Assessing Structural Racism and Discrimination Along the Pre-exposure Prophylaxis Continuum: A Systematic Review.

Structural racism and discrimination (SRD) is deeply embedded across U.S. healthcare institutions, but its impact on health outcomes is challenging to assess. The purpose of this systematic literature review is to understand the impact of SRD on pre-exposure prophylaxis (PrEP) care continuum outcomes across U.S. populations who could benefit from HIV prevention. Guided by PRISMA guidelines, we conducted a systematic review of the published literature up to September 2023 using PubMed and PsycInfo and included peer-reviewed articles meeting inclusion criteria. At least two authors independently screened studies, performed quality assessments, and abstracted data relevant to the topic. Exposure variables included race/ethnicity and any level of SRD (interpersonal, intra- and extra-organizational SRD). Outcomes consisted of any steps of the PrEP care continuum. A total of 66 studies met inclusion criteria and demonstrated the negative impact of SRD on the PrEP care continuum. At the interpersonal level, medical mistrust (i.e., lack of trust in medical organizations and professionals rooted from current or historical practices of discrimination) was negatively associated with almost all the steps across the PrEP care continuum: individuals with medical mistrust were less likely to have PrEP knowledge, adhere to PrEP care, and be retained in care. At the intra-organizational level, PrEP prescription was lower for Black patients due to healthcare provider perception of higher sex-risk behaviors. At the extra-organizational level, factors such as homelessness, low socioeconomic status, and incarceration were associated with decreased PrEP uptake. On the other hand, healthcare provider trust, higher patient education, and access to health insurance were associated with increased PrEP use and retention in care. In addition, analyses using race/ethnicity as an exposure did not consistently show associations with PrEP continuum outcomes. We found that SRD has a negative impact at all steps of the PrEP care continuum. Our results suggest that when assessing the effects of race/ethnicity without the context of SRD, certain relationships and associations are missed. Addressing multi-level barriers related to SRD are needed to reduce HIV transmission and promote health equity.

Hijacking and rewiring of host CircRNA/miRNA/mRNA competitive endogenous RNA (ceRNA) regulatory networks by oncoviruses during development of viral cancers.

A significant portion of human cancers are caused by oncoviruses (12%-25%). Oncoviruses employ various strategies to promote their replication and induce tumourigenesis in host cells, one of which involves modifying the gene expression patterns of the host cells, leading to the rewiring of genes and resulting in significant changes in cellular processes and signalling pathways. In recent studies, a specific mode of gene regulation known as circular RNA (circRNA)-mediated competing endogenous RNA (ceRNA) networks has emerged as a key player in this context. CircRNAs, a class of non-coding RNA molecules, can interact with other RNA molecules, such as mRNAs and microRNAs (miRNAs), through a process known as ceRNA crosstalk. This interaction occurs when circRNAs, acting as sponges, sequester miRNAs, thereby preventing them from binding to their target mRNAs and modulating their expression. By rewiring the host cell genome, oncoviruses have the ability to manipulate the expression and activity of circRNAs, thereby influencing the ceRNA networks that can profoundly impact cellular processes such as cell proliferation, differentiation, apoptosis, and immune responses. This review focuses on a comprehensive evaluation of the latest findings on the involvement of virus-induced reprogramming of host circRNA-mediated ceRNA networks in the development and pathophysiology of human viral cancers, including cervical cancer, gastric cancer, nasopharyngeal carcinoma, Kaposi's sarcoma, hepatocellular carcinoma, and diffuse large B cell lymphoma. Understanding these mechanisms can improve our knowledge of how oncoviruses contribute to human tumourigenesis and identify potential targets for developing optimised therapies and diagnostic tools for viral cancers.

Increasing antiretroviral therapy adherence and retention in care among adults living with HIV in Philadelphia: a study protocol for a stepped-wedge cluster-randomised type 2 hybrid effectiveness-implementation trial of managed problem-solving plus (MAPS+) delivered by community health workers.

