1
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Schneeweiss-Gleixner M, Hillebrand C, Jaksits S, Fries J, Zauner M, Heinz G, Sengölge G, Staudinger T, Zauner C, Aletaha D, Machold KP, Schellongowski P, Bécède M. Characteristics and outcome of critically ill patients with systemic rheumatic diseases referred to the intensive care unit. RMD Open 2023; 9:e003287. [PMID: 38030230 PMCID: PMC10689389 DOI: 10.1136/rmdopen-2023-003287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 11/07/2023] [Indexed: 12/01/2023] Open
Abstract
OBJECTIVES Patients with systemic rheumatic diseases (SRDs) are at risk of admission to the intensive care unit (ICU). Data concerning these critically ill patients are limited to few retrospective studies. METHODS This is a single-centre retrospective study of patients with SRDs admitted to an ICU at the Vienna General Hospital between 2012 and 2020. Single-predictor and multiple logistic regression analysis was performed to identify potential outcome determinants. RESULTS A total of 144 patients accounting for 192 ICU admissions were included. Connective tissue diseases (CTDs), vasculitides and rheumatoid arthritis were the most common SRDs requiring ICU admission. Leading causes for ICU admission were respiratory failure and shock, as reflected by a high number of patients requiring mechanical ventilation (60.4%) and vasopressor therapy (72.9%). Overall, 29.2% of admissions were due to SRD-related critical illness. In 70.8% patients, co-existent SRD not responsible for the acute critical illness was documented. When comparing these subgroups, CTDs and vasculitides had a higher frequency in the patients with SRD-related critical illness. In a significantly higher proportion of patients in the SRD-related subgroup, diagnosis of SRD was made at the ICU. ICU and 6-month mortality in the overall population was 20.3% and 38.5%, respectively. Age, glucocorticoid therapy prior to hospital admission and disease severity were associated with poor outcome. CONCLUSIONS In this study, respiratory failure was the leading cause of ICU admission as reflected by high rates of required mechanical ventilation. Despite considerable severity of critical illness, survival rates were comparable to a general ICU population.
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Affiliation(s)
- Mathias Schneeweiss-Gleixner
- Clinical Division of Gastroenterology and Hepatology, Department of Medicine III, Intensive Care Unit 13.h1, Medical University of Vienna, Vienna, Austria
| | - Caroline Hillebrand
- Clinical Division of Rheumatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Stephanie Jaksits
- Clinical Division of Rheumatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Jonathan Fries
- Department of Developmental and Educational Psychology, Faculty of Psychology, University of Vienna, Vienna, Austria
| | - Michael Zauner
- Clinical Division of Rheumatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Gottfried Heinz
- Clinical Division of Cardiology, Department of Medicine II, Medical University of Vienna, Vienna, Austria
| | - Gürkan Sengölge
- Clinical Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Thomas Staudinger
- Intensive Care Unit 13.i2, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Christian Zauner
- Clinical Division of Gastroenterology and Hepatology, Department of Medicine III, Intensive Care Unit 13.h1, Medical University of Vienna, Vienna, Austria
| | - Daniel Aletaha
- Clinical Division of Rheumatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Klaus P Machold
- Clinical Division of Rheumatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Peter Schellongowski
- Intensive Care Unit 13.i2, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Manuel Bécède
- Clinical Division of Rheumatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
- Lower Austrian Centre for Rheumatology, Department of Medicine II, State Hospital Stockerau, Stockerau, Austria
- Karl Landsteiner Institute for Clinical Rheumatology, Stockerau, Austria
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2
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Ohta S, Matsuyoshi T, Kaneko H, Kosen D, Suzuki H, Hamaguchi J, Sato Y, Shimizu K. Venovenous Extracorporeal Membrane Oxygenation in Diffuse Alveolar Hemorrhage Secondary to Anti-neutrophil Cytoplasmic Autoantibody-associated Vasculitis: Starting without Systemic Anticoagulation. Intern Med 2022; 61:3569-3573. [PMID: 35569985 PMCID: PMC9790777 DOI: 10.2169/internalmedicine.9472-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Regarding extracorporeal membrane oxygenation (ECMO) support against hemorrhagic conditions, there seems to be a dilemma when deciding between maintaining the circuit patency by systemic anticoagulation and increasing the risk of bleeding. We herein report two cases of diffuse alveolar hemorrhage (DAH) caused by myeloperoxidase (MPO) anti-neutrophil cytoplasmic autoantibody-associated vasculitis (AAV) successfully treated with venovenous (VV)-ECMO support, both initially started without systemic anticoagulation. Under anticoagulation-free ECMO management, we should consider the shortcomings of frequent circuit exchange and hemorrhagic diathesis related to circuit-induced disseminated intravascular coagulation (DIC).
