Transcriptional Signatures of Sleep Duration Discordance in Monozygotic Twins

Introduction

Habitual short sleep duration is associated with adverse metabolic, cardiovascular, and inflammatory effects. Co-twin study methodologies account for familial (eg, genetics and shared environmental) confounding, allowing assessment of subtle environmental effects, such as the effect of habitual short sleep duration on gene expression. Therefore, we investigated gene expression in monozygotic twins discordant for actigraphically phenotyped habitual sleep duration.

Methods

Eleven healthy monozygotic twin pairs (82% female; mean age 42.7 years; SD = 18.1), selected based on subjective sleep duration discordance, were objectively phenotyped for habitual sleep duration with 2 weeks of wrist actigraphy. Peripheral blood leukocyte (PBL) RNA from fasting blood samples was obtained on the final day of actigraphic measurement and hybridized to Illumina humanHT-12 microarrays. Differential gene expression was determined between paired samples and mapped to functional categories using Gene Ontology. Finally, a more comprehensive gene set enrichment analysis was performed based on the entire PBL transcriptome.

Results

The mean 24-hour sleep duration of the total sample was 439.2 minutes (SD = 46.8 minutes; range 325.4-521.6 minutes). Mean within-pair sleep duration difference per 24 hours was 64.4 minutes (SD = 21.2; range 45.9-114.6 minutes). The twin cohort displayed distinctive pathway enrichment based on sleep duration differences. Habitual short sleep was associated with up-regulation of genes involved in transcription, ribosome, translation, and oxidative phosphorylation. Unexpectedly, genes down-regulated in short sleep twins were highly enriched in immuno-inflammatory pathways such as interleukin signaling and leukocyte activation, as well as developmental programs, coagulation cascade, and cell adhesion.

Conclusions

Objectively assessed habitual sleep duration in monozygotic twin pairs appears to be associated with distinct patterns of differential gene expression and pathway enrichment. By accounting for familial confounding and measuring real life sleep duration, our study shows the transcriptomic effects of habitual short sleep on dysregulated immune response and provides a potential link between sleep deprivation and adverse metabolic, cardiovascular, and inflammatory outcomes.

Extracorporeal membrane oxygenation in spina bifida and (H1N1)-induced acute respiratory distress syndrome

Acute respiratory distress syndrome (ARDS) is characterized as an acute hypoxemic and/or hypercapnic respiratory failure seen in critically ill patients and is still, although decreased over the past few years, associated with high mortality. Furthermore, ARDS may be a life-threatening complication of H1N1 pneumonia. We report on a 45-year-old spina bifida patient with confirmed H1N1 influenza virus infection causing acute respiratory failure, who was successfully weaned from 42-day veno-venous extracorporeal membrane oxygenation (vv-ECMO) treatment with an excellent outcome. Due to the physical constitution of spina bifida patients, we experienced challenges concerning cannula positioning and mechanical ventilation settings during weaning.

Effect of body mass index on the outcome of surgical patients receiving extracorporeal devices (VV ECMO, pECLA) for respiratory failure

INTRODUCTION

To determine whether obese surgical patients are at a significant disadvantage in terms of outcomes after extracorporeal device (ECD) support, such as veno-venous extracorporeal membrane oxygenation (VV ECMO) or pumpless extracorporeal lung assist (pECLA), for respiratory failure, the relationship between body mass index (BMI) and hospital outcomes was analyzed.

METHODS

This retrospective study included data on patients who were supported with an ECD between January 1, 2008 and December 31, 2014. The analysis included 89 patients (74 male).

RESULTS

The median BMI was 30 kg/m2 (19-88.5). The median duration of the ECD support was 9.0 days, with a maximum of 37.1 days. The median LOS (length of stay) in the intensive care unit (ICU) was 21 days (range 0.06-197.6). The median hospital LOS was 34.9 days (range 0.1-213.8). VV ECMO was performed 72 times, and pECLA was performed 18 times. The number of patients successfully weaned off the ECD was 54 (60.6%). Survival at the discharge from the hospital was 48.3%.

