Search

The use of extracorporeal membrane oxygenation (ECMO) is growing rapidly in all patient populations, especially adults for both acute lung or heart failure. ECMO is a complex, high risk, resource-intense, expensive modality that requires appropriate planning, training, and management for successful outcomes. This article provides an optimal approach and the basic framework for initiating a new ECMO program, which can be tailored to meet local needs. Setting up a new ECMO program and sustaining it requires institutional commitment, physician champions, multidisciplinary team involvement, ongoing training, and education of the ECMO team personnel and a robust quality assurance program to minimize complications and improve outcomes., Competing Interests: Disclosure: R.P.B. is the Extracorporeal Life Support Organization (ELSO) Registry Chair; he reports grants from National Institute of Health (NIH) R01 HL 153519, R01 HD015434. The other authors have no conflicts of interest to report., (Copyright © ASAIO 2022.)

Although pharmaceutical pollution is a global environmental concern, much remains unknown about the transformation of pharmaceuticals in the wild and their effects on wildlife. In the environment, pharmaceuticals typically transform to some extent into different, structurally related compounds. Pharmaceutical transformation products resulting from exposure to sunlight (i.e., ultraviolet radiation) in surface waters are of particular concern; these products can be more hydrophobic, persistent, and toxic than their parent compounds. In the present study, naproxen, a widely used nonsteroidal anti-inflammatory drug, and its phototransformation products were studied to assess the overall persistence and photochemical fate of naproxen. Southern toad (Anaxyrus terrestris) larvae were used as model aquatic vertebrates to evaluate the acute toxicity of naproxen and its phototransformation products singly and in mixtures. The phototransformation products were observed to be more persistent and more toxic than naproxen itself. The slower phototransformation of the phototransformation products relative to naproxen suggests a greater potential to accumulate in the environment, particularly when naproxen is continually released. Mixtures of naproxen and its phototransformation products, in ratios observed during phototransformation, were more toxic than naproxen alone, as predicted by the model of concentration addition and the greater toxicity of the phototransformation products. Together, these results indicate that the ecological risk of naproxen may be underestimated by considering environmental levels of naproxen alone. Environ Toxicol Chem 2019;38:2008-2019. © 2019 SETAC., (© 2019 SETAC.)

The correct selection and placement of a single-site Avalon ® Elite Dual Lumen Cannula for veno-venous extracorporeal membrane oxygenation (ECMO) in children weighing less than 20 kg is dependent on both the mechanical characteristics of the catheter, including length and diameter, as well as the unique vascular anatomic considerations of the patient. This manuscript describes the development of a clinical strategy, over a four-year period from 2012-2016, for cannula selection to reduce the risk of migration and malposition in 20 critically ill children weighing less than 20 kg who presented for veno-venous ECMO.

Introduction: Anastomotic leak after pancreaticoduodenectomy is the most important cause of postoperative morbidity and mortality. Histological studies of bowel anastomoses have provided valuable insights regarding causes of anastomotic failure. However, this crucial information is lacking for pancreatico-enteric anastomoses., Methods: Pancreaticoduodenectomy was performed in a porcine model. Animals were survived up to 10 days and then the pancreatico-enteral anastomosis specimen was resected en bloc. Anastomotic bursting pressure was measured and histological sections of the anastomoses were examined., Results: Six out of 8 animals had excellent healing of the anastomoses. One animal developed a clinically significant leak at the pancreaticoduodenal anastomosis (12.5%) and one animal had a subclinical duodeno-duodenal leak discovered on necropsy (12.5%). Both anastomoses that failed had a collagen-to-tissue ratio less than 40%. In contrast, none of the anastomoses with a ratio greater than 40% showed any evidence of disruption., Conclusion: Our results indicate that quantitative measurement of collagen deposition at the pancreatic anastomosis provides objective assessment of healing of the pancreatic anastomosis. A survival porcine model of pancreaticoduodenectomy results in a similar leak rate to published data on pancreaticoduodenectomy in humans and will be useful for future studies assessing novel pharmacologic or technical interventions aimed at improving outcomes.

