Reduced anticoagulation targets in extracorporeal life support (RATE): study protocol for a randomized controlled trial

BACKGROUND

Although life-saving in selected patients, ECMO treatment still has high mortality which for a large part is due to treatment-related complications. A feared complication is ischemic stroke for which heparin is routinely administered for which the dosage is usually guided by activated partial thromboplastin time (aPTT). However, there is no relation between aPTT and the rare occurrence of ischemic stroke (1.2%), but there is a relation with the much more frequent occurrence of bleeding complications (55%) and blood transfusion. Both are strongly related to outcome.

METHODS

We will conduct a three-arm non-inferiority randomized controlled trial, in adult patients treated with ECMO. Participants will be randomized between heparin administration with a target of 2-2.5 times baseline aPTT, 1.5-2 times baseline aPTT, or low molecular weight heparin guided by weight and renal function. Apart from anticoagulation targets, treatment will be according to standard care. The primary outcome parameter is a combined endpoint consisting of major bleeding including hemorrhagic stroke, severe thromboembolic complications including ischemic stroke, and mortality at 6 months.

DISCUSSION

We hypothesize that with lower anticoagulation targets or anticoagulation with LMWH during ECMO therapy, patients will have fewer hemorrhagic complications without an increase in thromboembolic complication or a negative effect on their outcome. If our hypothesis is confirmed, this study could lead to a change in anticoagulation protocols and a better outcome for patients treated with ECMO.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04536272 . Registered on 2 September 2020. Netherlands Trial Register NL7969.

Ultrasound measurement of the optic nerve sheath diameter in traumatic brain injury: a narrative review

Background : Raised intracranial pressure (ICP) needs to be investigated in various situations, especially in traumatic brain injury (TBI). Ultra-sonographic (US) measurement of the optic nerve sheath diameter (ONSD) is a promising noninvasive tool for assessing elevated ICP. Objectives : This narrative review aimed to explain the history of and indications forUS measurement of ONSD. We focused on the detection of elevated ICP after TBI and discussed the possible improvements in detection methods. Conclusions : US measurement of ONSD in TBI cases provides a qualitative but no quantitative assessment of ICP. Current studies usually calculate their own optimum cutoff value for detecting raised ICP based on the balance between sensitivity and specificity of the method when compared with invasive methods. There is no universally accepted threshold. We did not find any paper focusing on the prognosis of patients benefiting from it when compared with usual care. Another limitation is the lack of standardization. US measurement of ONSD cannot be used as the sole technique to detect elevated ICP and monitor its evolution, but it can be a useful tool in a multimodal protocol and it might help to determine the prognosis of patients in various situations.

[ACE-inhibition and bradykinin-mediated angioedema]

Angiotensin converting enzyme inhibitors (ACE-i) are the most common cause of bradykininin angioedema. These bradykinin-mediated angioedemas are sometimes confused with histamine-induced angioedema, which may cause a late diagnosis and hence poor initial management, deleterious to the patient. This report describes a patient with a bradykinin-mediated angioedema soon after the initiation of perindopril, with laryngeal involvement requiring orotracheal intubation in emergency. The diagnosis was confirmed later and the assay of the activity of the enzymes involved in the catabolism of kinins - aminopeptidase P (APP), carboxypeptidase N (CPN) and Angiotensin-Converting Enzyme (ACE) - demonstrated a decrease of activity of both APP and ACE. As the diagnosis was not made initially, the specific treatments - concentrate of C1 inhibitor or antagonist of the B2 receptor of bradykinin (Icatibant) - were not administered. Any angioedema occurring during a treatment with ACE-i should be considered as a bradykinin-mediated angioedema.

Is early enteral nutrition dangerous in acute non surgical complicated diverticulitis? About 25 patients fed with oral fiber free energetic liquid diet

BACKGROUND AND STUDY AIMS

Complicated Acute Colonic Diverticulitis (ACD) is usually treated by parenteral way thus keeping the bowel at rest. To date there are no clear recommendations regarding the route of nutrition administration. We study the safety of early feeding by oral energetic fiber-free liquid diet in non-surgical complicated ACD patients.

PATIENTS AND METHODS

From February 2008 to October 2011, 25 patients were admitted with complicated ACD and took part in this prospective study. Surgical and medical assessments were performed at admission. Initial treatment was given with perfusion, intravenous antibiotics and hydric diet. Within 72 hours of admission, antibiotic therapy was switched to oral administration for 5 up to 15 days depending on the progression of the disease. At the same time the patient received oral liquid fiber-free feeding. Solid but fiber-free diet was introduced 24h hours before discharge.

