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BACKGROUND Data from patient questionnaires reveal that the intensity of postoperative pain is widely underestimated. Insufficient pain control may contribute to impaired short- and long-term outcome. Preoperative administration of methadone might potentially improve postoperative pain control due to its long pharmacological half-life. METHODS The aim of this study was to evaluate the effect of a single dose of methadone administered at anesthesia induction on postoperative analgesic requirements in ASA I-III patients after moderate-to-severely painful surgery scheduled for ≥90 minutes. Patients were randomized to receive either a single dose of methadone (0.2 mg/kg) or fentanyl (standard, 0.003 mg/kg) intravenously (IV) at anesthesia induction. For postoperative pain control, all study patients were accommodated with morphine on the basis of patient-controlled analgesia (PCA). RESULTS Per-protocol analysis revealed that the median cumulative morphine consumption was significantly lower in patients receiving a single dose of methadone, in the Postanesthesia Care Unit (0 mg vs. 7 mg of morphine, P

Background The pathophysiology of pulmonary edema is generally considered to result from elevated pulmonary capillary hydrostatic pressure due to increased left atrial pressure in consequence of a failing left ventricle. Case presentation We present a case of pulmonary edema secondary to severe hypalbuminemia under excessive respiratory drive in a 29-year-old Caucasian woman in respiratory distress with detected bilateral central pulmonary embolism. Conclusion In conjunction with severe hypalbuminemia, even the negative intrathoracic pressure swings of respiratory distress may cause pulmonary edema. Detrimental consequences of non-invasive ventilation due to uncontrolled tidal volume and pressure swings need to be considered when treating patients in hypoxemic respiratory failure with low serum albumin.

Purpose of review This review highlights the aspects of pathophysiology that make it difficult to predict the effects of any attempt to improve brain perfusion and reviews the options to improve brain perfusion according to the needs of an individual patient, focusing on the choice of a suitable threshold for cerebral perfusion pressure. Recent findings Typically, vasopressors or vasodilators that do not directly influence the cerebral vascular bed are used to improve cerebral perfusion. Positive inotropic substances are rarely used, as the relationship between cardiac output and cerebral blood flow is complex and difficult to measure. Combining perfusion pressure monitoring with monitoring of brain metabolism or oxygenation to adapt cerebral perfusion to the needs of an individual patient has been disappointing. Recently, attempts to individualize perfusion pressure based on measurements of cerebrovascular autoregulation have shown promising results in the management of traumatic brain injury and during cardiac surgery. Currently, only preliminary data are available linking optimized cerebral perfusion to improved outcome. Summary Optimizing cerebral perfusion remains a difficult goal. All our attempts to manipulate brain perfusion are influenced in an unpredictable manner by underlying diseases. Autoregulation-based strategies to individualize cerebral perfusion management warrant further investigation.

Rapid estimates of the central venous pressure (CVP) can be helpful to administer early fluid therapy or to manage cardiac preload in intensive care units, operating rooms or emergency rooms in order to start and monitor an adequate medical therapy. Invasive CVP measurements have inherent and non-negligible complication rates as well as great expenditures. Several noninvasive methods of CVP measurements, like ultrasound-guided techniques, are available, but require trained skills and special equipment which might not be at hand in all situations. Our purpose was to evaluate the feasibility and accuracy of CVP estimates assessed upon the height of hand veins collapse (HVC) using invasively measured CVP as the gold standard. The HVC was determined by slowly lifting the patient's hand while watching the dorsal hand veins to collapse. The vertical distance from the dorsal hand to a transducer air zero port was noted and converted to mmHg. The observer was blinded to the simultaneously measured CVP values, which were categorized as low (7 mmHg), normal (7-12 mmHg) and high (12 mmHg). Measurements were performed in 82 patients who had a median [IQR] age of 67 [60;74]. Median CVP was 12 [8;15] mmHg and the median absolute difference between the measured HVC and CVP was 4 [2;7] mmHg. The Spearman correlation coefficient between CVP and HVC was 0.55, 95%-CI [0.35;0.69]. Overall CVP categorization was correct in 45% of the cases. HVC had a sensitivity of 92% for a low CVP with a negative predictive value of 98%. A high HVC had a sensitivity of 29% but a high specificity of 94% for a high CVP. The overall performance of observing the hand vein collapse to estimate CVP was only moderate in the intensive care setting. However, the median difference to the CVP was low and HVC identifies a low CVP with a high sensitivity and excellent negative predictive value.

Background: Aim of this study was to evaluate the outcomes of endocarditis patients undergoing valve surgery with the Cytosorb® hemoadsorption (HA) device during cardiopulmonary bypass. Methods: From 2009 until 2019, 241 patients had undergone valve surgery due to endocarditis at the Department of Cardiac Surgery, University Hospital of Basel. We compared patients who received HA during surgery (n = 41) versus patients without HA (n = 200), after applying inverse probability of treatment weighting. Results: In-hospital mortality, major adverse cardiac and cerebrovascular events and postoperative renal failure were similar in both groups. Demand for norepinephrine (88.4 vs. 52.8%, p = 0.001), milrinone (42.2 vs. 17.2%, p = 0.046), red blood cell concentrates (65.2 vs. 30.6%, p = 0.003), and platelets (HA vs. Control: 36.7 vs. 9.8%, p = 0.013) were higher in the HA group. In addition, a higher incidence of reoperation for bleeding (34.0 vs. 7.7 %, p = 0.011), and a prolonged length of in-hospital stay (15.2 (11.8 to 19.6) vs. 9.0 (7.1 to 11.3) days, p = 0.017) were observed in the HA group. Conclusions: No benefits of HA-therapy were observed in patients with infective endocarditis undergoing valve surgery.

From the *Department for Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine, and Pain Therapy, University Hospital Basel, Basel, Switzerland; and †Department of Anesthesia and Intensive Medicine, Cantonal Hospital Baden, Baden, Switzerland. Address reprint requests to Alexa Hollinger, MD, Anesthesiology, University Hospital Basel, Spitalstrasse 21, CH-4031, Basel, Switzerland E-mail: alexa.hollinger@usb.ch © 2015 Elsevier Inc. All rights reserved. 1053-0770/2601-0001$36.00/0 http://dx.doi.org/10.1053/j.jvca.2014.08.021

Introduction To describe PBM practices in cardiac surgery in 9 European countries and formulate an expert opinion on the identification and management of main risk factors for bleeding or transfusion. Methods Online survey addressing PBM practices in 2 clinical situations, risk factors, and previous experience with antifibrinolytics; enriched by expert opinion. Results In a non-emergency situation, no respondents would make use of preoperative red blood cell transfusion in an anaemic patient, while cell salvage (89%) and antifibrinolytics (82%) would almost always be used. Haemoglobin level optimization (36%) and use of off-pump techniques (34%), minimally invasive surgery (25%) and modern CPB technologies (mini-bypass:32%; autologous priming: 38%) varied greatly across countries. In an emergency clinical situation, topical haemostatic agents would frequently be used (61%). Tranexamic acid (72%) and aprotinin (20%) were the main antifibrinolytics used, with chosen procedures for aprotinin varying across countries. 5 factors were considered at high risk for bleeding or transfusion by at least 90% of respondents: pre-operative anaemia, prior cardiac surgery, clopidogrel 5 days or less before surgery, use of other P2Y12 inhibitors at any point, and thrombocytopenia Conclusion PBM guidelines are not always implemented in European cardiac surgery centres, resulting in discrepancies in techniques and products used for a given clinical situation. Main risk factors identified in the survey and by the expert opinion matched.