INTRODUCTION: To end the HIV epidemic in Philadelphia, implementation of evidence-based practices (EBP) to increase viral suppression and retention in HIV care is critical. Managed problem solving (MAPS), an EBP for antiretroviral therapy adherence, follows a problem-solving approach to empower people living with HIV (PWH) to manage their health. To overcome barriers to care experienced by PWH in Philadelphia, the EBP was adapted to include a focus on care retention and delivery by community health workers (CHWs). The adapted intervention is MAPS+. To maximise the clinical impact and reach of the intervention, evaluation of the effectiveness and implementation of MAPS+ is necessary. METHODS AND ANALYSIS: This manuscript describes the protocol for a stepped-wedge cluster-randomised type 2 hybrid effectiveness-implementation trial in 10 clinics in Philadelphia. This research incorporates innovative approaches to accomplish three objectives: (1) to evaluate the effectiveness of the CHW-led MAPS+ intervention to improve viral suppression and retention in care 1 year after the individual implementation period (N=390 participants), (2) to examine the effect of the menu of implementation strategies on reach and implementation cost and (3) to examine processes, mechanisms, and sustainment of the implementation strategies for MAPS+ (N=56 participants). Due to various factors (eg, COVID-19), protocol modifications have occurred. ETHICS AND DISSEMINATION: The institutional review board (IRB) at the city of Philadelphia serves as the primary IRB; initial approval was granted on 21 December 2020. The University of Pennsylvania and Northwestern University executed reliance agreements. A safety monitoring committee comprised experts in implementation science, biostatistics and infectious diseases oversee this study. This research will offer insights into achieving the goals to end the HIV epidemic in Philadelphia as well as implementation efforts of MAPS+ and other behavioural interventions aimed at increasing medication adherence and retention in care. Dissemination will include deliverables (eg, peer-reviewed manuscripts and lay publications) to reach multiple constituents. TRIAL REGISTRATION NUMBER: NCT04560621.

Acceptability and Feasibility of a Mobile Phone Application to Support HIV Pre-exposure Prophylaxis Among Women with Opioid Use Disorder.

Despite evidence supporting HIV pre-exposure prophylaxis (PrEP) effectiveness, very few women with opioid use disorder (OUD) take PrEP. Interventions that improve medication assisted treatment (MAT) uptake and adherence may also be beneficial for PrEP. The reSET-O mobile phone app is a component of the evidence-based Therapeutic Education System, which improves retention and abstinence for people with OUD. To better understand use of this mobile health tool as a support for PrEP among women with OUD, pre-implementation contextual inquiry is needed. Therefore, we set out to assess target user characteristics, implementation barriers, feasibility, and acceptability of reSET-O. We recruited women with OUD receiving care from a community-based organization in Philadelphia to complete semi-structured interviews. All participants were prescribed reSET-O. We interviewed 20 participants (average age 37 years; 70% white, 15% Hispanic, 5% Black) from 5/2021 to 2/2022. We used an integrated analysis approach combining modified grounded theory and implementation science constructs. Half reported recent injection drug use, and 6 were taking buprenorphine. Mental health symptoms were common, and half described engaging in transactional sex. The majority expressed strong interest in PrEP. Participants reported the app would be highly acceptable for PrEP and MAT adherence support, but only two redeemed the prescription. The most common barriers included phone and internet access. Our findings highlight potential implementation challenges for the use of such an app to support PrEP use in this population. Poor uptake of the app at follow-up indicates that initial prescription redemption is a major barrier to reSET-O implementation.

The Effect of Rainbow Trout (Oncorhynchus mykiss) Collagen Incorporated with Exo-Polysaccharides Derived from Rhodotorula mucilaginosa sp. on Burn Healing.

