Christian Porubsky

Extracellular concentrations of fosfomycin in lung tissue of septic patients

OBJECTIVES The present investigation explored the ability of fosfomycin to penetrate lung tissue of septic patients by utilizing the microdialysis technique. METHODS After microdialysis probe insertion into healthy and infected lung tissue, a single intravenous dose of 4 g of fosfomycin was administered. RESULTS The mean C(max), T(max), AUC(0-4) and AUC(0-infinity) for healthy lung were 131.6 +/- 110.6 mg/L, 1.1 +/- 0.4 h, 242.4 +/- 101.6 mgxh/L and 367.6 +/- 111.9 mgxh/L, respectively. The corresponding values for infected lung were 107.5 +/- 60.2 mg/L, 1.4 +/- 0.5 h, 203.5 +/- 118.4 mgxh/L and 315.1 +/- 151.2 mgxh/L. The half-life of fosfomycin ranged from 2.2 to 2.7 h between compartments. The magnitude of lung tissue penetration, as determined by the ratios of the AUC(0-infinity) for lung to the AUC(0-infinity) for plasma, was 0.63 +/- 0.31 and 0.53 +/- 0.31 for healthy and infected lung, respectively. CONCLUSIONS We conclude that fosfomycin achieves antimicrobially effective concentrations in infected lung tissue.

Repetitive Long-Term Hyperbaric Oxygen Treatment (HBOT) Administered after Experimental Traumatic Brain Injury in Rats Induces Significant Remyelination and a Recovery of Sensorimotor Function

Cells in the central nervous system rely almost exclusively on aerobic metabolism. Oxygen deprivation, such as injury-associated ischemia, results in detrimental apoptotic and necrotic cell loss. There is evidence that repetitive hyperbaric oxygen therapy (HBOT) improves outcomes in traumatic brain-injured patients. However, there are no experimental studies investigating the mechanism of repetitive long-term HBOT treatment-associated protective effects. We have therefore analysed the effect of long-term repetitive HBOT treatment on brain trauma-associated cerebral modulations using the lateral fluid percussion model for rats. Trauma-associated neurological impairment regressed significantly in the group of HBO-treated animals within three weeks post trauma. Evaluation of somatosensory-evoked potentials indicated a possible remyelination of neurons in the injured hemisphere following HBOT. This presumption was confirmed by a pronounced increase in myelin basic protein isoforms, PLP expression as well as an increase in myelin following three weeks of repetitive HBO treatment. Our results indicate that protective long-term HBOT effects following brain injury is mediated by a pronounced remyelination in the ipsilateral injured cortex as substantiated by the associated recovery of sensorimotor function.

Hyperbaric oxygenation in the treatment of life-threatening isobutyl nitrite-induced methemoglobinemia--a case report.

Methemoglobinemia usually results from exposure to oxidizing substances such as nitrates or nitrites. Iron within hemoglobin is oxidized from the ferrous (Fe2+) state to the ferric (Fe3+) state, resulting in the inability to transport oxygen and carbon dioxide. Clinically, this condition causes functional cyanosis. As methemoglobin levels increase, patients show evidence of cellular hypoxia in all tissues. Death usually occurs when methemoglobin fractions approach 70% of total hemoglobin. We describe the case of a 35-year-old female patient with severe life-threatening isobutyl nitrite-induced methemoglobinemia of 75% of total hemoglobin. Toluidine-blue was administered as first-line antidotal therapy immediately, followed by hyperbaric oxygenation. The patient recovered uneventfully and could be discharged 3 days later.

Occult solitary submucosal jejunal metastasis from esophageal carcinoma

BackgroundMetastatic tumors of the intestinal tract from extra-abdominal sites are rare. In esophageal cancer, the liver, lung and the bones are the most common sites of metastases. Metastasis to intestines are very rare.Case presentationA 54-year old male was admitted with esophageal squamous cell carcinoma (SCC) associated with dysphagia II-III and weight loss of 20 kg. Preoperative routine staging failed to detect any metastases. A transthoracic esophagectomy and orthotopic gastric pull-up with collar esophago-gastrostomy, associated with 2-field lymphadenectomy was perfromed. During the digital placement of the naso-jejunal feeding catheter a submucosal jejunal nodule with a diameter of 1 cm, about 40 cm distal to the duodeno-jejunal fold was detected which was completely resected by jejunotomy. Histopathology of jejunal nodule showed metastasis from esophageal squamous cell carcinoma.ConclusionBecause of the extensic esophageal lymphatic system, an occult widespread dissemination of the tumor cells into the abdominal cavity is possible. Additional intraoperative evaluation of the small intestine and the complete abdominal cavity should be performed in every operation of esophageal carcinoma to detect possible occult intraabdominal metastases.

