Safety of Continuous Erector Spinae Catheters in Chest Trauma: A Retrospective Cohort Study.

BACKGROUND: The erector spinae block is an efficacious analgesic option for the management of rib fracture--related pain. Despite there being minimal published data specifically addressing the safety profile of this block, many societies have made statements regarding its safety and its use as an alternative to traditional regional anesthesia techniques in patients at risk of complications. The primary aim of this study was to characterize the safety profile of erector spinae plane block catheters by determining the incidence of early complications. The secondary aim of this study was to characterize the incidence of late adverse events, as well as the erector spinae plane block catheter failure rate. METHODS: We analyzed electronic medical record data of patients who had an erector spinae plane block catheter inserted for the management of rib fractures between November 2017 and September 2020. To assess early adverse events, data collection included hypotension, hypoxemia, local anesthetic systemic toxicity, and pneumothorax thought to be associated with erector spinae plane block catheter insertion. Late complications included catheter site infection and catheter site hematoma. RESULTS: A total of 224 patients received 244 continuous erector spinae catheters during the study period. After insertion of the erector spinae, there were no immediate complications such as hypotension, hypoxia, local anesthetic toxicity, or pneumothorax. Of all blocks inserted, 7.7% were removed due to catheter failure (8.4 per 100 catheters; 95% confidence interval [CI], 5.1-13.9 per 100 catheters). This resulted in a failure rate of 1.9 per 1000 catheter days (95% CI, 1.1-6.7 catheter days). Late complications included 2 erythematous catheter sites and 2 small hematomas not requiring intervention. The incidence of a minor late complication was 16.7 per 1000 catheters (95% CI, 6.1-45.5 per 1000 catheters). CONCLUSIONS: This study supports the statements made by regional anesthesia societies regarding the safety of the erector spinae plane block. Based on the results presented in this population of trauma patients, the erector spinae plane block catheter is a low-risk analgesic technique that may be performed in the presence of abnormal coagulation status or systemic infection.

Linkage analysis and residual heterozygotes derived near isogenic lines reveals a novel protein quantitative trait loci from a Glycine soja accession.

Modern soybean [Glycine max (L.) Merr] cultivars have low overall genetic variation due to repeated bottleneck events that arose during domestication and from selection strategies typical of many soybean breeding programs. In both public and private soybean breeding programs, the introgression of wild soybean (Glycine soja Siebold and Zucc.) alleles is a viable option to increase genetic diversity and identify new sources for traits of value. The objectives of our study were to examine the genetic architecture responsible for seed protein and oil using a recombinant inbred line (RIL) population derived from hybridizing a G. max line ('Osage') with a G. soja accession (PI 593983). Linkage mapping identified a total of seven significant quantitative trait loci on chromosomes 14 and 20 for seed protein and on chromosome 8 for seed oil with LOD scores ranging from 5.3 to 31.7 for seed protein content and from 9.8 to 25.9 for seed oil content. We analyzed 3,015 single F4:9 soybean plants to develop two residual heterozygotes derived near isogenic lines (RHD-NIL) populations by targeting nine SNP markers from genotype-by-sequencing, which corresponded to two novel quantitative trait loci (QTL) derived from G. soja: one for a novel seed oil QTL on chromosome 8 and another for a novel protein QTL on chromosome 14. Single marker analysis and linkage analysis using 50 RHD-NILs validated the chromosome 14 protein QTL, and whole genome sequencing of RHD-NILs allowed us to reduce the QTL interval from ∼16.5 to ∼4.6 Mbp. We identified two genomic regions based on recombination events which had significant increases of 0.65 and 0.72% in seed protein content without a significant decrease in seed oil content. A new Kompetitive allele-specific polymerase chain reaction (KASP) assay, which will be useful for introgression of this trait into modern elite G. max cultivars, was developed in one region. Within the significantly associated genomic regions, a total of eight genes are considered as candidate genes, based on the presence of gene annotations associated with the protein or amino acid metabolism/movement. Our results provide better insights into utilizing wild soybean as a source of genetic diversity for soybean cultivar improvement utilizing native traits.

Transforming medical education to strengthen the health professional training in Viet Nam: A case study.

