Direct hemoperfusion with a polymyxin B-immobilized fiber column eliminates neutrophils and improves pulmonary oxygenation--a comparison of two cases with acute exacerbation of idiopathic pulmonary fibrosis]

Idiopathic pulmonary fibrosis (IPF) is characterized by radiographically evident interstitial infiltrates predominantly affecting the lung bases and by progressive dyspnea and worsening pulmonary function. Acute exacerbation of IPF is recognized widely as an accelerated phase occurring suddenly in the course of IPF, which leads to a catastrophic outcome. No treatment has proven to be effective so far. We describe two cases of acute exacerbation of IPF which were treated by direct hemoperfusion with a polymyxin B-immobilized fiber column (PMX) after steroid pulse therapy. One patient died on the 21st day after direct hemoperfusion and the other is alive at present. The survivor showed significant improvement of pulmonary oxygenation correlating with a decrease in the neutrophil count, SP-D and KL-6 after direct hemoperfusion with PMX. On the other hand, the non-survivor showed no improvement of pulmonary oxygenation, SP-D and KL-6 despite a decrease in neutrophil count comparable with that of the survivor. Neutrophil count which decreased temporarily after direct hemoperfusion with PMX soon convert to increase in the non-survivor, which is a characteristic difference between two. We reached the conclusions that (1) direct hemoperfusion with PMX absorbs neutrophils and this mechanism is effective to improve pulmonary oxygenation, (2) sometimes neutrophil absorption is not enough to control pulmonary inflammation in patients with acute exacerbation of IPF.     

Angiopoietin balance in septic shock patients with acute lung injury: effect of direct hemoperfusion with polymyxin B-immobilized fiber

Acute lung injury (ALI) in sepsis is characterized by an increase in microvascular permeability, resulting in pulmonary edema. Several studies have suggested that angiopoietin-1 and -2 play a contributory role in the pathogenesis of ALI. Polymyxin B-immobilized fiber column hemoperfusion is effective for sepsis-induced ALI. We investigated the angiopoietin levels before and after direct hemoperfusion with polymyxin B-immobilized fiber column (PMX) therapy. Enzyme-linked immunoassay was used to measure the serum angiopoietin-1 and -2 levels in 25 patients with septic shock treated with PMX. Eleven of the 25 patients were diagnosed with ALI. There was a significant positive correlation between the angiopoietin-1 level and the PaO(2) /FiO(2) ratio, but there was a significant inverse correlation between the angiopoietin-2 level and the PaO(2) /FiO(2) ratio. The mean angiopoietin-1 level before PMX therapy in the ALI group was significantly lower and the mean angiopoietin-2 level was significantly higher than in the non-ALI group. The mean angiopoietin-1 level of the ALI patients in response to PMX therapy was increased during PMX therapy, but that of the non-ALI patients with newly occurring ALI showed a decreased angiopoietin-1 level. On the other hand, the mean angiopoietin-2 level of the responders was decreased during PMX therapy, but that of patients with newly occurring ALI showed an increased angiopoietin-2 level. This result suggested that each angiopoietin-1 and -2 level may play a role in the pathogenesis of ALI and that PMX therapy ameliorates the angiopoietin balance in patients with ALI in sepsis.     

Polymyxin B-immobilized fiber hemoperfusion after emergency surgery in patients with chronic renal failure

