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Background In patients with a body mass index ( BMI) > 35 kg/m2, or in extreme cases weighting > 250 kg, we are faced with special challenges in therapy and logistics. The aim was to analyze the feasibility of the extracorporeal membrane oxygenation ( ECMO) in these patients. Methods We report 12 adult patients [10 male, 2 female; mean age 56.7 (34-74) years; mean BMI 47.9 (35-88.6) kg/m2] with acute lung failure treated with veno-venous ECMO from 1 January 2009 to 30 June 2013. All patients were cannulated percutaneously into the right internal jugular vein and one of the femoral veins at the bedside. Results The mean time to ECMO after admission to the intensive care unit ( ICU) was 2 days (0-10), and the mean ECMO run time was 9 days (4 h-20 days). Lung failure occurred in the contexts of wound infection (two patients), anaphylactic shock (one patient), major trauma (one patients) and pneumonia after surgery (four patients), and respiratory failure in abdominal sepsis (four patients). The mean time in the ICU was 31 days (0-89), and the mean time at the hospital was 38 days (0-101). Three patients died on the system because of multiorgan failure; nine patients were weaned from ECMO (75%); and six were patients discharged from the ICU and from the hospital (survival rate 50%). Conclusions ECMO in obese patients is feasible and life saving. Therefore, a percutaneous cannulation remains feasible. The goals of the ECMO therapy include early spontaneous breathing, tracheotomy, rapid reduction of sedation and adequate analgesia. Rehabilitation includes nutritional therapy, as well as psychiatric therapy and bariatric surgery, as perspectives for the future. [ABSTRACT FROM AUTHOR]

Acute lung injury ( ALI) and acute respiratory distress syndrome ( ARDS) are life-threatening complications in trauma patients. Despite the implantation of a veno-venous extracorporeal membrane oxygenation (vv ECMO), sufficient oxygenation (arterial SaO2 > 90%) is not always achieved. The additive use of high-frequency oscillation ventilation ( HFOV) and ECMO in the critical phase after trauma could prevent the occurrence of life-threatening hypoxaemia and multi-organ failure. We report on a 26-year-old female ( Injury Severity Score 29) who had multiple injuries as follows: an unstable pelvic fracture, a blunt abdominal trauma, a blunt trauma of the left thigh, and a thoracic injury. Three days after admission, the patient developed fulminant ARDS (Murray lung injury score of 11 and Horovitz- Index <80 mmHg), and vv ECMO therapy was initiated. The Horovitz- Index was <80 mm Hg, and the lung compliance was minimal. With HFOV, almost complete recruitment of the lung was achieved, and the fraction of inspired oxygen ( FiO2) was significantly reduced. The pelvic fracture was treated non-operatively. The HFOV was terminated after 3 days, and the ECMO was stopped after 19 days. [ABSTRACT FROM AUTHOR]

Objectives: Outcomes in patients with iliofemoral and concomitant iliofemoral-remote arteriopathies who cannot undergo transfemoral or other alternative transvascular approaches have not been studied so far. This study aimed to evaluate the early and midterm outcomes after transapical (TA)-transcatheter aortic valve implantation (TAVI) in patients with femoral and femoral-remote arteriopathies who cannot undergo transvascular approaches., Methods: Multimorbid patients with severe aortic stenosis and distinct panarteriopathy underwent TA-TAVI treatment between January 2012 and January 2021 at the authors' institution. Second- and third-generation self- and balloon-expanding valves were used. For patients without arterial access, TA-TAVI was modified to the artery-no-touch technique., Results: Seventy-two consecutive elderly patients (78.2 ± 6.9 years; 73% male) were included in the study. The Society of Thoracic Surgery-Predicted Risk of Mortality score was 7 ± 5%. No procedural deaths or conversion to conventional surgery was registered. The 30-day and midterm mortality rates were 5% and 28%, respectively. The median time of freedom from a composite of death and cardiocerebral adverse events was 34.3 months (95% confidence interval: 17.6-51.1). The rate of moderate/severe paravalvular leakage was 0%. The pacemaker rate was 11%., Conclusions: TA-TAVI is a safe method with low-rate procedural complications and shows good early and midterm outcomes in patients with extensive panarteriopathy for whom transfemoral and other alternative transvascular approaches are contraindicated or at high interventional risk. The modified artery-no-touch TA-TAVI method is safe and feasible for selected patients with no other possible arterial approach., (© 2022 The Authors. Journal of Cardiac Surgery published by Wiley Periodicals LLC.)

