Determination of radon concentrations and physicochemical parameters of non-alcoholic carbonated beverages consumed in Türkiye and assessment of radiological health risk.

The strategy for controlling the existence of radionuclides in drinking water depends upon an individual dose criterion (IDC) of 0.1 mSv/y, which represents a very low level of risk that is not expected to cause any identified adverse health effects. Radon gas, considered a carcinogenic radionuclide, can dissolve and accumulate in drinking water. Non-alcoholic carbonated beverages (NACBs), which mainly contain drinking water, phosphoric acid, citric acid, caffeine, and sugar, represent one of the most consumed groups worldwide and in Türkiye. In this study, the radon activity concentration and some physicochemical characteristics of 45 NACB samples from 24 most preferred commercial brands in Türkiye were determined to assess the radiological health risk associated with the ingestion of these samples. Radon activity concentrations measured in NACB samples using the AlphaGUARD radon analyzer ranged from 22.8 ± 0.7 to 54.9 ± 1.7 mBq/L. The pH, conductivity, total dissolved solids, and brix values in NACB samples ranged from 2.31 to 7.29, 401 to 3281 µSv/cm, 355 to 2453 mg/L, and 0.10 to 12.95%, respectively. Total (ingestion and inhalation) annual effective doses and the corresponding excess lifetime cancer risks estimated for adults to assess the radiological health risk are significantly below the IDC and advised safety limit (10-3), respectively.

Evaluation of radiological health risk due to ingestion and inhalation of radon in commercial packaged fruit juices consumed in Turkey.

Fruit juices (FJs) are among the most popular beverages frequently preferred by consumers, believing FJs contain the nutritional values, minerals, phytochemicals, vitamins, and antioxidants necessary for a healthy life. However, FJs may contain natural radionuclides such as radon (222Rn), which originates from the fruit and water utilized in their production, at levels that may pose a health risk to people. Inhalation and ingestion of 222Rn gas increases the risk of lung and stomach cancer. In this study, commercially packaged FJs from the seventeen most popular brands consumed in Turkey were analyzed for physicochemical properties and 222Rn activity concentrations to evaluate the radiological health risk. The values of pH, brix and 222Rn activity concentrations in FJ samples varied from 2.68 to 4.28, 2.50 to 14.30%, 9.6 ± 1.1 to 25.2 ± 2.5 mBq/L, respectively. The radiological health risk caused by internal exposure was evaluated for children and adults by estimating the ingestion and inhalation annual effective dose. The average values of the total annual effective dose for children and adults were found as 0.039 µSv and 0.056 µSv, respectively, which are much lower than the recommended dose of 100 µSv for drinking water.

Is methyl methacrylate fixator reliable for the treatment of gartland type IV supracondylar fractures?

Background: In childhood supracondylar fractures of the humerus, fixation with percutaneous Kirschner wire is the standard treatment. In the case of irreducible-unstable fractures, these can be defined as fractures in which reduction is not well-achieved or in which fixation cannot be achieved with the K-wire. Intraoperative management of these types of fractures may be difficult. Treatment with a methyl methacrylate fixator consisting of K-wire and methyl methacrylate cement, as defined by the senior author of the article, may be a good option for Gartland type IV supracondylar humeral fractures where the fracture is unstable in flexion and extension due to complete periosteal tearing. Materials and Methods: The short-term and mid-term results of 27 patients between the ages of 4-12 with Gartland type IV supracondylar fracture of the humerus treated with methyl methacrylate fixation were reviewed. The patients were scored in terms of function and cosmetic satisfaction. Results: A total of 19 of the 27 patients treated with the methyl methacrylate fixator had full elbow motion function and rated the outcome of the treatment as excellent, which was judged by orthopedic surgeons on the basis of Flynn's criteria. Six patients had nearly full elbow motion and evaluated their recovery outcome as good. Two patients reported nearly full range of motion (ROM) and evaluated the method as moderate in terms of treatment. Discussion: Treatment with the methyl methacrylate fixation method is an inexpensive method that allows early joint mobilization, provides strong biomechanical stability, ensures good outcomes, and should be considered in the treatment of irreducible and unstable supracondylar fractures of the humerus.