The purpose of this study was to evaluate the effect of direct hemoperfusion using a Polymyxin B (PMX) immobilized fiber column in septic patients with chronic renal failure after emergency surgery. Twenty-four renal failure patients, including 19 dialysis patients, with sepsis or septic shock were treated with direct hemoperfusion after emergency surgery. The 24 consecutive patients included nine with necrotic enterocolitis, six with colonic perforation due to diverticulitis, three with ruptured suture after colectomy, one with duodenal perforation, four with blood access infection, and one with an infected abdominal aortic aneurysm. The acute physiology and chronic health evaluation II score ranged from 13 to 26 (19 +/- 3). After completion of the first and the second hemoperfusion, mean blood pressure was significantly elevated from 69 +/- 12 mm Hg to 89 +/- 15 mm Hg and from 78 +/- 14 mm Hg to 95 +/- 13 mm Hg, respectively (P < 0.01). In addition, the catecholamine dosage needed to maintain the circulation could be decreased markedly after the treatment. The blood concentration of endotoxin in patients with Gram-negative sepsis, before and after the treatment, significantly decreased from 36 +/- 19 pg/mL to 19 +/- 19 pg/mL (P < 0.05). PMX was effective in patients with Gram-positive sepsis as well as Gram-negative sepsis. The 28-day mortality rate in patients who had emergency abdominal surgery was 10% (2/20), whereas that in patients with dialysis access infection was 50% (2/4). There was a significant difference in the Sequential Organ Failure Assessment (SOFA) score of all patients before and after treatment using PMX (9.2 +/- 3.3 vs. 7.5 +/- 3.5, P < 0.05). Furthermore, the SOFA score of survivors decreased significantly after PMX treatment (8.4 +/- 3.5 vs. 6.7 +/- 2.6, P < 0.01). Our results suggest that the early application of PMX may prevent multiple organ failure and improve survival in patients with chronic renal failure and sepsis/septic shock after emergency abdominal surgery, regardless of the type of pathogenic bacteria involved.     

Direct Hemoperfusion With a β2-Microglobulin-selective Adsorbent Column Eliminates Inflammatory Cytokines and Improves Pulmonary Oxygenation

Abstract: Acute respiratory distress syndrome (ARDS) and acute lung injury (ALI) are characterized by a high mortality rate; therefore, ARDS/ALI in humans is a leading cause of morbidity and mortality in critically ill patients. As previously reported, cytokines play a critical role as signaling molecules that initiate, amplify, and perpetuate inflammatory responses on a local and systemic basis, and the polymyxin-B immobilized direct hemoperfusion system (PMX–DHP) is effective for the treatment of ARDS/ALI. Furthermore, another direct hemoperfusion system using the β2-microglobulin-selective adsorbent column, Lixelle, the direct hemoperfusion treatment (Lixelle–DHP), has been applied in some cases to patients who are affected with systemic inflammatory response syndrome. The aim of this study is to evaluate the therapeutic efficacy of Lixelle–DHP in the treatment of ARDS/ALI. Four patients, aged 67–79 years old (mean 72 ± 6.2 years), diagnosed with ARDS/ALI were treated with Lixelle–DHP. The P_aO₂/fraction of inspired oxygen (F_iO₂) ratio (PF ratio) was 90.0 ± 22.9 before the treatment, and it increased to 129.9 ± 5.6 at 72 h afterward the start of treatment. Inflammatory cytokines such as interleukin (IL)-1β, IL-6, soluble intercellular adhesion molecule 1 (sICAM-1) decreased significantly after the treatment. All patients were still alive after one month. However, while IL-2 had decreased significantly after the treatment, it had returned by the next treatment. It is possible that Lixelle–DHP might be able to improve the PF ratio and mortality rate as a result of decreased cytokines, and it has been suggested that Lixelle–DHP has a beneficial influence in the treatment of ARDS/ALI.     

Rapidly progressive interstitial pneumonia associated with clinically amyopathic dermatomyositis successfully treated with polymyxin B-immobilized fiber column hemoperfusion

Amyopathic dermatomyositis (ADM) is a clinical subtype of dermatomyositis, characterized by the absence of motor weakness and the presence of normal muscle enzyme levels. ADM is sometimes accompanied by interstitial pneumonia that shows a rapid progressive course associated with a poor prognosis. We describe a 70-year-old man who presented rapidly progressive interstitial pneumonia associated with clinically ADM (C-ADM); he was successfully treated with polymyxin B-immobilized fiber column (PMX) hemoperfusion.     