Burn is one of the physically debilitating injuries that can be potentially fatal; therefore, providing appropriate coverage in order to reduce possible mortality risk and accelerate wound healing is mandatory. In this study, collagen/exo-polysaccharide (Col/EPS 1-3%) scaffolds are synthesized from rainbow trout (Oncorhynchus mykiss) skins incorporated with Rhodotorula mucilaginosa sp. GUMS16, respectively, for promoting Grade 3 burn wound healing. Physicochemical characterizations and, consequently, biological properties of the Col/EPS scaffolds are tested. The results show that the presence of EPS does not affect the minimum porosity dimensions, while raising the EPS amount significantly reduces the maximum porosity dimensions. Thermogravimetric analysis (TGA), FTIR, and tensile property results confirm the successful incorporation of the EPS into Col scaffolds. Furthermore,the biological results show that the increasing EPS does not affect Col biodegradability and cell viability, and the use of Col/EPS 1% on rat models displays a faster healing rate. Finally, histopathological examination reveals that the Col/EPS 1% treatment accelerates wound healing, through greater re-epithelialization and dermal remodeling, more abundant fibroblast cells and Col accumulation. These findings suggest that Col/EPS 1% promotes dermal wound healing via antioxidant and anti-inflammatory activities, which can be a potential medical process in the treatment of burn wounds.

Racial/Ethnic Differences in COVID-19 Vaccine Hesitancy Among Health Care Workers in 2 Large Academic Hospitals.

IMPORTANCE: Significant differences in hesitancy to receive COVID-19 vaccination by race/ethnicity have been observed in several settings. Racial/ethnic differences in COVID-19 vaccine hesitancy among health care workers (HCWs), who face occupational and community exposure to COVID-19, have not been well described. OBJECTIVE: To assess hesitancy to COVID-19 vaccination among HCWs across different racial/ethnic groups and assess factors associated with vaccine hesitancy. DESIGN, SETTING, AND PARTICIPANTS: This survey study was conducted among HCWs from 2 large academic hospitals (ie, a children's hospital and an adult hospital) over a 3-week period in November and December 2020. Eligible participants were HCWs with and without direct patient contact. A 3-step hierarchical multivariable logistic regression was used to evaluate associations between race/ethnicity and vaccine hesitancy controlling for demographic characteristics, employment characteristics, COVID-19 exposure risk, and being up to date with routine vaccinations. Data were analyzed from February through March 2021. MAIN OUTCOMES AND MEASURES: Vaccine hesitancy, defined as not planning on, being unsure about, or planning to delay vaccination, served as the outcome. RESULTS: Among 34 865 HCWs eligible for this study, 12 034 individuals (34.5%) completed the survey and 10 871 individuals (32.2%) completed the survey and reported their race/ethnicity. Among 10 866 of these HCWs with data on sex, 8362 individuals (76.9%) were women, and among 10 833 HCWs with age data, 5923 individuals (54.5%) were younger than age 40 years. (Percentages for demographic and clinical characteristics are among the number of respondents for each type of question.) There were 8388 White individuals (77.2%), 882 Black individuals (8.1%), 845 Asian individuals (7.8%), and 449 individuals with other or mixed race/ethnicity (4.1%), and there were 307 Hispanic or Latino individuals (2.8%). Vaccine hesitancy was highest among Black HCWs (732 individuals [83.0%]) and Hispanic or Latino HCWs (195 individuals [63.5%]) (P < .001). Among 5440 HCWs with vaccine hesitancy, reasons given for hesitancy included concerns about side effects (4737 individuals [87.1%]), newness of the vaccine (4306 individuals [79.2%]), and lack of vaccine knowledge (4091 individuals [75.2%]). The adjusted odds ratio (aOR) for vaccine hesitancy was 4.98 (95% CI, 4.11-6.03) among Black HCWs, 2.10 (95% CI, 1.63-2.70) among Hispanic or Latino HCWs, 1.48 (95% CI, 1.21-1.82) among HCWs with other or mixed race/ethnicity, and 1.47 (95% CI, 1.26-1.71) among Asian HCWs compared with White HCWs (P < .001). The aOR was decreased among Black HCWs when adjusting for employment characteristics and COVID-19 exposure risk (aOR, 4.87; 95% CI, 3.96-6.00; P < .001) and being up to date with prior vaccines (aOR, 4.48; 95% CI, 3.62-5.53; P < .001) but not among HCWs with other racial/ethnic backgrounds. CONCLUSIONS AND RELEVANCE: This study found that vaccine hesitancy before the authorization of the COVID-19 vaccine was increased among Black, Hispanic or Latino, and Asian HCWs compared with White HCWs. These findings suggest that interventions focused on addressing vaccine hesitancy among HCWs are needed.

