The effect of delirium preventive measures on the occurrence of postoperative cognitive dysfunction in older adults undergoing cardiovascular surgery. The DelPOCD randomised controlled trial.

STUDY OBJECTIVE: This trial examines the effect of delirium preventive measures on the incidence of postoperative cognitive dysfunction in older adults. DESIGN: In a randomised approach, a delirium prevention and a standard care group were compared regarding manifestation of postoperative cognitive dysfunction at seven days, three and twelve months postoperatively (primary outcome). To correct for practice effects and age-depended cognitive decline, a control group of age-matched healthy subjects was included. SETTING: The trial was conducted at the University Medical Centre Hamburg between 2014 and 2018, data assessment took place in the Anaesthesia Outpatient Clinic and on the surgical ward. PATIENTS: A total of 609 patients ≥60 years scheduled for cardiovascular surgery were enrolled, allocated treatment was received by 284 patients in the delirium prevention and 274 patients in the standard care group. INTERVENTION: The intervention consisted of a delirium prevention bundle including reorientation measures, sleeping aids and early mobilisation. MEASUREMENTS: Cognitive functions were assessed via neuropsychological testing of attention, executive functions including word fluency, and verbal memory utilizing a computerised test of attentional performance, the trail making test, the digit span subtest from the Wechsler Adult Intelligence Scale-IV, the verbal learning and memory test, and the Regensburg Word Fluency Test. Assessments were performed preoperatively and at three time points postoperatively (one week, three months and 12 months). MAIN RESULTS: Postoperative cognitive dysfunction was defined as a clinically meaningful decline in at least two out of nine chosen test parameters compared to the preoperative level (reliable change index ≤ - 1.96). The rates of postoperative cognitive dysfunction were 25.9% (delirium prevention group, n = 284) vs. 28.1% (standard care group, n = 274) [X2(1,n = 433) = 0.245;p = 0.621] at postoperative day seven and declined to 7.8% vs. 6.8% [X2(1,n = 219) = 0.081;p = 0.775] and 1.3% vs. 5.6% (p = 0.215, Fisher's exact test) at three and 12 months following surgery, respectively. The postoperative delirium rates did not differ between the two groups (delirium prevention group: 13.4% vs. standard care group: 17.3%). Attentional performance was impaired shortly after surgery, whereas verbal delayed recall was most frequently affected over the whole postoperative period. CONCLUSION: These findings suggest that an intervention combining specific measures extracted from established postoperative delirium prevention programs did not reduce the rate of postoperative cognitive dysfunction in older adults.

Low doses of eriocitrin attenuate metabolic impairment of glucose and lipids in ongoing obesogenic diet in mice.

Eriocitrin is a citrus flavonoid with a high capacity to reduce the oxidative stress related to metabolic disorders and obesity. We assessed the effects of low doses of eriocitrin on the oxidative stress, inflammation, and metabolism of glucose and lipids of high-fat diet (HFD)-fed obese mice. Fifty male C57BL/6J mice were randomly assigned into five groups (n 10). The mice were fed an HFD (45 % kcal from fat, i.e. lard) for 4 weeks for obesity induction. After this period, the mice continued receiving the same HFD, but supplemented with eriocitrin at 10, 25 or 100 mg/kg body weight (bw) for an additional 4 weeks. Control groups were fed with standard diet (10 % kcal of fat, i.e. soy oil) or with HFD without eriocitrin, for eight consecutive weeks. At the end of the study, mice supplemented with eriocitrin showed lower levels of blood serum glucose and blood and liver triacylglycerols (P < 0⋅05). There was also improved levels of insulin, HOMA-IR, total-cholesterol, resistin and lipid peroxidation in the supplemented mice. It was concluded that the 25 mg dose of eriocitrin improved all the parameters studied and had positive effects on oxidative stress, systemic inflammation and metabolism of lipids and glucose in general.

Validation of a new patient-reported outcome instrument of health-related quality of life specific to patients with alcohol use disorder: the Alcohol Quality of Life Scale (AQoLS).