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Affiliation(s)
- Soichi Ohta
- Emergency and Critical Care Center, Tokyo Metropolitan Tama Medical Center, Japan
| | - Takeo Matsuyoshi
- Emergency and Critical Care Center, Tokyo Metropolitan Tama Medical Center, Japan
| | - Hitoshi Kaneko
- Emergency and Critical Care Center, Tokyo Metropolitan Tama Medical Center, Japan
| | - Daiyu Kosen
- Emergency and Critical Care Center, Tokyo Metropolitan Tama Medical Center, Japan
| | - Hiroaki Suzuki
- Emergency and Critical Care Center, Tokyo Metropolitan Tama Medical Center, Japan
| | - Jun Hamaguchi
- Emergency and Critical Care Center, Tokyo Metropolitan Tama Medical Center, Japan
| | - Yuichi Sato
- Emergency and Critical Care Center, Tokyo Metropolitan Tama Medical Center, Japan
| | - Keiki Shimizu
- Emergency and Critical Care Center, Tokyo Metropolitan Tama Medical Center, Japan
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3
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Hu Z, Feng X, Zhang B, Huang J. Rare cause of diffuse alveolar haemorrhage and subconjunctival haemorrhage rescued by extracorporeal membrane oxygenation and rituximab. BMJ Case Rep 2022; 15:e250025. [PMID: 35750426 PMCID: PMC9234909 DOI: 10.1136/bcr-2022-250025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A previously healthy man in his 20s presented with acute respiratory distress syndrome and subconjunctival haemorrhage. Imaging was indicative of pervasive pulmonary haemorrhage. There was no evidence of renal involvement. The patient rapidly deteriorated with aggravating respiratory failure regardless of invasive mechanical ventilation and required extracorporeal membrane oxygenation (ECMO). This maintained the patient adequate time to allow aggressive therapy. Skin biopsy indicated leucocytoclastic vasculitis. Given that the patient was C-antinuclear cytoplasmic autoantibody (ANCA) positive, pulse dose steroids and rituximab were initiated for the suspicion of ANCA-associated vasculitis (AAV) which resulted in improvement of airspace disease and subconjunctival haemorrhage. Only a few cases reported successful use of ECMO in severe diffuse alveolar haemorrhage (DAH) due to AAV, but no case was in DAH combined with subconjunctival haemorrhage. The need for systemic anticoagulation with pre-existing haemorrhage is still a challenging dilemma.
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Affiliation(s)
- Zaiying Hu
- Department of Rheumatology, Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Xiaoxue Feng
- Department of Rheumatology, Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Baiyu Zhang
- Department of Rheumatology, Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Jianlin Huang
- Department of Rheumatology, Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
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4
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Finkel R, Honig J, Chao CP, Rescoe E, Solomon S. The use of ECMO in pediatric granulomatosis with polyangiitis. Pediatr Rheumatol Online J 2022; 20:35. [PMID: 35538584 PMCID: PMC9092879 DOI: 10.1186/s12969-022-00693-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 04/23/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Granulomatosis with polyangiitis (GPA) vasculitis with pulmonary-renal syndrome rarely presents in children and is associated with high mortality rates. CASE PRESENTATION We present the case of a 13-year-old male with newly diagnosed GPA vasculitis, treated with extracorporeal membrane oxygenation, continuous renal replacement therapy, plasmapheresis, rituximab, cyclophosphamide, and corticosteroids. CONCLUSION This case presentation demonstrates that ECMO can be used as a life supporting therapy in pediatric patients with pulmonary hemorrhage from ANCA vasculitis in conjunction with other therapies.
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Affiliation(s)
- Rachel Finkel
- grid.260917.b0000 0001 0728 151XDepartment of Pediatrics, Maria Fareri Children’s Hospital, Westchester Medical Center, New York Medical College, Valhalla, New York USA
| | - Jesse Honig
- grid.260917.b0000 0001 0728 151XDepartment of Pediatrics, New York Medical College, Valhalla, New York USA
| | - Chun P. Chao
- grid.260917.b0000 0001 0728 151XDivision of Rheumatology, Maria Fareri Children’s Hospital, Westchester Medical Center, Boston Children’s Health Physicians, New York Medical College, Valhalla, New York USA
| | - Erin Rescoe
- grid.260917.b0000 0001 0728 151XDivision of Critical Care Medicine, Maria Fareri Children’s Hospital, Westchester Medical Center, Boston Children’s Health Physicians, New York Medical College, Valhalla, New York USA
| | - Sonia Solomon
- Division of Pediatric Nephrology, Maria Fareri Children's Hospital, Westchester Medical Center, Boston Children's Health Physicians, New York Medical College, Valhalla, NY, USA.