Bone Marrow Aspiration/Biopsy in the Evaluation of Fever of Unknown Origin in Patients with AIDS.

BACKGROUND: HIV can interrupt the normal development of bone marrow cell lines. Bone marrow aspiration/biopsy (BMA/B) has been described as a diagnostic tool in AIDS patients with fever of unknown origin (FUO). In this review, we aimed to study patients with AIDS who had undergone a BMA/B to investigate FUO and describe the pathologies diagnosed in the biopsy. METHODS: Thirty-four BMA/B samples were collected from AIDS patients admitted for work-up of FUO to the infectious disease ward of a tertiary referral HIV center in Tehran, Iran, between September 2014 and September 2015. Data including age, sex, duration of disease, CD4 cell counts, hepatitis B (HBV) and C (HCV) coinfection, the primary presentation of AIDS, and the treatment history were retrieved and analyzed. Patients underwent BMA/B. An expert pathologist reviewed the BMA/B specimens. RESULTS: The mean age of the patients was 37.5 years (range, 26-56), and 27 (79%) were men. Twenty-seven (79%) patients contracted HIV from injection drug use, and 7 (21%) via sexual transmission. Only 3 (9%) of the BMA/B examinations were normal. Hypocellular bone marrow was diagnosed in 22 (65%) patients. Other pathologies included granulomas in 6 (18%), hematologic malignancies in 2 (6%), and leishmaniasis Aspergillosis, each in 1 (3%) patient. Six (17%) of the specimens were found to have tuberculosis infections. CONCLUSION: Hypocellular bone marrow was the most common pathology on BMA/B examinations, followed by the presence of granulomas. Tuberculosis, Aspergillosis, and Leishmaniasis the opportunistic infections diagnosed on BMA/B specimens. Our results support BMA/B as an appropriate diagnostic tool for early diagnosis of opportunistic infections and malignancies in AIDS. BMA/B is indispensable in the armament of diagnostic tools of the physicians managing AIDS patients.

Prevalence of COVID-19-like Symptoms among People Living with HIV, and Using Antiretroviral Therapy for Prevention and Treatment.

BACKGROUND: COVID-19 has spread globally with remarkable speed, and currently, there is limited data available exploring any aspect of the intersection between HIV and SARSCoV- 2 co-infection. OBJECTIVE: To estimate the prevalence of clinical symptoms associated with COVID-19 among people living with HIV (PLWH) in Tehran, Iran. DESIGN: Cross-sectional study. METHODS: A total of 200 PLWH were recruited through the positive club via sampling, and completed the symptom-based questionnaire for COVID-19, which was delivered by trained peers. RESULTS: Of 200 participants, respiratory symptoms, including cough, sputum, and shortness of breath, were the most prevalent among participants, but only one person developed symptoms collectively suggested COVID-19 and sought treatments. CONCLUSION: It appears that existing infection with HIV or receiving antiretroviral treatment (ART) might reduce the susceptibility to the infection with SARS-CoV-2 or decrease the severity of the infection acquired. Further research is needed to understand causal mechanisms.

Symmetrical polyneuropathy in coronavirus disease 2019 (COVID-19).

The outbreak of the novel coronavirus that began in late December 2019 was announced as a pandemic by the World Health Organization as the number of cases is increasing exponentially throughout the globe. We presented a patient with confirmed SARS-CoV-2 pneumonia developing symmetric polyneuropathy. To our knowledge, extrapulmonary clinical presentations of 2019 novel coronavirus disease (COVID-19) have rarely been reported. This case highlights the possible association between SARS-CoV-2 infection and nervous system involvement.

Epidemiology of HIV in Iran.

