Effect of Liver Disease Etiology on ROTEM Profiles in Patients Undergoing Liver Transplantation.

BACKGROUND: Coagulation abnormalities in liver transplant patients are complex and may be related to the underlying liver disease. We evaluated the effects of disease etiology on whole-blood rotational thromboelastometry (ROTEM; Pentapharm GmbH, Munich, Germany) profile and association with thrombotic complications following liver transplantation. METHODS: Analysis of perioperative data from patients undergoing liver transplantation between January 1, 2012 and December 31, 2016. Patients were grouped based on the biology of their underlying liver disease: hepatocellular carcinoma (HCC), biliary etiology, and non-biliary etiology. The primary outcome was the EXTEM A10 value of the pre-incision ROTEM. Secondary outcomes included associations between EXTEM A10 value and incidence of postoperative thrombotic complications. RESULTS: Three hundred fifty patients met the eligibility criteria: 60 had biliary etiologies, 203 had non-biliary etiologies, and 87 had HCC. EXTEM A10 values were significantly higher in patients with biliary etiologies than those with non-biliary etiologies (mean difference, 13.8; 95% CI: 10.1 to 17.5; P = .001) and those with HCC (mean difference, 10.4; 95% CI: 6.2 to 14.7; P = .001). Patients with non-biliary etiologies had slightly higher values than those with HCC (mean difference, -3.3; 95% CI: -6.6 to -0.1; P = .04). Higher values for biliary etiologies remained after adjusting for liver disease severity, platelet count, and fibrinogen level. There was no significant difference in EXTEM A10 values between patients who suffered thrombotic complications and those who did not (mean difference: 4.3, 95% CI: -1.3 to 9.9, P = .13). CONCLUSION: Patients with biliary diseases demonstrated higher EXTEM A10 values compared to those with non-biliary diseases or HCC. This was not fully explained by differences in disease severity, platelet count, or fibrinogen level. Pre-incision EXTEM A10 values do not predict incidence of postoperative thrombotic complications.

A randomized controlled trial (volunteer study) of sitafloxacin, enoxacin, levofloxacin and sparfloxacin phototoxicity.

BACKGROUND: Fluoroquinolone antibiotics (FQs) are associated with phototoxic skin reactions following exposure to sunlight. OBJECTIVES: We aimed to compare the phototoxic potential of sitafloxacin, a novel FQ with three others: sparfloxacin, enoxacin, levofloxacin and placebo in Caucasian volunteers. In a second study, two dosage regimens of sitafloxacin were compared with placebo in Oriental subjects. METHODS: Randomized, placebo-controlled, assessor-blinded clinical trial. In 40 healthy Caucasians, sitafloxacin 100 mg twice a day (n = 8), sparfloxacin 200 mg day-1 (n = 8), enoxacin 200 mg three times a day (n = 8), levofloxacin 100 mg three times a day (n = 8) and placebo (n = 8) were given in oral doses for 6 days. In the second study, sitafloxacin 50 mg and 100 mg, both twice daily, were compared with placebo in 17 healthy Oriental subjects. Using an established monochromator technique, baseline threshold erythema levels were established pre-drug and on-drug. The phototoxic index (PI) baseline, minimal erythema dose (MED) divided by on-drug MED for each medication at each wavelength was determined and related to sitafloxacin peak plasma levels. The duration of susceptibility to phototoxicity was assessed by repeat phototesting daily after stopping medication. RESULTS: In the Caucasian study, sitafloxacin 100 mg twice a day produced mild ultraviolet (UV) A-dependent phototoxicity (median PI = 1.45) at 365 +/- 30 nm (half-maximum bandwidth), maximal at 24 h with normalization by 24 h postdrug cessation. The sparfloxacin group experienced severe phototoxicity maximal at 24 h and, unusually for an FQ, extended in the visible region (430 +/- 30 nm), maximal at 400 +/- 30 nm (median PI = 12.35) with abnormal pigmentation at on-drug phototest sites lasting, although fading, for up to 1 year. Enoxacin showed UVA-dependent phototoxicity (335-365 +/- 30 nm) median PI 3.94 (at 365 +/- 30 nm) returning to normal 48 h after stopping the drug. Fading pigmentation at phototoxic sites also lasted up to 1 year. Phototoxicity was not detected in the levofloxacin or placebo groups. In the Oriental study, no clinically relevant phototoxicity was seen with either sitafloxacin or placebo groups. CONCLUSIONS: We conclude that 100 mg twice a day sitafloxacin in Caucasians is associated with a mild degree of cutaneous phototoxicity. Enoxacin 200 mg three times a day and sparfloxacin 200 mg day-1 are much more photoactive. Sparfloxacin phototoxicity is induced by UVA and visible wavelengths. Levofloxacin and placebo failed to show a phototoxic effect. In the Oriental study, sitafloxacin 50 mg twice a day and 100 mg twice a day failed to demonstrate a clinically significant phototoxic effect.

