Causes of death in critically ill multiple sclerosis patients

BACKGROUND

Patients with multiple sclerosis (MS) experience higher mortality rates as compared to the general population. While the risk of intensive care unit (ICU) admission is also reported to be higher, little is known about causes of death CoD in critically ill MS patients.

AIM

To study the causes of death (CoD) in the series of critically ill patients with MS verified by autopsy.

METHODS

We reviewed hospital electronic charts of MS patients treated at the neurological ICU of a tertiary care hospital between 2000 and 2015. We compared clinical and pathological CoD for those who were autopsied.

RESULTS

Overall, 10 patients were identified (seven female; median age at death 65 years, range 27-80), and six of them were autopsied. The median MS duration prior to ICU admission was 27.5 years (range 1-50), and the median EDSS score at the time of ICU admission was 9 (range 5-9.5). The median length of ICU stay was 3 days (range 2-213). All the individuals in our series had experienced respiratory insufficiency during their ICU stay. The autopsy examination of brain tissue did not reveal evidences of MS lesions in one patient. In another patient, Lewy bodies were found on brain immunohistochemistry.

CONCLUSION

Mortality in critically ill MS patients is largely driven by respiratory complications. Sporadic disparities between clinical and pathological findings can be expected.

Granule fraction inhomogeneity of calcium carbonate/sorbitol in roller compacted granules

The granule fraction inhomogeneity of roller compacted granules was examined on mixtures of three different morphologic forms of calcium carbonate and three particle sizes of sorbitol. The granule fraction inhomogeneity was determined by the distribution of the calcium carbonate in each of the 10 size fractions between 0 and 2000 microm and by calculating the demixing potential. Significant inhomogeneous occurrence of calcium carbonate in the size fractions was demonstrated, depending mostly on the particles sizes of sorbitol but also on the morphological forms of calcium carbonate. The heterogeneous distribution of calcium carbonate was related to the decrease in compactibility of roller compacted granules in comparison to the ungranulated materials. This phenomenon was explained by a mechanism where fracturing of the ribbon during granulation occurred at the weakest interparticulate bonds (the calcium carbonate: calcium carbonate bonds) and consequently exposed the weakest areas of bond formation on the surface of the granules. Accordingly, the non-uniform allocation of the interparticulate attractive forces in a tablet would cause a lowering of the compactibility. Furthermore, the ability of the powder to agglomerate in the roller compactor was demonstrated to be related to the ability of the powder to be compacted into a tablet, thus the most compactable calcium carbonate and the smallest sized sorbitol improved the homogeneity by decreasing the demixing potential.

Improving the compaction properties of roller compacted calcium carbonate

The effects of roller compaction process parameters, morphological forms of calcium carbonate and particle size of sorbitol on flow, compaction and compression properties were investigated. The morphology of the calcium carbonate and the sorbitol particle size were more influential on the compaction properties than the settings of the roller compactor. The roller compaction process was demonstrated to be robust and stable in regard to flowability and compactibility. The flowability of the granules was improved adequately to facilitate compression in a production scale rotary tablet press. By adding sorbitol to the calcium carbonate, the compressibility - characterized by the Walker coefficient W(ID) - and the compactibility C(P) were improved considerably. A correlation between the consolidation characteristics was demonstrated. Compactibility data from the compaction simulator correlated with the tablet press for two of the calcium carbonates, the cubic form and the ground quality.

[Short-term dynamics of intertidal microphytobenthos biomass. Mathematical model]

We formulate a deterministic mathematical model to describe the dynamics of the microphytobenthos of intertidal mudflats. It is 'minimal' because it only takes into account the essential processes governing the functioning of the system: the autotrophic production, the active upward and downward migrations of epipelic microalgae, the saturation of the mud surface by a biofilm of diatoms and the global net loss rates of biomass. According to the photic environment of the benthic diatoms inhabiting intertidal mudflats, and to their migration rhythm, the model is composed of two sub-systems of ordinary differential equations; they describe the simultaneous evolution of the biomass 'S' concentrated in the mud surface biofilm--the photic layer--and of the biomass 'F' diluted in the topmost centimetre of the mud--the aphotic layer. Qualitatively, the model solutions agree fairly well with the in situ observed dynamics of the S + F biomass. The study of the mathematical properties of the model, under some simplifying assumptions, shows the convergence of solutions to a stable cyclic equilibrium, whatever the frequencies of the physical synchronizers of the production. The sensitivity analysis reveals the necessity of a better knowledge of the processes of biomass losses, which so far are uncertain, and may further vary in space and time.

