Oxygenation Failure Research Articles

Optimizing knowledge and skills through protocol-based ECMO management and simulation-based training: A novice clinician's perspectives of a successful ECMO program

Background: Starting a new extracorporeal membrane oxygenation (ECMO) program requires synergizing different organizational aspects and extensive training of a core team to deliver care safely.1,2 Sidra Medicine, a newly opened facility in Qatar, started accepting acute inpatients and activated its ECMO program in 2018. The aim of this quality review is to evaluate the training of ECMO Specialists through benchmarking our ECMO program mechanical complications to the Extracorporeal Life Support Organization (ELSO) data. Methods: The hospital trained ECMO Specialists (experts and novices) come from different parts of the world with varying degrees of knowledge and experience and use a comprehensive training program based on the ELSO guidelines for ECMO training and continuous education.3 This program was delivered over a two-year period to all ECMO team members and included: multiple conferences on key ECMO topics; basic wet labs and emergency drills including the change of different components, and; immersive simulation-based training (SBT) on a modified neonatal manikin (Figures 1 and 2). These face to face interactions, in small groups, with different critical scenarios were followed by debriefing.4,5 SBT sessions started before the opening of the acute unit and continued after the acceptance of the first ECMO patient. Immersive SBT sessions occur monthly and include minor and major troubleshooting, de-airing, priming, circuit change, oxygen failure, pump failure, and other problems that can be encountered during ECMO runs.All ECMO Specialists, both experts and novices, completed a full ECMO training program and had gone through the Sidra ECMO certification examination before handling ECMO patients. They were evaluated and certified using a checklist assessment tool and with skills having to be demonstrated competently by the candidates. Novice clinicians were initially ECMO bedside nurses and as they became familiar with the ECMO daily routine and learned the protocols and policies, they started caring for patients as ECMO Specialists.We retrospectively reviewed collected data of technical complications for the 13 patients who have received ECMO therapy since program activation. We analyzed ECMO mechanical complications and benchmarked them with ELSO registry data in corresponding categories to evaluate the training of ECMO specialists and our ECMO program infrastructure. Result: The Sidra ECMO program has now trained a total of 20 ECMO Specialists (experts and novices). Out of the 13 novice clinicians who volunteered to be trained, 8 successfully became ECMO Specialists.There has been a total of 13 patients on ECMO (Table 1). One of these was the first successful neonatal respiratory ECMO patient in Qatar. Over the 13 cases, minor mechanical complications and usual circuit clots were experienced. There was no pump failure or oxygenator failure encountered. Conclusion: SBT is a valuable ECMO educational approach. It offers the opportunity to practice technical skills repeatedly and to become proficient in high-risk/low frequency events while avoiding harm to patients. Using consistent and continuous training is the key for the success of the ECMO Specialist's model. This is a limited study due to the low number of patients, but as ECMO is a low-volume/high-risk procedure, it still highlights the benefits of simulation in establishing new ECMO programs.

High-flow nasal cannula oxygen therapy in children: a clinical review.

High-flow nasal cannula (HFNC) is a relatively safe and effective noninvasive ventilation method that was recently accepted as a treatment option for acute respiratory support before endotracheal intubation or invasive ventilation. The action mechanism of HFNC includes a decrease in nasopharyngeal resistance, washout of dead space, reduction in inflow of ambient air, and an increase in airway pressure. In preterm infants, HFNC can be used to prevent reintubation and initial noninvasive respiratory support after birth. In children, flow level adjustments are crucial considering their maximal efficacy and complications. Randomized controlled studies suggest that HFNC can be used in cases of moderate to severe bronchiolitis upon initial low-flow oxygen failure. HFNC can also reduce intubation and mechanical ventilation in children with respiratory failure. Several observational studies have shown that HFNC can be beneficial in acute asthma and other respiratory distress. Multicenter randomized studies are warranted to determine the feasibility and adherence of HFNC and continuous positive airway pressure in pediatric intensive care units. The development of clinical guidelines for HFNC, including flow settings, indications, and contraindications, device management, efficacy identification, and safety issues are needed, particularly in children.

Insights into the immuno-pathogenesis of acute respiratory distress syndrome.

