Wide variation in pre-procedural blood product transfusion practices in cirrhosis: a national multidisciplinary survey.

BACKGROUND AND AIMS: Recent guidelines recognize the limitations of standard coagulation tests in predicting bleeding and guiding pre-procedural blood component prophylaxis in cirrhosis. It is unclear whether these recommendations are reflected in clinical practice. We performed a nationwide survey to investigate pre-procedural transfusion practices and opinions of key health care stakeholders involved in managing cirrhosis. METHODS: We designed a 36-item multiple-choice questionnaire to investigate the international normalized ratio and platelet cutoffs utilized to guide pre-procedural transfusion of fresh frozen plasma and platelets in patients with cirrhosis undergoing a range of low and high-risk invasive procedures. Eighty medical colleagues from all mainland States involved in managing patients with cirrhosis were invited by email to participate. RESULTS: Overall, 48 specialists across Australia completed the questionnaire: 21 gastroenterologists, 22 radiologists, and 5 hepatobiliary surgeons. 50% of respondents reported that their main workplace did not have written guidelines relating to pre-procedural blood component prophylaxis in patients with cirrhosis. There was marked variation in routine prophylactic transfusion practices across institutions for the different procedures and international normalized ratio and platelet cutoffs. This variation was present both within and between specialty groups and held for both low and high-risk procedures. For scenarios where the platelet count was ≤ 50 × 109/L, 61% of respondents stated that prophylactic platelet transfusions would be given before low-risk and 62% before high-risk procedures at their center. For scenarios where the international normalized ratio was ≥2, 46% of respondents stated that prophylactic fresh frozen plasma would be routinely given before low-risk procedures and 74% before high-risk procedures. CONCLUSION: Our survey reveals significant heterogeneity of pre-procedural prophylactic transfusion practices in patients with cirrhosis and discrepancies between guidelines and clinical practice.

A practical guide to mathematical methods for estimating infectious disease outbreak risks.

Mathematical models are increasingly used throughout infectious disease outbreaks to guide control measures. In this review article, we focus on the initial stages of an outbreak, when a pathogen has just been observed in a new location (e.g., a town, region or country). We provide a beginner's guide to two methods for estimating the risk that introduced cases lead to sustained local transmission (i.e., the probability of a major outbreak), as opposed to the outbreak fading out with only a small number of cases. We discuss how these simple methods can be extended for epidemiological models with any level of complexity, facilitating their wider use, and describe how estimates of the probability of a major outbreak can be used to guide pathogen surveillance and control strategies. We also give an overview of previous applications of these approaches. This guide is intended to help quantitative researchers develop their own epidemiological models and use them to estimate the risks associated with pathogens arriving in new host populations. The development of these models is crucial for future outbreak preparedness. This manuscript was submitted as part of a theme issue on "Modelling COVID-19 and Preparedness for Future Pandemics".

A direct comparison of methods for assessing the threat from emerging infectious diseases in seasonally varying environments.

Seasonal variations in environmental conditions lead to changing infectious disease epidemic risks at different times of year. The probability that early cases initiate a major epidemic depends on the season in which the pathogen enters the population. The instantaneous epidemic risk (IER) can be tracked. This quantity is straightforward to calculate, and corresponds to the probability of a major epidemic starting from a single case introduced at time t=t0, assuming that environmental conditions remain identical from that time onwards (i.e. for all t≥t0). However, the threat when a pathogen enters the population in fact depends on changes in environmental conditions occurring within the timescale of the initial phase of the outbreak. For that reason, we compare the IER with a different metric: the case epidemic risk (CER). The CER corresponds to the probability of a major epidemic starting from a single case entering the population at time t=t0, accounting for changes in environmental conditions after that time. We show how the IER and CER can be calculated using different epidemiological models (the stochastic Susceptible-Infectious-Removed model and a stochastic host-vector model that is parameterised using temperature data for Miami) in which transmission parameter values vary temporally. While the IER is always easy to calculate numerically, the adaptable method we provide for calculating the CER for the host-vector model can also be applied easily and solved using widely available software tools. In line with previous research, we demonstrate that, if a pathogen is likely to either invade the population or fade out on a fast timescale compared to changes in environmental conditions, the IER closely matches the CER. However, if this is not the case, the IER and the CER can be significantly different, and so the CER should be used. This demonstrates the need to consider future changes in environmental conditions carefully when assessing the risk posed by emerging pathogens.

