Impact of High Dose Early Mobilization on Outcomes for Patients with Diabetes: A Secondary Analysis of the TEAM Trial

RATIONALE

Patients with diabetes represent almost 20% of all ICU admissions and might respond differently to high dose early active mobilization.

OBJECTIVES

To assess whether diabetes modified the relationship between the dose of early mobilization on clinical outcomes in the TEAM trial.

METHODS

All TEAM trial patients were included. The primary outcome was days alive and out of hospital at day 180. Secondary outcomes included 180-day mortality and long-term functional outcomes at day 180. Logistic and median regression models were used to explore the effect of high dose early mobilization on outcomes by diabetes status.

MEASUREMENTS AND MAIN RESULTS

All 741 patients from the original trial were included. Of these, 159 patients (21.4%) had diabetes. Patients with diabetes had a lower number of days alive and out of hospital at day 180 (124 [0-153] vs. 147 [82-164], p = 0.013), and higher 180-day mortality (30% vs. 18%, p = 0.044). In patients receiving high dose early mobilization, days alive and out of hospital at day 180 was 73.0 (0.0 - 144.5) in patients with diabetes and 146.5 (95.8 - 163.0) in patients without diabetes (p for interaction = 0.108). However, in patients with diabetes, high dose early mobilization increased the odds of mortality at 180 days (adjusted odds ratio 3.47; 95% confidence interval [CI], 1.67-7.61, p value for interaction, 0.001).

CONCLUSIONS

In this secondary analysis of the TEAM trial, in patients with diabetes, a high dose early mobilization strategy did not significantly decrease the number of days alive and out of hospital at day 180 but it increased 180-day mortality.

Anti-Factor-Xa and Activated Partial Thromboplastin Time Concordance and Outcomes in Adults Undergoing Extracorporeal Membrane Oxygenation: A Secondary Analysis of the Pilot Low-Dose Heparin in Critically Ill Patients Undergoing Extracorporeal Membrane Oxygenation Randomized Trial

OBJECTIVES

To determine the concordance between activated partial thromboplastin time (aPTT) and anti-factor-Xa (anti-Xa) in adults undergoing extracorporeal membrane oxygenation (ECMO) and to identify the factors associated with discordant paired aPTT/anti-Xa.

DESIGN

Pre-planned secondary analysis of the Low-Dose Heparin in Critically Ill Patients Undergoing Extracorporeal Membrane Oxygenation pilot randomized unblinded, parallel-group controlled trial.

SETTING

Two ICUs in two university hospitals.

PATIENTS

Thirty-two critically ill patients who underwent ECMO and who had at least one paired aPTT and anti-Xa assay performed at the same time.

INTERVENTIONS

We analyzed the concordance between aPTT and anti-Xa and identified factors associated with discordant paired aPTT/anti-Xa based on their respective therapeutic ranges. We also compared biological parameters between heparin resistance episode and no heparin resistance.

MEASUREMENTS AND MAIN RESULTS

Of the 32 patients who were included in this study, 24 (75%) had at least one discordant paired aPTT/anti-Xa. Of the 581 paired aPTT/anti-Xa that were analyzed, 202 were discordant. The aPTT was relatively lower than anti-Xa in 66 cases (32.7%) or relatively higher than anti-Xa in 136 cases (67.3%). Thirty-three heparin resistance episodes were identified in six patients (19%).

CONCLUSIONS

In these critically ill patients undergoing ECMO, one third of paired aPTT/anti-Xa measures was discordant. Coagulopathy and heparin resistance might be the reasons for discordance. Our results support the potential importance of routinely monitoring both tests in this setting.

Early Active Mobilization during Mechanical Ventilation in the ICU

BACKGROUND

Intensive care unit (ICU)-acquired weakness often develops in patients who are undergoing invasive mechanical ventilation. Early active mobilization may mitigate ICU-acquired weakness, increase survival, and reduce disability.

METHODS

We randomly assigned 750 adult patients in the ICU who were undergoing invasive mechanical ventilation to receive increased early mobilization (sedation minimization and daily physiotherapy) or usual care (the level of mobilization that was normally provided in each ICU). The primary outcome was the number of days that the patients were alive and out of the hospital at 180 days after randomization.

RESULTS

The median number of days that patients were alive and out of the hospital was 143 (interquartile range, 21 to 161) in the early-mobilization group and 145 days (interquartile range, 51 to 164) in the usual-care group (absolute difference, -2.0 days; 95% confidence interval [CI], -10 to 6; P = 0.62). The mean (±SD) daily duration of active mobilization was 20.8±14.6 minutes and 8.8±9.0 minutes in the two groups, respectively (difference, 12.0 minutes per day; 95% CI, 10.4 to 13.6). A total of 77% of the patients in both groups were able to stand by a median interval of 3 days and 5 days, respectively (difference, -2 days; 95% CI, -3.4 to -0.6). By day 180, death had occurred in 22.5% of the patients in the early-mobilization group and in 19.5% of those in the usual-care group (odds ratio, 1.15; 95% CI, 0.81 to 1.65). Among survivors, quality of life, activities of daily living, disability, cognitive function, and psychological function were similar in the two groups. Serious adverse events were reported in 7 patients in the early-mobilization group and in 1 patient in the usual-care group. Adverse events that were potentially due to mobilization (arrhythmias, altered blood pressure, and desaturation) were reported in 34 of 371 patients (9.2%) in the early-mobilization group and in 15 of 370 patients (4.1%) in the usual-care group (P = 0.005).

CONCLUSIONS

Among adults undergoing mechanical ventilation in the ICU, an increase in early active mobilization did not result in a significantly greater number of days that patients were alive and out of the hospital than did the usual level of mobilization in the ICU. The intervention was associated with increased adverse events. (Funded by the National Health and Medical Research Council of Australia and the Health Research Council of New Zealand; TEAM ClinicalTrials.gov number, NCT03133377.).