Pharmaceutically active compounds (PhACs) are released into the environment where they undergo soil sorption, photodegradation, and chemical transformation into structurally similar compounds. Here we report on studies of naproxen (NAP) and ibuprofen (IBP), two widely-used nonsteroidal anti-inflammatory drugs (NSAIDS), in soils and water. Organic matter (OM) was observed to play an important role in each of these processes. Sorption was observed to be stronger and nonlinear in higher OM soils while weaker but still significant in lower OM, higher clay soils; the amphiphilic nature of these two PhACs combined with the complex charged and nonpolar surfaces available in the soil was observed to control the sorption behavior. Simulated solar photodegradation rates of NAP and IBP in water were observed to change in the presence of humic acid or fulvic acid. Structural analogs of each compound were observed as the result of chemical transformation in both photoexposed aqueous solutions and non-photoexposed soil. Two of these transformation products were detected as both soil and photo transformation products for both PhACs. OM was observed to influence the chemical transformation of both pharmaceuticals., (Copyright © 2016 Elsevier B.V. All rights reserved.)

Background: Preoperative risk stratification for postoperative pancreatic fistula in patients undergoing distal pancreatectomy is needed., Methods: Risk factors for postoperative pancreatic fistula in 220 consecutive patients undergoing distal pancreatectomy at 2 major institutions were recorded retrospectively. Gland density was measured on noncontrast computed tomography scans (n = 101), and histologic scoring of fat infiltration and fibrosis was performed by a pathologist (n = 120)., Results: Forty-two patients (21%) developed a clinically significant pancreatic fistula within 90 days of surgery. Fat infiltration was significantly associated with gland density (P = .0013), but density did not predict pancreatic fistula (P = .5). Recursive partitioning resulted in a decision tree that predicted fistula in this cohort with a misclassification rate less than 15% using gland fibrosis (histology), density (HU), margin thickness (cm), and pathologic diagnosis., Conclusions: This multicenter study shows that no single perioperative factor reliably predicts postoperative pancreatic fistula after distal pancreatectomy. A decision tree was constructed for risk stratification., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Introduction: Routine lymphadenectomy in the surgical treatment of intrahepatic cholangiocarcinoma (ICC) is not routinely performed. We aim to define predictive indicators of survival in patients with positive lymph nodes., Methods: The National Cancer Data Base (NCDB) was queried for patients who underwent major hepatectomy for ICC between 1998 and 2011. Clinical and pathologic data were assessed using uni- and multi-variate analyses. A sub-analysis was performed on the 160 patients with positive lymph nodes., Results: Of 849 patients with lymph node data, 57% had at least one lymph node examined. Median survival for lymph node negative patients was 37 months versus 15 months for lymph node positive patients. In lymph node positive patients, poorer survival was associated with not receiving chemotherapy (HR 1.83, p = 0.003), tumor size > 5 cm (p = 0.029), and older age (p < 0.0001). Lymph node positive patients age less than 45 had a median survival of 27 months., Conclusions: Overall survival in patients with lymph node metastases from ICC is poor. Adjuvant therapy was associated with a longer survival in lymph node positive patients, although prospective data are needed. Routine lymphadenectomy should be strongly considered to provide prognostic information and guidance for adjuvant therapy., (Copyright © 2015 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

Background: Total pancreatectomy is infrequently performed for pancreatic cancer. Perceived operative mortality and questionable survival benefit deter many surgeons. Clinical outcomes, described in single-center series, remain largely unknown., Methods: The National Cancer Database was queried for cases of pancreatic ductal adenocarcinoma undergoing total pancreatectomy (1998-2011). Univariate survival analyses were performed for 21 variables: demographic (8), tumor characteristics (5), surgery outcomes (6), and adjuvant therapy (2). The Log-rank test of differences in Kaplan-Meier survival curves was used for categorical variables. Variables with p < 0.05 were included in a multivariate analysis. Cox proportional hazards regression was used to analyze continuous variables and multivariate models., Results: 2582 patients with staging and survival data made up the study population. 30-day mortality was 5.5%. Median overall survival was 15 months, with 1, 3, and 5-year survival rates of 60%, 22%, and 13%, respectively. Age, facility type, tumor size and grade, lymph node positivity, margin positivity, and adjuvant therapy significantly impacted survival in multivariate analysis., Conclusion: Although total pancreatectomy is a reasonable option for selected patients with pancreatic ductal adenocarcinoma, survival of the entire group is limited. Operative mortality is improved from prior reports. Greater survival benefits were seen in younger patients with smaller, node negative tumors resected with negative margins in academic research centers., (Copyright © 2015 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

