Arterial and pseudoaneurysm ruptures complicating liver transplantation

Ruptures of the hepatic artery and hepatic pseudoaneurysms (PA) are rare but serious complications of hepatic transplantation. We conducted a retrospective study of 640 liver transplantations performed in our institution for a variety of pathologies. After surgery, seven major arterial bleeds occurred (0.9%). Of these seven cases, there were due to hepatic artery rupture (HAr) and four to PA rupture; all confirmed at either surgery (six cases) or autopsy (one case). Five of the seven patients died. In all cases the transplantation was difficult. All vascular injuries but one were caused by sepsis and occurred either after an undetermined cause septicemic syndrome (five cases) or graft dysfunction (one case). The last vascular injury was biliary drainage related. Six of the seven patients had imaging studies. Sonography (five cases) found a sub-hepatic hypoechoic collection in three cases but failed to do so in two. Duplex doppler (three cases) failed in all three cases to demonstrate a PA. Computed tomography (three cases) showed one PA, one perihilar sub-hepatic collection and failed in one. Conventional angiography (three cases) depicted a PA in all three cases. At the present time, our practice is to perform systematic angiography in patients with undetermined cause septicemic syndrome to research a PA. And if angiography is normal, to then puncture systematically any sub-hepatic collection to determine the bacteriological nature of this collection. Correspondence to: H. Caillet     

Ethics roundtable debate: Patients and surrogates want 'everything done' – what does 'everything' mean?

Highly complex and specialized care plans sometimes overwhelm the comprehension of patients and families. Many optimistic surrogates of critically ill patients err on the side of desiring that everything be done but with a nebulous idea of what 'everything' entails. Physicians must work closely to educate surrogates as to the benefits versus the risks of treatment. Our roundtable experts ponder the question of whether providers possess the authority to interpret unilaterally the nature of requests for everything.     

Dependence of 2,3-DPG and oxygen affinity of haemoglobin on sex and pregnancy in the guinea-pig

Oxygen half-saturation of blood (P50), 2,3-diphosphoglycerate concentration (2,3-DPG) and Bohr effect were determined in male, and nonpregnant and pregnant female guinea pigs, according to a randomized block design. P50 was significantly higher in the female group (26.3 Torr plus or minus 0.22 SEM) than in the male group (24.8 Torr plus or minus 0.26 SEM) and was significantly lower in both these groups than in the pregnant group (27 Torr plus or minus 0.35 SEM). This difference in oxygen affinity was explained by differences in 2,3-DPG: 1.08 plus or minus 0.02 SEM in males, 1.24 plus or minus 0.03 in non-pregnant females and 1.34 plus or minus 0.03 mol/mol HB in pregnant females P50, 2,3-DPG and haemoglobin concentrations were significantly correlated for the ensemble of the 3 groups. There was no significant difference in Bohr effect between the 3 groups.     

Recovery and outcomes after the acute respiratory distress syndrome (ARDS) in patients and their family caregivers

Outcomes after acute respiratory distress syndrome (ARDS) are similar to those of other survivors of critical illness and largely affect the nerve, muscle, and central nervous system but also include a constellation of varied physical devastations ranging from contractures and frozen joints to tooth loss and cosmesis. Compromised quality of life is related to a spectrum of impairment of physical, social, emotional, and neurocognitive function and to a much lesser extent discrete pulmonary disability. Intensive care unit-acquired weakness (ICUAW) is ubiquitous and includes contributions from both critical illness polyneuropathy and myopathy, and recovery from these lesions may be incomplete at 5 years after ICU discharge. Cognitive impairment in ARDS survivors ranges from 70 to 100 % at hospital discharge, 46 to 80 % at 1 year, and 20 % at 5 years, and mood disorders including depression and post-traumatic stress disorder (PTSD) are also sustained and prevalent. Robust multidisciplinary and longitudinal interventions that improve these outcomes are still uncertain and data in our literature are conflicting. Studies are needed in family members of ARDS survivors to better understand long-term outcomes of the post-ICU family syndrome and to evaluate how it affects patient recovery.     

