Objective: Volumetric visceral abdominal adipose tissue (VAT) and subcutaneous abdominal adipose tissue (SAT) as measured by computed tomography (CT) are associated with metabolic risk factors. We ...sought to identify the correlations of VAT and SAT between area-based measures at different anatomic locations with volumetric measurements to identify the optimal anatomic site, and to relate measurements at this site with metabolic risk factors. Methods: We measured SAT and VAT volumes across the total imaging volume, whereas we measured SAT and VAT area at seven predefined anatomic landmarks in 200 participants from the Framingham Heart Study (mean age 54 years, 50% women) who underwent abdominal multi-detector CT. Correlation coefficients were used to assess the association between area measurements and volumes as well as metabolic risk factors stratified by gender. Results: Area-based measurements of SAT and VAT obtained at all anatomic landmarks were strongly associated with SAT and VAT volumes (all r>0.93, P<0.0001 and r>0.87, P<0.0001, for women and men; respectively). Consistently, area-based measurements of SAT and VAT obtained at L3/4 were most strongly associated with volumetric measured VAT and SAT independent of age (both r=0.99 in men, r=0.96 for SAT and r=0.99 for VAT in women, all P-value <0.0001) and were similarly correlated with risk factors compared with SAT and VAT volumes (all P<0.05 for fasting plasma glucose, triglycerides, high-density lipoprotein, systolic blood pressure). Conclusion: Among area-based measurements of SAT and VAT, those obtained at the level of L3/4 were strongly associated with SAT and VAT volumes and cardio-metabolic risk factors in both men and women.
The American Society of Anesthesiologists classification of physical status (ASA PS) is a widely used system for categorizing the preoperative status of patients. The ASA class is a good independent ...predictor of perioperative morbidity and mortality. The definitions of the ASA classes have been amended several times since 1941, resulting in inconsistent and confusing usage in the current literature. Conflicting definitions of ASA PS exist, particularly for classes III, IV and V. The high variability of individual classifications by different anesthesiologist, however, can be explained by the previous lack of examples for diagnoses. In 2014, the ASA has added a catalogue of examples for a simplified definition for classification of the ASA PS. This has so far received limited attention in German-speaking countries. This article describes the transition of the ASA classification over the past 75 years und summarizes the currently valid definitions.
Obesity leads to better survival in critically ill patients. Although there are several studies confirming this thesis, the "obesity paradox" is still surprising from the clinician's perspective. One ...explanation for the "obesity paradox" is the fact that the body mass index (BMI), which is used in almost all clinical evaluations to determine weight categories, is not an appropriate measure of fat and skeletal muscle mass and its distribution in critically ill patients. In addition, height and weight are frequently estimated rather than measured. Central obesity has been identified in many disorders as an independent risk factor for an unfavourable outcome. The first clues are to be found in intensive care. Along with obesity, an individual's entire muscle mass is a variable that has an influence on outcome. Central obesity can be measured relatively easily with an abdominal calliper, but the calculation of muscle mass is more complex. A valid and detailed measurement of this can be obtained using computed tomography (CT) images, acquired during routine care. For future clinical observation or interventional studies, single cross-sectional CT is a more sophisticated tool for measuring patients' anthropometry than a measuring tape and callipers. Patients with sarcopenic obesity, for example, who may be at a particular risk, can only be identified using imaging procedures such as single cross-sectional CT. Thus, BMI should take a back seat as an anthropometric tool, both in the clinic and in research.
ASA-Klassifikation Irlbeck, T.; Zwißler, B.; Bauer, A.
Der Anaesthesist,
2017/1, Volume:
66, Issue:
1
Journal Article
Zusammenfassung
Die Klassifikation der American Society of Anesthesiologists (ASA-Klassifikation) ist eine flächendeckend angewandte Kategorisierung des präoperativen Status von Patienten. Sie hat ...einen guten prädiktiven Wert bezüglich der perioperativen Morbidität und Letalität. Die Definitionen der ASA-Klassen wurden seit 1941 mehrfach verändert. In der aktuellen Literatur wird die aktuell gültige Klassifikation jedoch nicht einheitlich zitiert. Hierbei existieren insbesondere bei den ASA-Klassen 3, 4 und 5 konkurrierende Definitionen. Die hohe Variabilität der individuellen Eingruppierung durch unterschiedliche Anästhesisten ist aber auch durch bisher fehlende Beispieldiagnosen zu erklären. Seit 2014 wird von der ASA ein Beispielkatalog für Diagnosen zur vereinfachten Klassifikation vorgehalten. Dieser hat bisher im deutschsprachigen Raum nur begrenzt Aufmerksamkeit gefunden. Der vorliegende Beitrag beschreibt den Wandel der ASA-Klassifikation über die letzten fast 75 Jahre und fasst die aktuell gültige Definition zusammen.