PURPOSE: The Alcohol Quality of Life Scale (AQoLS) is a new patient-reported outcome 34-item questionnaire measuring health-related quality of life (HRQOL), specific to patients with an alcohol use disorder, developed from the patients' perspective. This is the first report establishing evidence in support of measurement reliability and validity of the AQoLS. METHODS: A total of 285 randomly selected patients receiving interventions for alcohol use disorder in addiction specialised care settings in France were included in the study (response rate 80.1 %). Exploratory factor analysis was conducted to evaluate the hypothesised-during-development-stage dimensional structure of the AQoLS. Internal consistency of the total score and the dimensions subscores were assessed through Cronbach's alpha coefficients. Construct validity was tested through correlations with the Short-Form 36 Health Survey (SF-36) and EuroQol 5 dimensions (EQ-5D). RESULTS: Exploratory analysis indicated seven observed dimensions which differed slightly from the 7 dimensions defined a priori in the framework hypothesised during the scale development: activities, relationships, living conditions, negative emotions, self-esteem, control and sleep. A major common factor allows the summing of the 34 items to obtain a total score. All the 34 items were acceptable. Cronbach's alpha for the AQoLS total score was 0.96 and ranged from 0.8 to 0.9 for the dimensions subscores. Negative correlations between AQoLS and all dimensions of the SF-36, but general health and positive correlations between AQoLS and all items of the EQ-5D were shown. As expected, the correlations were mostly moderate in magnitude, low with scores referring to physical areas and the highest with the SF-36 MSC. CONCLUSION: This study provides evidence of the measure's psychometric properties in terms of construct validity and internal consistency. The "control" and "self-esteem" dimensions are of particular interest as these concepts are not captured in existing HRQOL. Further longitudinal validation of the scale is necessary to assess sensitivity to change.

Who receives treatment for alcohol use disorders in the European Union? A cross-sectional representative study in primary and specialized health care.

BACKGROUND: Alcohol use disorders (AUDs) are highly prevalent in Europe, but only a minority of those affected receive treatment. It is therefore important to identify factors that predict treatment in order to reframe strategies aimed at improving treatment rates. METHODS: Representative cross-sectional study with patients aged 18-64 from primary health care (PC, six European countries, n=8476, data collection 01/13-01/14) and from specialized health care (SC, eight European countries, n=1762, data collection 01/13-03/14). For descriptive purposes, six groups were distinguished, based on type of DSM-IV AUD and treatment setting. Treatment status (yes/no) for any treatment (model 1), and for SC treatment (model 2) were main outcome measures in logistic regression models. RESULTS: AUDs were prevalent in PC (12-month prevalence: 11.8%, 95% confidence interval (CI): 11.2-12.5%), with 17.6% receiving current treatment (95%CI: 15.3-19.9%). There were clear differences between the six groups regarding key variables from all five predictor domains. Prediction of any treatment (model 1) or SC treatment (model 2) was successful with high overall accuracy (both models: 95%), sufficient sensitivity (model 1: 79%/model 2: 76%) and high specificity (both models: 98%). The most predictive single variables were daily drinking level, anxiety, severity of mental distress, and number of inpatient nights during the last 6 months. CONCLUSIONS: Variables from four domains were highly predictive in identifying treatment for AUD, with SC treatment groups showing very high levels of social disintegration, drinking, comorbidity and functional losses. Earlier intervention and formal treatment for AUD in PC should be implemented to reduce these high levels of adverse outcomes.

Chromosomal patterns of diversity and differentiation in creepers: a next-gen phylogeographic investigation of Certhia americana.

With methods for sequencing thousands of loci for many individuals, phylogeographic studies have increased inferential power and the potential for applications to new questions. In songbirds, strong patterns of inter-chromosomal synteny, the published genome of a songbird and the ability to obtain thousands of genetic loci for many individuals permit the investigation of differentiation between and diversity within lineages across chromosomes. Here, we investigate patterns of differentiation and diversity in Certhia americana, a widespread North American songbird, using next-generation sequencing. Additionally, we reassess previous phylogeographic studies within the group. Based on ~30 million sequencing reads and more than 16,000 single-nucleotide polymorphisms in 41 individuals, we identified a strong positive relationship between genetic differentiation and chromosome size, with a negative relationship between genetic diversity and chromosome size. A combination of selection and drift may explain these patterns, although we found no evidence for selection. Because the observed genomic patterns are very similar between widespread, allopatric clades, it is unlikely that selective pressures would be so similar across such different ecological conditions. Alternatively, the accumulation of fixed differences between lineages and loss of genetic variation within lineages due to genetic drift alone may explain the observed patterns. Due to relatively higher recombination rates on smaller chromosomes, larger chromosomes would, on average, accumulate fixed differences between lineages and lose genetic variation within lineages faster, leading to the patterns observed here in C. americana.