The competency-based undergraduate curriculum reform at the University of Medicine and Pharmacy at Ho Chi Minh City, Faculty of Medicine (UMP-FM) is detailed and reviewed in reference to the instructional and institutional reforms, and enabling actions recommended by the Lancet 2010 Commission for Health Professional Education. Key objectives are to: revise the overall 6-year curriculum to be more integrated and competency-based; reinforce students' knowledge application, problem-solving, clinical competence, self-directed learning and soft skills; develop a comprehensive and performance-based student assessment programme; and establish a comprehensive quality monitoring programme to facilitate changes and improvements. New features include early introduction to the practice of medicine, family- and community-based medicine, professionalism, interprofessional education, electives experiences, and a scholarly project. Institutional reform introduces a faculty development programme, joint planning mechanism, a "culture of critical inquiry", and a transparent faculty reward system. Lessons learnt from the curriculum reform at UMP-FM could be helpful to medical schools from low- and middle-income countries considering transitioning from a traditional to a competency-based curriculum. Funding: This work receives no external funding.

Structural characterization of the active form of PerR: insights into the metal-induced activation of PerR and Fur proteins for DNA binding.

In Bacillus subtilis, the transcription factor PerR is an iron dependant sensor of H(2)O(2). The sensing mechanism relies on a selective metal catalysed oxidation of two histidine residues of the regulatory site. Here we present the first crystal structure of the active PerR protein in complex with a Mn(2+) ion. In addition, X-ray absorption spectroscopy experiments were performed to characterize the corresponding iron form of the protein. Both studies reveal a penta-coordinate arrangement of the regulatory site that involves three histidines and two aspartates. One of the histidine ligand belongs to the N-terminal domain. Binding of this residue to the regulatory metal allows the protein to adopt a caliper-like conformation suited to DNA binding. Since this histidine is conserved in all PerR and a vast majority of Fur proteins, it is likely that the allosteric switch induced by the regulatory metal is general for this family of metalloregulators.

Effect of feeding cassava and/or Stylosanthes foliage on the performance of crossbred growing cattle.

The effect of feeding different levels of cassava foliage (Manihot esculenta, Crantz) and/or Stylosanthes guianensis foliage on the growth and digestibility was studied using twenty eight 6-month-old crossbred growing cattle (50% local Yellow cattle and 50% Sindhi) (both Bos indicus) weighing on average 114 kg at start. All animals were fed a basal diet consisting of urea treated rice straw (URTRS) fed ad libitum, 0.87 kg concentrate and 0.22 kg molasses on dry matter (DM) basis. The treatments were four supplements: soybean meal, cassava foliage, stylosanthes foliage or a mix of stylosanthes foliage and cassava foliage all giving the same nitrogen intake. The consumption of tannins and hydrogen cyanide (HCN) were significantly higher in groups fed a mixture of foliages compared with only cassava foliage, respectively. There were 30% and 19%, respectively, higher live weight gain in the group fed a mixture of foliages as compared to the groups fed only cassava or stylosanthes. The factors of low organic matter and high level of HCN in the diet when feeding only cassava foliage might explain the negative effects on intake, neutral detergent fibre digestibility and nitrogen retention, and resulted in lower growth rates.

Health Care Worker Preferences and Perspectives on Doses per Container for 2 Lyophilized Vaccines in Senegal, Vietnam, and Zambia.

INTRODUCTION: Limited information exists on health care workers' (HCWs) perceptions about use of multidose vaccine vials and their preferences about doses per container (DPC). We present findings from qualitative studies conducted in Senegal, Vietnam, and Zambia to explore HCWs' behavior regarding opening vials and their perceptions and preferences for the number of doses in vials of BCG and measles-containing vaccine (MCV). Zambia and Senegal currently offer MCV in 10-dose vials and BCG in 20-dose vials; 10-dose vials are used for both vaccines in Vietnam. Unused doses in vials of these reconstituted vaccines must be discarded within 6 hours. METHODS: Key informant interviews (KIIs) were conducted with frontline HCWs in Senegal, Vietnam, and Zambia. In Senegal and Vietnam, the KIIs were conducted as part of broader formative research; in Zambia, KIIs were conducted in control districts using 10-dose MCV vials only and in intervention districts that switched from 10- to 5-dose vials during the study. During analysis, themes common to all 3 countries were synthesized. Critical themes relevant to country contexts were also examined. RESULTS: HCWs in all 3 countries preferred containers with fewer doses for BCG and MCV to reduce wastage and increase the likelihood of vaccinating every eligible child. HCWs in Senegal and HCWs using 10-dose vials in Zambia reported sending unvaccinated children away because not enough children were present to warrant opening a new vial. In Vietnam, where sessions are typically held monthly, and in Zambia when the 5-dose vials were used, almost all HCWs reported opening a vial of MCV for even 1 child. DISCUSSION: HCWs prefer vials with fewer DPC. Their concerns about balancing coverage and wastage influence their decisions to vaccinate every eligible child; and their perspectives are crucial to ensuring that all target populations are reached with vaccines in a timely manner.