Infection-related ventilator-associated complications in ICU patients colonised with extended-spectrum β-lactamase-producing Enterobacteriaceae

Purpose

To investigate the clinical significance of infection-related ventilator-associated complications (IVAC) and their impact on carbapenem consumption in mechanically ventilated (MV) patients colonised with extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBLE).

Methods

Inception cohort study from the French prospective multicenter OUTCOMEREA database (17 ICUs, 1997–2015) including all ESBLE carriers (systematic rectal swabbing at admission then weekly and/or urinary or superficial surgical site colonisation) with MV duration?>?48 h and?≥?1 episode of IVAC after carriage documentation. All ICU-acquired infections were microbiologically documented.

Results

The 318 enrolled ESBLE carriers (median age 68 years; males 67%; medical admission 68%; imported carriage 53%) experienced a total of 576 IVAC comprising 361 episodes (63%) without documented infection, 124 (21%) related to infections other than ventilator-associated pneumonia (VAP), 73 (13%) related to non-ESBLE VAP and 18 (3%) related to ESBLE VAP. Overall, ESBLE infections accounted for only 43 episodes (7%). Carbapenem exposure within the preceding 3 days was the sole independent predictor of ESBLE infection as the causative event of IVAC, with a protective effect (adjusted odds ratio 0.2, 95% confidence interval 0.05–0.6; P?<?0.01). Carbapenems were initiated in 9% of IVAC without infection, 15% of IVAC related to non-VAP infections, 42% of IVAC related to non-ESBLE VAP, and 56% of IVAC related to ESBLE VAP (ESBLE VAP versus non-ESBLE VAP: P?=?0.43).

Conclusions

IVAC in ESBLE carriers mostly reflect noninfectious events but act as a strong driver of empirical carbapenem consumption. ESBLE infections are scarce yet hard to predict, strengthening the need for novel diagnostic approaches and carbapenem-sparing alternatives.

     

Simultaneous versus delayed hepatectomy for synchronous colorectal liver metastases: a systematic review and meta-analysis

Objective

This was a systematic review and meta-analysis to compare outcomes between patients undergoing simultaneous or delayed hepatectomy for synchronous colorectal liver metastases.

Differential effect of HIV protease inhibitors on adipogenesis: intracellular ritonavir is not sufficient to inhibit differentiation

OBJECTIVES: Lipodystrophy is a major side effect of HIV protease inhibitor (PI) antiretroviral therapy. It has been shown that protease inhibitors interfere in vitro with adipocyte differentiation. However, there is no evidence that PIs accumulate into preadipocytes and adipocytes and that intra-cellular accumulation is sufficient to alter differentiation. We assessed the effect of six different PIs on the differentiation of cells from four clonal lines. We also studied the capacity of ritonavir to accumulate both into drug-sensitive and drug-resistant cultured adipocytes. METHODS: Adipocyte differentiation of mouse 3T3-F442A, 3T3-L1 and Ob1771 cells as well as embryonic stem cells were investigated at pharmacological concentrations of indinavir, saquinavir, ritonavir, amprenavir, nelfinavir and lopinavir. We used a sensitive ELISA to determine intracellular concentration of ritonavir from 3T3-L1 and Ob1771 preadipocytes. RESULTS: Nelfinavir and lopinavir inhibited adipocyte differentiation whereas amprenavir was ineffective. Indinavir, saquinavir and ritonavir inhibited differentiation of 3T3-L1 and 3T3-F442A cells but did not alter differentiation of either Ob1771 or embryonic stem cells. We showed that ritonavir accumulated in preadipocytes and fully differentiated 3T3-L1 adipocytes as a function of its extracellular concentration. Although Ob1771 cells were resistant and 3T3-L1 cells were sensitive to ritonavir, the drug accumulated to similar levels in both cases. CONCLUSIONS: Protease inhibitors inhibit adipocyte differentiation depending on the cell model used. We showed for the first time that ritonavir accumulates into preadipocytes and adipocytes, suggesting a direct effect on intracellular targets. However, intracellular accumulation was clearly not sufficient as Ob1771 cells remained resistant to the inhibitory effect of ritonavir.