Utilization of Services and Clinical Outcomes among American Indian/Alaska Native (AIAN) Women with Breast Cancer at an Academic Medical Center (AMC)

PURPOSE/OBJECTIVE(S)

AIAN patients have worse cancer outcomes than other races and may face barriers in accessing care. Data on healthcare utilization or outcomes for AIAN patients across healthcare systems are limited. We report patient characteristics, treatment patterns, and clinical outcomes for AIAN women with breast cancer seen at a tertiary AMC in the Pacific Northwest.

MATERIALS/METHODS

We performed a retrospective chart review of self-identified AIAN women with an encounter for unilateral breast cancer between January /2000 and January 2021. Patient demographics; AJCC 8th prognostic stage; treatment (surgery, radiation, systemic therapy); were abstracted and summarized with median (interquartile range) or number (%) and compared with χ2 or t-tests. Progression-free (recurrent or new breast cancer) and overall survival (PFS; OS) were estimated per Kaplan-Meier and compared with log-rank tests.

RESULTS

Of 21,013 patients with cancer encounters, 2,168 (10%) self-identified as AIAN and 246 (0.01%) were AIAN women with unilateral breast cancer. The median age at diagnosis was 52 (43 - 53) years; 37% lived in the same county as the AMC while 80% lived in the same state. At diagnosis, 181 (74%) had early-stage (0 - 2A), 24 (10%) locally-advanced (2B - 3), 30 (12%) non-metastatic, and 11 (4%) metastatic disease. Of the 181 (74%) women treated at the AMC, 39% lived in the same county; 86% had curative-intent therapy: 52 (71%) surgery, 114 (37%) radiation, and 65 (64%) systemic therapy; 26% had surveillance, oncoplastic surgery or non-cancer care only. Women who had surgery at the AMC were older (P < 0.01), less likely to live in the same county (40%, P = 0.4), had mostly early-stage disease (81%, P = 0.005), and were more likely to receive adjuvant therapy at the AMC (75%, P < 0.01). Patients treated for metastatic disease at the AMC (19%) rarely lived in the same county (21%, P = 0.03), or had prior treatment at the AMC (32%, P = 0.03); 92% had systemic therapy, 38% radiation, and 12% surgery. With median 6.4 (3.2 - 10.9) years follow-up, median OS for all AIAN patients was 51.4 (unreached [UR] - UR) years. Patients who presented to the AMC with metastatic disease had median OS 13.4 (8.4 - UR) years. With median 5.1 (2.6 - 9.3) years follow-up, median PFS was 20.6 (14.2 - UR) years, and longer for patients who received any curative-intent treatment at the AMC (P = 0.006).

CONCLUSION

Most AIAN women with breast cancer seen at the AMC received curative treatment for early-stage disease with excellent outcomes. Most treated for metastatic disease had no prior treatment at the AMC and may be more likely to transfer care to the AMC to engage with specialized services or clinical trials, particularly for systemic therapy. Understanding the prognostic stage, treatment utilization, and outcomes of the AIAN patients served may allow us to improve cancer services and outcomes for this community.

New Collaborative Research on Suicide Prevention, Practice, and Policy With American Indian and Alaska Native Communities Holds Promise for All Peoples

Youth suicide is increasing in the United States, with deaths among younger people of color driving this upward trend. For more than four decades, American Indian and Alaska Native (AIAN) communities have suffered disproportionate rates of youth suicide and years of productive life lost compared to other U.S. Races. The National Institute of Mental Health (NIMH) recently funded three regional Collaborative Hubs to carry out suicide prevention research, practice, and policy development with AIAN communities in Alaska and rural and urban areas of the Southwestern United States. The Hub partnerships are supporting a diverse array of tribally-driven studies, approaches, and policies with immediate value for increasing empirically driven public health strategies to address youth suicide. We discuss unique features of the cross-Hub work, including: (a) long-standing Community-Based Participatory Research processes that led to the Hubs' innovative designs and novel approaches to suicide prevention and evaluation, (b) comprehensive ecological theoretical approaches that contextualize individual risk and protective factors in multilevel social contexts; (c) unique task-shifting and systems of care approaches to increase reach and impact on youth suicide in low-resource settings; and (d) prioritization of strengths-based approaches. The work of the Collaborative Hubs for AIAN youth suicide prevention is generating specific and substantive implications for practice, policy, and research presented in this article at a time when youth suicide prevention is a dire national priority. Approaches also have relevance for historically marginalized communities worldwide.

