Human cytomegalovirus seropositivity is associated with reduced patient survival during sepsis.

BACKGROUND: Sepsis is one of the leading causes of death. Treatment attempts targeting the immune response regularly fail in clinical trials. As HCMV latency can modulate the immune response and changes the immune cell composition, we hypothesized that HCMV serostatus affects mortality in sepsis patients. METHODS: We determined the HCMV serostatus (i.e., latency) of 410 prospectively enrolled patients of the multicenter SepsisDataNet.NRW study. Patients were recruited according to the SEPSIS-3 criteria and clinical data were recorded in an observational approach. We quantified 13 cytokines at Days 1, 4, and 8 after enrollment. Proteomics data were analyzed from the plasma samples of 171 patients. RESULTS: The 30-day mortality was higher in HCMV-seropositive patients than in seronegative sepsis patients (38% vs. 25%, respectively; p = 0.008; HR, 1.656; 95% CI 1.135-2.417). This effect was observed independent of age (p = 0.010; HR, 1.673; 95% CI 1.131-2.477). The predictive value on the outcome of the increased concentrations of IL-6 was present only in the seropositive cohort (30-day mortality, 63% vs. 24%; HR 3.250; 95% CI 2.075-5.090; p < 0.001) with no significant differences in serum concentrations of IL-6 between the two groups. Procalcitonin and IL-10 exhibited the same behavior and were predictive of the outcome only in HCMV-seropositive patients. CONCLUSION: We suggest that the predictive value of inflammation-associated biomarkers should be re-evaluated with regard to the HCMV serostatus. Targeting HCMV latency might open a new approach to selecting suitable patients for individualized treatment in sepsis.

CHRM3 rs2165870 polymorphism is independently associated with postoperative nausea and vomiting, but combined prophylaxis is effective.

BACKGROUND: Clinical risk factors for postoperative nausea and vomiting (PONV) are evaluated with the Apfel score, however patients with low Apfel scores still experience PONV suggesting a genetic predisposition. PONV risk associates with specific M3 muscarinic acetylcholine receptor (CHRM3) rs 2165870 polymorphism. We investigated whether the Apfel score and this genetic variation independently contribute to PONV risk and whether prophylaxis reduces PONV in patients with low Apfel score but at high genetic risk. METHODS: In a prospective, controlled study, 454 subjects undergoing elective surgery were genotyped for rs2165870 and its association with PONV was investigated with log-binomial regression analysis. Subjects were randomised to receive acustimulation/dexamethasone, acustimulation/vehicle, sham acustimulation/dexamethasone, or sham acustimulation/vehicle to investigate their effects on PONV risk. RESULTS: Early PONV occurred in 37% of subjects. The rs2165870 genotype distribution was GG in 191, GA in 207, and AA in 56 subjects. The CHRM3 polymorphism was associated with a relative risk (RR) of 1.5 for GA vs GG [95% confidence interval (CI): 1.1-1.9; P=0.003] and 1.6 for AA vs GG (95% CI: 1.1-2.2; P=0.009) genotypes to develop PONV, and this was independent from the Apfel score (RR per Apfel point: 1.3, 95% CI: 1.2-1.5; P<0.0001). While dexamethasone and acustimulation each reduced the PONV risk by 30% in AA genotype carriers with low Apfel score, combined therapy reduced the risk by 86% (P=0.015). CONCLUSIONS: The CHRM3 polymorphism and the Apfel score independently predict PONV susceptibility. Dexamethasone/acustimulation should be considered in patients with low Apfel score but at high genetic risk. CLINICAL TRIAL REGISTRATION: DRKS00005664.

The minimally invasive MitraClip™ procedure for mitral regurgitation under general anaesthesia: immediate effects on the pulmonary circulation and right ventricular function.

