血液净化在儿童重症过敏性紫癜中的应用

过敏性紫癜作为血清免疫球蛋白A介导的自身免疫性疾病,患者的基本表现就是出现全身性小血管炎,如腹痛、皮肤紫癜、蛋白尿、关节肿痛、血尿,偶见颅内出血情况。这一病症容易复发,病情反复发作与重症肾脏损害也属于治疗的难点问题,对患儿的实际预后效果产生一定影响。如果患者的病症无法在短时间内得到缓解,可能会引发肠套叠、皮肤感染坏死的情况,直接影响患者的生命健康,导致临床治疗的难度加大。过敏性重症紫癜的传统治疗方式,主要就是将致敏因素清除,并且进行对症处理与干预,但是可能存在无法有效逆转患儿病情的情况。近几年,血液净化技术得到了广泛的利用,临床效果确切。本文对儿童重症过敏性紫癜诊断进行论述,并结合血液净化在儿童重症过敏性紫癜的应用进展作一综述,旨在为治疗儿童重症过敏性紫癜提供参考。     

Fractionated Plasma Separation and Adsorption System: A Novel System for Blood Purification to Remove Albumin Bound Substances

The removal of albumin bound substances has gained increasing interest in different diseases, especially in acute and chronic liver disease. Therefore, a new system, the fractionated plasma separation and adsorption (FPSA) system, was developed based on combined membrane and adsorbent blood purification techniques. The most important contribution to the FPSA system was the development of a new polysulfone hollow-fiber filter, which is characterized by a sieving coefficient of 0.89 for human serum albumin (HSA) but only of 0.17 for fibrinogen, and 0 (zero) for IgM immunoglobulins. Using a closed filtrate circuit connected to the new polysulfone filter which integrates 1 or 2 adsorption columns and also a high flux dialyzer adapted to a dialysis machine, the FPSA system opens excellent possibilities for the relatively specific removal of albumin bound substances from the blood such as albumin bound bilirubin or even tryptophan. In comparison to other systems (for example, the Molecular Adsorbent Recirculating System [MARS] and albumin dialysis systems), the FPSA system enables much higher elimination of strongly bound albumin substances. The first clinical investigations have recently started based on a modified dialysis machine designed with all necessary safety measures.     

Plasma Lipids and Fatty Acid Levels in Chronically Uremic Patients Undergoing Blood Purification with Different Methods

Levels of plasma lipids and the fatty acid composition of major plasma lipid classes have been determined in chronically uremic patients before and after treatments with hemofiltration, high efficiency paired filtration dialysis, or acetate-free biofiltration. The major findings are a decrease of triglycerides and an increase of total free fatty acids (FFAs) at the end of the dialytic session--already reported in the literature--that do not appear to be strictly dependent on heparin administration. The changes in the plasma concentrations of selected saturated and polyunsaturated fatty acids, which may contribute to alteration of functional parameters in the cardiovascular system in dialyzed patients, are different in the various types of techniques.     

A New Noninvasive Method to Measure Blood Pressure: Results of a Multicenter Trial

Background: Blood pressure (BP) monitoring with arterial waveform display requires an arterial cannula. We evaluated a new noninvasive device, Vasotrac (Medwave, Arden Hills, MN) that provides BP measurements approximately every 12-15 beats and displays pulse rate and a calibrated arterial waveform for each BP measurement.

Methods: Surgical and critically ill patients (n = 80) served as subjects for the study. BPs, pulse waveforms, and pulse rates measured viaa radial artery catheter were compared with those obtained by the Vasotrac from the opposite radial artery. Data were analyzed to determine agreement between the two systems of measurement.

Results: Blood pressure measured noninvasively by the Vasotrac demonstrated excellent correlation (P < 0.01) with BP measured via a radial arterial catheter (systolic r2 = 0.93; diastolic r2 = 0.89; mean r2 = 0. 95). Differences in BP measured by the Vasotrac versus the radial arterial catheter were small. The mean +/- SD bias and precision were as follows: systolic BP 0.02 +/- 5.4 mmHg and 3.9 +/- 3.7 mmHg; diastolic BP -0.39 +/- 3.9 mmHg and 2.7 +/- 2.8 mmHg; mean BP -0.21 +/- 3.0 mm Hg and 2.1 +/- 2.2 mmHg compared with radial artery measurements. The Vasotrac pulse rates were almost identical to those measured directly (r2 = 0.95). The Vasotrac BP waveform resembled those directly obtained radial artery pulsatile waveforms.     

