Armando Lenz

Heparin-induced thrombocytopenia (HIT) is a life-threatening complication associated with high medical costs. Factor Xa inhibitors gradually replace approved treatment with intravenous direct thrombin inhibitors despite their off-label indication, because of easier management and favorable economic profile. Whether they are cost-effective remains unclear. We evaluated the cost-effectiveness of approved and off-label anticoagulants in patients with suspected HIT, based on census data from the largest Swiss hospital between 2015 and 2018. We constructed a decision tree model that reflects important clinical events associated with HIT. Relevant cost data were obtained from the finance department or estimated based on the Swiss-wide cost tariff. We estimated averted adverse events (AEs) and incremental cost-effectiveness ratio as primary outcome parameters. We performed deterministic and probabilistic sensitivity analyses with 2000 simulations to assess the robustness of our results. In the base-case analysis, the total cost of averting 1 AE was 49 565 Swiss francs (CHF) for argatroban, 30 380 CHF for fondaparinux, and 30 610 CHF for rivaroxaban; after adjusting for 4Ts score: 41 152 CHF (argatroban), 27 710 CHF (fondaparinux), and 37 699 CHF (rivaroxaban). Fondaparinux and rivaroxaban were more clinically effective than argatroban, with AEs averted of 0.820, 0.834, and 0.917 for argatroban, fondaparinux, and rivaroxaban, respectively. Treatment with fondaparinux resulted in less cost and more AEs averted, hence dominating argatroban. Results were most sensitive to AE rates and prolongation of stay. Monte Carlo simulations affirmed our base-case analysis. This is the first cost-effectiveness analysis comparing argatroban with fondaparinux and rivaroxaban using primary data. Fondaparinux and rivaroxaban resulted in more averted AEs, but fondaparinux had greater cost savings. Fondaparinux could be a viable alternative to argatroban.

Levosimendan is a potent non-adrenergic inodilator agent. The net effect of hemodynamic changes may result in a hyperdynamic state with low systemic vascular resistance. We conducted a systematic review and meta-analysis assessing hemodynamics in cardiac surgery patients treated with levosimendan. English-language literature was searched systematically from 2006 until October 2018, including randomized controlled trials and case-matched or retrospective studies providing at least two sequentially measured hemodynamic variables in adult patients who underwent cardiac surgery with cardiopulmonary bypass and were treated with levosimendan in comparison to alternative drugs or devices. Cardiac index significantly increased in the levosimendan group by 0.74 (0.24 to 1.23) [standardized mean difference (95% CI); p = 0.003] from baseline to postoperative day (POD) 1, and by 0.75 (0.25 to 1.25; p = 0.003) from baseline to POD 7, when corrected for the standardized mean difference at baseline by a multivariate mixed effects meta-analysis model. With this correction for baseline differences, other hemodynamic variables including systemic vascular resistance did not significantly differ until POD 1 [−0.17 (−0.64 to 0.30), p = 0.48] and POD 7 [−0.13 (−0.61 to 0.34), p = 0.58] between the levosimendan and the comparator group. Levosimendan increases cardiac index in patients undergoing cardiac surgery. Although levosimendan has inodilator properties, this meta-analysis finds no clinical evidence that levosimendan produces vasopressor-resistant vasoplegic syndrome.

