Mortality on extracorporeal membrane oxygenation: Evaluation of independent risk factors and causes of death during venoarterial and venovenous support

INTRODUCTION

Most patients on extracorporeal membrane oxygenation (ECMO) decease during therapy on the system. However, the actual causes of death have not been studied sufficiently. This study analyses the etiology, prevalence, and risk factors for the outcome variable death during ongoing ECMO for all patients and divided according to venoarterial (VA) or venovenous (VV) support.

METHODS

We retrospectively analysed all patients receiving ECMO support at our institution between March 2006 to January 2021. Only the patients deceased during ongoing support were included.

RESULTS

2016 patients were placed on VA (n = 1168; 58%) or VV (n = 848; 42%) ECMO; 759 patients (37.7%) deceased on support. The causes of death differed between the support types: VA ECMO patients mostly died from cerebral ischemia (34%), low-cardiac output (LCO; 24.1%) and multi-organ failure (MOF; 21.6%), whereas in VV ECMO cases, refractory respiratory failure (28.2%), and sepsis (20.4%) dominated. Multivariate regression analysis revealed cardiopulmonary resuscitation (CPR) and acidosis prior to ECMO as risk factors for dying on VA ECMO, while high inotropic doses pre-ECMO, a high fraction of inspired oxygen on day 1, elevated lactate dehydrogenase, and international normalized ratio levels lead to an unfavourable outcome in VV ECMO patients.

CONCLUSION

Even in highly experienced centers, ECMO mortality remains high and occurs mainly on support or 24 h after its termination. The causes of death differ between VV and VA ECMO, depending on the underlying diseases responsible for the need of extracorporeal support.

Evaluation of treatment options for postoperative and spontaneous chylothorax in adults

 

OBJECTIVES

Both postoperative and spontaneous chylothorax remain therapeutic challenges without recommendations for a standardized treatment approach. Regardless of its aetiology, patients with chylothorax experience prolonged hospitalization and suffer from the associated complications or the invasive therapy administered.

METHODS

We conducted a retrospective, observational review of adult patients with chylothorax treated between January 2010 and September 2019. The primary end point was successful management with sustained cessation and/or controlled chylous output. Therapy duration, inpatient stay and the incidence of complications were evaluated as secondary end points.

RESULTS

Of the 36 patients included (22 men; median age 63 years), 24 patients (67%) suffered from a postoperative accumulation of chylous fluid in the pleural space; in the remaining 12 (33%) patients, chylothoraces occurred spontaneously. Initial conservative treatment was successful in 42% (n = 15); in the other 20 cases (56%) additional invasive therapeutic strategies were followed. A complicated course requiring more than 1 treatment was seen in 54% (n = 13) of the postoperative and in 58% (n = 7) of the spontaneous cases. The median length of hospitalization was significantly longer in the postoperative group (37.5 vs 15.5 days; P = 0.016). Serious complications were observed only in the postoperative group (P = 0.28). There were no in-hospital deaths.

CONCLUSIONS

Basic treatment of both postoperative and spontaneous chylothorax should include dietary measures in all patients. Additional sclerosing radiotherapy and interventional or surgical therapy are often necessary. The choice of therapeutic approach should be indicated, depending on the aetiology and development of the chylothorax. Early, multimodal treatment is recommended.

Complicated chylous pericardial and thoracic effusion as the first clinical manifestation of thoracic lymphatic malformation

Lymphatic malformations are benign focal proliferations of lymphatic vessels with a congenital origin. We present a case of an 18-year-old patient with post-traumatic chylopericardium and recurrent left-sided chylothorax, who was unresponsive to a variety of therapeutic measures until he was diagnosed with a complicated thoracic lymphatic malformation.

In situ investigation of production processes in a large chamber scanning electron microscope

A large-chamber scanning electron microscope (LC-SEM) provides an ideal platform for the installation of large-scale in situ experiments. Our LC-SEM has internal chamber dimensions of 1,2 × 1,3 × 1,4 m³ (W × H × D) (Fig.1) and makes it possible to incorporate novel in situ experimental devices, which are reported on here. The present manuscript describes in detail the development of in situ test equipment for the study of a broad range of processes in production engineering. Direct observation of the materials modification mechanisms provides fundamental insight into the underlying process characteristics. An in situ turning device was developed, tested and used to observe the chip formation on the microstructure scale of a 43CrMo4-sample. Laser beam micro welding was integrated into the LC-SEM to achieve in situ analysis of the welding process on stainless steel 1.4310. A heating module was employed for in situ wetting experiments to observe the formation and solidification of the melt of a tin-copper brazing filler on an aluminium cast alloy.

