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Mechanical circulatory support (MCS) is often required to stabilize patients with acute fulminant myocarditis with cardiogenic shock. This review gives an overview of the successful use of left-sided Impella in the setting of fulminant myocarditis and cardiogenic shock as the sole means of MCS as well as in combination with right ventricular (RV) support devices including extracorporeal life support (ECLS) (ECMELLA) or an Impella RP (BI-PELLA). It further provides evidence from endomyocardial biopsies that in addition to giving adequate support, LV unloading by Impella exhibits disease-modifying effects important for myocardial recovery (i.e., bridge-to-recovery) achieved by this newly termed “prolonged Impella” (PROPELLA) concept in which LV-IMPELLA 5.0, implanted via an axillary approach, provides support in awake, mobilized patients for several weeks. Finally, this review addresses the question of how to define the appropriate time point for weaning strategies and for changing or discontinuing unloading in fulminant myocarditis.

Objectives: Mechanical circulatory support (MCS) is often required to stabilize therapy-refractory cardiogenic shock patients. Left ventricular (LV) unloading by mechanical ventricular support (MVS) via percutaneous devices, such as with Impella® axial pumps, alone or in combination with extracorporeal life support (ECLS, ECMELLA approach), has emerged as a potential clinical breakthrough in the field. While the weaning from MCS is essentially based on the evaluation of circulatory stability of patients, weaning from MVS holds a higher complexity, being dependent on bi-ventricular function and its adaption to load. As a result of this, weaning from MVS is mostly performed in the absence of established algorithms. MVS via Impella is applied in several cardiogenic shock etiologies, such as acute myocardial infarction (support over days) or acute fulminant myocarditis (prolonged support over weeks, PROPELLA). The time point of weaning from Impella in these cohorts of patients remains unclear. We here propose a novel cardiovascular physiology-based weaning algorithm for MVS. Methods: The proposed algorithm is based on the experience gathered at our center undergoing an Impella weaning between 2017 and 2020. Before undertaking a weaning process, patients must had been ECMO-free, afebrile, and euvolemic, with hemodynamic stability guaranteed in the absence of any inotropic support. The algorithm consists of 4 steps according to the acronym TIDE: (i) Transthoracic echocardiography under full Impella-unloading; (ii) Impella rate reduction in single 8–24 h-steps according to patients hemodynamics (blood pressure, heart rate, and ScVO 2 ), including a daily echocardiographic assessment at minimal flow (P2); (iii) Dobutamine stress-echocardiography; (iv) Right heart catheterization at rest and during Exercise-testing via handgrip. We here present clinical and hemodynamic data (including LV conductance data) from paradigmatic weaning protocols of awake patients admitted to our intensive care unit with cardiogenic shock. We discuss the clinical consequences of the TIDE algorithm, leading to either a bridge-to-recovery, or to a bridge-to-permanent LV assist device (LVAD) and/or transplantation. With this protocol we were able to wean 74.2% of the investigated patients successfully. 25.8% showed a permanent weaning failure and became LVAD candidates. Conclusions: The proposed novel cardiovascular physiology-based weaning algorithm is based on the characterization of the extent and sustainment of LV unloading reached during hospitalization in patients with cardiogenic shock undergoing MVS with Impella in our center. Prospective studies are needed to validate the algorithm.

Purpose Climate warming can change the geographic distribution and intensity of the transmission of vector-borne diseases such as malaria. The transmitted parasites usually benefit from increased temperatures as both their reproduction and development are accelerated. Lower Saxony (northwestern Germany) has been a malaria region until the 1950s, and the vector species are still present throughout Germany. This gave reason to investigate whether a new autochthonous transmission could take place if the malaria pathogen was introduced again in Germany. Materials and methods The spatial distribution of potential temperature-driven malaria transmissions was investigated using the basic reproduction rate (R ₀) to model and geostatistically map areas at risk of an outbreak of tertian malaria based on measured (1961-1990, 1991-2007) and predicted (1991-2020, 2021-2050, 2051-2080) monthly mean air temperature data. Results From the computations, maps were derived showing that during the period 1961-1990, the seasonal transmission gate ranges from 0 to 4 months and then expands up to 5 months in the period 1991-2007. For the projection of future trends, the regional climate models REMO and WettReg were used each with two different scenarios (A1B and B1). Both modelling approaches resulted in prolonged seasonal transmission gates in the future, enabling malaria transmissions up to 6 months in the climate reference period 2051-2080 (REMO, scenario A1B). Discussion The presented risk prognosis is based on the R ₀ formula for the estimation of the reproduction of the malaria pathogen Plasmodium vivax. The presented model focuses on mean air temperatures; thus, other driving factors like the distribution of water bodies (breeding habitats) or population density are not integrated. Nevertheless, the modelling presented in this study can help identify areas at risk and initiate prevention. The described findings may also help in the investigation and assessment of related diseases caused by temperature-dependent vectors and pathogens, including those being dangerous for livestock as well, e.g. insect-borne bluetongue disease transmitted by culicoids.

Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) is increasingly used in bi-ventricular failure with cardiogenic shock to maintain systemic perfusion. Nonetheless, it tends to increase left ventricular (LV) afterload and myocardial oxygen demand. In order to mitigate these negative effects on the myocardium, an Impella CP® (3.5 L/min Cardiac Output) can be used in conjunction with V-A ECMO (ECMELLA approach). We implemented this strategy in a patient with severe acute myocarditis complicated by cardiogenic shock. Due to a hemolysis crisis, Impella CP® had to be substituted with PulseCath iVAC2L®, which applies pulsatile flow to unload the LV. A subsequent improvement in LV systolic function was noted, with increased LV ejection fraction (LVEF), LV end-diastolic diameter (LVEDD) reduction, and a reduction in plasma free hemoglobin. This case documents the efficacy of iVAC2L in replacing Impella CP as a LV vent during V-A ECMO, with less hemolysis.

Background Recent clinical trials have shown that pulmonary artery pressure-guided therapy via the CardioMEMS™ system reduces the risk of recurrent hospitalizations in chronic heart failure (HF) patients. The CardioMEMS™ pressure sensor is percutaneously implanted in a branch of the pulmonary artery and allows telemetric pressure monitoring via a receiver. According to the most recent ESC guidelines, this technology has currently a class IIb indication in patients with class III New York Heart Association symptoms and a previous hospitalization for congestive heart failure within the last year, regardless of ejection fraction. Aim of this guided-therapy is multifold, including an early prediction of upcoming decompensation, optimization of patients’ therapy and thereby avoidance of hospital admissions. In addition, it can be used during acute decompensation events as a novel tool to direct intra-hospital therapeutic interventions such as inotropes infusion or left ventricular (LV) assist device monitoring, with the aim of achieving an optimal volume status. Case presentation We present a case series of three end-stage HF patients with reduced ejection fraction (HFrEF) who received a CardioMEMS™ device as an aid in their clinical management. The CardioMEMS™ system enabled a closer non-invasive hemodynamic monitoring of these patients and guided the extent of therapeutic interventions. Patients were free from device- or system-related complications. In addition, no pressure-sensor failure was observed. Two patients received a 24-h infusion of the calcium sensitizer levosimendan. One patient showed a refractory acute decompensation and underwent LV assist device (LVAD) implantation as a bridge to cardiac transplantation. Switching a patient with recurrent hospitalizations to the Angiotensin Receptor Neprilysin Inhibitor (ARNI, Sacubitril-Valsartan) on top of the optimal heart failure-therapy improved its subjective condition and hemodynamics, avoiding further hospitalization. Conclusions Our case series underlines the potential impact of CardioMEMS™ derived data in the daily clinical management of end-stage HF patients. The new concept to combine CardioMEMS™ in the setting of an outpatient levosimendan program as well as a bridge to LVAD-implantation/heart transplantation looks promising but needs further investigations.

The sustained climate change is going to modify the geographic distribution, the seasonal transmission gate and the intensity of the transmission of vector-borne diseases such as malaria or the bluetongue disease. These diseases occur nowadays at higher latitudes or altitudes. A further rise in ambient temperature and rainfall will extend the duration of the season in which mosquito vectors are transmitting pathogens. The parasites transmitted by the vectors also benefit from increasing temperatures, as both their reproduction and development are then accelerated, too. Thus, it seemed prudent to examine potential effects on the seasonal transmission gate due to the ongoing and predicted climate changes. Lower Saxony (northwest Germany) is a former malaria region with highest incidences of Anopheles atroparvus and tertian malaria along the coastal zones before malaria had finally become extinct in the early 1950s. Nevertheless, the Anopheles mosquitoes which transmit the malaria pathogens have still been present in Lower Saxony up to now. This together with the climate change-related implications gave reason to investigate whether a new autochthonous transmission could take place if the malaria pathogen is introduced again in Lower Saxony. Thus, the potential spatial and temporal structure of temperature-driven malaria transmissions was mapped using the basic reproduction rate (R0) and measured and predicted air temperatures (1947–1960, 1961–1990, 1985–2004, 2020, 2060, 2100, each best case and worst case scenario). This paper focuses on both the summarizing of the results from this risk modelling approach and on the conclusions to be drawn. The recommendations highlight the need to link vector monitoring as one of the key elements of an epidemiological monitoring with the environmental monitoring.

