Clinical ex vivo lung perfusion--pushing the limits.

Ex vivo lung perfusion (EVLP) provides the ability to evaluate donor lungs before transplantation. Yet, limited prospective clinical data exist with regard to its potential to recondition unacceptable donor lungs. This paper summarizes the results of a prospective study of lung transplantation using only initially unacceptable donor lungs, which were improved by EVLP for 2-4 h. From March 2010-June 2011, 13 lungs were evaluated ex vivo. Median donor PaO(2) at FiO(2) 1.0/PEEP5 was 216 mmHg (range 133-271). Four lungs, all with trauma history, showed no improvement and were discarded. Nine lungs improved to a ΔPO(2) higher than 350 mmHg. Median PvO(2) at final assessment in these lungs was 466 mmHg (range 434-525). These lungs were transplanted with a median total ischemic time of 577 min (range 486-678). None of the patients developed primary graft dysfunction grades 2 or 3 within 72 h after transplantation. One patient with secondary pulmonary hypertension was left on a planned prolonged extracorporeal membrane oxygenation postoperatively. Median intubation time was 2 days. Thirty-day mortality was 0%. During the observation period, 119 patients received standard lung transplantation with comparable perioperative outcome. EVLP has a significant potential to improve the quality of otherwise unacceptable donor lungs.

[Levobupivacaine for regional anesthesia. A systematic review]. / Levobupivacain in der Regionalanästhesie. Eine systematische Ubersicht der klinischen Anwendungen.

Levobupivacaine [S(-)bupivacaine], the levorotatory S-enantiomer of racemic bupivacaine, is commercially available in the U.S. and in most European countries. We performed a systematic review (MEDLINE database) and identified 88 articles on the clinical application of levobupivacaine in more than 3,000 patients. The use of levobupivacaine is described for epidural, caudal, and spinal anesthesia, for peripheral nerve blocks, for ophthalmic and dental anesthesia, for different pediatric indications and for intravenous regional anesthesia. In these regional techniques, levobupivacaine was used for all common indications in a wide range of clinical settings. Epidural levobupivacaine was combined with fentanyl, morphine, sufentanil, epinephrine, and clonidine, spinal levobupivacaine was combined with sufentanil, fentanyl, and epinephrine. In most studies, levobupivacaine was compared to bupivacaine and/or ropivacaine.

Vasopressors for shock.

BACKGROUND: Besides reversing the underlying cause, the first line treatment for the symptoms of shock is usually the administration of intravenous fluids. If this method is not successful, vasopressors such as dopamine, dobutamine, adrenaline, noradrenaline and vasopressin are recommended. It is unclear if there is a vasopressor of choice, either for the treatment of particular forms of shock or for the treatment of shock in general. OBJECTIVES: To assess the efficacy of vasopressors for circulatory shock in critically ill patients. Our main aim was to assess whether particular vasopressors reduce overall mortality. We also intended to identify whether the choice of vasopressor influences outcomes such as length-of-stay in the intensive care unit and health-related quality of life. SEARCH STRATEGY: We searched MEDLINE, the Cochrane Central Register of Controlled Trials, EMBASE, PASCAL BioMed, CINAHL, BIOSIS, and PsychINFO:all from inception to November 2003; for randomized controlled trials. We also asked experts in the field and searched meta-registries for ongoing trials. SELECTION CRITERIA: We included randomized controlled trials comparing various vasopressors, vasopressors with placebo or vasopressors with intravenous fluids for the treatment of any kind of circulatory failure (shock). Mortality was the main outcome. DATA COLLECTION AND ANALYSIS: Two reviewers abstracted data independently. Disagreement between two reviewers was discussed and resolved with a third reviewer. We used random effects models for combining quantitative data. MAIN RESULTS: We identified eight randomized controlled trials. Reporting of methodological details was for many items not satisfactory: only two studies reported allocation concealment, and two that the outcome assessor was blind to the intervention. Two studies compared norepinephrine plus dobutamine with epinephrine alone in patients with septic shock (52 patients, relative risk of death 0.98, 95% confidence interval 0.57 to 1.67). Three studies compared norepinephrine with dopamine in patients with septic shock (62 patients, relative risk 0.88, 0.57 to 1.36). Two studies compared vasopressin with placebo in patients with septic shock (58 patients, relative risk 1.04, 0.06 to 19.33). One study compared terlipressin with norepinephrine in patients with refractory hypotension after general anaesthesia but there were no deaths (20 patients). REVIEWERS' CONCLUSIONS: The current available evidence is not suited to inform clinical practice. We were unable to determine whether a particular vasopressor is superior to other agents in the treatment of states of shock.

