Does adherence to a quality indicator regarding early weaning from invasive ventilation improve economic outcome? A single-centre retrospective study

ObjectivesTo measure and assess the economic impact of adherence to a single quality indicator (QI) regarding weaning from invasive ventilation.DesignRetrospective observational single-centre study, based on electronic medical and administrative records.SettingIntensive care unit (ICU) of a German university hospital, reference centre for acute respiratory distress syndrome.ParticipantsRecords of 3063 consecutive mechanically ventilated patients admitted to the ICU between 2012 and 2017 were extracted, of whom 583 were eligible adults for further analysis. Patients’ weaning protocols were evaluated for daily adherence to quality standards until ICU discharge. Patients with <65% compliance were assigned to the low adherence group (LAG), patients with ≥65% to the high adherence group (HAG).Primary and secondary outcome measuresEconomic healthcare costs, clinical outcomes and patients’ characteristics.ResultsThe LAG consisted of 378 patients with a median negative economic results of −€3969, HAG of 205 (−€1030), respectively (p<0.001). Median duration of ventilation was 476 (248; 769) hours in the LAG and 389 (247; 608) hours in the HAG (p<0.001). Length of stay (LOS) in the LAG on ICU was 21 (12; 35) days and 16 (11; 25) days in the HAG (p<0.001). LOS in the hospital was 36 (22; 61) days in the LAG, and within the HAG, respectively, 26 (18; 48) days (p=0.001).ConclusionsHigh adherence to this single QI is associated with better clinical outcome and improved economic returns. Therefore, the results support the adherence to QI. However, the examined QI does not influence economic outcome as the decisive factor

ATPase activity of DFCP1 controls selective autophagy

Cellular homeostasis is governed by removal of damaged organelles and protein aggregates by selective autophagy mediated by cargo adaptors such as p62/SQSTM1. Autophagosomes can assemble in specialized cup-shaped regions of the endoplasmic reticulum (ER) known as omegasomes, which are characterized by the presence of the ER protein DFCP1/ZFYVE1. The function of DFCP1 is unknown, as are the mechanisms of omegasome formation and constriction. Here, we demonstrate that DFCP1 is an ATPase that is activated by membrane binding and dimerizes in an ATP-dependent fashion. Whereas depletion of DFCP1 has a minor effect on bulk autophagic flux, DFCP1 is required to maintain the autophagic flux of p62 under both fed and starved conditions, and this is dependent on its ability to bind and hydrolyse ATP. While DFCP1 mutants defective in ATP binding or hydrolysis localize to forming omegasomes, these omegasomes fail to constrict properly in a size-dependent manner. Consequently, the release of nascent autophagosomes from large omegasomes is markedly delayed. While knockout of DFCP1 does not affect bulk autophagy, it inhibits selective autophagy, including aggrephagy, mitophagy and micronucleophagy. We conclude that DFCP1 mediates ATPase-driven constriction of large omegasomes to release autophagosomes for selective autophagy

Influence of genetic variations in TLR4 and TIRAP/Mal on the course of sepsis and pneumonia and cytokine release: an observational study in three cohorts

Introduction: It has been proposed that individual genetic variation contributes to the course of severe infections and sepsis. Recent studies of single nucleotide polymorphisms (SNPs) within the endotoxin receptor and its signaling system showed an association with the risk of disease development. This study aims to examine the response associated with genetic variations of TLR4, the receptor for bacterial LPS, and a central intracellular signal transducer (TIRAP/Mal) on cytokine release and for susceptibility and course of severe hospital acquired infections in distinct patient populations. Methods: Three intensive care units in tertiary care university hospitals in Greece and Germany participated. 375 and 415 postoperative patients and 159 patients with ventilator associated pneumonia (VAP) were included. TLR4 and TIRAP/Mal polymorphisms in 375 general surgical patients were associated with risk of infection, clinical course and outcome. In two prospective studies, 415 patients following cardiac surgery and 159 patients with newly diagnosed VAP predominantly caused by Gram-negative bacteria were studied for cytokine levels in-vivo and after ex-vivo monocyte stimulation and clinical course. Results: Patients simultaneously carrying polymorphisms in TIRAP/Mal and TLR4 and patients homozygous for the TIRAP/Mal SNP had a significantly higher risk of severe infections after surgery (odds ratio (OR) 5.5; confidence interval (CI): 1.34 - 22.64; P = 0.02 and OR: 7.3; CI: 1.89 - 28.50; P < 0.01 respectively). Additionally we found significantly lower circulating cytokine levels in double-mutant individuals with ventilator associated pneumonia and reduced cytokine production in an ex-vivo monocyte stimulation assay, but this difference was not apparent in TIRAP/Mal-homozygous patients. In cardiac surgery patients without infection, the cytokine release profiles were not changed when comparing different genotypes. Conclusions: Carriers of mutations in sequential components of the TLR signaling system may have an increased risk for severe infections. Patients with this genotype showed a decrease in cytokine release when infected which was not apparent in patients with sterile inflammation following cardiac surgery

