Exchange transfusion as an adjunct to the treatment of severe falciparum malaria: case report and review

Malaria associated with complications or a fatal outcome is almost always caused by Plasmodium falciparum. The mortality due to this disease parallels the degree of parasitemia. Successful use of exchange blood transfusion as a therapeutic adjunct for this infection was first reported in 1974, although the efficacy of this procedure has not been established by randomized, controlled trials. The rationale for this form of therapy is based on: (1) rapid reduction in the parasite load by direct removal; (2) decreased risk of severe intravascular hemolysis and its consequences (disseminated intravascular coagulation and renal dysfunction); (3) improved rheology with transfused blood and reduced microcirculatory sludging; and (4) improved oxygen-carrying capacity with transfused erythrocytes. We describe a case of severe falciparum malaria and review the literature describing the use of exchange transfusion for treatment of this infection.     

Wege zu einer integrierten Gesundheitsversorgung in Deutschland am Beispiel kardiologischer Patienten

Ohne Zusammenfassung     

Do different mattresses affect the quality of cardiopulmonary resuscitation?

Objective To determine the effect of different mattresses on cardiopulmonary resuscitation performance and establish whether emergency deflation of an inflatable mattress improves the quality of resuscitation.Design and setting Randomised controlled cross-over trial performed in a general ICUParticipants Critical care staff from a general ICU.Interventions Cardiopulmonary resuscitation on a manikin on the floor or on a bed with a standard foam mattress and inflated and deflated pressure redistributing mattresses. Maximal compression force was measured at different bed heights.Measurements and results Compression depth, duty cycle and rate and percentage correct expired air ventilation were recorded on a manikin. Compression depth was significantly lower on the foam (35.2 mm), inflated (37.2 mm) and deflated mattress (39.1 mm) than the floor (44.2 mm). There were no clinically important differences in duty cycle or compression rate. The quality of ventilation was poor on all surfaces. Maximal compression force declined as bed height increased.Conclusions Resuscitation performance is adversely affected when performed on a bed (irrespective of mattress type) compared to the floor. There were no differences between the inflated and deflated mattresses, although the deflation process did not adversely affect performance. This study does not support the routine deflation of an inflated mattress during resuscitation and questions the potential benefits from using a backboard. The finding that bed height affects maximal compression forces, challenges the recommendation that cardiopulmonary resuscitation be performed with the bed at middle-thigh level and requires further investigation.Dr. Robert Benny was tragically killed in a road accident during the Summer of 2003. Dr. Benny was at the very start of a promising career in surgery. Our thoughts go to his family and friends.G.D.P. and M.T. have received travelling fellowships from Huntleigh Healthcare, and M.T. has previously delivered lectures for Huntleigh Healthcare.     

An international consensus on the appropriate evaluation and treatment for adults with spinal deformity

Purpose

Evaluation and surgical management for adult spinal deformity (ASD) patients varies between health care providers. The purpose of this study is to identify appropriateness of specific approaches and management strategies for the treatment of ASD.

Methods

From January to July 2015, the AOSpine Knowledge Deformity Forum performed a modified Delphi survey where 53 experienced deformity surgeons from 24 countries, rated the appropriateness of management strategies for multiple ASD clinical scenarios. Four rounds were performed: three surveys and a face-to-face meeting. Consensus was achieved with ≥70% agreement.

Results

Appropriate surgical goals are improvement of function, pain, and neural symptoms. Appropriate preoperative patient evaluation includes recording information on history and comorbidities, and radiographic workup, including long standing films and MRI for all patients. Preoperative pulmonary and cardiac testing and DEXA scan is appropriate for at-risk patients. Intraoperatively, appropriate surgical strategies include long fusions with deformity correction for patients with large deformity and sagittal imbalance, and pelvic fixation for multilevel fusions with large curves, sagittal imbalance, and osteoporosis. Decompression alone is inappropriate in patients with large curves, sagittal imbalance, and progressive deformity. It is inappropriate to fuse to L5 in patients with symptomatic disk degeneration at L5–S1.

Conclusions

These results provide guidance for informed decision-making in the evaluation and management of ASD. Appropriate care for ASD, a very diverse spectrum of disease, must be responsive to patient preference and values, and considerations of the care provider, and the healthcare system. A monolithic approach to care should be avoided.

     

ADL performance and dependency on nursing care in patients with hip fractures and acute confusion in a task allocation care system

In a prospective study 35 patients operated on for cervical hip-fractures were followed with respect to Acute Confusional State (ACS), problems of basic nursing care and dependency on care-givers. Fifteen patients became acutely confused after the fracture. They turned out to be more dependent on help from others than the non-confused patients were even before the fracture. They rapidly reached a significantly higher level of dependence than the non-confused patients and remained on that level throughout the study month. Six months after the fracture the post-operatively confused patients were still highly dependent on care-givers, significantly more than they were before the fracture. Only three of them were not hospitalised. All the non-confused patients lived in their own homes six months after the fracture and had regained the same level of independence as before it. These findings will be discussed in relation to the organisation of the nursing care. Task allocation nursing care was applied in the wards. A model for the development of dependency in acutely confused hip-fracture patients will be presented and suggestions for how to reduce nurse/patient dependency induced by nursing care will be made.     