Q fever in acute exacerbation of chronic lower respiratory tract infection]

We studied the effect of Q fever in acute exacerbation of chronic lower respiratory tract infection. The subjects consisted of 80 cases with acute exacerbation of chronic lower respiratory tract infection treated during the period from March 2002 till October 2004. Q fever was diagnosed using a PanBio Coxiella burnetii ELISA test kit. Two cases (2.5%) were positive for IgM in the acute stage, and were diagnosed as having acute infection by C. burnetii. They were elderly women with bronchiectasis, aged 76 and 82. They had no history of keeping cats or dogs, but the onset of acute exacerbation of chronic lower respiratory tract infection was June and March which is the breeding seasons for cats and dogs. Acute exacerbation of chronic lower respiratory tract infection were considerd to be a mixed infection with Pseudomonas aeruginosa (the 76-year-case) and Haemophilus influenzae (the 82-year-case). It is concluded that C. burnetii can induce exacerbation of chronic lower respiratory tract infection, their cases were considerd to be mixed infection with C. burnetii and other bacteria.     

Lophomonas blattarum infection presented as acute exacerbation of chronic obstructive pulmonary disease

The present case described a 70-year-old male who was initially diagnosed and treated as acute exacerbation of chronic obstructive pulmonary disease (AECOPD). Ultimately Lophomonas blattarum (L. blattarum), a rare protozoan causing opportunistic infection, was found in suction sputum smear. Bronchoscopy showed a lot of purulent sputum in airways, diffusely swelling and friable mucus on bronchus. After single tinidazole treatment, symptoms and image showed marked improvement. It indicates though in the untraditional immunocompromised case, the suspect of opportunistic diseases is necessary, especially in the cases failed to improvement under empirical treatment. It also supports the tinidazole treatment is efficacy in L. blattarum infection.     

Clinical study of 10 cases of acute or subacute interstitial pneumonia associated with dermatomyositis

The prognosis for dermatomyositis (DM) with acute interstitial pneumonia (IP) is very poor. In the past 5 years, we have treated 10 DM patients with acute or subacute IP. Six cases were of acute-type IP, and 4 were of subacute-type IP. The treatment was a combination therapy of methylprednisolone (m-PSL) pulse therapy, cyclophosphamide (CPA) pulse therapy, oral cyclosporine A (CsA), and oral PSL. The outcome was 5 deaths and 5 survivals. All 5 cases of death had acute-type IP, four of which were complicated with pneumomediastinum, and these patients died within 40 days of IP onset. Furthermore, 4 of the 5 death cases were diagnosed with amyopathic DM, and one had hypomyopathic DM. The survivors comprised one case of acute-type IP with marked myositis, and 4 subacute cases. These results suggested that the prognosis for DM with IP might be dependent on the type of IP, the severity of the myositis, and the existence of pneumomediastinum. The rapid establishment of a more useful diagnostic technique and therapy for early-phase DM with acute IP is hoped for.     

A case of successful treatment with polymyxin B-immobilized fiber column direct hemoperfusion in acute respiratory distress syndrome after influenza A infection

We report a case of acute respiratory distress syndrome (ARDS) after influenza A infection who was successfully treated with combined treatment including direct hemoperfusion with polymyxin B-immobilized fiber (PMX-DHP) column. A 56-year-old Japanese man was admitted to our hospital in January 2010 because of progressive dyspnea, hypoxemia, fever and bilateral diffuse infiltration on chest radiograph after pandemic influenza A infection. His chest computed tomography showed diffuse and patchy bilateral ground-glass opacities, and we diagnosed ARDS after influenza A infection. The patient was successfully treated with PMX-DHP in addition to the treatment with oseltamivir, corticosteroid, sivelestat and antibiotics with mechanical ventilation, and the patient recovered with only minor pulmonary fibrotic change. Although the efficacy of PMX-DHP treatment in patients with acute lung injury (ALI)/ARDS after influenza virus infection is not well established, this treatment could be a possible therapeutic modality in treating the patients with this disease.     

血液透析与血液灌流联合抢救急性重症毒物中毒分析

目的分析血液透析联合血液灌流术在抢救急性重症中毒患者中的治疗效果。方法对23例急性重症中毒患者采用血液透析联合血液灌流术的治疗观察,并与同期随机选择的非血液灌流内科综合治疗的30例急性重症中毒患者做疗效对照观察。结果血液透析联合血液灌流能有效清除体内有毒物质,治疗组患者全部治愈出院。结论血液透析联合血液灌流是抢救急性重症中毒的快速而有效的重要治疗方法。     

The Severity of Hyperdynamic Circulation May Predict the Effects of Direct Hemoperfusion with the Adsorbent Column Using Polymyxin B‐Immobilized Fiber in Patients with Gram‐Negative Septic Shock