Induction opioids for caesarean section under general anaesthesia: a systematic review and meta-analysis of randomised controlled trials.

INTRODUCTION: The adverse effects of induction opioids on the neonate are poorly characterised. The study aim was to investigate whether induction opioids can be used in caesarean section without adversely affecting the neonate. METHODS: Six databases were systematically searched from inception until January 2019. Included studies compared induction opioids and placebo in caesarean section. Results were presented as odds ratios (95% confidence intervals) for dichotomous outcomes and weighted mean difference for continuous outcomes. An I2 statistic of >50% was significant for heterogeneity. The primary outcome was Apgar score (1 and 5 min). Secondary outcomes included neonatal adverse events, cord blood gas analyses, maternal haemodynamic parameters (systolic blood pressure (SBP), mean arterial pressure (MAP), heart rate (HR) and catecholamine concentrations. RESULTS: Seventeen studies (n=987) were included in the meta-analysis. Remifentanil 0.5-1 µg/kg or 2-3 µg/kg/h, alfentanil 7.5-10 µg/kg and fentanyl 0.5-1 µg/kg were compared to placebo. There was no significant difference in Apgar scores at 1 min (P=0.25, 0.58 and 0.89 respectively) for all three opioids or at 5 min for remifentanil and alfentanil (P=0.08 and 0.21 respectively). Fentanyl significantly reduced 5 min Apgar scores (P=0.002). There was no difference in neonatal airway interventions with remifentanil or alfentanil (P <0.05). All three induction opioids caused a significant reduction in maximum SBP (P <0.0001), MAP (P <0.00001) and HR (P <0.00001). CONCLUSION: Induction opioids are effective sympatholytic agents. Remifentanil and alfentanil appear to be safe, with no significant effect on Apgar scores or neonatal airway intervention, but a well-powered trial is required to confirm these findings.

Tissue-type plasminogen activator increases the binding of glu-plasminogen to clots.

Porcine tissue-type plasminogen activator (t-PA) increases the binding of 125I-glu-plasminogen to clots made from human plasma or purified fibrinogen in a time and t-PA concentration dependent fashion. The accumulation of plasminogen was faster and greater on noncrosslinked plasma clots than on clots which had been crosslinked by Factor XIIIa. Furthermore, the uptake of plasminogen to crosslinked fibrin clots occurred at a slower rate in the presence of alpha 2-plasmin inhibitor (alpha 2 PI) than in its absence. The kinetics of the uptake of 125I-plasminogen were analyzed using SDS-polyacrylamide gel electrophoresis and radioautography of solubilized plasma clots formed in the presence of t-PA. During the initial phase there was a decrease of clot-bound glu-plasminogen; simultaneously, there was a slight increase in clot-bound glu-plasmin and in plasmin complexed to alpha 2 PI that was crosslinked to alpha-chain polymers of fibrin. This was followed by a marked increase in clot-bound plasminogen having glutamic acid as NH2-terminal (glu-plasminogen) and gluplasmin. t-PA-induced enhancement of glu-plasminogen uptake appears to be mediated by plasmin but does not require the conversion of glu-plasminogen to plasminogen having lysine or methionine as NH2-terminal. The described mechanism assures an adequate supply of clot-bound plasmin, which is the enzyme ultimately involved in the degradation of fibrin.

Studies on the release of a plasminogen activator inhibitor by human platelets.