Low frequency of the TIRAP S180L polymorphism in Africa, and its potential role in malaria, sepsis, and leprosy

<p>Abstract</p> <p>Background</p> <p>The Toll-like receptors (TLRs) mediate innate immunity to various pathogens. A mutation (S180L) in the TLR downstream signal transducer <it>TIRAP </it>has recently been reported to be common in Europeans and Africans and to roughly half the risks of heterogeneous infectious diseases including malaria, tuberculosis, bacteremia, and invasive pneumococal disease in heterozygous mutation carriers.</p> <p>Methods</p> <p>We assessed the <it>TIRAP </it>S180L variant by melting curve and RFLP analysis in 1095 delivering women from malaria-endemic Ghana, as well as in a further 1114 individuals participating in case control studies on sepsis and leprosy in Germany, Turkey and Bangladesh.</p> <p>Results</p> <p>In Ghana, the <it>TIRAP </it>S180L polymorphism was virtually absent. In contrast, the mutation was observed among 26.6%, 32.9% and 12% of German, Bangladesh and Turkish controls, respectively. No significant association of the heterozygous genotype with sepsis or leprosy was observed. Remarkably, homozygous <it>TIRAP </it>180L tend to increase the risk of sepsis in the German study (<it>P </it>= 0.04).</p> <p>Conclusion</p> <p>A broad protective effect of <it>TIRAP </it>S180L against infectious diseases <it>per se </it>is not discernible.</p

The influence of genetic variations in the endotoxin-receptor-complex on susceptibility and course of systemic infections

Lipopolysaccharid (LPS), ein Hauptbestandteil Gram-negativer Bakterien, wird durch den Rezeptorkomplex des Toll-like Rezeptor (TLR)4, vom angeborenen Immunsystem des Menschen erkannt. Genetische Variationen, sogenannte single nucleotide polymorphisms (SNPs), von Bestandteilen dieses Komplexes sind möglicherweise verantwortlich für die Empfindlichkeit des Organismus, eine bakterielle Infektion zu erleiden oder beeinflussen deren Schweregrad. In einer prospektiven Untersuchung an 62 Patienten wurde gezeigt, dass der TLR4 Polymorphismus Asp299/Thr399 bei ex-vivo Vollblutstimulation durch LPS die Produktion von TNF und IL-6 nicht beeinflusst. Zusätzlich wurde eine seltene genetische Variation des extrazellulären Adapters von TLR4, MD-2 gefunden, der eine verminderte Stimulierbarkeit von NF-κB und in einer Patientin eine deutlich verminderte Zytokinantwort zeigte, jedoch keinen Einfluss auf die Expression oder das Bindungsverhalten des Moleküls. Eine dritte Studie ging der Frage nach, ob ein SNP in dem intrazellulären Adaptermolekül von TLR4, TIRAP/Mal, Einfluss auf Infektionshäufigkeit und Verlauf sowie in-vivo und in- vitro Zytokinantwort hat. Es zeigte sich bei retrospektiver Analyse von 375 Patienten, dass das simultane Vorliegen von TLR4 und TIRAP/Mal Polymorphismen sowie der homozygote Trägerstatus für TIRAP/Mal den Verlauf von septischen Erkrankungen negativ beeinflussen. In einer griechischen Patientengruppe mit Gram-negativer Sepsis zeigte sich, dass eine Assoziation zwischen dem doppelt mutierten Genotyp und niedrigeren Zytokinserumspiegeln besteht. Diese Patienten hatten zudem eine verminderte Stimulierbarkeit von Zytokinen in ex- vivo Monozyten-Stimulationsversuchen. Aus einer dritten prospektiven Untersuchung an 54 Patienten nach kardio- und gefäßchirurgischen Eingriffen hatte nach einer Fall-Kontroll-Analyse der Genotyp keinen Einfluss auf die Freisetzung von Zytokinen. Zusammenfassend existiert eine Assoziation zwischen der Existenz von genetischen Variationen des TLR4-Komplexes und seiner Adaptermoleküle und dem Verlauf schwerer Infektionen. Ebenso ist ein funktioneller Effekt dieser SNPs im Rahmen von Infektionskrankheiten detektierbar. Diese Unterschiede sind bei sterilen Inflammationsreaktionen nicht nachzuweisen.Lipopolysaccharide (LPS), a major constituent of Gram-negative bacteria, is recognized by the receptor complex of Toll-like receptor (TLR) 4 of the human innate immune system. Genetic variations, so called single nucleotide polymorphisms (SNPs), in components of this complex may be responsible for the susceptibility of the organism to suffer a bacterial infection or affect its severity. A prospective study in 62 patients showed that the TLR4 polymorphism Asp299/Thr399 did not influence the production of TNF and IL-6 following ex vivo whole blood stimulation with LPS. In addition, a rare genetic variation of the TLR4 extracellular adapter MD-2 was found to result in reduced NF-kappa B stimulation and in one patient showed a significantly decreased cytokine response. This did not affect the expression or the binding behavior of the molecule. A third study examined the question whether a SNP in the intracellular adapter molecule of TLR4, TIRAP/Mal, influenced the incidence and the course of infection and the in-vivo and in-vitro cytokine response. It was shown in a retrospective analysis in 375 patients that the simultaneous presence of TLR4 and TIRAP / Mal polymorphisms and the homozygous carrier state for TIRAP/Mal affected the course of septic incections negatively. In a group of Greek patients with Gram-negative sepsis there was an association between the double mutant genotype and lower cytokine levels. These patients also had lower cytokine levels following stimulation in ex-vivo monocyte stimulation experiments. A third prospective study of 54 patients after cardiac and vascular surgery showed no influence of the genotype on cytokine release in a case-control analysis. In summary, there is an association between the existence of genetic variations in the TLR4 complex and its adapter molecules and the course of severe infections. Similarly, a functional effect of these SNPs in the context of infectious diseases can be detected. These differences could not be detected in sterile inflammatory response