A relatively new minimally invasive cardiological procedure, called the MitraClip(™), does not require sternotomy and may have a number of advantages compared with open mitral valve surgery, but its acute impact on the pulmonary circulation and right ventricular function during general anaesthesia is unclear. We prospectively assessed the effects of the MitraClip procedure in 81 patients with or without pulmonary hypertension (defined as mean pulmonary artery pressure > 25 mmHg), who were anaesthetised using fentanyl (5 µg.kg(-1)), etomidate (0.2-0.3 mg.kg(-1)), rocuronium (0.5-0.6 mg.kg(-1)) and isoflurane. Placement of the MitraClip led to a 60% increase in mean (SD) right ventricular stroke work index (from 512 (321) to 820 (470) mmHg.ml.m(-2), p < 0.0001), while mean (SD) pulmonary vascular resistance index decreased by 24% (522 (330) to 399 (244) dyn.s.cm(-5), p < 0.0001), and mean (SD) pulmonary artery pressure decreased by 10% (30 (8) to 27 (8) mmHg, p < 0.0001). Patients with pulmonary hypertension experienced a similar decrease in mean pulmonary artery pressure compared with those without, and they also had a slight reduction in mean (SD) pulmonary artery occlusion pressure (22 (6) down to 20 (6) mmHg, p = 0.044). We conclude that successful MitraClip treatment for mitral regurgitation acutely improves right ventricular performance by reducing right ventricular afterload, regardless of whether patients have pre-operative pulmonary hypertension.

Myocardial protection by remote ischaemic pre-conditioning is abolished in sulphonylurea-treated diabetics undergoing coronary revascularisation.

BACKGROUND: Remote ischaemic pre-conditioning attenuates myocardial injury. Because sulphonylurea drugs interfere with ischaemic and anaesthetic pre-conditioning, we assessed whether remote ischaemic pre-conditioning effects are altered in sulphonylurea-treated diabetics. METHODS: Using the database of our ongoing randomised, placebo-controlled study (ClinicalTrials.gov NCT01406678), we assessed the troponin I concentration area under curve (measurements: baseline, 1, 6, 12, 24, 48, and 72 h post-operatively) in sulphonylurea-treated diabetics (n = 27) and non-diabetics (n = 230) without and with remote ischaemic pre-conditioning (three 5-min periods of left upper arm ischaemia with 5-min reperfusion each) during isoflurane anaesthesia before two- to three-vessel coronary artery surgery. RESULTS: Remote ischaemic pre-conditioning in non-diabetic patients evoked a 41% decrease in the troponin I concentration area under curve (514 ng/ml × 72 h ± 600 vs. 302 ± 190, P = 0.001) but no change (404 ng/ml × 72 h ± 224 vs. 471 ± 383, P = 0.62) in sulphonylurea-treated diabetics. There was no significant correlation between the troponin I concentration area under curve and arterial glucose concentrations, and the latter was not an independent confounder. CONCLUSION: Cardioprotection by remote ischaemic pre-conditioning during isoflurane anaesthesia is abolished in sulphonylurea-treated diabetics.

ß2-Adrenoceptor gene variants affect vasopressor requirements in patients after thoracic epidural anaesthesia.