Aims: To test if contingency management (CM) interventions for alcohol and drug abstinence were associated with increased alcohol and drug abstinence among American Indian adults with alcohol dependence who also use drugs., Design: In this 2 × 2 factorial randomized controlled trial, American Indian adults with alcohol dependence who also used drugs were randomized to four conditions: (1) incentives for submission of urine samples only (control condition), (2) CM incentives for alcohol abstinence, (3) CM incentives for drug abstinence or (4) CM incentives for abstinence from both alcohol and drugs., Setting: A Northern Plains Reservation in the United States., Participants: A total of 114 American Indian adults aged 35.8 years (standard deviation = 10.4); 49.1% were male., Intervention and Comparator: Participants received incentives if they demonstrated abstinence from alcohol (CM for alcohol, n = 30), abstinence from their most frequently used drug (CM for drugs, n = 27) or abstinence from both alcohol and their most frequently used drug (CM for alcohol and drugs, n = 32) as assessed by urine tests. Controls (n = 25) received incentives for submitting urine samples only., Measurements: Primary outcomes were urine ethyl glucuronide (alcohol) and drug tests conducted three times per week during the 12-week intervention period. Data analyses included listwise deletion and multiple imputation to account for missing data., Findings: The three CM groups were significantly (P < 0.05) more likely to submit alcohol-abstinent urine samples compared with the control condition, with odds ratios ranging from 2.4 to 4.8. The CM for drugs (OR = 3.2) and CM for alcohol and drugs (OR = 2.5) were significantly more likely to submit urine samples that indicated drug abstinence, relative to the control condition (P < 0.05). However, these differences were not significant in multiple imputation analyses (P > 0.05)., Conclusions: Contingency management (CM) incentives for abstinence were associated with increased alcohol abstinence in American Indian adults diagnosed with alcohol dependence who also used drugs, living on a rural reservation. The effect of CM incentives on drug abstinence was inconclusive., (© 2020 Society for the Study of Addiction.)

Objectives: Among American Indians, prior research has found associations between early life trauma and the development of post-traumatic stress disorder (PTSD) in adulthood. Given the physiological changes associated with PTSD, early life trauma could indirectly contribute to chronic disease risk. However, the impact of early life trauma on adult physical health in this population has not been previously investigated., Methods: We evaluated associations among early life trauma, PTSD, and 13 physiological biomarkers that index cardiovascular, metabolic, neuroendocrine, anthropometric, and immune function in adulthood by conducting correlation and structural equation modeling path analyses (N = 197). Physiological systems were analyzed individually as well as in a composite measure of allostatic load., Results: We found early life trauma was related to PTSD, which in turn was related to elevated allostatic load in adulthood. Among the various components of allostatic load, the neuroendocrine system was the only one significantly related to early life stress and subsequent PTSD development., Conclusions: Changes in allostatic load might reflect adaptive adjustments that maximize short-term survival by enhancing stress reactivity, but at a cost to later health. Interventions should focus on improving access to resources for children who experience early life trauma in order to avoid PTSD and other harmful sequelae., (© 2016 Wiley Periodicals, Inc.)

The technique of miniaturized cardiopulmonary bypass (M-CPB) for beating-heart coronary artery bypass grafting (CABG) is relatively new and has potential advantages when compared to conventional cardiopulmonary bypass (CPB). M-CPB consists of less tubing length and requires less priming volume. The system is phosphorylcholine coated and results in minimal pump-related inflammatory response and organ injury. Finally, this technique combines the advantages of the off-pump CABG (OPCAB) with the better exposure provided by CPB to facilitate complete revascularization. The hypothesis is that CABG with M-CPB has a better outcome in terms of complete coronary revascularization and perioperative results as that compared to off-pump CABG (OPCAB). In a retrospective study, 302 patients underwent beating-heart CABG, 117 (39%) of them with the use of M-CPB and 185 (61%) with OPCAB. After propensity score matching 62 patients in both groups were demographically similar. The most important intra- and early-postoperative parameters were analyzed. Endpoints were hospital mortality and complete revascularization. Hospital mortality was comparable between the groups. The revascularization was significantly more complete in M-CPB patients than in patients in the OPCAB group. Beating-heart CABG with M-CPB is a safe procedure and it provides an optimal operative exposure with significantly more complete coronary revascularization when compared to OPCAB. Beating-heart CABG with the support of a M-CPB is the operation of choice when total coronary revascularization is needed.

Objective: To determine the type and frequency of neurologic signs and symptoms in individuals with fibromyalgia (FM)., Methods: Persons with FM (n = 166) and pain-free controls (n = 66) underwent systematic neurologic examination by a neurologist blinded to disease status. Neurologic symptoms lasting at least 3 months were assessed with a standard questionnaire. We used logistic regression to evaluate the association of neurologic symptoms and examination findings with FM status. Within the FM group we examined the correlation between self-reported symptoms and physical examination findings., Results: Age- and sex-adjusted estimates revealed that compared with the control group, the FM group had significantly more neurologic abnormalities in multiple categories, including greater dysfunction in cranial nerves IX and X (42% versus 8%) and more sensory (65% versus 25%), motor (33% versus 3%), and gait (28% versus 7%) abnormalities. Similarly, the FM group had significantly more neurologic symptoms than the control group in 27 of 29 categories, with the greatest differences observed for photophobia (70% versus 6%), poor balance (63% versus 4%), and weakness (58% versus 2%) and tingling (54% versus 4%) in the arms or legs. Poor balance or coordination, tingling or weakness in the arms or legs, and numbness in any part of the body correlated with appropriate neurologic examination findings in the FM group., Conclusion: This blinded, controlled study demonstrated neurologic physical examination findings in persons with FM. The FM group had more neurologic symptoms than did the controls, with moderate correlation between symptoms and signs. These findings have implications for the medical evaluation of patients with FM.

