Point-of-care haemostasis monitoring during liver transplantation is cost effective.

Background Optimal haemostasis management in orthotropic liver transplant (OLT) could reduce blood loss and transfusion volume, improve patient outcomes and reduce cost. Methods We performed a study including 336 OLTs to evaluate the clinical and cost effectiveness of a new point-of-care (POC)-based haemostatic management approach in OLT patients. Results In terms of health benefit we found that the new approach showed a significant reduction in transfusion requirements (red blood cell transfusion units were reduced from 5.3±4.6 to 2.8±2.9 [p<0.001], free frozen plasma from 3.1±3.3 to 0.4±1.0 [p<0.001] and platelets from 2.9±3.9 to 0.4±0.9 [p<0.001], transfusion avoidance, 9.7% vs. 29.1% [p<0.001] and massive transfusion, 14.5% vs. 3.8% [p=0.001]); we also found a significant improvement in patient outcomes, such, reoperation for bleeding or acute-kidney-failure (8.3% vs. 2.4%, p=0.015; 33.6% vs. 5.4%, p<0.001), with a significant reduction in the length of the hospital total stay (40.6±13.8 days vs. 38.2±14.4 days, p=0.001). The lowest cost incurred was observed with the new approach (€73,038.80 vs. €158,912.90) with significant patient saving associated to transfusion avoidance (€1278.36), ICU-stay (€3037.26), total-stay (€3800.76) and reoperation for bleeding (€80,899.64). Conclusions POC haemostatic monitoring during OLT is cost effective.

Mobile Laboratory Unit: a disruptor solution for hemostasis management during major surgery. Usage in the context of face transplantation.

BACKGROUND: The management of surgical bleeding during a face transplant in a patient diagnosed with bilateral neurofibromatosis is quite complex. With the actual methods and technology for hemostasis management, it may not always be possible to give the clinician the support needed to manage operative associated bleeding. Bedside hemostasis monitors are needed urgently to assist clinicians in making the correct diagnosis in a timely manner. METHODS: Our Mobile Laboratory Unit is a disruptive solution for hemostasis management during major surgery as it allows real-time monitoring, the predominant mechanism of bleeding and goal-direct coagulation therapy. The unit is an autonomous mobile platform that can be moved immediately to anywhere its service is needed and offers a complete flexible laboratory test which includes biochemistry, hematology and coagulation studies as standard equipment. RESULTS: In our case the test performed by the unit allowed us to identify the reason for our patient's bleeding at the bedside. Severely decreased clot firmness of the fibrin-based clot and a less impaired firmness of the whole blood clot, suggested an acceptable contribution of platelets to the clot quality, but decreased polymerization of fibrinogen into fibrin. CONCLUSIONS: In our opinion new insights into the pathophysiology of coagulopathy, the availability of technology such as our Mobile Laboratory Unit, and awareness of side effects of intravenous fluids should encourage the idea that perhaps it is time to change hemostasis management in operation-related bleeding.

Differential Nitrogen Nutrition Modifies Polyamines and the Amino-Acid Profile of Sweet Pepper Under Salinity Stress.

The horticultural industry demands high-quality resources to achieve excellence in yield and optimal revenues. Nitrogen is a pivotal nutrient to accomplish these goals for plant growth and product quality. However, competition for water in semi-arid regions can force the use of brackish waters, which can impair N uptake. The lower N uptake can be due to several reasons, such as an antagonism between ions, an absence of ATP, and/or alteration of N metabolism. The effect of supplying N as NO 3 - alone or in combination with NH 4 + , coupled with low or high salinity (8 or 20 mM NaCl), has been studied in sweet pepper fruits (Capsicum annuum L. cv. Melchor). The application of NH 4 + at high salinity affected chromatic parameters (a∗, b∗, and C∗), while chlorophyll a and b levels declined and ß-carotene increased. The concentrations of P, K, Ca, Mg, and Cu were reduced in the fruits of plants irrigated with NH 4 + . The concentration of Na was only reduced when NH 4 + was supplied. Likewise, the concentration of total phenolics was also reduced at high salinity. However, total protein was unaffected. The amino acid profile was altered by the supply of NH 4 + , which reduced the concentrations of histidine and phenylalanine. Moreover, the concentrations of putrescine and cadaverine were increased by NH 4 + at high salinity, whereas that of cadaverine was reduced by NH 4 + at low salinity. The observed changes in fruit quality triggered by salinity, under the conditions of this study, should be borne in mind for this crop with regard to the envisaged palliative effect of the supply of N- NH 4 + .