Nucleated red blood cells are a predictor of mortality in patients under extracorporeal membrane oxygenation

BACKGROUND

The presence of Nucleated Red Blood Cells (NRBCs) in critically ill patients is associated with higher mortality and poor prognosis. Although patients on extracorporeal support such as veno-venous or veno-arterial extracorporeal membrane oxygenation (VV/VA-ECMO) are severely ill, NRBCs have rarely been investigated regarding their predictive value so far.

METHODS

As part of a retrospective study, we examined all cardiothoracic surgery patients from July 2019 to September 2020 who received ECMO treatment during their inpatient stay. The aim of this study was to investigate the occurrence of NRBCs during ECMO support in terms of their predictive value for mortality.

RESULTS

In total 30 patients (age at admission: 62.7 ± 14.3 year; 26 male; ECMO duration: 8.5 ± 5.1 days; ICU duration: 18.0 ± 14.5 days) were included. 16 patients (53.3%) died during their inpatient stay. There were no significant differences in demographic characteristics between VA- or VV- ECMO patients. NRBCs occurred in all patients while under ECMO support. NRBC value was significant higher in those who died (2299.6 ± 4356.6 µl) compared to the surviving patients (133.6 ± 218.8 µl, p < 0.001). Univariate analysis found that patients with a cutoff value of ≥ 270 NRBCs/µl during ECMO support were 39 times more likely to die (OR 39.0, 95% CI 1.5-997.5, p < 0.001). 12 out of 13 patients (92.3%) with ≥ 270 NRBCs/µl died. The area under the curve (AUC) of the receiver operating characteristic curve was 0.85 (95% CI 0.69-0.96) with a sensitivity of 75.0% and a specificity of 92.9%.

CONCLUSION

NRBCs appear to be an accurate biomarker for mortality in patients with ECMO support. They may be helpful in deciding if therapy becomes futile. Trial registration DRKS00023626 (December 20th 2020).

Mortality rates of severe COVID-19-related respiratory failure with and without extracorporeal membrane oxygenation in the Middle Ruhr Region of Germany

The use of extracorporeal membrane oxygenation (ECMO) is discussed to improve patients' outcome in severe COVID-19 with respiratory failure, but data on ECMO remains controversial. The aim of the study was to determine the characteristics of patients under invasive mechanical ventilation (IMV) with or without veno-venous ECMO support and to evaluate outcome parameters. Ventilated patients with COVID-19 with and without additional ECMO support were analyzed in a retrospective multicenter study regarding clinical characteristics, respiratory and laboratory parameters in day-to-day follow-up. Recruitment of patients was conducted during the first three COVID-19 waves at four German university hospitals of the Ruhr University Bochum, located in the Middle Ruhr Region. From March 1, 2020 to August 31, 2021, the charts of 149 patients who were ventilated for COVID-19 infection, were included (63.8% male, median age 67 years). Fifty patients (33.6%) received additional ECMO support. On average, ECMO therapy was initiated 15.6 ± 9.4 days after symptom onset, 10.6 ± 7.1 days after hospital admission, and 4.8 ± 6.4 days after the start of IMV. Male sex and higher SOFA and RESP scores were observed significantly more often in the high-volume ECMO center. Pre-medication with antidepressants was more often detected in survivors (22.0% vs. 6.5%; p = 0.006). ECMO patients were 14 years younger and presented a lower rate of concomitant cardiovascular diseases (18.0% vs. 47.5%; p = 0.0004). Additionally, cytokine-adsorption (46.0% vs. 13.1%; p < 0.0001) and renal replacement therapy (76.0% vs. 43.4%; p = 0.0001) were carried out more frequently; in ECMO patients thrombocytes were transfused 12-fold more often related to more than fourfold higher bleeding complications. Undulating C-reactive protein (CRP) and massive increase in bilirubin levels (at terminal stage) could be observed in deceased ECMO patients. In-hospital mortality was high (Overall: 72.5%, ECMO: 80.0%, ns). Regardless of ECMO therapy half of the study population deceased within 30 days after hospital admission. Despite being younger and with less comorbidities ECMO therapy did not improve survival in severely ill COVID-19 patients. Undulating CRP levels, a massive increase of bilirubin level and a high use of cytokine-adsorption were associated with worse outcomes. In conclusion, ECMO support might be helpful in selected severe cases of COVID-19.