Intravascular Oxygenator: A New Alternative Method for Augmenting Blood Gas Transfer in Patients With Acute Respiratory Failure

A unique hollow fiber membrane oxygenator (IVOX) has been developed, which is inserted into the vena caval blood stream to transfer O2/CO2 to/from circulating blood in an intact subject without involving the natural lungs. Extensive laboratory testing has demonstrated that the device can transfer significant quantities of O2 and CO2 for up to 3 weeks without significant harmful sequelae or complications. Clinical trials are in progress under FDA supervision, in which IVOX has been utilized to date in 56 patients with ARDS. Preliminary findings indicate that risks and hazards from IVOX are nil, and evidence of benefit to the patient has been demonstrated in 86% of the patients. At this time, clinical utilization of IVOX is in the experimental, data collecting mode to determine its proper role or niche as a method for temporary augmentation of blood gas transfer in patients with advanced acute respiratory failure.     

Blood Purification in the Intensive Care Unit: Neo-Galenism for the New Millennium or a Quantum Leap Forward-Introduction

   apd: 12 April 2001     

Bone-Resorbing Cytokines from Peripheral Blood Mononuclear Cells after Hormone Replacement Therapy: A Longitudinal Study

Conflicting results have been reported in several cross-sectional studies measuring cytokine production from adherent monocytes in pre- and postmenopausal women. Furthermore, the target cells for the action of estrogen are still debated. We therefore assessed in a longitudinal manner the cytokine production from different fractions of peripheral blood mononuclear cells (PBMC) cultured for 48 h. PBMC were obtained from 30 postmenopausal women before and after 6 months of hormone replacement therapy (HRT). Women were randomly allocated to two groups: an adherent PBMC group (n= 20) and a total PBMC group (n= 9). After 6 months of treatment, urinary pyridinoline levels were markedly decreased in both groups (353 ± 24 vs 114 ± 13 μg/mmol creatinine and 325 ± 35 vs 164 ± 31 μg/mmol creatinine respectively, p<0.01). Culture supernatants were assayed for interleukin 1β (IL-1β), interleukin 6 (IL-6), soluble IL-6 receptor (IL-6rs) and tumor necrosis factor alpha (TNF-α). In the adherent PBMC group, HRT induced a nonsignificant trend toward decreased levels of IL-1β (35 ± 10 vs 13 ± 5 pg/ml), TNF-α (333 ± 58 vs 222 ± 30 pg/ml) and IL-6 (115 ± 70 vs 17 ± 10 pg/ml). In contrast, in the total PBMC group, HRT induced a consistent and dramatic decrease in levels of IL-1β (104 ± 22 vs 25 ± 8 pg/ml), IL-6 (5950 ± 1041 vs 1011 ± 361 pg/ml), IL-6rs (148 ± 33 vs 35 ± 12 pg/ml) (p<0.01) and TNF-α (1468 ± 315 vs 585 ± 207 pg/ml, p= 0.05). We then evaluated whether HRT had the same effect in vitro. Adherent or total PBMC of 8 postmenopausal women were cultured with or without 10⁻⁸M 17β-estradiol or tibolone for 48 h. Production of IL-1β, TNF-α, IL-6 and IL-6rs was not affected by the presence of 17β-estradiol or tibolone in cultures of these cell fractions. In conclusion, our data indicate that non-adherent PBMC could mediate the response to HRT. HRT may exert its action indirectly via noncirculating cells, as suggested by the absence of an in vitro effect. Received: 11 July 2000 / Accepted: 15 January 2001     

A New Method to Protect Blood Supply in the Treatment of Femoral Neck Fractures: Bidirectional Compression Porous Tantalum Screws

ObjectiveTo explore the clinical effect of a new type of bidirectional pressurized porous tantalum screw (PTS) internal fixation in treating femoral neck fractures (FNFs).MethodsIn this study, geometric models of FNF were first established via reverse engineering method, followed by stimulation of the strength of PTSs in fixation of FNFs. A randomized control trial study was then conducted of 41 patients with FNF from October 2015 to December 2018. These patients included 12 males and 29 females with an average age of 59.9. The 41 patients were randomly divided into two groups: cannulated compression screws (CCSs) group (n = 21) and PTSs group (n = 20). Treatment outcomes in patients were evaluated using multiple imaging techniques, including X‐ray and digital subtraction angiography scanning as well as functional recovery Harris hip score. Without other postoperative complications, the primary outcome was defined as fracture healing after FNF internal fixation. Secondary outcomes are the incidence of the avascular necrosis of femoral head (ANFH), fracture nonunion, and reoperation rate.ResultsFollowing PTS internal fixation of FNF, finite element results revealed a firmly fixed fracture with a slight displacement of less than 0.5 mm. At follow‐up, we found a statistically significant difference in Harris scores in the two groups at 1 month and 3 months post‐surgery. In the PTSs group, there was no case of ANFH and fracture nonunion, and the average healing time was 94.45 ± 6.47 days. In the CCSs group, there were four cases of ANFH, the necrosis rate was 19.05% (4/21). There was one case of fracture nonunion in the CCSs group, the nonunion fracture rate was 4.76% (1/21), and the average healing time was 122.54 ± 11.37 days. Five patients underwent total hip arthroplasty, and the reoperation rate was 23.81% (5/21). There were significant differences in the postoperative complications, fracture healing time, and reoperation rate between the two groups (p < 0.05).ConclusionsPTSs fixation of FNF at the center, does not only avoid the destruction of blood supply in the femoral head and reduction in the incidence of postoperative complications of FNFs, but also induces early bone ingrowth and promotes fracture healing. These findings provide a potential surgical internal fixation system for treating FNFs.     