Determination of amoxicillin trihydrate impurities 4-hydroxyphenylglycine (4-HPG) and 6-Aminopenicylanic acid (6-APA) by means of ultraviolet spectroscopy.

Amoxicillin is one of the broad-spectrumß-lactam antibiotics widely used in the treatment of many diseases. It is inevitable that 4-hydroxyphenylglycine (4-HPG) and 6-Aminopenicylanic acid (6-APA), which are used during the production of this antibiotic, are incorporated into the molecular lattice of the product as impurities. Today, many expensive methods and chemical devices are used for the purification of Amoxicillin by determining 6-APA and 4-HPG, which are defined as impurities. In this study, it was aimed to develop a fast, simple, and specific UV-spectrophotometric method for the determination of 4-HPG and 6-APA. Another aim of this article is to cause as little harm as possible to the environment and human health by using as few chemicals as possible throughout the study. In this study, all attempts to determine 6-APA and 4-HPG, which are impurities in the production of amoxicillin, were carried out with the help of a UV/VIS spectrophotometer. Also, Four different concentrations of NaOH were used as a solvent for each impurity. UV spectra of 4-HPG and 6-APA concentrations between 210 and 400 nm were measured. In the literature, the UV spectrum of 4-HPG has been revealed for the first time in this study and examined in detail. The UV spectrum of 4-HPG was characterized in 3 regions. Again, the response of 6-APA to different NaOH concentrations was demonstrated for the first time in this study. It was determined that the peaks of 6-APA dissolved in NaOH shifted from 222 nm to 227 nm depending on the concentration amount. In addition, it is an ideal green procedure that makes a difference in the literature, as the study is carried out for the control and determination of impurities without the use of any organic solvents or chemicals harmful to the environment.

Role of T-helper 17 cell related cytokines in laryngeal cancer.

OBJECTIVE: To explore the role of T-helper 17 cells and their cascade in the pathogenesis of laryngeal cancer. METHODS: Prospectively, 110 consecutive patients with a suspicious laryngeal lesion were evaluated for serum levels of T-helper 17 cell related interleukins, including interleukins 23, 17A and 22, determined by enzyme-linked immunosorbent assay. The patients were divided into 2 groups after pathological evaluation: 49 patients with malignancy and 61 with benign pathology. Associations between interleukin levels and malignancy were determined via correlation analyses. RESULTS: Interleukin 17A and 22 levels were significantly higher in the malignancy group than the benign lesion group. Pearson correlation analysis showed that interleukins 17A and 22 acted in a cascade, but interleukin 23 did not. According to predictive values, interleukin 17A levels were 3.87 times and interleukin 22 levels were 1.09 times more likely to be associated with laryngeal cancer. The cut-off values for predicting laryngeal cancer were 3.55 pg/ml for interleukin 17A and 119.82 pg/ml for interleukin 22. CONCLUSION: T-helper 17 cell related interleukins are potential biomarkers that may be helpful in diagnosing laryngeal cancer. Moreover, these data may support neutralisation of T-helper 17 cell related cytokine activity, which could be an attractive strategy for treating laryngeal cancer.

The Value of Total antioxidant Status and Serum Tumor Necrosis Factor-α Levels at 24-28 Weeks of Gestation in the Prediction of Optimal Treatment Protocol in Gestational Diabetes Mellitus.