BACKGROUND: While the ß2-adrenoceptor pathway is essential for cardiovascular regulation, the impact of ADRB2 gene variations on circulatory responses is unclear, possibly due to neural compensatory mechanisms. We tested the hypotheses that (i) sympathetic block by thoracic epidural anaesthesia (TEA) unmasks the influence on arterial pressure of genetic variations and (ii) vasopressor requirements during TEA depend on ADRB2 gene variation. METHODS: Ninety-three elective patients undergoing abdominal surgery were included prospectively. After epidural bupivacaine 0.5% (15 mg test dose+50 mg), arterial pressure, heart rate, and progression of sensory block were measured for 20 min in the supine awake state and for 20 min after standardized anaesthetic induction of general anaesthesia. The primary endpoint was cumulative dose of the α-adrenoreceptor agonist phenylephrine administered to sustain a mean arterial pressure >70 mm Hg. The ADRB2 polymorphisms Arg16Gly and Gln27Glu were genotyped using Slowdown-PCR. RESULTS: After TEA, 86 (93%) patients required phenylephrine. The mean dosages (sd) were significantly different between the ADRB2 genotypes [Arg16Arg 357 µg (326), Arg16Gly 776 µg (449), Gly16Gly 600 µg (443), P=0.036; Gln27Gln 356 µg (254), Gln27Glu 639 µg (354), Glu27Glu 577 µg (388), P=0.007]. Multiple linear regression analysis revealed that age, male gender, rostral extent of sensory block, lower arterial pressure before TEA, and ADRB2 Glu27 allele together explained 37% of phenylephrine dosage variation, with genetic variants being the second most important predictor (10%; P<0.001). CONCLUSIONS: The ADRB2 Glu27 allele is an independent predictor of arterial hypotension and vasopressor requirements after TEA. Neural block can unmask genetic influences on neurohumoral regulation. Clinical trial registration DRKS00005260.

Genetic interactions in the ß-adrenoceptor/G-protein signal transduction pathway and survival after coronary artery bypass grafting: a pilot study.

BACKGROUND: In heart failure, ß-adrenergic receptor (ßAR) stimulation desensitizes the receptor, uncouples the downstream Gαs protein, and diminishes signal transduction. We tested the hypotheses that haplotype-tagging single-nucleotide polymorphisms (htSNPs) within the Gαs gene (GNAS) (i) are functionally active and alter Gαs expression, (ii) influence survival after coronary artery bypass grafting (CABG), and (iii) interact with ßAR SNPs. METHODS: Amplification of GNAS intron 1 was followed by cloning, reporter assays, electrophoretic mobility shift assays, and western blots. In a pilot study, 185 patients on ßAR blockade undergoing CABG were studied prospectively. The primary endpoint was cardiac-related mortality at 1 yr. RESULTS: Two htSNPs defined three common haplotypes with altered reporter activity, allele-specific transcription factor binding, and Gαs protein expression (highest in *3 carriers followed by *2 and *1 haplotypes, P=0.013). After CABG, mortality was GNAS diplotype-dependent: *3/*3: 0%; *3/*2: 2.4%; *3/*1: 2.9%; *2/*2: 4.5%; *2/*1: 9.1%; and *1/*1: 20.0% (P=0.004). While ß(1)AR SNPs were not associated with mortality, ß(2)AR Arg16 allele carriers were at higher risk than Gly16 allele carriers (P=0.008). Gene-gene interaction using gene-related risk alleles demonstrated the number of risk alleles to be independently associated with death (hazard ratio 2.3; 95% confidence interval: 1.5-3.5; P=0.0003). Carriers of the no-risk allele had higher maximum isoproterenol-stimulated adenylyl cyclase activities than risk allele carriers (P=0.003). CONCLUSIONS: Interactions in the ßAR/Gαs pathway may be associated with altered mortality after CABG. This could reconcile previously inconclusive data regarding the effects of ßAR SNPs on cardiovascular prognosis.

Role of the GNAS1 T393C polymorphism in patients with glioblastoma multiforme.

The T393C polymorphism of the GNAS1 locus, which encodes the Gαs protein, has recently been found to be associated with patient outcome in various malignancies. We investigated the association between GNAS1 genotype and survival among patients suffering from glioblastoma multiforme (GBM). One hundred and sixty-two patients with GBM were retrospectively investigated. Inclusion criteria were availability of DNA and, for surviving patients, a follow-up of at least 24 months. The results were analysed based on clinical data, type of surgical intervention, adjuvant therapy, and 2-year survival. At the 2-year follow up, 79.6% of patients had died. Two-year survival rates were as follows: CC-homozygous patients, 15.8%; CT-heterozygous patients, 23.1%; and TT-homozygous patients, 18.2% (p = 0.461). Subgroup analysis revealed different 2-year survival rates in the group that underwent stereotactic biopsy, with 0% for CC-homozygous, 2.8% for CT-heterozygous, and 15.4% survival for TT-homozygous patients, but the differences were not statistically significant (p = 0.229). Our results indicate that there is no association between the GNAS1 T393C polymorphism and 2-year survival among patients with GBM.

