bluuebunny/crossref_metadata_2025 huggingface dataset:
Bilateral Extracorporeal Circulation (“Drew Technique”) for Coronary Artery Bypass Surgery using Patient’s Lung as Oxygenator
Authors: Tassani P. , Pfauder M. , Richter J. A. , Meisner H.
Published: August 2023

The aim of this study was to determine: 1) whether a bilateral perfusion circuit (Drew technique) using the patient's own lung as the oxygenator is feasible for multi-vessel coronary artery bypass grafting; and 2) if the systemic inflammatory response to extracorporeal circulation differs compared to conventional cardiopulmonary bypass procedures.

Twenty patients were enrolled in a randomized, controlled study. In the Drew group (n=10) bilateral perfusion was used. The other patients (n= 1 0) were operated on with conventional perfusion techniques and served as the control group. Pro- (interleukin-6) and anti-inflammatory (interleukin-10) mediators were measured before operation, during rewarming, 30 min, 2, 4, and 24 hours after extracorporeal circulation.

The results show that: 1) multi-vessel coronary artery bypass grafting could be performed during 90 ± 8 min of bilateral cardiopulmonary bypass; 2) the concentration of the interleukin-6 was significantly lower in the Drew group at 2 hours (449 ± 82 versus 914 ± 152 pg/ml, p = 0.02), and 24 hours (146 ± 38 versus 424 ± 98 pg/ml, p = 0.02), after cardiopulmonary bypass.

The Drew technique seems to be a promising method of extracorporeal circulation which: 1) can safely be used during routine coronary bypass grafting procedures; and 2) significantly reduces the systemic inflammatory response as compared to conventional extracorporeal circulation.
Systemic Inflammatory Response Syndrome (SIRS) Following Emergency Cardiopulmonary Bypass: A Case Report and Literature Review
Authors: Sistino Joseph J. , Acsell Jeffrey R.
Published: August 2023

A complication of emergency resuscitation is the development of the Systemic Inflammatory Response Syndrome (SIRS). In the past, this has been identified as multiple organ failure, with symptoms similar to sepsis. The hallmark of this syndrome is peripheral vasodilation, which is associated with a breakdown of capillary membranes and the accumulation of excess interstitial fluid.

This case report discusses the development of SIRS in a patient following emergency cardiopulmonary bypass (CPB). The patient was a 53 year old male with significant left main coronary artery disease who developed sudden bradycardia and hypotension in the operating room and was emergently placed on cardiopulmonary bypass. During CPB, the patient was peripherally vasodilated, and required continuous alpha-adrenergic support to maintain normal systemic vascular resistance. In addition, metabolic acidosis was present despite high flow rates, high hematocrit, addition of colloids, and hemoconcentration. Despite excellent neurological and myocardial recovery following surgery, the patient died one week later in renal and hepatic failure.

Several mechanisms for the development of this syndrome have been hypothesized. One of these theories is that the ischemic injury in the gastrointestinal tract disturbs the gut barrier function and allows enteric bacterial endotoxins to pass into the circulation producing sepsislike symptoms. Other theories relate to the release patterns of cytokines associated with CPB. These mechanisms and the treatment of SIRS with new pharmacological agents and perfusion techniques are reviewed.
In vivo Evaluation of a Phosphorylcholine Coated Cardiopulmonary Bypass Circuit
Authors: De Somer F. , Van Belleghem Y. , Foubert L. , François K. , Dubrulle F. , De Wolf D. , Van Nooten G.
Published: August 2023

A complete phosphorylcholine coated cardiopulmonary bypass circuit, including the Dideco D901 oxygenator, was tested for gas transfer, blood path resistance, and biocompatibility in a standardized setting. Blood compatibility was tested by measuring complement and platelet activation.

Three dogs (mean body weight 28 ± 3 kg) were placed on cardiopulmonary bypass at a flow rate of 600 mL/min during 6 hours. The animals were weaned from cardiopulmonary bypass and sacrificed electively after 7 days.

Oxygen and carbon dioxide transfer were 26.6 ± 2.4 mL/min and 33.0 ± 1.9 mL/min, respectively. Mean pressure drop across the oxygenator was 52.6 ± 0.2 mmHg. The respective baseline values for thromboxane B2, prostaglandin E2 and platelet factor 4 were 1817 ± 283 pg/mL, 12783 ± 2109 pg/mL, and 0.35 ± 0.08 IU/mL. Thromboxane B2 and prostaglandin E2 increased slightly to 2881 ± 868 pg/mL and 18083 ± 3144 pg/mL at 30 minutes of bypass, whereas platelet factor 4 values remained stable curing the procedure. Concentrations of complement split products C5a were only mildly increased.

After use scanning electron microscopy was performed on the inner housing, heat exchanger, and outer surface of the hollow fibers. No thrombi nor organized cellular deposits were found on any of the components. Phosphorylcholine coating of CPB seems to be very promising regarding platelet activation and complement activation.
High Dose Thrombin Time versus the Activated Clotting Time during Cardiopulmonary Bypass
Authors: de Jong M.A.
Published: August 2023

In this study we compared the High Dose Thrombin Time (HiTT) with the Activated Clotting Time (ACT) during cardiopulmonary bypass (CPB) in non-aprotinin treated patients. On the advice of the HiTT test manufacturer each institution should perform comparative ACT/HiTT assays in the cardiac surgery population. In previous tests our target ACT value of 480 seconds corresponds with a mean HiTT value of 190 seconds.