Empfehlungen der S3-Leitlinie (AWMF) „Einsatz der extrakorporalen Zirkulation (ECLS/ECMO) bei Herz- und Kreislaufversagen“

In den vergangenen Jahren hat der Einsatz mechanischer Unterstützungssysteme für Patienten mit Herz- und Kreislaufversagen kontinuierlich zugenommen, sodass in Deutschland mittlerweile jährlich etwa 3000 ECLS-/ECMO-Systeme implantiert werden. Vor dem Hintergrund bislang fehlender umfassender Leitlinien bestand ein dringlicher Bedarf an der Formulierung evidenzbasierter Empfehlungen zu den zentralen Aspekten der ECLS-/ECMO-Therapie. Im Juli 2015 wurde daher die Erstellung einer S3-Leitlinie durch die Deutsche Gesellschaft für Thorax-, Herz- und Gefäßchirurgie (DGTHG) bei der zuständigen Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e. V. (AWMF) angemeldet. In einem strukturierten Konsensusprozess mit Einbindung von Experten aus Deutschland, Österreich und der Schweiz, delegiert aus 11 AWMF-Fachgesellschaften, 5 weiteren Fachgesellschaften sowie der Patientenvertretung, entstand unter Federführung der DGTHG die Leitlinie „Einsatz der extrakorporalen Zirkulation (ECLS/ECMO) bei Herz- und Kreislaufversagen“, die im Februar 2021 publiziert wurde. Die Leitlinie fokussiert auf klinische Aspekte der Initiierung, Fortführung, Entwöhnung und Nachsorge und adressiert hierbei auch strukturelle und ökonomische Fragestellungen. Dieser Artikel präsentiert eine Übersicht zu der Methodik und den konsentierten Empfehlungen.

Empfehlungen der S3-Leitlinie (AWMF) Einsatz der extrakorporalen Zirkulation (ECLS/ECMO) bei Herz- und Kreislaufversagen

In den vergangenen Jahren hat der Einsatz mechanischer Unterstützungssysteme für Patienten mit Herz- und Kreislaufversagen kontinuierlich zugenommen, sodass in Deutschland mittlerweile jährlich etwa 3000 ECLS/ECMO-Systeme implantiert werden. Vor dem Hintergrund bislang fehlender umfassender Leitlinien bestand ein dringlicher Bedarf an der Formulierung evidenzbasierter Empfehlungen zu den zentralen Aspekten der ECLS/ECMO-Therapie.

Im Juli 2015 wurde daher die Erstellung einer S3-Leitlinie durch die Deutsche Gesellschaft für Thorax-, Herz- und Gefäßchirurgie (DGTHG) bei der zuständigen Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e. V. (AWMF) angemeldet. In einem strukturierten Konsensusprozess mit Einbindung von Experten aus Deutschland, Österreich und der Schweiz, delegiert aus 11 AWMF-Fachgesellschaften, 5 weiteren Fachgesellschaften sowie der Patientenvertretung, entstand unter Federführung der DGTHG die Leitlinie „Einsatz der extrakorporalen Zirkulation (ECLS/ECMO) bei Herz- und Kreislaufversagen“, die im Februar 2021 publiziert wurde.

