Pleural and pericardial effusions with cardiac conduction system and myocardial involvement: A rare presentation of sarcoidosis.

Sarcoidosis is a granulomatous immune disorder that can infiltrate many organ systems. When the cardiac system is involved, the myocardium and conduction system are frequently affected. We report the case of a patient presenting with complete heart block following cardioversion from atrial flutter accompanied by pleural and pericardial involvement whose diagnosis of sarcoidosis was subsequently made on pathological examination. Pericardial effusion and pleural effusion are rare manifestations of sarcoid, and the both of them happening simultaneously (less than 10 case reports) in conjunction with cardiac conduction system and myocardial involvement are almost nonexistent in the literature (one case report). As cardiac involvement in sarcoid can drastically increase the mortality, it is important to be vigilant for the diverse manifestations of cardiac involvement in all patients for which there is clinical suspicion of sarcoid.

Potential of Donation After Unexpected Circulatory Death Programs Defined by Their Demographic Characteristics.

BACKGROUND: Donation after unexpected circulatory death (uDCD) donors are often suggested to increase the number of donor organs. In 2014, a uDCD protocol was implemented in three transplant centers in the Netherlands which unfortunately did not result in additional transplantations. This study was initiated to identify demographic factors influencing the potential success of uDCD programs. METHODS: Dutch resuscitation databases covering various demographic regions were analyzed for potential donors. The databases were compared with the uDCD implementation project and successful uDCD programs in Spain, France, and Russia. RESULTS: The resuscitation databases showed that 61% of all resuscitated patients were transferred to an emergency department. Age selection reduced this uDCD potential to 46% with only patients aged 18-65 years deemed eligible. Of these patients, 27% died in the emergency department. The urban region of Amsterdam showed the largest potential in absolute numbers (52 patients/y). Comparison with the uDCD implementation project showed large similarities in the percentage of potential donors; however, in absolute numbers, it showed a much smaller potential. Calculation of the potential per million persons and the extrapolation of the potential based on the international experience revealed the largest potential in urban regions. CONCLUSIONS: Implementation of a uDCD program should not only be based on the number of potential donors calculated from resuscitation databases. They show promising potential uDCD percentages for large rural regions and small urban regions; however, actual numbers per hospital are low, leading to insufficient exposure rates. It is, therefore, recommendable to limit uDCD programs to large urban regions.

CORRUPTIVE INCOMINGS LAUNDERING IN THE MEDICAL SPHERE.

OBJECTIVE: The aim: Characteristic of corruptive incomings laundering in the medical sphere and research of components for counteraction to this phenomenon. PATIENTS AND METHODS: Materials and methods: Some methods were used to ensure the completeness and complexity of scientific research: dialectical, formal, legal, epistemological, and systemstructural methods. CONCLUSION: Conclusions: It was concluded that corruptive incomings laundering in the medical sphere is becoming commonplace. New ways, means, and schemes for the commission of this crime are appearing. The authors analyze the main methods for corruptive incomings laundering in the medical sphere: during the purchase of medicines and medical equipment, during the procurements of medical preparations and medical equipment, building restoration and renovation, where health care facilities are located, price-fixing and gifting of chief medical officers. A comprehensive system of organizational, legal, and economic measures must be formed that will provide effective counteraction to the corruptive incomings laundering in the medical sphere.

Battlefield Extracorporeal Cardiopulmonary Resuscitation for Out-of-Hospital Cardiac Arrest: A Feasibility Study During Military Exercises.

PURPOSE: To evaluate the feasibility of prehospital extracorporeal cardiopulmonary resuscitation (E-CPR) in the military exercise setting. METHODS: Three 40kg Sus scrofa (wild swine) underwent controlled 35% blood loss and administration of potassium chloride to achieve cardiac arrest (CA). During CPR, initiated 1 minute after CA, the animals were transported to Role 1. Femoral vessels were cannulated, followed by E-CPR using a portable perfusion device. Crystalloid and blood transfusions were initiated, followed by tactical evacuation to Role 2 and 4-hour observation. RESULTS: All animals developed sustained asystole. Chest compressions supported effective but gradually deteriorating blood circulation. Two animals underwent successful E-CPR, with restoration of perfusion pressure to 80mmHg (70-90mmHg) 25 and 23 minutes after the induction of CA. After transportation to Role 2, one animal developed abdominal compartment syndrome as a result of extensive (9L) fluid replacement. The other animal received a lower volume of crystalloids (4L), and no complications occurred. In the third animal, multiple attempts to cannulate arteries were unsuccessful because of spasm and hypotension. Open aortic cannulation enabled the circuit to commence. No return of spontaneous circulation was ultimately achieved in either of the remaining animals. CONCLUSION: Our study demonstrates both the potential feasibility of battlefield E-CPR and the evolving capability in the care of severey injured combat casualties.