Our results showed that after heparinization (300–400 IU/kg body weight) 8 out of 20 patients did not reach the target ACT of 480 seconds, while the HiTT results in those 8 patients were higher than our target time of 190 seconds. Four heparin pretreated patients who received 400 IU/kg heparin, had relatively low ACT values (467 ± 14 sec.) and high HiTT values (324 ± 47 sec.). Before and during CPB there was a poor correlation between the HiTT and ACT (r = 0.38).

The results of this study show that for the individual patient the target HiTT of 190 seconds is no guarantee for reaching an adequate ACT of 480 seconds. Although the HiTT may be a very useful assay for monitoring heparin effects during CPB, the determination of the target time can be a point of discussion. In contrast of the advice of the manufacturer we therefore suggest that comparative ACT/HiTT assay should be done in every individual patient to determine a safe target HiTT time, instead of the whole group of patients.
Staffing Issues at Open-Heart Centers Offering both Pediatric and Adult Perfusion Service: 1998 Survey Results
Authors: Scott Lawson D. , Darling Edward M. , Collins Kevin , Smigla Gregory R. , Shearer Ian R.
Published: August 2023

A survey directed to centers offering both pediatric and adult perfusion services was conducted to determine how pediatric cases were distributed among individual perfusionists in their departments. These centers were also asked what they believed the clinical activity level should be for a perfusionist each year to remain proficient in pediatric cardiopulmonary bypass. The questions were asked via e-mail and then followed up with telephone interviews as necessary.

Out of the 100 centers contacted, 45 responded to the survey (43 North American, 2 European). Of the forty-five centers, forty-one provided both pediatric and adult perfusion services. Thirty-two centers (78%) offering adult as well as pediatric perfusion services distributed the pediatric caseload to a select group of perfusionists. Nine centers (22%) distributed the pediatric open-heart caseload to the entire staff. From the respondents, the average minimum number of pediatric cases believed necessary to remain proficient in pediatric perfusion was 42.8 cases annually. Centers having dedicated pediatric perfusionists had a slightly higher annual caseload than did those at non-specialized centers, despite practicing at institutions averaging fewer pediatric open-heart cases annually.
Avoiding Hyperoxemia at the Start of Cardiopulmonary Bypass While Optimizing Gas Flow and Temperature
Authors: Myers Gerard J. , Légaré Jean-François
Published: August 2023

There seems to be a wide range of practice in relation to the optimum oxygen setting before, and at the start of, cardiopulmonary bypass. Even manufacturers of blood oxygenators vary in their suggestions for this phase of extracorporeal circulation. Most of these suggestions are based on peak performance, Association for the Advancement of Medical Instrumentation (AAMI) standards, experience, and legal considerations. Therefore, suggested gas:blood flow ratios will vary from no gas flow at the start of bypass, to a ratio setting of 1:1. On the other hand, suggested inspired oxygen concentrations will generally vary between 0.80 to 1.0 at the start of cardiopulmonary bypass. In regard to perfusate temperatures before going on bypass, there are no clearly defined standards other than those of clinical preference. The manufacturer of the oxygenator used in this study clearly states in the operating instructions that gas flow should be proportional to blood flow at the start of bypass, and gas flow should be turned off when there is no fluid flow through the oxygenator.

The presence of hyperoxic perfusates and wide patient/perfusate temperature gradients at the start of bypass has been suspected in the appearance of gaseous microemboli during this critical period. Hyperoxemia during the bypass period is also implicated in the introduction of oxygen free radicals and nitric oxide into the hypoxic myocardium during cardioplegia delivery.

Presented here are the results of a randomized clinical study involving 39 adult patients undergoing cardiopulmonary bypass for the surgical treatment of coronary artery disease. All patients were randomly selected into five groupings. The first group had 1 L of gas flow through the perfusate before bypass, and bypass was then started with an FIO2 of 0.80. The second two groups had no gas flow through the perfusate prior to bypass and a starting FIO2 of 0.21. Groups 4 and 5 had 1 L of gas flowing through the perfusate and a starting FIO2 of 0.21.

Results indicate that gas flow through Normosol R/Albumin perfusates will prevent the acidosis that is found in this solution when the system is previously flushed with carbon dioxide. Also, suggested high FIO2 settings will produce hyperoxic perfusates at the start of cardiopulmonary bypass. However, the use of an FIO2 of 0.21 at the start of bypass will produce normoxemic conditions that are both safe and reliable for the conduct of initiating cardiopulmonary bypass.
Effects on C3 and CH50 Levels During and Following Extracorporeal Whole Body Hyperthermia
Authors: Shecterle L.M. , Wetherall N. , St. Cyr J.A.
Published: August 2023

Cardiopulmonary bypass can affect inflammatory reactions and evoke the “postperfusion syndrome,” manifested as multiple organ dysfunction in the recovery period. This syndrome is generated by the activation of complement, macrophages, neutrophils, and inflammatory cytokines. Following the use of hypothermia during cardiac procedures, active hyperthermic rewarming is used to reestablish body temperature. Complement levels and their interactions have been investigated during and following hypothermia. Hyperthermia is being used clinically; however, the effect of markedly elevated temperatures on complement is unknown and, therefore, needs to be investigated.