Campus drinking: an epidemiological model.

The drinking behaviours of college students have posed significant public health concerns for several generations. However, the dynamics of campus drinking have not been analysed using mathematical models. An epidemiological model capturing the dynamics of campus drinking is used to study how the 'disease' of drinking is spread on campus. The model suggests that the reproductive numbers are not sufficient to predict whether drinking behaviour will persist on campus and that the pattern of recruiting new members plays a significant role in the reduction of campus alcohol problems. In particular, campus alcohol abuse may be reduced by minimizing the ability of problem drinkers to directly recruit non-drinkers.

Genetic toxicity of a standardized mixture of citrus polymethoxylated flavones.

Flavonoids are a ubiquitous family of phytochemicals that display a variety of biological effects, both beneficial and adverse depending on the individual compound. Certain flavonoids are genotoxic while others inhibit the genotoxicity of other mutagens. In the present studies, the mutagenicity of a mixture of polymethoxylated flavones (PMFs) purified from citrus peel oil was evaluated. The mixture consisted of nobiletin (32.5%), 3,3',4',5,6,7,8-heptamethoxyflavone (25.0%), tangeretin (14.0%), trimethylscutellarein (9.1%), sinensetin (3.9%), 5-demethyl-nobiletin (2.8%), hexa-O-methylquercetagetin (3.3%), 5-demethyl-tetramethylscutellarein (0.7%), 5-hydroxy-3,3',4',6,7,8-hexamethoxyflavone (0.7%), and a small quantity of unidentified flavonoid compounds (3.9%). In vitro addition of the PMF mixture over a concentration range that spanned four log doses (0.0005-5.0 mg/plate) did not reveal any evidence of mutagenicity in five bacterial tester strains (Salmonella typhimurium TA98, TA100, TA102, TA1535 and TA1537) either in the absence or presence of S9 activation. The PMF mixture exhibited a statistically significant increase in mutagenicity of L5178Y tk(+/-) mouse lymphoma cells at 0.05 (38.5 x 10(-6); P<0.05) and 0.1 mg/ml (61 x 10(-6); P<0.01) compared with vehicle-treated controls (mutation frequency=19.7 x 10(-6)). However, these responses were within historical values observed in negative control cultures and extremely small compared to the positive control (EMS 0.5 microl/ml; 1685.3 x 10(-6)). Furthermore, in the presence of S9 there was no indication of genetic toxicity in L5178Y tk(+/-) cells. These results demonstrate that the PMF mixture is not genotoxic in in vitro assay systems.

Purification and characterization of a beta-glucosidase from Citrus sinensis var. Valencia fruit tissue.

A preliminary survey demonstrated activity for alpha-D-glucosidase, alpha-D-mannosidase, alpha-L-arabinosidase, beta-D-glucosidase, beta-D-xylosidase, and beta-D-galactosidase in orange fruit flavedo and albedo tissue. alpha-L-Rhamnosidase was not detected. Subsequently, a beta-glucosidase was purified from mature fruit rag tissue (composed of intersegmental septa, squeezed juice sacs, and fruit core tissue) of Citrus sinensis var. Valencia. The beta-glucosidase exhibited low levels of activity against p-nitrophenyl-beta-D-fucopyranoside (13.5%) and p-nitrophenyl-alpha-D-glucopyranoside (7.0%), compared to its activity against p-nitrophenyl-beta-D-glucopyranoside (pNPG, 100%). The enzyme was purified by a combination of ion exchange (anion and cation) and gel filtration (Superdex and Toyopearl HW-55S) chromatography. It has an apparent molecular mass of 64 kDa by denaturing electrophoresis or 55 kDa by gel filtration chromatography (BioGel P-100). Hydrolysis of pNPG demonstrated a pH optimum between 4.5 and 5.5. At pH 5.0 the temperature optimum was 40 degrees C. At pH 5.0 and 40 degrees C the K(m) for pNPG was 0.1146 mM and it had a V(max) of 5.2792 nkatal x mg(-1) protein (katal = 0.06 International Units = the amount of enzyme that produces, under standard conditions, one micromol of product per min). Of the substrates tested, the enzyme was most active against the disaccharide cellobiose (1-->4), but was not active against p-nitrophenyl-beta-D-cellobioside. High levels of activity also were observed with the disaccharides laminaribiose (1-->3), gentiobiose (1-->6), and sophorose (1-->2). Activity greater than that observed with pNPG was obtained with the flavonoids hesperetin-7-glucoside and prunin (naringenin-7-glucoside), salicin, mandelonitrile-beta-D-glucoside (a cyanogenic substrate), and sinigrin (a glucosinolate). The enzyme was not active against amygdalin, coniferin, or limonin glucoside.