RESULTS

25 cases of ACD were complicated with covered perforation and/or abscess. Mean hospitalisation time was 10A.4 days. 23 cases had good recovery and discharged, while 1 case progressed to colonic stenosis during hospitalisation, requiring a sigmoidectomy with a one-time anastomosis with good recovery. One patient relapsed his abscess during hospitalisation despite CT guided drainage and required sigmoidectomy with transient ileostomy. The mean daily treatment and nutrition cost for the non-surgical 23 patients was 30 euros.

CONCLUSIONS

Early enteral nutrition in complicated ACD is feasible, not harmful, and reduce both, mean hospitalization time and treatment cost. Further studies comparing enteral with parenteral nutrition are necessary to confirm our hypothesis.

Role of Bcl-2 as a prognostic factor for survival in lung cancer: a systematic review of the literature with meta-analysis

The role of the anti-apoptotic protein Bcl-2 in lung cancer remains controversial. In order to clarify its impact on survival in small and non-small cell lung cancer (NSCLC), we performed a systematic review of the literature. Trials were selected for further analysis if they provided an independent assessment of Bcl-2 in lung cancer and reported analysis of survival data according to Bcl-2 status. To make it possible to aggregate survival results of the published studies, their methodology was assessed using a quality scale designed by the European Lung Cancer Working Party (including study design, laboratory methods and analysis). Of 28 studies, 11 identified Bcl-2 expression as a favourable prognostic factor and three linked it with poor prognosis; 14 trials were not significant. No differences in scoring measurement were detected between the studies, except that significantly higher scores were found in the trials with the largest sample sizes. Assessments of methodology and of laboratory technique were made independently of the conclusion of the trials. A total of 25 trials, comprising 3370 patients, provided sufficient information for the meta-analysis. The studies were categorised according to histology, disease stage and laboratory technique. The combined hazard ratio (HR) suggested that a positive Bcl-2 status has a favourable impact on survival: 0.70 (95% confidence interval 0.57-0.86) in seven studies on stages I-II NSCLC; 0.50 (0.39-0.65) in eight studies on surgically resected NSCLC; 0.91 (0.76-1.10) in six studies on any stage NSCLC; 0.57 (0.41-0.78) in five studies on squamous cell cancer; 0.75 (0.61-0.93) and 0.71 (0.61-0.83) respectively for five studies detecting Bcl-2 by immunohistochemistry with Ab clone 100 and for 13 studies assessing Bcl-2 with Ab clone 124; 0.92 (0.73-1.16) for four studies on small cell lung cancer; 1.26 (0.58-2.72) for three studies on neuroendocrine tumours. In NSCLC, Bcl-2 expression was associated with a better prognosis. The data on Bcl-2 expression in small cell lung cancer were insufficient to assess its prognostic value.

Leucopenia is an independent predictor in cancer patients requiring invasive mechanical ventilation: a prognostic factor analysis in a series of 168 patients

OBJECTIVE

To determine prognostic factors predicting success of invasive mechanical ventilation in medical cancer patients admitted to ICU for a complication, in terms of extubation and ICU and hospital discharges.

DESIGN

Retrospective study

SETTING

Medical ICU of an European cancer hospital.

SUBJECTS

A total of 168 consecutive cancer patients who were admitted to ICU for an acute medical complication requiring immediate mechanical ventilation or who later needed mechanical ventilation.

MEASUREMENTS

Variables related to the demographic, cancer, scores and complication characteristics. Extubation rates, ICU and hospital mortalities and duration of survival were measured.

RESULTS

Respectively, 26%, 22% and 17% of the patients were extubated, discharged from the ICU and discharged from hospital. For weaning from mechanical ventilation, a higher APACHE II score and leucopenia were poor prognostic factors in univariate analysis, but leucopenia remained the only significant one in multivariate analysis. For ICU mortality, no significant prognostic feature was identified. For hospital mortality, leucopenia was the only significant factor in univariate as well as in multivariate analyses.

CONCLUSION

Leucopenia appeared to be the only independent poor prognostic factor for both extubation and hospital discharge. None of the variables related to the cancer disease process was shown to be a predictor of success.