A pilot canine study was designed to begin to explore what role hyperthermia may play on complement levels during and following extracorporeal whole body hyperthermia. Five dogs were heated to a core temperature of approximately 42°C, held at this elevated temperature for 90 minutes, then cooled to normothermia. A decline in C3 levels at the end of warming with further declines through day 4 post treatment was observed. CH50 levels mimicked the C3 level decline; however, there was a trend for rebounding by day 4. The findings involving complement factors following hyperthermia signify that this increase in temperature causes a decrease in both C3 and CH50 levels.
Hematological Effects of a Low-Prime Neonatal Cardiopulmonary Bypass Circuit Utilizing Vacuum-Assisted Venous Return in the Porcine Model
Authors: Ahlberg Kevin , Sistino Joseph J. , Nemoto Shintaro
Published: August 2023

Limiting hemodilution in neonates is difficult when extracorporeal circuits require priming volumes that are 2 to 3 times the blood volume of the newborn patient. This extreme hemodilution contributes to the development of significant postbypass coagulation disturbances. The purpose of this project was to design a low-prime neonatal bypass circuit and evaluate the coagulation status after reduced hemodilution. The null hypothesis stated there is no significant difference in the measured coagulation parameters between the low-prime circuit and the standard high-prime circuit.

Four neonatal piglets (2–4 kg) were divided into two groups and placed on cardiopulmonary bypass using either a low- (200 ml) or high-prime (500 ml) circuit. Both groups were cooled to 20°C, and, following cardioplegic arrest, underwent circulatory arrest for 20 minutes. The low-prime circuit used vacuum-assisted venous drainage, which permitted the circuit to be at the patient level. The high-prime circuit required fresh washed donor red blood cells to maintain the hematocrit in the desired range of 15–20%.

The platelet count on bypass decreased by 60 ± 1.0% in the low-prime group versus 79.6 ± 0.1% in the high-prime group. Following bypass, the platelet count was reduced by 38.3 ± 14.3% in the low-prime versus 60.2 ± 2.6% in the high-prime group. During rewarming, the mean heparinase activated clotting time (ACT) increased 5.1% above baseline in the lowprime group and 53.5% above baseline in the high-prime group. Mean plasma-free hemoglobin levels increased 40.4 mg/dl in the low-prime group versus 62.1 mg/dl in the high-prime group during bypass. This laboratory evaluation of a low-prime neonatal circuit demonstrates that coagulation disturbances often present in neonates can be reduced with the use of a low-prime circuit.
Systemic Inflammation Induced by Cardiopulmonary Bypass: A Review of Pathogenesis and Treatment
Authors: Nieman Gary , Searles Bruce , Carney David , McCann Ulysee , Schiller Henry , Lutz Charles , Finck Christine , Gatto Louis A. , Hodell Michael , Picone Anthony
Published: August 2023

The acute respiratory distress syndrome (ARDS) is a severe alteration in lung structure and function that develops secondary to a traumatic stimulus. When ARDS develops following cardiopulmonary bypass (CPB) it is know as postpump syndrome (PPS). ARDS can be caused by a single massive insult (“hit”); however, sequential minor insults (“hits”) are more common clinically. The concept of multiple sequential insults causing ARDS has been termed the “two-hit” model of ARDS. The purpose of this article is to summarize our studies testing the hypothesis that PPS is caused by multiple sequential insults. To confirm our hypothesis, we developed a porcine model of “two-hit” PPS. Our model was composed of sequential benign insults, with CPB as the “first hit” and low dose of endotoxin as the “second-hit.” It is our hypothesis that the mechanism of PPS is CPB-induced priming of polymorphonuclear leukocytes (PMNs) (“first-hit”) with subsequent PMN activation by a second insult (“second-hit”) such as endotoxin. Our model confirms this clinically relevant postulate, and we provide strategies to disrupt the inflammatory cascade leading to PPS.
The Use of Human Antithrombin III Concentrate for Treatment of Heparin Resistance During Cardiopulmonary Bypass
Authors: Brown Michael E. , Gallagher John M. , Armitage John M.
Published: August 2023

We report the administration of biologic antithrombin III (AT III) concentrate for the treatment of heparin resistance in 44 patients undergoing cardiopulmonary bypass (CPB). During CPB, the amount of heparin required to maintain an activated clotting time greater than 480 sec was significantly reduced following the administration of AT III concentrate (p = .000). The average increase in the ACT was 176 sec following the administration of AT III concentrate (p = .000). Thirteen of 44 patients did not require any additional heparin for the duration of CPB after AT III therapy. AT III concentrate seemed to be efficacious in the treatment of heparin resistance attributable to presumed AT III deficiency. Moreover, the reduction in heparin requirements following administration of AT III concentrate may reduce postoperative bleeding associated with heparin rebound, protamine requirements, and its associated complications and threat of intravascular coagulation during CPB.
Modified Ultrafiltration After Congenital Heart Surgery: A Veno–Venous Method Using a Dual-Lumen Hemodialysis Catheter
Authors: LaLone Brian J. , Turrentine Mark W. , Bando Ko , Frederick Chris C. , Horner Michael T. , Richmond Lon H. , Bezruczko Alex P. , Morris Susan M. , Frankenberg Deborah L. , Brown John W.
Published: August 2023

Perfusion practice surveys on modified ultrafiltration show most clinicians reporting the use of arterial to venous cannulation. With an arterial–venous (A–V) approach, the patient’s blood is accessed in a retrograde direction from the cardiopulmonary bypass aortic cannula, and the hemoconcentrated blood is returned to a catheter placed at a systemic venous return site. To avoid possible hazards of these arterial–venous techniques, we developed a veno–venous (V–V) modified ultrafiltration circuit and method that: (1) uses an 11.5 F dual-lumen hemodialysis catheter placed at a right atrial cannulation site for concomitant pickup and return of the patient’s blood; (2) places the ultrafiltration circuit within the cardioplegia delivery system, enabling the use of the heat exchanger/bubble trap features and also allowing hemoconcentration during cardiopulmonary bypass; and (3) uses an elevated, collapsible transfusion bag within the circuit as a holding reservoir for crystalloid-chased blood from the CPB circuit.