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5
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O'Neil ER, Quinn RE, Olson TL, Rycus PT, Anders MM, Chartan CA, Vogel TP, Silva-Carmona M, Coleman RD. Extracorporeal Membrane Oxygenation Support for Antineutrophil Cytoplasmic Antibody-associated Vasculitides: An ELSO Registry Analysis. ASAIO J 2022; 68:553-560. [PMID: 34324445 DOI: 10.1097/mat.0000000000001539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides with pulmonary involvement include granulomatosis with polyangiitis, microscopic polyangiitis, and eosinophilic granulomatosis with polyangiitis, and can present with life-threatening pulmonary hemorrhage in up to 40% of patients. Mortality in those patients who require intubation and mechanical ventilation can reach 77%. Extracorporeal membrane oxygenation (ECMO) can be used to support these patients through definitive diagnosis and treatment, although minimizing the risk of ventilator-induced lung injury. We aimed to determine factors associated with favorable outcomes in patients with (ANCA)-associated vasculitides supported on ECMO. We performed a retrospective observational study using the Extracorporeal Life Support Organization registry of pediatric and adult patients with ANCA-associated vasculitis supported on ECMO from 2010 to 2020. One hundred thirty-five patients were included for analysis. Many patients had renal involvement (39%) in addition to pulmonary involvement (93%). Survival was 73% in AAV patients supported on ECMO. The presence of pulmonary hemorrhage was not associated with worse outcomes in our cohort. Older age, the use of venoarterial ECMO, ECMO-cardiopulmonary resuscitation, or sustaining a cardiac arrest before ECMO was associated with decreased survival. In conclusion, venovenous ECMO should be considered as a supportive bridge to definitive diagnosis and treatment in (ANCA)-associated vasculitides, regardless if pulmonary hemorrhage is present.
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Affiliation(s)
- Erika R O'Neil
- From the Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Rachel E Quinn
- From the Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Taylor L Olson
- Children's National Hospital, Washington, District of Columbia
| | - Peter T Rycus
- The Extracorporeal Life Support Organization, Ann Arbor, Michigan
| | - Marc M Anders
- From the Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Corey A Chartan
- From the Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Tiphanie P Vogel
- From the Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | | | - Ryan D Coleman
- From the Department of Pediatrics, Baylor College of Medicine, Houston, Texas
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6
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Veno-venous extracorporeal membrane oxygenation (VV-ECMO) for life-threatening isolated pulmonary anti-GBM disease. Respir Med Case Rep 2022; 38:101680. [PMID: 35677578 PMCID: PMC9168115 DOI: 10.1016/j.rmcr.2022.101680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Revised: 05/18/2022] [Accepted: 05/25/2022] [Indexed: 11/30/2022] Open
Abstract
Anti-glomerular basement membrane disease (anti-GBM disease) associated with renal and lung lesions has a poor prognosis. Diffuse alveolar hemorrhage (DAH) is a complication that worsens anti-GBM disease prognosis. We report a rescue case using veno-venous extracorporeal membrane oxygenation (VV-ECMO) for diffuse alveolar hemorrhage due to isolated pulmonary anti-GBM disease; a rare anti-GBM syndrome. A 30-year-old Japanese female with no past medical history. Presented with acute hypoxemic respiratory failure requiring mechanical ventilation. Progressive deterioration and refractory hypoxemia prompted therapy with VV-ECMO. Serum anti-GBM antibody confirmed the diagnosis of anti-GBM disease. Multi-modal systemic therapy with pulse-dosed methylprednisolone, plasma exchange, and rituximab resulted in significant clinical improvement. VV-ECMO for 10 days was uncomplicated. Renal replacement therapy was not required. The patient was extubated on day 18 and discharged from the hospital after 45 days. VV-ECMO supportive therapy for DAH with refractory respiratory failure was demonstrated to be effective pending definitive diagnostic and therapeutic management in this case of isolated pulmonary anti-GBM disease. •We report a rescue case using VV-ECMO for diffuse alveolar hemorrhage with isolated pulmonary anti-GBM disease. •VV-ECMO can provide life-support bridge therapy until a response to disease control with fundamental specific therapy becomes effective. VV-ECMO with associated required anticoagulation was an effective and safe life-support therapy in the setting of DAH.