Treatment of in-stent restenosis with sirolimus-eluting-stents: results from the prospective German Cypher stent registry

Aims  Drug-eluting stents have been reported to effectively reduce in-stent restenosis (ISR). However, the effectiveness and safety have yet been investigated only in small trials or case series. The aim of this prospective large scale registry was to show that treatment of ISR with sirolimus eluting stents (SES) is safe, effective and feasible in daily routine. Methods and results  The German Cypher registry prospectively enrolled 6,555 patients undergoing implantation with SES for various indications, including 1,533 patients treated for ISR. Follow-up data (median 6.6 months) of this cohort was available for 1,531 patients (99.8%). Of these patients 75.8% were male. Of these patients 36.5% (n = 552) presented with acute coronary syndromes. In total, 1,932 SES were used with successful implantation in 98.9%. MI during hospitalization was observed in 0.7% (n = 11) while in-hospital mortality was only 0.1% (n = 2). MACE-rate at follow-up was 13.8% (n = 211) including a mortality of 1.3% (n = 20) and MI in 1.9% (n = 29). Total revascularization procedures including CABG (1.7%) were necessary in 12.3% (n = 186). Target vessel revascularization (TVR) rate was 9.3% (n = 139) and thus similar to patients with de novo lesions (8.1%, P = 0.69). Ten patients (0.65%) suffered from subacute stent thrombosis Vs. 0.24% observed in patients with de novo lesions (P = 0.03). Conclusion  This large registry confirms that treatment of ISR with sirolimus-eluting-stents is effective and save with good clinical results at index procedure and follow-up. TVR was not different from de novo lesions.     

A heat-treated factor VIII concentrate prepared by controlled-pore glass adsorption chromatography

Four years' experience with a method for preparing a high-purity, low-fibrinogen, heat-treated factor VIII concentrate is reported. The process, batch adsorption of a cryoprecipitate extract with controlled-pore glass granules, removes 77 percent of the cryoprecipitate fibrinogen, resulting in a final concentrate-specific activity of 0.74 IU factor VIII per mg of protein at a yield of 194 IU factor VIII per kg of starting plasma. Heat treatment of the lyophilized concentrate for 72 hours at 60 degrees C results in less than 10 percent loss of factor VIII activity. This process does not require expensive fractionation equipment, is suitable for small-to medium-scale batch concentrate production and could be adopted by moderately well-equipped regional blood processing laboratories for the decentralized production of a high-quality, heat-treated factor VIII concentrate.     

Pyrolysis Temperature-Dependent Changes in the Characteristics of Biochar-Borne Dissolved Organic Matter and Its Copper Binding Properties

Bulletin of Environmental Contamination and Toxicology - The dissolved organic matter (DOM) samples from biochars produced from Jerusalem artichoke stalks by pyrolysis at 300, 500, and...     

C11orf95‐RELA fusion present in a primary intracranial extra‐axial ependymoma: Report of a case with literature review

Ependymomas are gliomas that recapitulate the ependymal cells microscopically and ultrastructurally. They commonly occur along the ventricular surfaces and central canal of the brain and spinal cord. Intracranial extra‐axial ependymoma (IEAE) is a rare entity and is commonly misdiagnosed clinically and radiologically as a meningioma. The histogenesis of such IEAEs is obscure. A novel recurrent oncogenic fusion involving the C11orf95 and RELA genes was recently described in supratentorial ependymomas. A 9‐year‐old girl presented with a dural based parafalcine mass that, in addition to exhibiting classical immunohistochemical features of an ependymoma, also demonstrated C11orf95‐RELA fusion, characteristic of supratentorial ependymomas. We suggest that IEAEs share their histogenesis with their intra‐axial counterparts, arising either from dural extension of subcortical, subependymal rests or directly from ectopic dural rests.     

Assessment of renal artery stenosis: side-by-side comparison of angiography and duplex ultrasound with pressure gradient measurements.

AIMS: A ratio of distal renal pressure to aortic pressure (P(d)/P(a)) <0.90 can be considered a threshold for defining a significant renal artery stenosis (RAS). The aim of this study was to compare renal angiography (QRA) and colour duplex ultrasound (CDUS) to pressure measurements in assessing RAS. METHODS AND RESULTS: In 56 RAS, percent diameter stenosis (DS(angio)), minimal luminal diameter (MLD), Doppler-derived peak systolic velocity (PSV), end-diastolic velocity (EDV), and renal-to-aortic ratio (RAR) were obtained and compared with the P(d)/P(a) measured with a 0.014" pressure wire. P(d)/P(a) correlated with angiography- and CDUS-derived parameters. The best correlation was observed with EDV (R = -0.61). To identify stenosis associated with a P(d)/P(a) < 0.90, the diagnostic accuracy of DS(angio) > 50%, MLD < 2 mm, PSV > 180 cm/s, EDV > 90 cm/s and RAR > 3.5 were, respectively, 60%, 77%, 45%, 77% and 79%, yet, with a high proportion of false positives (38%, 15%, 55%, 11% and 15%, respectively) indicating an overestimation of the severity of the RAS by both QRA and CDUS. New cut-off values for QRA- and CDUS-derived indices were proposed. CONCLUSION: Generally accepted QRA and CDUS-derived indices of RAS severity overestimate the actual severity of RAS. This 'overdiagnosis' is likely the main cause of the disappointing results of renal angioplasty for renovascular hypertension.