Variations in truncal body circumferences affect fat mass quantification with bioimpedance analysis

OBJECTIVE

To test the hypothesis that variations in trunk circumferences influence the accuracy of bioimpedance analysis (BIA) for assessment of percent fat mass (%FM).

SUBJECTS AND METHODS

%FM was predicted with BIA, and compared with air-displacement plethysmography (ADP) in a small sample of 35 overweight (OW), 21 normal weight and 8 underweight volunteers. Waist and hip circumferences were assessed, and 15 of the OW subjects were measured before and after weight reduction.

RESULTS

BIA and ADP provided similar cross-sectional estimates of group mean %FM (28.9±10.0 and 31.3±13.0%, respectively). However, within individuals, there were large between-method differences (Diff(BIA-ADP)) ranging from -13 to +13 %FM. Furthermore, we found a systematic bias of BIA related to the degree of adiposity. Consequently, %FM and fat mass loss during weight reduction in OW were underestimated with BIA when compared with ADP. Waist and hip circumferences were inversely associated with resistance (R) and reactance (P<0.01), and with Diff(BIA-ADP) (P<0.001). In women, the variability in hip circumference explained 76%, and in men, the variability in waist circumference explained 59% of Diff(BIA-ADP).

CONCLUSION

Resistance changes associated with variations in trunk circumferences decrease resistance, and therefore impair the accuracy of BIA to assess %FM.

Neurohumoral and metabolic response to exercise in water

Atrial natriuretic peptide (ANP) stimulates lipid mobilization and lipid oxidation in humans. The mechanism appears to promote lipid mobilization during exercise. We tested the hypothesis that water immersion augments exercise-induced ANP release and that the change in ANP availability is associated with increased lipid mobilization and lipid oxidation. In an open randomized and cross-over fashion we studied 17 men (age 31+/-3.6 years; body mass index 24+/-1.7 kg/m(2); body fat 17+/-6.7%) on no medication. Subjects underwent two incremental exercise tests on a bicycle ergometer. One test was conducted on land and the other test during immersion in water up to the xiphoid process. In a subset (n=7), we obtained electromyography recordings in the left leg. We monitored gas exchange, blood pressure, and heart rate. In addition, we obtained blood samples towards the end of each exercise step to determine ANP, norepinephrine, epinephrine, lactate, free fatty acids, insulin, and glucose concentrations. Heart rate, systolic blood pressure, and oxygen consumption at the anaerobic threshold and during peak exercise were similar on land and with exercise in water. The respiratory quotient was mildly reduced when subjects exercised in water. Glucose and lactate measurements were decreased whereas free fatty acid concentrations were increased with exercise in water. Water immersion attenuated epinephrine and norepinephrine and augmented ANP release during exercise. Even though water immersion blunts exercise-induced sympathoadrenal activation, lipid mobilization and lipid oxidation rate are maintained or even improved. The response may be explained by augmented ANP release.

Determinants of exercise-induced fat oxidation in obese women and men

Endurance training at an intensity eliciting maximal fat oxidation may have a beneficial effect on body weight and glucose metabolism in obese patients. However, the exercise intensity at which maximal fat oxidation occurs and the factors limiting fat oxidation are not well studied in this population. Obese, otherwise healthy men (n=38) and women (n=91) performed an incremental exercise test up to exhaustion on a cycle ergometer. Substrate oxidation was estimated using indirect calorimetry. Magnetic resonance tomography and spectroscopy were conducted to assess body fat distribution and intramyocellular fat content. We determined the exercise intensity at which maximal body fat oxidation occurs and assessed whether body composition, body fat distribution, intramyocellular fat content, or oxidative capacity predict exercise-induced fat oxidation. Maximal exercise-induced fat oxidation was 0.30+/-0.02 g/min in men and 0.23+/-0.01 g/min in women (p<0.05). Exercise intensity at the maximum fat oxidation was 42+/-2.2% VO (2 max) in men and 43+/-1.7% VO (2 max) in women. With multivariate analysis, exercise-induced fat oxidation was related to fat-free mass, percent fat mass, and oxidative capacity, but not to absolute fat mass, visceral fat, or intramyocellular fat content. We conclude that in obese subjects the capacity to oxidize fat during exercise appears to be limited by skeletal muscle mass and oxidative capacity rather than the availability of visceral or intramyocellular fat.

Integrin-actin interactions

The integrin family of extracellular matrix receptors regulates many aspects of cell life, in particular cell adhesion and migration. These two processes depend on organization of the actin cytoskeleton into adhesive and protrusive organelles in response to extracellular signals. Integrins are important switch points for the spatiotemporal control of actin-based motility in higher eukaryotes. Ligands of integrin cytoplasmic tails are central elements of signalling pathways involving small GTPases as well as protein and lipid kinases in the regulation of Factin crosslinking, actin treadmilling and de novo nucleation of actin filaments. We present an overview of common pathways and discuss recent evidence for their differential use by individual integrin receptors.