Pediatric epilepsy and psychoeducational interventions: A review of the literature.

For many individuals, living with epilepsy is truly a family affair throughout the life span. When it comes to childhood epilepsy, the unpredictability of seizure patterns, comorbid conditions, the risk of sudden unexpected death in epilepsy (SUDEP), and societal stigma can be emotionally taxing on children and their primary caregivers. To this end, this article proposes to review psychoeducational interventions provided to primary caregivers of children with an epilepsy diagnosis and the impact of such interventions on general parental coping skills. There were three main themes identified (1) caregivers' knowledge and self-efficacy about seizure management; (2) parental epilepsy-related fears, anxiety, and stress; (3) parental sleep quality and SUDEP psychoeducation. Overall, considering research limitations, providing epilepsy-related psychoeducational interventions to primary caregivers of children with epilepsy seems to have promising evidence in the literature. After receiving such interventions, the studies show that caregivers' psychosocial outcomes improved; they become more empowered to manage their children's seizures and advocate for their children's psychosocial needs.

The Role of Laparoscopic Cholecystectomy After Severe and/or Necrotic Pancreatitis in the Setting of Modern Minimally Invasive Management of Pancreatic Necrosis.

OBJECTIVES: The trend toward minimally invasive procedures (MIP) in necrotizing pancreatitis is increasing. The optimal timing and technique of cholecystectomy in severe/necrotizing pancreatitis is unclear. This study aims to determine the role of laparoscopic cholecystectomy after severe/necrotizing pancreatitis in the context of MIP. METHODS: Retrospective analysis of a prospective database was performed for consecutive patients after cholecystectomy for gallstone pancreatitis between January 2011 and January 2018 at Monash Health, Melbourne, Australia. RESULTS: Three hundred fifty-five patients with gallstone pancreatitis underwent laparoscopic cholecystectomy with 2 conversions. Patients with severe pancreatitis were older (P = 0.002), with a more even sex distribution when compared with mild pancreatitis. Females predominated in the mild pancreatitis group.Patients with moderate/severe pancreatitis (P = 0.002) and necrosis (P > 0.001) were more likely to have delayed cholecystectomy compared with mild pancreatitis. There was no increase in biliary presentations while awaiting cholecystectomy. Length of stay for patients with severe/necrotizing pancreatitis (P = 0.001) was increased, surgical complications appeared similar. CONCLUSIONS: Laparoscopic cholecystectomy can be performed safely and effectively for pancreatitis, irrespective of severity. The paradigm shift in the management of severe necrotizing pancreatitis away from open necrosectomy toward MIP can be extended to encompass laparoscopic cholecystectomy.

A practical 'safe zone' technique for lag screw fixation of the fibula.

Introduction During ankle fracture fixation, iatrogenic trauma to retro fibula structures can result in morbidity and reoperation. We describe a safe zone for lag screw insertion. Materials and methods This study was completed in three sections. We identified the average entry and exit points for the lag screw using 45 Weber B ankle fractures identified from our trauma database. We then analysed 26 sequentially presented ankle magnetic resonance images, concentrating on axial sections at 4, 8, 12 and 16 mm above the ankle joint. Finally, we used 63 sequentially performed magnetic resonance scans to confirm the safe zone from these consistent structures. Results The typical lag screw exit point was 14.2 mm above the ankle joint (95% confidence Interval 11.3-17.1 mm). A safe zone trajectory occurred between 31 and 45 degrees taken from the anterior aspect of the flat fibular surface at this level. The obvious palpable landmark to direct screw trajectory and avoid 'at risk' structures was found to be the medial edge of the Achilles tendon. Our final dataset confirmed in 63 scans, the medial aspect of the Achilles tendon to be a consistent safe zone with a minimum distance of at risk structures of 4 mm. Conclusion This simple method of directing the fibula lag screw towards the palpable medial edge of the Achilles tendon is practical, easy to teach and directs the screw on a safe trajectory away from the most commonly injured structures around the back of the fibula.

Relationship Between Spiritual Well-Being and Hope in Patients with Cardiovascular Disease.

