[Proposal for participation in intensive care and emergency medicine studies for patients unable to give informed consent (Cologne Model)]

When conducting clinical trials in intensive care and emergency medicine, physicians, ethics committees, and legal experts have differing views regarding the inclusion of patients who are incapable of giving consent. These different views on the participation of patients who are not capable of giving consent also complicate how clinical trials are prepared and conducted. Based on the results of a literature search, a consensus model (Cologne Model) was developed by physicians performing clinical research, ethics committees, and lawyers in order to provide patients, those scientifically responsible for the study, ethics committees, and probate (guardianship) judges with a maximum of patient safety and legal certainty, while simultaneously enabling scientific research.

Distinct Genetically Determined Origins of Myd88/BCL2-Driven Aggressive Lymphoma Rationalize Targeted Therapeutic Intervention Strategies

Genomic profiling revealed the identity of at least 5 subtypes of diffuse large B-cell lymphoma (DLBCL), including the MCD/C5 cluster characterized by aberrations in MYD88, BCL2, PRDM1, and/or SPIB. We generated mouse models harboring B cell-specific Prdm1 or Spib aberrations on the background of oncogenic Myd88 and Bcl2 lesions. We deployed whole-exome sequencing, transcriptome, flow-cytometry, and mass cytometry analyses to demonstrate that Prdm1- or Spib-altered lymphomas display molecular features consistent with prememory B cells and light-zone B cells, whereas lymphomas lacking these alterations were enriched for late light-zone and plasmablast-associated gene sets. Consistent with the phenotypic evidence for increased B cell receptor signaling activity in Prdm1-altered lymphomas, we demonstrate that combined BTK/BCL2 inhibition displays therapeutic activity in mice and in five of six relapsed/refractory DLBCL patients. Moreover, Prdm1-altered lymphomas were immunogenic upon transplantation into immuno-competent hosts, displayed an actionable PD-L1 surface expression, and were sensitive to antimurine-CD19-CAR-T cell therapy, in vivo.

SIGNIFICANCE

Relapsed/refractory DLBCL remains a major medical challenge, and most of these patients succumb to their disease. Here, we generated mouse models, faithfully recapitulating the biology of MYD88-driven human DLBCL. These models revealed robust preclinical activity of combined BTK/BCL2 inhibition. We confirmed activity of this regimen in pretreated non-GCB-DLBCL patients. See related commentary by Leveille et al., p. 8. This article is highlighted in the In This Issue feature, p. 1.

Clinical presentation, disease course, and outcome of COVID-19 in hospitalized patients with and without pre-existing cardiac disease: a cohort study across 18 countries

AIMS

Patients with cardiac disease are considered high risk for poor outcomes following hospitalization with COVID-19. The primary aim of this study was to evaluate heterogeneity in associations between various heart disease subtypes and in-hospital mortality.

METHODS AND RESULTS

We used data from the CAPACITY-COVID registry and LEOSS study. Multivariable Poisson regression models were fitted to assess the association between different types of pre-existing heart disease and in-hospital mortality. A total of 16 511 patients with COVID-19 were included (21.1% aged 66-75 years; 40.2% female) and 31.5% had a history of heart disease. Patients with heart disease were older, predominantly male, and often had other comorbid conditions when compared with those without. Mortality was higher in patients with cardiac disease (29.7%; n = 1545 vs. 15.9%; n = 1797). However, following multivariable adjustment, this difference was not significant [adjusted risk ratio (aRR) 1.08, 95% confidence interval (CI) 1.02-1.15; P = 0.12 (corrected for multiple testing)]. Associations with in-hospital mortality by heart disease subtypes differed considerably, with the strongest association for heart failure (aRR 1.19, 95% CI 1.10-1.30; P < 0.018) particularly for severe (New York Heart Association class III/IV) heart failure (aRR 1.41, 95% CI 1.20-1.64; P < 0.018). None of the other heart disease subtypes, including ischaemic heart disease, remained significant after multivariable adjustment. Serious cardiac complications were diagnosed in <1% of patients.

CONCLUSION

Considerable heterogeneity exists in the strength of association between heart disease subtypes and in-hospital mortality. Of all patients with heart disease, those with heart failure are at greatest risk of death when hospitalized with COVID-19. Serious cardiac complications are rare during hospitalization.

[Prioritization of intensive medical treatment places - Concept proposal]

In the situation of a shortage of ventilation beds, ethically justifiable, transparent and comprehensible decisions must be made. This concept proposes that all patients are first intubated depending on necessity and then assessed by a triage team afterwards. In this situation newly admitted COVID patients compete with newly admitted Non-COVID patients as well as patients already treated in intensive care units for a ventilator. The combination of short-term and long-term prognoses should enable the interprofessional triage team to make comprehensible decisions. The aim of the prioritization concept is to save as many human lives as possible and to relieve the treatment team of the difficult decision on prioritization.

