Limited surgical resection for graft salvage following recovery from complicated exfoliative rejection in pediatric intestinal recipients

Complications of ER contribute significantly to morbidity and mortality following intestinal transplantation. The surgical management of three pediatric patients who experienced complications of late ER after composite LSB transplantation is described, highlighting the potential for allograft salvage after limited surgical resection. A retrospective case series was compiled. Data collected included time to ER from transplant, medical management of ER, complications, and surgical management of ER complications. All patients had undergone composite LSB transplantation between one and two yr of age. Time to ER after transplantation was 9.5–26.5 months. ER complications included ileal allograft stricture, intramural hematoma with perforation of jejunal allograft, and massive GI hemorrhage secondary to focal ulceration and pseudopolyp formation. With evidence of mucosal regeneration, all three patients underwent limited segmental allograft resection. Two patients continue to maintain satisfactory allograft function 39–44 months following operation. The third patient retained adequate allograft function until he developed PTLD, subsequently dying from disseminated Adenovirus infection 51 months after resection. Severe disruption of intestinal allograft integrity in ER can lend itself to medically refractory complications. Prompt recognition and surgical correction of complications can play a crucial role in allograft salvage and patient survival after ER.     

The Research Board of the European Dialysis and Transplantation Nurses Association/European Renal Care Association (EDTNA/ERCA)

The Research Board (RB) of EDTNA/ERCA is a multidisciplinary group, established by the participation of renal care centres all around Europe. The RB also works with the association's Special Interest Groups (SIGs) on developing guidelines for implementing safe renal clinical practice. It is composed of six permanent members, with co-opted experts from specific fields. This article describes how the RB works and the projects implemented since 1996.     

Does thoracic bioimpedance accurately determine cardiac output in COPD patients during maximal or intermittent exercise?

STUDY OBJECTIVES: The monitoring of cardiac output (CO) during exercise rehabilitation in patients with COPD, often including strenuous exercise, is advisable. Invasive methods (thermodilution, Fick method) are accurate, but for clinical routine use noninvasive CO estimation is required. We have shown that impedance cardiography (Physio Flow; Manatec Biomedical; Macheren, France) is reliable in COPD patients at rest and during a recumbent, light-intensity exercise. The aim of our study was to evaluate the validity of this noninvasive device in COPD patients during a maximal incremental exercise test (IET) and also during a strenuous intermittent work exercise test (IWET). DESIGN: Prospective comparative study of the impedance cardiograph vs the direct Fick method applied to oxygen. PATIENTS: Eight patients with moderate-to-severe COPD (59 +/- 6 years old; FEV(1), 38 +/- 15% predicted; residual volume, 194 +/- 64% predicted) [mean +/- SD].Measurements and main results: Forty-nine simultaneous measurements of CO by means of the direct Fick method (COfick) and CO measured by the impedance cardiograph (COpf) were obtained during the IET, and 108 measurements were made during the IWET. The correlation coefficients between the two measurements were r = 0.85 and r = 0.71 for the IET and the IWET, respectively. COpf was higher than COfick. The difference between the two methods was 3.2 +/- 2.9 L/min during the IET and 2.5 +/- 2.1 L/min during the IWET. Expressed as a percentage of the mean of the two measurements, this corresponded to 31 +/- 21% and 25 +/- 20%, respectively. CONCLUSIONS: The relatively high number of values differing by > 20% precludes the use of impedance cardiography in clinical routine in such a difficult setting (hyperinflated patients and intense exercise).     

European study on epidemiology and the management of HCV in the haemodialysis population--Part 1: centre policy

Haemodialysis patients are known to be at risk of infection of Hepatitis C Virus (HCV) through nosocomial spread. This paper presents the first part of a study on epidemiology and management of HCV, in a haemodialysis population, conducted by the EDTNA/ERCA Research Board. Data on HCV management and infection control procedures was collected from 136 European centres using an electronic questionnaire. The study identifies a number of possible risk factors for transmission of the virus: failing to disinfect devices between patients, sharing of single-use vials to prepare drugs or infusions for different patients, inadequate sterilisation or cleaning of machines between dialysis sessions, unsatisfactory environmental cleaning and distance less than one metre between chairs.     