The product literature and our lab testing of the hemodialysis catheter indicates adequate hemodynamics for modified ultrafiltration in children, and our clinical experience shows routine completion of the process in about 10–15 min (12.67 ± 1.73 mins; mean ± 1 SD, N = 9). Advantages of this V–V approach compared to A–V access include: (1) no potential aortic air entrainment at the aortic cannula purse-string suture; (2) modified ultrafiltration in patients regardless of aortic size or anatomy; and (3) avoidance of significant arterial to venous shunts during the performance of modified ultrafiltration. The elevated reservoir within the modified ultrafiltration circuit allows: (1) efficient pre- and/or postultrafiltration fluid chasing of blood from the main cardiopulmonary bypass circuit, thereby keeping it safely primed and allowing for the concentration of all circuit contents before and/or following the ultrafiltration method; (2) maintenance of desired patient filling pressures, temperature, and blood oxygen saturation within the ultrafiltration circuit by intermittent addition of warmed, oxygenated blood to the V–V modified ultrafiltration circuit.
The Use of r-Hirudin During Cardiopulmonary Bypass in a Patient with Heparin Induced Thrombocytopenia
Authors: Webb David P. , Vinas Michael S. , Drinkwater Davis C. , Merrill Walter H.
Published: August 2023

Heparin-induced thrombocytopenia and its related complications can be life-threatening in patients undergoing cardiopulmonary bypass (CPB) with heparin exposure. While the literature illustrates many different techniques which might be employed in this situation, most are used infrequently. This case report provides an overview of the successful use of r-Hirudin, and associated monitoring techniques, in a high-risk patient undergoing cardiac surgery utilizing CPB.
Use of a Low-Prime Circuit for Bloodless Heart Transplantation in Xenotransplant of 5—7 Kilogram Primates
Authors: Gomez Daniel , Olshove Vincent F. , Weinstein Samuel , Davis J. Terrance , Michler Robert E.
Published: August 2023

There is a great effort to decrease blood product use during open-heart surgery in pediatrics. We were presented with a research challenge to accomplish heart xenotransplantation from donor cynomologous monkey (Macaca fascicularis) to recipient olive baboon (Papio anubis) of 5–7 kilograms without benefit of donor or banked blood products. The purpose of this study was to design and implement a practical, low-volume circuit to minimize hemodilution and avoid the use of blood products.

A simple circuit was assembled using a low-volume oxygenator with hardshell venous reservoir, an 1/8-inch arterial line, an 1/4-inch venous line, and gravity drainage. Three xenotransplants were performed and evaluated. The mean recipient weights were 6.3 ± 0.7 kg. Circuit prime volume was 228 ± 5.8 mL, and bypass time was 85 ± 6.7 min. Blood flow rates were 585 ± 113 mL/min with postmembrane arterial line pressures of 344 ± 81 mmHg, and patient mean arterial pressures (MAP) of 51.4 ± 16.7 mmHg. Venous saturations were 63.7 ± 8.0%. The hematocrit prebypass was 37.4 ± 3.2, bypass 20.7 ± 0.9, post-MUF 27.8 ± 3.3, and 7 days postoperative 24.5 ± 7.5%. Platelet count was 289 ± 1.1 K/µL, 147 ± 37.1 K/µL, and 322 ± 292.7 K/µL prebypass, postbypass, and 7 days postoperative, respectively. Plasma-free hemoglobin prebypass was 7.5 ± 4.4 mg/dL and postbypass 22.2 ± 16.5 mg/dL with no noted hematuria during and after the procedure. All patients survived and were successfully weaned from cardiopulmonary bypass (CPB) with same day extubation.

A low-prime circuit for bloodless heart surgery is possible. To achieve low reservoir levels, especially without the use of an arterial line filter (ALF), it is necessary to have a full armament of monitoring and alarm devices.
Clinical Experience of a Vacuum-Assisted Nonroller Extra-Corporeal Circulation System
Authors: Hiroura M. , Furusawa T. , Amino M. , Moriya T. , Goto H. , Fukaya Y. , Amano J.
Published: August 2023

We designed a nonroller extra-corporeal circulation system (NRECC) to minimize space requirements and to improve the safety and ease of cardiopulmonary bypass. The NRECC includes a circuit, a centrifugal pump, and a vacuum regulator. The vacuum regulator has five channels, each of which can control negative pressure independently. Negative pressure is applied to suctions, a vent, and a venous reservoir. Auto Vent-SV and one-way valves were placed between the suctions/vent and the reservoir. The total space required for the NRECC with a heat exchanger was 0.49 m2, which is much smaller than that of our current roller pump system.

The maximum volume through the suction/vent was 2.5 L/min at −100 mmHg measured in a simulated system. We used the NRECC for six CABG cases and compared results with those of five CABG cases managed by traditional roller pump extra-corporeal circulation (RECC). The two systems were compared in terms of set-up time and stability/accuracy of the suction/vent. The set-up time of the NRECC (5.3 ± 1.9 min) was significantly shorter than that of RECC (29 ± 3.4 min) (p < .01). Stable and accurate blood flow were achieved with the NRECC operating between −15 mmHg and −25 mmHg. In conclusion, NRECC can run a bypass easily and safely and has the benefit of reducing space requirements and shortening set-up time.
A Dynamic Bubble Trap Reduces Microbubbles During Cardiopulmonary Bypass: A Case Study
Authors: Scho¨nburg Markus , Urbanek Petr , Erhardt Gunther , Taborski Uwe , Plechinger Hans , Hein Stefan , Roth Michael , Klo¨vekorn Wolf-Peter
Published: August 2023