Legal considerations surrounding surrogacy in Ukraine.

OBJECTIVE: The aim of the study is to analyze the legal framework regulating surrogacy relations in Ukraine, its main loopholes and collisions, and provide suggestions to improve the Ukrainian legislation on surrogacy. PATIENTS AND METHODS: Materials and methods: The methodological framework of the research consists of general methods of analysis and synthesis, formal logical method and formal legal method. CONCLUSION: Conclusions: The procedure for the implementation of surrogacy in Ukraine is enshrined in several regulatory acts. Ukrainian legislation has some loopholes and collisions, representing the challenges that have to be addressed in the nearest future. It is necessary to reconsider the existing legal acts to strengthen state control and supervision in this area for proper protection of the rights and responsibilities of subjects entering surrogate agreements.

FEATURES OF CRIMINAL LIABILITY OF A MEDICAL PROFESSIONAL FOR FAILURE TO PERFORM OR IMPROPER PERFORMANCE OF THEIR PROFESSIONAL DUTIES IN UKRAINE.

OBJECTIVE: The aim: Research of features of criminal responsibility of the medical worker for failure to performe or imptoter perfomance of their professional duties in Ukraine. PATIENTS AND METHODS: Materials and methods: The article uses general scientific and special scientific methods of cognition, which provided an objective analysis of the research goal. CONCLUSION: Conclusions: Criminal law, which provides for liability for improper performance of duties by a healthcare professional or pharmacist, must have a perfect design to ensure the rights and interests of both the patient and the medical worker.That is why, the existing construction of article 140 of the Criminal code of Ukraine requires a number of changes and additions.

Reperfusion Activates AP-1 and Heat Shock Response in Donor Kidney Parenchyma after Warm Ischemia.

Utilization of kidneys from extended criteria donors leads to an increase in average warm ischemia time (WIT), which is associated with larger degrees of ischemia-reperfusion injury (IRI). Kidney resuscitation by extracorporeal perfusion in situ allows up to 60 minutes of asystole after the circulatory death. Molecular studies of kidney grafts from human donors with critically expanded WIT are warranted. Transcriptomes of two human kidneys from two different donors were profiled after 35-45 minutes of WIT and after 120 minutes of normothermic perfusion and compared. Baseline gene expression patterns in ischemic grafts display substantial intrinsic differences. IRI does not lead to substantial change in overall transcription landscape but activates a highly connected protein network with hubs centered on Jun/Fos/ATF transcription factors and HSP1A/HSPA5 heat shock proteins. This response is regulated by positive feedback. IRI networks are enriched in soluble proteins and biofluids assayable substances, thus, indicating feasibility of the longitudinal, minimally invasive assessment in vivo. Mapping of IRI related molecules in ischemic and reperfused kidneys provides a rationale for possible organ conditioning during machine assisted ex vivo normothermic perfusion. A study of natural diversity of the transcriptional landscapes in presumably normal, transplantation-suitable human organs is warranted.

Flow diversion for the treatment of posterior inferior cerebellar artery aneurysms: a novel classification and strategies.