Abstract: It has been reported that direct hemoperfusion with the adsorbent column using polymyxin B‐immobilized fiber (DHP with PMX‐F column) ameliorates hyperdynamic circulation in septic shock and improves survival rate. However, the clinical characteristics of patients with an improvement of septic shock after DHP with PMX‐F column have not been evaluated. To clarify this issue, the clinical profiles of 46 patients who were suggested to have gram‐negative septic shock and treated using DHP with PMX‐F column were analyzed retrospectively. Of 46 patients, 31 were diagnosed with gram‐negative septic shock (G group). Mean arterial pressure (MAP) just before DHP with PMX‐F column was not different between the G and the non‐G group. As compared with the non‐G group, the G group had a higher cardiac index (CI) and a lower systemic vascular resistance (SVR). Significant increases in MAP and SVR with a significant decrease in CI were observed after DHP with PMX‐F column in the G group. In the non‐G group, MAP was significantly increased after the DHP therapy, but systemic hemodynamics were unchanged. Patients in the G group who fulfilled the following criteria were considered as the effective group: MAP was elevated more than 10 mm Hg or 125% of the basal MAP and/or the dose of vasopressors was reduced after DHP with PMX‐F column. Twenty‐one patients (67.8%) were in the effective group. In comparison with the effective group, the noneffective group was characterized by a significant increase in CI before DHP with PMX‐F column. All patients with a CI less than 6 L/min/m² were in the effective group. These data suggest that DHP with PMX‐F column was useful for patients with Gram‐negative septic shock who did not have severe hyperdynamic circulation.     

Cyclosporin treatment in steroid-resistant and acutely exacerbated interstitial pneumonia

OBJECTIVE: The aim of this study was to evaluate the efficacy of cyclosporin A (CsA) in patients with interstitial pneumonia (IP). DESIGN: Retrospective comparative study. PATIENTS: We reviewed 33 patients (23 males and 10 females with a mean age of 62.5 years) with histologically-proven progressive IP who were treated with CsA. All patients had corticosteroid-resistant IP or developed acute exacerbation of IP in their courses. RESULTS: The underlying systemic diseases were: idiopathic interstitial pneumonias (IIPs) in 19 patients, and collagen vascular diseases (CVDs) in 14. The histopathological patterns and underlying diseases of IP were classified as usual interstitial pneumonia (UIP)/idiopathic pulmonary fibrosis (IPF) in 10 patients, cellular-nonspecific interstitial pneumonia (NSIP)/IIPs in 3, fibrotic-NSIP/IIPs in 5, organizing pneumonia (OP)/IIP in 1, UIP/CVDs in 4, cellular-NSIP/CVDs in 7, fibrotic-NSIP/CVDs in 2, and diffuse alveolar damage (DAD)/CVD in 1, respectively. They received a low dosage of CsA combined with corticosteroids. The prognoses after treatment with CsA were well correlated with histopathological patterns. Cellular-NSIP and OP showed better prognoses than fibrotic-NSIP, UIP or DAD. In addition, CVDs had better prognoses than IIPs, when compared on the basis of the same histopathological patterns. Furthermore, the prognoses in the CsA-treated group were significantly better than in those without CsA treatment in regard to acute exacerbation of UIP/IPF. CONCLUSIONS: CsA combined with corticosteroids may be an efficacious treatment for corticosteroid-resistant IP and for acute exacerbation of IPF.     

A case of Sj?gren's syndrome and systemic sclerosis complicated with acute pancreatitis]