Marketing the dental hygienist as a manager in oral health care settings.

In 1985, the ADHA, in response to the changing health care environment, identified six roles for the future of dental hygiene. The administrator/manager role, one of the six, is an expansion of dental hygiene skills to facilitate the provision of quality oral health care. Oral health care settings require personnel trained in management to accomplish practice-related goals and objectives. Dental hygiene is preparing individuals to assume managerial roles to fill this health care need. This paper discusses the skills and knowledge level required to assume managerial roles and strategies for marketing the dental hygienist as a manager.

Regional variations in tuberculosis policy in the Cape and Ciskei.

Regional variations in tuberculosis policy in Cape Town, Paarl and Ciskei, as well as problems experienced by health workers, are examined. South African policy is compared with modern trends and recommendations drawn from the international literature and is found to conform in many respects, although tuberculosis services are not always integrated with curative services. The most marked variation occurs in Ciskei, where policy requires hospitalization of as many patients as possible. The majority of problems in implementing policy relate to lack of funds and medical infrastructure.

The implementation of tuberculosis policy in three areas in South Africa.

The implementation of tuberculosis policy at hospital and clinic level was examined in three areas (Cape Town, Paarl and Ciskei). Investigation showed that bacteriological diagnosis, standardized treatment regimens, supervision of therapy and contact tracing were not being correctly implemented. Compliance was also poor.

Tuberculosis--the patients' perspective.

This, the last of three studies examining aspects of tuberculosis (TB) control in South Africa, ascertained the views of the consumer--the TB patient. Aspects such as the impact of contracting TB on employment opportunities and social life, difficulties in getting treatment, and knowledge of TB were studied in a sample population of urban black working-class TB patients. Patients had difficulties in getting treatment at centralized points, and health education was not effective. Poor socio-economic conditions were also important in the experience of the TB sufferer.

Attitudes to the provision of primary health care at the day hospitals in Cape Town.

Day hospitals in Cape Town are examined against the criteria in the definition of primary health care of the World Health Organization's Declaration of Alma Ata. A survey of patients attending a day hospital was undertaken to ascertain the consumer perspective regarding access to and quality of the service offered. The provider's perspective was obtained from secondary sources and in-depth interviews. It was found that the services are generally acceptable to the users, but that factors such as waiting time and transport create problems for patients. Community participation is also very limited. The separation of preventive and curative services also places limitations on the day hospitals--they provide only curative health care. The most important reason given by patients for using the day hospitals is the low cost.

The private hospital industry in the greater Cape Town area.

Increasing emphasis is being placed on the role of the private sector in health in South Africa. This article uses the private hospital (PH) industry in the greater Cape Town area as a case study. The development and structure of the industry is described. Access to PHs is found to depend largely on membership of a medical aid fund. The PHs offer a relatively limited service, concentrating mainly on surgical cases. Problems between the PH industry and the medical aid schemes relating to the fixing of tariffs are outlined. Controversy exists over the future of PHs. It is concluded that PHs do not form an alternative to public sector services and may in fact weaken them.

Vasodilatory mechanisms in the tongue and nose of the dog under heat load.

Blood flow in vessels running to the nose and tongue was measured with electromagnetic flowmeters in anaesthetized dogs. In initial experiments the effect of electrical stimulation of the stellate ganglion on blood flow to the nose and tongue was studied and suitable doses of antagonist drugs to adrenergic and cholinergic receptors determined. In subsequent experiments the effect of receptor blockade on blood flow response was examined in animals subjected to hypothalamic heating at different body temperatures induced by whole body warming. It was found that heat load provoked an increase in blood flow to the nose which was due to a decrease in the activity of nerves supplying alpha adrenergic receptors. The heat induced vasodilatation observed in the tongue occurred by the same mechanism as in the nose when the thermal load was small and respiration rate was not increased from resting levels. However, when the thermal load was greater and panting was induced, a secondary "active" component became evident, and this was mediated neither by adrenergic nor cholinergic muscarinic receptors. Fibres responsible for this active vasodilatation to the tongue were postganglionic and ran apart from the vagosympathetic trunk.