Microemboli passing to the cerebral circulation during cardiopulmonary bypass can contribute to postoperative neurologic dysfunction. Many studies conclude that air microbubbles predominantly are responsible for this problem. A dynamic bubble trap (DBT) was developed to diminish the number of microbubbles in the arterial line of extracorporeal circulation. The DBT is able to substantially reduce the number of air microbubbles, as shown in two patients undergoing coronary artery bypass grafting, where a high number of microbubbles was assessed. Although a 40-µm arterial filter was used, many bubbles larger than 40 µm occurred in the arterial line. The DBT reduced the number of large microbubbles from 2,267 to 67 in patient 1 and from 897 to 61 in patient 2.
Centrifugal Pump and Reduction of Neurological Risk in Adult Cardiac Surgery
Authors: Alamanni Francesco , Parolari Alessandro , Zanobini Marco , Porqueddu Massimo , Dainese Luca , Bertera Antonella , Costa Cristina , Fusari Melissa , Spirito Rita , Biglioli Paolo
Published: August 2023

This study was performed to assess if the kind of pump used for CPB (roller vs. centrifugal) can influence neurological outcomes of adult cardiac surgery patients. Between 1994 and 1998, 3438 patients underwent coronary and/or valve surgery at our hospital; of these, 1805 (52.5%) underwent surgery with the use of a centrifugal pump, and 1633 (47.5%) were operated with a roller pump. The effect of the type of the pump and of common preoperative and intraoperative risk factors for five different neurological outcomes (permanent neurological deficit, coma, delirium, transient neurological deficit, overall neurological complications) were assessed with univariate and multivariate analyses in the whole patients population, in patients ≥ 75 years old and in patients with histories of previous neurological events. Centrifugal pump use was the only protective factor for perioperative permanent neurological deficit in multivariable models developed for the whole patient population and for patients ≥ 75 years old. In addition, it resulted as the only protective factor for perioperative coma occurrence in multivariable models developed for patients ≥ 75 years old, and for patients with histories of previous neurological events. The use of the centrifugal pump provided a risk reduction for the considered events ranging from 23 to 84%. Centrifugal pump use can be helpful in reducing the occurrence of some of the most feared neurological complications of adult cardiac surgery patients.
Use of Ecarin Clotting Time (ECT) with Lepirudin Therapy in Heparin-Induced Thrombocytopenia and Cardiopulmonary Bypass
Authors: Fabrizio M. Charlene
Published: August 2023

Heparin-induced thrombocytopenia (HIT) is described as an allergy-like adverse reaction to heparin. It is a potentially severe complication of heparin therapy that can result in serious or life–threatening venous or arterial thromboembolic events. In the United States, lepirudin (Aventis Pharma AG, Strasbourg, France) is an approved therapy for anticoagulation in patients with HIT requiring anticoagulation. Lepirudin is a recombinant form of hirudin, a leech enzyme that is a highly specific direct inhibitor of thrombin. Lepirudin monitoring during surgery can be managed with ecarin clotting time (ECT) (Cardiovascular Diagnostics, Inc., Raleigh, NC), which has recently been approved as a humanitarian device exemption (HDE) for use in the United States in the management of HIT with cardiopulmonary bypass. This case report describes a patient with HIT who was managed successfully with lepirudin and ECT during coronary artery bypass grafting.
Effect of Partial-Filling Autotransfusion Bowls on the Quality of Reinfused Product
Authors: Tremain Kimberly D. , Stammers Alfred H. , Niimi Kevin S. , Glogowski Kimberly R. , Muhle Michelle L. , Trowbridge Cody C. , Yang Tianyu
Published: August 2023

Intraoperative autotransfusion is used in a variety of surgical procedures with the quantity of blood loss dependent upon numerous factors. These procedures may or may not produce a full autotransfusion bowl. The inadequate removal of contaminants has been correlated to the incomplete filling of bowls, resulting in a condition called “Salvaged Blood Syndrome.” The purpose of this study was to assess the quality of aspirated whole blood after processing with an autotransfusion system using various fill volumes and two wash volumes. An in vitro circuit was designed to mimic the mechanical effects of extracorporeal flow on blood. Twenty-four Baylor-style bowls were filled at 400 mL min−1 and washed at 300 mL min−1. Two wash volumes, 1000 and 2000 mL, and three bowl volumes; low, mid, and full, were used in this study. The bowl volumes were determined by using red cell quantities of 60, 100, and 135 mL for the low-fill, mid-fill, and full bowls, respectively. Samples were drawn pre-autotransfusion and post-autotransfusion and analyzed for plasma-free hemoglobin, IL-8, white blood cell count, platelet count, albumin, and total protein. All data were analyzed using one-way analysis of variance (ANOVA) with significance accepted at p ≥ .05. Plasma-free hemoglobin levels and hematocrit were concentrated significantly (p < .05) as bowl volume increased. A significant difference in IL-8 levels was found in the wash volumes in the low-fill bowls (p < .02). Platelet count was significantly decreased between the full bowl with 1000 mL wash and the full bowl with 2000 mL wash (p < .0004). Total protein reduction was significantly less in the low-fill bowl with 1000 mL wash as compared to the other bowl treatments (p < .05). In conclusion, the quality of the washed product did not vary significantly between fill or wash volumes, with the exception of the low-fill bowl with 1000 mL wash.
Balanced Ultrafiltration, Modified Ultrafiltration, and Balanced Ultrafiltration with Modified Ultrafiltration in Pediatric Cardiopulmonary Bypass
Authors: Ming Zhu De , Wei Wang , Hong Chen , Wei Zhang , Xiang Ding Wen
Published: August 2023

