Antimicrobial Exposure in Critically Ill Patients with Sepsis-Associated Multi-Organ Dysfunction Requiring Extracorporeal Organ Support: A Narrative Review

Sepsis is a leading cause of disability and mortality worldwide. The pathophysiology of sepsis relies on the maladaptive host response to pathogens that fosters unbalanced organ crosstalk and induces multi-organ dysfunction, whose severity was directly associated with mortality. In septic patients, etiologic interventions aiming to reduce the pathogen load via appropriate antimicrobial therapy and the effective control of the source infection were demonstrated to improve clinical outcomes. Nonetheless, extracorporeal organ support represents a complementary intervention that may play a role in mitigating life-threatening complications caused by sepsis-associated multi-organ dysfunction. In this setting, an increasing amount of research raised concerns about the risk of suboptimal antimicrobial exposure in critically ill patients with sepsis, which may be worsened by the concomitant delivery of extracorporeal organ support. Accordingly, several strategies have been implemented to overcome this issue. In this narrative review, we discussed the pharmacokinetic features of antimicrobials and mechanisms that may favor drug removal during renal replacement therapy, coupled plasma filtration and absorption, therapeutic plasma exchange, hemoperfusion, extracorporeal CO₂ removal and extracorporeal membrane oxygenation. We also provided an overview of evidence-based strategies that may help the physician to safely prescribe effective antimicrobial doses in critically ill patients with sepsis-associated multi-organ dysfunction who receive extracorporeal organ support.

Is sternal bone marrow needle biopsy still a hazardous technique? Report of three further fatal cases

Three fatal cases of death following sternal bone marrow needle biopsy have come to the authors' attention in the past 10 years. The hazards of the technique may be related to the incongruous stylet guard-adjustment for the thickness and hardness of the sternal wall. All three cases involved suits for professional malpractice. Controversial aspects of these cases involving physician liability are discussed.

Dimensional salience and speeded sorting of orientation by kindergarten and fourth-grade children

Perceptual sensitivity and cognitive processing hypotheses relating to orientation perception in kindergarten and fourth-grade children were tested. Assessment of dimensional salience for orientation and form revealed that subjects at both grade levels identified geometric figures as being alike on the basis of form regardless of orientation condition. The effects of dimensional salience and orientation condition on speeded sorting were then investigated. Kindergarten results supported the cognitive processing prediction that orientation sorting times would vary as a function of orientation condition, but no differences were obtained for the fourth-grade subjects. In addition, the results indicated a substantial improvement in kindergarten performance when sorting on the basis of form as compared with orientation. Dimensional salience had much less effect on fourth-grade sorting times.

Transcriptional induction of urokinase in cultured human kidney carcinoma cells by tetradecanoyl-phorbol-acetate

A cell line derived from a human kidney carcinoma produces in vitro the urinary type of plasminogen activator (urokinase). The synthesis of plasminogen activator is enhanced by 12-O-tetradecanoyl-phorbol-13-acetate(TPA); the increase can be followed both in the cell lysate and in the culture medium. The effect requires RNA and protein synthesis as well as the continuous presence of the inducer. Immunofluorescence and immunoprecipitation experiments with monospecific antiurokinase IgG show that kidney carcinoma cells synthesize a 50,000-dalton urokinase and TPA enhances the synthesis of the same molecular species. Hybridization of the total cellular RNA to a human urokinase cDNA probe shows that TPA increases the urokinase mRNA level.