Incidence of death or disability at 6 months after extracorporeal membrane oxygenation in Australia: a prospective, multicentre, registry-embedded cohort study

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) is an invasive procedure used to support critically ill patients with the most severe forms of cardiac or respiratory failure in the short term, but long-term effects on incidence of death and disability are unknown. We aimed to assess incidence of death or disability associated with ECMO up to 6 months (180 days) after treatment.

METHODS

This prospective, multicentre, registry-embedded cohort study was done at 23 hospitals in Australia from Feb 15, 2019, to Dec 31, 2020. The EXCEL registry included all adults (≥18 years) in Australia who were admitted to an intensive care unit (ICU) in a participating centre at the time of the study and who underwent ECMO. All patients who received ECMO support for respiratory failure, cardiac failure, or cardiac arrest during their ICU stay were eligible for this study. The primary outcome was death or moderate-to-severe disability (defined using the WHO Disability Assessment Schedule 2.0, 12-item survey) at 6 months after ECMO initiation. We used Fisher's exact test to compare categorical variables. This study is registered with ClinicalTrials.gov, NCT03793257.

FINDINGS

Outcome data were available for 391 (88%) of 442 enrolled patients. The primary outcome of death or moderate-to-severe disability at 6 months was reported in 260 (66%) of 391 patients: 136 (67%) of 202 who received veno-arterial (VA)-ECMO, 60 (54%) of 111 who received veno-venous (VV)-ECMO, and 64 (82%) of 78 who received extracorporeal cardiopulmonary resuscitation (eCPR). After adjustment for age, comorbidities, Acute Physiology and Chronic Health Evaluation (APACHE) IV score, days between ICU admission and ECMO start, and use of vasopressors before ECMO, death or moderate-to-severe disability was higher in patients who received eCPR than in those who received VV-ECMO (VV-ECMO vs eCPR: risk difference [RD] -32% [95% CI -49 to -15]; p<0·001) but not VA-ECMO (VA-ECMO vs eCPR -8% [-22 to 6]; p=0·27).

INTERPRETATION

In our study, only a third of patients were alive without moderate-to-severe disability at 6 months after initiation of ECMO. The finding that disability was common across all areas of functioning points to the need for long-term, multidisciplinary care and support for surviving patients who have had ECMO. Further studies are needed to understand the 180-day and longer-term prognosis of patients with different diagnoses receiving different modes of ECMO, which could have important implications for the selection of patients for ECMO and management strategies in the ICU.

FUNDING

The National Health and Medical Research Council of Australia.

Protocol and statistical analysis plan for the phase 3 randomised controlled Treatment of Invasively Ventilated Adults with Early Activity and Mobilisation (TEAM III) trial

Objective: To describe the protocol and statistical analysis plan for the Treatment of Invasively Ventilated Adults with Early Activity and Mobilisation (TEAM III) trial. Design: An international, multicentre, parallel-group, randomised controlled phase 3 trial. Setting: Intensive care units (ICUs) in Australia, New Zealand, Germany, Ireland, the United Kingdom and Brazil. Patients: 750 adult patients expected to receive mechanical ventilation for more than 48 hours. Interventions: Early activity and mobilisation delivered to critically ill patients in an ICU for up to 28 days compared with standard care. Main outcome measures: The primary outcome is the number of days alive and out of hospital at 180 days after randomisation. Secondary outcomes include ICU-free days, ventilator-free days, delirium-free days, all-cause mortality at 28 and 180 days after randomisation, and functional outcome at 180 days after randomisation. Results: Recruitment at 46 research sites passed 576 patients in March 2021. Final collection of all 180-day outcome data for the target of 750 patients is anticipated by May 2022. Conclusions: Consistent with international guidelines, a detailed protocol and prospective analysis plan has been developed for the TEAM III trial. This plan specifies the statistical models for evaluating primary and secondary outcomes, defines covariates for adjusted analyses, and defines methods for exploratory analyses. Application of this protocol and statistical analysis plan to the forthcoming TEAM III trial will facilitate unbiased analyses of the clinical data collected. Trial registration:ClinicalTrials.gov identifier NCT03133377.

Effect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial

IMPORTANCE

Evidence regarding corticosteroid use for severe coronavirus disease 2019 (COVID-19) is limited.

OBJECTIVE

To determine whether hydrocortisone improves outcome for patients with severe COVID-19.

DESIGN, SETTING, AND PARTICIPANTS

An ongoing adaptive platform trial testing multiple interventions within multiple therapeutic domains, for example, antiviral agents, corticosteroids, or immunoglobulin. Between March 9 and June 17, 2020, 614 adult patients with suspected or confirmed COVID-19 were enrolled and randomized within at least 1 domain following admission to an intensive care unit (ICU) for respiratory or cardiovascular organ support at 121 sites in 8 countries. Of these, 403 were randomized to open-label interventions within the corticosteroid domain. The domain was halted after results from another trial were released. Follow-up ended August 12, 2020.

INTERVENTIONS

The corticosteroid domain randomized participants to a fixed 7-day course of intravenous hydrocortisone (50 mg or 100 mg every 6 hours) (n = 143), a shock-dependent course (50 mg every 6 hours when shock was clinically evident) (n = 152), or no hydrocortisone (n = 108).

MAIN OUTCOMES AND MEASURES

The primary end point was organ support-free days (days alive and free of ICU-based respiratory or cardiovascular support) within 21 days, where patients who died were assigned -1 day. The primary analysis was a bayesian cumulative logistic model that included all patients enrolled with severe COVID-19, adjusting for age, sex, site, region, time, assignment to interventions within other domains, and domain and intervention eligibility. Superiority was defined as the posterior probability of an odds ratio greater than 1 (threshold for trial conclusion of superiority >99%).