CONCLUSIONS

54 (60.6%) patients were successfully weaned off the ECD; 43 (48.3%) patients survived and were discharged from the hospital. The analysis of correlations between BMI and outcomes of surgical patients treated with ECD showed no association between BMI and mortality. Complications (especially oxygenator clotting) were not more frequent in obese and extremely obese patients. We hypothesized that patients with higher or morbid BMIs would have increased mortality after ECD support. A BMI of 30.66 kg/m2 corresponded to the desired sensitivity and specificity to predict mortality. This finding applied only to the study group. Treatment with ECD in obese patients presents unique challenges, including percutaneous cannulation and increased staff requirements. However, based on these data, obesity should not be an exclusion criterion for ECD therapy.

Scabies outbreak among healthcare workers in a German acute care hospital

BACKGROUND

This article reports on a scabies outbreak among healthcare workers (HCW) in an acute care hospital. The outbreak was associated with a patient suffering from a chronic skin disease that was later diagnosed as crusted scabies.

OBJECTIVE

The objective was to determine the outbreak drivers and define a prevention strategy against future outbreaks.

METHODS

All staff that had contact with the patient were treated with 5% permethrin ointment. An interdisciplinary outbreak investigation team was established. The team conducted a questionnaire-based case-control study.

FINDINGS

After the permethrin treatment, no further case was found. Twenty-seven HCWs who had contact with the index patient answered the questionnaire (response rate 73%). The outbreak questionnaire revealed 13 cases of secondary scabies among HCWs. In the multivariable analysis, a lack of glove use (odds ratio [OR], 9.8; P value = 0.036) and frequent close physical contact (OR, 8.151; P value = 0.038) were associated with increased risk of scabies acquisition.

DISCUSSION

The scabies outbreak was most likely driven by three factors: an index patient with crusted scabies; a delayed diagnosis of this patient; and close physical contact without gloves during his hospital stay. The use of disposable gloves for patients with unclear dermatological diagnosis have the potential to limit future scabies outbreaks.

RECCAS - REmoval of Cytokines during CArdiac Surgery: study protocol for a randomised controlled trial

Background

On-pump cardiac surgery triggers a significant postoperative systemic inflammatory response, sometimes resulting in multiple-organ dysfunction associated with poor clinical outcome. Extracorporeal cytokine elimination with a novel haemoadsorption (HA) device (CytoSorb®) promises to attenuate inflammatory response. This study primarily assesses the efficacy of intraoperative HA during cardiopulmonary bypass (CPB) to reduce the proinflammatory cytokine burden during and after on-pump cardiac surgery, and secondarily, we aim to evaluate effects on postoperative organ dysfunction and outcomes in patients at high risk.

Methods/design

This will be a single-centre randomised, two-arm, patient-blinded trial of intraoperative HA in patients undergoing on-pump cardiac surgery. Subjects will be allocated to receive either CPB with intraoperative HA or standard CPB without HA. The primary outcome is the difference in mean interleukin 6 (IL-6) serum levels between the two study groups on admission to the intensive care unit. A total number of 40 subjects was calculated as necessary to detect a clinically relevant 30 % reduction in postoperative IL-6 levels. Secondary objectives evaluate effects of HA on markers of inflammation up to 48 hours postoperatively, damage to the endothelial glycocalyx and effects on clinical scores and parameters of postoperative organ dysfunction and outcomes.

Discussion

In this pilot trial we try to assess whether intraoperative HA with CytoSorb® can relevantly reduce postoperative IL-6 levels in patients undergoing on-pump cardiac surgery. Differences in secondary outcome variables between the study groups may give rise to further studies and may lead to a better understanding of the mechanisms of haemoadsorption.