Chemical development of latent fingerprints: 1,2-indanedione has come of age

The performance of 1,2-indanedione as a latent fingerprint reagent on some types of paper was found to exceed that of DFO, the leading fluorogenic fingerprint reagent. It even exceeds the performance of the sequence, DFO, followed by ninhydrin. No new prints could be observed when ninhydrin was applied after indanedione. On a large number of actual exhibits (used checks) indanedione developed 46% more identifiable prints than the sequence DFO-ninhydrin. A standard procedure for fingerprint development by indanedione is proposed. Best results are obtained with a 0.2% indanedione solution in HFE7100 solvent containing 7% ethyl acetate, but no acetic acid. It can be recommended to start using 1,2-indanedione, which is already commercially available, in actual fingerprint casework.

Indications for a novel muscular dystrophy pathway. gamma-filamin, the muscle-specific filamin isoform, interacts with myotilin

gamma-Filamin, also called ABP-L, is a filamin isoform that is specifically expressed in striated muscles, where it is predominantly localized in myofibrillar Z-discs. A minor fraction of the protein shows subsarcolemmal localization. Although gamma-filamin has the same overall structure as the two other known isoforms, it is the only isoform that carries a unique insertion in its immunoglobulin (Ig)-like domain 20. Sequencing of the genomic region encoding this part of the molecule shows that this insert is encoded by an extra exon. Transient transfections of the insert-bearing domain in skeletal muscle cells and cardiomyocytes show that this single domain is sufficient for targeting to developing and mature Z-discs. The yeast two-hybrid method was used to identify possible binding partners for the insert-bearing Ig-like domain 20 of gamma-filamin. The two Ig-like domains of the recently described alpha-actinin-binding Z-disc protein myotilin were found to interact directly with this filamin domain, indicating that the amino-terminal end of gamma-filamin may be indirectly anchored to alpha-actinin in the Z-disc via myotilin. Since defects in the myotilin gene were recently reported to cause a form of autosomal dominant limb-girdle muscular dystrophy, our findings provide a further contribution to the molecular understanding of this disease.

Reagents for the chemical development of latent fingerprints: scope and limitations of benzo[f]ninhydrin in comparison to ninhydrin

Benzo[f]ninhydrin was compared to ninhydrin for fingerprint development on paper. Overall, the performance of ninhydrin on exhibits was slightly better than that of benzo[f]ninhydrin. The significant advantages of the benzo[f]ninhydrin over ninhydrin were the much stronger fluorescence it gave after treatment with zinc salts and a slightly quicker reaction under ambient conditions. This fluorescence is, however, similar to that obtained with other reagents, such as DFO or ninhydrin analogs. These advantages apparently are not sufficient to justify regular usage of benzo[f]ninhydrin, especially when one considers its low solubility and high cost.

Water molecules in the binding cavity of intestinal fatty acid binding protein: dynamic characterization by water 17O and 2H magnetic relaxation dispersion

The hydration of intestinal fatty acid binding protein (IFABP) in apo-form and complexed with palmitate, oleate, and 1-anilino-8-naphthalene sulfonate (ANS) has been studied by water 17O and 2H magnetic relaxation dispersion (MRD) measurements. These ligands bind in a large internal cavity, displacing most of the crystallographically identified cavity water molecules. Unlike most other proteins, IFABP gives rise to MRD profiles with two dispersion steps. The low-frequency dispersion yields a correlation time of 7 ns at 300 K, matching the known tumbling time of IFABP. The dispersion amplitude requires only three (apo) or four (holo) long-lived and ordered water molecules (residence time 0.01-4 microseconds at 300 K). Comparison of MRD profiles from the different complexes indicates that the displaced cavity water molecules are short-lived. The few long-lived (>10 ns) water molecules required by the MRD data are tentatively assigned to crystallographic hydration sites on the basis of accessibility, positional order, and H-bonding. The amplitude of the high-frequency dispersion corresponds to 10-20 moderately ordered water molecules, with a correlation time of ca. 1 ns that may reflect a transient opening of the cavity required for exchange with external water.

Existence of the Frank-Starling mechanism in the failing human heart. Investigations on the organ, tissue, and sarcomere levels

BACKGROUND

The Frank-Starling mechanism is one of the most important physiological principles for regulation of contractile performance. We therefore studied the question of whether this mechanism may be absent or attenuated in end-stage failing human left ventricular myocardium.