Iran has been one of the active countries fighting against HIV/AIDS in the Middle East during the last decades. Moreover, there is a strong push to strengthen the national health management system concerning HIV prevention and control. In Iran, HIV disease has its unique features, from changes in modes of transmission to improvement in treatment and care programs, which can make it a good case for closer scrutiny. The present review describes the HIV epidemic in Iran from the first case diagnosed until prevention among different groups at risk and co-infections. Not only we addressed the key populations and community-based attempts to overcome HIV-related issues in clinics, but we also elaborated on the efforts and trends in society and the actual behaviors related to HIV/AIDS. Being located in the Middle East and North Africa (MENA) region, given the countryspecific characteristics, and despite all the national efforts along with other countries in this region, Iran still needs to take extra measures to reduce HIV transmission, especially in health education. Although Iran is one of the pioneers in implementing applicable and appropriate policies in the MENA region, including harm reduction services to reduce HIV incidence, people with substance use disorder continue to be the majority of those living with HIV in the country. Similar to other countries in this region, the HIV prevention and control programs aim at 90-90-90 targets to eliminate HIV infection and reduce the transmission, especially the mother-to-child transmission and among other key populations.

Lung Involvement Found on Chest CT Scan in a Pre-Symptomatic Person with SARS-CoV-2 Infection: A Case Report.

The novel coronavirus SARS-CoV-2 infection is spreading worldwide, and there are many reports of acute respiratory distress syndrome caused by this infection. However, asymptomatic lung involvement has not been reported. We hereby present the case of a 44-year-old health-care worker, who was found to be infected with the SARS-CoV-2 virus after a CT-scan performed for an unrelated condition revealed a lesion in the lung field compatible with COVID-19 infection. His condition deteriorated initially, but eventually improved with supportive treatment and the compassionate use of antivirals and antimalarials and is now in a stable condition.

Successful pregnancy and weight loss management in a woman unknowingly pregnant at the time of bariatric surgery: a case report.

BACKGROUND: Preventing unintended pregnancy is an important issue for women undergoing bariatric surgery, not only to avoid an adverse fetal outcome but to also ensure maximum weight loss for mother. Current guidelines strongly advise to use a reliable method of contraception following surgery and to delay pregnancy for 12-18 months after surgery. CASE PRESENTATION: We present the case of a woman who underwent laparoscopic sleeve gastrectomy while she was unknowingly pregnant. She was monitored closely throughout her pregnancy for maternal-fetal wellbeing and delivered a healthy full-term girl. At her last follow-up visit 6 months post-delivery, both mother and infant were in good general condition and the mother achieved 94.4% excess weight loss. CONCLUSIONS: In all-female patients of childbearing age planning to undergo bariatric surgery, pregnancy should be avoided by using a reliable method of contraception well before surgery. Pregnancy should also be excluded on the day of surgery.

Obesity, Heart Failure, and Obesity Paradox.

The incidence and prevalence of obesity are fast increasing worldwide. Various indices have been used to measure and assess obesity. The body mass index (BMI) is the most common and practical of these indices. Overweight and obesity exert considerable adverse effects on the cardiovascular system. These effects are mediated through various neurohormonal and cytokine pathways, most of which are inflammatory mediators. Systolic and / or diastolic heart failure is more prevalent among obese and overweight individuals than among normal weight people. The concept of the "obesity paradox" has been proposed by some previously published studies, in which the prognosis of obese patients with established cardiovascular diseases, especially heart failure, is better than that of their leaner counterparts. In this review, we discuss the obesity paradox and its possible pathophysiologic mechanisms.

Interaction between harmane, a class of ß-carboline alkaloids, and the CA1 serotonergic system in modulation of memory acquisition.