Trial registration

German Clinical Trials Register number DRKS00007928 (Date of registration 3 Aug 2015)

Extracorporeal life support (ECLS) for cardiopulmonary resuscitation (CPR) with pulmonary embolism in surgical patients – a case series

Background:

Extracorporeal life support (ECLS) devices maintain the circulation and oxygenation of organs during acute right ventricular failure and cardiogenic shock, bypassing the lungs. A pulmonary embolism can cause this life-threatening condition. ECLS is a considerably less invasive treatment than surgical embolectomy. Whether to bridge embolectomy or for a therapeutic purpose, ECLS is used almost exclusively following failure of all other therapeutic options.

Methods:

From January 1, 2008 to June 30, 2014, five patients in cardiac arrest and with diagnosed pulmonary embolism (PE) were cannulated with the ECLS system.

Results:

PE was diagnosed using computer tomography scanning or echocardiography. Cardiac arrest was witnessed in the hospital in all cases and CPR (cardiopulmonary resuscitation) was initiated immediately. Cannulation of the femoral vein and femoral artery was always performed under CPR conditions. Right heart failure regressed during the ECLS therapy, usually under a blood flow of 4-5 L/min after 48 hours. Three patients were weaned from ECLS and one patient became an organ donor. Finally, two of the five PE patients treated with ECLS were discharged from inpatient treatment without neurological dysfunction. The duration of ECLS therapy depends on the patient’s condition. Irreversible damage to the organs after hypoxemia limits ECLS treatment and leads to futile multiorgan failure. Hemorrhages after thrombolysis and cerebral dysfunction were further complications.

Conclusions:

Veno-arterial cannulation for ECLS can be feasibly achieved and should be established during active CPR for cardiac arrest. In the case of PE, the immediate diagnosis and rapid implantation of the system are decisive for therapeutic success.

The use of double lumen cannula for veno-venous ECMO in trauma patients with ARDS

Background

The use of a double lumen cannula for veno-venous extracorporeal membrane oxygenation (v.v. ECMO) offers several advantages such as cannulation with only one cannula, patient comfort and the earlier mobilization and physiotherapy. The cannulation should be performed under visual wire and cannula placement into the right atrium, which is associated with risks of malposition and right ventricular perforation. The aim of this patient series is to describe the use of double lumen cannula in trauma patients with posttraumatic ARDS.

Material and methods

Criteria for the v.v ECMO treatment were defined as hypoxaemia (pO2/FiO2 < 200 mmHg, FiO2 0.8-1,0); tidal volume >4-6 ml/kg ideal body weight; mean inspiratory pressure (Pinsp) >32-34 mmHg; respiratory acidosis pH <7.25; and arterial saturation (SaO2) <90%. The analysis included the Injury Severity Score (ISS), the types of injury, time of treatment, complications and outcomes.

Results

A total of 24 patients with major trauma were treated for posttraumatic ARDS with v.v. ECMO. The double lumen cannula (Avalon®, Fa. Maquet, Rastatt, Germany) was used in six male patients. The mean ISS was 31 (20–48). The ECMO therapy was started in an average on the third day after trauma. The mean ECMO run time was 7 days ± 5 (6–18), and the hospital stay was in mean of 60 days ± 34 (21–105).

Conclusion

The use of double lumen cannula for v.v ECMO therapy in trauma patients is a feasible treatment option. No higher risk of bleeding could be found in this case series. A PTT-controlled heparinization is recommended using double lumen cannula. Therefore the use of this cannula type in trauma patients with high risk of bleeding is to discuss controversially.

Efficiency of gas transfer in venovenous extracorporeal membrane oxygenation: analysis of 317 cases with four different ECMO systems

PURPOSE

Polymethylpentene membrane oxygenators used in venovenous extracorporeal membrane oxygenation (vvECMO) differ in their physical characteristics. The aim of the study was to analyze the gas transfer capability of different ECMO systems in clinical practice, as the choice of the appropriate system may be influenced by the needs of the patient.