METHODS AND RESULTS

Different methodological approaches were used to analyze the effects of this mechanism on the organ, tissue, and sarcomere levels: (1) In excised human whole left ventricles (2 donor hearts, 5 failing hearts), diastolic and systolic pressure-volume relationships were obtained. (2) In isolated muscle strip preparations from the left ventricular wall of donor hearts (n = 14) and failing hearts from patients with idiopathic dilated cardiomyopathy (n = 21) and ischemic cardiomyopathy (n = 11), peak developed force was measured at different muscle lengths of the preparation. (3) Skinned fiber preparations were obtained from failing right and left ventricles (n = 12). In all three studies, we clearly observed the existence of the Frank-Starling mechanism: (1) In isolated failing human left ventricles, peak developed isometric pressure is increased when the preload is elevated. (2) Peak developed tension is increased by approximately 50% to 70% (P < .01) in left ventricular preparations of failing and nonfailing ventricles when the muscles are stretched from 90% to 100% optimum length. (3) An increase in sarcomere length leads to a sensitization of contractile proteins of ventricular skinned fiber preparations from failing human hearts. At 1.9-microns sarcomere length, the EC50 value was 5.56 +/- 0.06, and at 2.3 microns it was 5.70 +/- 0.05 (P < .01; n = 7).

CONCLUSIONS

The Frank-Starling mechanism is maintained in end-stage failing human hearts, whereas significant alterations of diastolic myocardial distensibility are evident in chronic heart failure.

Brainstem auditory evoked potentials in migraine--evidence of increased side differences during the pain-free interval

Brainstem auditory evoked potentials (BAEPs) were recorded in 38 unselected patients (6 m./32 f.; age 18-54 yrs.) with various forms of migraine, during the pain-free interval. The values were compared to those of 50 control persons (18 m./32 f.; age 17-75 yrs.). Peak latencies (PL I-VI), interpeak latencies (IPL I-III, III-V, I-V) and side differences of all peaks (delta I-VI) were calculated. In contrast to PL's of migraine patients, all PL's of control persons were normally distributed. In 6 migraine patients (2 with basilar migraine) PL's were pathologically delayed. Statistical analysis did not show any significant difference in regard to PL's and IPL's between migraine patients and controls. However, side differences of all peaks (except peak IV,VI) were significantly increased in migraine patients as compared to controls. Our results indicate a slight but permanent impairment of brainstem function in migraine.

Double disability of hemiplegia and hip disarticulation: rehabilitation outcome

Double disability of hemiplegia and hip disarticulation is uncommon. To our knowledge, there are no reports of such patients and their rehabilitation outcomes. We report on a patient with hemiplegia and hip disarticulation who became independent in prosthetic ambulation and activities of daily living. Motivation, age, good neuromuscular status, and past successful prosthetic use favored the excellent rehabilitation outcome in this patient.

[Characterization of the effect of retransfusion of UV-irradiated autologous blood--synoptic examination of clinical, metabolic, rheologic and hemodynamic results in patients with arterial occlusive disease]

In 6 inpatients with angiographically ascertained arterial obstructive disease the influence of the retransfusion of uv-radiated own blood on metabolic, haemorheological, clinical and haemodynamic parameters was examined. In 4 patients a pseudoradiation was performed as control. The results confirm that under the ultra-violet radiation changes develop in the sense of a normalisation of the parameters examined. Here an improved walking capacity is accompanied by an improvement of the O2- and substrate utilisation of the tissue and the flowing properties. On the basis of the results the improvement of the microcirculation under ultra-violet radiation is to be derived. The sites of action of the ultra-violet radiation are shown in the causal chain in arterial obstructive diseases and partial steps of the mode of action are described.

[Experimental studies on the rheologic behavior of blood in ultraviolet therapy]

The increased apparent blood viscosity proved in peripheral circulatory disease, the frequent failure of therapy by means of vasodilating medicaments and the successful therapy with the help of ultraviolet radiation of blood (UVB) by means of various techniques motivated investigations of the flow properties of blood with UVB. In six patients with angiologically ascertained arterial occlusive disease the flow properties of blood were investigated under standardized conditions by both viscosimetric techniques and independent of it by means of the centrifugation method. Plasma viscosity, apparent blood viscosity, parameters of aggregation and deformation of erythrocytes were determined before and after fictitious UVB on the hand one and before and after real UVB on the other hand. It was shown that within the limit of measurement accuracy there were no significant differences between fictitious and real UVB in plasma viscosities. Both the aggregation parameter of the centrifugation method and the apparent blood viscosity for low shear gradients before the 3rd UVB and all following ones differed significantly from those of the first UVB. No changes were found in the deformation parameters HCC infinity and the apparent viscosity for high shear gradients during UVB therapy. Possible mechanisms leading to the demonstrated improvements of the flow properties of blood by means of UVB are discussed.