Metastatic melanoma remains a life-threatening disease because most tumors develop resistance to targeted kinase inhibitors thereby regaining tumorigenic capacity. We show the 2nd generation hexavalent TRAIL receptor-targeted agonist IZI1551 to induce pronounced apoptotic cell death in mutBRAF melanoma cells. Aiming to identify molecular changes that may confer IZI1551 resistance we combined Dynamic Bayesian Network modelling with a sophisticated regularization strategy resulting in sparse and context-sensitive networks and show the performance of this strategy in the detection of cell line-specific deregulations of a signalling network. Comparing IZI1551-sensitive to IZI1551-resistant melanoma cells the model accurately and correctly predicted activation of NFκB in concert with upregulation of the anti-apoptotic protein XIAP as the key mediator of IZI1551 resistance. Thus, the incorporation of multiple regularization functions in logical network optimization may provide a promising avenue to assess the effects of drug combinations and to identify responders to selected combination therapies., Systems Biology and Cancer: Network analysis for TRAIL resistance in Melanoma Even though targeted kinase inhibitors have been invented to mutation-specifically fight melanoma, most patients present with initial or acquired resistance and suffer from tumor relapse. A multidisciplinary team lead by Dagmar Kulms at the Technical University of Dresden, has developed a predictive Dynamic Bayesian Network model that is able to predict alternative targets for melanoma treatment. Comparing melanoma cells being sensitive or resistant to death receptor induced apoptosis by a second-generation TRAIL agonist the model predicted molecular signatures of pro-survival/anti-apoptotic responses in a dynamic manner. They show that TRAIL holds a great potential of success for targeted cancer therapy in the near future, and that the incorporation of multiple regularization functions in logical networks may provide a promising avenue to assess the effects of drug combinations for personalized medicine.

Seit dem 15. November 2017 sind die revidierten medizin-ethischen Richtlinien der SAMW zur «Feststellung des Todes im Hinblick auf Organtransplantationen und Vorbereitung der Organentnahme» in Kraft.

Les directives medico-ethiques revisees de l'ASSM «Diagnostic de la mort en vue de la transplantation d’organes et prepa­ration du prelevement d’organes» sont en vigueur depuis le 15 novembre 2017.

Antibody-fusion proteins with ligands, e.g., of the TNF superfamily (TNFSF) can be adequately produced in mammalian expression systems. Here, we describe the transient production in adherent and suspension human embryonic kidney cells at laboratory scale, followed by purification procedures applying protein A and immobilized metal affinity chromatography for proteins with Fc domain and 6 × histidine-tag, respectively. In addition, characterization of the purified proteins by size exclusion chromatography is described.

This cohort study describes mortality predictors of necrotizing fasciitis (NF). Higher age, chronic kidney disease, and higher Charlson score increased the mortality rate. Mortality was >3 times higher in monomicrobial gram-negative NF than in type I or type II NF. Highest mortality was found with Enterobacteriales in non-Fournier NF.

Our goal was to evaluate the impact of the discontinuation times of dual antiplatelet therapy with clopidogrel, prasugrel or ticagrelor on postoperative bleeding rates and the use of blood products in patients undergoing isolated urgent coronary artery bypass grafting (CABG).We retrospectively analysed 334 patients with acute coronary syndrome undergoing urgent CABG at the University Hospital Basel. A total of 262 patients continued to take dual antiplatelet therapy during the surgery (72 received clopidogrel; 68, prasugrel; and 122, ticagrelor). They were stratified by the discontinuation time of dual antiplatelet therapy (24 h, 24-48 h, 48-72 h and72 h). Seventy-two patients taking acetylsalicylic acid (ASA) as monotherapy served as a comparison group.Median postsurgical bleeding rates were significantly higher with ticagrelor if it was discontinued24 h [1220 ml, interquartile range (IQR) 978-1520 ml; P 0.001], 24-48 h (1200 ml, IQR 800-1550 ml; P 0.001) and 48-72 h (1100 ml, IQR 845-1245 ml; P = 0.036) but not if discontinued72 h (700 ml, IQR 520-825 ml; P = 0.22) and with prasugrel if discontinued24 h (1320 ml, IQR 900-1950 ml; P 0.001) but not if discontinued 24-48 h (1050 ml, IQR 638-1438 ml; P = 0.089) or72 h (750 ml, IQR 488-1040; P = 0.63) compared to ASA monotherapy (800 ml, IQR 593-1043 ml). The postsurgical use of blood products compared to ASA monotherapy (0, IQR 0-2 units) was significantly higher with ticagrelor and prasugrel if discontinued24 h (2.5 units, IQR 0-6; P 0.001 and 2 units, IQR 1-6; P 0.001, respectively).Discontinuation of ticagrelor and prasugrel for more than 72 h before urgent CABG was not associated with higher bleeding rates compared to treatment with ASA monotherapy. In contrast, discontinuation for less than 24 h was associated with higher use of blood products. For ticagrelor, this study supports evidence and recent guidelines proposing a shorter discontinuation time of 3 days and raises the question of whether the same could be true for prasugrel.

Single-chain formats of TNF-related apoptosis inducing ligand (scTRAIL) can serve as effector components of tumour-associated antigen-targeted as well as non-targeted fusion proteins, being characterized by high tumour cell-specific induction of apoptosis through death receptor activation. We studied the suitability of immunoglobulin G as a scaffold for oligovalent and bispecific TRAIL fusion proteins. Thus, we developed novel targeted hexa- and dodecavalent IgG-scTRAIL molecules by fusing scTRAIL to the C-terminus of either light (LC-scTRAIL) or heavy immunoglobulin chain (HC-scTRAIL), or to both ends (LC/HC-scTRAIL) of the anti-EGFR IgG antibody hu225. The binding specificity to EGFR and death receptors was retained in all IgG-scTRAIL formats and translated into high antigen-specific bioactivity on EGFR-positive Colo205, HCT116 and WM1366 tumour cell lines, with or without sensitization to apoptosis by bortezomib. In vivo, therapeutic potential was assessed for one of the targeted variants, HC-scTRAIL, compared to the non-targeted Fc-scTRAIL. Both molecules showed a significant reduction of tumour volume and synergism with a Smac mimetic in a Colo205 xenograft tumour model. The IgG-scTRAIL format allows directing a defined, highly bioactive form of TRAIL to a wide variety of tumour antigens, enabling customized solutions for a patient-specific targeted cancer therapy with a reduced risk of side effects.

Avoiding secondary brain injury due to hypoxia and/or ischemia is the mainstay and declared goal of neurocritical care. Monitoring the brain's overall condition after trauma with intracranial pressure and cerebral perfusion pressure alone may be insufficient to prevent secondary brain damage. Therefore, additional parameters to quantify brain tissue oxygenation have been developed and introduced into clinical practice. In this chapter, reflectance spectrophotometry, near-infrared reflectance spectroscopy, oxygen electrode, optode, and briefly, imaging studies are presented. The technical details of each method are presented, and the evidence regarding their clinical usefulness to reduce secondary brain damage is discussed.

Antibody-fusion proteins with ligands, e.g., of the TNF superfamily (TNFSF) can be adequately produced in mammalian expression systems. Here, we describe the transient production in adherent and suspension human embryonic kidney cells at laboratory scale, followed by purification procedures applying protein A and immobilized metal affinity chromatography for proteins with Fc domain and 6 × histidine-tag, respectively. In addition, characterization of the purified proteins by size exclusion chromatography is described.