As pharmaceutically active compounds (PhACs) are increasingly detected in the aquatic environment, the importance of investigating their transformation products-products of naturally occurring hydrolysis, biodegradation, and solar-mediated photochemical reactions - for persistence and ecotoxicity remains an important part of assessing the pharmaceutical's environmental impact and fate. In this study, the solar phototransformation of vardenafil (active ingredient in Levitra®) and sildenafil (Viagra®), two structurally similar compounds used to treat erectile dysfunction, was studied, with special attention to potentially persistent phototransformation (PT) products. PT products for vardenafil are identified here for the first time. Dilute solutions were prepared in buffered (pH=7.4) aqueous solutions, both with and without Suwanee River humic acid (SRHA) and fulvic acid (SRFA), and exposed to simulated sunlight. The PT products were identified via Liquid Chromatography-Electrospray Ionization-Mass Spectrometry (LC-ESI-MS) and confirmed by MS/MS. Both SRHA and SRFA were observed to lead to more extensive degradation of VRD while having minimal effect on SLD. At least two PT products, SLD-392 and VRD-392, were observed to be notably persistent, indicating their potential impact in the aquatic environment and highlighting the need for investigations of transformation products in natural water samples., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

There have been numerous recent advances geared specifically toward the practice of pediatric cardiopulmonary bypass (CPB). These advances include the development of the first oxygenator intended solely for the neonatal CPB patient; pediatric oxygenators with low prime volumes and surface areas, which allow flows up to 2 L/min; pediatric oxygenators with integrated arterial filters; and miniature ultrafiltration (UF) devices, which allow for high rates of ultrafiltrate removal. When used in combination with heart lung machines with mast-mounted pumps, these advances can result in significant decreases in CPB circuit surface areas and prime volumes. This may attenuate CPB-associated hemodilution and decrease or eliminate the need for homologous red blood cells during or after CPB. In addition to these equipment-related advances, changes in myocardial protection strategies and the technique of modified UF as it relates to these advances are discussed., (© The Author(s) 2014.)

Objectives: This study investigated the impact of neoadjuvant radiation therapy (XRT) on postoperative outcomes following pancreaticoduodenectomy for pancreatic cancer., Methods: The American College of Surgeons National Quality Improvement Program database was queried for the period 2005-2010 to assess complication rates following pancreaticoduodenectomy for pancreatic cancer. Two groups of patients were identified, comprising those who received neoadjuvant XRT and those who did not (control group)., Results: A total of 4416 patients were identified, including 200 in the XRT group and 4216 in the control group. There were differences in patient characteristics between the groups, including in age, hypertension and bilirubin level. Despite the fact that weight loss was more common, median operative time was longer (423 min versus 368 min; P < 0.001), and vascular reconstruction was more commonly required (20.5% versus 8.4%; P < 0.001) in the XRT group. In addition, the XRT group had a shorter median hospital stay than the control group (9 days versus 10 days; P = 0.005). Mortality (3.0% versus 2.7%; P = 0.818) and morbidity (40.5% versus 37.6%; P = 0.404) rates were not influenced by neoadjuvant XRT. Blood transfusion rates were increased in the XRT group (13.0% versus 7.4%; P = 0.003). Severe complications were influenced by age >70 years, American Society of Anesthesiologists (ASA) class >2, preoperative sepsis, dyspnoea, weight loss, impaired functional status, peripheral vascular disease and operative time of >8 h., Conclusions: Neoadjuvant XRT is not associated with an increase in complications after pancreaticoduodenectomy., (© 2013 International Hepato-Pancreato-Biliary Association.)