The Form in Which Nitrogen Is Supplied Affects the Polyamines, Amino Acids, and Mineral Composition of Sweet Pepper Fruit under an Elevated CO2 Concentration.

We investigated the effect of supplying nitrogen, as NO3- or as NO3-/NH4+, on the composition of fruits of sweet pepper (Capsicum annuum L. cv. Melchor) plants grown with different CO2 concentrations ([CO2]): ambient or elevated (800 µmol mol-1). The results show that the application of NH4+ and high [CO2] affected the chroma related to the concentrations of chlorophylls. The concentrations of Ca, Cu, Mg, P, and Zn were significantly reduced in the fruits of plants nourished with NH4+, the loss of Fe being more dramatic at increased [CO2], which was also the case with the protein concentration. The concentration of total phenolics was increased by NH4+, being unaffected by [CO2]. Globally, the NH4+ was the main factor that affected fruit free amino acid concentrations. Polyamines were affected differently: putrescine was increased by elevated [CO2], while the response of cadaverine depended on the form of N supplied.

Photosynthetic acclimation to elevated CO2 concentration in a sweet pepper (Capsicum annuum) crop under Mediterranean greenhouse conditions: influence of the nitrogen source and salinity.

In many plant species, long-term exposure to elevated CO2 concentration results in a reduction in photosynthetic capacity, known as acclimation. This process is mainly explained by a feedback inhibition mechanism. The supply of a fraction of the nitrogen (N) in the nutrient solution as NH4+ can play an important role in the maintenance of photosynthetic activity and could mitigate the acclimation process. The aims of the present work were to study the photosynthetic response of sweet pepper (Capsicum annuum L.) to CO2 enrichment in Mediterranean greenhouse conditions, throughout the crop growth cycle and to evaluate the supply of NH4+ in the nutrient solution as a strategy to enhance the long-term response to CO2 at different levels of salinity. The experiment was conducted in two identical greenhouses: one with CO2 enrichment according to the ventilation, maintaining a high concentration when the vents were closed and a near-atmospheric level when the vents were open and one without. Sweet pepper plants were grown in both greenhouses, being irrigated with two levels of water salinity and two N sources: (i) NO3- and (ii) NO3- plus NH4+. A reduction in the response of photosynthesis to high CO2 concentration was found in the enriched plants after 135 days of CO2 supply, with respect to the reference plants. The leaf photosynthesis rate measured at high CO2 concentration showed a closer relationship with the leaf N concentration than the non-structural carbohydrate concentration. The relative yield gain of the CO2-enriched plants progressively decreased after reaching a maximum value; this was probably associated with the photosynthetic acclimation process. This decrease was delayed by the use of NH4+ in the nutrient solution at low salinity. Knowledge of the crop phase when acclimation to high CO2 concentration occurs can be the basis for deciding when to impose an early cessation of CO2 application, as a strategy to improve the economic efficiency of CO2 supply in Mediterranean conditions.

Point-of-care haemostasis monitoring during liver transplantation reduces transfusion requirements and improves patient outcome.

BACKGROUND: Optimal haemostasis management can improve patient outcomes and reduce blood loss and transfusion volume in orthotopic-liver-transplant (OLT). METHODS: We performed a prospective study including 200 consecutive OLTs. The first 100 patients were treated according to the clinic's standards and the next 100 patients were treated using the new point-of-care (POC)-based haemostasis management strategy. Transfusion parameters and other outcomes were compared between groups. RESULTS: Transfusion requirements were reduced in the POC group. The median and IQR of red-blood-cells (RBC) transfusion units were reduced from 5 [2-8] to 3 [0-5] (p < 0.001), plasma from 2 [0-4] to 0 (p < 0.001), and platelets from 1 [0-4] to 0 [0-1] (p < 0.001), into the POC group only four patients received tranexamic acid and fibrinogen transfusion rate was 1.13 ± 1.44 g (p = 0.001). We also improved the incidence of transfusion avoidance, 5% vs. 24% (p < 0.001) and reduced the incidence of massive transfusion (defined as the transfusion of more than 10 RBC units), 13% vs. 2% (p = 0.005). We also observed a relationship between RBC transfusion requirements and preoperative haemoglobin, and between platelet transfusion and preoperative fibrinogen levels. The incidence of postoperative complications, such as, reoperation for bleeding, acute-kidney-failure or haemodynamic instability was significantly lower (13.0% vs. 5%, p = 0.048, 17% vs. 2%, p < 0.001, and 29% vs. 16%, p = 0.028). Overall, blood product transfusion was associated with increased risk of postoperative complications. CONCLUSIONS: A haemostatic therapy algorithm based on POC monitoring reduced transfusion and improved outcome in OLT.