The effect of cold exposure on fluid balance, circulating arginine vasopressin concentration and milk secretion in the goat.

Total body water, water intake, urine output, milk yield, plasma, milk and urine osmolality and plasma arginine vasopressin concentration were measured in goats exposed to thermoneutral (20 degrees C) and cold (0-1.0 degrees C) environments for 24 h. Cold exposure caused the animals to reduce their water intake substantially. This was accompanied by a decrease in total body water and an increase in osmolality of plasma and milk. The output of urine decreased as cold exposure progressed but free water clearance by the kidney was not significantly different in thermoneutral and cold environments and cold exposure had no effect on circulating arginine vasopressin concentration. Milk yield was reduced by cold exposure and it is suggested that the reduced net movement of water from blood to milk is partly a consequence of the dehydration induced by cold exposure and that this, in turn, is due primarily to a decrease in water intake with no effective renal compensation.

Cold exposure and mammary glucose metabolism in the lactating goat.

1. [U-14C]glucose was infused intravenously into conscious lactating goats exposed to thermoneutral or cold environments for a total of 24 h. The irreversible loss of glucose from the whole body and uptake of glucose by the mammary gland was measured and glucose utilization in the udder was studied by measuring the incorporation of radioactivity into carbon dioxide in mammary venous blood, into milk lactose and milk triglyceride-glycerol. 2. Exposure to cold increased the circulating level of glucose and slightly though not significantly, increased the non-mammary irreversible loss of glucose. 3. The extraction of glucose from the circulation by the udder fell, the secretion of lactose by the udder also fell and this correlated closely with the reduced secretion of milk in the cold. 4. Simultaneous measurements of the concentrations of insulin, growth hormone and corticosteroids in the arterial plasma were made. 5. The plasma concentration of corticosteroids increased significantly in the cold. 6. It is concluded that reduced glucose uptake and lactose synthesis by the udder are important factors which reduce milk secretion during cold exposure.

Effect of adenosine triphosphate and some derivatives on cerebral blood flow and metabolism.

1. Responses of cerebral blood vessels to peri- and intravascular doses of ATP (adenosine triphosphate) and some derivatives were studied in cat and baboon. 2. Perivascular application of ATP to cat pial arterioles gave a threshold dilatory effect at a concentration of 10(-11) M. This figure is comparable to the amount of ATP calculated to be released from electrically stimulated brain slices. 3. It is concluded that adenine nucleotides have a major role to play in the local control of cerebral blood flow. 4. Intracarotid injection of ATP showed a calculated threshold effect at 4 x 10(8) M in the cat and 4 x 10(-9) M in the baboon. 5. The threshold response of the vasculature to intracarotid adenosine lay between 4 x 10(-7) M and 4 x 10(-6) M in the baboon. Little effect was produced with AMP, pyrophosphate and inorganic phosphate. 6. Intracarotid ATP increased the oxygen consumption of the baboon brain parenchyma. This effect was attributed in part to an elevation of the cellular cyclic AMP levels. 7. Osmotic disruption of the blood-brain barrier in baboon did not affect the vasodilatory or metabolic effect of intracarotid ATP. 8. It is postulated that circulating purine compounds mediate a form of metabolic communication inthe body. Also, release of purine compounds from active local nerves might influence cerebral blood flow.

Effect of cold exposure on mammary circulation oxygen consumption and milk secretion in the goat.

1. Measurements of milk secretion, mammary oxygen consumption and blood flow, cardiac output and blood pressure have been made in lactating goats exposed to a thermoneutral environment and to two levels of cold stress which were sufficient to raise total body oxygen consumption by an average of 18 and 46% above that in a thermoneutral environment. 2. Mammary blood flow and oxygen consumption were not appreciably affected by the milder cold stress but fell to 63 and 70%, respectively, of their thermoneutral value in the moderately cold environment. Resistance to blood flow through the udder was increased by this level of cold stress and the gland took a smaller fraction of an increased cardiac output. 3. Both levels of cold exposure caused a reduction in milk secretion, to 80 and 40% of its thermoneutral value in the mild and moderate cold respectively. The amount of milk secreted per unit volume of blood flowing through the gland decreased as the severity of the cold stress increased. 4. Voluntary food intake was not affected by the change in environmental temperature but the intake of water was reduced to 55% of the thermoneutral value during mild cold exposure and to 40% of the thermoneutral value during the moderate cold stress. 5. It is concluded that a reduction in blood flow to the mammary gland could be one of several possible mechanisms underlying the depression of milk secretion during cold exposure.