[Primary delayed indication for single-step continence resection in 300 patients with acute colonic diverticulitis]

Since 1980, a total of 300 patients with colonic diverticulitis have undergone surgery. A vital indication forced us to do an emergency colostomy or Hartmann procedure in 22 cases. Except for 3 patients, the indication for resection was intentionally delayed by means of conservative treatment and a primary anastomosis was performed. Histological findings verified an inflammatory tumor, and abscess, a fistula or perforation in 50% and circumscript inflammation in 37%. The main complications were drainage problems (infection/retention of secretion, n = 18) and anastomosis insufficiency (n = 5), lethality was less than 2%. In general, we think that multistep surgery is not mandatory--even in advanced cases.

Laparoscopic appendectomy

Appendectomy was performed using a laparoscopic approach in 915 patients. The collected data show that the technique is as feasible, rapid, and safe as open surgery. Few wound infections, minimal pain, and rapid postoperative mobilization are the main arguments in favor of laparoscopic appendectomy. The most important potential benefit, a lower incidence of long-term complications such as adhesive intestinal obstruction, remains to be confirmed by prolonged follow-up of our patients.

Kryokonservierung von Humanerythrozyten mit Hydroxyethylstärke (HES) - Teil 2: Vitalitätsanalytik

Aus 5 Vollblutkonserven wurden durch Zentrifugation und mehrfaches Waschen gereinigte Erythrozyten (RBC) präpariert. Der Hämatokrit und die HES-Konzentration in den einzufrierenden 108-ml-Proben wurden auf 40 Vol.-% bzw. 12 Gew.-% eingestellt. Das Abkühlen erfolgte durch Eintauchen in Flüssigstickstoff, wobei Frier-Container eingesetzt wurden, die flache Probengeometrien von 3 mm Schicht-dicke erzeugten. Nach dem Auftauen im Schüttelwasserbad wurden sowohl die HES als auch das freie Hämoglobin durch einen einfachen Waschschritt entfernt. Danach wurden die RBC in autologes Frischplasma bzw. Locke-Lösung überführt, um deren Eignung als Resuspensionsmedium zu untersuchen. Die anhand der Salzstabilität nach dem Tauen gemessene Uberlebensrate erreichte 86,3 ± 2,3%. Es zeigte sich, daß die Kryokonservierung zu keinen wesentlichen Veränderungen bezüglich der osmotischen Resistenz, dem 2,3-DPG oder dem intrazellulären Na⁺ bzw. K⁺ geführt hatte. Das zunächst um 16% reduzierte ATP normalisierte sich ebenso innerhalb von 3 h, wie auch vorübergehende morphologische Transformationen (Stomato-zyten, Echinozyten) nach 1,5 h in autologem Plasma verschwanden. Festzuhalten bleibt also, daß aufgrund der erhobenen In-vitro-Parameter davon auszugehen ist, daß diejenigen RBC, die den Konservierungsprozeß überstanden haben, vollkommen vital sind.

Laparoscopic appendectomy in 625 cases: from innovation to routine

Invented in 1982 by Semm, a gynecologist, laparoscopic appendectomy began to be used in operative surgery in 1987. Since then, we have modified and performed this promising procedure in > 700 patients. The data of the first 625 cases indicate that laparoscopic appendectomy is safe and practicable. With regard to patient age as well as the acuteness of the inflammation, the patients represent a cross section of the normal appendicitis population. The major benefits and possible problems of the method are presented and discussed.

[Laser-assisted laparoscopic appendectomy]

Our constantly good experience with approximately 300 laparoscopic appendectomies (almost 520 at present (Feb. 90)) encouraged us in 1988 to introduce Laser technology into laparoscopic abdominal surgery. 22 patients underwent Laser-aided laparoscopic appendectomy. We obtained good results by means of using both an CO2-Laser and a Nd-YAG-Laser.

Modified laparoscopic appendectomy in surgery. A report on 388 operations

Laparoscopic appendectomy, introduced in gynecology by Semm in 1982, has been modified and practiced in our surgical ward since May 1987 in more than 450 patients suffering from all stages of acute and chronic vermix diseases. We report our data on the first series of 388 operations, in which we had the encouraging experience that laparoscopic appendectomy is a practicable and reasonable alternative to routine surgery.