Jenseits des BMI Weig, T.; Irlbeck, T.; Frey, L. ...
Der Anaesthesist,
09/2016, Volume:
65, Issue:
9
Journal Article
Zusammenfassung
Adipositas führt zu einem besseren Überleben bei kritisch kranken Patienten. Diese in zahlreichen Untersuchungen nachgewiesene und für den Kliniker doch überraschende Beobachtung wird ...als „obesity paradox“ beschrieben. Ein Teil des „obesity paradox“ beruht auf der Tatsache, dass der Body Mass Index (BMI), welcher in nahezu allen klinischen Untersuchungen zur Einteilung der Gewichtsklassen verwendet wird, kein ausreichend geeignetes Instrument ist, um die Körperkonstitution mit Fett- und Muskelverteilung kritisch kranker Patienten zu beschreiben. Zusätzlich beruht er auf den meist nicht gemessenen, sondern geschätzten Parametern Körpergröße und -gewicht. Die abdominelle Adipositas konnte bei zahlreichen Krankheitsbildern als unabhängiger Risikofaktor für ein schlechteres Outcome identifiziert werden. In der Intensivmedizin gibt es dafür erste Hinweise. Neben der Adipositas ist die Gesamtmuskelmasse eines Menschen eine das Outcome beeinflussende Variable. Die abdominelle Adipositas kann relativ einfach mittels Schublehre gemessen werden. Die Erhebung der Muskelmasse ist komplexer. Aus im Rahmen der klinischen Routine angefertigten computertomographischen (CT) Aufnahmen kann diese valide und detailliert ermittelt werden. Für künftige klinische Beobachtungs- oder auch Interventionsstudien stellt die CT-Einzelschichtanalyse ein Werkzeug dar, um die Anthropometrie des Patienten über die Vermessung mit Maßband und Schublehre hinaus zu erfassen. Das möglicherweise besonders gefährdete Kollektiv der Patienten mit sarkopenischer Adipositas kann beispielsweise nur über bildgebende Verfahren wie die CT-Einzelschichtanalyse identifiziert werden. Somit sollte der BMI als anthropometrischer Parameter in Klinik und Forschung in den Hintergrund rücken.
Careful patient selection is the prerequisite to raise transplant benefit. In lung transplant (LT) candidates, the effect of body mass index (BMI) on postoperative outcome remains controversial, ...possibly due to the inaccuracy of BMI in discriminating between fat and muscle mass. We therefore hypothesized that assessment of body composition by muscle mass measures is more accurate than by BMI regarding postoperative outcome.
All LT recipients from 2011 to 2014 were included and retrospectively analyzed. Lean psoas area (LPA) was assessed from pretransplant computed tomography scans, and associations with postoperative outcomes were investigated.
Included were 103 consecutive LT recipients with a mean pre-LT BMI of 22.0 ± 4.0 kg/m(2) and a mean LPA of 22.3 ± 8.3 cm(2). LPA was inversely associated with length of mechanical ventilation (p = 0.03), requirement of tracheostomy (p = 0.035), and length of stay in the intensive care unit (p = 0.02), while controlling for underlying disease, BMI, sex, age, and procedure; in contrast, BMI was not (p = 0.25, p = 0.54, and p = 0.42, respectively.). Multiple regression analysis revealed that the 6-minute walk distance at the end of pulmonary rehabilitation was significantly associated with LPA (p = 0.02).
LPA can easily be assessed in LT candidates as part of pretransplant evaluation and was significantly associated with short-term outcome, whereas BMI was not. Assessment of LPA may provide additional information on body composition beyond BMI. However, the clinical utility has to be further evaluated.
