Extracorporeal membrane oxygenation for diffuse alveolar hemorrhage and severe hypoxemic respiratory failure from silicone embolism.

Liquid silicone is an inert material that may be used for cosmetic procedures by physicians as well as illegally by non-medical personnel. The use of silicone may result in severe complications, disfigurement, and even death. In addition, the indications for extracorporeal membrane oxygenation (ECMO) support have been increasing as a salvage therapy for a variety of life-threatening conditions. The patient is a 27-year-old woman with no significant medical conditions who developed silicone emboli, and subsequent diffuse alveolar hemorrhage after being injected with silicone in her gluteal region without medical supervision. She became profoundly hypoxemic and suffered a brief asystolic cardiac arrest in this setting. The patient was placed on veno-venous ECMO support for 14 days. Medical care during ECMO was complicated by pulmonary hemorrhage, hemothorax, pneumothorax, and blood clot, resulting in oxygenator change-out. A modified adult ECMO circuit (Jostra QuadroxD, Maquet Cardiopulmonary, Rastatt, Germany) was used to transport the patient from a nearby community affiliate hospital and then reconfigured for the medical intensive care unit on a standard HL-20 heart-lung console. Although the use of ECMO for severe hypoxemic respiratory failure has been widely reported, to our knowledge, this is the first reported successful use of ECMO for silicone embolism syndrome associated with diffuse alveolar hemorrhage and severe hypoxemic respiratory failure.

Simultaneous pulmonary embolectomy and aortic root replacement.

Massive pulmonary embolism (PE) is characterized by hypotension and cardiogenic shock due to right ventricular failure, and is associated with a high mortality rate. In this case study, we report a simultaneous pulmonary embolectomy and aortic root replacement in a 71-year-old woman with a known ascending aortic aneurysm who sustained a massive PE following a VATS left upper lobectomy for non-small cell lung cancer.

The contemporary surgical intensive care unit. Structure, staffing, and issues.

Modern ICUs present unique challenges to physician-administrators in the current health care environment. Several models of care (e.g., open versus closed ICUs, physician extenders in the ICU) are used throughout the country, with varying degrees of success. Although all care models may work, the ideal model for a given ICU can be found only through ongoing performance improvement.

End-of-life decision-making in the hospital: current practice and future prospects.

Chart review of patients who died in the hospital was used to describe the pattern of end-of-life decision-making and care for hospitalized dying patients and to propose a structured process of assessing the suitability of patients for palliative care. The setting was a large urban academic medical center, and the sample comprised 200 of 205 consecutive adult deaths during the first 4 months of 1996. The main outcome measures were identification of the patient as dying, do-not-resuscitate (DNR) orders, and comfort care plans. Charts of 72% of the patients had evidence that they were considered dying. DNR orders were in place for 77% of all the patients, and 46% had comfort care plans. Presence of a health care proxy was significantly associated with DNR orders and comfort care plans (P < 0.001). On average, comfort care plans were put in place 15 days after admission, as compared with an overall mean length of stay of 17 days. Substantial proportions of patients with comfort care plans continued to receive antibiotics (41%) and blood draws (30%). Only 13% of the patients on mechanical ventilation and 19% of those on artificial nutrition and hydration underwent withdrawal of these interventions prior to death. These findings suggest opportunities and challenges for improving practice patterns for hospitalized dying patients. We recommend several measurable objectives for evaluating end-of-life decision-making and care and propose the development of a goals of care assessment tool to guide appropriate transitions from life-sustaining treatment to comfort care and plan palliative services.

Interventions in the human genome: some moral and ethical considerations.

In the debate regarding the different possibilities for gene therapy, it is presupposed that the manipulations are limited to the nuclear genome (nDNA). Given recent advances in genetics, mitochondrial genome (mtDNA) and diseases must be considered as well. In this paper, we propose a three dimensional framework for the ethical debate of gene therapy where we add the genomic type (nDNA vs. mtDNA) as a third dimension to be considered beside the paradigmatic dimensions of target cell (somatic vs. germ-line) and purpose (therapeutic vs. enhancement). Somatic gene therapy can be viewed today as generally accepted, and we review the contemporary arguments surrounding it on the basis of bioethical-pragmatic, socio-political and deontological classifications. Many of the supposed ethical questions of somatic gene therapy today are not new; they are well-known issues of research ethics. We also critically summarize the different international perspectives and the German ethical discussion regarding manipulations of germ-line cells.

Quality of life of hepatitis B and C patients after liver transplantation.

Liver transplantation is an accepted treatment for end-stage liver disease due to hepatitis C (HCV), but remains controversial for patients with hepatitis B(HBV). Recently, the use of aggressive hepatitis B immunoglobulin (HBIg) to maintain hepatitis B surface antibody (anti-HBs) titers greater than 500 IU/L has been reported to improve outcome of transplantation for hepatitis B. The aim of this study was to compare the quality of life of patients transplanted for HBV using this regimen of HBIg immunoprophylaxis (group 1) to patients transplanted for HCV (group 2). The State-Trait Anxiety Inventory (STAI), Sickness Impact Profile (SIP), and a work survey were administered to two groups of patients. The STAI measured anxiety while the SIP evaluated physical and psychosocial function. Lower scores indicated less anxiety and dysfunction. Questions regarding hours worked prior to illness and hours worked after transplantation were administered to both groups. Group 1 included a majority of patients who were hepatitis B e antigen (HBeAg) positive prior to transplantation. Survey response was 13:16 (81%) for group 1; and 17:24 (72%) for group 2. Group 1 revealed significantly lower scores than group 2 on the STAI and the overall SIP score. Group 1 reported working similar hours after transplantation as prior to illness while group 2 did not. Thus, patients transplanted for HBV and treated with aggressive HBIg immunoprophylaxis attained a higher quality of life than patients transplanted for HCV.

Response to "Germ-line therapy to cure mitochondrial disease: protocol and ethics of in vitro ovum nuclear transplantation" by Donald S. Rubenstein, David C. Thomasma, Eric A. Schon, and Michael J. Zinaman (CQ Vol 4, No 3)

As a result of the dramatic advances made in molecular biology, gene therapy has become viable. The initial endeavors were with monogenetic disorders, but gene therapy may also be of benefit in cancer therapy and treatment of infectious diseases. The current framework for the ethical discussion of gene therapy is a two-dimensional scheme. The first dimension is the target tissue (somatic cells versus germ-line cells) and the second dimension is the purpose (therapy/prevention versus enhancement). Although the mitochondrial genome occurs in eukaryotic cells at several hundred copies and the sequence has been known since the late 1980s, it has been excluded from the ethical discussions of gene therapy or genetic interventions. With the development of the first IVONT protocol and successful experiments with mitochondrial transfection vectors, the two-dimensional framework is no longer adequate. Therefore, we propose a three-dimensional framework for the ethical debate of genetic interventions in humans, whereby we include the genome type (nDNA versus mtDNA) as a third dimension. The ethical evaluation of all imaginable genetic interventions is located on five different levels. The demands for ethical justification are different for each.