Die Leitlinie fokussiert auf klinische Aspekte der Initiierung, Fortführung, Entwöhnung und Nachsorge und adressiert hierbei auch strukturelle und ökonomische Fragestellungen. Dieser Artikel präsentiert eine Übersicht zu der Methodik und den konsentierten Empfehlungen.

Transapical-transcatheter aortic valve implantation in patients without transvascular options: Modified transapical approach

OBJECTIVES

Outcomes in patients with iliofemoral and concomitant iliofemoral-remote arteriopathies who cannot undergo transfemoral or other alternative transvascular approaches have not been studied so far. This study aimed to evaluate the early and midterm outcomes after transapical (TA)-transcatheter aortic valve implantation (TAVI) in patients with femoral and femoral-remote arteriopathies who cannot undergo transvascular approaches.

METHODS

Multimorbid patients with severe aortic stenosis and distinct panarteriopathy underwent TA-TAVI treatment between January 2012 and January 2021 at the authors' institution. Second- and third-generation self- and balloon-expanding valves were used. For patients without arterial access, TA-TAVI was modified to the artery-no-touch technique.

RESULTS

Seventy-two consecutive elderly patients (78.2 ± 6.9 years; 73% male) were included in the study. The Society of Thoracic Surgery-Predicted Risk of Mortality score was 7 ± 5%. No procedural deaths or conversion to conventional surgery was registered. The 30-day and midterm mortality rates were 5% and 28%, respectively. The median time of freedom from a composite of death and cardiocerebral adverse events was 34.3 months (95% confidence interval: 17.6-51.1). The rate of moderate/severe paravalvular leakage was 0%. The pacemaker rate was 11%.

CONCLUSIONS

TA-TAVI is a safe method with low-rate procedural complications and shows good early and midterm outcomes in patients with extensive panarteriopathy for whom transfemoral and other alternative transvascular approaches are contraindicated or at high interventional risk. The modified artery-no-touch TA-TAVI method is safe and feasible for selected patients with no other possible arterial approach.

Use of On-Site Digital Subtraction Angiography for Left Subclavian Artery Management During Hybrid Aortic Arch Repair in DeBakey I Dissection

PURPOSE

A hybrid aortic repair using the frozen elephant trunk (FET) technique with an open distal anastomosis in zone 2 and debranching of the left subclavian artery (LSA) has been demonstrated to be favorable and safe. Although a transposition of the LSA reduces the risk of cerebellar or medullar ischemia, this may be challenging in difficult LSA anatomies.

CASE REPORT

We present the case of a 61-year old patient with DeBakey I aortic dissection, treated with FET in moderate hypothermic circulatory arrest (26°C) and selective cerebral perfusion using a Thoraflex-Hybrid (Vascutek Terumo) prosthesis anchored in zone 2, with overstenting of the LSA orifice and no additional LSA debranching. Sufficient perfusion of the LSA was proved intraoperatively using LSA backflow analysis during selective cerebral perfusion in combination with on-site digital subtraction angiography (ARTIS Pheno syngo software). No neurologic dysfunction or ischemia occurred in the postoperative course. An angiographic computed tomography revealed physiologic LSA perfusion, with subsequent thrombotic occlusion of the false lumen in the proximal descending aorta after 7 days.

CONCLUSION

Using an angiography-guided management in patients with complex DeBakey I dissection and difficult anatomy may simplify a proximalization of the distal anastomosis in zone 2 for FET, even without an additional LSA debranching.

Sustaining suicide prevention programs in American Indian and Alaska Native communities and Tribal health centers

Background:

Research on sustaining community-based interventions is limited. This is particularly true for suicide prevention programs and in American Indian and Alaska Native (AIAN) settings. Aiming to inform research in this area, this paper sought to identify factors and strategies that are key to sustain suicide prevention efforts in AIAN communities.