AIM: The aim of this study was to investigate the serum oxidative stress markers, antioxidant enzyme and tumor necrosis factor-α (TNF-α) levels at 24-28 weeks of gestation and to evaluate the predictive value of them on the subsequent treatment protocol in gestational diabetes mellitus (GDM). METHODS: A total of 58 GDM patients (30 treated with only conventional healthy dietary recommendation (CHDR), 28 treated with insulin) and 30 healthy pregnant women at 24-28 weeks of gestation, were enrolled in this prospective case-control study. The oxidative status, antioxidant enzyme and TNF-α levels were evaluated to determine if there is an association with the need of insulin therapy for glycemic control by using multivariable logistic regression analysis. RESULTS: TNF-α (OR=11.976, 95%CI: 2.441-58.754, P=0.002) and total antioxidant status (TAS) (OR=12.769, 95%CI: 2.464-66.182, P=0.002) were found to be predictive for GDM at 24-28 weeks of gestation. Besides, further evaluation considering the treatment modality showed that increased TNF-α (OR=18.615, 95%CI: 2.338-148.240, P=0.006) and lower TAS levels (OR=99.471, 95%CI: 2.865-3 453.061, P=0.011) were independent predictors of the need for insulin treatment in GDM patients. CONCLUSIONS: Increased TNF-α levels and low TAS are significantly associated with the increased risk of insulin requirement for achieving good glycemic control in GDM.

The relationship between severity of ulcerative colitis and thiol-disulphide homeostasis.

OBJECTIVES: The aim of the study was to determine dynamic thiol-disulphide homeostasis in patients with ulcerative colitis, compare it with those of healthy control and to investigate the relationship between the severity of the disease and homeostasisMETHODS: A total of 78 patients and 58 healthy subjects were included in the study. Serum native thiol, total thiol and disulphide amounts were measured by using a novel automated method. Obtained results were compared and relationships were determined by correlation analysis. RESULTS: Serum native thiol, total thiol, disulphide amounts and disulphide/native thiol percent ratio (index) were significantly lower (p = 0.003 for index ratio and p < 0.001 for other parameters) in patients with ulcerative colitis than in healthy controls. Native thiol, total thiol and disulphide amounts were significantly higher (p < 0.001) in patients with ulcerative colitis in remission than in patients with active ulcerative colitis and near to those of healthy control. There were significant negative correlations between the severity of the disease and thiol-disulphide homeostasis parameters (r = -0.55, p < 0.001 for native thiol; r = -0.64, p < 0.0001 for total thiol; r = -0.65, p < 0.001 for disulphide and r = -0.33, p = 0.011 for index). CONCLUSION: The thiol-disulphide homeostasis was weakened in ulcerative colitis. Strong correlations between the activity of the disease and thiol-disulfide homeostasis indicate that homeostasis may play a role in the pathogenesis of the disease (Tab. 3, Fig. 3, Ref. 30).

The effects of Desflurane and Sevoflurane on Nesfatin-1 levels in laparoscopic Cholecystectomy: a randomized controlled trial.

BACKGROUND: Nesfatin-1 is involved in cardiovascular regulation, stress-related responses. The objective of this study is to investigate the impact of volatile anesthetics on Nesfatin-1 levels. METHOD: Fourty-two patients aged 30-65 years with the American Society Anesthesiology (ASA) Class I-II who were scheduled for laparoscopic cholecystectomy were included in the study Patients were randomized into two group; desflurane administered group (Group I, n = 21) and sevoflurane administered group (Group II, n = 21). For anesthesia maintenance, the patients received 6% desflurane or 2% sevoflurane in 40% O2 and 60% air. The patient's heart rate (HR), mean, systolic and diastolic arterial pressures (MAP, SAP, DAP), peripheral O2 saturation (SpO2) were monitored and recorded before induction, after induction, after intubation, and during extubation. Blood samples were collected before induction (T1), and after extubation when aldrete score was 10 (T2). RESULTS: Demographic data were similar between the groups. The preoperative levels of nesfatin were similar in the two groups (p = 0.715). In desflurane group, post-operative nesfatin levels were similar compared to preoperative levels (p = 0.073). In sevoflurane group, post-operative nesfatin levels were similar (p = 0.131). The nesfatin levels (postoperative vs preoperative) were similar between the groups (p = 0.900). CONCLUSION: In conclusion, this study results suggest that nesfatin-1 levels are not affected by the use of sevoflurane or desflurane in patients undergoing laparoscopic cholecystectomy. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry, ACTRN12617001023347 , retrospectively registered on 17 July 2017.