This study evaluates the effect of balanced ultrafiltration, modified ultrafiltration, and balanced ultrafiltration with modified ultrafiltration on inflammatory mediators in children’s open-heart surgery. Eighty children with congenital heart disease were randomly divided into four groups: control group (C group); balanced ultrafiltration group (BUF group); modified ultrafiltration group (MUF group); and balanced ultrafiltration with modified ultrafiltration group (B+M group). Clinical data of these groups were similar. Tumor necrosis factor (TNF), interleukin-8(IL-8), and E-selectin were measured at the beginning of cardiopulmonary bypass (CPB), 30 min later, at the cessation of CPB, at the cessation of MUF (MUF group and B+M group), and 2 hours postoperatively. During CPB, the concentrations of TNF, IL-8, and E-selectin increased significantly in C and MUF groups and did not change significantly in BUF and B+M groups. In the period of MUF, TNF and IL-8 increased; whereas, Eselectin did not change. The study shows that ultrafiltration can filter out the inflammatory mediators, but only BUF can decrease the concentrations of them. Moreover, MUF only can concentrate blood. Combining both techniques has both effects, but the effect of BUF was offset by MUF.
Alternative Methods for Anticoagulation Monitoring in Pediatric Patients with Applicability to a Patient with Severe Hemophilia A and Circulating Inhibitor
Authors: McNamara Jerri L. , Lombardi John P. , Ferguson Robert , Manning Peter B. , Gruppo Ralph A.
Published: August 2023

Anticoagulation monitoring in pediatric patients can be problematic because of the immaturity of the coagulation system in this population. In addition, the hemodilution required to place a small patient on bypass can interfere with standard monitoring methods. In this institution, the Hemochron Jr. ACT (activated clotting time)+ assay has been the standard of care for anticoagulation monitoring since 1997. This assay, with a target ACT of 400 s for initiating bypass, was compared to both the Medtronic HMS system (N = 7) and the Hemochron HiTT assay (N = 6) in pediatric patients. All three assays were then employed to monitor a pediatric Hemophilia A patient (Factor VIII <1%) with high inhibitor titer. Both the HiTT clotting time and the HMS heparin level showed statistically significant correlation to the ACT+ (HiTT, N = 24, r = 0.761; HMS, N = 31, r = 0.818). An HMS target heparin level of 1.5 mg/kg and a HiTT target clotting time of 180 s were found to be clinically equivalent to the 400-s ACT+ as indicators of the need for additional heparin. When a 7-year-old male with severe hemophilia A and high inhibitor titer required tricuspid valve replacement, all three assays were used to ensure appropriate anticoagulation management. During bypass, this patient’s ACT+ remained out of range (>1005 s). The HiTT was maintained at >180 s and the HMS heparin level at >1.5 mg/kg. Heparin was administered when any single parameter was below the cutoff value. The use of the combination of three distinct monitoring assays for this patient allowed the surgical team an added level of confidence that appropriate anticoagulation had been maintained.
Cor Triatriatum Sinister Associated with Total Anomalous Pulmonary
Venous Connection
Authors: Ergani Seval Yılmaz , Yılmaz Osman
Published: August 2023

Cor triatriatum sinister is rare congenital heart disease. It is defined as the
presence of an abnormal septum dividing the left atrium into two chambers, and in
some cases may be associated with a total abnormal pulmonary venous connection.
Prenatal diagnosis of cor triatriatum sinister may be possible with fetal
echocardiography and the diagnosis can be made earlier than postnatal imaging
techniques. In the fetal echocardiography performed in our patient, cor triatriatum
sinister was present and the main pathology was the flow of right and left pulmonary
vein return from the accessory atrium to the right atrium.
Maligne Neoplasien der Orbita
Authors: Bertelmann Eckart , von Sonnleithner Christoph
Published: August 2023

Weil die Erstsymptomatik maligner Neoplasien der Orbita häufig das Auge betrifft (Exophthalmus, Diplopie, Schmerzen), ist der Augenarzt häufig der erste mit der Problematik des jeweiligen
Krankheitsbildes konfrontierte Arzt, von dessen Kenntnissen, richtiger Einordnung und richtigen weiteren Entscheidungen die adäquate weitere Therapiesteuerung und die Prognose des Patienten
entscheidend abhängen.
Virale Bindehautentzündungen: Befunde, Therapie und Prophylaxe
Authors: Kowanz Dominik H. , Rokohl Alexander C. , Heindl Ludwig M.
Published: August 2023

Besonders in den Winter- und Herbstmonaten füllen sie Augenarztpraxen und Ambulanzen von Augenkliniken: Patienten mit stark geröteten, tränenden Augen, die oftmals auch zusätzliche
Allgemeinsymptome zu beklagen haben. Doch nicht jede Bindehautentzündung wird durch respiratorische Erreger mit typischer, saisonaler epidemiologischer Dynamik verursacht, bei bestimmten
Erregern manifestiert sich in erster Linie ein charakteristischer Hautbefund.
Erste pädiatrische Nutzung eines AID-Systems mit automatischem Korrekturbolus in Deutschland
Authors: von dem Berge Thekla , Biester Sarah , Remus Kerstin , Reschke Felix , Klusmeier Britta , Adolph Kerstin , Kordonouri Olga , Danne Thomas , Biester Torben
Published: August 2023

Einleitung Als Upgrade eines teilautomatischen Insulindosierungssystems (AID) ist die Weiterentwicklung einer prädiktiven Insulinabschaltung vom Hypoglykämieschutz (Basal-IQ) zu Tandem Control IQ das zweite in Deutschland für Kinder und Jugendliche zu Lasten der gesetzlichen Krankenversicherung rezeptierbare System mit automatischer Basalratenmodulation und Korrekturbolusgaben erhältlich. In dieser Studie wurden der iterative Umstieg von zunächst nur prädiktiver Abschaltung mit dem sofortigen Beginn von AID mit Insulinmodulation zur Reduktion von Hypo- und Hyperglykämie verglichen.