We report a case of Sj?gren's syndrome (SS) and systemic sclerosis (SSc) complicated with acute pancreatitis. A 51-year-old woman had been diagnosed as SS in 1973. She noticed Raynaud's phenomenon in 1977. In 1988, interstitial pneumonia (IP) was pointed out and she was treated with methylprednisolone (mPSL) pulse therapy. Prednisolone (PSL) was gradually tapered to 3-5 mg daily and she visited our outpatient clinic in 1995. On her first admission to our hospital in 1996, she showed xerostomia, keratoconjunctivitis sicca, sclerotic skin changes of her distal extremities and face, thickening of her sublinguinal frenulum, and regurgitative esophagitis. She was positive with anti-SS-A and SS-B antibodies. She was diagnosed as SS and SSc. Radiographic and laboratory data also established the diagnosis of inactive IP, renal tubular acidosis (RTA) and chronic renal failure (CRF). In April 30th 1997, she was admitted to our hospital again with complaints of dyspnea, dysesthesia, epigastralgia and petechia. Active IP and mononeuritis multiplex were diagnosed, and petechia was considered to be associated with vasculopathy. Her serum amylase level was 891 mU/ml on admission and spontaneously increased to 2440 mU/ml on May 12th along with increase of fibrinogen degradation product, D-dimer and alpha 2 plasmin-plasmin inhibitor complex levels. Ultrasonography depicted swelling of her pancreatic head and the diagnosis of acute pancreatitis was made. She was treated with protease inhibitors and intravenous hyperalimentation for acute pancreatitis. mPSL pulse therapy (500 mg/day for 3 days) was instituted for IP and mononeuritis multiplex on May 22, followed by 50 mg of daily PSL. While IP and mononeuritis multiplex gradually improved by the high-dose steroid therapy, serum amylase level raised to more than 4293 mU/ml, suggesting the modification of pancreatitis by the treatment with steroid. Since she did not respond to the conservative therapy for acute pancreatitis, she was treated with plasmapheresis, which turned out to be very effective. However, she was suffered from fungal pneumonia and died of respiratory failure. As far as we know, only three cases of SS with acute pancreatitis have been reported so far. The immunopathological mechanisms of development of acute pancreatitis in our case, especially focusing on the significance of microvasculopathy and hypercoagulability, were discussed.     

Cyclosporin A treatment of interstitial pneumonia]

To assist in making prognoses for patients with interstitial pneumonia (IP) who were treated with cyclosporin A (CsA), we conducted a review of forty-nine patients (32 men and 17 women with a mean age of 62 yrs) with progressive IP during the period from 1997 through 2001. All patients were steroid-resistant or acutely exacerbated cases. They received a low dosage of CsA (100-130 mg/day) combined with corticosteroids. Before and after the CsA therapy, blood gas analysis and HRCT scans were evaluated. Twenty-five patients underwent video-assisted thoracoscopic surgery (VATS) or autopsy for a histopathological evaluation. Among the 49 patients with IP, the documented underlying systemic diseases were of unknown etiology (IPF or IIP) in 26 and were collagen vascular diseases (CVD) in 23. The chest CT pattern and underlying systemic diseases of IP were classified as a usual interstitial pneumonia (UIP) pattern/IPF in 16 cases, a non-UIP pattern/IIP in 10 cases, a UIP pattern/CVD in 7 cases, and a non-UIP pattern/CVD in 16 cases. The prognoses after CsA treatment were improved or unchanged in 27% of cases with a UIP pattern/IPF, 78% of cases with a non-UIP pattern/IIP, 71% of cases with a UIP pattern/CVD and 75% of cases with a non-UIP pattern/CVD; deteriorated in 73%, 22%, 29% and 25% of cases, respectively, with these patterns and underlying diseases. At present, four out of thirteen (31%) patients with acute exacerbation of UIP pattern/IPF have survived for four to twelve months (mean: 7.5 months). Four patients revealed re-exacerbation of IP after the dose of CsA was tapered. Among the 25 patients with IP, the histopathological patterns of IP were classified as usual interstitial pneumonia (UIP) in 10 cases, nonspecific interstitial pneumonia (NSIP) in 14 cases (group I, 2; group II, 5; group III, 7) and diffuse alveolar damage (DAD) in 1 case. The prognoses were improved or unchanged in all cases of NSIP group I, in 80% of cases with NSIP group II, in 29% of cases of NSIP group III and in 20% of cases of UIP; and deteriorated in the case of DAD, in 80% of cases of UIP, in 71% of cases of NSIP group III, and in 20% of cases of NSIP group II. It should be emphasized that CsA combined with corticosteroids may be effective for the treatment of steroid-resistant or acute exacerbation cases of IP. Further studies are required to determine long-term outcome with this treatment.     