[The critically ill CAR T-cell patient : Relevant toxicities, their management and challenges in critical care]

BACKGROUND

CAR‑T cell therapy has been implemented as clinical routine treatment option during the last decade. Despite beneficial outcomes in many patients severe side effects and toxicities are seen regularly that can compromise the treatment success.

METHODS

Literature review: CAR T‑cell therapy, toxicities and their management RESULTS: The cytokine release syndrome (CRS) and the immune effector cell-associated neurotoxicity syndrome (ICANS) are seen regularly after CAR T‑cell treatment. CRS symptoms can range from mild flu-like symptoms to severe organ dysfunction requiring vasopressor therapy, mechanical ventilation and other intensive care support. ICANS symptoms usually develop later and can range from disorientation and aphasia to potentially life-threatening brain edema. IL‑6 is a key factor in the pathophysiology of CRS. The pathophysiology of ICANS is not fully understood. The ASTCT consensus grading is recommended to stratify patients for different management options. An interdisciplinary team including hematologist, intensivist, neurologists and other specialties is needed to optimize the treatment.

DISCUSSION

Severe and potentially life-threatening toxicities occur regularly after CAR T‑cell therapy. Treatment strategies for CRS and ICANS still need to be evaluated prospectively. Due to the increasing number of patients treated with CAR T‑cells the number of patients requiring temporary intensive care management due to CRS and ICANS is expected to increase during the next years.

[Core curriculum Medical intensive care medicine of the German Society of Medical Intensive Care and Emergency Medicine (DGIIN)]

Medical intensive care medicine treats patients with severe, potentially life-threatening diseases covering the complete spectrum of internal medicine. The qualification in medical intensive care medicine requires a broad spectrum of knowledge and skills in medical intensive care medicine, but also in the general field of internal medicine. Both sides of the coin must be taken into account, the treatment with life-sustaining strategies of the acute illness of the patient and also the treatment of patient's underlying chronic diseases. The indispensable foundation of medical intensive care medicine as described in this curriculum includes basic knowledge and skills (level of competence I-III) as well as of behavior and attitudes. This curriculum is primarily dedicated to the internist in advanced training in medical intensive care medicine. However, this curriculum also intends to reach trainers in intensive care medicine and also the German physician chambers with their examiners, showing them which knowledge, skills as well as behavior and attitudes should be taught to trainees according to the education criteria of the German Society of Medical Intensive Care and Emergency Medicine (DGIIN).

An Autochthonous Mouse Model of Myd88- and BCL2-Driven Diffuse Large B-cell Lymphoma Reveals Actionable Molecular Vulnerabilities

Based on gene expression profiles, diffuse large B cell lymphoma (DLBCL) is sub-divided into germinal center B cell-like (GCB) and activated B cell-like (ABC) DLBCL. Two of the most common genomic aberrations in ABC-DLBCL are mutations in MYD88, as well as BCL2 copy number gains. Here, we employ immune phenotyping, RNA-Seq and whole exome sequencing to characterize a Myd88 and Bcl2-driven mouse model of ABC-DLBCL. We show that this model resembles features of human ABC-DLBCL. We further demonstrate an actionable dependence of our murine ABC-DLBCL model on BCL2. This BCL2 dependence was also detectable in human ABC-DLBCL cell lines. Moreover, human ABC-DLBCLs displayed increased PD-L1 expression, compared to GCB-DLBCL. In vivo experiments in our ABC-DLBCL model showed that combined venetoclax and RMP1-14 significantly increased the overall survival of lymphoma bearing animals, indicating that this combination may be a viable option for selected human ABC-DLBCL cases harboring MYD88 and BCL2 aberrations.

[Evolving Epidemiology of Home Mechanical Ventilation: A Rapidly Growing Challenge for Patient Care]

BACKGROUND

 Home mechanical ventilation is dramatically evolving in Germany. Patients with non-invasive and invasive ventilation are increasingly treated at home. In-hospital treatment of these patients is also necessary either for control visits or the management of acute medical problems. However, the development of in-hospital patient care, morbidity and mortality of these patients is unknown.

METHODS

 All patients with long-term dependence on mechanical ventilation for more than three months requiring hospitalisation between 2006 and 2016 were analysed (data obtained from the Federal Statistical Office of Germany).