3Ds: decorin, discordance, and diamniotic dichorionic twins.

aullimary Investigation: The cause of discordance in dichorionic diamniotic (DD) twins is still unknown. The authors aimed to compare decorin (DCN) and oxidative/antioxidative state levels between the placentas of discordant and concordant twins. MATERIALS AND METHODS: Prospective study of 43 spontaneous DD twin pregnancies included and placentas samples taken from each twin and prepared for homogenization. Total oxidant/antioxidant status levels in placental tissue were determined by automated colorimetric method. Decorin levels were detected by using ELISA method; 23 of these were discordant and 20 of them were concordant. RESULTS: DCN levels in the placentas of the low birth-weight twins were significantly lower than the levels of the placentas of appropriate gestational age twins (p = 0.006). There were no statistically significant differences in total antioxidant status (TAS), total oxidant status (TOS), or arylesterase (ARES) levels in discordant (p = 0.631, p = 0.370, and p = 0.079, respectively) and in the placental DCN, TAS, TOS, or ARES levels of the concordant twins (p = 0.407, p = 0.035, p = 0.194, and p = 0.979, respectively). When the authors compared the twins of similar birth weight, the DCN, TAS, and TOS levels were significantly lower in the discordant twins (p < 0.001, p < 0.001, and p = 0.002, respectively). CONCLUSIONS: Decreased levels of DCN in discordant twin fetuses compared to the same birth weight-concordant twins shows that it contributes to disease pathogenesis.

Thiol/disulphide homeostasis in Bell's palsy as a novel pathogenetic marker.

OBJECTIVES: The aim of this study was to investigate the relationship between Bell's palsy and a novel oxidative stress parameter, thiol/disulphide homeostasis. DESIGN: A prospective study evaluating oxidative stress in Bell's palsy. SETTING: This research took place in the department of Otorhinolaryngology, Ataturk Training and Research Hospital. PARTICIPANTS: Totally, 77 patients with Bell's palsy and 38 healthy controls were included in this study. MAIN OUTCOME MEASURES: The blood levels of total and native thiol and disulphide activity were assessed, and their levels were compared in the patients and controls. RESULTS: There were statistically significant differences between the patients and controls regarding thiol/disulphide parameters. The mean native thiol and total thiol were significantly lower and disulphide levels were higher in the Bell's palsy than controls. On binary logistic regression analysis, the created model showed 45.3% variation. The cut-off value was 18.95 for disulphides. CONCLUSION: Native and total thiol levels were low in the Bell's palsy. This metabolic disturbance may have a role in the pathogenesis of Bell's palsy.

Dynamic thiol-disulfide homeostasis in hyperemesis gravidarum.

OBJECTIVE: To determine serum thiol-disulfide homeostasis in hyperemesis gravidarum. STUDY DESIGN: Twenty-six pregnant women with hyperemesis gravidarum and 37 healthy pregnant women were included in the study. Native thiol, disulfide and total thiol concentrations were measured with a novel automated method. RESULTS: Serum disulfide levels were 15.68±4.41 µmol l(-1) in the hyperemesis gravidarum group and 13.49±2.81 µmol l(-1) in the healthy group (P=0.031). Native thiol levels were 213.86±26.29 µmol l(-1) in the hyperemesis gravidarum group and 232.18±19.21 µmol l(-1) in healthy group (P=0.004), and total thiol levels were 245.23±28.58 µmol l(-1) in the hyperemesis gravidarum group and 259.17±19.94 µmol l(-1) in the healthy group (P=0.038). CONCLUSION: Native and total thiol were deficient in the hyperemesis gravidarum group and this deficiency was correlated with the severity of the disease. The thiol-disulfide balance has shifted to the oxidative side. This metabolic disturbance may have a role in the pathogenesis of hyperemesis gravidarum.

Methylene blue as an antioxidant agent in experimentally-induced injury in rat liver.