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7
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Esumi R, Kaneko T, Ito A, Ieki Y, Yamamoto Y, Nakajima A, Imai H. Anticoagulant-free venovenous extracorporeal membrane oxygenation for diffuse alveolar hemorrhage with bowel bleeding caused by antineutrophil cytoplasmic antibody-associated vasculitis: A case report. Respir Med Case Rep 2021; 34:101513. [PMID: 34540581 PMCID: PMC8441063 DOI: 10.1016/j.rmcr.2021.101513] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 08/24/2021] [Accepted: 09/07/2021] [Indexed: 11/18/2022] Open
Abstract
Antineutrophil cytoplasmic antibody-associated vasculitis (AAV) is sometimes complicated by diffuse alveolar hemorrhage (DAH), which may cause respiratory failure. Venovenous extracorporeal membrane oxygenation (VV-ECMO) without an anticoagulant because of hemorrhagic status, showed the effectiveness for severe respiratory failure by DAH with AAV. A 44-year-old woman developed DAH with bowel bleeding following the onset of AAV, with positive anti-proteinase-3 (PR3) antibodies. Although ventilator management could not support her respiratory status, VV-ECMO was performed. The patient was given immunosuppressive therapy comprising a steroid pulse, plasma exchange, and cyclophosphamide. After about 10 days of VV-ECMO and immunosuppressive therapy, VV-ECMO was withdrawn, and on day 12, ventilator support was stopped. Although a thrombus developed within the inferior vena cava (IVC), which required IVC filtration, the patient was discharged on day 51. VV-ECMO support was effective for treating DAH in this patient with new-onset AAV, which takes some time to achieve remission with immunosuppressive therapy.
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Affiliation(s)
- Ryo Esumi
- Emergency and Critical Care Center, Mie University Hospital, Japan
| | - Tadashi Kaneko
- Emergency and Critical Care Center, Mie University Hospital, Japan
- Corresponding author. Emergency and Critical Care Center, Mie University Hospital, Tsu, Mie, 514-8507, Japan.
| | - Asami Ito
- Emergency and Critical Care Center, Mie University Hospital, Japan
| | - Yohei Ieki
- Emergency and Critical Care Center, Mie University Hospital, Japan
| | - Yoshiki Yamamoto
- Department of Rheumatology, Center for Rheumatic Diseases, Mie University Hospital, Japan
| | - Ayako Nakajima
- Department of Rheumatology, Center for Rheumatic Diseases, Mie University Hospital, Japan
| | - Hiroshi Imai
- Emergency and Critical Care Center, Mie University Hospital, Japan
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8
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Wang L, Wang J, Xu Y, Jiao J, Xie L, Mo G. A novel therapeutic strategy using extracorporeal membrane oxygenation in patients with anti-neutrophil cytoplasmic antibodies-associated vasculitis: a case report and literature review. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1267. [PMID: 34532404 PMCID: PMC8421983 DOI: 10.21037/atm-21-3133] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 07/19/2021] [Indexed: 12/20/2022]
Abstract
Diffuse alveolar hemorrhage (DAH) secondary to anti-neutrophil cytoplasmic antibodies (ANCA)-associated vasculitis (AAV) often results in severe respiratory failure which requires emergent management. In patients who are resistant to traditional mechanical respiratory support, extracorporeal membrane oxygenation (ECMO) can be used to maintain gas exchange, thereby providing time for the administration of immunosuppressive therapy to control the inflammation. Herein, we report the application of ECMO to support an adult patient with AAV complicated by severe respiratory failure due to DAH. Similar cases in the literature were identified and discussed. The patient in our case study was successfully treated with ECMO in the acute phase and relieved by immunosuppressive therapy after withdrawal of ECMO. A search in the PubMed database revealed 32 similar cases with DAH, of which 11 cases were microscopic polyangiitis (MPA), 2 cases were eosinophilic granulomatosis with polyangiitis (EGPA), and 19 cases were granulomatosis with polyangiitis (GPA). These patients were all treated with ECMO. Therefore, to date, we identified 33 patients who were effectively treated with ECMO, including 13 (39.4%) males and 20 (60.6%) females, with a ratio of 1:1.54. The average age was 32.4±17.5 and 36.0±16.1 years for males and females, respectively (t=0.610, P=0.547). Most patients received ECMO on the first day of admission to the intensive care unit (ICU) and it appeared that early initiation of ECMO was associated with a shorter duration of ECMO. In general, complications of ECMO in these patients were mild and were not often seen in the clinical setting. This study suggested that early recognition of respiratory failure and referral for ECMO are vital to achieve a satisfactory outcome in AAV patients with DAH.