BACKGROUND: The pipeline embolization device (PED) is frequently used in the treatment of anterior circulation aneurysms, especially around the carotid siphon, with generally excellent results. However, treatment of posterior inferior cerebellar artery (PICA) aneurysms with flow diversion (FD) has not been specifically described or discussed. While there are reports of treating PICA aneurysms using placement of FD stents in the vertebral artery, there are no reports of treating these lesions by placement of flow diverting stents in the PICA vessel itself. Due to the unique anatomy and morphology of these aneurysms, it requires special attention. We assessed our multi-institutional experience treating these lesions, including the first reported cases of the PED placed within the PICA. METHODS: Institutional databases of neuroendovascular procedures were reviewed for cases of intracranial aneurysms treated with the PED. Patient and aneurysm data as well as angiographic imaging were reviewed for all cases of PICA aneurysms treated with the PED. PICA aneurysms were defined as aneurysms that involved the PICA. Vertebral aneurysms without disease in the PICA were excluded from the study. RESULTS: 10 PICA aneurysms were treated during the study period. These were classified based on their morphology and location into two main types and five total subtypes for consideration of treatment with flow diversion. All aneurysms were successfully treated, with 8/10 completely obliterated and 2 with a partial reduction in size. Three patients had the PED placed entirely in the PICA and no patient suffered from a medullary or cerebellar stroke. All PEDs were patent and all patients were independent at the last follow-up. CONCLUSIONS: The PED may be used successfully to treat select aneurysms of the PICA. We present the first described cases of successful PED treatment of PICA aneurysms with direct placement of the PED in the PICA vessel itself. The proposed classification system aids in that selection.

Intraventricular Cavernomas of the Third Ventricle: Report of 2 Cases and a Systematic Review of the Literature.

BACKGROUND: Intraventricular cavernous malformations are relatively rare benign vascular malformations. Patients may be asymptomatic or present with headache, seizure, hemorrhage, or neurologic deficits. We report 2 cases of patients with cavernomas in the third ventricle and at the foramen of Monro. We also performed a systematic review of the literature to examine the clinical features and efficacy of the current standard of care for these lesions. METHODS: We performed the systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Multiple databases were queried; the title/abstract and MeSH keywords used included "cavernous malformation," "cavernoma," "cavernous hemangioma," "cavernous angioma," "foramen of Monro," "third ventricle," and "intraventricular," along with "AND" and "OR" operators. Patient demographic and clinical data were collected for qualitative synthesis. RESULTS: Patients presented at a median age of 38 years; the most common symptom was headaches. Gross total resection was performed in 84.6% of patients, and 81.8% had clinical improvement with intervention. The incidence of intraventricular hemorrhage and hydrocephalus was 15.4% and 59%, respectively. CONCLUSIONS: The specific location of the cavernoma determines clinical features seen and approach used in surgical resection. Ventriculoperitoneal shunting was not required in most cases, as hydrocephalus improved with removal of the obstruction at the foramen of Monro. Gross total resection appears to be the optimal management strategy in symptomatic patients and leads to a good outcome in most cases.

siRNA technology in kidney transplantation: current status and future potential.

Kidney transplantation is one of the most common transplantation operations in the world, accounting for up to 50 % of all transplantation surgeries. To curtail the damage to transplanted organs that is caused by ischemia-reperfusion injury and the recipient's immune system, small interfering RNA (siRNA) technology is being explored. Importantly, the kidney as a whole is a preferential site for non-specific systemic delivery of siRNA. To date, most attempts at siRNA-based therapy for transplantation-related conditions have remained at the in vitro stage, with only a few of them being advanced into animal models. Hydrodynamic intravenous injection of naked or carrier-bound siRNAs is currently the most common route for delivery of therapeutic constructs. To our knowledge, no systematic screens for siRNA targets most relevant for kidney transplantation have been attempted so far. A majority of researchers have arrived at one or another target of interest by analyzing current literature that dissects pathological processes taking place in transplanted organs. A majority of the genes that make up the list of 53 siRNA targets that have been tested in transplantation-related models so far belong to either apoptosis- or immune rejection-centered networks. There is an opportunity for therapeutic siRNA combinations that may be delivered within the same delivery vector or injected at the same time and, by targeting more than one pathway, or by hitting the same pathways within two different key points, will augment the effects of each other.

Uncontrolled donors with controlled reperfusion after sixty minutes of asystole: a novel reliable resource for kidney transplantation.