Rhabdomyolysis is frequently occurring in critically ill patients, resulting in a high risk of acute kidney injury (AKI) and potentially permanent kidney damage due to increased myoglobin levels. The ...extracorporeal elimination of myoglobin might be an approach to prevent AKI, but its molecular weight of 17 kDa complicates an elimination with conventional dialysis membranes. Question of interest is, if myoglobin can be successfully eliminated with the cytokine adsorber Cytosorb® (CS) integrated in a high-flux dialysis system.
Patients were included between 10/2014 and 05/2020 in the study population if they had an anuric renal failure with the need of renal replacement therapy, if CS therapy was longer than 90 min and if myoglobin level was > 5.000 ng/ml before treatment. The measurement times of the laboratory values were: d-1 = 24-36 h before CS, d0 = shortly before starting CS and d1 = 12-24 h after starting CS treatment. Statistical analysis were performed with Spearman's correlation coefficient, Wilcoxon test with associated samples and linear regression analysis.
Forty-three patients were included in the evaluation (median age: 56 years, 77% male patients, 32.6% ECMO therapy, median SAPS II: 80 points and in-hospital mortality: 67%). There was a significant equilateral correlation between creatine kinase (CK) and myoglobin at all measurement points. Furthermore, there was a significant reduction of myoglobin (p = 0.03, 95% confidence interval (CI): - 9030, - 908 ng/ml) during CS treatment, with a median relative reduction of 29%. A higher median reduction of 38% was seen in patients without ongoing rhabdomyolysis (CK decreased during CS treatment, n = 21). In contrast, myoglobin levels did not relevantly change in patients with increasing CK and therefore ongoing rhabdomyolysis (n = 22, median relative reduction 4%). Moreover, there was no significant difference in myoglobin elimination in patients with and without ECMO therapy.
Blood purification with Cytosorb® during high-flux dialysis led to a significant reduction of myoglobin in patients with severe rhabdomyolysis. The effect might be obscured by sustained rhabdomyolysis, which was seen in patients with rising CK during treatment. Prospective clinical trials would be useful in investigating its benefits in avoiding permanent kidney damage.
Long-lasting, latently infected resting CD4
T cells are the greatest obstacle to obtaining a cure for HIV infection, as these cells can persist despite decades of treatment with antiretroviral ...therapy (ART). Estimates indicate that more than 70 years of continuous, fully suppressive ART are needed to eliminate the HIV reservoir
. Alternatively, induction of HIV from its latent state could accelerate the decrease in the reservoir, thus reducing the time to eradication. Previous attempts to reactivate latent HIV in preclinical animal models and in clinical trials have measured HIV induction in the peripheral blood with minimal focus on tissue reservoirs and have had limited effect
. Here we show that activation of the non-canonical NF-κB signalling pathway by AZD5582 results in the induction of HIV and SIV RNA expression in the blood and tissues of ART-suppressed bone-marrow-liver-thymus (BLT) humanized mice and rhesus macaques infected with HIV and SIV, respectively. Analysis of resting CD4
T cells from tissues after AZD5582 treatment revealed increased SIV RNA expression in the lymph nodes of macaques and robust induction of HIV in almost all tissues analysed in humanized mice, including the lymph nodes, thymus, bone marrow, liver and lung. This promising approach to latency reversal-in combination with appropriate tools for systemic clearance of persistent HIV infection-greatly increases opportunities for HIV eradication.
There are different methods of artificial liver support for patients with acute liver dysfunction (ALD). However, CytoSorb (CS) might be a new approved option for those patients. Question of interest ...is whether the elimination performance of CS was comparable to that of advanced organ support (ADVOS). Patients, treated with CS (integrated into high-flux dialysis) or ADVOS and a total bilirubin > 10 mg/dl were included. Laboratory parameters were evaluated before starting therapy (d0) and 12-24 h thereafter (d1). The Wilcoxon-test with associated samples was used for statistical analysis. Thirty-nine patients (33 CS, 6 ADVOS) were included. The median bilirubin at d0 was 16.9 and 17.7 mg/dl and at d1 was 13.2 and 15.9 mg/dl, in the CS and ADVOS group, respectively. There was a significant bilirubin reduction as well in the CS group (p < 0.001, median relative reduction: 22.5%) as in the ADVOS group (p = 0.028, median relative reduction: 22.8%). There was no significant difference in the relative bilirubin reduction between CS and ADVOS therapies. The use of CytoSorb and ADVOS in patients with ALD led to a significant and comparable decrease in total bilirubin. The easy use of CS might be an advantage compared to other procedures.
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