Combined Use of CytoSorb and ECMO in Patients with Severe Pneumogenic Sepsis.

BACKGROUND: High morbidity and mortality are frequently reported in intensive care patients suffering from severe sepsis with systemic inflammation. With the development of severe respiratory failure, extracorporeal membrane oxygenation (ECMO) is often required. In this study, cytokine adsorption therapy in combination with ECMO is applied in patients with acute respiratory distress syndrome (ARDS) due to severe pneumogenic sepsis. The efficacy of this therapy is evaluated compared with a historical cohort without hemoadsorption therapy. METHODS: Between January and May 2018, combined high-flow venovenous ECMO and CytoSorb therapy (CytoSorb filter connected to ECMO circuit) was applied in patients (n = 13) with pneumogenic sepsis and ARDS. These patients were prospectively included (CytoSorb group). Data from patients (n = 7) with pneumogenic sepsis and ECMO therapy were retrospectively analyzed (control group). RESULTS: All patients survived in the CytoSorb group, where the 30-day mortality rate reached 57% in the control group. After CytoSorb therapy, we instantly observed a significant reduction in procalcitonin (PCT) and C-reactive protein (CRP) levels compared with the control group. Within 48 hours, the initial high doses of catecholamine could be weaned off only in the CytoSorb group. CONCLUSIONS: Our results indicate that CytoSorb in combination with ECMO is an effective therapy to prevent escalation of sepsis with rapid weaning off high-dose catecholamine infusions and quick reduction in PCT and CRP levels. Optimal timing of immunomodulatory therapy and impact on ECMO-related inflammation still need to be furtherly investigated.

Veno-Venous Extracorporeal Lung Support as a Bridge to or Through Lung Volume Reduction Surgery in Patients with Severe Hypercapnia.

Extracorporeal lung support (ECLS) represents an essential support tool especially for critically ill patients undergoing thoracic surgical procedures. Lung volume reduction surgery (LVRS) is an important treatment option for end-stage lung emphysema in carefully selected patients. Here, we report the efficacy of veno-venous ECLS (VV ECLS) as a bridge to or through LVRS in patients with end-stage lung emphysema and severe hypercapnia. Between January 2016 and May 2017, 125 patients with end-stage lung emphysema undergoing LVRS were prospectively enrolled into this study. Patients with severe hypercapnia caused by chronic respiratory failure were bridged to or through LVRS with low-flow VV ECLS (65 patients, group 1). Patients with preoperative normocapnia served as a control group (60 patients, group 2). In group 1, VV ECLS was implemented preoperatively in five patients and in 60 patients intraoperatively. Extracorporeal lung support was continued postoperatively in all 65 patients. Mean length of postoperative VV ECLS support was 3 ± 1 day. The 90 day mortality rate was 7.8% in group 1 compared with 5% in group 2 (p = 0.5). Postoperatively, a significant improvement was observed in quality of life, exercise capacity, and dyspnea symptoms in both groups. VV ECLS in patients with severe hypercapnia undergoing LVRS is an effective and well-tolerated treatment option. In particular, it increases the intraoperative safety, supports de-escalation of ventilatory strategies, and reduces the rate of postoperative complications in a cohort of patients considered "high risk" for LVRS in the current literature.

Rib osteosynthesis is a safe and effective treatment and leads to a significant reduction of trauma associated pain.

PURPOSE: The usefulness of chest wall stabilization after blunt chest wall trauma with unstable rib fractures has recently been intensely discussed. Thereby, the surgical approach seems to influence outcome, mortality and the long-term complication rate including chronic chest pain, thoracic deformity and quality of life. Here, we present the outcome after surgical stabilization of unstable rib fractures using intramedullary splints and plate osteosynthesis. METHODS: n = 50 patients were enrolled in this trial. Surgical stabilization was performed using intramedullary splints and/or plate osteosynthesis. Video-assisted thoracoscopy was performed in all patients for the inspection of the thoracic cavity and to exactly localize the fractured ribs. The pre- and postoperative pain course was documented using the visual analog scale. RESULTS: A total of n = 50 patients (10 females, mean age 63 years) were included into the analysis. All patients presented with traumatic serial rib fractures with a mean of 3 fractured ribs (range 2-8 ribs) and an unstable thorax wall. Rib osteosynthesis was performed using intramedullary splints (n = 17 patients), locking plates (n = 17 patients), or a combined use of both procedures (n = 16 patients). Mean operating time was 80 min (31-161 min). No major complications were seen intra- and postoperatively. Mean hospital stay was 8 ± 2 days (2-21 days). In all patients, excellent chest wall stability was achieved. Moreover, a significant reduction of pain was observed (2.6 ± 0.3 postoperatively vs. 8 ± 1.15 preoperatively, p < 0.0001) already during the hospital stay. CONCLUSIONS: Rib osteosynthesis is a safe and effective treatment option for patients with unstable rib fractures after blunt chest wall trauma. It leads to a significant reduction of the trauma-associated pain caused by the rib fractures and supports a quick recovery of the patients.