The rise of the air temperature is assured to be part of the global climatic change, but there is still a lack of knowledge about its effects at a regional scale. The article tackles the correlation of air temperature with the phenology of selected plants by the example of Baden-Württemberg to provide a spatial valid data base for regional climate change models. To this end, the data on air temperature and plant phenology, gathered from measurement sites without congruent coverage, were correlated after performing geostatistical analysis and estimation. In addition, geostatistics are used to analyze and cartographically depict the spatial structure of the phenology of plants in spring and in summer. The statistical analysis reveals a significant relationship between the rising air temperature and the earlier beginning of phenological phases like blooming or fruit maturation: From 1991 to 1999 spring time, as indicated by plant phenology, has begun up to 15 days earlier than from 1961 to 1990. As shown by geostatistics, this holds true for the whole territory of Baden-Württemberg. The effects of the rise of air temperature should be investigated not only by monitoring biological individuals, as for example plants, but on an ecosystem level as well. In Germany, the environmental monitoring should be supplemented by the study of the effects of the climatic change in ecosystems. Because air temperature and humidity have a great influence on the temporal and spatial distribution of pathogen carriers (vectors) and pathogens, mapping of the environmental determinants of vector and pathogen distribution in space and time should be performed in order to identify hot spots for risk assessment and further detailed epidemiological studies.

The approval of genetically modified organisms [GMO] for deliberate release and placing on the market requires GMO environmental risk assessment [ERA] and GMO environmental monitoring [EM]. Both GMO ERA and GMO EM are still under discussion. The goal of this article is, firstly, to analyse principles of GMO EM as published in the Association of German Engineers [VDI] Guideline 4330 Part 1, focusing on the characterisation of the receiving environment affected by GMO cultivation and the representativeness of GMO EM to assess large-scale implications of GMO cultivation. Secondly, the article introduces measures to meet these issues by the use of map data and statistics within a geographical information system [GIS]. Finally, three case studies exemplify the application of data and methods. To deal with spatial issues of GMO EM as outlined in the VDI Guideline 4330 Part 1, a GIS-based approach is presented. It relies on both spatial data collected from several sources which were derived from sample point data and geostatistical and multivariate statistical methods within a GIS environment. Data used for describing the receiving environment and for planning and evaluating monitoring schemes comprise information about land use, climate, phenology, soil coverage, species distribution and ecoregions. The case studies deal with (1) ecological land classification for characterisation of GMO-receiving environments and representative EM, (2) selection of representative sites for modelling GMO dispersal, and (3) delineation and mapping of segregation distances. Even a systematic and stepwise-structured risk assessment cannot cover all risk relevant questions, especially large-scale, long-term and combinatory effects which may not occur before the conventional application of the respective GMO. Hence, GMO EM is crucial to deal with unanticipated and undesirable effects. The article gives an overview of a GIS implementation and relevant geodata promoting GMO EM.

Background, aim and scope European legislation stipulates that genetically modified organisms (GMO) have to be monitored to identify potential adverse environmental effects. A wealth of different types of monitoring data from various sources including existing environmental monitoring programmes is expected to accumulate. This requires an information system to efficiently structure, process and evaluate the monitoring data. Methods A structure for an Information System for Monitoring GMO (ISMO) was developed by a multidisciplinary research team. It is based on the requirement to organise all relevant information in a logical, readily accessible and functional manner. Results For the ISMO, we present a combination of three interrelated components: Firstly, an ISMO should comprise a knowledge database structured according to information related to the different scale levels of biological organisation relevant to GMO monitoring and scientific hypotheses on cause-effects which should be validated by monitoring data. Secondly, a monitoring database should be part of an ISMO containing GMO-specific monitoring data and meta-data. This monitoring database should be linked with monitoring data from other monitoring programmes which are relevant for GMO-related questions. Thirdly, an ISMO should encompass a database covering administrative and procedural data. Neither national nor international approaches to an ISMO exist yet. Conclusions An ISMO as designed in this paper could support competent authorities in both the GMO notification process and in post-market monitoring. This includes evaluating the environmental risks of experimentally releasing GMO and placing them on the market, assessing monitoring plans and evaluating monitoring results. The ISMO should be implemented on both the national and international level, preferably combining different administrative scales. Harmonisation approaches towards GMO monitoring data are at an initial stage, but they are a precondition to coordinated GMO monitoring and to successfully implementing an ISMO. It is recommended to set up a legal basis and to agree on common strategies for the data coordination and harmonisation.

A fast approximation method to three dimensional equations in quasi-static uncoupled thermoelasticity is proposed. We approximate the density via Gaussian approximating functions introduced in the method approximate approximations. In this way the action of the integral operators on such functions is presented in a simple analytical form. If the density has separated representation, the problem is reduced to the computation of one-dimensional integrals which admit efficient cubature procedures. The comparison of the numerical and exact solution shows that these formulas are accurate and provide the predicted approximation rate 2 , 4 , 6 and 8 .