Rescue extracorporeal cardiopulmonary resuscitation in pediatric patients: a nine-year single-center experience in Zagreb,Croatia

AimTo investigate the risk factors and the outcomes of extracorporeal membrane oxygenation (ECMO) in pediatric patients treated at the University Hospital Center Zagreb, the largest center in Croatia providing pediatric ECMO.MethodsThis retrospective study enrolled all the pediatric patients who required E-CPR from 2011 to 2019. Demographic data, cardiac anatomy, ECMO indications, ECMO complications, and neurodevelopmental status at hospital discharge were analyzed.ResultsIn the investigated period, E-CPR was used in 16 children, and the overall survival rate was 37.5%. Six patients were in the neonatal age group, 5 in the infant group, and 5 in the “older” group. There was no significant difference between the sexes. Four patients had an out-of-hospital arrest and 12 had an in-hospital arrest. Twelve out of 16 patients experienced renal failure and needed hemodialysis, with 4 out of 6 patients in the survivor group and 8 out of 10 in the non-survivor group. Survivors and non-survivors did not differ in E-CPR duration time, lactate levels before ECMO, time for lactate normalization, and pH levels before and after the start of ECMO.ConclusionThe similarity of our results to those obtained by other studies indicates that the ECMO program in our hospital should be maintained and improved.

The use of extracorporeal cardiopulmonary resuscitation (E-CPR) is increasing (1). E-CPR is defined as an initiation of extracorporeal membrane oxygenation (ECMO) during active chest compressions. Its main goal is to provide immediate cardiovascular support to patients who do not react to CPR (2) and to lead to survival and a better neurological outcome (3). After administering CPR for more than 30 minutes, survival with conventional CPR measures ranges between 0%-5% (4,5).The most recent systematic review by the International Liaison Committee on Resuscitation from 2015 recommended that E-CPR should be considered for children with underlying cardiac conditions who have an in-hospital cardiac arrest when appropriate protocols, expertise, and equipment are available (6). According to the Extracorporeal Life Support Organization (ELSO) registry from 2017 (7), more than 60 000 people received extracorporeal life support (ECLS), between 2009 and 2015, with an overall survival rate of 61% (7). Pediatric ECMO experience in Slovenia shows that ECMO programs may be incorporated in smaller hospitals in the region (8-10). The ELSO database includes data on all reported pediatric ECMO runs, including those conducted with E-CPR, and in patients with congenital heart surgery and neonates with diaphragmatic hernia or meconium aspiration syndrome, etc. During the 6-year period, 3005 E-CPR runs were reported, with an overall survival to hospital discharge of 43% (7). A survival rate of 31% was reported by Ergűn et al (11) and in E-CPR patients with severe burn injury (12). The longer the CPR duration time, the lower was the survival to discharge rate. Matos et al reported an E-CPR survival-to-discharge rate of 33% after >35 min of chest compressions (13). Other studies reported that the overall survival rate of pediatric E-CPR cases was growing, with better neurological outcomes than among the patients in the CPR group only (14). Pilar et al found that in 73 pediatric cardiac patients requiring cardiopulmonary resuscitation for >30 min (15), the survival to hospital discharge was 43.8%, with 3/4 of the patients having normal neurological function or mild neurological disability (15). Based on ELSO registry, approximately 10% of all ECMO patients meet brain death criteria (7). One of the biggest single-center studies, involving 184 pediatric ECPR patients (16), showed a successful ECMO weaning in 63% of the patients and the overall survival rate to hospital discharge of 43%. In the same study, the risk factors linked to increased mortality were presupport pH<7.1, mechanical complications, and neurological complications (16). The E-CPR use can involve many complications, not necessarily linked to factors preceding cardiac arrest, such as low cardiac output syndrome or irreversible respiratory failure (17). Furthermore, common complications of ECMO treatment are fluid overload and acute kidney injury (18). Many studies showed renal replacement therapy (RRT) to be negatively associated with survival (15,16,18,19).This study assessed the risk factors and the outcomes of ECMO in the largest Croatian center providing pediatric E-CPR experience over nine years and compared the survivor and the non-survivor group.     

External iliac artery endofibrosis in an amateur runner: hemodynamic, angiographic, histopathological evaluation and percutaneous revascularization

We describe a case of external iliac artery endofibrosis in an amateur competitive runner. The diagnosis was made by a combination of hemodynamic, angiographic and histopathological assessment and percutaneous revascularization was performed using a balloon expandable stent.     