Use of a Powered Stapling System for Minimally Invasive Lung Volume Reduction Surgery: Results of a Prospective Double-Blind Single-Center Randomized Trial.

BACKGROUND: Video-assisted thoracoscopic surgery (VATS)-lung volume reduction surgery (LVRS) represents an important treatment option for patients with advanced lung emphysema. For VATS lung resection, endoscopic staplers are routinely used. Recently, a new generation of electronically powered stapling systems was developed. In this study, the iDrive powered stapling system (Covidien, Germany) was first tested during VATS-LVRS and compared with a non-electronic conventional device. METHODS: Forty patients with advanced emphysema were enrolled in a prospective randomized trial. All patients underwent bilateral VATS-LVRS. Patients were randomized for iDrive use on the right lung (n = 20) or left lung resection (n = 20). A conventional endoscopic stapler (EndoGIA, Covidien) was used for contralateral resection in same patients. Therefore, 40 resections were performed with the iDrive and 40 with the EndoGIA. The duration of surgery, air leakage after extubation, and on postoperative day 1 (POD1), as well as length of chest tube therapy, were documented. RESULTS: The application of the new system was uneventful. Mean duration of surgery was 52 ± 2.5 minute in the iDrive group compared with 54 ± 3.8 minute in the EndoGIA-group (p = 0.5). After extubation, the mean air leakage in the iDrive-group did not differ significantly from that in the EndoGIA-group (p = 0.6). This was also observed on POD1 (p = 0.7). Moreover, length of drainage therapy also did not show significant differences between both groups (p = 0.6). CONCLUSION: The iDrive powered stapling system offers one-handed, push-button operation, which eliminates the manual firing force and possibly enables more precise resection. In the current study, the novel system led to comparable results with the conventional mechanical stapler without any disadvantages in patients undergoing bilateral VATS-LVRS.

[Application of Intrabronchial Valves in High Risk Patients with Bronchopleural Fistula: an Alternative Therapeutic Option]. / Applikation intrabronchialer Ventile zur Behandlung der persistierenden bronchopleuralen Fistel nach komplikativem Pleuraempyem mit Lungendestruktion.

OBJECTIVES: Persistent air leak or bronchopleural fistula (BPF) is a challenging and frequently observed problem after pulmonary resection and may lead to prolonged chest tube therapy. One efficient nonsurgical approach to manage such a fistula is the application of intrabronchial valves. This may support earlier chest tube removal and hospital discharge. METHODS: Between 04/2015 and 03/2017, n = 8 patients (n = 4 female) with severe pleural empyema and necrotising lung tissue defects developed prolonged air leak and persistent BPF after surgery. Radiological and bronchoscopical investigations revealed the presence of a BPF. For closure, intrabronchial valves were endoscopically inserted into the affected bronchi. In patients with repeat development of empyema, a chest wall window was required (n = 6 patients). RESULTS: The mean age was 61 years (45 - 85 years). After repeated surgical debridement, the space was sterile and the chest wall window was closed. After valve placement, air leaks were no longer detectable. In all patients, the procedures were well tolerated without any negative events. After successful valve placement, chest tubes could be removed in all n = 8 patients within 7 days (3 - 15 days) and patients were discharged thereafter. CONCLUSIONS: Placement of intrabronchial valves presents an alternative option to conventional surgical and non-surgical methods for the treatment of postoperative persistent air leak or BPF. Particularly in high risk patients, this procedure is safe and effective.

Analysis of autoantibodies against human retinal antigens in sera of patients with glaucoma and ocular hypertension.