Immunotoxicity of a standardized citrus polymethoxylated flavone extract.

Polymethoxylated flavones (PMFs) from citrus inhibit production of TNF-alpha and other pro-inflammatory cytokines. As TNF-alpha also modulates NK cell activity, the current studies were conducted to assess the potential for a standardized citrus PMF mixture to suppress humoral and innate immune functions. PMFs were isolated from orange peel oil using a procedure that obtained a consistent mixture of PMFs both in identity and proportion. The mixture consisted of nobiletin (30.7%), 3,3',4',5,6,7,8-heptamethoxyflavone (27.9%), trimethylscutellarein (14.5%), tangeretin (10.4%), sinensetin (5.8%), 5-demethyl-nobiletin (2.0%), hexa-O-methylquercetagetin (1.3%), 5-demethyl-tetramethylscutellarein (0.6%), and other flavonoids (2.7%). To assess the effect of the PMF mixture on humoral immune responses, female B(6)C(3)F(1) mice (n=8) were exposed to the PMF by gavage at 5, 50, 150 and 500 mg/kg/day for 28 days. On day 25, mice were sensitized to sRBC by tail vein injection and AFC response determined 4 days later. Humoral immunity was insensitive to suppression following exposure to all concentrations of the PMF mixture. Suppression of NK cell activity was observed only following 500 mg/kg/day for 28 days. Body weights were not affected by exposure to any concentration of the PMF mixture in sRBC immunized or non-immunized mice. However, in sRBC-immunized mice, higher concentrations of PMF were associated with a statistically insignificant increase in spleen weight (P>0.05). No change in spleen weight was observed in non-immunized mice. As anticipated, based on previously published in vitro observations, long-term, high-dose exposure to a standardized mixture of citrus PMFs caused a mild suppression of NK cell activity; however, humoral immunity was not sensitive to suppression at the same exposure levels.

Phenols in citrus peel byproducts. Concentrations of hydroxycinnamates and polymethoxylated flavones in citrus peel molasses.

In addition to the main flavanone glycosides (i.e., hesperidin and naringin) in citrus peel, polymethoxylated flavones and numerous hydroxycinnamates also occur and are major phenolic constituents of the molasses byproduct generated from fruit processing. Although a small number of the hydroxycinnamates in citrus occur as amides, most occur as esters and are susceptible to alkaline hydrolysis. This susceptibility to alkaline hydrolysis was used in measuring the concentrations of hydroxycinnamates in citrus peel molasses. The highest concentrations of hydroxycinnamates occurred in molasses of orange [C. sinensis (L.) Osbeck] and tangerine (C. reticulata Blanco.) compared to grapefruit (C. paradisi Macf.) and lemon [C. limon (L.) Burm.]. Concentrations of two phenolic glucosides, phlorin (phloroglucinol-beta-O-glucoside) and coniferin (coniferyl alcohol-4-beta-O-glucoside), were also measured. Measurements of the polymethoxylated flavones in molasses from several tangerine and orange varieties showed that these compounds occurred in the highest amounts in Dancy tangerine, whereas samples from two other tangerine molasses contained significantly lower levels, similar to those in the molasses samples from late- and early/mid-season oranges.

Biological properties of citrus flavonoids pertaining to cancer and inflammation.

