Intra-arrest formation of right-heart thrombi -- a case illustrated by real-time ultrasonography.

The presence of free-floating right-heart thrombus has been reported in a cardiac arrest patient in the periarrest period. Free-floating right atrial thrombus is a rare phenomenon seen in patients developing severe pulmonary embolism, and is associated with increased mortality. However, there have been no previously reported cases of right-heart thrombus formation during a resuscitated cardiac arrest. We present the pre-hospital case of a woman in the clinical setting of cardiogenic shock due to acute myocardial infarction who developed asystolic cardiac arrest on the scene. Recent implementation of ultrasonography into the regional pre-hospital care protocol enabled sonographic investigation before and during cardiac arrest. This allowed detection of right atrial septal thrombus formation in the course of advanced life support and its migration through the tricuspid valve. The pathophysiological consequences, clinical significance and potential therapeutic options are discussed.

The practice of therapeutic mild hypothermia in cardiac arrest survivors in the Czech republic.

BACKGROUND: The proper performance of therapeutic mild hypothermia (TH) in cardiac arrest survivors is a prerequisite for achieving the best possible outcome. We analyzed the recent technical issues of in-hospital TH practices in the Czech Republic. METHODS: As the second project of the PRE-COOL (Pre-hospital Cooling in Cardiac Arrest Patients) working group, we compiled the directory of all non-surgical intensive care units (ICUs) in the Czech republic. A head physician of every ICU was provided a structured questionnaire in October 2008. RESULTS: From a total of 487 ICUs that were sent the questionnaire, 41.5% responded. We analyzed the responders that provide early post-resuscitation care, including TH (N=90). The site of TH initiation was most frequently an ICU bed (93.3%). A broad TH indication irrespective of the initial rhythm, cardiac arrest location or the presence of witnesses was reported by 48.9% of the responders. Up to 81.1% of the responding ICUs did not exclude from TH therapy patients who were developing post-resuscitation shock. Complex neuroprotective and cardioprotective approaches (TH, urgent coronary intervention, control of glycemia and early goal-directed hemodynamic support) were practiced at 52.2% of the ICUs. Of the responders, 54.4% cooled patients for 24 hours. The most frequently used cooling techniques were surface cooling with ice packs (88.9%) and intravenous cold infusion (84.4%). CONCLUSION: The survey revealed the recent practice of TH management of cardiac arrest survivors in the Czech republic. The modes of TH practice were different in many aspects, and unifying the basic components is advisable.

[Current cooling methods for induction of mild hypothermia in cardiac arrest survivors]. / Soucasné ochlazovací metody pro indukci mírné hypotermie po srdecní zástave.

Induction of mild therapeutic hypothermia early after return of spontaneous circulation improves prognosis of cardiac arrest survivors. Rapid cooling of the patients and correct maintainance of the target therapeutic temperature followed by controlled slow rewarming can be achieved by several noninvasive and invasive methods of various efficacy. Elementary and the most frequently used methods are surface cooling via ice-packs and rapid intravenous administration of cold crystaloids. Mattress cooling systems and facilities for endovascular cathether-cooling are more sophisticated, manageable and ensure more precise titration of therapeutic temperature. Cooling caps and helmets leading to selective head cooling can be used as the complementary techniques. Several other methods are too instrumentation-intensive, too invasive or investigated in animal experiments only. Anyway, near future may bring a rapid development of new effective and safe cooling systems.

[Overcooling during mild hypothermia in cardiac arrest survivors--phenomenon we should keep in mind]. / Nadmerné othlazení behem mírné hypotermie po srdecní zástave--fenomén zasluhující pozornost.