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Affiliation(s)
- Li Wang
- Department of Critical Care Medicine, The First Medical Center of PLA General Hospital, Haidian District, Beijing, China
| | - Jiang Wang
- Department of Pulmonary & Critical Care Medicine, The Eighth Medical Center of PLA General Hospital, Haidian District, Beijing, China
| | - Yi Xu
- Department of Pulmonary & Critical Care Medicine, The Eighth Medical Center of PLA General Hospital, Haidian District, Beijing, China
| | - Jie Jiao
- Department of Critical Care Medicine, Hainan Hospital of PLA General Hospital, Sanya, China
| | - Lixin Xie
- Department of Pulmonary & Critical Care Medicine, The Eighth Medical Center of PLA General Hospital, Haidian District, Beijing, China
| | - Guoxin Mo
- Department of Pulmonary & Critical Care Medicine, The Eighth Medical Center of PLA General Hospital, Haidian District, Beijing, China
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9
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Günther F, Fleck M. [Severe organ manifestations in rheumatic diseases]. Dtsch Med Wochenschr 2021; 146:1152-1158. [PMID: 34448191 DOI: 10.1055/a-0949-4889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Several inflammatory rheumatic diseases can severely affect any organ system and require immediate intervention and intensive care admission. The early detection of impending organ failure and the underlying rheumatic disease is of paramount importance for the prognosis and outcome of affected patients. Therefore, a thorough knowledge of the potential life threatening organ manifestations of systemic rheumatic diseases is of particular interest for clinicians working in intensive care. This paper provides an overview of diagnostic steps and therapy of organ manifestations in critically ill patients with underlying systemic rheumatic diseases. The presentation of the relevant systemic rheumatic diseases is structured according to the most important organ systems, i. e. the respiratory system, the kidney and the cardiovascular system. Furthermore, there is a focus in this paper on macrophage activation syndrome (MAS) as a potentially lethal complication of several rheumatic diseases and the catastrophic antiphospholipid syndrome (CAPS) as a rare cause of multi organ failure.
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10
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Ahmad Y, Morawietz G, Ksouri H, Schefold JC, Zuercher P. Granulomatosis with polyangiitis (Wegener's) complicated by splenic rupture and severe acute respiratory distress syndrome: A case report. Clin Case Rep 2021; 9:e04369. [PMID: 34267899 PMCID: PMC8271247 DOI: 10.1002/ccr3.4369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 05/08/2021] [Accepted: 05/11/2021] [Indexed: 12/02/2022] Open
Abstract
Even in the absence of disease-specific radiological signs of granulomatosis with polyangiitis (GPA), severe intrapulmonary GPA may be present. Rapidly establishing the diagnosis with a confirmatory biopsy is key to initiate lifesaving therapy.
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Affiliation(s)
- Yannis Ahmad
- Intensive Care UnitHFR Hôpital Cantonal FribourgFribourgSwitzerland
| | | | - Hatem Ksouri
- Intensive Care UnitHFR Hôpital Cantonal FribourgFribourgSwitzerland
| | - Joerg C. Schefold
- Department of Intensive Care MedicineInselspitalBern University HospitalUniversity of BernBernSwitzerland
| | - Patrick Zuercher
- Department of Intensive Care MedicineInselspitalBern University HospitalUniversity of BernBernSwitzerland
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11
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Wan R, Yang W, Ma X, Yang W, Pan P, Hu C, Chen Q, Zhou Y, Lu R, Fang Y, Li Y. ECMO Rescues Patients With Acute Respiratory Failure Related to GPA. Front Med (Lausanne) 2021; 8:671396. [PMID: 34124098 PMCID: PMC8192709 DOI: 10.3389/fmed.2021.671396] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 04/22/2021] [Indexed: 01/19/2023] Open
Abstract
Granulomatosis with polyangiitis (GPA) is a subtype of anti-neutrophil cytoplasmic antibody-associated vasculitis with a wide range of clinical symptoms related to the systemic involvement of small blood vessels. The respiratory system is one of the most frequently involved, and life-threatening acute respiratory failure could occur due to diffusive alveolar hemorrhage and tracheal stenosis. When maximum mechanical ventilation is unable to maintain oxygenation, extracorporeal membrane oxygenation (ECMO) should be considered as the final respiratory supportive method, if available. Here we present a 32-year-old male patient with acute respiratory failure (ARF) related to GPA, who was rescued by winning time for accurate diagnosis and appropriate treatment. Additionally, we reviewed more than 60 GPA-related ARF cases on multiple online databases, summarized the clinical manifestations of these patients, and concluded that ECMO plays an important role in further respiratory support for ARF patients with GPA and assists in accurate and timely diagnosis and appropriate treatment, thus helping them recuperate.