This study set to assess the involvement of dorsal hippocampus (CA1) serotonergic system on harmane induced memory acquisition deficit. We used one trial step-down inhibitory avoidancetask to evaluate memory retention and then, open field test to evaluate locomotor activity in adult male NMRI mice. The results showed that pre-training intra-peritoneal (i.p.) administration of harmane (12mg/kg) induced impairment of memory acquisition. Pre-training intra-CA1 administration of 5-HT1B/1D receptor agonist (CP94253; 0.5 and 5ng/mouse) and 5-HT2A/2B/2C receptor agonist (α-methyl 5-HT; 50ng/mouse) impaired memory acquisition. Furthermore, intra-CA1 administration of 5-HT1B/1D receptor antagonist (GR127935; 0.5ng/mouse) and 5-HT2 receptor antagonist (cinancerine; 5ng/mouse) improved memory acquisition. In addition, pre-training intra-CA1 injection of sub-threshold dose of CP94253 (0.05ng/mouse) and α-methyl 5-HT (5ng/mouse) potentiated impairment of memory acquisition induced by harmane (12mg/kg, i.p.). On the other hand, pre-training intra-CA1 infusion of sub-threshold dose of GR127935 (0.05ng/mouse) and cinancerine (0.5ng/mouse) with the administration of harmane (12mg/kg, i.p.) weakened impairment of memory acquisition. Moreover, all above doses of drugs did not change locomotor activity. The present findings suggest that there is an interaction between harmane and the CA1 serotonergic system in modulation of memory acquisition.

HLA-Cw Allele Frequency in Definite Meniere's Disease Compared to Probable Meniere's Disease and Healthy Controls in an Iranian Sample.

INTRODUCTION: Several lines of evidence support the contribution of autoimmune mechanisms in the pathogenesis of Meniere's disease. The aim of this study was determining the association between HLA-Cw Alleles in patients with definite Meniere's disease and patients with probable Meniere's disease and a control group. MATERIALS AND METHODS: HLA-Cw genotyping was performed in 23 patients with definite Meniere's disease, 24 with probable Meniere's disease, and 91 healthy normal subjects, using sequence specific primers polymerase chain reaction technique. The statistical analysis was performed using stata 8 software. RESULTS: There was a significant association between HLA-Cw*04 and HLA-Cw*16 in both definite and probable Meniere's disease compared to normal healthy controls. We observed a significant difference in HLA-Cw*12 frequencies between patients with definite Meniere's disease compared to patients with probable Meniere's disease (P=0.04). The frequency of HLA-Cw*18 is significantly higher in healthy controls (P=0.002). CONCLUSION: Our findings support the rule of HLA-Cw Alleles in both definite and probable Meniere's disease. In addition, differences in HLA-Cw*12 frequency in definite and probable Meniere's disease in our study's population might indicate distinct immune and inflammatory mechanisms involved in each condition.

[A randomized, double blind trial of prophylactic fibrinogen to reduce bleeding in cardiac surgery]. / Estudo randômico e duplo-cego de profilaxia com fibrinogênio para reduzir o sangramento em cirurgia cardíaca.

BACKGROUND AND OBJECTIVES: Postoperative bleeding has a great clinical importance and can contribute to increased mortality and morbidity in patients undergoing coronary artery bypass graft surgery. In this prospective, randomized, double-blind study, we evaluated the effect of prophylactic administration of fibrinogen concentrate on post-coronary artery bypass graft surgery bleeding. METHODS: A total of 60 patients undergoing coronary artery bypass surgery were randomly divided into two groups. Patients in the fibrinogen group received 1g of fibrinogen concentrate 30min prior to the operation, while patients in the control group received placebo. Post-operative bleeding volumes, prothrombin time, partial thromboplastin time, INR, hemoglobin and transfused blood products in both groups were recorded. A strict red blood cell transfusion protocol was used in all patients. RESULTS: There were no significant differences between intra-operative packed red blood cells infusion in the studied groups (1.0±1.4 in fibrinogen group, and 1.3±1.1 in control group). Less postoperative bleeding was observed in the fibrinogen group (477±143 versus 703±179, p=0.0001). Fifteen patients in the fibrinogen group and 21 in the control group required post-op packed red blood cells infusion (p=0.094). No thrombotic event was observed through 72h after surgery. CONCLUSION: Prophylactic fibrinogen reduces post-operative bleeding in patients undergoing coronary artery bypass graft.

A randomized, double blind trial of prophylactic fibrinogen to reduce bleeding in cardiac surgery.

