Kristalloide versus Kolloide A never ending story?

Ohne Zusammenfassung     

When should we commence dialysis? The story of a lingering problem and today's scene after the IDEAL study

Over the last 15-20 years, there has been an increasing trend for dialysis to be commenced earlier in the development of chronic kidney disease (CKD). The drivers for initiation of dialysis at higher levels of renal function are complex but were primarily based on the assumption that by improving solute and water clearances with earlier dialysis, morbidity, mortality and quality of life would be improved. The Initiating Dialysis Early and Late (IDEAL) trial definitively demonstrated that elective earlier initiation of dialysis was not associated with improved clinical outcomes or quality of life. Indeed, no subset of patients was found to benefit from earlier dialysis. Observational data suggests that patients who commence dialysis with higher levels of renal function are more likely to have significant comorbidity that results in higher mortality rates compared to patients who remain clinically well and biochemically stable and are able to defer the initiation of dialysis till later in the course of CKD. However, patients who are able to defer dialysis should have appropriate access created so as to avoid the use of temporary catheters and to facilitate initiation using the preferred dialysis modality. Estimates of glomerular filtration rates in Stage 5 CKD have been poorly validated and should not be used as the key determinant influencing the commencement of dialysis. The results of the IDEAL trial have influenced guidelines internationally and provide clinicians, patients and health care providers with important information to drive clinical decision making and rational service planning.     

Dupuytren’s disease – the story of an eponym

December 5, 1831, baron Guillaume Dupuytren presents at the surgical clinics of the Hotel-Dieu of Paris a report upon "an entirely new subject, with a new theory and a new method of treatment for a disease generally regarded as incurable". The patient presented had a permanent contraction of the ring finger and adjacent fingers of both hands, which appeared spontaneously without any injury or previous illness. Dupuytren explains he had the opportunity to dissect the hand of a man who died after having had a contraction of the fingers for many years. He defines the cause of the contraction to be the palmar fascia. He describes the operative treatment: aponeurotomy by a transverse incision. "Probably many surgeons (Cline 1808, Astley Cooper 1822) were aware of the palmar aponeurosis producing this condition before Dupuytren's lecture". "Thoroughness of his demonstration, the brilliance of the presentation and the supremacy of his surgical authority combined to link permanently the name of Dupuytren with this hand deformity" (J. Hueston).     

Murder for a duct. Wirsüng and Hoffmann: the true story of the discovery of the main pancreatic duct

The Authors reconstruct the vicissitudes that led to the murder of Georg Wirsüng on the evening of 22nd August 1643 in Padua. Among the motives for the murder, it was later assumed, was jealousy over the discovery of the main pancreatic duct. The Authors recall that this discovery, which removed the pancreas from the sphere of amorphous organs in order to correctly place it among the glands, was not originally made by the celebrated scientist himself but is attributable to his young co-worker Moritz Hoffmann. However, Georg Wirsüng had the merit of confirming and disclosing the discovery. This circumstance, which even today is not widely recognised among the scientific community, is worth remembering in the name of respect for the historical truth.     

The complement system: an old story or target of new therapeutic approaches?

The complement system is a multifactorial protein cascade system which is essentially involved in the early unspecific immune response. Its major function is the activation of cellular defense mechanisms, opsonisation of foreign particles and the destruction of target cells. While the impact of the different complement components for bacterial elimination still remains controversial, overwhelming activation of the complement cascade, however, can induce life threatening tissue damage due to the effective cytotoxic properties. In the last years a variety of studies demonstrated beneficial, organ protective effects of complement modulation in models of severe inflammation. Attempts to control the complement system include the application of endogenous complement inhibitors e.g. C1-inhibitor (C1-INH) or the administration of recombinant complement receptors such as the soluble complement receptor 1 (rsCR1). Moreover antibodies against key proteins (C3, C5), against their activation products (C5a) or against complement receptor 3 (CR3, CD18/11b) mediated adhesion of leukocytes to the vascular endothelium, represent effective options of complement modulation. Besides this, insertion of membrane bound human complement regulators (DAF- CD55, MCP- CD46 or CD59) into xenogenic donor organs has proven effectiveness to prevent xenograft rejection. The described interventions protected from severe organ damage in various animal models of sepsis, myocardial and intestinal ischaemia-reperfusion injury, ARDS, nephritis, and xenograft rejection. With respect to recent clinical data, complement inhibition could represent a useful therapeutic strategy to control overwhelming inflammation. Own experiments demonstrated protective effects of complement modulation with C1 INH and rsCR1 in a model of complement induced pulmonary injury. With respect to sufficient host defense, however, the use of complement inhibitors must be considered carefully.     

The National Trauma Data Bank story for emergency department thoracotomy: How old is too old?

Background

The fastest growing segment of the American population is the elderly (>65 years). This change in demographics also is being seen in trauma centers. Emergency department thoracotomy is utilized in an attempt to restore circulation for patients arriving in extremis. The purpose of this study was to investigate the relationship between clinical variables, particularly age, and outcomes for injured patients receiving an emergency department thoracotomy.

“Like a rabbit from a hat!”—a case of a sacrocolpopexy mesh being taken out by a patient

Sacrocolpopexy, be it laparoscopic or abdominal, is associated with a risk of mesh extrusion. We report an interesting case of mesh extrusion with subsequent removal of the mesh from the vagina by the patient. We take this opportunity to review the literature regarding incidence, predisposing factors and complications of sacrocolpopexy mesh extrusion with specific reference to this case.