Management considerations of massive hemoptysis while on extracorporeal membrane oxygenation.

BACKGROUND: Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) is a life-saving procedure in patients with both respiratory and cardiac failure. Bleeding complications are common since patients must be maintained on anticoagulation. Massive hemoptysis is a rare complication of ECMO; however, it may result in death if not managed thoughtfully and expeditiously. METHODS: A retrospective chart review was performed of consecutive ECMO patients from 7/2010-8/2014 to identify episodes of massive hemoptysis. The management of and the outcomes in these patients were studied. Massive hemoptysis was defined as an inability to control bleeding (\u3e300 mL/day) from the endotracheal tube with conventional maneuvers, such as bronchoscopy with cold saline lavage, diluted epinephrine lavage and selective lung isolation. All of these episodes necessitated disconnecting the ventilator tubing and clamping the endotracheal tube, causing full airway tamponade. RESULTS: During the period of review, we identified 118 patients on ECMO and 3 (2.5%) patients had the complication of massive hemoptysis. One case was directly related to pulmonary catheter migration and the other two were spontaneous bleeding events that were propagated by antiplatelet agents. All three patients underwent bronchial artery embolization in the interventional radiology suite. Anticoagulation was held during the period of massive hemoptysis without any embolic complications. There was no recurrent bleed after appropriate intervention. All three patients were successfully separated from ECMO. CONCLUSIONS: Bleeding complications remain a major issue in patients on ECMO. Disconnection of the ventilator and clamping the endotracheal tube with full respiratory and cardiac support by V-A ECMO is safe. Early involvement of interventional radiology to embolize any potential sources of the bleed can prevent re-hemoptysis and enable continued cardiac and respiratory recovery

An old problem with a new therapy: GI bleeding in VAD patients and deep bowel enteroscopy (Double balloon. Spiral enteroscopy).

An old problem with a new therapy: GI Bleeding in VAD patients and deep bowel enteroscopy (Spiral and Double Balloon Enteroscopy) Purpose: Evidence suggests that patients treated with non-pulsatile ventricular assist devices (VAD) are at an increased risk for gastrointestinal bleeding (GIB) beyond what is expected from routine anticoagulation. Diagnostic and treatment algorithms are currently undefined. We reviewed our experience of GIB in VAD patients and propose a new algorithm utilizing deep bowel enteroscopy (DBE) aimed to speed diagnosis and limit transfusions. (471) Methods & Procedures From 2004 to 2011, we studied 62 patients who received a non-pulsatile VAD at our center for episodes of GIB. GIB was defined as heme-positive stool, hematemeisis, or drop in Hgb\u3e1gm. All patients were anticoagulated and no patient had any previous bleeding history. The diagnostic and treatment modalities utilized consisted of standard GIB tests but evolved into an algorithm based primarily on DBE. DBE consists of double-balloon and spiral enteroscopy that allow us to see and treat pathology in the small bowel upt o 400 cm beyond the Ligament of Treitz. (723) Results: There were 41 individual episodes of GIB in 14 patients. Separating the episodes into two groups based on days to diagnosis and days to treatment, we found that when the diagnosis was made and treated within 2 hospital days, patients received half (3.53 v. 7.33 with

The effect of Staphylococcus aureus carriage in late pregnancy on antibody levels to staphylococcal toxins in cord blood and breast milk.

We investigated the effect of carriage of Staphylococcus aureus in the later stages of pregnancy on levels of antibody specific to the S. aureus toxins, staphylococcal enterotoxin B (SEB), staphylococcal enterotoxin C (SEC) and toxic shock syndrome toxin-1 (TSST-1), in cord blood and breast milk and also explored the relationship between levels of antibody in antenatal serum and cord blood. Nasopharyngeal swabs and stool samples were collected on two occasions, from 96 women, during the last 6 weeks of pregnancy. Samples were cultured and S. aureus isolates were identified. Antenatal and cord blood samples from the same women and their infants were analysed for IgG antibody to SEB, SEC and TSST-1 by enzyme-linked immunosorbent assay. Breast milk samples were analysed for IgA antibody to the same toxins. We found that S. aureus carriage in pregnancy is common and exposure to a toxin-producing isolate boosts immunity. Over 89% of women and infants have some protective antibody to the toxins, and antitoxin IgG levels are higher in cord blood samples compared with antenatal samples. Levels of cord blood IgG and breast milk IgA specific for the staphylococcal toxins vary. Some infants lack protection and could be at risk of toxin-induced disease

Adult ECMO and gastrointestinal bleeding from small bowel arteriovenous malformations: A novel treatment using spiral enteroscopy.

Hemorrhagic complications on extracorporeal membrane oxygenation (ECMO) are common because of the need for anticoagulation to maintain the oxygenator and circuitry. Gastrointestinal bleeding (GIB) is reported to occur in 3-6% of ECMO patients, 1 requiring frequent transfusions as well as multiple diagnostic and therapeutic interventions. Multiple transfusions can result in volume overload, coagulopathies and infections leading to significant morbidity and mortality. We present the first published case of GIB from an arteriovenous malformation (AVM) treated with a novel therapy termed spiral enteroscopy while the patient remained on venoarterial (VA) ECMO

Efficacy of miniaturized imacor trans-esophageal echocardiografm (TEE) prove in mechanical circulatory support.

