0.14-11.39). Immunosuppressive therapy with mycophenolate mofetil and use of ganciclovir prophylaxis in addition to careful postoperative surveillance and surgical expertise can lead to improved results after lung transplantation.

Adolescent↗

Relative reactivities of N-chloramines and hypochlorous acid with human plasma constituents.

Hypochlorous acid (HOCl), the major strong oxidant produced by the phagocyte enzyme myeloperoxidase, reacts readily with free amino groups to form N-chloramines. Since different N-chloramines have different stabilities and reactivities depending on their structures, we investigated the relative reactivities of three model N-chloramines and HOCl with human plasma constituents. TheN-chloramines studied were N(alpha)-acetyl-lysine chloramine (LysCA, a model of protein-associated N-chloramines), taurine chloramine (TaurCA, the primary N-chloramine produced by activated neutrophils), and monochloramine (MonoCA, a lipophilic N-chloramine). Addition of these chlorine species (100--1000 microM each) to plasma resulted in rapid loss of thiols, with the extent of thiol oxidation decreasing in the order TaurCA = LysCA > MonoCA = HOCl. The single reduced thiol of albumin was the major target. Loss of plasma ascorbate also occurred, with the extent decreasing in the order HOCl > LysCA > TaurCA > MonoCA. Experiments comparing equimolar albumin thiols and ascorbate showed that while HOCl caused equivalent loss of thiols and ascorbate, theN-chloramines reacted preferentially with thiols. The chlorine species also inactivated alpha(1)-antiproteinase, implicating oxidation of methionine residues, and ascorbate provided variable protection depending on the chlorine species involved. Together, our data indicate that in biological fluids N-chloramines react more readily with protein thiols than with methionine residues or ascorbate, and thus may cause biologically relevant, selective loss of thiol groups.

Ascorbic Acid↗

[Automatic tube compensation (ATC)].

The endotracheal tube (ETT) is a considerably flow-dependent and, therefore, variable mechanical load. Conventional modes of respiratory support cannot adequately compensate for the tube resistance in inspiratorion and not at all in expiration. Automatic tube compensation (ATC) compensates for the flow-dependent pressure drop across the tracheal tube by a positive pressure support in inspiration and by a negative pressure support in expiration. The pressure support closely follows the nonlinear pressure-flow curve of the ETT. Automatic tube compensation has an indirect closed-loop working principle since the target tracheal pressure is not directly measured but rather calculated from continuously measured airway pressure and flow rate. It is not an own ventilatory mode but rather a component of flow-proportional pressure support which can be combined with all conventional ventilatory modes, and provides a rational basis for subdividing the pressure support to overcome the mechanical load of the tubing and to overcome that of the respiratory system. Partial tube obstructions, which could decrease the effectivity of ATC, could be detected automatically by analysing the expiratory flow signal using a software, which could be easily implemented into the ventilator. The effectivity of ATC during long-term application can be maintained by intermittent short-term measurement of the tracheal pressure. Up to now there is no commercially available ventilator which allows complete expiratory ATC. Studies in volunteers and in mechanically ventilated patients have convincingly shown that ATC reduces work of breathing and increases respiratory comfort. In addition, successful extubation could be better predicted with this mode in difficult-to-wean patients compared to other modes. There are no special rules in the clinical application of ATC. However, to prevent overassist the support level of the ventilatory mode which is combined with ATC should be reduced.

Algorithms↗

[Experiences with using a potentially temporary vena cava filter in multiple trauma patients].

INTRODUCTION: In Europe, there is little experience in the application of temporary cava filters in patients with multiple injuries. Especially patients with pelvic injuries, fractures of the spine, and the lower extremities are at high risk for thromboembolic events like thrombosis or pulmonary emboli. Moreover, in patients with severe head injuries, anticoagulation is contraindicated. METHOD: We present in this paper our experience with 24 consecutive patients with multiple injuries who were treated with a temporary cava filter. The insertion site was either the femoral (n = 20) or the jugular (n = 4) vein. The 24 patients revealed a mean ISS of 35.1 +/- 2.01 points. Nineteen patients had pelvic injuries and 17 patients suffered from severe head injury. In 17 patients the insertion of the filter was prophylactic, in 4 patients a thrombosis was present and in 3 patients a non-fatal pulmonary emboli was diagnosed before the application of a cava filter. RESULTS: No complication occurred due to insertion of the filter. In one patient a thrombosis of the cava was observed as the only overall complication (1 of 24 = 4.2%). CONCLUSION: The insertion of a cava filter in patients with multiple injuries with contraindication for anticoagulation is a safe and effective procedure to prevent fatal pulmonary emboli.

Adult↗