A New Smartphone‐Based Method for Wound Area Measurement

Proper wound healing can be assessed by monitoring the wound surface area. Its reduction by 10 or 50% should be achieved after 1 or 4 weeks, respectively, from the start of the applied therapy. There are various methods of wound area measurement, which differ in terms of the cost of the devices and their accuracy. This article presents an originally developed method for wound area measurement. It is based on the automatic recognition of the wound contour with a software application running on a smartphone. The wound boundaries have to be traced manually on transparent foil placed over the wound. After taking a picture of the wound outline over a grid of 1 × 1 cm, the AreaMe software calculates the wound area, sends the data to a clinical database using an Internet connection, and creates a graph of the wound area change over time. The accuracy and precision of the new method was assessed and compared with the accuracy and precision of commercial devices: Visitrak and SilhouetteMobile. The comparison was performed using 108 wound shapes that were measured five times with each device, using an optical scanner as a reference device. The accuracy of the new method was evaluated by calculating relative errors and comparing them with relative errors for the Visitrak and the SilhouetteMobile devices. The precision of the new method was determined by calculating the coefficients of variation and comparing them with the coefficients of variation for the Visitrak and the SilhouetteMobile devices. A statistical analysis revealed that the new method was more accurate and more precise than the Visitrak device but less accurate and less precise than the SilhouetteMobile device. Thus, the AreaMe application is a superior alternative to the Visitrak device because it provides not only a more accurate measurement of the wound area but also stores the data for future use by the physician.     

Blood Purification With CytoSorb in Critically Ill Patients: Single‐Center Preliminary Experience

The CytoSorb adsorber, a blood purification therapy, is able to remove molecules in the 5–60 kDa range which comprises the majority of inflammatory mediators and some endogenous molecules. We aimed to evaluate CytoSorb therapy on clinical outcomes in critically ill patients. A retrospective case series study, from February 2016 to May 2017, was performed in 40 patients with multiple organ failure who received CytoSorb treatment. There were 28 patients with cardiogenic shock, 2 with septic shock, 9 with acute respiratory distress syndrome, and 1 with liver failure. Nineteen patients (47%) underwent extracorporeal membrane oxygenation, 11 (27%) had an intra‐aortic balloon pump, 9 (22%) were implanted with Impella, 6 (15%) had a ventricular assist device, and 18 (45%) were treated with continuous veno‐venous hemofiltration. After CytoSorb treatment, total bilirubin decreased from 11.6 ± 9.2 to 6.8 ± 5.1 mg/dL (P = 0.005), lactate from 12.1 ± 8.7 to 2.9 ± 2.5 mmol/L (P < 0.001), CPK from 2416 (670–8615) to 281 (44–2769) U/L (P < 0.001) and LDH from 1230 (860–3157) to 787 (536–1148) U/L (P < 0.001). The vasoactive‐inotropic score after 48 h of treatment was reduced to 10 points, P = 0.009. Thirty‐day mortality was 55% and ICU mortality was 52.5% at expected ICU mortality of 80%. Our study shows that CytoSorb^TM treatment is effective in reducing bilirubin, lactate, CPK and LDH, in critically ill patients mainly due to cardiogenic shock. There is a need for randomized controlled trials to conclude on the potential benefits blood purification with CytoSorb in critically ill patients.     