RESULTS

 There was an exponential increase in the number of in-patients with long-term dependence of mechanical ventilation. While 24 845 patients were treated in-hospital in 2006, 86 117 patients were treated in 2016. Correspondingly, mortality decreased from 13.2 % (2006) to 5.7 % (2016). In addition, in 2016 47 % of all patients were treated on the intensive care or high dependency care unit. Overall, patients had been severely ill, as there were plenty of medical and neurological co-morbidities. The most common diagnosis was COPD with 58 % of all cases, followed by several cardiology diagnosis. A high number of patients had an impairment of renal function (24 %), in part requiring dialysis.

CONCLUSIONS

 The rapid development of home mechanical ventilation substantially impacts on the development of the hospital landscape in Germany. The exponential increase of these care-intensive patients is challenging for the health care system and requires a discussion about its limits.

[Diagnosis and treatment of immune-related adverse events during checkpoint inhibitor therapy in intensive care medicine]

BACKGROUND

Due to the use of checkpoint inhibitors, intensive care units will be confronted with an increasing number of patients with immune-related adverse events. A broad spectrum of symptoms and potentially lethal consequences make diagnosis and treatment challenging.

OBJECTIVES

Diagnosis and treatment of immune-related adverse events in the treatment with checkpoint inhibitors with a special focus on intensive care units.

MATERIALS AND METHODS

Review of current publications about incidence, symptoms and treatment of adverse events after the use of checkpoint inhibitors relevant for intensive care medicine.

RESULTS

Immune-related adverse events during therapy with checkpoint inhibitors are difficult to diagnose and present with various symptoms. Severe complications can often successfully be treated with early therapy.

CONCLUSIONS

The early treatment of immune-related adverse events according to their severity is needed to prevent a potentially life-threatening course.

Pelvic cellulitis caused by Raoultella planticola in a neutropenic patient

Raoultella planticola is a gram-negative, encapsulated, aerobic bacterium within the Enterobacteriaceae family. It has been primarily described as pathogen in cases with pneumonia and gastrointestinal infections. Here we describe a case of severe pelvic cellulitis in a patient with neutropenia following induction therapy for myeloid sarcoma. The patient experienced a septic shock and was treated successfully with antibiotic therapy. A literature review is provided to put this case in context with previous reports on R. planticola. This report highlights that awareness for uncommon pathogens is crucial in the clinical management of infections in neutropenic patients.

Consensus statement for cancer patients requiring intensive care support

This consensus statement is directed to intensivists, hematologists, and oncologists caring for critically ill cancer patients and focuses on the management of these patients.

[Diagnostic management of fever]

Fever is a symptom of a wide range of diseases. Its diagnostic management is of crucial importance, whereby the interface between general practitioner and hospital plays an important role. The family practitioner is of particular importance in the detection of life-threatening or complex situations involving fever. The diagnostic algorithm presented here can serve as the basis for rapid and targeted diagnostics. Good communication between the doctor and the hospital doctor is mandatory.

Infektiologie

Das Kapitel Infektiologie stellt die neue Sepsis-3-Definition, Management und die letzten Sepsisleitlinien von 2012 vor und beleuchtet auch die neuen Entwicklungen seitdem. Darüber hinaus werden Therapievorschläge für die wichtigsten infektiösen Erkrankungen (intraabdominelle Infektionen, akute Pankreatitis, Harnwegsinfekt mit Urosepsis, Pneumonie etc.) auf der Intensivstation gegeben und auch auf spezielle Erkrankungen wie komplizierte Malaria, opportunistische Infektionserkrankungen bei immunsupprimierten Patienten (u. a. HIV) eingegangen. Besonderer Wert wurde auf die mikrobiologische Erregerdiagnostik gelegt (Behälter, Transportmedien, Lagerung der Proben wie auch die richtige Probengewinnung). Zuletzt wird neben den Pilzinfektionen und deren Behandlung jedes der gängigsten Antibiotika und Antimykotika steckbriefartig zusammengefasst.

Transplantationsmedizin in der Intensivmedizin

Die Betreuung von Patienten vor und nach einer Organtransplantation gehört zum Gebiet der „speziellen Intensivmedizin“ des jeweiligen Fachbereichs. Die transplantationsspezifische Intensivmedizin setzt daher ein interdisziplinäres Management voraus. Neben der Organprotektion bzw. dem Monitoring von speziellen transplantationsrelevanten Problemen steht die Immunsuppression. Auf das Management mit Immunsuppressiva und von transplantationsassoziierten, intensivmedizinisch relevanten Problemen wird in diesem Kapitel eingegangen. Speziell werden Herz-, Lungen-, Leber-, Nieren- und Stammzelltransplantationen dargestellt.