Purpose of review Monitoring and therapy of patients in neurocritical care are areas of intensive research and the current evidence needs further confirmation. Recent findings A consensus statement of the Neurocritical Care Society and the European Society of Intensive Care Medicine provided pragmatic guidance and recommendations for multimodal monitoring in neurocritical care patients. Only a minority of these recommendations have strong evidence. In addition, recent multicenter randomized controlled trials concerning the therapy of subarachnoidal hemorrhage and traumatic brain injury could not show decreased mortality or improved functional neurologic outcome after the interventions. The current evidence for monitoring and medical therapy in patients after traumatic brain injury and aneurysmal subarachnoid hemorrhage is highlighted in this review. Summary Although strong evidence is lacking, multimodal monitoring is of great value in neurocritical care patients and may help to provide patients with the optimal therapy based on the individual pathophysiological changes.

whether, in the elderly, intraoperative cerebral autoregulation and oxygenation were affected. † The lowered cerebral autoregulation in the elderly was not considered clinically significant. † Cerebral oxygenation was not associated with the advanced age. † The study did not support the hypothesis that the brain in the elderly is more vulnerable to the systemic changes. Background. Age is an important risk factor for perioperative cerebral complications such as stroke, postoperative cognitive dysfunction, and delirium. We explored the hypothesis that intraoperative cerebrovascular autoregulation is less efficient and brain tissue oxygenation lower in elderly patients, thus, increasing the vulnerability of elderly brains to systemic insults such as hypotension. Methods. We monitored intraoperative cerebral perfusion in 50 patients aged 18–40 and 77 patients .65 yr at two Swiss university hospitals. Mean arterial pressure (MAP) was measured continuously using a plethysmographic method. An index of cerebrovascular autoregulation (Mx) was calculated based on changes in transcranial Doppler flow velocity due to changes in MAP. Cerebral oxygenation was assessed by the tissue oxygenation index (TOI) using near-infrared spectroscopy. End-tidal CO2 ,O 2, and sevoflurane concentrations and peripheral oxygen saturation were recorded continuously. Standardized anaesthesia was administered in all patients (thiopental, sevoflurane, fentanyl, atracurium). Results. Autoregulation was less efficient in patients aged .65 yr [by 0.10 (SE 0.04; P¼0.020)] in a multivariable linear regression analysis. This difference was not attributable to differences in MAP, end-tidal CO2, or higher doses of sevoflurane. TOI was not significantly associated with age, sevoflurane dose, or Mx but increased with increasing flow velocity [by 0.09 (SE 0.04; P¼0.028)] and increasing MAP [by 0.11 (SE 0.05; P¼0.043)]. Conclusions. Our results do not support the hypothesis that older patients’ brains are more vulnerable to systemic insults. The difference of autoregulation between the two groups was small and most likely clinically insignificant.

Background/objectives Delirium is a neurobehavioural disturbance that frequently develops particularly in the intensive care unit (ICU) population. It was first described more than half a century ago, where it was already discovered as a state that might come along with serious complications such as prolonged ICU and hospital stay, reduced quality of life and increased mortality. However, in most cases, there is still lack of proof for causal relationship. Its presence frequently remains unrecognised due to suggested predominance of the hypoactive form. Furthermore, in the general ICU population, it has been shown that the duration of delirium is associated with worse long-term cognitive function. Due to the multifactorial origin of delirium, we have several but no incontestable treatment options. Nonetheless, delirium bears a high burden for patient, family members and the medical care team.The Basel ProDex Study targets improvement of hyperactive and mixed delirium therapy in critically ill patients. We will focus on reducing the duration and severity of delirium by implementing dexmedetomidine into the treatment plan. Dexmedetomidine compared with other sedatives shows fewer side effects representing a better risk profile for delirium treatment in general. This could further contribute to higher patient safety.The aim of the BaProDex Trial is to assess the superiority of dexmedetomidine to propofol for treatment of hyperactive and mixed delirium in the ICU. We hypothesise that dexmedetomidine, compared with propofol administered at night, shortens both the duration and severity of delirium. Methods/design The Basel ProDex Study is an investigator-initiated, one-institutional, two-centre randomised controlled clinical trial for the treatment of delirium with dexmedetomidine versus propofol in 316 critically ill patients suffering from hyperactive and mixed delirium. The primary outcome measure is delirium duration in hours. Secondary outcomes include delirium-free days at day 28, death at day 28, delirium severity, amount of ventilator days, amount of rescue sedation with haloperidol, length of ICU and hospital stay, and pharmaceutical economic analysis of the treatments. Sample size was estimated to be able to show the superiority of dexmedetomidine compared with propofol regarding the duration of delirium in hours. The trial will be externally monitored according to good clinical practice (GCP) requirements. There are no interim analyses planned for this trial. Ethics and dissemination This study will be conducted in compliance with the protocol, the current version of the Declaration of Helsinki, the International Conference on Harmonization- Good Clinical Practice (ICH-GCP) or Europaische Norm International Organization for Standardization (ISO EN 14155; as far as applicable) as well as all national legal and regulatory requirements. Only the study team will have access to trial specific data. Anonymisation will be achieved by a unique patient identification code. Trial data will be archived for a minimum of 10 years after study termination. We plan to publish the data in a major peer-reviewed clinical journal. Trials registration ClinicalTrials.gov Identifier: NCT02807467 PROTOCOL VERSION: Clinical Study Protocol Version 2, 16.08.2016.

The TNF-related apoptosis-inducing ligand (TRAIL) has been considered as a promising molecule for cancer treatment. However, clinical studies with soluble TRAIL failed to show therapeutic activity, which resulted in subsequent development of more potent TRAIL-based therapeutics. In this study, we applied defined oligomerization and tumor targeting as strategies to further improve the activity of a single-chain version of TRAIL (scTRAIL). We compared three different formats of EGF receptor (EGFR)-targeting dimeric scTRAIL fusion proteins [Diabody (Db)-scTRAIL, scFv-IgE heavy chain domain 2 (EHD2)-scTRAIL, scFv-Fc-scTRAIL] as well as two nontargeted dimeric scTRAIL molecules (EHD2-scTRAIL, Fc-scTRAIL) to reveal the influence of targeting and protein format on antitumor activity. All EGFR-targeted dimeric scTRAIL molecules showed similar binding properties and comparable cell death induction in vitro, exceeding the activity of the respective nontargeted dimeric format and monomeric scTRAIL. Superior properties were observed for the Fc fusion proteins with respect to production and in vivo half-life. In vivo studies using a Colo205 xenograft model revealed potent antitumor activity of all EGFR-targeting formats and Fc-scTRAIL and furthermore highlighted the higher efficacy of fusion proteins comprising an Fc part. Despite enhanced in vitro cell death induction of targeted scTRAIL molecules, however, comparable antitumor activities were found for the EGFR-targeting scFv-Fc-scTRAIL and the nontargeting Fc-scTRAIL in vivo. Mol Cancer Ther; 16(12); 2792–802. ©2017 AACR.

Postoperative delirium (POD) is a common complication after cardiac surgery and is associated with increased patient morbidity and mortality. The objective of this study was to identify risk factors for long duration and overall burden of POD after cardiac surgery.One-year, single-center, retrospective, observational cohort study.University hospital.Adult patients undergoing cardiac surgery with cardiopulmonary bypass in 2013.None.Patients were screened for POD using the Intensive Care Delirium Screening Checklist. The primary outcome measure was the incidence of POD. Secondary outcome measures were the duration of POD and the area under the curve determined using the Intensive Care Delirium Screening Checklist score over time. Independent predictors of POD were estimated in multivariable logistic regression models. Hospital length of stay, medications, and outcome data also were analyzed. Among the 656 patients included in the cohort, 618 were analyzed. The overall incidence of POD was 39%. Older patient age (odds ratio [95% confidence interval]) 1.06 [1.04-1.09] for an increase of 1 year, p0.001); low preoperative serum albumin (1.08 [1.03-1.13] for a decrease of 1 g/L, p0.001); a history of atrial fibrillation (2.30 [1.30-4.09], p = 0.004); perioperative stroke (6.27 [1.54-43.64], p = 0.008); ascending aortic replacement surgery (2.99 [1.50-6.05], p = 0.002); longer duration of procedure (1.37 [1.16-1.63] for an increase of 1 hour, p0.001); and increased postoperative C-reactive protein concentration (2.16 [1.49-3.16] for a 2-fold increase, p0.001) were associated with higher odds of POD. Among patients affected by POD, older age, perioperative stroke, longer procedure time, and increased postoperative C-reactive protein were consistently predictive of longer duration of POD and greater area under the curve.Known risk factors for the development of POD after cardiac surgery also are predictive of prolonged duration and high overall burden of POD.