Methods:

We used a modified Nominal Group Technique with a purposeful sample of N = 35 suicide prevention research experts, program implementors and AIAN community leaders to develop a list of prioritized factors and sustainability strategies. We then compared this list with the Public Health Program Capacity for Sustainability Framework (PHPCSF) to examine the extent the factors identified aligned with the existing literature.

Results:

Major factors identified included cultural fit of intervention approaches, buy in from local communities, importance of leadership and policy making, and demonstrated program success. Strategies to promote these factors included partnership building, continuous growth of leadership, policy development, and ongoing strategic planning and advocacy. All domains of the PHPCF were representative, but additional factors and strategies were identified that emerged as important in AIAN settings.

Conclusions:

Sustaining effective and culturally informed suicide prevention efforts is of paramount importance to prevent suicide and save lives. Future research will focus on generating empirical evidence of these strategies and their effectiveness at promoting program sustainability in AIAN communities.

Use of extracorporeal circulation (ECLS/ECMO) for cardiac and circulatory failure -A clinical practice Guideline Level 3

Aims Worldwide applications of extracorporeal circulation for mechanical support in cardiac and circulatory failure, which are referred to as extracorporeal life support (ECLS) or veno‐arterial extracorporeal membrane oxygenation (va‐ECMO), have dramatically increased over the past decade. In spite of the expanding use and the immense medical as well as socio‐economic impact of this therapeutic approach, there has been a lack of interdisciplinary recommendations considering the best available evidence for ECLS treatment.

Methods and Results In a multiprofessional, interdisciplinary scientific effort of all scientific societies involved in the treatment of patients with acute cardiac and circulatory failure, the first evidence‐ and expert consensus‐based guideline (level S3) on ECLS/ECMO therapy was developed in a structured approach under regulations of the AWMF (Association of the Scientific Medical Societies in Germany) and under use of GRADE (Grading of Recommendations Assessment, Development and Evaluation) criteria. This article presents all recommendations created by the expert panel, addressing a multitude of aspects for ECLS initiation, continuation, weaning and aftercare as well as structural and personnel requirements.

Conclusions This first evidence‐ and expert consensus‐based guideline (level S3) on ECLS/ECMO therapy should be used to apply the best available care nationwide. Beyond clinical practice advice, remaining important research aspects for future scientific efforts are formulated.

[Use of extracorporeal circulation (ECLS/ECMO) for cardiac and circulatory failure : Short version of the S3 guideline]

In Germany, a remarkable increase regarding the usage of extracorporeal membrane oxygenation (ECMO) and extracorporeal life support (ECLS) systems has been observed in recent years with approximately 3000 ECLS/ECMO implantations annually since 2015. Despite the widespread use of ECLS/ECMO, evidence-based recommendations or guidelines are still lacking regarding indications, contraindications, limitations and management of ECMO/ECLS patients. Therefore in 2015, the German Society of Thoracic and Cardiovascular Surgery (GSTCVS) registered the multidisciplinary S3 guideline "Use of extracorporeal circulation (ECLS/ECMO) for cardiac and circulatory failure" to develop evidence-based recommendations for ECMO/ECLS systems according to the requirements of the Association of the Scientific Medical Societies in Germany (AWMF). Although the clinical application of ECMO/ECLS represents the main focus, the presented guideline also addresses structural and economic issues. Experts from 17 German, Austrian and Swiss scientific societies and a patients' organization, guided by the GSTCVS, completed the project in February 2021. In this report, we present a summary of the methodological concept and tables displaying the recommendations for each chapter of the guideline.