BACKGROUND AND OBJECTIVES: Postoperative bleeding has a great clinical importance and can contribute to increased mortality and morbidity in patients undergoing coronary artery bypass graft surgery. In this prospective, randomized, double-blind study, we evaluated the effect of prophylactic administration of fibrinogen concentrate on post-coronary artery bypass graft surgery bleeding. METHODS: A total of 60 patients undergoing coronary artery bypass surgery were randomly divided into two groups. Patients in the fibrinogen group received 1g of fibrinogen concentrate 30 min prior to the operation, while patients in the control group received placebo. Post-operative bleeding volumes, prothrombin time, partial thromboplastin time, INR, hemoglobin and transfused blood products in both groups were recorded. A strict red blood cell transfusion protocol was used in all patients. RESULTS: There were no significant differences between intra-operative packed red blood cells infusion in the studied groups (1.0±1.4 in fibrinogen group, and 1.3±1.1 in control group). Less postoperative bleeding was observed in the fibrinogen group (477±143 versus 703±179, p=0.0001). Fifteen patients in the fibrinogen group and 21 in the control group required post-op packed red blood cells infusion (p=0.094). No thrombotic event was observed through 72 h after surgery. CONCLUSION: Prophylactic fibrinogen reduces post-operative bleeding in patients undergoing coronary artery bypass graft.

A randomized, double blind trial of prophylactic fibrinogen to reduce bleeding in cardiac surgery / Estudo randômico e duplo-cego de profilaxia com fibrinogênio para reduzir o sangramento em cirurgia cardíaca / Estudio aleatorizado y doble ciego de profilaxis con fibrinógeno para reducir el sangrado en cirugía cardíaca

BACKGROUND AND OBJECTIVES: Postoperative bleeding has a great clinical importance and can contribute to increased mortality and morbidity in patients undergoing coronary artery bypass graft surgery. In this prospective, randomized, double-blind study, we evaluated the effect of prophylactic administration of fibrinogen concentrate on post-coronary artery bypass graft surgery bleeding. METHODS: A total of 60 patients undergoing coronary artery bypass surgery were randomly divided into two groups. Patients in the fibrinogen group received 1 g of fibrinogen concentrate 30 min prior to the operation, while patients in the control group received placebo. Post-operative bleeding volumes, prothrombin time, partial thromboplastin time, INR, hemoglobin and transfused blood products in both groups were recorded. A strict red blood cell transfusion protocol was used in all patients. RESULTS: There were no significant differences between intra-operative packed red blood cells infusion in the studied groups (1.0 ± 1.4 in fibrinogen group, and 1.3 ± 1.1 in control group). Less postoperative bleeding was observed in the fibrinogen group (477 ± 143 versus 703 ± 179, p = 0.0001). Fifteen patients in the fibrinogen group and 21 in the control group required post-op packed red blood cells infusion (p = 0.094). No thrombotic event was observed through 72 h after surgery. CONCLUSION: Prophylactic fibrinogen reduces post-operative bleeding in patients undergoing coronary artery bypass graft. .

JUSTIFICATIVA E OBJETIVO: a hemorragia no período pós-operatório é de grande importância clínica e pode contribuir para o aumento da morbidade e mortalidade em pacientes submetidos à cirurgia de revascularização coronária. Nesse estudo prospectivo, randômico e duplo-cego, avaliamos o efeito da administração profilática de concentrado de fibrinogênio sobre o sangramento após cirurgia de revascularização coronária. MÉTODOS: no total, 60 pacientes submetidos à cirurgia de revascularização coronária foram randomicamente divididos em dois grupos. Os pacientes do grupo fibrinogênio receberam 1 g de concentrado de fibrinogênio 30 minutos antes da operação, enquanto os doentes do grupo controle receberam placebo. Os volumes de sangramento no pós-operatório, tempo de protrombina, tempo de tromboplastina parcial, INR, hemoglobina e hemoderivados transfundidos em ambos os grupos foram registrados. Um protocolo de conduta rigoroso para transfusão de hemácias foi usado em todos os pacientes. RESULTADOS: não houve diferenças significantes entre as infusões de concentrados de hemácias nos grupos estudados (1,0 ± 1,4 no grupo fibrinogênio e 1,3 ± 1,1 no grupo controle). O grupo fibrinogênio apresentou menos sangramento no pós-operatório (477 ± 143 versus 703 ± 179, p = 0,0001). Quinze pacientes do grupo fibrinogênio e 21 do grupo controle precisaram de infusão de concentrado de hemácias no pós-operatório (p = 0,094). Evento trombótico não foi observado durante 72 h após a cirurgia. CONCLUSÃO: profilaxia com fibrinogênio reduz o sangramento no período pós-operatório de pacientes submetidos à revascularização coronária. .