Influenza virus infections in patients with malignancies -- characteristics and outcome of the season 2014/15. A survey conducted by the Infectious Diseases Working Party (AGIHO) of the German Society of Haematology and Medical Oncology (DGHO)

Influenza virus infections (IVI) may pose a vital threat to immunocompromised patients such as those suffering from malignancies, but specific data on epidemiology and outcome in these patients are scarce. In this study, we collected data on patients with active cancer or with a history of cancer, presenting with documented IVI in eight centres in Germany. Two hundred and three patients were identified, suffering from haematological malignancies or solid tumours; 109 (54 %) patients had active malignant disease. Influenza A was detected in 155 (77 %) and Influenza B in 46 (23 %) of patients (genera not determined in two patients). Clinical symptoms were consistent with upper respiratory tract infection in 55/203 (27 %), influenza-like illness in 82/203 (40 %), and pneumonia in 67/203 (33 %). Anti-viral treatment with oseltamivir was received by 116/195 (59 %). Superinfections occurred in 37/203 (18 %), and admission on an intensive care unit was required in 26/203 (13 %). Seventeen patients (9 %) died. Independent risk factors for death were delayed diagnosis of IVI and bacterial or fungal superinfection, but not underlying malignancy or ongoing immunosuppression. In conclusion, patients with IVI show high rates of pneumonia and mortality. Early and rapid diagnosis is essential. The high rate of pneumonia and superinfections should be taken into account when managing IVI in these patients.

[Staffing needs of an intensive care unit in consideration of applicable hygiene guidelines--an exploratory analysis]

The patient burden in intensive care units (ICU) has continually increased worldwide over the past decades. Age, co-morbidities and an increasing complexity of conditions and treatments increase the number of patients who are either colonized or infected with antibiotic-resistant pathogens. To prevent nosocomial infections, hygiene guidelines play an important role. In this paper, we investigate the time needed for nursing of five hypothetical critically ill patients in the intensive care unit. The results show that current staffing is not sufficient under the given hygiene guidelines and that a nurse to patient ratio of one will be necessary to meet the requirements. In a national survey of university hospitals, however, we found that the current nurse to patient ratio is 1: 2.47 in German intensive care units. The apparent staffing shortage is compensated by an extraordinary personal commitment of nurses caring for patients in the ICU.

[Morbidity and mortality conferences in internal medicine--experience at the University Hospital of Cologne]

Morbidity and mortality (M&M) conferences serve as a forum for the discussion of adverse events and errors in the treatment of patients. In the United States M&M conferences are an established part of medical training programs. While being state of the art in specialities like surgery and anesthesiology, they were established later on in internal medicine. To date, no reports have been published on M&M conferences in departments of internal medicine in Germany. Since August 2010 a morbidity and mortality conference takes place once per month in the Department I of Internal Medicine of the university hospital of Cologne. Cases with unexpected death, unexpected complications or medical errors are discussed. The primary goal is to create an open and confidential forum for doctors, where errors can be discussed without any assignment of guilt. The uncovering of structural problems frequently leads to direct improvements in patient care. Furthermore, the conference can play an important role in medical education.

[Hematologic and oncologic emergencies]

The rapid development of novel, targeted drugs in cancer medicine has led to an increase in chronically ill cancer patients and hematology patients, who are being treated aggressively despite significant comorbidities and higher age. This development will lead to an increase in the number of hematologic and oncologic emergencies, and these patients will be seen by various specialties. This review article, therefore, aims at providing clinical management algorithms for the most frequent emergencies.

[Ranolazine--an additional anti-anginal drug]

Ranolazine is a new drug for use in patients with stable angina pectoris. Unlike other antianginal drugs ranolazine does not alter heart rate or systemic blood pressure. Inhibition of the persistent or late sodium current (I(Na,late)) by ranolazine reduces [Na(+) ](i)-dependent Ca(2+) overload and the effects of ischaemia. Moreover, ranolazine holds potential promise to be effective in treatment of atrial fibrillation and diastolic heart failure.

Multiple malignant diseases in a patient with Rothmund-Thomson syndrome with RECQL4 mutations: Case report and literature review

RECQL4 mutations cause genetic instability and increase the risk of malignant disease. We report on a patient with compound heterozygosity for two novel RECQL4 mutations: mutation c.1919_1924delTCACAG, p.L640_A642delinsP in exon 12 of the RECQL4 gene and mutation c.1704+1G>A in intron 10 of the RECQL4 gene. He subsequently developed large cell anaplastic T cell lymphoma at the age of 9 years, diffuse large cell B lymphoma and osteosarcoma when he was 14 years old, and finally acute lymphatic leukemia when he was 21 years old. The most remarkable clinical features are young age, spontaneous remission of diffuse large cell lymphoma, and severe CNS and skin toxicity of cytotoxic treatment.