Acute respiratory distress syndrome (ARDS) is a clinical syndrome associated with oxygenation failure resulting from a direct pulmonary or indirect systemic insult. It is a complex etiological phenomenon involving an array of immune cells acting in a delicate balance between pathogen clearance and immunopathology. There is emerging evidence of the involvement of different immune cell types in ARDS pathogenesis. This includes polarization of alveolar macrophages (AMs), neutrophil netosis, the pro-inflammatory response of T helper 17 subsets, and the anti-inflammatory and regenerative role of T regulatory cell subsets. Knowledge of these pathogenic mechanisms has led to translational opportunities, for example, research in the use of methylprednisolone, DNAse, aspirin, keratinocyte growth factor and in the development of stem cell therapy for ARDS. Discovering subgroups of patients with ARDS afflicted with homogenous pathologic mechanisms can provide prognostic and/or predictive insight that will enable precision medicine. Lastly, new high dimensional immunomic technologies are promising tools in evaluating the host immune response in ARDS and will be discussed in this review.

Team Stress and Adverse Events during Neonatal Tracheal Intubations: A Report from NEAR4NEOS.

This study aimed to examine the association between team stress level and adverse tracheal intubation (TI)-associated events during neonatal intubations. TIs from 10 academic neonatal intensive care units were analyzed. Team stress level was rated immediately after TI using a 7-point Likert scale (1 = high stress). Associations among team stress, adverse TI-associated events, and TI characteristics were evaluated. In this study, 208 of 2,009 TIs (10%) had high stress levels (score < 4). Oxygenation failure, hemodynamic instability, and family presence were associated with high stress level. Video laryngoscopy and premedication were associated with lower stress levels. High stress level TIs were associated with adverse TI-associated event rates (31 vs. 16%, p < 0.001), which remained significant after adjusting for potential confounders including patient, provider, and practice factors associated with high stress (odds ratio: 1.90, 96% confidence interval: 1.36-2.67, p < 0.001). High team stress levels during TI were more frequently reported among TIs with adverse events.

Follow-up after Percutaneous Patent Ductus Arteriosus Occlusion in Lower Weight Infants

To describe longer term outcomes for infants <6kg undergoing percutaneous occlusion of the patent ductus arteriosus (PDA). This was a retrospective cohort study of infants <6kg who underwent isolated percutaneous closure of the PDA at a single, tertiary center (2003-2017). Cardiopulmonary outcomes and device-related complications (eg, left pulmonary artery obstruction) were examined for differences across weight thresholds (very low weight, <3kg; low weight, 3-<6kg). We assessed composite measures of respiratory status during and beyond the initial hospitalization using linear mixed effects models. In this cohort of lower weight infants, 92 of 106 percutaneous occlusion procedures were successful. Median age and weight at procedure were 3.0months (range, 0.5-11.1months) and 3.7kg (range, 1.4-5.9kg), respectively. Among infants with pulmonary artery obstruction on initial postprocedural echocardiograms (n=20 [22%]), obstruction persisted through hospital discharge in 3 infants. No measured variables were associated with device-related complications. Rates of oxygenation failure (28% vs 8%; P<.01) and decreased left ventricular systolic function (29% vs 5%; P<.01) were higher among very low weight than low weight infants. Pulmonary scores decreased (indicating improved respiratory status) following percutaneous PDA closure. Percutaneous PDA occlusion among lower weight infants is associated with potential longer term improvements in respiratory health. Risks of device-related complications and adverse cardiopulmonary outcomes, particularly among very low weight infants, underscore the need for continued device modification. Before widespread use, clinical trials comparing percutaneous occlusion vs alternative treatments are needed.

Treating oxygen failure in angioedema: a case series employing noninvasive nasal positive pressure with the SuperNO2VA device

Angioedema encompasses a wide-range of clinical presentations of nonpitting edema involving the dermis to the submucosal tissue. When vital structures surrounding the upper airway are involved, life-threatening hypoxemia may ensue along with difficulty in securing the airway. Supplemental oxygen devices are often insufficient in the setting of obstruction and the placement of invasive airway devices may exacerbate edema contributing to morbidity. With the tissues of the nasal cavity spared in angioedema, noninvasive positive pressure via a nasal mask is an effective modality by which upper airway patency may be maintained and high concentrations of oxygen delivered to the patient during acute episodes of angioedema. We present here 4 cases of angioedema with inadequate oxygenation where the SuperNO2VA device was used to reestablish upper airway patency and normal oxygen saturation when connected to a Mapleson C circuit in the Emergency Department. Nasal positive pressure delivery using the SuperNO2VA device should be considered as an option primary oxygenation and ventilation technique in the treatment and evaluation of patients with angioedema.