Therapeutic use of granulocyte and granulocyte-macrophage colony-stimulating factors in febrile neutropenic cancer patients. A systematic review of the literature with meta-analysis

The effectiveness of granulocyte and granulocyte-macrophage colony-stimulating factor (G-CSF and GM-CSF) in the treatment of febrile neutropenic cancer patients remains controversial. To assess their role in this condition, we conducted a systematic review of randomised trials published as full papers. A methodological evaluation using a specifically designed quality scale was performed before meta-analysis. Eleven trials were eligible, 8 of which were meta-analysable. The median quality score for the 11 pooled trials was 58.3% (range: 33.3%-68.8%). No significant quality difference was observed between positive (colony-stimulating factor more effective) and negative trials ( P=0.36). No quality difference was observed between the 8 meta-analysable studies and the 3 others, with respective median scores of 59.3% and 50%. No advantage was detected for the use of CSF in terms of mortality from febrile neutropenia, with a relative risk of 0.71 (95% CI 0.44-1.15). The relative risk was 0.66 (95% CI 0.39-1.13) in the G-CSF subgroup and 0.97 (95% CI 0.34-2.79) in the GM-CSF subgroup. Aggregation of the results on infection-related mortality, length of stay in hospital, fever and of neutropenia duration, antibiotic therapy adaptation and duration, superinfection rate and toxicity was not possible owing to the lack of adequate data in the publications. On the basis of this review, we cannot recommend the routine use of G-CSF or GM-CSF in established febrile neutropenia.

[The role of chemotherapy in the treatment of non-metastatic, non-small cell bronchial cancers]

A systematic review of the literature about the role of chemotherapy in comparison to local therapies--surgery or radiotherapy--in non-small cells lung cancers has identified 35 randomised trials. The methodological assessment has not shown significant difference for quality scores between negative or positive studies in term of survival effect. The aggregation (meta-analysis) shows a significant effect of survival improvement by chemotherapy, whatever all indications are considered or subgroups like adjuvant chemotherapy to surgery, neoadjuvant chemotherapy, concomitant radio-chemotherapy and induction chemotherapy prior to thoracic irradiation.

Role of p53 as a prognostic factor for survival in lung cancer: a systematic review of the literature with a meta-analysis

The role of p53, as a prognostic factor for survival in lung cancer, is controversial and the purpose of the present systematic review of the literature is to determine this effect. Published studies were identified with the objective to aggregate the available survival results after a methodological assessment using a scale specifically designed by the European Lung Cancer Working Party (ELCWP). To be eligible, a study had to deal with p53 assessment in lung cancer (primary site) only, and to provide a survival comparison according to the p53 status. Among the 74 eligible papers, 30 identified p53 abnormalities as a univariate statistically significant poor prognostic factor and 56 provided sufficient data to allow survival results aggregation. There was no significant difference between the trials that either showed or did not show a prognostic effect of p53 according to the methodological score or to the laboratory technique used. The studies were categorized by histology, disease stage, treatment and laboratory technique. Combined hazard ratios suggested that an abnormal p53 status had an unfavourable impact on survival: in any stage nonsmall cell lung cancer (NSCLC) the mean (95% confidence interval) was 1.44 (1.20-1.72) (number of studies included in the subgroup was 11), 1.50 (1.32-1.70) in stages I-II NSCLC (n=19), 1.68 (1.23-2.29) in stages I-IIIB NSCLC (n=5), 1.68 (1.30-2.18) in stages III-IV NSCLC (n=9), 1.48 (1.29-1.70) in surgically resected NSCLC (n=20), 1.37 (1.02-1.85) in squamous cell carcinoma (n=9), 2.24 (1.70-2.95) in adenocarcinoma (n=9), 1.57 (1.28-1.91) for a positive immunohistochemistry with antibody 1801 (n=8), 1.25 (1.09-1.43) for a positive immunohistochemistry with antibody DO-7 (n=16), and 1.65 (1.35-2.00) for an abnormal molecular biology test (n=13). Data were insufficient to determine the prognostic value of p53 in small cell lung cancer. In each subgroup of nonsmall cell lung cancer, p53 abnormal status was shown to be associated with a poorer survival prognosis.

Electrocardiographic manifestations of heart metastasis from a primary lung cancer

Though acute myocardial infarction is one of the most frequent causes of ST segment elevation, there are other, less frequent, reasons for such electrocardiographic changes. In the present case, a cardiac metastasis from a squamous cell lung carcinoma was responsible for these changes. The secondary lesion was located in the apex of the left ventricle and induced an ECG alteration mimicking myocardial ischaemia. The literature includes few reports that describe the relation between electrocardiographic changes and heart metastases, since heart metastases are not usually discovered except at autopsy.