BACKGROUND: Organ shortage leads to usage of kidneys from donors after sudden cardiac death, or uncontrolled donors (UDCD). Ischemic injury due to cessation of circulation remains a crucial problem that limits adoption of UDCD. Our clinical investigation was to determine the applicability of kidneys obtained from UDCD and resuscitated by extracorporeal perfusion in situ after 60 minutes of asystole. METHODS: In 2009-2011, organ procurement service of St. Petersburg, obtained kidneys from 22 UDCD with critically expanded warm ischemic time (WIT). No patients were considered as potential organ donors initially. All donors died after sudden irreversible cardiac arrest. Mean WIT was 61.4±4.5 minutes. For kidney resuscitation, the subnormothermic extracorporeal abdominal perfusion with thrombolytics and leukocyte depletion was employed. Grafts were transplanted into 44 recipients. The outcomes of transplantation of resuscitated kidneys were compared to outcomes of 87 KTx from 74 brain death donors (BDDs). RESULTS: Immediate functioning of kidney grafts was observed in 21 of the 44 recipients, with no cases of primary non function. By the end of the first post-transplant year there was an acute rejection rate of 9.1% (4 episodes of rejection) in the UDCD group versus 14.2% (13 episodes of rejection) in the BDD group. The actual 1-year graft survival rate was 95.5% (n = 42) in UDCD group, and 94.6% (n = 87) in BDD group. Creatinine levels at the end of the first year were 0.116±0.008 and 0.115±0.004 mmol/l in UDCD and BDD groups, respectively. CONCLUSIONS: UDCD kidneys with critically expanded WIT could be succefully used for transplantation if in situ organ "resuscitation" perfusion is included into procurement protocol. The results of 1-year follow-up meet the generally accepted criteria for graft survival and function. In situ reperfusion may exert a therapeutic effect on grafts before procurement. This approach could substantially expand the organ donors' pool.

The critical pathway for deceased donation: reportable uniformity in the approach to deceased donation.

The critical pathway of deceased donation provides a systematic approach to the organ donation process, considering both donation after cardiac death than donation after brain death. The pathway provides a tool for assessing the potential of deceased donation and for the prospective identification and referral of possible deceased donors.

Kidney from uncontrolled donors after cardiac death with one hour warm ischemic time: resuscitation by extracorporal normothermic abdominal perfusion "in situ" by leukocytes-free oxygenated blood.

The availability of brain death donors is restricted by many factors. Use of uncontrolled donors after cardiac death could be a promising perspective, but the limiting factor in uncontrolled donation after cardiac death is the warm ischemic time. The purpose of our work was to develop an in situ kidney preservation protocol with application of the extracorporal normothermic abdominal perfusion for organ resuscitation in uncontrolled donors after cardiac death. The main attention was paid to the elimination of leukocytes as the key damaging factor from modified donor oxygenated blood circulating in the device. In 2009, we had 10 uncontrolled donors with warm ischemic time from 45 to 92 min; a normothermic extracorporal perfusion device was applied, providing preservation and restoration of kidney after ischemic damage. In 6 out of 20 kidney recipients, graft function was recovered immediately. All kidney grafts are functioning, and to the end of the third month, the average creatinine was 118.5 ± 19.9 mM. Treatment of ischemically damaged kidney by normothermic extracorporal perfusion with leukocyte depletion before procurement seems to be a challenging protocol for expanding donors' pool and demands further study.

The use of in-situ normothermic extracorporeal perfusion and leukocyte depletion for resuscitation of human donor kidneys.

The unexploited potential of donors after cardiac death is an actual issue for all countries where organ transplantation is performed. The crucial point in uncontrolled donation after cardiac death is the warm ischemic time. The primary purpose of our work was to define the limits of warm ischemic time. Another purpose was the development of an in situ kidney preservation protocol. In 8 uncontrolled donors with warm ischemic time from 45 to 91 minutes, a normothermic extracorporeal perfusion device was applied, providing preservation and restoration of the kidney after ischemic damage. Main attention was paid to the elimination of leukocytes as the key damaging factor from modified donor blood circulating in the device. In 6 out of 16 kidney recipients, graft function was recovered immediately and, by the end of the third month, the average creatinine was 117.9±21.9 mmol/L. Treatment of ischemically damaged kidneys by normothermic extracorporeal perfusion, with leukocyte depletion before procurement, seems to be a challenging protocol and demands further study. Implementation of perfusion systems in organ procurement practice could lead to a partial solution in the organ deficit problem.