Learning curve for multidisciplinary team setup in veno-venous extracorporeal membrane oxygenation for acute respiratory failure.

Quality control is essential for a successful extracorporeal membrane oxygenation program. We investigated the learning curve for outcome improvement and focused on factors associated with failure of extracorporeal membrane oxygenation treatment. Between August 2011 and May 2017, 150 patients were supported with veno-venous extracorporeal membrane oxygenation for acute respiratory failure. The learning curve was examined using cumulative sum analysis. We defined successful extracorporeal membrane oxygenation treatment as intensive care unit discharge, acceptable failure rate as 40%, and unacceptable failure rate as 60%. We chronologically divided patients into three periods with 50 consecutive patients each and retrospectively compared the clinical outcomes by period. Overall, weaning and survival to discharge rates were 72.7% and 56%, respectively. Cumulative sum analysis indicated that the extracorporeal membrane oxygenation team achieved nearly acceptable performance after 56 cases and consistently acceptable performance after 104 cases. Clinical outcomes were improved by period: weaning rate (58% vs. 80% vs. 80%, p = 0.017); intensive care unit discharge rate (42% vs. 60% vs. 78%, p = 0.001); survival to discharge rate (40% vs. 58% vs. 70%, p = 0.010); and 1 year survival rate (40% vs. 56% vs. 70%, p = 0.010). In multivariate analysis, infection (odds ratio: 4.54, 95% confidence interval: 1.83-11.27, p = 0.001), immune compromise (odds ratio: 5.78, 95% confidence interval: 1.66-20.14, p = 0.006), extracorporeal membrane oxygenation team period (odds ratio: 2.12, 95% confidence interval: 1.14-3.92, p = 0.017), and age (odds ratio: 1.09, 95% confidence interval: 1.05-1.14, p < 0.001) were associated with extracorporeal membrane oxygenation failure. More than 100 cases of extracorporeal membrane oxygenation experience were necessary for acceptable performance and stabilization of outcomes.

Anticipatory perioperative management for patent ductus arteriosus surgery: Understanding postligation cardiac syndrome.

Ligation of a hemodynamically significant ductus arteriosus results in significant changes in loading conditions which have predictable consequences. Postligation cardiac syndrome, defined as hypotension requiring inotropic support and failure of oxygenation and ventilation, may occur 6-12hours following ligation due to left ventricular systolic and diastolic failure, respectively. Afterload is the primary driver of this decompensation. In this review, we describe the pathophysiological changes in loading conditions associated with postligation cardiac syndrome and other contributors to cardiovascular dysfunction following ductal ligation. We present strategies for perioperative optimization and a physiology-based algorithm for postoperative management guided by targeted neonatal echocardiography. The use of these strategies to reduce the frequency of postligation deterioration may be an avenue to improve outcomes for neonates in this vulnerable patient population.

Long term veno-venous extracorporeal life support without intravenous anticoagulation for diffuse alveolar hemorrhage

Diffuse alveolar damage is the histologic hallmark for the acute phase of acute respiratory distress syndrome and can occasionally present as diffuse alveolar hemorrhage. We report a patient with diffuse alveolar hemorrhage and acute respiratory distress syndrome requiring veno-venous extracorporeal life support for 210 days, who was successfully treated for a period of 130 consecutive days without intravenous anticoagulation. Although there are a few brief reports detailing long extracorporeal life support runs, the literature is largely devoid of data regarding long-term extracorporeal life support without full systemic anticoagulation. Regular inspection of the extracorporeal membrane oxygenation circuit is critical because externally visible thrombi may predict internal thrombus generation with the potential for systemic embolization or abrupt oxygenator failure. In our case, multiple circuit and oxygenators changes were required. We have demonstrated that a patient with a contraindication for systemic anticoagulation can safely have veno-venous extracorporeal life support for prolonged periods without catastrophic thrombotic complications.