Data regarding immunomodulatory effects of parenteral n-3 fatty acids in sepsis are conflicting. In this study, the effect of administration of parenteral n-3 fatty acids on markers of brain injury, incidence of sepsis-associated delirium, and inflammatory mediators in septic patients was investigated.; Fifty patients with sepsis were randomized to receive either 2 ml/kg/day of a lipid emulsion containing highly refined fish oil (equivalent to n-3 fatty acids 0.12 mg/kg/day) during 7 days after admission to the intensive care unit or standard treatment. Markers of brain injury and inflammatory mediators were measured on days 1, 2, 3 and 7. Assessment for sepsis-associated delirium was performed daily. The primary outcome was the difference in S-100β from baseline to peak level between both the intervention and the control group, compared by t-test. Changes of all markers over time were explored in both groups, fitting a generalized estimating equations model.; Mean difference in change of S-100β from baseline to peak level was 0.34 (95% CI: -0.18-0.85) between the intervention and control group, respectively (P = 0.19). We found no difference in plasma levels of S-100β, neuron-specific enolase, interleukin (IL)-6, IL-8, IL-10, and C-reactive protein between groups over time. Incidence of sepsis-associated delirium was 75% in the intervention and 71% in the control groups (risk difference 4%, 95% CI -24-31%, P = 0.796).; Administration of n-3 fatty acids did not affect markers of brain injury, incidence of sepsis-associated delirium, and inflammatory mediators in septic patients.

We applied the immunoglobulin E (IgE) heavy-chain domain 2 (EHD2) as the covalently linked homodimerization module to generate antibody–scTRAIL fusion proteins. By fusing a humanized single-chain fragment variable (scFv) directed against EGFR to the N-terminus of the EHD2 and a single-chain derivative of TRAIL (scTRAIL) to the C-terminus of the EHD2, we produced a dimeric, tetravalent fusion protein. The fusion protein retained its binding activity for EGFR and TRAIL receptors. In vitro, the targeted antibody–scTRAIL fusion protein exhibited an approximately 8- to 18-fold increased cytotoxic activity compared with the untargeted EHD2-scTRAIL fusion protein. This resulted in increased antitumor activity in a subcutaneous Colo205 xenograft tumor murine model. In summary, the scFv-EHD2-scTRAIL fusion protein combines target cell selectivity with an increased TRAIL activity leading to improved antitumor activities. Mol Cancer Ther; 13(1); 101–11. ©2013 AACR.

Objectives: To evaluate the influence of genetic polymorphisms on the susceptibility to Candida colonization and intra-abdominal candidiasis, a blood culture–negative life-threatening infection in high-risk surgical ICU patients. Design: Prospective observational cohort study. Setting: Surgical ICUs from two University hospitals of the Fungal Infection Network of Switzerland. Patients: Eighty-nine patients at high risk for intra-abdominal candidiasis (68 with recurrent gastrointestinal perforation and 21 with acute necrotizing pancreatitis). Measurements and Main Results: Eighteen single-nucleotide polymorphisms in 16 genes previously associated with development of fungal infections were analyzed from patient’s DNA by using an Illumina Veracode genotyping platform. Candida colonization was defined by recovery of Candida species from at least one nonsterile site by twice weekly monitoring of cultures from oropharynx, stools, urine, skin, and/or respiratory tract. A corrected colonization index greater than or equal to 0.4 defined “heavy” colonization. Intra-abdominal candidiasis was defined by the presence of clinical symptoms and signs of peritonitis or intra-abdominal abscess and isolation of Candida species either in pure or mixed culture from intraoperatively collected abdominal samples. Single-nucleotide polymorphisms in three innate immune genes were associated with development of a Candida corrected colonization index greater than or equal to 0.4 (Toll-like receptor rs4986790, hazard ratio = 3.39; 95% CI, 1.45–7.93; p = 0.005) or occurrence of intra-abdominal candidiasis (tumor necrosis factor-α rs1800629, hazard ratio = 4.31; 95% CI, 1.85–10.1; p= 0.0007; β-defensin 1 rs1800972, hazard ratio = 3.21; 95% CI, 1.36–7.59; p = 0.008). Conclusion: We report a strong association between the promoter rs1800629 single-nucleotide polymorphism in tumor necrosis factor-α and an increased susceptibility to intra-abdominal candidiasis in a homogenous prospective cohort of high-risk surgical ICU patients. This finding highlights the relevance of the tumor necrosis factor-α functional polymorphism in immune response to fungal pathogens. Immunogenetic profiling in patients at clinical high risk followed by targeted antifungal interventions may improve the prevention or preemptive management of this life-threatening infection.

Introduction Approximately 40% of patients undergoing cardiac surgery will require a blood transfusion. Whilst this may be life-saving, there is also a morbidity and mortality associated with it. In recent years Patient Blood Management (PBM) has evolved to integrate peri-operative haemostasis care in an attempt to drive down transfusion. However, it has evolved in different ways across the different health care systems across Europe (1). This has led to discrepancies between guidelines (2,3) and actual clinical practice across countries. The objective of this study is to understand how PBM strategies differ throughout Europe. Methods A 10-minute long online survey was developed with a group of European anesthesiologists. Between January and July 2019 the survey was disseminated by the National and European scientific societies of Austria, Finland, France, Germany, Ireland, Switzerland, the Netherlands and United Kingdom. Its first seven questions provide epidemiological data about transfusion need and local patient blood management practice depending of guidelines. Following this, we present two clinical cases and ask questions about how these patients would be managed by the respondent. Results Results are expected for Summer 2019. These pictures of the local practices will serve as a basis of discussion for the European working group of experts involved in PBM. Discussion This description and analysis of the differences among countries and against current guidelines will help to improve the existing guidelines for PBM (2,3).

Life-threatening intraabdominal candidiasis (IAC) occurs in 30 to 40% of high-risk surgical intensive care unit (ICU) patients. Although early IAC diagnosis is crucial, blood cultures are negative, and the role of Candida score/colonization indexes is not established.The aim of this prospective Fungal Infection Network of Switzerland (FUNGINOS) cohort study was to assess accuracy of 1,3-β-d-glucan (BG) antigenemia for diagnosis of IAC.Four hundred thirty-four consecutive adults with abdominal surgery or acute pancreatitis and ICU stay 72 hours or longer were screened: 89 (20.5%) at high risk for IAC were studied (68 recurrent gastrointestinal tract perforation, 21 acute necrotizing pancreatitis). Diagnostic accuracy of serum BG (Fungitell), Candida score, and colonization indexes was compared.Fifty-eight of 89 (65%) patients were colonized by Candida; 29 of 89 (33%) presented IAC (27 of 29 with negative blood cultures). Nine hundred twenty-one sera were analyzed (9/patient): median BG was 253 pg/ml (46-9,557) in IAC versus 99 pg/ml (8-440) in colonization (P0.01). Sensitivity and specificity of two consecutive BG measurements greater than or equal to 80 pg/ml were 65 and 78%, respectively. In recurrent gastrointestinal tract perforation it was 75 and 77% versus 90 and 38% (Candida score ≥ 3), 79 and 34% (colonization index ≥ 0.5), and 54 and 63% (corrected colonization index ≥ 0.4), respectively. BG positivity anticipated IAC diagnosis (5 d) and antifungal therapy (6 d). Severe sepsis/septic shock and death occurred in 10 of 11 (91%) and 4 of 11 (36%) patients with BG 400 pg/ml or more versus 5 of 18 (28%, P = 0.002) and 1 of 18 (6%, P = 0.05) with BG measurement less than 400 pg/ml. β-Glucan decreased in IAC responding to therapy and increased in nonresponse.BG antigenemia is superior to Candida score and colonization indexes and anticipates diagnosis of blood culture-negative IAC. This proof-of-concept observation in strictly selected high-risk surgical ICU patients deserves investigation of BG-driven preemptive therapy.