Semi-automatic detection of myocardial trabeculation using cardiovascular magnetic resonance: correlation with histology and reproducibility in a mouse model of non-compaction

Background

The definition of left ventricular (LV) non-compaction is controversial, and discriminating between normal and excessive LV trabeculation remains challenging. Our goal was to quantify LV trabeculation on cardiovascular magnetic resonance (CMR) images in a genetic mouse model of non-compaction using a dedicated semi-automatic software package and to compare our results to the histology used as a gold standard.

Methods

Adult mice with ventricular non-compaction were generated by conditional trabecular deletion of Nkx2–5. Thirteen mice (5 controls, 8 Nkx2–5 mutants) were included in the study. Cine CMR series were acquired in the mid LV short axis plane (resolution 0.086?×?0.086x1mm³) (11.75 T). In a sub set of 6 mice, 5 to 7 cine CMR were acquired in LV short axis to cover the whole LV with a lower resolution (0.172?×?0.172x1mm3). We used semi-automatic software to quantify the compacted mass (M_c), the trabeculated mass (M_t) and the percentage of trabeculation (M_t/M_c) on all cine acquisitions_. After CMR all hearts were sliced along the short axis and stained with eosin, and histological LV contouring was performed manually, blinded from the CMR results, and M_t, M_c and M_t/M_c were quantified. Intra and interobserver reproducibility was evaluated by computing the intra class correlation coefficient (ICC).

Results

Whole heart acquisition showed no statistical significant difference between trabeculation measured at the basal, midventricular and apical parts of the LV. On the mid-LV cine CMR slice, the median M_t was 0.92 mg (range 0.07–2.56 mg), M_c was 12.24 mg (9.58–17.51 mg), M_t/M_c was 6.74% (0.66–17.33%). There was a strong correlation between CMR and the histology for M_t, M_c and M_t/ M_c with respectively: r²?=?0.94 (p?<?0.001), r²?=?0.91 (p?<?0.001), r²?=?0.83 (p?<?0.001). Intra- and interobserver reproducibility was 0.97 and 0.8 for M_t; 0.98 and 0.97 for M_c; 0.96 and 0.72 for M_t/M_c, respectively and significantly more trabeculation was observed in the M_c Mutant mice than the controls.

Conclusion

The proposed semi-automatic quantification software is accurate in comparison to the histology and reproducible in evaluating M_c, M_t and M_t/ M_c on cine CMR.

     

Performance of a second generation pulmonary capnotracking system for continuous monitoring of cardiac output

Technologies for minimally-invasive cardiac output measurement in patients during surgery remain little used in routine practice. We tested a redeveloped system based on CO₂ elimination (VCO₂) by the lungs for use in ventilated patients, which can be seamlessly integrated into a modern anesthesia/monitoring platform, and provides automated, continuous breath-by-breath cardiac output monitoring. A prototype measurement system was constructed to measure VCO₂ and end-tidal CO₂ concentration with each breath. A baseline measurement of non-shunt cardiac output was made during a brief oscillating change in ventilator rate, according to the differential CO₂ Fick approach and repeated at 5–10 min intervals. Continuous breath-by-breath monitoring of cardiac output was performed between these intervals from measurement of VCO₂, using a derivation of the Fick equation applied to pulmonary CO₂ elimination and cardiac output displayed in real time. Measurements were compared with simultaneous measurements by thermodilution in 50 patients undergoing cardiac surgery or liver transplantation. Overall mean bias [sd] for agreement in cardiac output measurement was ??0.3 [1.1] L/min, percentage error?±?38.7%, intraclass correlation coefficient?=?0.91. Concordance in measurement of changes of at least 15% in cardiac output was 81.4%, with a mean angular bias of ??1.7°, and radial limits of agreement of ±?76.2° on polar plot analysis. The accuracy and precision compared favourably to other clinical techniques. The method is relatively seamless and automated and has potential for continuous, cardiac output monitoring in ventilated patients during anesthesia and critical care.