Impact of Discharge Location After Transcatheter Aortic Valve Replacement on 1-Year Outcomes in Women: Results From the WIN-TAVI Registry

BackgroundSeveral clinical and procedural factors determine outcomes after transcatheter aortic valve replacement (TAVR), but data are scarce on the impact of post-TAVR discharge disposition on long-term outcomes. We sought to analyse whether discharge location after TAVR is associated with 1-year outcomes in women undergoing contemporary TAVR. MethodsThe Women’s INternational Transcatheter Aortic Valve Implantation (WIN-TAVI) registry is the first all-female TAVR registry to study the safety and performance of contemporary TAVR in women (n = 1019). Information on discharge location was available in 817 patients (80.2%). We compared women discharged home vs those discharged to another location (nursing home, rehabilitation, or other hospital). One-year outcomes were adjusted using multivariable Cox regression methods with discharge home as the reference group. ResultsOf the study subjects, 75.2% (n = 614) were discharged home and 24.8% (n = 203) to another location. Women discharged to other locations were older with a greater prevalence of severe lung disease requiring home oxygen and renal failure on dialysis but were less frequently considered frail or at high surgical risk compared with women discharged home. After multivariable adjustment, non-home discharge was associated with greater hazard for 1-year Valve Academic Research Consortium 2 efficacy (21.3% vs 10.8%, hazards ratio [HR] 1.9, 95% confidence interval [CI] 1.2-2.9) and safety endpoints (31.5% vs 15.2%, HR 2.1, 95% CI 1.5-3.0), cardiovascular death (12.7% vs 5.5%, HR 2.0, 95% CI 1.1-3.6), and stroke (6.5% vs 0.8%, HR 8.5, 95% CI 2.9-25.6). ConclusionsIn women undergoing contemporary TAVR, discharge disposition significantly affects 1-year risk of outcomes even after adjustment for recorded baseline differences. This might suggest the necessity of considering additional factors beyond comorbidities in the TAVR decision-making process.

Comparison of Bubble CPAP Devices Using RAM Cannula for Extubation Failure in Very Low Birth Weight Infants: Randomized and Cohort Studies

Introduction: Bubble continuous positive airway pressure (bCPAP) generates a variable pressure due to bubble size and frequency, and these pressure oscillations may contribute to lung recruitment and gas exchange. Single-outlet bCPAP devices generate larger pressure fluctuation than bCPAP devices with diffusers, but clinical efficacy is unclear. Our hypothesis was that a single-outlet bCPAP device (B&B Bubbler^©) would decrease extubation failure and improve oxygenation compared with a bCPAP device with a diffuser (BabiPlus^©). Methods: Bench testing of bCPAP devices with the RAM^© cannula determined pressure averages, fluctuations, and CPAP transmission at prongs. The B&B Bubbler^© and the BabiPlus^© devices were compared for oxygenation and bCPAP failure within 72 h of extubation in a randomized trial in infants less than 1,250 g (n = 43). Additionally, a cohort study with infants extubated to BabiPlus^© (n = 128), B&B Bubbler^© (n = 119), and noninvasive positive pressure ventilation (NIPPV) (n = 107) were compared. Results: Small differences in pressure fluctuations between bCPAP devices are attenuated by the RAM^© cannula. Pressures at RAM^© prongs are 62% of set pressure. The bCPAP extubation failure rate (35%) and oxygenation were similar between the bCPAP devices. bCPAP success was associated with lower FiO₂ at extubation and decreased need for additional FiO₂ in both groups. In the setting of the RAM^© cannula, there were no differences in extubation failure rate for infants extubated to bCPAP or NIPPV. Conclusions: There were no clinical differences at extubation between the B&B Bubbler^© and BabiPlus^© devices. Oxygenation may predict bCPAP failure. The use of the RAM^© cannula as a bCPAP interface should be more closely examined.

Effect of Stress, Depression and Type D Personality on Immune System in the Incidence of Coronary Artery Disease.

BACKGROUND:Psychoneuroimmunology (PNI) is the study of the interaction between psychological processes and the nervous and immune systems of the human body. The impact of psychological factors on the immune system and the role of this system in Coronary Artery Disease (CAD) are confirmed. Coronary Heart Disease (CHD) is arisen due to the failure of blood and oxygen to the heart tissues.AIM:The present study aimed to describe psychoneuroimmunological processes which contribute to CAD and CHD progression.METHOD:Such psychological risk factors like stress, depression and type D personality were investigated here. Psychoneuroimmunological pathways of all three mentioned risk factors were described for CAD.RESULTS:The studies review indicated that stress could be accompanied with myocardial ischemia and help to rupture. The depression involves in the transfer of stable atherosclerotic plaque to unstable, and type D personality is effective in the initial stages of a CAD.CONCLUSION:As more information on cardiovascular immunity becomes available, this will provide a better understanding and thus act as the foundation for the potential development of new treatment strategies for treatment of cardiovascular disorders.