METHODS

Retrospective study on prospectively collected data of adults with severe respiratory failure requiring vvECMO support (Regensburg ECMO Registry, 2009-2013). Oxygen (O2) transfer and carbon dioxide (CO2) elimination of four different ECMO systems (PLS system, n = 163; Cardiohelp system (CH), n = 59, Maquet Cardiopulmonary, Rastatt, Germany; Hilite 7000 LT system, n = 56, Medos Medizintechnik, Stolberg, Germany; ECC.05 system, n = 39, Sorin Group, Mirandola (MO), Italy) were analyzed.

RESULTS

Gas transfer depended on type of ECMO system, blood flow, and gas flow (p ≤ 0.05, each). CO2 removal is dependent on sweep gas flow and blood flow, with higher blood flow and/or gas flow eliminating more CO2 (p ≤ 0.001). CO2 elimination capacity was highest with the PLS system (p ≤ 0.001). O2 transfer at blood flow rates below 3 l/min depended on blood flow, at higher blood flow rates on blood flow and gas flow. The system with the smallest gas exchange surface (ECC.05 system) was least effective in O2 transfer, but in terms of the gas exchange surface was the most effective.

CONCLUSION

Our analysis suggests that patients with severe hypoxemia and need for high flow ECMO benefit more from the PLS/CH or Hilite 7000 LT system. The ECC.05 system is advisable for patients with moderate hypoxemia and/or hypercapnia.

Surgical extraction after thrombosis around the Avalon dual lumen cannula

The use of a dual lumen cannula (DLC) for venovenous extracorporeal membrane oxygenation (ECMO) has several advantages and reports of complications are rare. We present a case of thrombosis around and inside the Avalon Elite™ bicaval DLC (Avalon Laboratories, Rancho Dominguez, CA, US), for which simple removal by retraction was impossible. A 30-year-old man had experienced an unstable C6/7 fracture with spinal contusion and haematoma in the spinal canal with incomplete neurological paraplegia and thoracic trauma. He developed acute respiratory failure due to posttraumatic systemic inflammatory response syndrome and venovenous extracorporeal membrane oxygenation (ECMO) support was indicated. The cannulation was performed with an Avalon Elite™ cannula (31Fr) in the right jugular vein under fluoroscopy. After 18 days of ECMO therapy, despite the continuous administration of heparin (400iu/h), ECMO was discontinued because of the formation of a massive thrombus in the oxygenator. At that time, the patient's haemodynamic and respiratory parameters were stable, and we were able to induce a rapid weaning from ECMO. The surgical removal of the cannula became necessary and was performed using a small neck incision without complications. We report this case to emphasise that any resistance encountered during an attempt to extract the Avalon Elite™ cannula may cause serious complications. In such cases, surgical removal must be considered.

Intratumoral Mistletoe (Viscum album L) Therapy in Patients With Unresectable Pancreas Carcinoma: A Retrospective Analysis

Pancreatic carcinoma remains one of the main causes for cancer-related death. Intratumoral application of anticancer agents is discussed as a promising method for solid tumors such as pancreatic cancer. Endoscopic ultrasound provides a good tool to examine and treat the pancreas. European mistletoe (Viscum album L) is a phytotherapeutic commonly used in integrative oncology in Central Europe. Its complementary use seeks to induce immunostimulation and antitumoral effects as well as alleviate chemotherapeutic side effects. Intratumoral mistletoe application has induced local tumor response in various cancer entities. This off-label use needs to be validated carefully in terms of safety and benefits. Here we report on 39 patients with advanced, inoperable pancreatic cancer, who received in total 223 intratumoral applications of mistletoe, endoscopic ultrasound guided or under transabdominal ultrasound control. No severe procedure-related events were reported. Adverse drug reactions were mainly increased body temperature or fever in 14% and 11% of the applications, respectively. Other adverse drug reactions, such as pain or nausea, occurred in less than 7% of the procedures. No severe adverse drug reaction was recorded. Patients received standard first- and second-line chemotherapy and underwent adequate palliative surgical interventions as well as additive subcutaneous and partly intravenous mistletoe application. A median survival of 11 months was observed for all patients, or 11.8 and 8.3 months for stages III and IV, respectively. Due to the multimodal therapeutic setting and the lack of a control group, the effect of intratumoral mistletoe administration alone remains unclear. This retrospective analysis suggests that intratumoral-applicated mistletoe might contribute to improve survival of patients with pancreatic cancer. In conclusion, the application is feasible and safe, and its efficacy should be evaluated in a randomized controlled trial.