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Affiliation(s)
- Rongjun Wan
- Department of Respiratory Medicine (Department of Respiratory and Critical Care Medicine), Xiangya Hospital, Central South University, Changsha, China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Wenzhe Yang
- Department of Respiratory Medicine (Department of Respiratory and Critical Care Medicine), Xiangya Hospital, Central South University, Changsha, China
| | - Xinhua Ma
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, China
| | - Wei Yang
- Department of Respiratory Medicine (Department of Respiratory and Critical Care Medicine), Xiangya Hospital, Central South University, Changsha, China
| | - Pinhua Pan
- Department of Respiratory Medicine (Department of Respiratory and Critical Care Medicine), Xiangya Hospital, Central South University, Changsha, China
| | - Chengping Hu
- Department of Respiratory Medicine (Department of Respiratory and Critical Care Medicine), Xiangya Hospital, Central South University, Changsha, China
| | - Qiong Chen
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Yaou Zhou
- Department of Rheumatology and Immunology, Xiangya Hospital, Central South University, Changsha, China
| | - Rongli Lu
- Department of Respiratory Medicine (Department of Respiratory and Critical Care Medicine), Xiangya Hospital, Central South University, Changsha, China
| | - Yimin Fang
- Department of Respiratory Medicine (Department of Respiratory and Critical Care Medicine), Xiangya Hospital, Central South University, Changsha, China
| | - Yuanyuan Li
- Department of Respiratory Medicine (Department of Respiratory and Critical Care Medicine), Xiangya Hospital, Central South University, Changsha, China
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12
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Extracorporeal membrane oxygenation in cardiopulmonary disease of rheumatic conditions: A systematic review. Med Clin (Barc) 2020; 155:454-458. [PMID: 32446682 DOI: 10.1016/j.medcli.2020.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 02/13/2020] [Accepted: 02/18/2020] [Indexed: 11/24/2022]
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13
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Arnold S, Deja M, Nitschke M, Bohnet S, Wallis S, Humrich JY, Riemekasten G, Steinhoff J, Lamprecht P. Extracorporeal membrane oxygenation in ANCA-associated vasculitis. Autoimmun Rev 2020; 20:102702. [PMID: 33188916 DOI: 10.1016/j.autrev.2020.102702] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 10/19/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Sabrina Arnold
- Department of Rheumatology and Clinical Immunology, University of Lübeck, Lübeck, Germany
| | - Maria Deja
- Department of Anaesthesiology and Intensive Care, University of Lübeck, Lübeck, Germany
| | - Martin Nitschke
- Department of Nephrology, University of Lübeck, Lübeck, Germany
| | - Sabine Bohnet
- Department of Pulmonology, University of Lübeck, Lübeck, Germany
| | - Sönke Wallis
- Department of Pulmonology, University of Lübeck, Lübeck, Germany
| | - Jens Y Humrich
- Department of Rheumatology and Clinical Immunology, University of Lübeck, Lübeck, Germany
| | - Gabriela Riemekasten
- Department of Rheumatology and Clinical Immunology, University of Lübeck, Lübeck, Germany
| | | | - Peter Lamprecht
- Department of Rheumatology and Clinical Immunology, University of Lübeck, Lübeck, Germany.
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14
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Fan K, McArthur J, Morrison RR, Ghafoor S. Diffuse Alveolar Hemorrhage After Pediatric Hematopoietic Stem Cell Transplantation. Front Oncol 2020; 10:1757. [PMID: 33014865 PMCID: PMC7509147 DOI: 10.3389/fonc.2020.01757] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 08/05/2020] [Indexed: 12/21/2022] Open
Abstract
Pulmonary complications are common following hematopoietic cell transplantation (HCT) and contribute significantly to its morbidity and mortality. Diffuse alveolar hemorrhage is a devastating non-infectious complication that occurs in up to 5% of patients post-HCT. Historically, it carries a high mortality burden of 60–100%. The etiology remains ill-defined but is thought to be due to lung injury from conditioning regimens, total body irradiation, occult infections, and other comorbidities such as graft vs. host disease, thrombotic microangiopathy, and subsequent cytokine release and inflammation. Clinically, patients present with hypoxemia, dyspnea, and diffuse opacities consistent with an alveolar disease process on chest radiography. Diagnosis is most commonly confirmed with bronchoscopy findings of progressively bloodier bronchoalveolar lavage or the presence of hemosiderin-laden macrophages on microscopy. Treatment with glucocorticoids is common though dosing and duration of therapy remains variable. Other agents, such as aminocaproic acid, tranexamic acid, and activated recombinant factor VIIa have also been tried with mixed results. We present a review of diffuse alveolar hemorrhage with a focus on its pathogenesis and treatment options.