BACKGROUND: We aimed to test the methylene blue (MB) as a dye and also to test its antioxidant activities in devascularization-induced liver injury. METHODS: Twenty rats weighing 240-280 g were randomly divided into two groups, each containing 10 rats. High-grade liver injury was induced by using a pair of long pliers with blades. MB was injected into portal vein of the rats with no hepatic injury (Group 1; control group) and those with injured livers (Group 2; injury group). Liver and hepatic function tests, paraoxonase, stimulated paraoxonase, arylesterase activity, total antioxidant, and oxidant status were evaluated before and 24 h after MB injection. RESULTS: MB did not stain the non-perfused area. Total antioxidant status decreased significantly in Group 2 at hour 24 compared to Group 1. In Group 2, total antioxidant status was lower at hour 24 compared to hour 0. Total oxidant status in Group 2 at hour 0 increased significantly compared to Group 1. Total oxidant status in Group 2 at hour 24 was lower compared to that at hour 0. Lipid peroxidation parameters did not alter due to devascularization. CONCLUSION: MB is useful in defining the devascularization area. Moreover, it showed to have a beneficial effect on oxidant status (Tab. 3, Fig. 3, Ref. 25).

PTEN, Akt, MAPK, p53 and p95 expression to predict trastuzumab resistance in HER2 positive breast cancer.

PURPOSE: Mutations that activate the PIK3CA oncogene and inhibit the tumor suppressor gene PTEN action are commonly found in breast tumors. Akt is a key activator of cell survival. p53 is frequently found mutated in human tumors, and mutant p53 protein actively contributes to tumorigenesis. In selected cases of breast cancer, trastuzumab (TZMB) is incorporated in the primary treatment in the adjuvant and metastatic settings. Many studies have reported that selected patients are resistant to TZMB due to the presence of p95 HER2 fragments. To address this, we analysed PTEN, Akt, MAPK, p53 and p95 expression in breast cancer patients treated with TZMB. METHODS: Out of 90 patients histologically diagnosed with breast cancer between 2004 and 2011, analysed were 25 patients with HER2 positive, and estrogen (ER) and progesterone receptors (PR) negative, metastatic or locally advanced disease. All 25 patients were treated with TZMB and resistance to TZMB was assessed. All patients were on anthracycline-and taxane-containing regimens. Tissue samples were obtained from paraffin blocks and evaluated immunohistochemically for PTEN, Akt, MAPK, p53, and p95 expression. RESULTS: TZMB resistance was detected in 5 (20%) patients. Akt expression was positive in 2 patients (8%) and MAPK, p95, and p53 expression was positive in 1 patient (4%); PTEN expression was negative in 3 patients (12%). No significant differences were found between TZMB resistance and PTEN, Akt, MAPK, p53, and p95 expression. Subgroup analysis was carried out in the neoadjuvant treatment group. Complete pathologic response was detected in 3 patients (21.4%). Statistically significant differences were not found between the complete response rate and PTEN, Akt, MAPK, and p95 expression. There was a statistically significant correlation between p53 expression and complete pathologic response (p=0.02). CONCLUSION: No statistically significant correlation between TZMB resistance and the expression of these biomarkers was noted. In patients with HER2-positive breast cancer that were treated with 4 dose-dense sequential cycles of doxorubicin and cyclophosphamide, followed by TZMB and paclitaxel combination therapy in the neodjuvant setting, p53 expression could predict complete response to chemotherapy.

The impact of blood conservation on outcomes in cardiac surgery: is it safe and effective?