As the result of an increasing incidence and a prevalent therapy resistance of hepatocellular carcinoma (HCC), there is a strong need for novel strategies to enhance treatment responses in HCC. Tumor necrosis factor–related apoptosis-inducing ligand (TRAIL) has been proposed as a promising anticancer drug because it can selectively induce apoptosis in cancer cells, but not in healthy cells. Nevertheless, most tumor cells show TRAIL resistance, emphasizing the requirement for apoptosis-sensitizing agents and TRAIL molecules with improved tumor specificity. In this study, we employed a recombinant TRAIL molecule, in which three TRAIL protomers were expressed as a single polypeptide chain (scTRAIL), and a novel TRAIL variant, in which scTRAIL was additionally fused to an antibody fragment recognizing epidermal growth factor receptor (EGFR) to improve its HCC-targeting properties. We analyzed the proapoptotic effects of both TRAIL versions in combination with the proteasome inhibitor bortezomib (BZB) in hepatoma cells and primary human hepatocytes as well as in intact explants from HCC and healthy liver tissue. We demonstrate that EGFR-targeted TRAIL in combination with BZB induced significantly higher caspase activation and cell death in hepatoma cells, but not in primary hepatocytes. Importantly, when incubated with fresh liver explants, the combination of EGFR-targeted TRAIL and BZB displayed selective cytotoxicity for HCC, but not for tumor-free liver tissue, which could even be verified in liver explants from the same individuals. Unlike nontargeted TRAIL, EGFR-targeted TRAIL combined with BZB exerted no toxicity in liver tissues from nonalcoholic fatty liver disease patients. Conclusion: EGFR-targeted TRAIL reveals increased antitumor activity toward HCC without inducing toxicity to tumor-free liver tissue and might therefore represent a promising novel strategy for HCC treatment. (HEPATOLOGY 2013)

Prolonged infusion of β-lactam antibiotics as either extended (over at least 2 hours) or continuous infusion is increasingly applied in intensive care units around the world in an attempt to optimise treatment with this most commonly used class of antibiotics, whose effectiveness is challenged by increasing resistance rates. The pharmacokinetics of β-lactam antibiotics in critically ill patients is profoundly altered secondary to an increased volume of distribution and the presence of altered renal function, including augmented renal clearance. This may lead to a significant decrease in plasma concentrations of β-lactam antibiotics. As a consequence, low pharmacokinetic/pharmacodynamic (PK/PD) target attainment, which is described as the percentage of time that the free drug concentration is maintained above the minimal inhibitory concentration (MIC) of the causative organism (fT>MIC), has been documented for β-lactam treatment in these patients when using standard intermittent bolus dosing, even for the most conservative target (50% fT>MIC). Prolonged infusion of β-lactams has consistently been shown to improve PK/PD target attainment, particularly in patients with severe infections. However, evidence regarding relevant patient outcomes is still limited. Whereas previous observational studies have suggested a clinical benefit of prolonged infusion, results from two recent randomised controlled trials of continuous infusion versus intermittent bolus administration of β-lactams are conflicting. In particular, the larger, double-blind placebo-controlled randomised controlled trial including 443 patients did not demonstrate any difference in clinical outcomes. We believe that a personalised approach is required to truly optimise β-lactam treatment in critically ill patients. This may include therapeutic drug monitoring with real-time adaptive feedback, rapid MIC determination and the use of antibiotic dosing software tools that incorporate patient parameters, dosing history, drug concentration and site of infection. Universal administration of β-lactam antibiotics as prolonged infusion, even if supported by therapeutic drug monitoring, is not yet ready for "prime time", as evidence for its clinical benefit is modest. There is a need for prospective randomised controlled trials that assess patient-centred outcomes (e.g. mortality) of a personalised approach in selected critically ill patients including prolonged infusion of β-lactams compared with the current standard of care.

Objectives We hypothesized that antegrade open stent graft implantation in the descending aorta during acute type A aortic dissection surgery is safe and improves patient outcome compared with the standard repair technique. Methods Hundred and forty-one consecutive patients underwent surgery for acute type A aortic dissection at our institution from 2010 to 2016. Of those, 104 patients underwent ascending aorta and hemiarch repair under hypothermic circulatory arrest with antegrade cerebral perfusion (standard group). Since 2013, 37 patients have undergone the standard procedure combined with antegrade stent implantation in the descending aorta (stented group). A matched analysis using the logistic EuroSCORE (37 patients per group) was done. All data were collected prospectively. Results The mean logistic EuroSCORE was 29 in both groups, P = 1. Cardiopulmonary bypass time was 150 ± 57 (standard) vs 157 ± 48 (stented) min, P = 0.6; aortic clamping 99 ± 47 (standard) vs 100 ± 36 (stented) min, P = 1. Stented patients had longer circulatory arrest times with antegrade cerebral perfusion, 23 ± 7 vs 15 ± 7 min, P < 0.001. Stroke occurred in 24.3% (standard) vs 8.1% (stented), P = 0.1; paraplegia developed in 2.7% (standard) vs 0% (stented), P = 1. Abdominal intervention due to suspected visceral ischaemia was needed in 18.9% (standard) vs 5.4% (stented), P = 0.2. 30-day mortality was 13.5% (standard) vs 0% (stented), P = 0.05. Survival at 6-month was 100% and 86.5% in patients with implanted stents and standard repair, respectively, P = 0.02. Conclusions Antegrade, open stent graft implantation into the descending aorta during acute type A aortic dissection repair is safe and is associated with improved outcomes at 6 months postoperatively compared to the standard repair technique.

Fusion proteins combining oligomeric assemblies of a genetically obtained single-chain (sc) variant of tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) with antibodies directed against tumor-associated antigens represent a promising strategy to overcome the limited therapeutic activity of conventional soluble TRAIL. To further improve the scTRAIL module in order to obtain a robust, thermostable molecule of high activity, we performed a comprehensive analysis of the minimal TNF homology domain (THD) and optimized linkers between the 3 TRAIL subunits constituting a scTRAIL. Through a stepwise mutagenesis of the N- and C-terminal region and the joining linker sequences, we generated bioactive scTRAIL molecules comprising a covalent linkage of the C-terminal Val280 and the N-terminal position 122 by only 2 amino acid residues in combination with conservative exchanges at positions 122 and 279. The increased thermal stability and solubility of such optimized scTRAIL molecules translated into increased bioactivity in the diabody-scTRAIL (Db-scTRAIL) format, exemplified here for an epidermal growth factor receptor-specific Db-scTRAIL. Additional modifications within the diabody linkers resulted in a fusion protein exerting high, target-dependent apoptosis induction in tumor cell lines in vitro and potent antitumor activity in vivo. Our results illustrate that protein engineering of scTRAIL and associated peptide linkers provides a promising strategy to develop antibody-scTRAIL fusion proteins as effective antitumor therapeutics.