Extracellular ATP is a danger signal activating P2X7 receptor in a LPS mediated inflammation (ARDS/ALI).

Acute respiratory distress syndrome (ARDS) is a life-threating lung condition resulting from a direct and indirect injury to the lungs [1, 2]. Pathophysiologically it is characterized by an acute alveolar damage, an increased permeability of the microvascular-barrier, leading to protein-rich pulmonary edema and subsequent impairment of arterial oxygenation and respiratory failure [1]. This study examined the role of extracellular ATP in recruiting inflammatory cells to the lung after induction of acute lung injury with lipopolysaccharide (LPS). However, the precise mechanism is poorly understood. Our objective was to investigate the functional role of the P2X7 receptor in the pathogenesis of acute respiratory distress syndrome (ARDS/ acute lung injury (ALI)) in vitro and in vivo. We show that intratracheally applied LPS causes an acute accumulation of ATP in the BALF (bronchoalveolar lavage) and lungs of mice. Prophylactic and therapeutic inhibition of P2X7R signalling by a specific antagonist and knock-out experiments was able to ameliorate the inflammatory response demonstrated by reduced ATP-levels, number of neutrophils and concentration of pro-inflammatory cytokine levels in the BALF. Experiments with chimeric mice showed that P2X7R expression on immune cells was responsible for the observed effect. Consistently, the inflammatory response is diminished only by a cell-type specific knockdown of P2X7 receptor on non-stationary immune cells. Since the results of BALF from patients with acute ARDS or pneumonia simulated the in vivo data after LPS exposure, the P2X7 receptor may be a new therapeutic target for treatment in acute respiratory distress syndrome (ARDS/ALI).

Prediction of difficult airway by thyromental height test- a comparison with modified mallampati test.

Background: Management of airway is central to the Practice of anaesthesia. One of the anaesthesiologist fundamental roles is to maintain a patent airway at a all times.Maintaining a patent airway is essential for adequate oxygenation and ventilation and failure to do so, even for a brief period of time, can be life threatening. Recently, thyromental height test (TMHT) has been proposed as one of the highly sensitive and specific bedside tests to predict difficult airway.Objective: To assess the predictivity of thyromental height test in comparison to modified Mallampati test.Methods: This cross sectional study was carried out in Anesthesiology department of ISMCH during the period of January, 2015 to December, 2016. A total number of 139 consecutive patients scheduled for elective surgical procedure under general anaesthesia requiring intubation having American Society of Anesthesiologists grading I-II. Statistical analyses of the results were obtained by SPSS-20. Sensitivity, specificity, accuracy, positive predictive value and negative predictive value of Thyromental height test and Modified mallampati scoring in diagnosis of difficult airway were calculated.Results: Most (74.4) of the patients belonged to age ≤50 years. Male to female ratio was 1.01:1. Majority 91(65.5%) patients had thyromental height of ≥50 mm. In the diagnosis of difficult airway, Thyromental height test was 92.7% sensitivity, 93.5% specificity, 93.5% accuracy and 85.4% positive predictive values, 97.8% negative predictive value, 13.1% positive likelihood ratio, 0.05 negative likelihood ratio. On the other hand Modified mallampati scoring was 48.8% sensitivity, 92.7% specificity, 79.1% accuracy, 75.0% positive predictive values, 80.2% negative predictive value, 6.7% positive likelihood ratio, 0.55 negative likelihood ratio for prediction of difficult airway.Conclusions: It can be concluded that the thyromental height is useful diagnostic modality for predicting difficult airway.Bangladesh Journal of Medical Science Vol.17(3) 2018 p.455-461