Spirituality and hope have been identified as important constructs in health research, since both are thought to enhance a person's ability to cope with the consequences of serious illness. The aim of this study was to examine the relationship between spiritual well-being and hope in patients with cardiovascular disease. Using descriptive, correlational methodology, the investigator gathered data on a convenience sample of 500 patients with cardiovascular disease who were hospitalized in a medical institution in Iran. The study was conducted over a four-month period. Participants completed a demographic questionnaire, the Spiritual Well-Being Scale (SWBS) and the Herth Hope Index (HHI). The mean score on the SWBS and HHI was 86.21 (SD 12.46) and 34.80 (SD 5.05), respectively. Multivariate predictors for spiritual well-being were female gender (p = 0.047), religiosity (p = 0.018), and hope (p < 0.001). Significant predictors of hope were marital status (p < 0.001), educational status (p < 0.001), economic status (p < 0.001), and spiritual well-being (p < 0.001). Findings suggest that multiple factors may impact spiritual well-being and hope. Therefore, this study has implications for those providing care to patients with cardiovascular disease.

Inadvertent intrathecal injections and best practice management.

The intrathecal space has become an important anatomic site for medical intervention not only in anesthesia practice, but also in many other medical specialties. Undesired/inadvertent intrathecal injections (UII) are generally rare. There is tremendous variation in reported inadvertent administrations via an intrathecal route in the literature, mainly as individual cases and very small case-series reports. This review aims to identify potential sources of UII, its clinical presentations, and appropriate management. The inadvertent injectants are classified as anesthetic agents and pain medicines, chemotherapeutics, radiological contrast agents, antibiotics and corticosteroids, and miscellaneous chemical agents such as tranexamic acid. The clinical effects of UII are dependent upon inadvertent injectant(s) and dose being administered intrathecally, and can range from no adverse effect to profound neurological consequences and/or death. Prompt cerebrospinal fluid (CSF) lavage and cardiopulmonary support seem to be the mainstay of treatment. If serious consequences are anticipated, CSF lavage could be lifesaving. This review additionally provides some options for comprehensive management and preventing strategies.

The emergent role of exosomes in glioma.

Extracellular vesicles (EVs) are known mediators of intercellular communication for both normal and tumour cells. With the capability to transfer nucleic acids, proteins and lipids, EVs are able to influence numerous functional and pathological aspects of both donor and recipient cells. The tumour microenvironment possesses a high level of complex heterogeneity, particularly within the most prominent brain malignancy, glioblastoma multiforme (GBM). This complexity relies on a network-based communication between many different components of the local niche, including the various cell types, stroma, blood vessels, secreted factors and surrounding matrix. Exosomes are one type of EV which facilitates this intercellular communication and cross-talk within the tumour microenvironment. Exosomes secreted by tumour cells are increasingly recognized in a number of processes underlying tumour progression including facilitating the transport of receptors, signalling molecules, oncogenic genes and miRNA. They are emerging as a key component in the biogenesis of glioma, in addition to contributing to the modification of the surrounding microenvironment to support tumour progression. In this review we describe advancements in the understanding of the biology of exosomes, as well as their roles in tumour progression, as a tumour biomarker for tracking cancer progression, and as a potential therapeutic target/delivery system, with a contextual emphasis on GBM.

Use of tissue plasminogen activator in the treatment of shunt blockage secondary to intraventricular haemorrhage.

A 51-year-old woman with a history of idiopathic aqueduct stenosis, treated initially with insertion of a ventriculo peritoneal shunt, presented to our institution with shunt dysfunction. She had previously undergone multiple shunt revisions for shunt infection, shunt blockage and low-pressure symptoms, most recently with conversion to a ventriculo atrial (VA) shunt. Her VA shunt was again revised, with replacement of the ventricular catheter, however surgery was complicated by a large intraventricular haemorrhage (IVH) requiring placement of an external ventricular drain (EVD). Prior to eventual removal of her EVD it was determined that the VA shunt had blocked as a result of the IVH. Subsequently alteplase, a recombinant tissue plasminogen activator (tPA), was administered into the shunt reservoir, resulting in successful return of shunt function, therefore avoiding the need for further shunt revision. This is the first description of the use of tPA to unblock a shunt obstructed by blood.

Water network-mediated, electron-induced proton transfer in [C5H5N ⋠(H2O)n](-) clusters.