Eine 26-jahrige Zweitgravida-, Primipara-Patientin mit einer Praeklampsie in der Anamnese wurde vom Gynakologen in der 19 + 1 Schwangerschaftswoche (SSW) bei zwischen den Schulterblattern auftretenden, stechenden Ruckenschmerzen mit gurtelformig nach ventral ziehender Ausstrahlung und Dyspnoe in die regionale Notfallstation zur weiteren Beurteilung zugewiesen. Nach Anfertigung eines Elektrokardiogramms und Bestimmung der Herzenzyme erfolgte mit der Diagnose von muskulo-skelettalen Beschwerden eine ambulante analgetische Behandlung mit Paracetamol und Tramadol-Hydrochlorid p.o. bei Bedarf. Eine Woche spater wies sich die Patientin selbst auf die Notfallstation ein, mit persistierenden, stechenden Ruckschmerzen sowie neu aufgetretenen neurolo gischen Symptomen (Kopfschmerzen, Sehstorungen und Erbrechen). Dort wurde eine schwangerschaftsinduzierte Hypertonie mit Werten um 160/90 mm Hg bei ansonsten intakter Schwangerschaft diagnostiziert und die Patientin zur stationaren, antihypertensiven Therapie aufgenommen. Im Rahmen der weiteren ambulanten gynakologischen Betreuung wurde in der 24 + 5 SSW eine intrauterine Wachstumsretardierung festgestellt und die Patientin wurde nach Induktion der Lungenreifung in ein Spital mit angebundener Neonatologie zur weiteren Betreuung uberwiesen. In der 25 + 1 SSW kam es mittels Sectio caesarea in Spinalanasthesie zur Entbindung, wobei die Patientin intraoperativ uber medikamentos nicht beherrschbare Ruckenschmerzen klagte. Eine adaquate Analgesie konnte lediglich mittels Konversion des Anasthesieverfahrens in eine Allgemeinanasthesie erreicht werden. Das gemessene sensorische Niveau der Spinalanasthesie zu diesem Zeitpunkt lag beidseits beim Segment thorakal 4. Das Kind verstarb am sechsten postpartalen Tag. Nach Normalisierung der Blutdruckwerte bei der Patientin erfolgte die Entlassung ohne weitere medikamentose Therapie. Sechs Tage nach der Entlassung kam es zum erneuten Auftreten von Schmerzen im Rucken und Oberbauch mit Ausstrahlung in die unteren Extremitaten und einem initialen, sensomotorischen Defizit in beiden Beinen. Die Patientin wurde nach Beurteilung in einer regionalen Notfallstation mit der Diagnose einer akuten Lumboischialgie an das nachstgelegene Spital mit einer neurologischen Abteilung uberwiesen. Es prasentierte sich eine erneut hypertensive Patientin mit einer inkompletten Plegie des rechten Beines sowie einem lauten Systolikum uber der Aortenklappe. Im spinalen Magnetresonanztomogramm wurde die Verdachtsdiagnose einer Myelitis des Conus medullaris gestellt. In der durchgefuhrten Liquordiagnostik fanden sich keine vollstandig passenden Resultate, und die Patientin wurde zur weiteren Uberwachung und Diagnostik stationar aufgenommen. Am Folgetag wurde bei zunehmender livider Verfarbung und Pulslosigkeit beider Fusse und somit Verdacht auf eine Ischamie der Beine eine Duplexsonographie der Becken-/Beinachse und eine thorako-abdominale Computertomographie (CT) durchgefuhrt. Dort zeigte sich eine Aortendissektion Stanford Typ A (Abb. 1) mit Fortsetzung der Dissektionsmembran bis in beide Arteriae iliacae communes mit komplettem Verschluss der rechten Beckenachse (Abb. 2). Nach Verlegung in ein Zentrumsspital erfolgte die operative Versorgung mittels eines suprakoronaren Ascendens-Ersatzes mit Aortenklappenresuspension, einer anterograden Stent-Implantation in die proximale Aorta descendens, einer infrarenalen Versorgung mittels einer Y-Prothese (links iliacaler, rechts femoraler Anschluss) sowie, aufgrund der protrahierten absoluten Ischamie des rechten Beines, einer Logenspaltung am rechten Unterschenkel zur Vorbeugung eines Kompartmentsyndroms. Obwohl im CT eine hochstgradige Einengung des wahren Lumens der Aorta auf Hohe der Abgange von Truncus coeliacus und Arteria

BACKGROUND: Disparity between the macro- and microcirculation is thought to occur as a result of (micro)vascular dysfunction in some types of shock. Whether this occurs during hemorrhagic shock, however, is unknown. We therefore investigated both macro- and microcirculatory variables in the heart as a vital organ and the gut as a nonvital organ. We hypothesized that the microcirculation in the gut would follow the macrocirculation in the acute phase of hemorrhagic shock and isovolemic autologous whole blood resuscitation, but that the microcirculation in the heart would be preserved even under conditions of macrocirculatory depression. STUDY DESIGN AND METHODS: Eleven pigs (23 ± 4 kg) were anesthetized and subjected to a controlled hemorrhagic shock (30 and 45% reduction of total blood volume) and isovolemic resuscitation with autologous blood. Quantitative measurement of microvascular oxygen pressures (µpO2) was performed by phosphorimetry on the gut and heart simultaneously. Measurements of systemic hemodynamic and regional oxygen-derived variables as well as µpO2 were performed at baseline, after the first and second phases of hemorrhage, and after resuscitation. RESULTS: Five pigs responded to resuscitation, while six pigs died spontaneously within 20 to 30 minutes after reinfusion of the withdrawn blood, without significant differences in macro- or microcirculatory variables at baseline and after hemorrhage. Correlation analysis showed that microvascular pO2 in the heart and the gut were closely related to macrocirculatory variables (cardiac index, mean arterial pressure, and oxygen delivery) during hemorrhage and resuscitation. CONCLUSIONS: This study demonstrated that the microcirculation in the gut (being a nonvital organ) and heart (being a vital organ) follow the macrocirculation in the acute phase of hemorrhagic shock and isovolemic autologous whole blood resuscitation.

Background Ventilator-associated pneumonia (VAP) is the most common hospital-acquired, life-threatening infection. Poor outcome and health-care costs of nosocomial pneumonia remain a global burden. Currently, physicians rely on their experience to discriminate patients with good and poor outcome. However, standardized prognostic measures might guide medical decisions in the future. Pancreatic stone protein (PSP)/regenerating protein (reg) is associated with inflammation, infection, and other disease-related stimuli. The prognostic value of PSP/reg among critically ill patients is unknown. The aim of this pilot study was to evaluate PSP/reg in VAP. Methods One hundred one patients with clinically diagnosed VAP were assessed. PSP/reg was retrospectively analyzed using deep-frozen serum samples from VAP onset up to day 7. The main end point was death within 28 days after VAP onset. Results Serum PSP/reg was associated with the sequential organ failure assessment score from VAP onset (Spearman rank correlation coefficient 0.49 P Conclusions Serum PSP/reg is a biomarker related to organ failure and outcome in patients with VAP. Trial registry ISRCTN.org; No.: ISRCTN61015974; URL: www.isrctn.org.

Zusammenfassung: Thrombotische Mikroangiopathien sind durch Thrombozytenaktivierung, Endothelzellschädigung, Hämolyse und mikrovaskuläre Okklusionen gekennzeichnet. Es handelt sich hierbei um eine Gruppe von Erkrankungen, deren Hauptvertreter die thrombotische thrombozytopenische Purpura (TTP) und das hämolytisch-urämische Syndrom (HUS) sind. Klinisch bestehen bei den Patienten eine mikroangiopathische hämolytische Anämie mit Thrombozytopenie und okklusionsbedingte Organischämien in variabler Ausprägung. Die Symptomatik der einzelnen Krankheitsbilder überschneidet sich häufig, sodass eine eindeutige Zuordnung anhand klinischer Kriterien oft schwierig ist. Aufgrund einer hohen Mortalität, insbesondere der TTP, sind eine schnelle Diagnostik und Therapie erforderlich. Es wird über 2Patienten mit thrombotischen Mikroangiopathien nach kardiochirurgischen Eingriffen berichtet. Da TTP, HUS und eine medikamentöse Ätiologie weitgehend ausgeschlossen wurden, wurde ein Zusammenhang zwischen der extrakorporalen Zirkulation während dem herzchirurgischen Eingriff und der thrombotischen Mikroangiopathie vermutet