GNAS1 T393C polymorphism and disease progression in patients with malignant melanoma.

BACKGROUND: Once metastasized, despite a variety of therapeutic options, the prognosis of patients with malignant melanoma (MM) is still poor. Therefore, the search for reliable markers to identify patients with high risk of disease progression is of high clinical importance. We have recently shown that TT genotypes of the single-nucleotide polymorphism (SNP) T393C in the gene GNAS1 are significantly associated with better outcome in a variety of carcinomas. - PATIENTS: In the present study we assessed whether the T393C SNP is also related to the clinical course in MM. 328 patients with MM were retrospectively genotyped and genotypes were correlated with clinical outcome. - RESULTS: While the allele frequency in the MM group (fC 0.52) did not significantly differ from that of healthy blood donors, the T393C SNP was associated with tumor progression of MM. Carriers of the C-allele showed a significantly more severe tumor progression as estimated from the time period to develop metastasis (HR 2.2, 95% CI 1.1-3.2, p = 0.017). Proportions of 5-year metastasis-free intervals were 87.1% for TT genotypes and 66.0% for C-allele carriers. Moreover, multivariable Cox regression analysis including tumor stage and melanoma subtype proved the T393C polymorphism to be an independent factor for metastasis (p = 0.012). - CONCLUSIONS: In summary, the GNAS1 T393C SNP represents a genetic host factor for predicting tumor progression also in patients with MM; genotyping of this SNP may contribute to better define patients who could benefit from an early individualized therapy.

Effect of P6 acustimulation on post-operative nausea and vomiting in patients undergoing a laparoscopic cholecystectomy.

BACKGROUND: Non-pharmacologic techniques such as electrical acustimulation may mitigate post-operative nausea and vomiting (PONV). The primary purpose of this study was to investigate the effectiveness of acustimulation on attenuating PONV. Moreover, we tested whether a pre- or a post-induction application of acustimulation results in differences in PONV reduction. METHODS: In this prospective, double-blind, randomized, controlled trial, we studied 200 patients undergoing a laparoscopic cholecystectomy during propofol (induction) fentanyl/isoflurane/atracurium (maintenance) anaesthesia. In the acustimulation group (n=101), subdivided into groups with pre-induction (n=57) and post-induction (n=44) acustimulation, an active ReliefBand device was placed at the P6 acupoint. In the sham group (n=99), also subdivided into pre-induction (n=55) or post-induction (n=44) groups, an inactive device was applied instead. The ReliefBand remained in place for 24 h after surgery. Nausea and vomiting/retching were recorded at 2, 6, and 24 h post-operatively. RESULTS: The incidence of early nausea (up to 2 h) was significantly lower in the acustimulation than in the sham group (29% vs. 42%; P=0.043). No significant effect could be detected for retching/vomiting. Moreover, acustimulation showed no effect on PONV after 6 and 24 h. Risk factor analysis (female gender, non-smoker, history of PONV/motion sickness, and post-operative morphine usage) revealed a relative reduction in risk of 40% for nausea (P=0.021) and 55% for retching/vomiting (P=0.048) in patients with three or four risk factors present. The timing of (pre- vs. post-induction) acustimulation had no significant effect on PONV reduction. CONCLUSION: Acustimulation at the P6 acupoint reduces early nausea, but not vomiting, after laparoscopic cholecystectomy, irrespective of its pre- or post-induction application.

P6 acustimulation effectively decreases postoperative nausea and vomiting in high-risk patients.