BACKGROUND: The aim of the study was to determine if training in transesophageal echocardiography (TEE) using a TEE simulator improves the ability of novice operators to perform and interpret a focused critical care TEE. METHODS: In this prospective, randomized, controlled study with blinded outcome assessment, 44 intensive care unit trainees were randomly assigned to a control group receiving 4 hours of lecture-based training only, or an intervention group which was additionally trained for 4 hours using a TEE simulator. After the training intervention, each participant performed 2 TEEs in intensive care unit patients which were evaluated by blinded assessors. The imaging quality of TEEs was measured using a predefined examination quality score ranging from 0 to 100 points. The correct quantification of pathologies and the interpretation of the TEEs were evaluated by blinded assessors using focused and comprehensive expert TEEs as comparators. RESULTS: A total of 114 TEEs were assessed. The mean examination quality score was 55.9 (95% confidence interval [CI], 50.3–61.5) for TEEs of the control group, 75.6 (95% CI, 70.1–81.0) for TEEs of the intervention group, and 88.5 (95% CI, 79.3–97.7) for TEEs in the expert group. The multiple comparisons revealed significant differences between all groups (19.7 [95% CI, 12.8–26.6], P < .001 for intervention versus control; 32.6 [95% CI, 23.0–42.3], P < .001 for expert versus control; 12.9 [95% CI, 3.4–22.5], P = .008 for expert versus intervention). Substantial agreement of the quantification and interpretation ratings of basic TEEs by the intervention (86.7% for quantification and 97.1% for interpretation) or expert group (93.2% for quantification and 98.4% for interpretation) with blinded assessors was detected. The control groups TEEs agreed less (75.6% for quantification and 91.8% for interpretation). CONCLUSIONS: Simulation-based TEE training improves the ability of novice operators to perform a focused critical care TEE in comparison to lecture-based education only. After 8 hours of simulator and lecture-based training, the majority of TEEs of novices are of sufficient quality for clinical use. Furthermore, a substantial skill level in correct quantification and interpretation of imaging is achieved.

Summary: We investigated how deciduous trees can adjust their freezing resistance in response to temperature during the progress of the ecodormancy phase, from midwinter to budburst. We regularly sampled twigs of four different temperate deciduous tree species from January to the leaf‐out date. Using computer‐controlled freezers and climate chambers, the freezing resistance of buds was measured directly after sampling and also after the application of artificial hardening and dehardening treatments, simulating cold and warm spells. The thermal time to budburst in forcing conditions (c. 20°C) was also quantified at each sampling as a proxy for dormancy depth. Earlier flushing species showed higher freezing resistance than late flushing species at either similar bud development stage or similar dormancy depth. Overall, freezing resistance and its hardening and dehardening potential dramatically decreased during the progress of ecodormancy and became almost nil during budburst. Our results suggest that extreme cold events in winter are not critical for trees, as freezing resistance can be largely enhanced during this period. By contrast, the timing of budburst is a critical component of tree fitness. Our results provide quantitative values of the freezing resistance dynamics during ecodormancy, particularly valuable in process‐based species distribution models.

Summary: Attempts at explaining range limits of temperate tree species still rest on correlations with climatic data that lack a physiological justification. Here, we present a synthesis of a multidisciplinary project that offers mechanistic explanations. Employing climatology, biogeography, dendrology, population and reproduction biology, stress physiology and phenology, we combine results from in situ elevational (Swiss Alps) and latitudinal (Alps vs. Scandinavia) comparisons, from reciprocal common garden and phytotron studies for eight European broadleaf tree species. We show that unlike for low‐stature plants, tree canopy temperatures can be predicted from weather station data, and that low‐temperature extremes in winter do not explain range limits. At the current low‐temperature range limit, all species recruit well. Transplants revealed that the local environment rather than elevation of seed origin dominates growth and phenology. Tree ring width at the range limit is not related to season length, but to growing season temperature, with no evidence of carbon shortage. Bud break and leaf emergence in adults trees are timed in such a way that the probability of freezing damage is almost zero, with a uniform safety margin across elevations and taxa. More freezing‐resistant species flush earlier than less resistant species. Synthesis: we conclude that the range limits of the examined tree species are set by the interactive influence of freezing resistance in spring, phenology settings, and the time required to mature tissue. Microevolution of spring phenology compromises between demands set by freezing resistance of young, immature tissue and season length requirements related to autumnal tissue maturation.