RESULTS

After excluding 19 participants who withdrew consent, there were 384 patients (mean age, 60 years; 29% female) randomized to the fixed-dose (n = 137), shock-dependent (n = 146), and no (n = 101) hydrocortisone groups; 379 (99%) completed the study and were included in the analysis. The mean age for the 3 groups ranged between 59.5 and 60.4 years; most patients were male (range, 70.6%-71.5%); mean body mass index ranged between 29.7 and 30.9; and patients receiving mechanical ventilation ranged between 50.0% and 63.5%. For the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively, the median organ support-free days were 0 (IQR, -1 to 15), 0 (IQR, -1 to 13), and 0 (-1 to 11) days (composed of 30%, 26%, and 33% mortality rates and 11.5, 9.5, and 6 median organ support-free days among survivors). The median adjusted odds ratio and bayesian probability of superiority were 1.43 (95% credible interval, 0.91-2.27) and 93% for fixed-dose hydrocortisone, respectively, and were 1.22 (95% credible interval, 0.76-1.94) and 80% for shock-dependent hydrocortisone compared with no hydrocortisone. Serious adverse events were reported in 4 (3%), 5 (3%), and 1 (1%) patients in the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively.

CONCLUSIONS AND RELEVANCE

Among patients with severe COVID-19, treatment with a 7-day fixed-dose course of hydrocortisone or shock-dependent dosing of hydrocortisone, compared with no hydrocortisone, resulted in 93% and 80% probabilities of superiority with regard to the odds of improvement in organ support-free days within 21 days. However, the trial was stopped early and no treatment strategy met prespecified criteria for statistical superiority, precluding definitive conclusions.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02735707.

Effect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial

IMPORTANCE

Evidence regarding corticosteroid use for severe coronavirus disease 2019 (COVID-19) is limited.

OBJECTIVE

To determine whether hydrocortisone improves outcome for patients with severe COVID-19.

DESIGN, SETTING, AND PARTICIPANTS

An ongoing adaptive platform trial testing multiple interventions within multiple therapeutic domains, for example, antiviral agents, corticosteroids, or immunoglobulin. Between March 9 and June 17, 2020, 614 adult patients with suspected or confirmed COVID-19 were enrolled and randomized within at least 1 domain following admission to an intensive care unit (ICU) for respiratory or cardiovascular organ support at 121 sites in 8 countries. Of these, 403 were randomized to open-label interventions within the corticosteroid domain. The domain was halted after results from another trial were released. Follow-up ended August 12, 2020.

INTERVENTIONS

The corticosteroid domain randomized participants to a fixed 7-day course of intravenous hydrocortisone (50 mg or 100 mg every 6 hours) (n = 143), a shock-dependent course (50 mg every 6 hours when shock was clinically evident) (n = 152), or no hydrocortisone (n = 108).

MAIN OUTCOMES AND MEASURES

The primary end point was organ support-free days (days alive and free of ICU-based respiratory or cardiovascular support) within 21 days, where patients who died were assigned -1 day. The primary analysis was a bayesian cumulative logistic model that included all patients enrolled with severe COVID-19, adjusting for age, sex, site, region, time, assignment to interventions within other domains, and domain and intervention eligibility. Superiority was defined as the posterior probability of an odds ratio greater than 1 (threshold for trial conclusion of superiority >99%).

RESULTS

After excluding 19 participants who withdrew consent, there were 384 patients (mean age, 60 years; 29% female) randomized to the fixed-dose (n = 137), shock-dependent (n = 146), and no (n = 101) hydrocortisone groups; 379 (99%) completed the study and were included in the analysis. The mean age for the 3 groups ranged between 59.5 and 60.4 years; most patients were male (range, 70.6%-71.5%); mean body mass index ranged between 29.7 and 30.9; and patients receiving mechanical ventilation ranged between 50.0% and 63.5%. For the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively, the median organ support-free days were 0 (IQR, -1 to 15), 0 (IQR, -1 to 13), and 0 (-1 to 11) days (composed of 30%, 26%, and 33% mortality rates and 11.5, 9.5, and 6 median organ support-free days among survivors). The median adjusted odds ratio and bayesian probability of superiority were 1.43 (95% credible interval, 0.91-2.27) and 93% for fixed-dose hydrocortisone, respectively, and were 1.22 (95% credible interval, 0.76-1.94) and 80% for shock-dependent hydrocortisone compared with no hydrocortisone. Serious adverse events were reported in 4 (3%), 5 (3%), and 1 (1%) patients in the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively.

CONCLUSIONS AND RELEVANCE

Among patients with severe COVID-19, treatment with a 7-day fixed-dose course of hydrocortisone or shock-dependent dosing of hydrocortisone, compared with no hydrocortisone, resulted in 93% and 80% probabilities of superiority with regard to the odds of improvement in organ support-free days within 21 days. However, the trial was stopped early and no treatment strategy met prespecified criteria for statistical superiority, precluding definitive conclusions.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02735707.

A survey of extracorporeal membrane oxygenation practice in 23 Australian adult intensive care units

In Australia, extracorporeal membrane oxygenation (ECMO) is one of the most expensive diagnosis-related groups, costing $305 463 per complex admission to the intensive care unit(ICU). Mortality in this group of patients is high, about 43% for respiratory failure and 68% for cardiac failure. ECMO is associated with significant risk to the patient and requires specialist training andexpertise. Variation in clinical practice for patients supported with ECMO may compromise patient care and outcomes.