Hyperbaric oxygen in the treatment of hydrogen sulphide intoxication

used thromboelastometry (RoTEM) and platelet adhesion was inhibited by pre-treatment with cytochalasin D (FibTEM measurement); therefore, adhesion of the clot to the pin and cup depended on fibrinogen or fibrin constituents. De Lorenzo et al. showed that in FibTEM measurements, fibrinogen could not even correct the effect of a 20% HES hemodilution, in contrast to the ExTEM measurements. This signifies the importance of platelet contribution also in HES dilution coagulopathy, as measured by thromboelastometry. We therefore suggest that platelet adhesion during dilutional consumption coagulopathy influences thromboelastometry and this should be considered. More research on the adhesive properties of blood, the interaction with plastic surfaces and the specific role of platelets herein is, however, necessary.

High extracellular levels of cefpirome in unaffected and infected lung tissue of patients

OBJECTIVES the objective of the present investigation was to measure the extracellular concentrations of cefpirome in unaffected and infected lung tissue of septic patients. METHODS a single intravenous dose of 30 mg/kg total body weight of cefpirome was administered to eight patients every 12 h prior to insertion of microdialysis probes into lung tissue. RESULTS the median (minimum, maximum) peak concentration (C(max)), time to C(max) (T(max)), area under the concentration-time curve from 0 to 4 h (AUC(0-4)) and AUC(0-∞) of unbound cefpirome for unaffected lung were 48 (32, 107) mg/L, 0.83 (0.17, 3.17) h, 117 (60, 177) mg · h/L and 182 (80, 382) mg · h/L, respectively. The corresponding values for infected lung tissue were 45 (6, 122) mg/L, 1.17 (0.83, 2.83) h, 92 (17, 253) mg · h/L and 206 (49, 379) mg · h/L, respectively. The median apparent terminal elimination half-lives (t(½z)) of cefpirome were 2.61, 3.05 and 3.39 h for plasma, unaffected lung and infected lung, respectively. The median ratios of the AUC(0)(-∞) for lung to the AUC(0)(-∞) for plasma were 0.63 (0.19, 1.55) and 0.46 (0.32, 0.98) for unaffected and infected lung, respectively. CONCLUSIONS we provide strong evidence that cefpirome penetrates effectively into the extracellular space fluid of lung tissue. Under steady-state conditions, the median concentrations of cefpirome in plasma, unaffected lung and infected lung exceeded the MICs of the majority of relevant bacteria over the entire dosing interval of up to 12 h after intravenous administration of a dose of 30 mg/kg total body weight.

Complete Resection of an Isolated Chest Wall Metastasis from Esophageal Carcinoma after Transhiatal Esophagectomy and Gastric Pull-up at One and a Half-Year Follow-Up

Introduction: In esophageal cancer, the liver, lung, and bones are the most common sites of visceral metastases. Isolated chest wall metastases are quite extraordinary and occur very rarely. Methods: In February 2004, a 59-year-old male patient was admitted with esophageal adenocarcinoma. Preoperative routine staging failed to detect any metastases. A transhiatal esophagectomy and retrosternal gastric pull-up with cervical esophago-gastrostomy were performed. The definitive histopathological staging showed an adenocarcinoma, Union Internationale Contre le Cancer stage I. The first check-up 6 months later consisted of a computed tomographic scan of the neck, thorax, and abdomen as well as endoscopy, and raised no suspicion of distant metastases and/or local recurrence. We detected an isolated subcutaneous tumor at the area of the right ventrolateral chest wall 18 months after surgery. The magnetic resonance tomography scan of the thorax showed a solid subcutaneous expansion. The surgical biopsy of this lesion confirmed the suspicion of an isolated chest wall metastasis of the resected esophageal adenocarcinoma. Results: A complete resection of the metastasis was performed without any complications, and the chest wall deficiency became stabilized using a Prolene-Mesh and could be closed directly by skin and subcutaneous tissue. Conclusions: In case of transhiatal esophageal resection without operative participation of the chest wall, an isolated thoracic wall metastasis can be explained by an occult widespread dissemination of the tumor cells along the extensive esophageal lymphatic and hematogenous system. The final decision of surgical resection of this chest wall metastasis should always be made by an interdisciplinary tumor board.

Traumatic Pericardial Rupture With Cardiac Herniation

If undiagnosed, traumatic pericardial rupture with herniation of the heart may have fatal consequences. We report two cases of multiple trauma with pericardial rupture, which was missed in the preoperative diagnoses of both patients, in spite of suggestive signs on computed tomographic scans. One patient had unexplained, persistent hemodynamic instability; the second patient had cardiac arrest during laparotomy for minor hepatic laceration. In both, the left-sided rupture of the pericardium with cardiac herniation into the pleural space was found and corrected in an emergency intervention. Both patients recovered completely.