Pulmonary embolism and myocardial hypoxia during extracorporeal membrane oxygenation

The treatment of a newborn with severe meconium aspiration by venoarterial extracorporeal membrane oxygenation (ECMO) was complicated by myocardial hypoxia with a marked decrease of myocardial contractility. The onset of the cardiac hypoxia was related to a pulmonary artery embolus. The origin of the embolus was a deep femoral vein thrombosis, caused by a central vein catheter, which was inserted 1 day before ECMO by venous cutdown. The possible pathophysiology of myocardial hypoxia in this patient is discussed, especially with regard to myocardial perfusion, supporting the hypothesis of coronary perfusion occuring with blood from the left ventricle and not from the arterial cannula in the aorta.     

A prospective comparison of immune reconstitution in pediatric recipients of positively selected CD34+ peripheral blood stem cells from unrelated donors vs recipients of unmanipulated bone marrow from related donors

Positively selected CD34(+) hematopoietic stem cells from unrelated donors (UD-HSCT) have been successfully transplanted, but little is known about immune reconstitution in this setting. Here we report a prospective comparison of immune reconstitution in recipients of UD-HSCT and of unmanipulated bone marrow from matched sibling donors (MSD-BMT). T-cell reconstitution occurred more than 100 days later in the UD-HSCT than in the MSD-BMT group. The first T cells after UD-HSCT were almost exclusively CD45RO(+) HLA-DR(+), whereas early-emerging T cells after MSD-BMT more frequently expressed CD62L, CD28, and CD25. In both groups, numbers of CD45RA(+) naive T cells increased after 180 days. After UD-HSCT, the T-cell-receptor (TCR)-repertoire was severely skewed and showed significantly reduced diversity during the first year, but only minor abnormalities were seen after MSD-BMT. TCR-diversity increased simultaneously with the number of naive T cells. In both groups, we observed transient expansions of gammadelta T cells. B cells were reconstituted more rapidly in UD-HSCT than in MSD-BMT recipients, whereas the rapidity of NK-cell reconstitution was similar in the two groups. In summary, T-cell reconstitution was slower after UD-HSCT than after MSD-BMT because of the delayed recovery of early memory-type T cells with reduced TCR-diversity, whereas naive T-, NK-, and B cells were reconstituted similarly in the two groups.     

Distinct contributions of CD4(+) and CD8(+) naive and memory T-cell subsets to overall T-cell-receptor repertoire complexity following transplantation of T-cell-depleted CD34-selected hematopoietic progenitor cells from unrelated donors

Normalization of restricted T-cell-receptor (TCR) repertoire is critical following T-cell-depleted (TCD) stem cell transplantation. We present a prospective study analyzing respective contributions of naive and memory T-cell subsets within the CD4(+) and CD8(+) compartments to the evolution of overall TCR-repertoire complexity following transplantation of CD34-selected peripheral blood progenitor cells from unrelated donors. During the first year after transplantation, sorted CD4/45RA, CD4/45R0, CD8/45RA, and CD8/45R0 subsets were analyzed at 3-month intervals for TCR-repertoire complexity by CDR3 size spectratyping. Skew in TCR-repertoire was observed only in early memory-type T cells. CD4(+) and CD8(+) subsets differed in clonal distribution of CDR3 sizes, with rapid Gaussian normalization of bands in CD4/45R0(+) T cells. Naive T cells displayed normal repertoire complexity and contributed significantly to skew correction. Our data provide direct evidence for an important role of de novo maturation of naive T cells in normalization of an initially restricted TCR-repertoire following transplantation of CD34-selected, TCD-depleted peripheral blood progenitors from unrelated donors.     

Veränderungen des Säure-Basenhaushaltes und Elektrolytverschiebungen bei tiefer Magenunterkühlung und morphologische Veränderungen an den Abdominalorganen

Ohne ZusammenfassungMit 5 AbbildungenVortragender:R. Zwirner-Freiburg i. Brsg.     

Are rates of psychiatric disorders in the homeless population changing?

OBJECTIVES: We examined the prevalence of psychiatric illness among 3 homeless populations in St. Louis, Mo, in approximately 1980, 1990, and 2000. The 3 studies were conducted with the same systemic research methodology. METHODS: We compared selected demographics and lifetime substance abuse and dependence and other mental illness among the 3 populations. RESULTS: Among the homeless populations we studied, the prevalence of mood and substance use disorders dramatically increased, and the number of minorities within these populations has increased. CONCLUSIONS: The prevalence of psychiatric illness, including substance abuse and dependence, is not static in the homeless population. Service systems need to be aware of potential prevalence changes and the impact of these changes on service needs.     

The Homeless Supplement to the Diagnostic Interview Schedule: test-retest analyses

This study sought to extend previous work on reliability of self-reported residential history in a homeless population with high rates of drug abuse. The latest version of the Homeless Supplement to the Diagnostic Interview Schedule (DIS/HS) was used to achieve reliability on homelessness experience, use of shelters, transience, and recent residential patterns. Homeless study volunteers were recruited for a test-retest study from a drop-in day centre for mentally ill homeless people (N = 25) and a substance abuse day programme (N = 30). They were administered the instrument approximately one to two days apart. Kappa and intraclass correlation analyses were performed to assess reliability. Overall, the reliabilities of most variables were acceptable, ranging from fair to excellent. Six items were reconstructed to achieve reliability and two were dropped. Substance dependence and adult antisocial behaviour patterns did not affect reliability on most items. This study has developed a reliable self report instrument for measuring residential history that can be used with homeless and drug abusing populations. Replication is needed in larger, more representative samples and comparison of reliability with other psychiatric and cognitive characteristics.     

Modeling service access in a homeless population

Previous research has shown use of greater amounts and more types of services to be robustly associated with positive outcomes. However, research has neither adequately explored nor conceptualized the complex interactions among demographics, homelessness, mental illness, and service use. Subjects (N=396) were systematically sampled. Service use was divided into four sectors: homeless amelioration, homeless maintenance, mental health, and chemical dependency services. Three nested conceptual models were analyzed using logistic regressions predicting service use for each service sector (30 day and lifetime): (1) need factors, (2) need factors, comorbidity, and demographics; and (3) all of the above plus other sector service use. Improvements in predictive ability were tested for each pair of nested equations. A fourth set of analyses including all variables used in any analysis was tested for further improvement. In most analyses, the third conceptual model demonstrated significant advantage over simpler models. Models including all variables did not add significant improvement. Mental health and addiction service use were relatively strongly predicted by diagnosis. Despite limitations, the study has implications for service use: (a) services should facilitate individual level cross-sector use; (b) homelessness sectors require attending to need factors; (c) service providers should be aware of barriers unintentionally imposed by service restrictions.