BACKGROUND: Increasing evidence shows that perioperative blood transfusion in cardiac surgery is associated with increased postoperative morbidity and mortality and decreased long-term survival. Tolerance of "permissive anemia" is an important element of perioperative blood conservation strategy. The safety of tolerating perioperative anemia has been a significant deterrent for widespread application of blood conservation. This study examines whether blood conservation is equally safe or superior to the common practice of transfusion in cardiac surgery. METHODS: The total study population consisted of 32,449 patients who underwent isolated coronary artery bypass surgery from June 2000 until December 2004 with complete data from 17 institutions in the State of New Jersey. Englewood Hospital and Medical Center (EH) has a well-established blood conservation program. Five hundred eighty-six EH patients (blood conservation cohort) were compared with a propensity score-matched cohort of 586 patients from the other New Jersey institutions (OH-M) representing the common practice of transfusion. Outcomes were classified as very serious complications, serious complications, or neither (no very serious complication or serious complication). Analysis consisted of McNemar tests and multiple logistic regression. RESULTS: Fewer patients were transfused at EH compared with OH-M (10.6% versus 42.5%; p < 0.0001). Englewood Hospital had 5 (0.8%) deaths versus 15 (2.5%) in the OH-M group (p = 0.02). Of the EH patients, 11.1% experienced a very serious complication or serious complication versus 18.7% in the OH-M cohort (p = 0.0002). Transfusion was associated with an increased risk of an adverse outcome in both cohorts (EH: odds ratio, 7.3; 95% confidence interval, 3.7 to 14.4 versus OH-M: odds ratio, 4.6; 95% confidence interval, 2.8 to 7.7). CONCLUSIONS: Blood conservation is safe and effective in reducing transfusions. Tolerance of perioperative anemia, which is one of the main components of blood conservation, does not increase the risk of complications or death in cardiac surgery. Avoidance of transfusion reduces the risk of complications. This study further solidifies the relationship between transfusion and adverse outcome in cardiac surgery.

Reinforcement bronchial stump increases early mechanical integrity: an ex-vivo experimental study.

OBJECTIVE: The purpose of this study was to investigate the effects of different bronchial suture techniques, with and without tissue reinforcement, on the resistance to pressure of the bronchial stump. MATERIALS AND METHODS: Fifty-four tracheo-bronchial trees obtained from the local slaughterhouse were prepared for manual closure. After right pneumonectomy, specimens were divided into three groups (n = 18). Interrupted suture pattern (group 1), continuous horizontal mattress + over-over continuous pattern (group 2) and continuous over-over + coverage with a diaphragmatic part with interrupted U sutures pattern (group 3) were used for bronchial closure. Multifilament absorbable 4-0 sutures were used in all specimens. Air leakage pressures were measured with a sphygmomanometer. RESULTS: Groups 1 and 2 had nearly equal mean air leakage pressures (98 +/- 37 and 95 +/- 51 mmHg, respectively, p = 0.985). Group 3 showed significantly higher mean leakage pressure (153 +/- 66 mmHg, p = 0.002) compared to the other groups. CONCLUSION: Reinforcement of the bronchial stump with viable tissue contributes to the bronchial stump integrity by increasing the air leakage resistance.

Potential organ donor concept is developing in emergency departments: Gazi University Hospital experience.

INTRODUCTION: The gap between cadaver organ donation and waiting list forces us to develop new strategies. Many institutions have turned to emergency departments (ED). METHODS: Patients evaluated as potential organ donors were studied prospectively. RESULTS: Organ Procurement Organizations (OPO) were established in 2006. The Transplantation Department has two coordinators who initiated educational seminars and organized campaigns to improve public awareness about organ donation. A new law that it was mandatory to declare brain death for donors has been accepted. Thereafter, 19 patients were assessed as potential donors, 6 of whom were from the ED. Family consent was obtained for harvest from 9. DISCUSSION: Deaths in the ED are often sudden, unexpected, and traumatic, involving young patients. The emergency physician (EP) has an obligation to care for a dying person to the best of one's abilities. Then, the duty of care is owed to the relatives and friends of the deceased to meet their needs. Finally, the EP should use resources of the health care system in the most efficient manner. Any patient who has been declared brain dead or is scheduled to be taken off life-support measures should be seen as a candidate for transplantation. The coordination between the EP and OPO can change a life lost at the ED into a source of light for others waiting for transplantation. Emergency staff must be alert while evaluating people suffering sudden traumatic and medical death for the possibility that they might be added to the donor pool. CONCLUSION: Educational support and proper management from OPO-like organizations to emergency medical staff will provide better outcomes.

Postoperative blood loss and transfusion associated with use of Hextend in cardiac surgery patients at a blood conservation center.