Methodik Kindern und Jugendlichen mit intensivierter Insulintherapie (ICT oder CSII) mit Krankenkassengenehmigung für Tandem Basal IQ wurde vor Markteinführung des neuen Systems eine Behandlung mit dem AID-System Control IQ angeboten. Teilnehmende und Eltern erhielten eine Systemschulung. Eine Gruppe nutzte zuvor kein anderes AID-System (START-Gruppe). Eine andere Gruppe, die bereits Tandem Basal IQ nutzte, wurde vor Markteinführung des neuen Systems ein Pumpenupgrade (SWITCH-Gruppe) auf das AID-System Control IQ angeboten. Es wurden die Therapiedaten und Fragebögen zum Wohlbefinden vor Beginn der neuen Therapieform und nach 3 Monaten miteinander verglichen.

Resultate Insgesamt konnten 49 Kinder und Jugendliche (mittleres Alter 12±3,4 Jahre, 38% weiblich, BMI-SDS 0,28±1,0, Diabetesdauer 4,7±4,1 Jahre) ausgewertet werden, eine Jugendliche musste aufgrund eines allergischen Kontaktekzems abbrechen. Der primäre Endpunkt Time in Range (TIR) zeigte sich nach der Intervention signifikant erhöht mit 68,8±12,0 vs. zuvor 64,1±16,2 %, p=0.003; die Zeit in der Unterzuckerung sank von 2,7±2,0 auf 1,7±1,6 % (p=0.02)

Verbesserte glykämische Parameter nach drei Monaten lagen sowohl bei START (HbA1c 7,1±1,1 vs. 6,9±0,8 %, TIR 66,6±17,5 vs. 69,8±13,9 %, TBR (54–70 mg/dl) 2,7±2,2 vs. 1,4±1,6 %, TBR (<54 mg/dl) 1,3±1,6 vs. 0,5±0,9 %) wie auch SWITCH (HbA1c 6,9±0,6 vs. 6,9±0,6 %, TIR 6,.9±14,9 vs. 67,7±10,1 %, TBR (54–70 mg/dl) 2,6±1,8 vs. 1,9±1,6 %) vor. Signifikante Verbesserungen elterlicher Hypoglykämieangst waren bei 2 bzw. 8 Items in beiden Gruppen zu finden.

Schlussfolgerung Nach Therapieumstellung auf ein AID-System konnte bei bereits guten Ausgangswerten des Kollektivs sowohl in der START- wie auch der SWITCH-Gruppe trotzdem eine Verbesserung der glykämischen Parameter erzielt werden, auch über das Gesamtkollektiv bestand eine Verbesserung. Die elterliche Hypoglykämieangst konnte signifikant reduziert werden.
Real-Time Shear Wave Elastography for Determining the Ideal Site of Liver Biopsy in Diffuse Liver Disease
Authors: Patidar Yashwant , Singh Jitender , Chatterjee Navojit , Mukund Amar , Rastogi Archana , Kumar Guresh , Sharma Manoj Kumar
Published: August 2023

Objectives The objective of the study was to identify accurate site of liver biopsy under ultrasound and elastography guidance and compare the shear wave elastography (SWE) and transient elastography (TE) diagnostic accuracy with histopathological correlation.

Methods This was a prospective single-center study where patients scheduled for nonfocal liver biopsy were divided into two groups (group U: ultrasound; group E elastography) by sequential nonrandom selection of patients. Elastography was performed before the biopsy and biopsies from the maximum stiffness segment were taken.

Results There was no significant difference of intersegmental liver stiffness with mean velocity; however, biopsy segment velocities show significant difference with mean liver stiffness suggestive of heterogenous distribution of fibrosis. The rho (r; Spearman's correlation) value between biopsy segments and mean velocities shows excellent correlation. The diagnostic performance of TE was good for fibrosis stages F2, F3, and F4, while SWE was fair for the diagnosis of fibrosis stages F1 and F2 and fairly equal for the diagnosis stages F2 and F3. Area under the curve (AUC) values in differentiating mild (F1) or no fibrosis from significant fibrosis (≥F2) were 95.5 with cutoff value of at least 1.94 m/s.

Conclusions The diagnostic performance of SWE is comparable with TE in liver fibrosis staging and monitoring. Fibrosis is heterogeneously distributed in different segments of the right lobe liver. Therefore, elastography at the time of biopsy may help in defining the accurate site for biopsy and improve histopathological yield in detecting liver fibrosis in patients with chronic liver disease.

Advances in Knowledge Elastography-guided biopsy is helpful to determine the ideal site of biopsy.
Activity of cefotaxime versus ceftriaxone against pathogens isolated from various systemic infections: A prospective, multicenter, comparative, in vitro Indian study
Authors: Gondane Ajitkumar A. , Pawar Dattatray B.
Published: August 2023

Objectives:

To determine the susceptibility of isolated pathogens with different samples collected from patients taking cefotaxime as compared with ceftriaxone.

Materials and Methods

In vitro susceptibility study was conducted at microbiology laboratories of east (Bhubaneshwar), west (Ahmedabad), north (Delhi), and south (Srikakulam) India. Samples of treatment naïve patients with various clinical infections were included if they were positive for bacterial culture. Minimum inhibitory concentration (MIC) and zone of inhibitions (ZoIs) for each isolate were determined using Ezy MIC strip test and disk diffusion methods, respectively. Findings of MIC and ZoI were interpreted as per the Clinical and Laboratory Standards Institute guidelines. Appropriate statistical tests were used.