Developing technologies have changed both the components and the management style when extracorporeal membrane oxygenation (ECMO) is used to support critically ill cardiac and respiratory patients. The Cardiohelp system is a small, portable extracorporeal system just recently available within the United States. Manufacturing standards and quality processes have made mechanical failure and malfunction of extracorporeal components less common; however, there is still potential for mechanical failure or component malfunction before or during extracorporeal support. This case review describes the malfunction of a Retroguard unidirectional flow valve integrated into the priming setup of a Cardiohelp system during the priming process.

Unlabelled: The timing of blood product administration after cardiopulmonary bypass (CPB) may influence the amount of postoperative transfusion and chest tube output. We performed a retrospective study of a novel technique of administering blood products during modified ultrafiltration (MUF) in congenital cardiac surgery. A Control Group (CG; n = 55) received cryoprecipitate and platelets after modified ultrafiltration. The Treatment Group (TG; n = 59) received cryoprecipitate and platelets during MUF. Volumes of blood products transfused in the operating room, initial coagulation parameters in the cardiac intensive care unit, and first 24-hour chest tube output were recorded. Age (116 +/- 198 versus 84 +/- 91 days), weight (4.6 +/- 1.8 versus 4.5 +/- 1.4 kg), duration of bypass (121 +/- 50 versus 139 +/- 57 minutes), and Aristotle scoring (9.3 +/- 2.7 versus 9.1 +/- 3.1) were not significantly different when comparing the control and treatment groups, respectively. Intraoperative packed red blood cells (74.4 +/- 34.8 versus 79.3 +/- 58.0 mL/kg, p = .710), fresh-frozen plasma (58.3 +/- 27.1 versus 59.1 +/- 27.2 mL/kg, p = .849), cryoprecipitate (7.3 +/- 5.1 versus 8.6 +/- 5.9 mL/kg, p = .109), and platelet (19.0 +/- 14.6 versus 23.7 +/- 20.8 mL/kg, p = .176) administration were the same in the control and treatment groups, respectively. However, fibrinogen levels on arrival in the coronary intensive care unit were significantly higher (305 +/- 80 versus 255 +/- 40 mg/dL, p < .001) in the CG compared with the TG. Twenty-four-hour chest tube output was not significantly different but the CG (17.76 +/- 9.34 mL/kg/24 hours) was trending lower than the TG (19.52 +/- 10.94 mL/kg/24 hours, p = .357). In an attempt to minimize CPB-associated bleeding and transfusions, we changed our practice by adjusting the timing of blood product administration after patient separation from CPB. The goals of the change in practice were not measurably different in terms of shorter intraoperative times, fewer blood transfusions, or less chest tube output at our institution., Keywords: congenital heart disease, modified ultrafiltration, cryoprecipitate, platelets, cardiopulmonary bypass.

Background. The treatment of pancreatic cancer and other periampullary neoplasms is complex and challenging. Major high-volume cancer centers can provide excellent multidisciplinary care of these patients but almost two-thirds of pancreatic cancer patients are treated at low volume centers. There is very little published data from low volume community cancer programs in regards to the treatment of periampullary cancer. In this study, a review of comprehensive periampullary cancer care at two low volume hospitals with comparison to national standards is presented. Methods. This is a retrospective review of 70 consecutive patients with periampullary neoplasms who underwent surgery over a 5-year period (2006-2010) at two community hospitals. Results. There were 51 successful resections of 70 explorations (73%) including 34 Whipple procedures. Mortality rate was 2.9%. Comparison of these patients to national standards was made in terms of operative mortality, resectability rate, administration of adjuvant therapy, clinical trial participation and overall survival. The results in these patients were comparable to national standards. Conclusions. With adequate commitment of resources and experienced surgical and oncologic practitioners, community cancer centers can meet national tertiary care standards in terms of pancreatic and periampullary cancer care.

The forced degradation of 11 ibuprofen tablet brands was carried out according to current industry best practices. The results indicated an incompatibility between ibuprofen and two common tablet excipients (polyethylene glycol and polysorbate 80) that were observed to accelerate the degradation of ibuprofen in tablets stored for three weeks at 70°C/75% RH. Studies of binary drug/excipient samples supported the conclusion. One degradant that was observed at increased levels was 4-isobutylacetophenone (4-IBAP), which is a known toxin.