Expressions of Topoisomerase IIα and BCRP in Metastatic Cells are Associated with Overall Survival in Small Cell Lung Cancer Patients

The aim of this study was to investigate the mRNA expression levels of multidrug resistance-associated proteins in chemo-na?ve metastatic lung cancer cells and to determine the correlation with response to chemotherapy and overall survival. Metastatic cells were obtained by transbronchial fine needle aspiration biopsy of enlarged mediastinal lymph nodes in 14 patients with small cell lung cancer (SCLC) and 7 patients with non-small cell lung cancer (NSCLC). After cytological confirmation of lung cancer type, total RNA was extracted from biopsy samples and reverse transcribed to cDNA, and real-time PCR for the genes of interest [P-glycoprotein (P-gp), multidrug resistance protein 1 (MRP1), breast cancer resistance protein (BCRP), lung resistance protein (LRP) and topoisomerase IIα (TOPIIα)], was performed. We observed significantly decreased expression of BCRP and significantly increased expression of TOPIIα in metastatic SCLC cells compared to NSCLC. Furthermore, in SCLC high topoisomerase IIα and low BCRP expression levels positively correlated with longer overall survival. Our results showed higher expression levels of BCRP as well as lower levels of topoisomerase IIα in chemo-na?ve metastatic cells in NSCLC than in SCLC. These results correlate with previous observations that metastatic SCLC cells at the beginning of chemotherapy are potentially more sensitive to chemotherapeutic agents while in metastatic NSCLC cells resistance is usually inherent. We also showed that altered levels of topoisomerase IIα and BCRP in SCLC are important factors that contribute to resistance to chemotherapeutics that interfere with the enzyme and/or DNA and are highly associated with overall survival.     

The E3 ubiquitin ligase RNF186 and RNF186 risk variants regulate innate receptor-induced outcomes

Balancing microbial-induced cytokines and microbial clearance is critical at mucosal sites such as the intestine. How the inflammatory bowel disease (IBD)–associated gene RNF186 regulates this balance is unclear. We found that macrophages from IBD-risk rs6426833 carriers in the RNF186 region showed reduced cytokines to stimulation through multiple pattern recognition receptors (PRRs). Upon stimulation of PRRs, the E3-ubiquitin ligase RNF186 promoted ubiquitination of signaling complex molecules shared across PRRs and those unique to select PRRs. Furthermore, RNF186 was required for PRR-initiated signaling complex assembly and downstream signaling. RNF186, along with its intact E3-ubiquitin ligase activity, was required for optimal PRR-induced antimicrobial reactive oxygen species, reactive nitrogen species, and autophagy pathways and intracellular bacterial clearance in human macrophages and for bacterial clearance in intestinal myeloid cells. Cells transfected with the rare RNF186-A64T IBD-risk variant and macrophages from common rs6426833 RNF186 IBD-risk carriers demonstrated a reduction in these RNF186-dependent outcomes. These studies identify mechanisms through which RNF186 regulates innate immunity and show that RNF186 IBD-risk variants demonstrate a loss of function in PRR-initiated outcomes.