Endotoxin adsorption therapy using polymyxin B-immobilized fiber as a treatment for septic shock-associated severe acute cholangitis

The application of endotoxin adsorption therapy for severe acute cholangitis is controversial. We present a survival case of septic shock and multiple organ failure due to severe acute cholangitis. The patient was treated by endotoxin adsorption therapy using polymyxin B-immobilized fiber because he continued to remain in shock even after successful endoscopic nasobiliary drainage. The patient was an 84-year-old male diagnosed with acute cholangitis and acute pancreatitis who was transferred to our department because of shock and severe dyspnea. The patient had already developed acute respiratory failure, acute renal failure, and disseminated intravascular coagulation. We performed endoscopic nasobiliary drainage immediately, but the patient continued to remain in shock and plasma endotoxin level was markedly elevated at 133.6 pg/mL. Therefore, we performed direct hemoperfusion with polymyxin B-immobilized fiber. On starting the hemoperfusion, blood pressure and urine volume increased, and the plasma endotoxin level reduced considerably. On the basis of our experience in this case, we think that direct hemoperfusion with polymyxin B-immobilized fiber may be a useful modality in the management of severe acute cholangitis.     

PaO2-guided Low-dose Oxygen Therapy for Pneumatosis Cystoides Intestinalis to Prevent Acute Exacerbation of Interstitial Pneumonia

We herein report the first case of low-dose oxygen therapy for pneumatosis cystoides intestinalis (PCI) using PaO₂ as a therapeutic index to prevent acute exacerbation of interstitial pneumonia. An 86-year-old man was admitted to our hospital with abdominal distension. PCI was diagnosed by abdominal computed tomography. Low-dose oxygen therapy was started to avoid acute exacerbation of interstitial pneumonia. The oxygen dose was adjusted so that the PaO₂ value was approximately 100 mmHg. After seven days of treatment, the colon gas had disappeared, and no acute exacerbation of interstitial pneumonia was observed. A PaO₂ value around 100 mmHg is effective for PCI without inducing acute exacerbation of interstitial pneumonia.     

A New Treatment for Endotoxemia with Direct Hemoperfusion by Polymyxin Immobilized Fiber

Abstract: Guest Editor's Introduction: Endotoxins, which consist of lipopolysaccharides (LPS), are known to be a pathogenic substance in patients with septic shock. Since Nolan reported endotoxin adsorption by ion exchange resin and activated charcoal, the search for more effective adsorbents were continued and have lead to the development of polymyxin B immobilized fibers. Polymyxin B is a cationic antibiotic agent which interacts with acidic phospholipids and LPL by electrostatic force. This paper was the first report written in English regarding polymixin B immobilized fibers. The adsorbent is now known as Toraymyxin PMX‐20R and manufactured by Toray Co. This paper was published in Therapeutic Apheresis: A Critical Look, Y. Nosé, P.S. Malchesky, and J,W. Smith eds., ISAO Press, page 167–170 (1984). A new method of preparing polymyxin B fixed to insoluble fiber (PMX‐F) was developed. PMX‐F (1 g) was detoxified with 0.5–4.8 mg of lipopolysaccharides (LPS) as endotoxin (ET) in a batch system. Fixed polymyxin B(PX) was found to be firmly attached to fiber even after washing with isotonic saline or endotoxin solution. Toxicological study of the mortality of mice after injection of PMX‐F‐treated ET indicated that 24% (5 of 21) of the treated group survived, whereas 100% (21 of 21) of the untreated group died. In ex vivo experiments, direct hemoperfusion (DHP) by PMX‐F was performed for ET‐injected canine. Only 12.5% (1 of 8) survived in the control group, but 83% (10 of 12) survived in the group receiving DHP with PMX‐F. Mortality in the treated group decreased remarkably. The results thus indicate the efficacy of PMX‐F in neutralizing ET.     