The relative contribution of platelets to plasminogen activator inhibitor (PA-inhibitor) activity in blood was investigated. From the difference in PA-inhibitor levels in platelet-poor plasmas of 12 donors (3 +/- 1 U/ml, mean +/- 95% confidence limits) and in the corresponding platelet-rich plasmas after induction of platelet aggregation by collagen, ADP or epinephrine (7 +/- 1 U/ml), it may be concluded that a greater amount of PA-inhibitor in blood is associated with platelets than with plasma. In collagen-stimulated platelets maximal release of PA-inhibitor and of beta-thromboglobulin (beta-TG) was attained within fifteen seconds, whereas in ADP-stimulated platelets the release of both factors was slower. In platelet-poor plasma no correlation was found between the level of PA-inhibitor and that of beta-TG. Thus, the PA-inhibitor found in plasma is not derived from platelets that had been stimulated after blood collection. The rate of complex formation and the Mr of the principal complexes of radioiodinated tissue-type plasminogen activator (t-PA) or urokinase (UK), in platelet-poor plasma, in platelet-rich plasma after platelet aggregation or in an extract of washed platelets was the same. Moreover, complexes of UK or t-PA with plasmatic PA-inhibitor or with the PA-inhibitor(s) from platelets bound to immobilized antibodies against bovine endothelial cell-derived PA-inhibitor. These results show that the PA-inhibitors in plasma and in platelets are very similar or identical.

The fast-acting inhibitor of tissue-type plasminogen activator in plasma is also the primary plasma inhibitor of urokinase.

We have compared the ability of a plasminogen activator inhibitor (PA-inhibitor) in human plasma, to form complexes with radioiodinated tissue-type plasminogen activator (t-PA) and high molecular weight urokinase (HMr-UK). Addition of 125I-t-PA (final concentration 10 IU/ml) or of 125I-HMr-UK (2 IU/ml) to a plasma containing 33 U/ml of PA-inhibitor resulted in the rapid formation of a 110,000 Mr complex of 125I-t-PA or a 95,000 Mr complex of 125I-HMr-UK with PA-inhibitor. Upon prolonged incubation of the plasma with 125I-HMr-UK a secondary complex of a Mr of 88,000 was observed, which probably derives from limited degradation of the 95,000 complex. Preincubation of the plasma with unlabelled t-PA, HMr-UK or LMr-UK at higher concentrations prevented the subsequent formation of complexes between radiolabelled PAs and the PA-inhibitor. These results thus demonstrate that t-PA and UK form complexes with the same PA-inhibitor. The rate of complex formation of 125I-t-PA or of 125I-HMr-UK with the plasma PA-inhibitor was similar (second order rate constant of association with PA-inhibitor in the order of 10(7) M-1s-1).

Plasminogen activators and plasminogen activator inhibitors in liver deficiencies caused by chronic alcoholism or infectious hepatitis.

Plasma concentrations of tissue-type plasminogen activator (t-PA), urokinase (u-PA), plasminogen activator inhibitor 1 (PAI-1) and PAI-2 were studied in 53 patients with liver deficiency caused by chronic alcoholism (n = 40), viral hepatitis (n = 10) or malignant disease of the liver (n = 3) and compared to that of a control group (n = 20) of healthy subjects. u-PA and PAI-1 levels were significantly increased in all patients with chronic alcoholism, whereas high t-PA was only observed in combination with disturbed liver function tests or with liver cirrhosis (two and six-fold above control values, respectively). A good correlation was observed between t-PA and gamma glutamyl transferase (r = 0.615; p less than 0.001). In patients with infectious hepatitis or with malignant disease of the liver t-PA was normal whereas u-PA and PAI-1 were increased. PAI-2 levels were close to or below the detection limit (15 ng/ml) in the control group and in most patients. However, in two patients with alcohol induced cirrhosis PAI-2 levels were approximately 45 ng/ml and in one patient with hepatocarcinoma even 66 ng/ml. Thus, in liver disease, marked elevations of t-PA, u-PA and PAI-1 levels may occur, with increased PAI-1 as an early marker of liver defects and t-PA a marker of severe liver defects.

Laminin degradation by human colon carcinoma cells: a role for urinary and tissue plasminogen activators.