Prospective observational study of mechanical cardiopulmonary resuscitation, extracorporeal membrane oxygenation and early reperfusion for refractory cardiac arrest in Sydney: the 2CHEER study

BACKGROUND: Patients with prolonged cardiac arrest that is not responsive to conventional cardiopulmonary resuscitation have poor outcomes. The use of extracorporeal membrane oxygenation (ECMO) in refractory cardiac arrest has shown promising results in carefully selected cases. We sought to validate the results from an earlier extracorporeal cardiopulmonary resuscitation (ECPR) study (the CHEER trial). METHODS: Prospective, consecutive patients with refractory in-hospital (IHCA) or out-of-hospital cardiac arrest (OHCA) who met predefined inclusion criteria received protocolised care, including mechanical cardiopulmonary resuscitation, initiation of ECMO, and early coronary angiography (if an acute coronary syndrome was suspected). RESULTS: Twenty-five patients were enrolled in the study (11 OHCA, 14 IHCA); the median age was 57 years (interquartile range [IQR], 39–65 years), and 17 patients (68%) were male. ECMO was established in all patients, with a median time from arrest to ECMO support of 57 minutes (IQR, 38–73 min). Percutaneous coronary intervention was performed on 18 patients (72%). The median duration of ECMO support was 52 hours (IQR, 24–108 h). Survival to hospital discharge with favourable neurological recovery occurred in 11/25 patients (44%, of which 72% had IHCA and 27% had OHCA). When adjusting for lactate, arrest to ECMO flow time was predictive of survival (odds ratio, 0.904; P = 0.035). CONCLUSION: ECMO for refractory cardiac arrest shows promising survival rates if protocolised care is applied in conjunction with predefined selection criteria.

Prospective observational study of mechanical cardiopulmonary resuscitation, extracorporeal membrane oxygenation and early reperfusion for refractory cardiac arrest in Sydney: the 2CHEER study

BACKGROUND

Patients with prolonged cardiac arrest that is not responsive to conventional cardiopulmonary resuscitation have poor outcomes. The use of extracorporeal membrane oxygenation (ECMO) in refractory cardiac arrest has shown promising results in carefully selected cases. We sought to validate the results from an earlier extracorporeal cardiopulmonary resuscitation (ECPR) study (the CHEER trial).

METHODS

Prospective, consecutive patients with refractory in-hospital (IHCA) or out-of-hospital cardiac arrest (OHCA) who met predefined inclusion criteria received protocolised care, including mechanical cardiopulmonary resuscitation, initiation of ECMO, and early coronary angiography (if an acute coronary syndrome was suspected).

RESULTS

Twenty-five patients were enrolled in the study (11 OHCA, 14 IHCA); the median age was 57 years (interquartile range [IQR], 39-65 years), and 17 patients (68%) were male. ECMO was established in all patients, with a median time from arrest to ECMO support of 57 minutes (IQR, 38-73 min). Percutaneous coronary intervention was performed on 18 patients (72%). The median duration of ECMO support was 52 hours (IQR, 24-108 h). Survival to hospital discharge with favourable neurological recovery occurred in 11/25 patients (44%, of which 72% had IHCA and 27% had OHCA). When adjusting for lactate, arrest to ECMO flow time was predictive of survival (odds ratio, 0.904; P = 0.035).

CONCLUSION

ECMO for refractory cardiac arrest shows promising survival rates if protocolised care is applied in conjunction with predefined selection criteria.

Internet health information use by surrogate decision makers of patients admitted to the intensive care unit: a multicentre survey

OBJECTIVES

To investigate the use, understanding, trust and influence of the internet and other sources of health information used by the next of kin (NOK) of patients admitted to the intensive care unit (ICU).

DESIGN

Multicentre structured survey.

SETTING

The ICUs of 13 public and private Australian hospitals.

PARTICIPANTS

NOK who self-identified as the primary surrogate decision maker for a patient admitted to the ICU.

MAIN OUTCOME MEASURES

The frequency, understanding, trust and influence of online sources of health information, and the quality of health websites visited using the Health on the Net Foundation Code of Conduct (HONcode) for medical and health websites.

RESULTS

There were 473 survey responses. The median ICU admission days and number of ICU visits by the NOK at the time of completing the survey was 3 (IQR, 2-6 days) and 4 (IQR, 2-7), respectively. The most commonly reported sources of health information used very frequently were the ICU nurse (55.6%), ICU doctor (38.7%), family (23.3%), hospital doctor (21.4%), and the internet (11.3%). Compared with the 243 NOK (51.6%) not using the internet, NOK using the internet were less likely to report complete understanding (odds ratio [OR], 0.57; 95% CI, 0.38-0.88), trust (OR, 0.34; 95% CI, 0.19-0.59), or influence (OR, 0.58; 95% CI, 0.38-0.88) associated with the ICU doctor. Overall, the quality of the 40 different reported websites accessed was moderately high.

CONCLUSIONS

A substantial proportion of ICU NOK report using the internet as a source of health information. Internet use is associated with lower reported understanding, trust and influence of the ICU doctor.

The effect of augmenting early nutritional energy delivery on quality of life and employment status one year after ICU admission

Augmenting energy delivery during the acute phase of critical illness may reduce mortality and improve functional outcomes. The objective of this sub-study was to evaluate the effect of early augmented enteral nutrition (EN) during critical illness, on outcomes one year later. We performed prospective longitudinal evaluation of study participants, initially enrolled in The Augmented versus Routine approach to Giving Energy Trial (TARGET), a feasibility study that randomised critically ill patients to 1.5 kcal/ml (augmented) or 1.0 kcal/ml (routine) EN administered at the same rate for up to ten days, who were alive at one year. One year after randomisation Short Form-36 version 2 (SF-36v2) and EuroQol-5D-5L quality of life surveys, and employment status were assessed via telephone survey. At one year there were 71 survivors (1.5 kcal/ml 38 versus 1.0 kcal/ml 33; P=0.55). Thirty-nine (55%) patients consented to this follow-up study and completed the surveys (n = 23 and 16, respectively). The SF-36v2 physical and mental component summary scores were below normal population means but were similar in 1.5 kcal/ml and 1.0 kcal/ml groups (P=0.90 and P=0.71). EuroQol-5D-5L data were also comparable between groups (P=0.70). However, at one-year follow-up, more patients who received 1.5 kcal/ml were employed (7 versus 2; P=0.022). The delivery of 1.5 kcal/ml for a maximum of ten days did not affect self-rated quality of life one year later.