BACKGROUND: Mild hypothermia (MH) in cardiac arrest survivors has became a routine part of early postresuscitative support. Overcooling is a frequent phenomenon with the unknown outcome. AIM OF THE STUDY: To analyze the incidence and outcome ofovercooling below body core temperature (BT) of 32 degrees C. MATERIAL AND METHODS: We performed retrospective analysis of all 56 consecutive cardiac arrest survivors treated by MH who reached therapeutic BT in the 2nd Department of Internal Medicine, General Teaching Hospital, Prague. MH was initiated as soon as possible after the return of spontaneous circulation to reach BT of 33 degrees C followed by maintainance of BT 32-34 degrees C for 12 hours. Patients were cooled by surface cooling via ice-packs and by interavenous infusion of cold crystaloids. RESULTS: Overcooling below BT of 32 degrees C was observed in 23 patients (41%). This group of patients had more frequently asystole as the initial rhythm (34.8 vs 9.1%), more frequently were cooled by combinatory cooling approach (56.5 vs 27.3%), more frequently had lower baseline BT (35.3 +/- 1.3 vs 36.2 +/- 1.2 degrees C), higher cooling rate (the interval required for a decrease of BT by 1 degrees C 61.5 +/- 53.1 vs 90.1 +/- 50.0 min) (all p < 0.05) than patients with proper profile of BT during MH. Overcooling was independent negative predictor of discharge favourable neurological outcome (OR 0.16, 0.022-0.77, p = 0.037). CONCLUSION: Induction of MH by conventional cooling approach is burdened by high risk of overcooling. This phenomenon is probably associated with worse outcome.

An experimental immunoscintigraphic study with anti-CEA monoclonal antibody (DG2).

Monoclonal antibody D11-DG2 (DG2) against carcinoembryonic antigen (CEA) was examined for suitability for radioimmunodetection of human tumors grown in nude mice. Antibodies DG2 and a control antibody of the same IgG1 subclass were labeled with 131I and injected into mice bearing one of three types of CEA-containing tumors (cell lines LS 174T, HT-29 and Rec S) and/or a CEA-negative tumor (Rec R). Gamma-camera imaging and distribution studies revealed that CEA-containing tumors selectively accumulate DG2 but Rec R does not. As the tumors differ in CEA-content, the highest accumulation of 131I-DG2 (corresponding to the best scintigraphic imaging) was found in LS 174T tumors, intermediate in Rec S and lowest in HT-29 tumors. The mean tumor-to-blood ratios on the sixth day after antibody administration were 4.6, 3.2, and 2.1, respectively, in the control experiments the value of this parameter was always lower than 1. The results showed the applicability of DG2 for immunoscintigraphic studies in patients. Furthermore, a positive correlation was found between the uptake of anti-CEA antibody and CEA-content in the tumors.

Distribution, kinetics and immunoscintigraphy of 131-I labelled intact antifibrinogen-fibrin antibody (AbFbg) and its F(ab')2 fragment.

131-I-labelled anti fibrin-fibrinogen antibody (AbFbg) was compared with its F(ab')2 fragment in distribution studies and by immunoscintigraphy with a view to tumour visualization in tumour bearing rats. The distribution studies indicated that the intact antibody is more concentrated in tumour tissue than the F(ab')2 fragment. By 168h after injection, when tumour-to-tissue ratios were highest in the majority of tissues, the tumour concentration of intact antibody was 3 to 4 times that of the F(ab')2 fragment. The intact antibody is more suitable than the F(ab')2 fragment for tumour imaging especially in the abdominal region where the highest tumour-to tissue ratios were obtained with intact antibody in liver, spleen, intestines and kidneys.

[Immunoscintigraphy in experiments and clinical practice: its possibilities, advantages and limitations]. / Imunoscintigrafie v experimentu, klinice, její moznosti, výhody a omezení.

The authors present their experience gained in preparing, isolating and labeling antibodies with radionuclides for the purpose of using them in immunoscintigraphy. The experimental part includes results obtained with different labeled antibodies and their F/ab/2 fragments in distribution studies, involving also immunoscintigraphic imaging of tumors. The clinical part presents results of immunoscintigraphy obtained with the commercial antibody kits Iodomab and Imacis in patients with tumors of the digestive tract.

Antiferritin antibodies in immunoscintigraphic detection of human tumor xenografts.

Affinity-purified antibodies against human placental ferritin and their F(ab)2 fragments labeled with 131I were examined for suitability for radioimmunodetection of ferritin-containing tumors. The nude mouse model (BALB/c, nu/nu) with xenografts of HeLa cell tumors and human adenocarcinoma of the rectum (with proven ferritin content) was used. Gamma-camera imaging and tissue distribution studies revealed that both kinds of tumor selectively accumulate antiferritin antibodies and their fragments. In large necrotic tumors nonspecific uptake of radiolabeled normal IgG occurred, but otherwise there was no tumor localisation. This study, in accordance with the literature, confirms the utility of antiferritin antibodies for the detection of human tumors in an animal model.