JUSTIFICACIÓN Y OBJETIVOS: la hemorragia en el período postoperatorio es de gran importancia clínica y puede contribuir al aumento de la morbimortalidad en pacientes sometidos a cirugía de revascularización del miocardio. En este estudio prospectivo, aleatorizado y doble ciego, evaluamos el efecto de la administración profiláctica del concentrado de fibrinógeno sobre el sangrado después de la cirugía de revascularización del miocardio. MÉTODOS: en total, 60 pacientes sometidos a cirugía de revascularización del miocardio fueron aleatoriamente divididos en 2 grupos. Los pacientes del grupo fibrinógeno recibieron 1 g de concentrado de fibrinógeno 30 min antes de la operación, mientras que los del grupo control recibieron placebo. Los volúmenes de sangrado en el postoperatorio, tiempo de protrombina, tiempo de tromboplastina parcial, INR, hemoglobina y hemoderivados transfundidos en ambos grupos fueron registrados. En todo los pacientes se usó un protocolo de conducta riguroso para la transfusión de hematíes. RESULTADOS: no hubo diferencias significativas entre las infusiones de concentrados de hematíes en los grupos estudiados (1 ± 1,4 en el grupo fibrinógeno y 1,3 ± 1,1 en el grupo control). El grupo fibrinógeno presentó menos sangrado en el postoperatorio (477 ± 143 versus 703 ± 179, p = 0,0001). Quince pacientes del grupo fibrinógeno y 21 del grupo control necesitaron infusión de concentrado de hematíes en el postoperatorio (p = 0,094). Ningún evento trombótico fue observado durante 72 h después de la cirugía. CONCLUSIÓN: la profilaxis con fibrinógeno reduce el sangrado en el período postoperatorio de pacientes sometidos a revascularización del miocardio. .

Ondansetron reducing pain on injection of etomidate: a controlled randomized study.

INTRODUCTION: Etomidate causes pain when injected intravenously. In this study we sought to determine if pretreatment by ondansetron reduces the pain on injection of etomidate. METHODS: In this randomized, double blinded, placebo-controlled clinical trial, 20 patients of both sexes aged between 18 and 50 years of American Society of Anesthesiologists (ASA) physical status class I or II, whom were candidates for various elective surgical procedures and need more than one intravenous access were enrolled in the study. On arrival to the operating room two 22 gauge cannulas were inserted into veins on the dorsum of both hands. Following the infusion of 100mL normal saline into both intravenous lines, using an elastic band, venous drainage of hands was occluded at midarm. The patients were administered 8 mg (2 mL) of ondansetron into one hand and 2 mL of 0.9% saline into the other hand at the same time. The elastic band was removed after 1 min and 2mg (1 mL) of etomidate was administered at the same rate simultaneously into intravenous lines. The patients were asked to give a score of pain based on a verbal analog scale (VAS) to each hand. RESULTS: A total number of 20 patients were studied (male = 55%, female = 45%). The mean age of the participants was 37.5 ± 13.1 years old and the mean weight was 67.7 ± 7.3 kg. The mean VAS for injection pain of etomidate after pre-administration of intravenous ondansetron was 1.5 ± 1.2 which was lower compared to pre-administration of placebo (3.2 ± 2.8, p < 0.05). CONCLUSION: This study illustrates that pre-treatment with intravenous ondansetron significantly reduces the pain on injection of etomidate.