Early mobilization and recovery in mechanically ventilated patients in the ICU: a bi-national, multi-centre, prospective cohort study

Introduction

The aim of this study was to investigate current mobilization practice, strength at ICU discharge and functional recovery at 6 months among mechanically ventilated ICU patients.

Method

This was a prospective, multi-centre, cohort study conducted in twelve ICUs in Australia and New Zealand. Patients were previously functionally independent and expected to be ventilated for >48 hours. We measured mobilization during invasive ventilation, sedation depth using the Richmond Agitation and Sedation Scale (RASS), co-interventions, duration of mechanical ventilation, ICU-acquired weakness (ICUAW) at ICU discharge, mortality at day 90, and 6-month functional recovery including return to work.

Results

We studied 192 patients (mean age 58.1 ± 15.8 years; mean Acute Physiology and Chronic Health Evaluation (APACHE) (IQR) II score, 18.0 (14 to 24)). Mortality at day 90 was 26.6% (51/192). Over 1,351 study days, we collected information during 1,288 planned early mobilization episodes in patients on mechanical ventilation for the first 14 days or until extubation (whichever occurred first). We recorded the highest level of early mobilization. Despite the presence of dedicated physical therapy staff, no mobilization occurred in 1,079 (84%) of these episodes. Where mobilization occurred, the maximum levels of mobilization were exercises in bed (N = 94, 7%), standing at the bed side (N = 11, 0.9%) or walking (N = 26, 2%). On day three, all patients who were mobilized were mechanically ventilated via an endotracheal tube (N = 10), whereas by day five 50% of the patients mobilized were mechanically ventilated via a tracheostomy tube (N = 18).

In 94 of the 156 ICU survivors, strength was assessed at ICU discharge and 48 (52%) had ICU-acquired weakness (Medical Research Council Manual Muscle Test Sum Score (MRC-SS) score <48/60). The MRC-SS score was higher in those patients who mobilized while mechanically ventilated (50.0 ± 11.2 versus 42.0 ± 10.8, P = 0.003). Patients who survived to ICU discharge but who had died by day 90 had a mean MRC score of 28.9 ± 13.2 compared with 44.9 ± 11.4 for day-90 survivors (P <0.0001).

Conclusions

Early mobilization of patients receiving mechanical ventilation was uncommon. More than 50% of patients discharged from the ICU had developed ICU-acquired weakness, which was associated with death between ICU discharge and day-90.

Clinical trial registration

ClinicalTrials.gov NCT01674608. Registered 14 August 2012.

Investigation of the performance of digital mammographic X-ray equipment: determination of noise equivalent quanta (NEQQC) and detective quantum efficiency (DQEQC) compared with the automated analysis of CDMAM test images with CDCOM and CDIC programs

PURPOSE

The purpose of this study was to determine the values for noise equivalent quanta, detective quantum efficiency, modulation transfer function, noise power spectrum, and the values for the parameters for automated CDMAM test phantom analyses required to achieve satisfactory quality of digital mammograms.

MATERIALS AND METHODS

During the course of tests according to PAS 1054 (8 CR and 12 DR systems), test images were made with a test phantom insertion plate containing two lead edges in nearly horizontal and vertical directions. Only original data were processed with a program that was developed at the Cologne University of Applied Sciences (FH-Köln). All equipment systems complied with the requirements regarding visual recognition of gold-plated mammo detail test objects. CDMAM test images were also evaluated using the CDIC (CUAS) and CDCOM (EUREF) programs.

RESULTS

CDMAM test images show comparable values for the parameters, precision, sensitivity and specificity. DR systems require about half the dose used for CR systems for similar results. The NEQ values achieved with the dose used for the CDMAM test images show larger scatter ranges. The MTF of the different equipment system types differ significantly from each other.

CONCLUSION

Visual evaluation of CDMAM test images can be replaced by automated evaluation. Limiting values were determined for each parameter. Automated evaluation of CDMAM test phantom images should be used to determine the physical parameter NEQQC. This method is much more sensitive to noise and sharpness influences and has a higher validity than diagnostic methods. Automated evaluation objectivizes testing.

Structure and stability of the negative hydrogen molecular ion

We present the results of a Coulomb explosion experiment that allows for the imaging of the rovibrational wave function of the metastable H2- ion. Our measurements confirm the predicted large internuclear separation of 6 a.u., and they show that the ion decays by autodetachment rather than by spontaneous dissociation. Imaging of the resulting H2 products reveals a large angular momentum of J = 25 ± 2, quantifying the rotation that leads to the metastability of this most fundamental molecular anion.

Hot water molecules from dissociative recombination of D3O+ with cold electrons

Individual product channels in the dissociative recombination of deuterated hydronium ions and cold electrons are studied in an ion storage ring by velocity imaging using spatial and mass-sensitive detection of the neutral reaction fragments. Initial and final molecular excitation are analyzed, finding the outgoing water molecules to carry internal excitation of more than 3 eV in 90% of the recombination events. Initial rotation is found to be substantial and in three-body breakup strongly asymmetric energy repartition among the deuterium products is enhanced for hot parent ions.

[Results of an automatic evaluation of test images according to PAS 1054 and IEC 6220-1-2 on different types of digital mammographic units]

AIM

To test whether image processing methods are suitable for detecting differences in the image quality of digital mammography units and whether the methods are more sensitive than visual test methods like the evaluation of CDMAM test images.

METHODS

Test images according to PAS 1054 were acquired with CR and DR systems and analyzed automatically. Only parameters were used that are obligatory for calculating the detective quantum efficiency (DQE), the noise power spectrum (NPS), the spatial resolution (MTF, modulation transfer function), and the averaged glandular dose (AGD). The derived value, the NEQ index, is linked to the noise equivalent quanta (NEQ). Additionally CDMAM test images were acquired and evaluated at one CR and one DR system.

RESULTS

The accuracy of the evaluated values is in the range below of 2 %. The accuracy requirements are fulfilled to establish values for detecting changes in image quality related to changes in dose no greater than one exposure value. If a visual evaluation of test images is used, a significant difference in image quality can only be detected when the dose is doubled.

