Atrial fibrillation and survival on a medical intensive care unit

BACKGROUND

Atrial fibrillation (AF) is common among patients in the intensive care unit (ICU) and can be triggered by severe illness or preexisting conditions. It is debated if AF is an independent predictor of poor outcome.

METHODS

Data derives from a single center retrospective registry including all patients with a stay on the medical ICU for >24 h. The primary endpoint was ICU survival. Secondary endpoints included receiving mechanical support (renal, respiratory or circulatory), hemodynamic parameters during AF, rate and rhythm control strategies, anticoagulation, and documentation.

RESULTS

A total of 616 patients (male gender 62.3%, median age 75 years) were included in our analysis. New-onset AF was diagnosed in 87 patients (14.1%), 136 (22.1%) presented with preexisting AF, and 393 (63.8%) did not develop AF. Initial episodes of new-onset AF exhibited higher hemodynamic instability than episodes in preexisting cases, with elevated heart rates and increased catecholamine doses (both p < 0.001). ICU survival in new-onset AF was 80.5% (70/87) compared to 92.4% (363/393) in patients without AF (OR 0.340, CI 0.182-0.658, p < 0.001). Likewise, ICU survival in preexisting AF was 86.8% (118/136) was significantly lower compared to no AF (OR 0.542, CI 0.290-0.986, p = 0.050*). Independent predictors of ICU survival for patients were atrial fibrillation (p = 0.016), resuscitation before or during ICU stay (p < 0.001), and receiving acute dialysis on ICU (p = 0.002).

CONCLUSIONS

ICU survival is noticeably lower in patients with new-onset or preexisting atrial fibrillation compared to those without. Patients who develop new-onset AF during their ICU stay warrant special attention for both short-term and long-term care strategies.

Fracture risk of vertebral bodies after cryosurgery using a miniature cryoprobe: A biomechanical in-vitro analysis on human bones

INTRODUCTION

Due to spinal instability and compressive neurologic deficits surgical management is sometimes necessary in patients with metastatic spinal lesions. However, in some cases open surgery is not possible and minimally invasive procedures, like cryoablation, are needed. The aim of the current study was to investigate whether a miniature cryoprobe provides adequate tissue cooling in vertebrae and to evaluate the direct impact of cryosurgery on vertebral body stability.

MATERIALS AND METHODS

Twelve thoracic vertebral bodies were harvested from fresh cadavers. After documenting bone density cryoablation was performed in six vertebral bodies according to a standardized procedure. Afterwards temperature inside the vertebral body and maximum breaking force were measured in the control and experimental groups.

RESULTS

Required temperature of -50° was reached in all areas. There was a significant correlation between maximum breaking force and measured bone density (p= 0.001). Mean breaking force within the experimental group was 5047 N (SD = 2955 N) compared to 4458 N (SD = 2554 N) in the control group. There were no observable differences in maximum breaking force between both groups.

CONCLUSION

Miniature cryoprobe can deliver adequate tissue cooling to -50°C in vertebral bodies. The procedure does not seem to influence breaking force of the treated bones in-vitro. Therefore, using miniature probes cryosurgery may provide a valuable alternative to conventional surgical resection of neoplastic diseases as well as of benign locally aggressive bone tumors.

Catheter-directed foam sclerotherapy of great saphenous veins in combination with pre-treatment reduction of the diameter employing the principals of perivenous tumescent local anesthesia

OBJECTIVES

The aim of this study was to evaluate occlusion rates of great saphenous veins (GSV) with a diameter between 5-10 mm that received a pre-treatment size reduction via perivenous tumescent application (TA) followed by catheter-directed foam sclerotherapy (CDFS).

METHODS

A prospective blinded randomized clinical trial comparing the occlusion rates of GSV at 1-, 6-, and 12-month follow-up. Fifty patients were included and randomized into two groups. CDFS was performed accessing the GSV at knee level and applying 8 mL of 2% polidocanol-foam (EasyFoam) while the catheter was withdrawn. Strictly perivenous TA was performed in group 1 before applying the sclerosant agent. Occlusion rates and clinical scores were assessed by blinded examiners.

RESULTS

After 12 months in group 1 full occlusion was achieved in 73.9%, partial occlusion in 8.7%, and 17.4% were classified as treatment failure. In group 2, 75% of the targeted GSV were fully occluded, 20% were partially occluded, and 5% were diagnosed as treatment failure. Both groups showed a significant reduction of the vein diameter. Patient's tolerance and satisfaction with the treatment was high in both groups.

CONCLUSION

No benefit could be found using additional TA to reduce the vein diameter before the treatment.

[Treatment-refractory anti-laminin 332 mucous membrane pemphigoid. Remission following adjuvant immunoadsorption and rituximab]

Mucous membrane pemphigoid (MMP) is clinically characterized by predominant involvement of mucous membranes which in case of conjunctival lesions can lead to blindness. In MMP, autoantibodies are directed against different proteins of the dermal-epidermal junction; in 25% of cases, laminin 332 is the target. Anti-laminin 332 MMP with ocular involvement is particularly difficult to treat. A 46-year-old Caucasian man with anti-laminin 332 pemphigoid and extensive oral and nasal erosions as well as severe conjunctival involvement did not respond to intravenous dexamethasone-cyclophosphamide pulses combined with oral cyclophosphamide. After initiation of a therapeutic regimen originally established for the treatment of pemphigus, including immunoapheresis and rituximab in combination with intravenous dexamethasone-cyclophosphamide pulses and oral mycophenolate mofetil, lesions cleared within 4 months and circulating autoantibody levels became undetectable 3 months later. This is the first report of the successful use of adjuvant immunoapheresis and rituximab in previously treatment-refractory anti-laminin 332 MMP.