The role of proton-assisted charge accommodation in electron capture by a heterocyclic electron scavenger is investigated through theoretical analysis of the vibrational spectra of cold, gas phase [Py ⋅ (H2O)n=3-5](-) clusters. These radical anions are formed when an excess electron is attached to water clusters containing a single pyridine (Py) molecule in a supersonic jet ion source. Under these conditions, the cluster ion distribution starts promptly at n = 3, and the photoelectron spectra, combined with vibrational predissociation spectra of the Ar-tagged anions, establish that for n > 3, these species are best described as hydrated hydroxide ions with the neutral pyridinium radical, PyH((0)), occupying one of the primary solvation sites of the OH(-). The n = 3 cluster appears to be a special case where charge localization on Py and hydroxide is nearly isoenergetic, and the nature of this species is explored with ab initio molecular dynamics calculations of the trajectories that start from metastable arrangements of the anion based on a diffuse, essentially dipole-bound electron. These calculations indicate that the reaction proceeds via a relatively slow rearrangement of the water network to create a favorable hydration configuration around the water molecule that eventually donates a proton to the Py nitrogen atom to yield the product hydroxide ion. The correlation between the degree of excess charge localization and the evolving shape of the water network revealed by this approach thus provides a microscopic picture of the "solvent coordinate" at the heart of a prototypical proton-coupled electron transfer reaction.

Hydrocodone bitartrate for chronic pain.

Hydrocodone bitartrate is the most commonly used drug for acute and chronic pain in the U.S. with over 135 million prescriptions in 2012. The U.S. is the primary consumer of hydrocodone, using 99% of the global supply for 4.4% of the global population. With its easy availability and abuse patterns, hydrocodone has been touted as a primary driver of opioid-related abuse and misuse. There are no clinical efficacy studies of hydrocodone in short-acting form in combination with acetaminophen or ibuprofen in chronic pain. Hydrocodone has been approved with two long-term formulations since 2014. The FDA has rescheduled hydrocodone from Schedule III to Schedule II which went into effect on October 6, 2014, along with a limit on added acetaminophen of 325 mg for each dose of hydrocodone. This review examines the evolution of hydrocodone into a common and yet controversial drug in the U.S. with its pharmacokinetics, pharmacodynamics, safety and efficacy.

The German Version of the Herth Hope Index (HHI-D): Development and Psychometric Properties.

BACKGROUND: The importance of hope is evident in clinical oncological care. Hope is associated with psychological and also physical functioning. However, there is still a dearth of empirical research on hope as a multidimensional concept. The Herth Hope Index is a reliable and valid instrument for the measurement of hope and is available in many languages. Until now no authorized German translation has been published and validated. METHODS: After translation, the questionnaire was completed by 192 patients with different tumor entities in radiation therapy. Reliability, concurrent validity, and factor structure of the questionnaire were determined. RESULTS: Correlations were high with depression and anxiety as well as optimism and pessimism. As expected, correlations with coping styles were moderate. Internal consistency and test-retest reliability were satisfactory. We could not replicate the original 3-factor model. Application of the scree plot criterion in an exploratory factor analysis resulted in a single-factor structure. CONCLUSIONS: The Herth Hope Index - German Version (HHI-D) is a short, reliable, and valid instrument for the assessment of hope in patient populations. We recommend using only the HHI-D total score until further research gives more insights into possible factorial solutions and subscales.

Comparative study of three different supraglottic airway devices in simulated difficult airway situations.

BACKGROUND: Supraglottic airway devices (SAD) provide an effective way for managing difficult airways. Numerous SADs have been developed in recent years. We compared three SADs utilizing simulated airways. The major aim of this study was to provide evidence for the efficacy of SADs in the management of simulated difficult airway situations. METHODS: The study utilized an airway simulation manikin (Laerdal SimMan® 3G) to assess feasibility and time to final placement of three different airway devices (the classic laryngeal mask airway [LMA], the Laryngeal tube [LT], and the EasyTube® [EzT]). Thirty anesthesiologists inserted each of the SADs under standard physiologic airway conditions (STD) as well as pathological airway conditions, including tongue edema (TE) and trismus combined with limited mobility of the cervical spine (TCS), mimicking a patient with cramps. RESULTS: In STD and TE, all participants were able to successfully place the LMA, LT, and EzT correctly. In TCS, one participant failed to place the LMA correctly, whereas six participants failed to place the LT correctly (P=0.031). Under STD and TE conditions, we found a significantly longer time to final placement with the EzT (P=0.001). Under TCS conditions, there was no significant difference between the tested SADs. Under STD conditions, the participants rated the LMA best (P<0.001). Under TE and TCS condition, the EzT was significantly higher rated (P<0.001). CONCLUSION: The EzT showed benefits in two difficult airway situations (TE and TCS) in a prospective manikin study amongst anesthesiologists.