CONCLUSION

A method is proposed for establishing dose-correlated tolerances for values used in constancy and acceptance tests independently of the type of mammography unit (CR and DR systems). A method which abstains from visual tests for establishing the performance of digital mammography units could be used in acceptance tests.

Application of genetic screening in families with hereditary medullary thyroid carcinoma

In 34 families out of 35 with hereditary medullary thyroid cancer a mutation in the RET proto-ongene could be identified. In 84 family members gene carrier state could be proven, in 75 family members gene carrier state could be excluded. The majority of gene carriers (67 out of 84) were symptomatic while 17 gene carriers were diagnosed in a presymptomatic state. 9 of the 17 presymptomatic gene carriers had prophylactic thyroidectomy. On histological examination C-cell hyperplasia or multifocal microcarcinomas could be proven. In one of our families with familial MTC no germline mutation in the RET gene could be detected. In this family pentagastrintests and indirect genotyping are necessary. Four family members of MEN 2A families have had thyroidectomy on the basis of pentagastrin testing and now proved not to be gene carriers. The application of genetic testing in families with hereditary thyroid carcinoma has further improved management in these families - it is the first step in the evaluation of family members at risk.

Rotational cooling of HD+ molecular ions by superelastic collisions with electrons

Merging an HD+ beam with velocity matched electrons in a heavy ion storage ring we observed rapid cooling of the rotational excitations of the HD+ ions by superelastic collisions (SEC) with the electrons. The cooling process is well described using theoretical SEC rate coefficients obtained by combining the molecular R-matrix approach with the adiabatic nuclei rotation approximation. We verify the DeltaJ=-2 SEC rate coefficients, which are predicted to be dominant as opposed to the DeltaJ=-1 rates and to amount to (1-2)x10;{-6} cm;{3} s;{-1} for initial angular momentum states with J< or =7, to within 30%.

Anisotropy and molecular rotation in resonant low-energy dissociative recombination

Angular fragment distributions from the dissociative recombination (DR) of HD(+) were measured with well directed monochromatic low-energy electrons over a dense grid of collision energies from 7 to 35 meV, where pronounced rovibrational Feshbach resonances occur. Significant higher-order anisotropies are found in the distributions, whose size varies along energy in a partial correlation with the relative DR rate from fast-rotating molecules. This may indicate a breakdown of the nonrotation assumption so far applied to predict angular DR fragment distributions.

Effects of molecular rotation in low-energy electron collisions of H3+

Measurements on the energetic structure of the dissociative recombination rate coefficient in the millielectronvolt range are described for H3+ ions produced in the lowest rotational levels by collisional cooling and stored as a fast beam in the magnetic storage ring TSR (Test Storage Ring). The observed resonant structure is consistent with that found previously at the storage ring facility CRYRING in Stockholm, Sweden; theoretical predictions yield good agreement on the overall size of the rate coefficient, but do not reproduce the detailed structure. First studies on the nuclear spin symmetry influencing the lowest level populations show a small effect different from the theoretical predictions. Heating processes in the residual gas and by collisions with energetic electrons, as well as cooling owing to interaction with cold electrons, were observed in long-time storage experiments, using the low-energy dissociative recombination rate coefficient as a probe, and their consistency with the recent cold H3+ measurements is discussed.

Long-term outcome in 46 gene carriers of hereditary medullary thyroid carcinoma after prophylactic thyroidectomy: impact of individual RET genotype

OBJECTIVE

In children with RET proto-oncogene mutation, curative treatment of medullary thyroid carcinoma (MTC) is possible by prophylactic thyroidectomy. Recommendations on the timing and extent of thyroidectomy are based upon a model that utilises genotype-phenotype correlations to stratify mutations into three risk groups.

DESIGN

We evaluated the long-term outcome (mean follow-up 6.4 years, 15 patients more than 10 years, 26 patients more than 5 years) of operated gene carriers stratified into two risk groups (levels 1 and 2) based on the biological aggressiveness of MTC.

RESULTS

In 46 RET gene carriers, prophylactic thyroidectomy was carried out between the ages of 4 and 21 years. Level 1 mutations were harboured by 11 patients (codons 790, 791, 804 and 891). Histology was completely normal in two patients; in seven patients C-cell hyperplasia (CCH) and in two patients T1 tumours were diagnosed. All patients with level 1 mutations were cured. Level 2 mutations were harboured by 35 patients (codons 618, 620, 630 and 634). Histology of these patients showed CCH in 11 patients, T1 tumours in 21, T2 tumour in 1, T3 tumour in 1 and Tx in 1 patient. Histology showed no lymph node involvement. Five patients with level 2 mutations failed to be cured; in two patients, persistence of MTC was diagnosed directly after thyroidectomy and in three during follow-up. In two patients carrying a 634 mutation, other endocrinopathies (hyperparathyroidism and bilateral pheochromocytoma) manifested during follow-up.

CONCLUSIONS

If prophylactic thyroidectomy is done at early ages, cure rate is high. Timing and extent of prophylactic thyroidectomy can be modified by individual RET mutation.

High-resolution dissociative recombination of cold H3+and first evidence for nuclear spin effects

The energy-resolved rate coefficient for the dissociative recombination (DR) of H(3)(+) with slow electrons has been measured by the storage-ring method using an ion beam produced from a radiofrequency multipole ion trap, employing buffer-gas cooling at 13 K. The electron energy spread of the merged-beams measurement is reduced to 500 microeV by using a cryogenic GaAs photocathode. This and a previous cold- measurement jointly confirm the capability of ion storage rings, with suitable ion sources, to store and investigate H(3)(+) in the two lowest, (J,G) = (1,1) and (1,0) rotational states prevailing also in cold interstellar matter. The use of para-H(2) in the ion source, expected to enhance para-H(3)(+) in the stored ion beam, is found to increase the DR rate coefficient at meV electron energies.