BACKGROUND: Electrical acustimulation can reduce postoperative nausea and vomiting (PONV). The primary purpose of this study was to investigate the effectiveness of acustimulation in relation to known risk factors for PONV. We also tested the secondary hypothesis that pre- or post-induction application of acustimulation results in differences in PONV reduction. METHODS: Two hundred women undergoing vaginal hysterectomy were enrolled in this prospective, observer-blind, randomized controlled trial. Patients received randomly for 24 h acustimulation (n=101), subdivided into groups of pre-induction (n=48) and post-induction (n=53), or sham stimulation (n=99), subdivided into groups of pre-induction (n=49) or post-induction (n=50). Nausea and vomiting/retching was recorded for 24 h after operation in the whole group and stratified by risk factors (female gender, non-smoker, history of PONV/motion sickness, and postoperative morphine usage). RESULTS: The incidence of PONV and need for rescue therapy was significantly lower in the acustimulation than in the sham group (PONV, 33% vs 63%, P<0.001; rescue therapy, 39% vs 61%, P=0.001). The risk ratio for acustimulation and PONV was 0.29 [95% confidence interval (CI) 0.16-0.52] and for rescue therapy, it was 0.38 (95% CI 0.21-0.66). Subgroup analyses according to the simplified risk score by Apfel and colleagues revealed a reduction in high-risk patients, that is, when three or four risk factors were present. Binary logistic regression analysis revealed that no history of PONV and usage of acustimulation were independent predictors for risk reduction of all PONV qualities. No significant difference in PONV reducing effects could be detected between pre- and post-induction. CONCLUSIONS: Continuous 24 h acustimulation decreases PONV, particularly in patients at high risk.

A functional GNAS promoter polymorphism is associated with altered weight loss during short-term fasting.

In mice, heterozygous knockout of the stimulatory G protein Gas results in obesity which suggests a key role of Gas in body weight regulation. We have recently identified a functional G(-1211)A promoter polymorphism in the human GNAS gene encoding Gas, the GG genotype being associated with increased promoter activity and lipolysis in vitro and increased weight loss capacity in vivo. The present study aimed to independently confirm these results. We genotyped 87 subjects who underwent a 7-day modified fast for the GNAS polymorphism and recorded weight, hunger, and mood. While both mood and hunger were not dependent on genotype, GNAS genotypes were significantly associated with weight loss (GG: -5.0 +/- 1.5 kg, n = 28; AG: -4.2 +/- 1.1 kg, n = 50; AA: -3.2 +/- 1.2, n = 9; p = 0.0003). The present study reconfirms our earlier reported findings and suggests that GNAS genotypes also influence weight loss during short-term fasting. related to a low vascular density (CD31 expression) in CDC.

The C allele of the GNB3 C825T polymorphism of the G protein beta3-subunit is associated with an increased risk for the development of oncocytic thyroid tumours.

Carriers of the C allele of the common C825T polymorphism in the GNB3 gene of the G protein have been associated with the development of follicular thyroid adenomas. Since the C allele of this polymorphism is related to a lower signalling capacity, it was speculated whether the C825T polymorphism may play a particular role in oncocytic thyroid tumours, which are recognized for their reduced ability to synthesize thyroid-specific proteins and hormones, although they possess an intact thyroid-stimulating hormone receptor-adenylyl cyclase system. Using pyrosequencing, both the genotype distribution and the allele frequency of the C825T polymorphism were investigated in a series of 104 patients with oncocytic thyroid tumours of follicular cell origin [58 adenomas, 41 follicular thyroid carcinomas (FTCs), and five papillary thyroid carcinomas (PTCs)]; the results were compared with those obtained from 321 age and gender-matched healthy blood donors and a series of 327 non-oncocytic thyroid tumours of follicular cell origin (119 adenomas, 80 FTCs, and 186 PTCs). Analysis of the genotype distribution (comparing oncocytic with non-oncocytic tumours of the present series) revealed a significantly increased odds ratio (OR) for CC versus TT (OR = 4.22; p = 0.011) and CC versus CT (OR = 1.62; p = 0.049) carriers to develop an oncocytic thyroid tumour; ORs to develop an oncocytic thyroid tumour were also increased comparing the genotype distribution between the group of oncocytic tumours and healthy controls for CC versus TT (OR = 3.73; p = 0.017) and CC versus all T carriers (OR = 1.56; p = 0.034). Oncocytic thyroid tumours as a group showed a statistically significant increase of the C-allele frequency when compared with all non-oncocytic tumours (p = 0.0039) as well as healthy blood donors (p = 0.017). The results strongly suggest that the C allele of the GNB3 C825T polymorphism of the G protein beta3-subunit is associated with an increased risk for the development of oncocytic thyroid tumours. This polymorphism may thus be considered a (co)factor favouring the development of oncocytic thyroid tumours, although the biological mechanism(s) underlying this association remain obscure.