[Use of extracorporeal circulation (ECLS/ECMO) for cardiac and circulatory failure : Short version of the S3 guideline]

In Germany, a remarkable increase regarding the usage of extracorporeal membrane oxygenation (ECMO) and extracorporeal life support (ECLS) systems has been observed in recent years with approximately 3000 ECLS/ECMO implantations annually since 2015. Despite the widespread use of ECLS/ECMO, evidence-based recommendations or guidelines are still lacking regarding indications, contraindications, limitations and management of ECMO/ECLS patients. Therefore in 2015, the German Society of Thoracic and Cardiovascular Surgery (GSTCVS) registered the multidisciplinary S3 guideline "Use of extracorporeal circulation (ECLS/ECMO) for cardiac and circulatory failure" to develop evidence-based recommendations for ECMO/ECLS systems according to the requirements of the Association of the Scientific Medical Societies in Germany (AWMF). Although the clinical application of ECMO/ECLS represents the main focus, the presented guideline also addresses structural and economic issues. Experts from 17 German, Austrian and Swiss scientific societies and a patients' organization, guided by the GSTCVS, completed the project in February 2021. In this report, we present a summary of the methodological concept and tables displaying the recommendations for each chapter of the guideline.

Hemoadsorption: effective in reducing circulating fragments of the endothelial glycocalyx during cardiopulmonary bypass in patients undergoing on-pump cardiac surgery?

BACKGROUND

The vascular endothelial glycocalyx is susceptible to ischemia and hypoxia. Released soluble components of the endothelial glycocalyx (EG) have been identified as potential damage associated molecular patterns (DAMPs) able to enhance an ongoing inflammatory response. Shedding of the EG has been associated with released atrial-natriuretic peptide (ANP) during cardiac surgery procedures. A novel hemoadsorption technique (CytoSorb^®) has been shown to effectively remove molecules up to 55 kDa unspecifically from circulation. It is not known whether ANP or glycocalyx components can be removed successfully by this technique.

METHODS

In 15 patients undergoing on-pump cardiac surgery, the hemoadsorption device was integrated in the cardiopulmonary bypass (CPB) circuit. Pre- and post-adsorber concentrations of ANP, heparan sulphate (HEP), syndecan-1 (SYN) and hyaluronan (HYA) were measured at 10 (T1), 30 (T2), and 60 (T3) minutes after aortic cross-clamping and complete CPB.

RESULTS

Hemoadsorption significantly reduced mean HEP concentrations (-157.5 [333.4] ng/mL; P<0.001) post adsorber. For ANP and SYN no statistically significant changes were detected whereas mean [SD] HYA concentrations even increased significantly (+21.6 [43.0] ng/mL; P<0.001) post adsorber.

CONCLUSIONS

In this study representing a real-life scenario, we could demonstrate that the novel hemoadsorption device (CytoSorb^®) was able to effectively adsorb HEP from the circulation if integrated in a CPB circuit. However, blood concentrations of HYA, SYN, and ANP could not be reduced during CPB in our investigation.

Extracorporeal membrane oxygenation for acute respiratory distress syndrome in burn patients: a case series and literature update

Background

Acute respiratory distress syndrome (ARDS) has a reported incidence of 34–43% in ventilated burn patients and is associated with a mortality of 59% in the severe form. The use and experience with extracorporeal membrane oxygenation (ECMO) in burn patients developing ARDS are still limited. We present our results and discuss the significance of ECMO in treating burn patients.

Methods

A retrospective analysis of burn patients treated with ECMO for ARDS between January 2017 and January 2019 was performed. Demographic, clinical, and outcome data were collected and analyzed.

Results

Eight burn patients were treated at our institution with ECMO in the designated time period. Of these, all but one patient had inhalation injury, burn percentage of TBSA was 37 ± 23%, ABSI score was 8.4 ± 2, and R-Baux-score was 98 ± 21. Seven patients developed severe ARDS and one patient moderate ARDS according to the Berlin classification with a PaO₂/FiO₂ ratio upon initiation of ECMO therapy of 62 ± 22 mmHg. ECMO duration was 388 ± 283 h. Three patients died from severe sepsis while five patients survived to hospital discharge.