Changes of Cytokines in Direct Endotoxin Adsorption Treatment on Postoperative Multiple Organ Failure

Abstract: Multiple organ failure (MOF) is a serious condition that involves simultaneous or consecutive functional failure of several important organs. Furthermore, sepsis is known to play an important role in the occurrence of MOF. Hemoadsorption therapy with the endotoxin adsorption column containing polymyxin B immobilized fibers by direct hemoperfusion (PMX‐DHP) is reportedly effective in the treatment of septic shock. This study examined the changes induced on cytokines upon PMX‐DHP treatment in 25 patients who underwent emergency abdominal surgery and were immediately started on a postoperative regimen of continuous hemodiafiltration (CHDF) and PMX‐DHP. Postoperative MOF was observed in these patients with a mean APACHE II SCORE of 25.5. Eighty percent of patients survived for more than 1 month. We were able to reduce the necessary dose of dopamine in 85.7% of patients because hemodynamic stability improved after administration of PMX‐DHP. Interleukin 6 blood levels did not change significantly before or after PMX‐DHP treatment in either the surviving or nonsurviving patients. Blood interleukin 1 receptor antagonist levels decreased in both groups. Intercellular adhesion molecular‐1, NOx, and thrombomodulin did not change significantly during the course of treatment in either group. Decreased blood levels of PAI‐1 levels were found in the surviving patients whereas increased levels of PAI‐1 were found in the nonsurviving patients. In conclusion, PMX‐DHP treatment may be limited clinically in its ability to remove inflammatory cytokines and humoral mediators. However, PMX‐DHP treatment is useful for hemodynamic stabilization, which prevents development of MOF.     

Hemoperfusion With an Immobilized Polymyxin B Fiber Column Decreases Macrophage and Monocyte Activity

We investigated whether direct hemoperfusion with a polymyxin B column (DHP‐PMX) was able to decrease macrophage and monocyte activity in patients with sepsis. Nineteen patients with sepsis were enrolled in the study. They all had signs of systemic inflammatory response syndrome (SIRS) due to infection and a mean arterial blood pressure ≥65 mm Hg (irrespective of the use of catecholamines). A thermodilution catheter was inserted prior to DHP‐PMX for intravenous infusion, and DHP‐PMX was performed twice within 24 h for 3 h each time. Serum neopterin was measured four times: before DHP‐PMX, and 24, 48, 72 h after it had begun. The serum concentrations of neopterin were 654 ± 234 nmol/L prior to DHP‐PMX vs. 573 ± 196 nmol/L at 24 h, 452 ± 161 nmol/L at 48 h, and 372 ± 139 nmol/L at 72 h, showing a significant decrease from 48 h onwards compared with before treatment. These data suggest that DHP‐PMX decreases macrophage and monocyte activity.     

Clinical preparedness for severe pneumonia with highly pathogenic avian influenza A (H5N1): Experiences with cases in Vietnam

BackgroundAvian influenza A (H5N1) in human presents a global pandemic threat, and preparedness is urgently required in high-risk countries.MethodsA retrospective chart review was conducted on 8 patients with H5N1 infection (aged 2–30 years; 3 fatal) who were hospitalized in Bach Mai Hospital (BMH), Vietnam, or in affiliated hospitals with consultation by physicians in BMH between 2007 and 2010. Demographic background, chest radiographs, and clinical and laboratory data were evaluated to determine the critical issues in relation to clinical outcomes. Treatment of 4 patients with acute respiratory distress syndrome (ARDS) (2 fatal) was assessed for renal replacement therapy using continuous hemodiafiltration (CHDF), polymyxin B-immobilized (PMX) hemoperfusion, or their combination.ResultsPatients had direct contact with dead/sick poultry infected with H5N1 virus or lived in areas where H5N1 poultry outbreaks had been reported at the same time as their illness. Time to initiation of oseltamivir from symptom onset was 2–6 days for survivors and 7–9 days for non-survivors. All patients except one had infiltrative shadows on chest radiographs on admission. Patients with delayed treatment developed ARDS. Renal replacement therapy contributed to patient survival, with improvement of oxygenation and a dramatic decrease in serum cytokine levels if initiated earlier.ConclusionsUnderstanding local H5N1 poultry outbreaks and chest radiography assist early diagnosis and initiation of antiviral treatment. Developing a network among local and tertiary care hospitals can reduce the time to initiation of treatment. CHDF and PMX hemoperfusion are possible candidates for effective treatment of ARDS with H5N1 if applied earlier.