Concerted ESCRT and clathrin recruitment waves define the timing and morphology of intraluminal vesicle formation

The endosomal sorting complex required for transport (ESCRT) machinery mediates cargo sorting, membrane deformation and membrane scission on the surface of endosomes, generating intraluminal vesicles (ILVs) to degrade signaling receptors. By live-cell imaging of individual endosomes in human cells, we find that ESCRT proteins are recruited in a repetitive pattern: ESCRT-0 and -I show a gradual and linear recruitment and dissociation, whereas ESCRT-III and its regulatory ATPase VPS4 display fast and transient dynamics. Electron microscopy shows that ILVs are formed consecutively, starting immediately after endocytic uptake of cargo proteins and correlating with the repeated ESCRT recruitment waves, unraveling the timing of ILV formation. Clathrin, recruited by ESCRT-0, is required for timely ESCRT-0 dissociation, efficient ILV formation, correct ILV size and cargo degradation. Thus, cargo sorting and ILV formation occur by concerted, coordinated and repetitive recruitment waves of individual ESCRT subcomplexes and are controlled by clathrin

Successful on-ECLS Repair of CDH and Omphalocele in a Newborn

Both congenital diaphragmatic hernias (CDHs) and omphaloceles show relevant overall mortality rates as individual findings. The combination of the two has been described only sparsely in the literature and almost always with a fatal course. Here, we describe a term neonate with a rare high-risk constellation of left-sided CDH and a large omphalocele who was successfully treated on extracorporeal life support (ECLS). Prenatally, the patient was diagnosed with a large omphalocele and a left CDH with a lung volume of ∼27% and an observed to expected lung-to-head ratio of 30%. Due to respiratory insufficiency, an ECLS device was implanted. As weaning from ECLS was not foreseeable, the female infant underwent successful surgery on ECLS on the ninth day of life. Perioperative high-frequency oscillatory ventilation and circulatory and coagulation management under point-of-care monitoring were the main anesthesiological challenges. Over the following 3 days, ECLS weaning was successful, and the patient was extubated after another 43 days. Surgical treatment on ECLS can expand the spectrum of therapy in high-risk constellations if potential risks are minimized and there is close interdisciplinary cooperation