Evidence for subthermal rotational populations in stored molecular ions through state-dependent dissociative recombination

We demonstrate that the dissociative recombination of D2H+ with low-energy electrons depends on the rotational energy of the molecular ion such that highly excited ions have a larger rate coefficient than colder ones. Observations on an ion beam continuously interacting with electrons at low relative velocity indicate that excited rotational levels are preferentially depleted which, in competition with radiative heating due to blackbody radiation, provides an opportunity for controlling the rotational temperature of stored molecules.

Expression of ryanodine receptor type 3 and TRP channels in endothelial cells: comparison of in situ and cultured human endothelial cells

OBJECTIVE

Ca(2+) mobilization plays an important role in endothelial function by stimulating Ca(2+)-dependent synthesis of vasodilating factors. In addition to inositol-1,4,5-trisphosphate (InsP(3)) mediated Ca(2+) mobilization, Ca(2+) release from ryanodine-sensitive pools and Ca(2+)-influx through TRP channels have been suggested to be important in endothelial Ca(2+)-signaling. However, the function and molecular identity of TRP channels and ryanodine receptors in human endothelium in situ are still elusive. We hypothesized that expression of ryanodine-receptors (RyR) and TRP channels differs between human endothelium in situ and in cultured cells.

METHODS

By combining single-cell RT-PCR and patch-clamp techniques, expression of RyR and TRP channels was determined in situ in endothelial cells of human mesenteric artery (HMAECs) obtained from patients undergoing bowel resection and in the endothelial cell line EA.hy926.

RESULTS

At the single cell level, expression of RyR 3 was detected in 25 and 5% of HMAECs and EA.hy926 samples, respectively. Expression of the RyR 1 and 2 was not detected in either HMAECs or EA.hy926. In patch-clamp experiments in HMAECs, applications of caffeine (0.5 mM) induced sustained hyperpolarization mediated by activation of Ca(2+)-activated K channels. In EA.hy926, caffeine-induced hyperpolarization was not detected. Single HMAECs expressed the TRP genes, TRP1 and TRP3, but not TRP 4 and 6. The TRP1 was the predominantly expressed TRP gene in HMAECs in situ whereas TRP3 expression was rarely detected. EA.hy926 expressed only TRP1. In patch clamp experiments in HMAECs, Ca(2+)-store depletion activated non-selective cation currents leading to Ca(2+) entry.

CONCLUSIONS

Our findings suggest that, in addition to InsP(3) mediated Ca(2+) release, Ca(2+) release from ryanodine-sensitive stores mediated by RyR3 and Ca(2+) entry through TRP1 might represent important components of endothelial Ca(2+) signaling in situ and thereby of endothelial function in intact human blood vessels.

Effect of fluid resuscitation with and without endothelin A receptor blockade on hemoconcentration and organ function in experimental pancreatitis

BACKGROUND

Intravascular fluid loss contributes to pancreatitis-associated multiple organ dysfunction and is thus a major target for therapy in this life-threatening disease.

AIM

To evaluate intravascular fluid loss and extravascular fluid sequestration together with cardiorespiratory and renal function in a well-established rat model of severe acute pancreatitis (AP) and to investigate the effect of fluid resuscitation with and without endothelin receptor A blockade on these parameters.

METHOD

Induction of AP in rats by a standardized bile salt infusion into the pancreatic duct and intravenous cerulein hyperstimulation. Six hours after AP induction, animals were randomized into 4 groups to receive (1) no therapy; (2) 4 ml/kg/h Ringer's lactate (RL) i.v.; (3) 8 ml/kg/h RL i.v., or (4) 4 ml/kg/h RL plus an endothelin receptor antagonist. Target parameters measured before and after AP induction and during the 24-hour observation period included: mean arterial blood pressure, heart rate, hematocrit, arterial blood gases, urine production, ascites and pleural effusions.

RESULTS

After 6 h, all animals presented with severe hemoconcentration (hematocrit >57%) and oliguria (<0.5 ml/6 h). Cardiorespiratory parameters were within the normal range. Up to 12 h after AP induction, animals without therapy had an increased hematocrit and oliguria and developed metabolic acidosis. Animals receiving fluid resuscitation had a significant drop in hematocrit and maintained compensated blood gas values. A significant increase in urine production was only observed in animals given 8 mg/kg/h RL. Between 12 and 24 h, urine production significantly increased with fluid resuscitation and respiratory parameters stabilized except for animals treated with 8 ml/kg/h RL which developed arterial hypoxia and hypercapnia.

CONCLUSIONS

Intravascular fluid loss and extravascular fluid sequestration together with decreased urine production characterize the early phase of this model of severe AP. Massive fluid resuscitation necessary for increasing urine output may lead to respiratory distress. Reduction of intravascular fluid loss by endothelin receptor blockade is associated with improved renal and respiratory function.

Expression of functional GABAA receptors in isolated human insulinoma cells

Pancreatic islets contain and release high concentrations of GABA. GABA is thought to play a paracrine role in beta-cells. Searching for a paracrine function of GABA in neoplastic beta-cells we performed patch-clamp studies in isolated human insulinoma cells. We show that human insulinoma cells can express functional GABAA receptors. Activation of GABAA receptors caused a reversible membrane depolarization in a subgroup of insulinoma cells. Membrane depolarization resulted in transmembraneous calcium influx through voltage-gated calcium channels and stimulation of insulin secretion. Insulin secretion was increased by the GABAA receptor agonist muscimol (50 microM) by about 280%. Thus, GABAA receptors can be expressed in human insulinoma cells and can regulate their insulin release.

Laser-induced thermotherapy for the treatment of liver metastasis. Correlation of gadolinium-DTPA-enhanced MRI with histomorphologic findings to determine criteria for follow-up monitoring

PURPOSE

To evaluate gadolinium (Gd)-diethylenetriamine-pentaacetic-acid (DTPA)-enhanced magnetic resonance imaging (MRI) for follow-up monitoring of laser-induced thermotherapy (LITT) and to determine a useful examination schedule.