CARDIOVASCULAR DERANGEMENT IN NEONATAL HERPES INFECTION

Abstract BACKGROUND Disseminated Herpes Simplex infection is a severe neonatal illness with high mortality and morbidity. Despite acyclovir treatment, the fulminant disease may be rapidly progressive and treatment is largely supportive. A significant proportion of neonates with this illness require intensive care support for circulatory insufficiency and hypoxic respiratory failure. Extracorporeal membrane oxygenation may be used as rescue therapy, though mortality remains high. The pathophysiological contributors to the disease phenotype, the mechanisms underlying the hemodynamic instability and therapeutic strategies to treat such cardiovascular dysfunction have not been well described. OBJECTIVES To describe patterns of cardiovascular dysfunction using targeted neonatal echocardiography and response to therapy for neonates with disseminated herpes infection in a quaternary neonatal intensive care unit. DESIGN/METHODS A cohort of all neonates with confirmed disseminated herpes simplex virus (HSV) infection admitted over the period of November 2014- April 2017 were included in this study. All neonates were evaluated by comprehensive targeted neonatal echocardiography (TnECHO) assessment within the first 24h of admission. Demographic and clinical features were collected retrospectively from the electronic medical record. All TnECHO measurements were performed by a single expert operator. Ethical approval was obtained from the institutional ethics board. RESULTS Five neonates, 3 with HSV 1 and 2 with HSV 2, were identified during the study period. All had features of profound circulatory insufficiency such as hypotension, metabolic acidosis with high lactate, oliguria/anuria, poor capillary refill etc. Three neonates had severe oxygenation failure. On functional echocardiographic assessment, we found that all cases demonstrated underfilled cardiac chambers and low cardiac outputs suggesting severe vasodilatation and third space losses. These cases were managed by aggressive volume resuscitation and use of peripheral vasoconstrictors such as Vasopressin and Nor-Epinephrine. Primary ventricular dysfunction was identified in 3 neonates, who were treated with dobutamine and/or epinephrine. Significant pulmonary hypertension was detected in three infants which prompted the use of Inhaled Nitric Oxide. Acyclovir was initiated early on. Significant cardiovascular stabilization could be achieved by such targeted hemodynamic therapy. However, in view of extensive neurological and hepatic damage, life sustaining therapy was eventually withdrawn in all of them. CONCLUSION Cardiovascular dysfunction in neonates with disseminated HSV infection may be due to either primary ventricular dysfunction, vasodilatation and third space losses or due to pulmonary hypertension. Early targeted neonatal echocardiography may enhance physiologic definition and facilitate targeted therapy. Mortality from multisystem complications, however, remains universal, which raises the question of the role of ECMO in this population.

Extra Corporeal Oxygenation &amp; Ozonation, EBOO &amp; AQUAPHERESIS method of Ozone Therapy, Clinical Application in Chronic Diseases

Introduction: The top 10 causes of death around the world are usually ranked with heart diseases, cancers, drugs/medication/iatrogenic chemicals, strokes etc. These are totally detectable, predictable, avoidable, preventable because it is classified as non-communicable diseases. Acute diseases are denoted by acute inflammation which has intensive cell-cell communications, resulting intensive repair rebuilding rehabilitation and it is life extending. Often it is self defensive and we over come it. The real culprit for chronic diseases is chronic inflammations, denoted by constant &amp; silent, undetectable &amp; insensible lost of cell-cell signaling, basement membrane disease, tight junction destructions, mitochondrial dysfunctions, mismatched metabolism, nutritional losses, mineral depletion, hormonal imbalances, opportunistic antigenicity wasting away the helpful immunity, leading to immune senescence &amp; stem cell depletions eventually leading to chronic degeneration and devastating incapacitated regeneration ability. Often it is self destructive and we usually succumb to it. Mitochondrial decay &amp; incapacitation of oxygenation and aerobic respiration failure leading to chronic anaerobic conditions breeding many chronic diseases Ozone therapy is one of the best method to reverse chronic diseases. Its hormetic response curve of 10 to 80 gamma units typically reveals the secret of ozone healing hormesis. The low dose concept is to be respected all time. And with in safety limits we can practice low &amp; escalating dosage, with increasing in volume of blood exposure to ozone, to evolve from minor AHT to major AHT, all the way into continuous auto-hemotherapy via extra-corporeal blood circuits with the proper method. Its action on mitochondrial health and its regenerative power is well known and documented. METHOD: 1. Ozone properties &amp; therapeutic applications &amp; methods of extracorporeal circuits 2. EBOO / AQUAPHERESIS set up &amp; therapy method 3. Safeties &amp; precautions, limitations &amp; patient selections 4. Selections of machines &amp; GED gas exchange devices 5. Therapeutic steps for patient, and adjuvant photonic therapy 6. Post therapeutic monitoring &amp; documentations 7. Clinical results of various cases treated with EBOO &amp; AQUAPHERESIS RESULTS: Definition of extra corporeal circulations method would be discussed. Original EBOO therapy method and scientific studies would be reviewed. A modified economical method of EBOO would be illustrated. A further improvised AQUAPHERESIS method of continuous blood ozonation / oxygenations would be illustrated and discussed. To ensure safety and long term success, selection of machines, materials, circuits, disposables, disposal of dialysates &amp; ozone residue, all the way to selections of dialyzer &amp; GED gas exchange devices would be discussed. Dangers of wrong machines and wrong GED/Dialyzers with related precautions to be considered during EBOO &amp; AQUAPHERESIS would be discussed. A few case study would be illustrated and discussed CONCLUSIONS: Ozone is a wonderful new well known medical drug. Its benefits is vast &amp; economically easily available. Within the safety limits we can extend the ozonation &amp; oxygenation of blood to a much longer, larger therapeutic window via the extra corporeal circuit method. Both EBOO &amp; AQUAPHERESIS are additional interesting method to deliver ozone therapy to patient reaping also the benefits of plasma apheresis in AQUAPHERESIS method. With correct knowledge and higher standard of machines &amp; disposables, these methods are safe and effective to be applied to patient and it deliver significant result clinically. Further studies are encouraged &amp; worth explored.