Application of the miniaturized ImaCor Trans-Esophageal Echocardiogram (TEE) probe in Heart Transplant/Mechanical Cardiac Support Patients In the surgical cardiac care unit (SCCU), therapeutic interventions often need to be done at the bedside, necessitating the need for a rapidly employable diagnostic tool for the cardiac intensivist. We report the clinical utility of the miniature ImaCor TEE-probe in guiding management of post heart transplant (H-Txp) and mechanical cardiac support patients (MCS) and describe the economic benefit of such a device. This is an IRB approved retrospective review of MCS/H-Txp patients who had ImaCor TEE monitoring in the SCCU of our institution in 2011. The effect on management was stratified into 3 categories; Major (tamponade/device selection/RV failure), Moderate (weaning support device guidance/ inotrope management/fluid management/hemodynamic instability) and Minor (line placement/useful data). The ImaCor TEE-Probe was utilized in a total of 34 patients, of which 21 were either supported by MCS or were post H-Txp. Of these, 13 were on ECMO, 9 were post-VAD, 3 supported by the Impella device and 4 were post-H-Txp. 6 patients were placed on more than 1 method of MCS and 1 patient was supported by ECMO after a H-Txp. The device had a Major effect on management in 4 patients (19%), Moderate effect in 13 (62%) and a Minor effect in 4 (19%). The cost difference between this new device and the traditional TEE is also significant (900 USD vs 4000 USD). Our institution saved in excess of 150,000 USD with the use of this device instead of traditional TEE. This figure did not include the ability of this probe to be used repeatedly within a 72-hour time frame, and the potential cost of going to the operating theatre for further management. This device has proven to be an invaluable new adjunct in the SCCU by allowing previously unobtainable continuous real time monitoring of the MCS/H-Txp patient. Use of the ImaCor TEE-probe provides the cardiac intensivist with timely important clinical data that improves patient care and is economically advantageous

The Touch of Iconoclasm

This article reflects on some depicted, intentional acts of iconoclasm undertaken by Isis in Northern Iraq, and viewed as online videos. It attempts to consider what makes these moving images compelling to audiences who share an orientation to the protection and preservation of ancient artefacts. In doing so it prompts a reflection on their circulation as part of stories that get told about cultural heritage, and particularly the simple civilizational oppositions that get set up between ‘Western’ and ‘Islamic’ culture. Centring on the significance of the sensation of touch to practices of cultural inscription, it suggests that the Northern Iraq videos animate forms of synaesthesic material engagement that are denied by the modernist technologies of museum culture

Generalised growth models for aquatic species with an application to blacklip abalone (Haliotis rubra)

This paper presents a maximum likelihood method for estimating growth parameters for an aquatic species that incorporates growth covariates, and takes into consideration multiple tag-recapture data. Individual variability in asymptotic length, age-at-tagging, and measurement error are also considered in the model structure. Using distribution theory, the log-likelihood function is derived under a generalised framework for the von Bertalanffy and Gompertz growth models. Due to the generality of the derivation, covariate effects can be included for both models with seasonality and tagging effects investigated. Method robustness is established via comparison with the Fabens, improved Fabens, James and a non-linear mixed-effects growth models, with the maximum likelihood method performing the best. The method is illustrated further with an application to blacklip abalone ( Haliotis rubra) for which a strong growth-retarding tagging effect that persisted for several months was detected

Pressures towards and against formalization: Regulation and informal employment in Mozambique

The informal economy accounts for the bulk of employment in many emerging economies. Regulation theory suggests that all economic activity is characterized by a complex combination of formal and informal regulation. Looking at the case of Mozambique, this article explores the pressures towards and against formalization, and the forms regulation can take, drawing on qualitative research based on in-depth elite interviews and observation. The findings highlight how the State's role in promoting formalization of the informal economy is ambivalent; its approach incorporates both "progressive" elements, which focus on the modernization of regulations and institutions, and "conservative" elements, which inhibit this process of change

Effect of the tetrahedral distortion on the electronic properties of iron-pnictides

We study the dependence of the electronic structure of iron pnictides on the angle formed by the arsenic-iron bonds. Within a Slater-Koster tight binding model which captures the correct symmetry properties of the bands, we show that the density of states and the band structure are sensitive to the distortion of the tetrahedral environment of the iron atoms. This sensitivity is extremely strong in a two-orbital (d_xz, d_yz) model due to the formation of a flat band around the Fermi level. Inclusion of the d_xy orbital destroys the flat band while keeping a considerable angle dependence in the band structure.Comment: 5 pages, including 5 figures. Fig. 5 replaced. Minor changes in the tex

Transgenic Overexpression of the Type I Isoform of Neuregulin 1 Affects Working Memory and Hippocampal Oscillations but not Long-term Potentiation

Neuregulin 1 (NRG1) is a growth factor involved in neurodevelopment and plasticity. It is a schizophrenia candidate gene, and hippocampal expression of the NRG1 type I isoform is increased in the disorder. We have studied transgenic mice overexpressing NRG1 type I (NRG1tg-type I) and their wild-type littermates and measured hippocampal electrophysiological and behavioral phenotypes. Young NRG1tg-type I mice showed normal memory performance, but in older NRG1tg-type I mice, hippocampus-dependent spatial working memory was selectively impaired. Hippocampal slice preparations from NRG1tg-type I mice exhibited a reduced frequency of carbachol-induced gamma oscillations and an increased tendency to epileptiform activity. Long-term potentiation in NRG1tg-type I mice was normal. The results provide evidence that NRG1 type I impacts on hippocampal function and circuitry. The effects are likely mediated via inhibitory interneurons and may be relevant to the involvement of NRG1 in schizophrenia. However, the findings, in concert with those from other genetic and pharmacological manipulations of NRG1, emphasize the complex and pleiotropic nature of the gene, even with regard to a single isoform