METHODS

LITT of the liver was performed in 55 rabbits using a neodymium: yttrium-aluminum-garnet (Nd:YAG) laser (4-W power output, 840-s exposure time). Gd-DTPA MRI and histologic examinations were performed at different times (0-168 days).

RESULTS

Laser-induced lesions underwent regeneration and volume size reduction (69% after 168 days). The correlation coefficient (MR vs. macroscopic analysis) for the mean lesion diameter was r = 0.96. Histology of lesions comprised the four zones that correlated best with MRI findings. Coagulation necroses immediately after LITT was seen as an area of no enhancement on Gd-DTPA MRI. Circular enhancement was first seen 72-96 h after LITT, which was due to early mesenchymal proliferation.

CONCLUSIONS

Gd-DTPA MRI is a good monitoring procedure for LITT. MRI should be performed 24 and 96 h after LITT.

Expression of functional P2-purinergic receptors in primary cultures of human colorectal carcinoma cells

Primary cell cultures of human colorectal carcinomas were established and characterized immunocytochemically. In the isolated cancer cells intracellular Ca2+ concentrations ([Ca2+]i) were measured by the fura-2 method. Stimulation with either extracellular ATP or UTP caused a biphasic rise of [Ca2+]i in a dose-dependent manner and cross-desensitization between both nucleotides was observed. The rank order of potency was ATP >== UTP > ATP-gamma-S > ADP > adenosine which is characteristic for a P2U-receptor subtype. Selective agonists of P1-, or P2X- purinoceptors had no effect on [Ca2+]i. The initial rise in [Ca2+]i was independent of extracellular calcium [Ca2+]e, whereas the second phase was not observed under [Ca2+]e-free conditions suggesting a capacitative Ca2+-entry-mechanism. Intracellular Ca2+ mobilization was proven by use of the Ca2+-ATPase inhibitor thapsigargin. P2U-specific mRNA could be detected by RT-PCR in both colorectal tumor tissues and in the human colorectal cancer cell line HT 29. In HT 29 cells, the hydrolysis-resistant ATP analog ATP-gamma-S inhibited cell proliferation and, also, induced apoptosis in a dose-dependent manner. Thus, human colorectal cancer cells express functional P2U-receptors which may play a role in the regulation of cell proliferation and apoptosis.

Inhibition of L-type calcium channels by octreotide in isolated human neuroendocrine tumor cells of the gut

The observation that somatostatin and its analogue octreotide inhibit the release of various peptide hormones and transmitters from neuroendocrine tumors has stimulated interest in the signal transduction pathway mediated by these compounds. Using the whole cell mode of the patch-clamp technique, we investigated the inhibitory effects of somatostatin and octreotide on voltage-dependent calcium channels (VDCC) in isolated human neuroendocrine tumor cells of the gut. Both peptides dose dependently and reversibly inhibited VDCC. Somatostatin (100 nM) reduced the current amplitude by 38 +/- 19% and 100 nM octreotide by 35 +/- 14%. Human neuroendocrine gut tumor cells preferentially express dihydropyridine-sensitive L-type VDCC, since most of the inward current was sensitive to the dihydropyridine isradipine. The inhibitory effects of isradipine and octreotide were not additive and octreotide had little effect on the isradipine-resistant inward current. Since octrotide selectively binds to the somatostatin receptor subtypes 2 and 5, these results suggest that inhibition of calcium-dependent hormone release by somatostatin from human neuroendocrine gut cells appears to involve somatostatin receptor subtypes 2 and 5, as well as dihydropyridine-sensitive L-type VDCC.

Results and follow-up in eleven MEN 2A gene carriers after prophylactic thyroidectomy

In 11 MEN 2A gene carriers prophylactic thyroidectomy was carried out between the age of 4 to 17 years. All gene carriers had pathological basal and/or pentagastrin stimulated serum calcitonin levels. On histological examination in five patients C-cell hyperplasia (CCH) and in 6 patients medullary microcarcinoma (< 1 cm, mostly multifocally) was shown. No patient had lymph node involvement. There was no recurrent laryngeal nerve damage in these 11 patients and no permanent hypoparathyroidism. After prophylactic thyroidectomy all 11 patients were cured, they showed normal basal and pentagastrin stimulated calcitonin levels. In the follow-up (mean 19 months) under thyroxine substitution therapy in 9 of these 11 patients TSH was at least at one examination out of the normal range. In 2 patients TSH was suppressed, in 1 of these FT3 was slightly elevated. In 7 patients TSH was elevated between 4.9 to 147 microU/ml. The application of genetic testing is save concerning diagnostic accuracy. If prophylactic thyroidectomy is done at early ages cure rate is 100%. Despite this encouraging results thyroxine substitution therapy in the follow-up carries some problems concerning optimal dosage and non-compliance. Therefore TSH has to be estimated in the follow-up every 3 months.

[Intramural pseudodiverticulosis of the esophagus]

Esophageal intramural pseudodiverticulosis is a rare benign condition with the cardinal symptom of dysphagia mostly due to inflammatory strictures. The disease frequently develops in connection with alcohol abuse and esophageal reflux, candidiasis or motility disorders. Characteristic is the radiological visualization of intramural saccular contrast accumulations. We report on five patients with esophageal pseudodiverticulosis endoscopically diagnosed at our hospital within a period of five years. Four of these patients underwent extensive investigations for additional esophageal conditions: Histological/cytological examinations, manometry, pH-metry and endoscopic ultrasonography. These four patients had a pathological reflux with marked esophagitis and inflammatory strictures. We achieved long-lasting therapeutic results with complete relief by bougienage and reflux therapy with additional candidiasis treatment in two and motility treatment in one patient each. The detailed discussion deals with the clinical aspects, characteristics, therapy and pathogenesis.