A Comparative Proteome Profile of Female Mouse Gonads Suggests a Tight Link between the Electron Transport Chain and Meiosis Initiation

Generation of haploid gametes by meiosis is a unique property of germ cells and is critical for sexual reproduction. Leaving mitosis and entering meiosis is a key step in germ cell development. Several inducers or intrinsic genes are known to be important for meiotic initiation, but the regulation of meiotic initiation, especially at the protein level, is still not well understood. We constructed a comparative proteome profile of female mouse fetal gonads at specific time points (11.5, 12.5, and 13.5 days post coitum), spanning a critical window for initiation of meiosis in female germ cells. We identified 3666 proteins, of which 473 were differentially expressed. Further bioinformatics analysis showed that these differentially expressed proteins were enriched in the mitochondria, especially in the electron transport chain and, notably, 9 proteins in electron transport chain Complex I were differentially expressed. We disrupted the mitochondrial electron transport chain function by adding the complex I inhibitor, rotenone to 11.5 days post coitum female gonads cultured in vitro. This treatment resulted in a decreased proportion of meiotic germ cells, as assessed by staining for histone γH2AX. Rotenone treatment also caused decreased ATP levels, increased reactive oxygen species levels and failure of the germ cells to undergo premeiotic DNA replication. These effects were partially rescued by adding Coenzyme Q10. Taken together, our results suggested that a functional electron transport chain is important for meiosis initiation. Our characterization of the quantitative proteome of female gonads provides an inventory of proteins, useful for understanding the mechanisms of meiosis initiation and female fertility.

Steel reinforced composite silicone membranes and its integration to microfluidic oxygenators for high performance gas exchange.

Respiratory distress syndrome (RDS) is one of the main causes of fatality in newborn infants, particularly in neonates with low birth-weight. Commercial extracorporeal oxygenators have been used for low-birth-weight neonates in neonatal intensive care units. However, these oxygenators require high blood volumes to prime. In the last decade, microfluidics oxygenators using enriched oxygen have been developed for this purpose. Some of these oxygenators use thin polydimethylsiloxane (PDMS) membranes to facilitate gas exchange between the blood flowing in the microchannels and the ambient air outside. However, PDMS is elastic and the thin membranes exhibit significant deformation and delamination under pressure which alters the architecture of the devices causing poor oxygenation or device failure. Therefore, an alternate membrane with high stability, low deformation under pressure, and high gas exchange was desired. In this paper, we present a novel composite membrane consisting of an ultra-thin stainless-steel mesh embedded in PDMS, designed specifically for a microfluidic single oxygenator unit (SOU). In comparison to homogeneous PDMS membranes, this composite membrane demonstrated high stability, low deformation under pressure, and high gas exchange. In addition, a new design for oxygenator with sloping profile and tapered inlet configuration has been introduced to achieve the same gas exchange at lower pressure drops. SOUs were tested by bovine blood to evaluate gas exchange properties. Among all tested SOUs, the flat design SOU with composite membrane has the highest oxygen exchange of 40.32 ml/min m2. The superior performance of the new device with composite membrane was demonstrated by constructing a lung assist device (LAD) with a low priming volume of 10 ml. The LAD was achieved by the oxygen uptake of 0.48-0.90 ml/min and the CO2 release of 1.05-2.27 ml/min at blood flow rates ranging between 8 and 48 ml/min. This LAD was shown to increase the oxygen saturation level by 25% at the low pressure drop of 29 mm Hg. Finally, a piglet was used to test the gas exchange capacity of the LAD in vivo. The animal experiment results were in accordance with in-vitro results, which shows that the LAD is capable of providing sufficient gas exchange at a blood flow rate of ∼24 ml/min.