BACKGROUND: Hydroxyethyl starch (HES) solutions are readily available colloids, but their widespread use is shadowed by controversies surrounding their effects on bleeding. This retrospective study was conducted to evaluate the relationship between Hextend (HEX; Hospira, Inc.) doses of 1 to 20 mL/kg and allogeneic transfusion and 24-hour chest tube drainage (CTD) in cardiac surgeries at a blood conservation center. STUDY DESIGN AND METHODS: After institutional review board approval, data on 748 patients undergoing coronary artery bypass grafting (CABG), valve, or combined CABG and valve surgeries were collected. Cases not receiving HEX (due to contraindications, e.g., renal failure, bleeding diathesis) or receiving more than 20 mL per kg HEX, not accepting transfusions, or requiring more extensive surgery were excluded, and the remaining 621 cases were analyzed. RESULTS: Overall transfusion rate and mean CTD were 12.7 percent and 460.4 mL, respectively. Patients who received transfusions received more HEX (10.8 mL/kg vs. 9.8 mL/kg; p = 0.043) but HEX per kg was not associated with higher transfusion rates in multivariate analysis (p = 0.077). HEX per kg was associated with CTD in both uni- and multivariate analyzes (p < 0.001) with 1.66 percent increase in CTD for every 1 mL per kg increase in HEX. CONCLUSIONS: Although HEX was associated with transfusion in univariate analysis and with CTD in uni- and multivariate analysis, the former was no longer significant when adjusted for other predictors of transfusion in our selected patient population at a blood conservation center. The clinical significance of the observed increase in CTD remains undetermined. To minimize transfusion and bleeding in these patients, it is recommended that HEX be used in amounts of not more than 20 mL per kg together with point-of-care coagulation tests and other blood conservation strategies.

Use of the Hemobag for modified ultrafiltration in a Jehovah's Witness patient undergoing cardiac surgery.

Modified ultrafiltration is an important technique to concentrate the patient's circulating blood volume and the residual whole blood in the extracorporeal circuit post-cardiopulmonary bypass. The Hemobag system is a device cleared by the US Food and Drug Administration and represents a novel and safe modification of traditional modified ultrafiltration systems. It is quick and easy to operate by the perfusionist during the hemoconcentration process. Hemoconcentration is accomplished by having the Hemobag "recovery loop" circuit separate from the extracorporeal circuit. This allows the surgeons to continue with surgery, decannulate, and administer protamine simultaneously while the Hemobag is in use. The successful use of the Hemobag in a Jehovah's Witness patient has not been previously described in the literature. This case report describes how to set up and operate the Hemobag in a Jehovah's Witness patient undergoing cardiac surgery that requires an extracorporeal circuit.

Composite aortic root replacement in acute type A dissection: time to rethink the indications?

OBJECTIVE: The indications for aortic root replacement in acute type A dissection are unclear. We reviewed the immediate and long-term outcome of consecutive patients in a series in which a low-threshold policy of composite aortic root replacement had evolved. METHODS: From a prospectively compiled aortic surgery database, we identified 162 patients who had either supracoronary interposition grafting, Group A (n=89), or composite root replacement, Group B (n=73) for acute type A dissection. Patients receiving total arch replacements were excluded. Operative and clinical details were analyzed and patient survival was compared to an age and gender matched census cohort. Need for reoperation on the proximal or distal aorta was also noted. Follow-up totaled 795.5 patient-years. RESULTS: Hospital mortality rates were identical in both groups (12.3%: 11 deaths in group A; 9 in group B). Chronic pulmonary disease, diabetes, malperfusion, hemodynamic compromise and aortic root dilatation were independent risk factors for hospital death. Actuarial survival estimates at 1, 5 and 10 years were 79% (71-88%), 64% (53-75%), and 55% (41-68%) for group A, and 79% (70-86%), 73% (62-83%), and 65% (52-78%) for group B (P=0.48). Age and operative patency of the ascending false lumen were independent risk factors for death after hospital discharge. Proximal aortic reoperation was required for four patients in group A and none in group B (P=0.085). CONCLUSION: A strategy of replacement rather than repair of the dissected aortic root for specific indications in type A dissection yielded high survival and low proximal reoperation rates. These results support an aggressive policy of composite root replacement in acute type A dissection.