The role of mitomycin in the treatment of non-small cell lung cancer: a systematic review with meta-analysis of the literature

In order to clarify the role of mitomycin (MMC) in the treatment of NSCLC, we performed a systematic review of the literature and qualitatively assessed the selected studies using the ELCWP and Chalmers scales. 5 trials (202 patients) assessed the activity of MMC as single-agent chemotherapy in NSCLC. The overall response rate was 25% (95% Cl 19-31). In 10 randomized phase III trials (1769 patients), we studied the role of MMC in combination therapy. A meta-analysis, based on the available published data, failed to show any survival advantage of the MMC containing regimens (hazard ratio = 0.95; 95% Cl 0.83-1.10). Finally, 4 eligible trials (139 patients) assessed the activity of MMC regimens as salvage therapy, 3 in combination with vindesine and one with cisplatin and vinblastine. The overall response rate for the MMC-vindesine regimen was 10.5% (95% Cl 1.7-19.4). In conclusion, MMC is an active drug for NSCLC but does not improve survival when combined with other active drugs, particularly cisplatin. Its use for salvage therapy appears to be associated with marginal activity only.

[Mechanical ventilation in the cancer patient]

The overall objective of this review is to analyze the literature published on artificial ventilation in cancer patients. First, we reviewed series of cancer patients treated by mechanical ventilation or intensive care series with data on artificial ventilation in a context of malignant solid tumors, hematology malignancies or complications of bone marrow transplantation. A second part of the review is devoted to characteristic diseases for which specific literature is available, with description of the clinical presentation, the causes and the proposed therapies. The third part is a discussion of considerations on care and therapeutic techniques. Finally, we propose guidelines for a practical approach to this type of patient taking into account the prognosis and new techniques such as noninvasive ventilation.

Isovolumic contraction time of right ventricle in d-transposition of great arteries

The pre-ejection period of the right ventricle in d-transposition of the great arteries is known to be prolonged, compared with the same interval of the left ventricle of normal subjects. In the present study, the echocardiographic measurement of the components of the pre-ejection period of the right ventricle of 14 patients with d-transposition of the great arteries shows that the isometric contraction time of the right ventricle in d-transposition of the great arteries is similar to the same interval calculated on the left ventricle of 76 normal children of comparable age. On the other hand, the electromechanical delay was significantly greater for the right ventricle of d-transposition of the great arteries than for the left ventricle of the normal subjects. It is concluded that the prolonged pre-ejection period of the right ventricle in d-transposition of the great arteries is not the result of right ventricular dysfunction but solely of a longer electromechanical delay.

[Hemodynamic effects of mexiletine]

The haemodynamic changes caused by intravenous mexiletine were studied in 12 patients. Initially the drug was given rapidly at the rate of 3 mg/kg/min for 10 minutes and then slowly at a rate of 0,06 mg/kg/min for 30 minutes. The plasma Mexiletine level measured after 20 minutes was used to divide the series of patients into two groups: in Group A the level was over 0,7 g/ml (0,961 +/- 0,109 microgram/ml) whilst in Group B the level was only 0,547 +/- 0,101 microgram/ml. The mean aortic pressure, heart rate and left ventricular end diastolic volume did not vary significantly in the two groups. The left ventricular end diastolic pressure rose, and the cardiac index and the ejection fraction fell in Group A. The indices of left ventricular contractility fell in all patients of the start of the injection. This depression only persisted to the end of the injection in Group A. Mexiteline did not cause significant changes in post extrasystolic potentialisation in the 5 cases in which this phenomenon was studied.

[Change in heart function in Duchênne de Boulogne myopathies at the severe progressive stage]

Left ventricular function was studied in 15 patients with rapidly progressive Duchenne de Boulogne muscular dystrophy. Only one patient had a previous history of cardiac failure. All patients had typical electrocardiographical changes. Haemodynamic and angiographic investigation was performed in all patients. Three groups of patients were distinguished according to angiographic criteria : group I comprising 7 normal patients. group II comprising 4 "intermediary" patients, and group III of 4 patients with hypokinetic cardiomyopathy. Segmental ventricular dyskinesis was observed in 6 patients. Mitral incompetence was present in 2 cases and mitral valve prolpse in 1 case. All patients had a normal resting cardiac index. Patients in group II and III had end diastolic left ventricular pressures greater than 15 mmHg. An intravenous angiotensin test was performed in 4 patients from groups I and II. Impaired left ventricular function was demonstrated in patients thought to be normal in the basal state. Finally, myocardial involvement in this group of patients runs a parallel course to the duration and severity of the peripheral muscular disease.