LEFT VENTRICULAR DIASTOLIC DYSFUNCTION AND OXYGEN SUPPLY OF LOWER EXTREMITIES IN PATIENTS WITH STABLE ISCHEMIC HEART DISEASE AND CONCOMITANT TYPE 2 DIABETES MELLITUS

Background. The peculiarities of diastolic heart failure and indices of arterial and venous blood oxygenation in patients with stable ischemic heart disease and concomitant type 2 diabetes mellitus are presented in the article. Obvious left ventricular diastolic dysfunction with the increased levels of natriuretic peptide, uric acid and decreased indices of arterial and venous blood oxygenation in the presence of comorbid type 2 diabetes mellitus have been revealed.Objective. The research was aimed to study the peculiarities of left ventricular diastolic function disorders, levels of NT-proBNP, uric acid and indices of arterial and venous blood oxygenation in patients suffering from stable exertional angina with underlying comorbid type 2 diabetes mellitus.Methods. 70 patients with IHD: stable exertional angina of the ІІІ functional class, were examined. The first group comprised 39 patients with stable exertional angina of the ІІІ functional class with left ventricular diastolic dysfunction; the second group – 31 patients with stable exertional angina of the ІІІ functional class with left ventricular diastolic dysfunction and concomitant type 2 diabetes mellitus. All the examined patients underwent BD- echocardioscopy, with the detailed evaluation of left ventricular diastolic function, NT-proBNP and uric acid levels in venous blood were determined by immunoenzyme method, indices of arterial and venous blood oxygenation were evaluated too.Results. The correlation between left ventricle diastolic function and oxygen volume consumed by the tissues of lower extremities in patients with stable ischemic heart disease and concomitant type 2 diabetes mellitus was determined.Conclusions. In patients with stable IHD, left ventricular diastolic dysfunction and concomitant type 2 diabetes mellitus the levels of NT-proBNP, uric acid and oxygen supply of lower extremities are significantly higher as compared to patients with IHD without type 2 diabetes mellitus.

Patient-specific Factors Associated with Difficult Mask Ventilation in the Emergency Department

Summary Background Difficult mask ventilation (DMV) leading to oxygen and ventilation failure can cause complications and fatal consequences in airway management, but has rarely been studied as a primary outcome in the emergency department (ED). This study aimed to determine the incidence and predictors of DMV in the ED. Methods A specially designed form recording potential risk factors for DMV was designed and subsequently completed by a research nurse and physicians who had performed the procedure for all mask ventilation attempts over a one-year period in the ED of a large hospital in Taipei, Taiwan. Univariate associations between patient characteristics and DMV were measured, and a risk assessment scale was created according to the independent risk factors for DMV ascertained by adjusted regression models. Results One hundred ten mask ventilation attempts were recorded during the study period. DMV occurred frequently in the ED (45.9% of mask ventilation attempts). Significantly elevated rates of DMV were observed in patients aged 65 years or older those lacking teeth, with sunken cheeks, a double chin or a thick short neck. In adjusted analyses, three easily recognizable predictors, namely lack of teeth, sunken cheeks, and a double chin were found to be independent risk factors for DMV, and accordingly a risk assessment scale- LSD method was made. Conclusion DMV is a frequent challenge in EDs. An easy-to-use LSD risk scale is created for clinicians to rapidly identify and appropriately manage the risk patients of DMV.