Relevance of the NOS3 T-786C and G894T variants for cholinergic and adrenergic coronary vasomotor responses in man.

OBJECTIVE: We investigated the impact of the -786C allele at the promoter and the 894T allele in exon 7 of the gene encoding the endothelial nitric oxide synthase (NOS3) on coronary vasomotor responses to exogenous and endogenous stimuli. METHODS: In 47 individuals undergoing coronary angiography for chest pain, but without significant stenosis in the left anterior descending artery (LAD), nitroglycerine and acetylcholine were infused intracoronarily, and a cold pressor test (CPT) was performed. Coronary blood flow (CBF) in the LAD was calculated from quantitative coronary angiography and intracoronary Doppler measurements. Aortic and coronary sinus lactate levels were determined in 18 individuals. To analyze the impact of NOS3 genotypes, a logistic regression model was used. RESULTS: In response to acetylcholine (p = 0.002) and CPT (p = 0.015) CBF reduction was associated with homocygosity for the -786C allele. Myocardial lactate uptake was reversed into net lactate production in CC homocygotes. No independent effects of the G894T polymorphism were observed in the present study. Haplotype analysis revealed a significant linkage disequilibrium between both polymorphisms (p < 0.001). CONCLUSIONS: Our findings suggest a pathophysiologically relevant role for the T-786C polymorphism in human coronary vasomotion. The observed linkage disequilibrium between both NOS3 genotypes deserves further research in future studies.

Methylenetetrahydrofolate reductase (MTHFR) gene 677C>T and 1298A>C polymorphisms are associated with differential apoptosis of leukemic B cells in vitro and disease progression in chronic lymphocytic leukemia.

Methylenetetrahydrofolate reductase (MTHFR) regulates the metabolism of folate and methionine, essential components of DNA synthesis and methylation. We investigated whether the two genetic MTHFR polymorphisms (677C>T and 1298A>C) are associated with an increased risk for chronic lymphocytic leukemia (CLL) or may predict disease progression. Moreover, we measured potential genotype effects on apoptosis of B-CLL cells.Allele frequencies and genotype distributions for both polymorphisms were not significantly different in 111 patients vs 92 healthy controls. While progression-free survival (PFS) was not significantly different in individuals with CLL including all stages, in patients with Binet stage A PFS was significantly longer in patients displaying the MTHFR 677CC (P=0.043) and the MTHFR 1298A/C or CC genotypes (P=0.019). In a multivariate analysis, MTHFR haplotype (677CC plus 1298CC or A/C) was the best independent prognostic factor for PFS compared with other known prognostic factors. Spontaneous apoptosis of B-CLL cells in vitro was significantly increased in the favorable risk group with MTHFR 677CC and MTHFR 1298AC, which may constitute the cellular basis of the observed associations. While MTHFR polymorphisms do not affect the risk for B-CLL, they may be independent prognostic markers that influence the PFS in patients with early-stage B-CLL.