Low temperature extremes drive species distribution at a global scale. Here, we assessed the acclimation potential of freezing resistance in European beech (Fagus sylvatica L.) during winter. We specifically asked (i) how do beech populations growing in contrasting climates differ in their maximum freezing resistance, (ii) do differences result from genetic differentiation or phenotypic plasticity to preceding temperatures and (iii) is beech at risk of freezing damage in winter across its distribution range. We investigated the genetic and environmental components of freezing resistance in buds of adult beech trees from three different populations along a natural large temperature gradient in north-western Switzerland, including the site holding the cold temperature record in Switzerland. Freezing resistance of leaf primordia in buds varied significantly among populations, with LT₅₀ values (lethal temperature for 50% of samples) ranging from −25 to −40 °C, correlating with midwinter temperatures of the site of origin. Cambial meristems and the pith of shoots showed high freezing resistance in all three populations, with only a trend to lower freezing resistance at the warmer site. After hardening samples at −6 °C for 5 days, freezing resistance of leaf primordia increased in all provenances by up to 4.5 K. After additional hardening at −15 °C for 3 days, all leaf primordia were freezing resistant to −40 °C. We demonstrate that freezing resistance of F. sylvatica has a high ability to acclimate to temperature changes in winter, whereas the genetic differentiation of freezing resistance among populations seems negligible over this small geographic scale but large climatic gradient. In contrast to the assumption made in most of the species distribution models, we suggest that absolute minimum temperature in winter is unlikely to shape the cold range limit of beech. We conclude that the rapid acclimation of freezing resistance to winter temperatures allows beech to track changing climatic conditions, especially during unusually warm winters interrupted by very cold weather.

Summary: Within the same forest stand, temperate deciduous trees generally exhibit a distinct pattern in leaf‐out timing, with some species flushing earlier than other species. This study aimed to explain the timing of leaf‐out of various temperate tree species in relation to the risk of freezing damage to leaves. We combined long‐term series of leaf‐out date (14–32 years) of five temperate tree species located in both low and high elevations in Switzerland, daily minimum temperatures recorded at the same sites and species‐specific freezing resistance (LT₅₀) of emerging leaves. We calculated temperature safety margins (the temperature difference between absolute minimum temperature during leaf‐out and species‐specific LT₅₀ values), and date safety margins (time lag between the last day when temperature falls below species‐specific LT₅₀ values and the date of leaf‐out). Leaf‐out occurred when the probability to encounter freezing damage approaches zero, irrespective of climatic conditions (low vs. high elevation) and species (early‐ and late‐flushing species). In other words, trees leaf out precisely at the beginning of the probabilistically safe period. Interestingly, the temperature safety margins did not differ significantly between low and high elevation. Yet, the date safety margin was smaller at high elevation, presumably due to a faster increase in temperature during the leaf‐out period at high elevation. When species‐specific freezing resistance is taken into account, the time of leaf‐out converges among species towards a marginal risk of freezing damage. Thus, leaf‐out time has likely evolved in a way that the risk of freezing damage is minimized over a large spectrum of climatic conditions. Species with a small safety margin against freezing temperature, like Fagus sylvatica, appear to employ photoperiod co‐control of spring phenology, whereas species with a large safety margin depend largely on temperature for the right timing of leaf‐out. Our results offer a new avenue to explain the differences in leaf‐out timing among co‐occurring tree species. They further suggest that in a warming climate, tree species can expand their distribution range to the extent their phenology matches the stochasticity of freezing temperatures in spring.

Temperate climates are defined by a distinct temperature seasonality with large and often unpredictable weather during any of the four seasons. To thrive in such climates, trees have to withstand a cold winter and the stochastic occurrence of freeze events during any time of the year. The physiological mechanisms trees adopt to escape, avoid and tolerate freezing temperatures include a cold acclimation in autumn, a dormancy period during winter (leafless in deciduous trees), and the maintenance of a certain freezing tolerance during dehardening in early spring. The change from one phase to the next is mediated by complex interactions between temperature and photoperiod. This review aims at providing an overview of the interplay between phenology of leaves and species-specific freezing resistance. First, we address the long-term evolutionary responses that enabled temperate trees to tolerate certain low temperature extremes. We provide evidence that short term acclimation of freezing resistance plays a crucial role both in dormant and active buds, including re-acclimation to cold conditions following warm spells. This ability declines to almost zero during leaf emergence. Second, we show that the risk that native temperate trees encounter freeze injuries is low and is confined to spring and underline that this risk might be altered by climate warming depending on species-specific phenological responses to environmental cues.