BACKGROUND: In this study, we tested the hypothesis that aortic cross-clamping (ACC) and reperfusion cause distributive alterations of oxygenation and perfusion in the microcirculation of the gut and kidneys despite normal systemic hemodynamics and oxygenation. METHODS: Fifteen anesthetized pigs were randomized between an ACC group (n = 10), undergoing 45 minutes of aortic clamping above the superior mesenteric artery, and a time-matched sham surgery control group (n = 5). Systemic, intestinal, and renal hemodynamics and oxygenation variables were monitored during 4 hours of reperfusion. Microvascular oxygen partial pressure (mu PO(2)) was measured in the intestinal serosa and mucosa and the renal cortex, using the Pd-porphyrin phosphorescence technique. Intestinal luminal PCO(2) was determined by air tonometry and the serosal microvascular flow by orthogonal polarization spectral imaging. RESULTS: Organ blood flow and renal and intestinal mu PO(2) decreased significantly during ACC, whereas the intestinal oxygen extraction and PCO(2) gap increased. The intestinal response to reperfusion after ACC was a sustained reactive hyperemia but no such effect was seen in the kidney. Despite a sustained high intestinal O(2) delivery, serosal mu PO(2) (median [range], 49 mm Hg [41-67 mm Hg] versus 37 mm Hg [27-41 mm Hg]; P < 0.05 baseline versus 4 hours reperfusion) and the absolute number of perfused microvessels decreased along with an increased intestinal PCO(2) gap (17 mm Hg [10-19 mm Hg] versus 23 mm Hg [19-30 mm Hg]; P < 0.05). In contrast, the kidney showed a progressive O(2) delivery decrease accompanied by a decrease in renal cortex oxygenation (70 mm Hg [52-93 mm Hg] versus 57 mm Hg [33-64 mm Hg]; P < 0.05). CONCLUSION: Increased systemic and regional blood flow and oxygen supply after ACC does not ensure adequate regional blood flow and microcirculatory oxygenation in all organs. (Anesth Analg 2010;111:345-53)

Aim of the study: Information on central venous pressure (CVP) is helpful in clinical situations like cardiac failure and sepsis. Compression ultrasound (CU) of a forearm vein has been shown to be a reliable method for CVP measurement when assessed by experienced personal under study conditions. To test the hypothesis, that CU can be reliably used for CVP measurement after a training program and using a portable ultrasound system, we investigated feasibility and accuracy of CU, comparing the results of vascular experts vs. trainees as well as high-end vs. a portable ultrasound system. Methods: CU with non-invasive CVP measurement (CVPni) was performed by four investigators in 50 patients of an intensive care unit and compared with invasive CVP measurement (CVPi). Results: Feasibility was between 88 and 92% in the different investigator groups. CVPni measurement showed a significant linear correlation (r = 0.58–0.68; p < 0.001) with CVPi in all groups. Mean difference between CVPi and CVPni was 2.4 ± 3.1 mmHg and similar between the investigators. No differences were observed between measurements done by vascular experts and trainees, as well as between high-end and portable ultrasound systems. Further we demonstrated, that CU is able to detect changes in CVP during the respiratory cycle. Conclusions: After a training program CU can be used by non-vascular clinician for reliable CVP measurement with good quality portable systems. Furthermore, respiratory changes in CVP are detectable by CU. These data suggest CU to be an efficient method for measuring CVP under real life conditions.

In patients with ventilator-associated pneumonia (VAP), guidelines recommend antibiotic therapy adjustment according to microbiology results after 72 h. Circulating procalcitonin levels may provide evidence that facilitates the reduction of antibiotic therapy. In a multicentre, randomised, controlled trial, 101 patients with VAP were assigned to an antibiotic discontinuation strategy according to guidelines (control group) or to serum procalcitonin concentrations (procalcitonin group) with an antibiotic regimen selected by the treating physician. The primary end-point was antibiotic-free days alive assessed 28 days after VAP onset and analysed on an intent-to-treat basis. Procalcitonin determination significantly increased the number of antibiotic free-days alive 28 days after VAP onset (13 (2-21) days versus 9.5 (1.5-17) days). This translated into a reduction in the overall duration of antibiotic therapy of 27% in the procalcitonin group (p = 0.038). After adjustment for age, microbiology and centre effect, the rate of antibiotic discontinuation on day 28 remained higher in the procalcitonin group compared with patients treated according to guidelines (hazard rate 1.6, 95% CI 1.02-2.71). The number of mechanical ventilation-free days alive, intensive care unit-free days alive, length of hospital stay and mortality rate on day 28 for the two groups were similar. Serum procalcitonin reduces antibiotic therapy exposure in patients with ventilator associated pneumonia.

Organ systems do not respond uniformly to changes in systemic oxygen delivery because of global and local redistributive mechanisms. We hypothesized that progressive hemodilution would evoke a different response in the microvascular oxygenation of the heart compared with kidney and gut. To evaluate this hypothesis, we studied the effect of stepwise isovolemic hemodilution on systemic hemodynamic and oxygenation parameters as well as the relation between systemic hematocrit (Ht) and microvascular PO(2) (microPO(2)) in heart, kidney, and intestines in an anesthetized and mechanically ventilated rat model. Baseline conditions were similar in the hemodilution group and in the control group. In the hemodilution group, Ht was diminished from 46.6 +/- 3.8% to 7.0 +/- 1.8% [mean +/- standard deviation (SD)]. This group had no effect on measured hemodynamics; only when Ht fell below 10% did blood pressure start to decrease. The microPO(2) values in heart, kidney, and intestines did not respond uniformly. Renal microPO(2) (56 +/- 10 mm Hg at baseline) started to decrease at a Ht of 38.5 +/- 8.6%, whereas intestinal microPO(2) (59 +/- 6 mm Hg at baseline) did not start to decrease until Ht reached 17.4 +/- 7.1%. Finally, cardiac microPO(2) (40 +/- 6 mm Hg at baseline) decreased only in the ultimate stage of the experiment at Ht of 8.7 +/- 3.5%. Based on these observations, we conclude that the regulation of microvascular oxygenation during progressive anemia is specific for each organ system. The relation between these observations and organ function and damage needs to be determined.

Sepsis is a common problem in intensive care patients. Early diagnosis of infective endocarditis is crucial and may improve patients' prognosis. The introduction of echocardiography has revolutionized the detection and management of this disease. Thus, echocardiography was quickly incorporated into international guidelines. The indication to perform an echocardiography, however, solely depends on clinical criteria which still remain the most important tools to make proper diagnosis. In suspected native valve endocarditis, transthoracic echocardiography is often sufficient for further manage' ment, especially in right heart endocarditis. Despite advances in modern medicine, the diagnosis of infective endocarditis remains challenging. The clinical picture is changing due to various reasons such as earlier presentation and changing profile of the patients and a shift of the infective agents. Collaboration between practitioners, cardiologists, infectiologists, and heart surgeons is essential.

Global left ventricular dysfunction after successful resuscitation from cardiac arrest may be treated successfully with dobutamine but the effects on intestinal perfusion are unknown.In 24 male Sprague-Dawley rats ventricular fibrillation was induced. After 4 min of untreated cardiac arrest, precordial chest compression was performed for 4 min; adrenaline (epinephrine) (90 microg kg(-1)) was injected, followed by defibrillation. Return of spontaneous circulation was achieved in 18 animals, which were allocated to receive saline 0.9% (control group, n = 6), dobutamine at 5 microg kg(-1) min(-1) (n = 6) or dobutamine at 10 microg kg(-1) min(-1) (n = 6). Measurements of haemodynamic variables and intestinal tonometer P(CO2) were made before induction of ventricular fibrillation and 15, 30, 60, and 120 min postresuscitation.At 120 min postresuscitation, mean aortic pressure was 82 +/- 20, 104 +/- 19, and 113 +/- 15 mmHg for the control group, the dobutamine (5 microg kg(-1) min(-1)) group and the dobutamine (10 microg kg(-1) min(-1)) group (P0.05 for comparison of the dobutamine (10 microg kg(-1) min(-1)) group versus the control group). Respective abdominal aortic blood flow was 107 +/- 16, 133 +/- 49, and 145 +/- 18 ml min(-1) kg(-1) (P0.05 for comparison of the dobutamine (10 microg kg(-1) min(-1)) group versus the control group), and superior mesenteric artery blood flow was 25 +/- 9, 28 +/- 8, and 33 +/- 8 ml min(-1) kg(-1). Arterial lactate was significantly higher (P0.05) in the control group (2.3 +/- 0.6 mmol l(-1)) than in the dobutamine (5 microg kg(-1) min(-1)) group (1.6 +/- 0.3 mmol l(-1)) and dobutamine (10 microg kg(-1) min(-1)) group (1.5 +/- 0.3 mmol l(-1)). Tonometrically derived P(CO2) gap was highly elevated at 15 min of postresuscitation and returned to prearrest level at 120 min postresuscitation in all groups.Dobutamine enhances the recovery of global haemodynamic and metabolic variables early after cardiac arrest.