Citrus flavonoids encompass a diverse set of structures, including numerous flavanone and flavone O- and C-glycosides and methoxylated flavones. Each of these groups of compounds exhibits a number of in vitro and in vivo anti-inflammatory and anticancer actions. These biological properties are consistent with their effects on the microvascular endothelial tissue. Evidence suggests that the biological actions of the citrus flavonoids are possibly linked to their interactions with key regulatory enzymes involved in cell activation and receptor binding. The citrus flavonoids show little effect on normal, healthy cells, and thus typically exhibit remarkably low toxicity in animals. The citrus flavonoids extend their influence in vivo through their induction of hepatic phase I and II enzymes, and through the biological actions of their metabolites. Evidence clearly indicates to the potential health promoting properties of these dietary compounds.

Acid-catalyzed hydrolysis of hesperidin at elevated temperatures.

Dilute sulfuric acid was used as a catalyst for hydrolysis of hesperidin suspensions in water at temperatures ranging from 25 to 180 degrees C. Significant acceleration of the reaction was observed at 120 degrees C and higher temperatures. This increase in the rate of hydrolysis can be attributed to increased solubilization of hesperidin in water at higher temperatures. Partial hydrolysis of hesperidin at 140 degrees C was used for the preparations of hesperetin-7-glucoside, which has a value in the synthesis of dihydrochalcone sweeteners. Simple separation of hesperetin and hesperetin-7-glucoside by extraction with dry acetone or lower alcohols has been developed.

Biological properties of flavonoids pertaining to inflammation.

Chronic venous insufficiency (CVI) is accompanied by a marked inflammatory response that is thought to contribute to the development and progression of the disorder. While compression therapy has long been considered the standard treatment for CVI, recent studies suggest that treatment with flavonoids may also be beneficial. The purpose of this review is to summarize how plant flavonoids attenuate inflammation and the immune response through their inhibition of important regulatory enzymes. Certain flavonoids are potent inhibitors of the production of prostaglandins, a group of powerful proinflammatory signaling molecules. Studies have shown that this effect is due to flavonoid inhibition of key enzymes involved in prostaglandin biosynthesis (i.e., lipoxygenase, phospholipase, and cyclooxygenase). Flavonoids also inhibit phosphodiesterases involved in cell activation. Much of this effect is upon the biosynthesis of protein cytokines that mediate adhesion of circulating leukocytes to sites of injury. The protein kinases are another class of regulatory enzymes affected by flavonoids. The inhibition of kinases is due to the competitive binding of flavonoids with ATP at catalytic sites on the enzymes. These modes of inhibition provide the mechanisms by which flavonoids inhibit the inflammation response and suggest that this class of molecules may be effective in the treatment of CVI.

Purification of citrus peel juice and molasses.

Citrus peel juice and molasses are extremely bitter and unpalatable byproducts of orange and grapefruit juice production. Major components of interest are soluble sugars, glucose, fructose, and sucrose, which account for 60-70% of the dry solids. Analyses indicate that the remaining components are suspended tissue fragments, proteins, organic acids, mineral ions, phenolic compounds, and polyols. A purification sequence that removed a majority of bitter limonoids and phenolic compounds by adsorption on nonionic, macroporous resins was tested. Residual phenolic compounds were removed by adsorption on activated carbon or anion-exchange resin, which also removed anions of organic and inorganic acids. Taste panel results suggested that debittered products could be acceptable for food uses.

Polymethoxylated flavones derived from citrus suppress tumor necrosis factor-alpha expression by human monocytes.

Flavonoids isolated from citrus were evaluated for their ability to affect the inflammation response through suppression of cytokine expression by human monocytes. Several polymethoxylated flavones inhibited lipopolysaccharide-induced monocyte expression of tumor necrosis factor (TNFalpha). Subsequent studies centered on the compound 3,5,6,7,8,3',4'-heptamethoxyflavone (HMF) which produced the highest inhibition (IC50 = 5 microM). HMF was also a potent inhibitor of macrophage inflammatory protein-1alpha (MIP-1alpha) and interleukin-10 (IL-10) production, but not of IL-1beta, IL-6, or IL-8 production. Suppression of TNFalpha production was at the level of mRNA induction as determined by quantitative reverse transcriptase-polymerase chain reaction (RT-PCR). HMF was also a potent inhibitor of human phosphodiesterase activity and was shown to induce a substantial elevation of cAMP levels in monocytes. The similarity of these results to the inhibition profile of the known phosphodiesterase inhibitor, 3-isobutyl-1-methylxanthine, suggests that the polymethoxylated flavones inhibit cytokine production in part by suppression of phosphodiesterase activity. The ability of HMF to also inhibit IL-10 production suggests the additional existence of a phosphodiesterase-independent mechanism for this compound.