The human colon carcinoma cell lines Co112 and Co115 are both invasive in nude mice following intraperitoneal implantation. Co115 cells only exhibit metastasis capacity under this condition. Characterization of the plasminogen activation system demonstrates that Co112 cells express the urinary-type plasminogen activator (uPA) and Co115 cells the tissue-type (tPA), exclusively. Immunocytochemical analyses revealed that the in vitro plasminogen-dependent lysis of exogenous basement membrane laminin induced by Co112 cells displayed a gradient-like pattern, whereas, in the case of Co115 cells, it was sharply confined to the pericellular area. Double-labeling experiments showed that uPA on Co112 and tPA on Co115 cells are cell-surface-associated constituents. The cellular distribution of laminin expressed by tumor cells themselves appears to be distributed homogeneously in the cytoplasm of both cell types. We suggest that the extracellular matrix degradation induced by tumor cell surface-associated plasmin implies two different mechanisms which are specifically related to uPA or to tPA, both contributing to matrix degradation and malignant invasion.

[Acquired von Willebrand's syndrome associated with malignant lymphoma]. / Syndrome de von Willebrand acquis associé à un lymphome malin.

The sudden development of multiple bleeding episodes in a 63-year-old patient with malignant lymphoma was shown to be due to the presence of an acquired von Willebrand syndrome, characterized by a prolonged bleeding time and low levels of the factors VIII: C, VIIR:Ag and VIII:Rcof. Crossed immunoelectrophoresis demonstrated diminution of the factor VIII portion with least anodic mobility. Mixing experiments of the patient's and normal plasma revealed a weak (T/2: 4.5 hours) inhibitory activity against the factors VIII:C, VIIIR:Ag and VIII:Rcof. After infusion of 800 units of cryoprecipitate there was rapid destruction (T/2: less than 1 hour) of infused factors VIII: C and VIIIR:Ag and no correction of the bleeding time. Chemotherapy resulted in disappearance of the lymphoma and the hemostatic defect, and its discontinuation in their reappearance. The weak inhibitory activity of the patient's plasma does not fully account for the factor VIII levels observed and other pathophysiological mechanisms, such as adsorption of factor VIII to the malignant lymphocytes, must be considered.

[Mycosis fungoides and monoclonal gammopathy. Fortuitous or causal association?]. / Mycosis fongoïde et gammapathie monoclonale. Association fortuite ou causale?

We report the case of a patient suffering from mycosis fungoides and plasma cell myeloma. It is postulated that this is not a fortuitous association, but that the B cell neoplasm evolved under the sustained inducer stimulus of the malignant T lymphocytes. This hypothesis is suggested by the demonstration of the helper phenotype of the cutaneous lymphocytes associated with a predominance of helper lymphocytes in blood.

[Acute monoblastic leukemia complicated by fatal splenic rupture following initiation of chemotherapy]. / Leucémie aiguë monoblastique compliquée par une rupture splénique fatale après initiation de chimiothérapie.

Fatal chemotherapy splenic rupture is a rare event in acute leukemia. We report on a patient with acute monoblastic leukemia who developed splenic rupture 13 hours after the initiation of aggressive chemotherapy. Histologic studies of the spleen showed diffuse capsular infiltration and disseminated areas of subcapsular necrosis. Lysis of the leukemic cells and release of their enzymatic content, induced by the chemotherapy, probably led to proteolytic injury of the splenic capsule. We suggest that this mechanism may be an important pathogenetic factor in the occurrence of splenic rupture in patients with acute leukemia.

[Willebrand's disease and multimeric analysis of the Willebrand factor]. / Maladie de Willebrand et analyse multimérique du facteur Willebrand.

The multimeric composition of von Willebrand factor (vWF) in the plasma of 20 von Willebrand's disease patients was analyzed to determine the type of von Willebrand's disease and to evaluate retrospectively the predictive value of the classical tests. Analysis of the multimeric pattern revealed that 3 had type II and the other 17 type I von Willebrand's disease. The classical tests, especially crossed immunoelectrophoresis of vWF and the ristocetin-induced platelet agglutination test, did not permit correct classification but led to overestimation of the type II von Willebrand variant. Multimeric analysis of von Willebrand factor is necessary to diagnose von Willebrand's disease type II, in which DDAVP infusions should not be given since they are ineffective or may cause thrombocytopenia.