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Affiliation(s)
- Kimberly Fan
- Division of Pediatric Critical Care, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Jennifer McArthur
- Division of Critical Care, St. Jude Children's Research Center, Memphis, TN, United States
| | - R Ray Morrison
- Division of Critical Care, St. Jude Children's Research Center, Memphis, TN, United States
| | - Saad Ghafoor
- Division of Critical Care, St. Jude Children's Research Center, Memphis, TN, United States
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15
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Frantzeskaki FG, Dimopoulos S, Konstantonis D, Katsibri P, Kostopanagiotou K, Theodorakopoulou M, Diakaki C, Dougenis D, Boumpas D, Karabinis A, Armaganidis A, Tsangaris I. Life-threatening antineutrophil cytoplasmic antibody-associated vasculitis after influenza A H1N1 infection requiring veno-venous extracorporeal membrane oxygenation. Perfusion 2020; 35:546-549. [PMID: 32529913 DOI: 10.1177/0267659120927210] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Antineutrophil cytoplasmic autoantibody-associated vasculitis is an immune-mediated necrotizing vasculitis, affecting small- and medium-sized vessels. CASE REPORT A 22-year-old female patient with free medical history presented with life-threatening pulmonary hemorrhage due to antineutrophil cytoplasmic autoantibody-associated vasculitis, temporarily associated with influenza A H1N1 infection. Due to rapidly worsening respiratory failure, despite conventional management, veno-venous peripheral extracorporeal membrane oxygenation was initiated and continued for 26 days, with subsequent renal replacement therapy. DISCUSSION We present a case of severe antineutrophil cytoplasmic autoantibody-associated pulmonary vasculitis, managed with veno-venous extracorporeal membrane oxygenation at the initial phase. Despite the significant challenges raised with the use of extracorporeal membrane oxygenation in pulmonary hemorrhage cases, extracorporeal membrane oxygenation may have a significant impact on outcome in this setting, by providing adequate time for a successful immunosuppressive treatment.
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Affiliation(s)
- Frantzeska G Frantzeskaki
- 2nd Critical Care Department, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Dimitrios Konstantonis
- 2nd Critical Care Department, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Pelagia Katsibri
- 4th Department of Internal Medicine, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Kostantinos Kostopanagiotou
- Department of Cardiac Surgery, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria Theodorakopoulou
- 2nd Critical Care Department, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Chrysi Diakaki
- 2nd Critical Care Department, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Dougenis
- Department of Cardiac Surgery, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Boumpas
- 4th Department of Internal Medicine, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Apostolos Armaganidis
- 2nd Critical Care Department, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Iraklis Tsangaris
- 2nd Critical Care Department, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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16
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Monti S, Montecucco C. Diagnostic and therapeutic challenges for patients with ANCA-associated vasculitides at the time of COVID-19. Response to: 'Rituximab for granulomatosis with polyangiitis in the pandemic of COVID-19: lessons from a case with severe pneumonia' by Guilpain et al. Ann Rheum Dis 2020; 80:e11. [PMID: 32354773 DOI: 10.1136/annrheumdis-2020-217555] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 04/17/2020] [Indexed: 12/20/2022]
Affiliation(s)
- Sara Monti
- Rheumatology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
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17
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Goel MK, Chauhan M, Kumar A, Wadwa P, Maitra G, Talegaonkkar M, Dewan S. A Case of Refractory Hypoxemic Respiratory Failure due to Antineutrophil Cytoplasmic Antibodies-associated Diffuse Alveolar Hemorrhage Rescued by Extracorporeal Membrane Oxygenation. Indian J Crit Care Med 2020; 24:879-881. [PMID: 33132578 PMCID: PMC7584836 DOI: 10.5005/jp-journals-10071-23585] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Diffuse alveolar hemorrhage (DAH) is a rare but life-threatening disease. Mortality is very high in those patients who require mechanical ventilation. Traditionally, active bleeding has been considered a contraindication for extracorporeal membrane oxygenation (ECMO) support. There is limited evidence for ECMO in DAH as rescue therapy. Herein, we describe a case of antineutrophil cytoplasmic antibodies-associated DAH with intractable hypoxemic respiratory failure. An appropriate ventilator strategy failed to improve her hypoxemia leading to imminent risk to her life. The patient was rescued with veno-venous ECMO targeting lower than usual range of anticoagulation. ECMO proved to be lifesaving in our patient who was initiated on prompt immunosuppressive therapy and plasmapheresis along with continuous veno-venous hemodiafiltration and hemodynamic support. We feel that ECMO could be considered as adjunctive therapy in severe hypoxemic respiratory failure associated with DAH after careful consideration of the risk of bleeding and a restrictive anticoagulation strategy. How to cite this article: Goel MK, Chauhan M, Kumar A, Wadwa P, Maitra G, Talegaonkkar M, et al. A Case of Refractory Hypoxemic Respiratory Failure due to Antineutrophil Cytoplasmic Antibodies-associated Diffuse Alveolar Hemorrhage Rescued by Extracorporeal Membrane Oxygenation. Indian J Crit Care Med 2020;24(9):879–881.