Statistical Analysis:

Probable diagnosis, type of sample, and isolated organisms was presented as the proportion. Geometric mean was calculated for MIC and arithmetic mean was calculated for ZoI and they were presented as mean (95% confidence interval).

Results:

Four hundred clinical samples of urinary tract infection (42.75%), lower respiratory tract infection (20.75%), skin and soft tissue infection (16.75%), and sepsis (12.75%) were evaluated. Escherichia coli (47.75%) was the most common organism isolated followed by Klebsiella (26%), Salmonella (7.75%), and Proteus mirabilis (3.75%). The mean MIC values for E. coli, Klebsiella, Staphylococcus, Citrobacter koseri, and Serratia marcescens were found to be lower when treated with cefotaxime compared with ceftriaxone, although the difference was not statistically significant. However, cefotaxime produced significantly (p < 0.05) more ZoI for E. coli, Klebsiella, and Salmonella as compared with ceftriaxone.

Conclusion:

Cefotaxime has shown better sensitivity profile in terms of MIC and ZoI to most of the isolated organisms as compared with ceftriaxone and thus can be preferred for empirical treatment of such patients.
Modulbau: Den CO2-Fußabdruck senken
Authors: Lang Michael
Published: August 2023

Medizinische Gebäude aus Modulen sind besonders nachhaltig. Die einzelnen Raummodule eignen sich sowohl für eine vorübergehende als auch eine dauerhafte Nutzung, und können mehrere „Leben“ haben. Der für das Grundgerüst verwendete Baustahl lässt sich zudem beliebig oft recyceln.
Sichere Wasserver- und entsorgung: Kostbares Nass
Authors: Joel Elena , Krause Steffen , Schaum Christian
Published: August 2023

Kliniken benötigen eine sichere Wasserver- und entsorgung, um ihren Betrieb aufrechtzuerhalten. Das Verbundprojekt Nowater hat untersucht, wie sich Krankenhäuser resilient gegenüber einem Wassermangel machen können.
Prime ministerial political leadership and the domestic politics of Brexit: Theresa May and Boris Johnson compared
Authors: Brusenbauch Meislová Monika , Bujard Birgit
Published: August 2023

This article explores and compares the political leadership of two successive British Prime Ministers, Theresa May and Boris Johnson, in their handling of the domestic politics of Brexit. Despite some similar dilemmas at the beginning of their premierships, their leadership delivered very different outcomes. The key argument developed here, using Richard Heffernan’s power resources model, is that the explanation for these outcomes does not only arise from a different political context and circumstances under which each prime minister pursued their Brexit policy. Rather Johnson, unlike May, made skilful use of the power resources at his command. He possessed more personal power resources and drew upon the available institutional power resources more effectively than May. As a result, unlike May, he was able to be predominant in his government’s Brexit policy. While we demonstrate the continued analytical value of Heffernan’s model, we also point to its limitations and suggest how it can be revised.
Mental health of children with gender and sexual minority parents: a review and future directions
Authors: Mazrekaj Deni , Jin Yuxuan
Published: August 2023

This article reviews the literature between 2015 and 2022 on mental health disparities between children with gender and sexual minority parents and children with different-sex parents. Although most studies indicate that children with gender and sexual minority parents do not experience more mental health problems than children with different-sex parents, the results are mixed and depend on the underlying sample. The review highlights important shortcomings that characterize this literature, including cross-sectional survey samples, correlational methods, lack of diversity by country, and a lack of research on children with transgender and bisexual parents. Therefore, substantial caution is warranted when attempting to arrive at an overall conclusion based on the current state of the literature. Suggestions are provided that can guide academic work when studying mental health outcomes of children with gender and sexual minority parents in the future.
Practical considerations for the analysis of time-resolved x-ray data
Authors: Schmidt Marius
Published: August 2023

The field of time-resolved macromolecular crystallography has been expanding rapidly after free electron lasers for hard x rays (XFELs) became available. Techniques to collect and process data from XFELs spread to synchrotron light sources. Although time-scales and data collection modalities can differ substantially between these types of light sources, the analysis of the resulting x-ray data proceeds essentially along the same pathway. At the base of a successful time-resolved experiment is a difference electron density (DED) map that contains chemically meaningful signal. If such a difference map cannot be obtained, the experiment has failed. Here, a practical approach is presented to calculate DED maps and use them to determine structural models.
Hyaluronic acid-modified metal–organic framework for two-photon imaging-guided photodynamic therapy in triple negative breast cancer
Authors: Song Ningning , Li Bo , Li Dandan , Yan Yunwen
Published: August 2023

Zr-based metal–organic frameworks (MOFs) using thiazolothiazole as an organic ligand exhibit excellent two-photon excited fluorescence performance, particularly in the generation of reactive oxygen species. In this study, a ZrTc nanoMOF was designed and modified with hyaluronic acid (HA) to provide good biocompatibility and cancer cell-specific targeting. In triple negative breast cancer (TNBC), the optimized composite ZrTc@HA exhibited considerable two-photon activity and excellent light-triggered O2·− generation ability at an excitation wavelength of 780 nm. ZrTc@HA can be used as a diagnostic probe for fluorescence imaging and as a therapeutic agent for photodynamic therapy (PDT) with no remarkable toxicity in vitro or in a subcutaneous tumor model in vivo. In summary, we developed a promising two-photon-activated ZrTc@HA for PDT in TNBC, with immense potential for advancements in monotherapy and synergistic phototherapy.