Inflammatory bowel disease (IBD) is characterized by dysregulated host–microbial responses and is composed of two subtypes: Crohn’s disease and ulcerative colitis (UC). Pattern recognition receptors (PRRs) are critical for recognition and responses to microbes. Both loss of function and gain of function in PRR-initiated outcomes can be associated with intestinal inflammation (1), thereby highlighting the importance of the balance in innate immune regulation in intestinal tissues. Despite the tremendous success in genetic studies identifying loci associated with susceptibility to IBD (2), altered functions for most of these loci are not well defined. One such region is on chromosome 1, encompassing the RNF186 gene (2, 3).The UC rs6426833 A risk variant in the RNF186 region is observed at a 0.395 to 0.548 frequency in European ancestry healthy individuals (per the Single Nucleotide Polymorphism Database; accessed July 2019), and this common variant confers a 1.265 increased risk of developing UC (2). Importantly, a rare Ring Finger Protein 186 (RNF186) Ala64Thr mutation confers a 1.49-fold increased risk for developing UC (4). RNF186 is a member of the RING family E3 ubiquitin ligases and has a conserved C₃HC₄ type zinc finger (ZnF) motif in the RING domain consistent with its ability to catalyze ubiquitination of select downstream substrates (5, 6). E3 ubiquitin ligases are key mediators for posttranslational modifications of PRR-initiated signaling intermediates (7). Only a few reports have examined roles for RNF186, and these have focused on its functions in epithelial cells (4–6, 8). In HeLa cells, RNF186 can localize to the endoplasmic reticulum (ER) and enhance ER stress-associated apoptotic signaling (5). RNF186-deficient and rare variant RNF186 A64T knockin mice demonstrated more severe dextran sodium sulfate–induced colitis associated with intestinal epithelial dysregulation (6). RNF186 can regulate nutrient sensing in epithelial cells (8). Therefore, while some functions for RNF186 have been identified in epithelial cells, roles for RNF186 in mediating outcomes in innate immunity, including downstream of PRRs, have not been examined. Moreover, the consequences of UC-associated common genetic variants in the RNF186 region have not been defined.We identify that RNF186 is expressed in human monocyte-derived and intestinal myeloid-derived cells. We establish that RNF186 is required for optimal PRR-induced signaling, cytokine secretion, and induction of a range of antimicrobial pathways. We define mechanisms and structural regions through which RNF186 regulates these PRR-initiated outcomes and identify that the rare and common RNF186 IBD-risk variants lead to a loss of function in these outcomes.     

Towards personalized and versatile monitoring of temperature fields within heterogeneous tissues during laser therapies

Advancements in medical laser technology have paved the way for its widespread acceptance in a variety of treatments and procedures. Selectively targeting particular tissue structures with minimally invasive procedures limits the damage to surrounding tissue and allows for reduced post-procedural downtime. In many treatments that are hyperthermia-based, the efficiency depends on the achieved temperature within the targeted tissues. Current approaches for monitoring subdermal temperature distributions are either invasive, complex, or offer inadequate spatial resolution. Numerical studies are often therapy-tailored and source tissue parameters from the literature, lacking versatility and a tissue-specific approach. Here, we show a protocol that estimates the temperature distribution within the tissue based on a thermographic recording of its surface temperature evolution. It couples a time-dependent matching algorithm and thermal-diffusion-based model, while recognizing tissue-specific characteristics yielded by a fast calibration process. The protocol was employed during hyperthermic laser treatment performed ex-vivo on a heterogeneous porcine tissue, and in-vivo on a human subject. In both cases the calibrated thermal parameters correlate with the range of values reported by other studies. The matching algorithm sufficiently reproduced the temperature dynamics of heterogeneous tissue. The estimated temperature distributions within ex-vivo tissue were validated by simultaneous reference measurements, and the ones estimated in-vivo reveal a distribution trend that correlates well with similar studies. The presented method is versatile, supported by the protocol for tissue-specific tailoring, and can readily be implemented for temperature monitoring of various hyperthermia-based procedures by means of recording the surface temperature evolution with a miniature thermal camera implemented within a handheld laser scanner or similar.     

Prognostic value of tumor microinvasion and metalloproteinases expression in intracranial pediatric ependymomas

Ependymomas are common pediatric intracranial neoplasms that often appear well circumscribed on imaging but may recur when they are treated by surgical resection alone. The current World Health Organization histological grading system does not accurately predict clinical behavior. The aim of this study was to identify histological and immunohistochemical features that correlate with clinical course in patients with ependymomas treated by gross total resection. We analyzed 41 pediatric ependymomas for microinvasion and correlated immunostaining for the metalloproteinase (MMP)-2 and MMP14 and for ezrin and bcl-2 with clinical outcome. Gross total resection had a significantly positive effect on overall survival and progression-free survival. In 28 patients who underwent gross total resection, microinvasion correlated with poor overall survival (p = 0.003) and progression-free survival (p = 0.03). Gross totally resected tumors with high expression of MMP2 and MMP14 had significantly shorter overall survival. Ezrin staining identified tumor cells invading the adjacent white matter that were not identified by routine stains, but Ezrin staining and bcl-2 staining did not provide strong prognostic correlations. The data indicate that tumor microinvasion into adjacent brain and tumor expression of MMP2 and MMP14 predict both overall and progression-free survival in pediatric ependymomas, and these are useful prognostic markers that may help stratify patients for adjuvant therapies.