[Capillary hemangioma of the heart: a case report]. / Kapilläres Hämangiom des Herzens: Ein Fallbericht.

In a 52-year-old man, within the left ventricle, a globular mass 1.5 cm in diameter was detected incidentally by echocardiography. Selective coronary angiography showed a mobile patch of hypervascularity suggesting the vascular nature of the cardiac mass. The patient was operated and a pedunculated tumor originating from the anterolateral papillary muscle was removed. Histological examination revealed a benign capillary hemangioma. Six months after surgery the patient was reevaluated by echocardiography. There was no evidence of tumor recurrence.

[Mechanical recanalization and local thrombolysis in a patient with fulminant pulmonary embolism and craniocerebral trauma]. / Mechanische Rekanalisation und lokale Thrombolyse bei einer Patientin mit fulminanter Lungenembolie und Schädeltrauma.

A 77-year-old female patient presenting with recurrent pulmonary embolism and shock had a severe craniocerebral trauma after collapsing at home 2 days before admission. Since systemic thrombolytic therapy appeared hazardous in this patient, percutaneous fragmentation and distal dispersion of the proximal pulmonary emboli was performed using a pigtail catheter. This procedure improved cardiac output immediately by 15%, whereas the mean pulmonary artery pressure dropped only slightly from 48 to 46 mmHg. Thereafter, a streptokinase infusion of 100,000 IU during 1 h was instituted through the pigtail catheter into the pulmonary artery. 12 hours after the treatment was started, cardiac output was raised by 70% and mean pulmonary artery pressure was decreased from 48 to 25 mmHg. 14 days after admission, control ventilation-perfusion scan showed a markedly improved pulmonary perfusion, and right heart catheterization revealed normal right heart pressures. The patient recovered rapidly and there was no evidence of recurrent pulmonary embolism 18 months later. This report demonstrates that a percutaneous catheter fragmentation of proximal pulmonary emboli combined with local intermediate-dose infusion of streptokinase may be a helpful therapeutic option in patients with massive pulmonary embolism in whom systemic thrombolytic therapy is contraindicated.

Popliteal venous aneurysm with pulmonary and paradoxical embolization.

A 31-year-old woman was admitted with recurrent pulmonary emboli. The patient subsequently developed right sided hemiplegia. A mobile left atrial mass attached to the interatrial septum was detected and paradoxical embolization was assumed to be the underlying cause of the cerebral event. Leg phlebography and B-mode ultrasonographic imaging showed that the most probable source of embolization was a right popliteal venous aneurysm containing thrombi adherent to the vein wall. The immediate treatment was restricted to full dose heparin therapy and supportive measures. Thirteen days after admission, the aneurysm was excised. Recovery was rapid and the patient was discharged for further rehabilitation with an only minimal neurological deficit 3 weeks after admission.

Comparative biochemical and immunohistochemical studies on the cathepsin D content of human breast cancer.

Cathepsin D (CD) has been introduced as a predictor of prognosis in patients with breast cancer due to its mitogenic effect and its role in tumour metastasis. Commonly, the CD content of tumours is examined by means of a biochemical method based upon the use of monoclonal antibodies, and immunohistochemical visualization of CD has not been used extensively. The present study compares the biochemical and immunohistochemical findings in 216 cases of human breast cancer. CD may occur in tumour cells and/or macrophages. Correlation of immunohistochemically determined CD content and biochemical CD content is better in tumour cells than in macrophages. The possible causes of this observation are briefly discussed. Although a statistical correlation between the biochemical and the immunohistochemical CD findings exists, the results in individual cases vary within a wide range. Hence, the results of biochemical and immunohistochemical CD assay in an individual tumour cannot be compared directly.