Background: The objective was to examine the association of self-reported Diagnostic and Statistical Manual-IV edition alcohol abuse and dependence with medical conditions among American Indians (AIs)., Methods: We analyzed data previously collected in a large epidemiological study of members of 2 culturally distinct AI tribes from the Southwest (SW; n = 1,446) and the Northern Plains (NP; n = 1,638) living on or near their reservations. Associations of combined self-reported alcohol abuse and alcohol dependence with 19 medical conditions were examined through multinomial logistic regression., Results: Medical conditions that had significant relationships with alcohol abuse/dependence were sprains and strains [odds ratio (OR) 2.04, p < 0.001], hearing and vision problems (OR 2.05, p < 0.001), kidney and bladder problems (OR 1.55, p < 0.01), head injuries (OR 2.20, p < 0.001), pneumonia/tuberculosis (OR 1.49, p < 0.01), dental problems (OR 1.89, p < 0.001), and liver problems/pancreatitis (OR 2.18, p < 0.001). The total count of medical conditions was also significantly related to alcohol abuse/dependence, with a higher count being associated with the outcome (OR 1.17, p < 0.001)., Conclusions: In this community-based study of rural AIs, diverse medical conditions were associated with alcohol abuse and dependence. Further research should examine, and confirm, the nature, extent, and tribal variation of the medical consequences of alcohol abuse and dependence in these unique populations.

Aims: First, define alcohol use categories among two reservation-based American Indian (AI) populations based on the relationship between alcohol consumption and dependence. Secondly, examine associations between the alcohol use categories and other indicators of health status., Design, Participants and Measurements: Epidemiological data on 1287 AIs aged 18-57 years who consumed alcohol during the past year. CHAID tree analysis, a hierarchical partitioning method, was used to analyze alcohol quantity (highest number of drinks consumed during 1 day) and frequency (number of days drank during the past month) data to define quantity-frequency categories distinguished by differing rates of alcohol dependence. Multivariate analyses assessed relationships between the alcohol use categories thus identified and a number of health outcomes., Findings: People who reported drinking 12 or more drinks during 1 day and more than 4 days a month had the highest prevalence of alcohol dependence. Among the males who drank > 18 drinks the prevalence was 42.12% and among females who drank 12 or more drinks, 44.58%. The prevalence among males who drank > 18 drinks yet drank less frequently was also high (24.06%). Although findings differed by gender, drinkers in the highest risk category for alcohol dependence were most likely to report drug use disorders, mood/anxiety disorders, alcohol-related physical disorders and lower quality of life., Conclusions: The quantity thresholds defined to identify AIs at highest risk for alcohol dependence in this study differed by gender and were higher than typically reported for non-AIs. They are consistent with previous findings regarding the pattern of high-quantity, low-frequency alcohol consumption among AIs residing on reservations.

Objective: To elucidate the humoral immune response in patients with chronic fatigue syndrome (CFS), by identification and characterization of autoantibodies., Methods: Initial immunofluorescence histochemistry studies of sera using human HEp-2 cell substrate were followed by antibody class subtyping and colocalization studies with reference antibodies. Association of CFS autoantigens with insoluble cellular components was determined by in situ extraction of soluble components and subsequent immunofluorescence histochemistry studies on the extracted cell substrate., Results: Of 60 CFS patients, 41 (68%) were positive for antinuclear antibodies. Localization of nuclear staining was found at the nuclear envelope (52%), in reticulated speckles (25%), in nucleoli (13%), and in dense fine speckles (5%). Twenty-eight CFS sera (47%) also had antibodies to cytoplasmic antigens. The major cytoplasmic staining pattern was of the intermediate filament type (35%). The observed nuclear envelope pattern of staining co-localized with lamina-associated polypeptide 2 (an integral nuclear membrane protein), the reticulated speckle pattern co-localized with non-small nuclear RNP splicing factor SC-35, and the intermediate filament pattern co-localized with vimentin. The intermediate filament antigen was shown to be vimentin in immunoblotting experiments using recombinant human vimentin, and one of the nuclear envelope antigens was shown previously to be lamin B1. Fifty of the 60 CFS patients (83%) had antibodies to one or another of these antigens, all of which are relatively insoluble cellular antigens, whereas a control group of patients without chronic fatigue had a significantly lower frequency of such antibodies (17%)., Conclusion: The high frequency of autoantibodies to insoluble cellular antigens in CFS represents a unique feature which might help to distinguish CFS from other rheumatic autoimmune diseases.

Fifty patients with primary fibromyalgia who had been followed in an academic rheumatology practice frequently reported symptoms thought to be typical of "chronic Epstein-Barr virus infection," but not of fibromyalgia: recurrent sore throat (54%), recurrent rash (47%), chronic cough (40%), recurrent adenopathy (33%), and recurrent low-grade fevers (28%). In 55% of the patients, illness had begun suddenly, with what seemed to be a viral syndrome. Antibody titers to Epstein-Barr virus in the patients with fibromyalgia, however, were not significantly different from those in age- and sex-matched "healthy" and "unhealthy" control subjects.