Autologous blood transfusion is the safest and most successful way to decrease transfusion-related risks such as postoperative infections, allo-immunization, and short- and long-term immunosuppression. In addition, these fibrin sealants are known to provide coagulation support at the surgical site and act as an adjunct to the control of postoperative bleeding. The physical formation of autologous platelet fibrin gel clot is dependent on both the common pathway of the coagulation cascade and platelet activation. Platelet gel can help provide control of intraoperative and postoperative bleeding. The Thrombelastograph Hemostasis Analyzer (TEG) measures the viscoelastic properties of a clot as it forms. Based on the information that the TEG provides, it promises to be a good choice for point of care measurement of the integrity of thrombus formed by platelet gels. Bovine blood from a single donor was sequestered into platelet-rich plasma and was made into platelet gel using calcium and three different concentrations of thrombin. The platelet gel samples were then analyzed with the TEG analyzer. The results for MA, tMA, CI, and angle were recorded and statistical analysis was performed to accept or reject the null hypothesis, which is: There is no difference between TEG parameters when analyzing platelet gels formed with calcium chloride, platelet-rich plasma and three different concentrations of thrombin A one-way analysis of variance test was performed between thrombin concentrations for MA (p = 0.19), tMA (p = 0.443), CI (p = 0.257), and angle (p = 0.323). The results showed that thrombin concentration did not affect the MA, tMA, CI, or angle as measured by the TEG analyzer. The null hypothesis was accepted. Based on a one-way analysis of variance test for MA, tMA, CI, and angle there was no significant statistical difference for the TEG samples in this experiment as reported with a 95% confidence interval.

Little in vitro research exists discussing platelet gel composition and the resulting strength and degradation characteristics using point-of-care technologies. There must be a quantifiable way of determining the structural integrity of the resulting formed platelet gel thrombus. The Thrombelastograph Hemostasis Analyzer (TEG) and Sonoclot measure the elasticity of a clot as it forms and subsequently degrades naturally. The objective of this study was to determine the application of TEG and Sonoclot technologies as point-of-care devices for technicians using platelet gel therapy. The collected bovine blood was anticoagulated with CPD and processed using a previously published plasma sequestration protocol, using normal saline as a wash solution. The resulting platelet-rich plasma was stored in a sequestration bag in a water bath to maintain the blood temperature at 37 degrees C. Sequestered bovine platelet-rich plasma was made into platelet gel using three different thrombin concentrations. A total of 30 experiments were performed on the platelet gel product using both the TEG and the Sonoclot. We discovered that 6 of the Sonoclot tests and 15 of the TEG tests were valid. None of the TEG clot signatures and nine of the Sonoclot signatures were discovered to be invalid. A chi2 test was performed on the resultant data. The value of the chi2 test was calculated to be 12.86, which translated into a p value of less than 0.001. Despite the vast use and growing popularity of platelet gels, a method in which to quantify platelet gels has yet to be reported. There remains a possibility that gels formed with different concentrations of components may prove useful in different areas of surgery or their uses may expand to a broader spectrum of medicine. However, technology to quantify platelet gels must first be standardized. On the basis of the data collected in this study, it was determined that the TEG and the Sonoclot are not equally capable of analyzing platelet gel clots. The TEG is a valid means for analysis, whereas the Sonoclot provided unreliable analysis based on a Chi-squared test.

As surface ultraviolet-B (UV-B) radiation levels increase due to the decline in the protective stratospheric ozone layer, ultraviolet radiation sunscreens will become more important for all plant species that grow in sunlight. Epicuticular waxes, which cover the aerial portions of all terrestrial plants, are ideally located to be sunscreens. The sun-screening ability of maize (Zea mays L.) epicuticular waxes was tested using the glossy1 mutant, which is specifically defective in juvenile wax production. A significant difference between the glossy1 mutant and wild type was seen in UV-induced leaf rolling and in some measurements of UV-induced DNA damage levels under enhanced UV. Isolated epicuticular wax layers absorbed significant amounts of UV, and leaves with wax absorbed more UV than leaves with little wax. Thus, by some measures, the epicuticular waxy layer acts as an ultraviolet radiation protectant in maize.