[Treatment of chronic viral hepatitis B with interferon alfa. Experience of the last 3 years]. / Lécba chronické virové hepatitidy B interferonem alfa. Zkusenosti poslednich 3 let.

BACKGROUND: interferon alpha is nowadays the drug of choice in the treatment of chronic viral hepatitis. The objective of the present work was to assess the effectiveness of interferon alpha in the treatment of chronic active hepatitis B in our population and to test whether the known "prognostic factors" of successful treatment are applicable in our patients. METHODS AND RESULTS: In 1991-1994 a total of 25 patients were treated (15 men, 10 women, mean age 46.1 years, range 18-69 years) suffering from chronic active hepatitis B (HBsAg and HBeAG positive) with interferon alpha 2b (Intron A, Schering-Plough International ). Seroconversion to anti-HBe and the drop of serum aminotransferase activity was achieved in 15 patients (60%). Only in one patient within one year after termination of treatment a relapse developed. In the group of successfully treated patients the activity of serum aminotransferases before treatment was significantly higher. The mean duration of the disease was surprisingly longer than in the group where treatment failed (106 vs. 62 months), but this difference was not statistically significant. Only in two successfully treated patients during the second and third month of treatment acute exacerbation of the inflammation occurred and manifestations of hepatic insufficiency with subsequent slow improvement developed. In the remainder the activities of serum aminotransferases declined slowly to normal values.

Clonidine as an adjuvant to local anaesthetic axillary brachial plexus block: a randomized, controlled study.

BACKGROUND: We compared the effects of clonidine added to levobupivacaine and bupivacaine on axillary brachial plexus block as well as the effectiveness of levobupivacaine alone compared with bupivacaine alone. METHODS: In this prospective, randomized, controlled, double-blind trial, four groups of 20 patients each were investigated, using (i) 40 ml of levobupivacaine 0.5% plus 0.150 mg of clonidine, (ii) 40 ml of levobupivacaine 0.5% plus 1 ml of NaCl 0.9%, (iii) 40 ml of bupivacaine 0.5% plus 0.150 mg of clonidine, and (iv) 40 ml of bupivacaine 0.5% plus 1 ml of NaCl 0.9%, respectively. The onset of motor and sensory block and duration of sensory block were recorded. RESULTS: There was no significant difference in duration between groups, but a significantly higher variance (P<0.001) was found in the two groups with clonidine than in the two groups without. CONCLUSIONS: These findings suggest responder and non-responder behaviour is a result of the addition of clonidine.

[Women serving the sick and the wounded in nineteenth century Russia]. / Kobiety w sluzbie chorych i rannych w Rosji XIX wieku.

The genesis of women's service to the sick and the wounded dates from the 1820s. At the instigation of the tsarist court, assistance to the sick and wounded was provided by the so-called "widows of charity" recruited at the empress's command from among the inmates of an institution for poor officers' widows, then the Sisters of Charity. As early as the middle of the century, the Sisters' charity work had taken on a twofold character: during peacetime they cared for the poorest inhabitants, mainly of large and small towns; during wartime they cared for the sick and wounded in areas of armed conflict. From the time of the Crimean War, the Sisters of Charity constituted a permanent medical presence in all the wars of the Russian Empire. They were involved in the transportation of the sick and wounded, field hospitals as well as land and ship hospitals. Their activities later became institutionalised. In peacetime they served the poorest of the population, working in municipal hospitals, often founded near their convents since their organisation was modelled on Christian monastic structures. Three categories of Sisters of Charity were established: Orthodox, Catholic, though very small in number, and secular - among them the Russian Red Cross, from 1867, and their service to the sick and wounded has taken on the name of a "female profession".

[Method of saving a sick person's strength in 19th century medical therapy]. / Metoda oszczedzania sil chorego w XIX-wiecznej terapii medycznej.

Saving a sick person's strength through limiting physical exercise has been used since the early ages. Slowing down the pace of functioning of the human body was intended to cause the decrease in the body temperature, improve general feeling and accelerate the process of recovery. However, saving patient's strength as a therapeutic method had been described only three years before the end of the 19th century. It was presented by Seweryn Sterling in the publication Krytyka Lekarska (Medical Critique) in 1897, in article entitled Care of the Sick as a Therapeutic Agent. The author presents the most important concepts of the above therapeutic method.