Mammalian Erythrocytes as Physiological Carriers of Fluorescent Exogenous Agents: A Comparative Study of Bovine and Camel Red Blood Cells

Abstract: Recently attention has been focused on the investigation of new and effective routes for drug administration in order to avoid their side effects in the human body. Red blood cells (RBCs) exhibit many advantages, i.e., they are naturally occurring, biodegradable, and non-immunogenic. Their use as drug carriers has many potential applications, including slow drug delivery to the body tissue and drug targeting to a specific site. In this work, the fluorescent exogenous agent sodium fluorescein (ura-nin) was used as the probe for the encapsulation of the RBCs. The encapsulation process was applied in two different mammalian RBCs: camel and bovine. The results indicate that the encapsulation efficiency of bovine RBCs was 34.0 ± 3.0% with an RBC recovery rate of ∼75% whereas that of camel RBCs was only 8.0 ± 2.0% with a cell recovery rate of ∼47%. These differences demonstrate the dependency of the encapsulation process on the type of mammalian source of the RBCs.     

Surface-induced Profound Hypothermia in Infant Cardiac Operations: A New System

A new system of surface-induced profound hypothermia for infant cardiac operations has been developed in order to overcome problems inherent in the current techniques using crushed ice, water baths, and similar methods. The hypothermic chamber consists of two parts: a lower part, containing a refrigeration unit and a blower fan capable of lowering the air temperature in the chamber to ?6°GC, and an upper part made of Plexiglas that has a completely detachable end to allow easy access to cannulas, the anesthesia hose, and the infant. A temperature panel recorder to monitor the infant's esophageal and rectal temperatures and the ambient chamber temperature is incorporated into the unit.Following evaluation in the animal laboratory, the hypothermic chamber has been successfully used in 10 infants without any complications attributable to the technique. This method provides a rapid and uniform drop of the body temperature and even skin cooling, eliminates the possibility of contact skin lesions, saves medical and paramedical personnel time in preparation of the infant and equipment, and allows observation of the child during the cooling phase. This hypothermic chamber has facilitated infant hypothermic operations.     

Cytokines and endotoxin removal by sorbents and its application in push-pull sorbent-based pheresis: the BioLogic-DTPF System

The BioLogic-DTPF System (DTPF) combines the Biologic-DT hemodiabsorption system (DT) in series with the Biologic PF push-pull pheresis system (PF) in which PF membranes separate plasma for direct contact between plasma proteins and the sorbents. Preliminary studies conducted in bovine serum albumin (BSA) solution and in bovine plasma allowed charcoal and silica to be evaluated as adsorbents for the PF module. Equilibrium binding experiments in BSA showed a high capacity of cytokine (IL-1 beta, TNF alpha) binding by powdered charcoal, 70-90 ng/g. Kinetic binding studies in bovine plasma revealed relatively quick adsorption of IL-1 beta and IL-6 by charcoal with the capacity range of 1.2-2.0 ng/g for tested cytokines (IL-1 beta and TNF alpha). Further laboratory studies with plasma have shown that powdered silica has an even greater binding capacity, up to 13 ng/g for TNF alpha depending upon particle size, and more rapid binding for all tested cytokines than powdered charcoal. Cholestyramine is a more efficient sorbent for removal of endotoxin than either charcoal or silica. In vitro tests using whole blood have demonstrated that the DTPF, with powdered charcoal as the sorbent, clears cytokines (TNF alpha, IL-1 beta, and IL-6) at 12.6-23.4 ml/min, bilirubin at 17.8-34.7 ml/min, and creatinine at 53.6-82.6 ml/min. The removal of some cytokines during the first clinical trial is also discussed.     

Therapeutic Plasma Exchange in Patients With Severe Hypertriglyceridemia: A Multicenter Study

Extremely high plasma triglyceride (TG) concentration is a recognized risk factor for acute pancreatitis (AP). In order to evaluate the therapeutic efficacy of plasma‐exchange plasmapheresis in treating patients with severe hypertriglyceridemia (sHTG), 17 patients who had not responded to conventional medical therapy (fat‐free diet plus pharmaceutical interventions) were referred for therapeutic plasma exchange (TPE) in a multicenter frame case series study. Two hundred seventeen TPE sessions were performed, and therapy is ongoing for five (30%) of the patients. After treatment, the mean plasma TG and total cholesterol concentrations were significantly reduced from 1929 and 510 mg/dL, to 762 and 227 mg/dL, respectively (P ≤ 0.001 in both cases). In most cases, the interval between treatments was related to the clinical presentation and individual circumstances. The removal of TG‐rich lipoproteins prevented relapses of AP. In this case series, TPE is confirmed as a safe and reliable method for treating patients with refractory sHTG when a severe complication, such as AP, is clinically demonstrated or can be actively prevented. Therefore, in cases where standard medical approaches fail to promote the clearance of TGs from plasma and a high risk of first or second hypertriglyceridemic pancreatitis persists, TPE provides a therapeutic option for preventing life‐threatening sHTG.