Background For more than 30 yr, the in vitro contracture test (IVCT) was the only appropriate diagnostic tool for malignant hyperthermia (MH). After the introduction of molecular genetics into MH research, guidelines for molecular genetic diagnosis of MH susceptibility were published. The aim of this study was to establish applicability of the guidelines, sensitivity, and specificity of genetic testing in MH and advantages for studied patients. Methods The IVCT was performed following the guidelines of the European MH Group. Mutation analyses were performed by amplification of genomic DNA by polymerase chain reaction and restriction enzyme digestion. Results Two hundred eight individuals underwent MH testing between January 2001 and April 2003. In 32 of 67 initially genetic-tested patients, the familial mutation was identified, and they were diagnosed as MH susceptible. The IVCT followed negative genetic test results in 20 patients, and all but one had negative IVCT results. Three patients were scheduled to undergo elective surgery, and IVCT and genetic testing were performed simultaneously. All three had positive IVCT results and were carriers of their familial mutation. Conclusions In families with known MH mutations, there is a 50% chance of reliably confirming MH susceptibility by noninvasive testing. The authors found the negative predictive value of genetic testing to be 0.95 (95% confidence interval, 0.75-0.99), but for patient safety, they still recommend following the guidelines for genetic testing in MH and therefore performing an IVCT in case of negative genetic results.

Background In this study, the hypothesis was tested that resuscitation with hemoglobin-based oxygen carriers (HBOCs) affects the oxygenation of the microcirculation differently between and within organs. To this end, we tested the influence of the volume of an HBOC on the microcirculatory oxygenation of the heart and the gut serosa and mucosa in a porcine model of hemorrhage. Methods In anesthetized open-chested pigs (n = 24), a controlled hemorrhage (30 mL/kg over 1 hour) was followed by resuscitation with 10, 20, or 30 mL/kg diaspirin-crosslinked hemoglobin (DCLHb) or isovolemic resuscitation with 30 mL/kg of a 6% hydroxyethyl starch solution (HAES). Measurements included systemic and regional hemodynamic and oxygenation parameters. Microvascular oxygen pressures (microPO2) of the epicardium and the serosa and mucosa of the ileum were measured simultaneously by the palladium-porphyrin phosphorescence technique. Measurements were obtained up to 120 minutes after resuscitation. Results After hemorrhage, a low volume of DCLHb restored both cardiac and intestinal microPO2. Resuscitation of gut microPO2 with a low volume of DCLHb was as effective as isovolemic resuscitation with HAES. Higher volumes of DCLHb did not restore cardiac microPO2, as did isovolemic resuscitation with HAES, but increased gut microPO2 to hyperoxic values, dose-dependently. Effects were similar for the serosal and mucosal microPo2. In contrast to a sustained hypertensive effect after resuscitation with DCLHb, effects of DCLHb on regional oxygenation and hemodynamics were transient. Conclusion This study showed that a low volume of DCLHb was effective in resuscitation of the microcirculatory oxygenation of the heart and gut back to control levels. Increasing the volume of DCLHb did not cause an additional increase in heart microPO2, but caused hyperoxic microvascular values in the gut to be attained. It is concluded that microcirculatory monitoring in this way elucidates the regional behavior of oxygen transport to the tissue by HBOCs, whereas systemic variables were ineffective in describing their response.

Objectives Accelerated gastric emptying (including dumping syndrome) occurs frequently after gastric resections, largely resulting from rapid entry of meal contents into the small intestine. The authors hypothesized that an ileocecal segment used as an interpositional graft placed between the remaining part of the stomach and the small intestine would slow down food transit and thus replace pyloric function. Methods Thirty Gottingen minipigs were randomized into three groups. Group 1: partial gastrectomy and Roux-en-Y reconstruction; Group 2: partial gastrectomy and ileocecal interpositional graft; and Group 3: sham laparotomy. Gastric emptying in the nonsedated animals was quantified using radioscintigraphy at 3 and 6 months postoperatively. The animals ingested 300 grams of soft food containing 99mTc labeled resin- pellets using a technique previously described. Data were analyzed using ANOVA. Results Three months postoperatively, the ileocecal group had a significantly prolonged gastric emptying time compared with the Roux-en-Y group, but gastric emptying time was also significantly faster compared to the control group (sham laparotomy). After 6 months no significant difference was seen between the ileocecal group and the controls, while emptying rates were still significantly faster in the Roux-en-Y group. Conclusions Reconstruction of the gastric reservoir with an ileocecal segment largely restores gastric emptying patterns of food in minipigs. Six months postoperatively, gastric emptying time is similar to that of controls, and significantly slower when compared with the group with Roux-en-Y reconstruction. These results suggest that the ileocecal interposition graft could offer specific advantages over current reconstruction procedures.

In the laboratory-scale production of antibody fragments or antibody fusion proteins, it is often difficult to keep track on the most suitable affinity tags for protein purification from either prokaryotic or eukaryotic host systems. Here, we describe how such recombinant proteins derived from Escherichia coli lysates as well as HEK293 cell culture supernatants are purified by IMAC and by different affinity chromatography methods based on fusions to FLAG-tag, Strep-tag, and Fc domains.

In the laboratory-scale production of antibody fragments or antibody fusion proteins, it is often difficult to keep track on the most suitable affinity tags for protein purification from either prokaryotic or eukaryotic host systems. Here, we describe how such recombinant proteins derived from Escherichia coli lysates as well as HEK293 cell culture supernatants are purified by IMAC and by different affinity chromatography methods based on fusions to FLAG-tag, Strep-tag, and Fc domains.

BACKGROUND: Although it is known that the transfusion of stored RBCs does not always improve tissue O2 consumption under conditions of limited tissue oxygenation, the efficiency of O2 delivery to the microcirculation by stored RBCs has never been determined. STUDY DESIGN AND METHODS: In a rat hemorrhagic shock model, the effects of resuscitation with fresh or 28-day-old RBCs stored in CPD plasma, saline-adenine-glucose-mannitol, and CPDA-1 plasma were investigated. Systemic hemodynamic and intestinal oxygenation measures were monitored. Intestinal microvascular PO2 was determined with the O2-dependent quenching of palladium-porphyrin phosphorescence, and the RBC deformability was measured with a Laser-assisted optic rotational cell analyzer. RESULTS: Hemodynamic and oxygenation measures were significantly decreased during hemorrhagic shock. Intestinal oxygen consumption and mesenteric venous pO2 were restored with the transfusion of both fresh and stored RBCs, except for CPD-stored RBCs. The intestinal microvascular pO2 improved only with the transfusion of fresh RBCs. Deformability of the stored RBCs was significantly decreased. CONCLUSION: In contrast to that of fresh RBCs, the transfusion of stored RBCs did not restore the microcirculatory oxygenation, possibly because of impaired O2 unloading, but, except for CPD-stored RBCs, the storage-induced changes were not enough to impair intestinal VO2 and mesenteric venous pO2.