Measurement of blood loss during postpartum haemorrhage.

BACKGROUND: We set out to validate the accuracy of gravimetric quantification of blood loss during simulated major postpartum haemorrhage and to evaluate the technique in a consecutive cohort of women experiencing major postpartum haemorrhage. The study took part in a large UK delivery suite over a one-year period. All women who experienced major postpartum haemorrhage were eligible for inclusion. METHODS: For the validation exercise, in a simulated postpartum haemorrhage scenario using known volumes of artificial blood, the accuracy of gravimetric measurement was compared with visual estimation made by delivery suite staff. In the clinical observation study, the blood volume lost during postpartum haemorrhage was measured gravimetrically according to our routine institutional protocol and was correlated with fall in haemoglobin. The main outcome measure was the accuracy of gravimetric measurement of blood loss. RESULTS: Validation exercise: the mean percentage error of gravimetrically measured blood volume was 4.0±2.7% compared to visually estimated blood volume with a mean percentage error of 34.7±32.1%. Clinical observation study: 356 out of 6187 deliveries were identified as having major postpartum haemorrhage. The correlation coefficient between measured blood loss and corrected fall in haemoglobin for all patients was 0.77; correlation was stronger (0.80) for postpartum haemorrhage >1500mL, and similar during routine and out-of-hours working. CONCLUSION: The accuracy of the gravimetric method was confirmed in simulated postpartum haemorrhage. The clinical study shows that gravimetric measurement of blood loss is correlated with the fall in haemoglobin in postpartum haemorrhage where blood loss exceeds 1500mL. The method is simple to perform, requires only basic equipment, and can be taught and used by all maternity services during major postpartum haemorrhage.

Glutamate quantification in patients with supratentorial gliomas using chemical shift imaging.

This study aimed to evaluate and validate chemical shift imaging (CSI) for in vivo glutamate (Glu) quantification in patients with supratentorial gliomas. If validated, CSI could become an extremely useful tool to investigate metabolic dysfunction of Glu in excitotoxic neuropathologies. Quantitative CSI estimates of Glu concentrations were compared with known concentrations of Glu in aqueous phantom solutions. Forty-one patients with known or likely supratentorial gliomas underwent preoperative CSI. The spectra obtained were analyzed for Glu concentrations and Glu to creatine (Cr) ratios. These in vivo measurements were correlated against ex vivo Glu content quantified by high performance liquid chromatography (HPLC) measured in 65 resected brain tumor and peritumoral brain specimens. For the phantom solutions the CSI estimates of Glu concentration and the Glu/Cr ratios were highly correlated with known Glu concentration (r² = 0.95, p = 0.002, and r² = 0.97, p < 0.0001, respectively). There was a modest, but statistically significant, correlation between the ex vivo measured Glu and in vivo spectroscopic Glu concentration (r² = 0.22, p = 0.04) and ratios of Glu to Cr (r² = 0.30, p = 0.002). Quantitative measurement of Glu content is feasible in patients with supratentorial gliomas using CSI. The in vitro and in vivo results suggest that this has the potential to be a reliable quantitative imaging assay for brain tumor patients. This may have wide clinical research applications in a number of neurological disorders where Glu excitotoxicity and metabolic dysfunction are known to play a role in pathogenesis, including tumor associated epilepsy, epilepsy, stroke and neurotrauma.

How do men and women define sexual desire and sexual arousal?

The purpose of this study was to understand how men and women define sexual desire and sexual arousal and how they distinguish between the two. The authors conducted 32 semi-structured interviews with individuals in South East England, using a purposive sampling strategy to maximize the variation in experience of sexual function across the group. The authors identified three criteria that participants used to define and distinguish between desire and arousal: the sequence in which they occurred; whether the mind or the body (or both) were engaged; and the extent to which feelings of desire or arousal were responsive (in response to person or stimulus) and motivational (oriented toward a goal). Most participants attempted to distinguish between desire and arousal when prompted, but often with difficulty. Participants commonly felt that desire preceded arousal; some felt that desire was "mind" and arousal "body"; and many felt that both desire and arousal were responsive and motivational. However, the authors identified numerous times when these distinctions were reversed or the differences between terms were blurred. The results support recent proposals to merge the two diagnostic categories of female sexual arousal disorder and hyposexual desire disorder into a single diagnostic category.