PURPOSE: The aim of this study was to show that complex antibody patterns against retinal antigens in sera of patients with glaucoma, found in previous studies, are autoantibodies against human antigens. METHODS: Sera of 179 patients were collected at the Department of Ophthalmology (University of Mainz, Germany): non-glaucomatous control patients (n=45), primary open-angle glaucoma (n=45), ocular hypertension (n=44), and normal tension glaucoma patients (n=45). The sera were tested against Western blots of human retinal antigens. IgG antibody patterns were analyzed by multivariate statistical techniques, and some significant antigens were identified by mass spectrometry. RESULTS: All subjects, even healthy ones, showed different and complex banding patterns. Glaucoma groups showed up- and down-regulations of antibody reactivities compared to the control group. The multivariate analysis of discriminance found significant differences (p<0.05) in IgG antibody profiles between glaucoma groups, ocular hypertension, and healthy subjects against human retinal antigens. The antigen band at 12 kDa was identified as Histone H4 via mass spectrometry, the 29 kDa band as cellular retinaldehyde-binding protein, and one at 49 kDa as retinal S-antigen. CONCLUSIONS: Using human retinal antigen, we demonstrated that complex autoantibody patterns exist in sera of patients with glaucoma. Large correlations with previous studies using bovine retinal antigens could be seen.

Sera of glaucoma patients show autoantibodies against myelin basic protein and complex autoantibody profiles against human optic nerve antigens.

BACKGROUND: The aim of this study was to gain more information about the possible immunological mechanisms in glaucoma. We analyzed the complex autoantibody patterns against human optic nerve antigens in sera of patients with glaucoma and tried to identify important antigens. METHODS: Sera of 133 patients were included: healthy control subjects (n = 44), primary open-angle glaucoma (n = 44), and normal tension glaucoma patients (n = 45). The sera were tested against Western blots of human optic nerve, and antibody bands were visualized with chloronaphthol. IgG antibody patterns were analyzed by multivariate statistical techniques, and the most significant antigens were identified by mass spectrometry (Maldi-TOFTOF). RESULTS: All subjects, even healthy ones, showed different and complex antibody patterns. Glaucoma groups showed specific up- and down-regulations of antibody reactivities compared to the control group. The multivariate analysis of discriminance found significant differences (P < 0.05) in IgG antibody profiles against human optic nerve antigens between both glaucoma groups and healthy subjects. The identified antigens include: myelin basic protein (up-regulated in the POAG group), glial fibrillary acidic protein (down-regulated in the glaucoma groups), and vimentin (down-regulated in the glaucoma groups in comparison to controls). CONCLUSIONS: Using human optic nerve antigen, we were able to demonstrate that complex IgG autoantibody patterns exist in sera of patients with glaucoma. Large correlations between the given and our previous studies using bovine optic nerve antigens could be seen. Furthermore, anti-myelin basic protein antibodies, which can also be detected in patients with multiple sclerosis, were found in sera of glaucoma patients.

What shall we do with the drunken sailor? Effects of alcohol on the performance of ship operators.

The purpose of this study was to specify the effects of alcohol on the performance of ship operators as a contribution to the development of new strategies against the risks of alcohol in water traffic. The nautical performance of 21 captains before and after alcohol consumption was assessed on a ship piloting simulator. The simulated scenarios represented passages of a container vessel through the German Bight. Performance was examined by nautical instructors according to standardised protocols. Mean (S.D.) blood alcohol concentrations (BACs) of 0.100 (0.024) g/dl before and 0.100 (0.017) g/dl after the performance trial resulted in striking effects on the nautical performance. The categories most severely affected were foresight and analysis of situation (impairment in 18 of 21 cases), concentration (impairment in 16 of 21 cases), accurateness, risk disposition and navigation (impairment in 15 of 21 cases). Chart work, preparation and communication were impaired in 12, 11 and 10 of 21 cases, respectively. None of the participants were capable to operate the simulated ship with an adequate safety after ingestion of alcohol. From these findings, and in consideration of the well-established impairment of a multitude of mental and physical functions by alcohol, it can be concluded that even low BACs bear high risks in water traffic, a concentration above 0.1 g/dl will hinder a sufficiently safe performance of ship operators. This should be considered in alcohol education and legislation.

Mucosa-associated lymphoid tissue lymphoma in the conjunctiva of a child.

Marginal zone lymphoma of the mucosa-associated lymphoid tissue (MALT) occurring in the conjunctiva has yet not been described in pediatric patients. We present a case of a 10-year-old girl with a MALT lymphoma involving the conjunctiva. The tumor consisted of plasma cells and marginal zone cells with discrete epitheliotropism. Immunohistochemical studies revealed positivity for CD20 and cytoplasmic immunoglobulin lambda light chain restriction. Polymerase chain reaction-based molecular analysis of the infiltrate showed a monoclonal rearrangement for the hypervariable complimentary determining region III immunoglobulin region; whereas, a polyclonal pattern was seen for the T-cell receptor gamma chain. Extensive further examination, including molecular techniques, revealed that the lymphoma was restricted to the conjunctiva (stage IA) and was not associated with any specific infection. The patient was treated with surgery and additional local cryotherapy. After 15 months of follow-up, the patient remains in complete remission.