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Affiliation(s)
- Manoj K Goel
- Department of Pulmonology, Critical Care and Sleep Medicine, Fortis Memorial Research Institute, Gurugram, Haryana, India
| | - Munish Chauhan
- Department of Critical Care Medicine, Fortis Memorial Research Institute, Gurugram, Haryana, India
| | - Ajay Kumar
- Department of Pulmonology, Critical Care and Sleep Medicine, Fortis Memorial Research Institute, Gurugram, Haryana, India
| | - Pooja Wadwa
- Department of Critical Care Medicine, Fortis Memorial Research Institute, Gurugram, Haryana, India
| | - Gargi Maitra
- Department of Pulmonology, Critical Care and Sleep Medicine, Fortis Memorial Research Institute, Gurugram, Haryana, India
| | - Milind Talegaonkkar
- Department of Critical Care Medicine, Fortis Memorial Research Institute, Gurugram, Haryana, India
| | - Sandeep Dewan
- Department of Critical Care Medicine, Fortis Memorial Research Institute, Gurugram, Haryana, India
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18
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Seeliger B, Stahl K, Schenk H, Schmidt JJ, Wiesner O, Welte T, Kuehn C, Bauersachs J, Hoeper MM, David S. Extracorporeal Membrane Oxygenation for Severe ARDS Due to Immune Diffuse Alveolar Hemorrhage: A Retrospective Observational Study. Chest 2019; 157:744-747. [PMID: 31711988 DOI: 10.1016/j.chest.2019.10.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 09/23/2019] [Accepted: 10/18/2019] [Indexed: 12/23/2022] Open
Affiliation(s)
| | - Klaus Stahl
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover, Germany
| | - Heiko Schenk
- Department of Nephrology and Hypertension, Hannover, Germany
| | | | - Olaf Wiesner
- Department of Respiratory Medicine, Hannover, Germany
| | - Tobias Welte
- Department of Respiratory Medicine, Hannover, Germany; Biomedical Research in End-Stage and Obstructive Lung Disease, Hannover, Germany
| | - Christian Kuehn
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover, Germany
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Marius M Hoeper
- Department of Respiratory Medicine, Hannover, Germany; Biomedical Research in End-Stage and Obstructive Lung Disease, Hannover, Germany
| | - Sascha David
- Department of Nephrology and Hypertension, Hannover, Germany.
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19
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Hellmich B, Löffler C. [What are the indications for rescue procedures? : Systemic rheumatic diseases in the intensive care unit]. Z Rheumatol 2019; 78:955-966. [PMID: 31485728 PMCID: PMC7101899 DOI: 10.1007/s00393-019-00687-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Schwere, organ- oder lebensbedrohliche Manifestationen entzündlicher rheumatischer Erkrankungen, wie z. B. eine diffuse alveoläre Hämorrhagie im Rahmen einer Kleingefäßvaskulitis, sprechen nicht immer ausreichend oder mit zeitlicher Verzögerung auf eine immunsuppressive Therapie an. Bei einem drohenden oder bereits eingetretenen Organversagen besteht dann nicht selten die Notwendigkeit, die immunsuppressive Therapie auf der Intensivstation um rasch wirksame Rescue-Therapieverfahren zu ergänzen. Aufgrund der Seltenheit vieler rheumatischer Erkrankungen ist die Evidenz zum Einsatz von Rescue-Therapieverfahren wie der Plasmapherese, der extrakorporalen Membranoxygenierung (ECMO) oder der Gabe von intravenösen Immunglobulinen (IVIG) für viele Indikationen eher gering. Der Einsatz der Plasmapherese wird bei einer akuten Anti-GBM(glomeruläre Basalmembran)-Erkrankung (Goodpasture Syndrom) oder einem katastrophalen Antiphospholipidantikörpersyndrom (CAPS) als sinnvoll angesehen. Eine ECMO-Therapie kann bei persistierender respiratorischer Insuffizienz trotz mechanischer Beatmung als Folge einer diffusen alveolären Hämorrhagie oder eines Acute-Respiratory-Distress-Syndroms (ARDS) anderer Ursache erwogen werden. Eine Gabe von IVIG ist bei einer akuten kardialen Beteiligung im Rahmen einer Kawasaki-Erkrankung indiziert und kann beim CAPS sowie bei therapierefraktären Myositiden erwogen werden.
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Affiliation(s)
- B Hellmich
- Vaskulitiszentrum Süd, Klinik für Innere Medizin, Rheumatologie und Immunologie, Medius Kliniken - Akademisches Lehrkrankenhaus, Universität Tübingen, Eugenstr. 3, 73230, Kirchheim u. Teck, Deutschland.
| | - C Löffler
- Vaskulitiszentrum Süd, Klinik für Innere Medizin, Rheumatologie und Immunologie, Medius Kliniken - Akademisches Lehrkrankenhaus, Universität Tübingen, Eugenstr. 3, 73230, Kirchheim u. Teck, Deutschland
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