Conclusions

ECMO is a viable therapy option in burn patients developing severe ARDS and can contribute to survival rates similar to ECMO therapy in non-burn-associated severe ARDS. Consequently, patients with severe respiratory insufficiency with unsuccessful conventional treatment and suspected worsening should be transferred to burn units with the possibility of ECMO treatment to improve outcome.

Obesity risk factors in American Indians and Alaska Natives: a systematic review

OBJECTIVES

We systematically reviewed the literature on risk factors for obesity in American Indians (AIs) and Alaska Natives (ANs) of all ages.

STUDY DESIGN

We searched titles and abstracts in PubMed with combinations of the following terms: obesity, body mass index (BMI), American Indian, Alaska Native, and Native American.

METHODS

We limited our review to articles that provided an empirically testable claim about a variable associated with obesity, measured obesity as a dependent variable, and provided data specific to AI/ANs.

RESULTS

Our final sample included 31 articles; 20 examined AI/AN youth (<18 years), and 11 examined AI/AN adults (≥18 years). Risk factors for obesity varied by age. In infants, low birth weight, early termination of breastfeeding, and high maternal BMI, and maternal diabetes increased the risk of childhood obesity. In children and adolescents, parental obesity, sedentary behaviors, and limited access to fruits and vegetables were associated with obesity. In adulthood, sedentary behaviors, diets high in fats and carbohydrates, stress, verbal abuse in childhood, and the belief that health cannot be controlled were associated with obesity.

CONCLUSIONS

Extant studies have three limitations: they do not apply a life course perspective, they lack nationally representative data and have limited knowledge of the resilience, resistance and resourcefulness of AI/ANs. Future studies that avoid these shortcomings are needed to inform interventions to reduce the prevalence of obesity in AI/ANs across the life course.

Two-stage weaning strategy using veno-veno-arterial perfusion for patients on extracorporeal membrane oxygenation following cardiogenic shock

Objectives:

Veno-arterial extracorporeal membrane oxygenation represents the last therapy option in refractory cardiogenic shock. Successful weaning becomes difficult if the myocardial function recovers but pulmonary impairment persists. We present our experience with a new weaning strategy, using a stepwise mode-switch from veno-arterial to veno-veno-arterial and veno-venous extracorporeal membrane oxygenation setting for patients with primary cardiogenic shock and subsequent respiratory failure.

Methods:

From 81 patients treated with veno-arterial extracorporeal membrane oxygenation following acute cardiogenic shock between January 2014 and April 2018, eight patients with cardiac and pulmonary failure were identified to be treated using the following protocol: patients were put on veno-arterial extracorporeal membrane oxygenation, a second inflow cannula was inserted via the right jugular vein and cardiac weaning was performed via veno-veno-arterial support. Finally, patients were pulmonary weaned via veno-venous extracorporeal membrane oxygenation mode.

Results:

In the mode-switch group, etiologies of cardiogenic shock were cardiac arrest (12.5%), myocardial infarction (12.5%) and post-cardiotomic heart failure (75%). Mean time between onset of cardiogenic shock and start of veno-arterial extracorporeal membrane oxygenation was 76 ± 117 min. At implantation, lactate and pH values were 9.5 ± 5.0 mmol/L and 7.2 ± 0.2. Total extracorporeal membrane oxygenation-time was 9.3 ± 4.7 days, with a mode-switch from veno-arterial to veno-veno-arterial after 3.9 ± 2.7 days. The weaning rate in the mode-switch group was 75% (vs. 41% in the entire cohort) and the 30-day survival was 50% (vs 32% in the cohort). 38% of the patients presented a favorable neurological outcome.

Conclusion:

Mode-switch from veno-arterial to veno-veno-arterial and weaning via veno-venous extracorporeal membrane oxygenation mode is feasible for combined cardiac and pulmonary failure, with promising results due to an optimized pre-pulmonary oxygenation.

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.