[Arteriovenous extracorporeal membrane oxygenation (ECMO). A therapeutic option for fulminant pulmonary embolism]

According to the guidelines of the European (2008) and German Societies of Cardiology (2009) thrombolysis is recommended for patients with pulmonary embolisms presenting with cardiogenic shock (recommendation level I, evidence level A). If there are contraindications or thrombolysis is not successful surgical embolectomy should be considered (recommendation level I, evidence level C). Additional options are catheter-based therapies in the proximal pulmonary artery (recommendation level IIb, evidence level C). The use of arteriovenous extracorporeal membrane oxygenation ( ECMO) was not included in these guidelines. A literature search in PubMed resulted in some case reports of the successful use of arteriovenous ECMO for resuscitation in patients with severe pulmonary embolisms following failed thrombolysis. In this article we present the case report of a patient who developed fulminant pulmonary embolism immediately after surgery. The patient was still in cardiogenic shock despite thrombolysis but the condition was stable following implementation of an arteriovenous ECMO. Acute heart failure and hypoxemia of all organs are the main symptoms of massive pulmonary embolisms. The use of arteriovenous ECMO represents a therapeutic option for life-threatening pulmonary embolism. A decisive factor for success is immediate diagnosis and rapid implementation of the system.

State of the art in neuroprotection during acute type A aortic dissection repair

Temporary (TND) or permanent neurologic dysfunctions (PND) represent the main neurological complications following acute aortic dissection repair. The aim of our experimental and clinical research was the improvement and update of the most common neuroprotective strategies which are in present use.

Hypothermic circulatory arrest (HCA): Cerebral metabolic suppression at the clinically most used temperatures (18-22°C) is less complete than had been assumed previously. If used as a ‘stand-alone’ neuroprotective strategy, cooling to 15-20°C with a jugular SO2 ≥ 95% is needed to provide sufficient metabolic suppression. Regardless of the depth of cooling, the HCA interval should not exceed 25 min. After 40 min of HCA, the incidence of TND and PND increases, after 60 min, the mortality rate increases.

Antegrade selective cerebral perfusion (ASCP): At moderate hypothermia (25-28°C), ASCP should be performed at a pump flow rate of 10ml/kg/min, targeting a cerebral perfusion pressure of 50-60mmHg. Experimental data revealed that these conditions offer an optimal regional blood flow in the cortex (80±27ml/min/100g), the cerebellum (77±32ml/min/100g), the pons (89±5ml/min/100g) and the hippocampus (55±16ml/min/100g) for 25 minutes. If prolonged, does ASCP at 32°C provide the same neuroprotective effect?

Cannulation strategy: Direct axillary artery cannulation ensures the advantage of performing both systemic cooling and ASCP through the same cannula, preventing additional manipulation with the attendant embolic risk. An additional cannulation of the left carotid artery ensures a bi-hemispheric perfusion, with a neurologic outcome of only 6% TND and 1% PND.

Neuromonitoring: Near-infrared spectroscopy and evoked potentials may prove the effectiveness of the neuroprotective strategy used, especially if the trend goes to less radical cooling.

Conclusion: A short interval of HCA (5 min) followed by a more extended period of ASCP (25 min) at moderate hypothermia (28°C), with a pump flow rate of 10ml/kg/min and a cerebral perfusion pressure of 50 mmHg, represents safe conditions for open arch surgery.