Fibrinolysis Resistance After Injury Is a Risk Factor for a Hospital-Acquired Pneumonia-Like Disease Pattern.

Background: Pneumonia is associated with increased morbidity and costs in the intensive care unit (ICU). Its early identification is key for optimal outcomes, but early biomarkers are lacking. Studies suggest that fibrinolysis resistance (FR) after major abdominal surgery is linked to an increased risk of infection. Patients and Methods: Patients in a randomized controlled trial for hemorrhagic shock were evaluated for FR. Fibrinolysis resistance was quantified by thrombelastography with exogenous tissue plasminogen activator (tPA-TEG) at 24- and 48-hours post-injury and measuring LY30 (%). A receiver-operating characteristics (ROC) curve analysis was used to identify a cutoff for increased risk of pneumonia, which was then validated in ICU patients at risk for venous thromboembolism (VTE). Multivariable logistic regression was used to control for confounders. Results: Forty-nine patients in the hemorrhagic shock cohort had tPA-TEGs at 24- and 48-hours (median ISS, 27; 7% pneumonia). A composite tPA-TEG LY30 of less than 4% at 24 and 48 hours was found to be the optimal cutoff for increased risk of pneumonia. This cohort had a seven-fold increased rate of pneumonia (4% vs. 28%; p = 0.048). Eighty-eight patients in the VTE cohort had tPA-TEGs at 24 and 48 hours post-ICU admission (median ISS, 28; 6% pneumonia). The tPA-TEG LY30 of less than 4% was associated with a 10-fold increased rate of pneumonia (19% vs. 1.5%; p = 0.002). In patients with traumatic brain injury, the same association was found (33% vs. 3.2%; p = 0.006). Adjusting for confounders, the tPA-TEG persisted as a substantial risk factor for pneumonia (adjusted odds ratio [OR], 35.7; 95% confidence interval [CI], 1.9-682; p = 0.018). Conclusions: Fibrinolysis resistance quantified by tPA-TEG within 48 hours of ICU admission is associated with an increased risk of pneumonia in patients in hemorrhagic shock and those at risk for VTE. Prospective validation of the tPA-TEG LY30 optimal cutoff for pneumonia and further investigation into whether endogenous FR is a cause of an altered immunity is warranted.

The in-vitro influence of urea concentration on thromboelastrography in patients with and without end stage renal disease.

BACKGROUND: End stage renal disease (ESRD) is associated with platelet dysfunction but also thromboembolic complications. The specific role of increased blood urea nitrogen (BUN) on coagulation is unclear. We aimed to characterize thromboelastography (TEG) parameters from males and females with ESRD and normal kidney function and evaluate if exogenous urea in vitro reproduced those TEG differences. METHODS: We collected blood samples from 20 living kidney donors and 20 kidney recipients. TEG was performed without and with two increasing urea concentrations in vitro. TEG parameters were compared between recipients and donors. RESULTS: Blood from kidney recipients showed baseline increased maximum amplitude (MA) and shortened time to maximum amplitude (TMA) compared to donors. These differences were not confirmed in females. In all patients, BUN was inversely correlated with TMA (r = -0.342; p = 0.031). In males, BUN and creatinine concentrations showed a direct correlation with MA (0.583; p = 0.007) and an inverse correlation with TMA (r = -0.520; p = 0.019). Urea in vitro decreased R-time (p = 0.005) and increased LY30 (p = 0.009) in donors but not recipients. CONCLUSIONS: ESRD is associated with increased MA and decreased TMA on TEG. No change in MA was observed with increasing urea concentrations in vitro. Gender-specific variability in TEG parameters were observed.

Low viscoelastic clot strength, platelet transfusions, and graft dysfunction are associated with persistent postoperative ascites following liver transplantation.

INTRODUCTION: High output, persistent ascites (PA) is a common complication following liver transplant (LT). Recent work has identified that platelets help maintain endothelial integrity and can decrease leakage in pathological states. We sought to assess the association of PA following LT with platelet count and platelet function. METHODS: Clot strength (MA) is a measure of platelet function and was quantified using thrombelastography (TEG). Total drain output following surgery was recorded in 24-h intervals during the same time frame as TEG. PA was considered >1 L on POD7, as that much output prohibits drain removal. RESULTS: 105 LT recipients with moderate or high volume preoperative ascites were prospectively enrolled. PA occurred in 28%. Platelet transfusions before and after surgery were associated with PA, in addition to POD5 TEG MA and POD5 MELD score. Patients with PA had a longer hospital length of stay and an increased rate of intraabdominal infections. CONCLUSION: Persistent ascites following liver transplant is relatively common and associated with platelet transfusions, low clot strength, and graft dysfunction.

Fibrinolysis resistance after liver transplant as a predictor of early infection.

BACKGROUND: Infection is a leading cause of morbidity in liver transplant (LT). Considering that the fibrinolytic system is altered in sepsis, we investigated the relationship between fibrinolysis resistance (FR) and post-transplant infection. METHODS: Fibrinolysis was quantified using thrombelastography (TEG) with the addition of tPA to quantify FR. FR was defined as LY30 = 0% and stratified as transient if present on POD1 or POD5 (tFR), persistent (pFR) if present on both, or no FR (nFR) if absent. RESULTS: 180 LT recipients were prospectively enrolled. 52 (29%) recipients developed infection. 72 had tFR; 37 had pFR; and 71 had nFR. Recipients with pFR had significantly greater incidence of infections (51% vs. 26% tFR vs. 20% nFR, p = 0.002). pFR was independently associated with increased odds of post-transplant infection (adjusted OR 3.39, p = 0.009). CONCLUSIONS: Persistent fibrinolysis resistance is associated with increased risk of post-transplant infection.

Evaluación de la confiabilidad de la información sanitaria en español sobre la Covid-19 en Google / Evaluation of the health information reliability in spanish about Covid-19 on Google

Introducción: La pandemia de la COVID-19 ha generado un incremento de la información sobre esta enfermedad, por lo que es fundamental garantizar la credibilidad y confiabilidad de las páginas web que brindan esta información. Objetivo: Evaluar la confiabilidad de la información sanitaria en español sobre la COVID-19 en el motor de búsqueda Google considerando los criterios de la herramienta HONcode. Material y métodos: Estudio observacional de corte transversal. Las páginas web de Google se analizaron en diciembre del 2020 desde Lima-Perú, utilizando 4 términos de búsqueda. Se evaluó la confiabilidad de la información sanitaria de las páginas web mediante la herramienta HONcode (versión 3.1.3). Se clasificaron según la fuente de información y su procedencia. El análisis estadístico se realizó para un nivel de significancia de p<0,05. Resultados: Se evaluaron 200 páginas web en español, el 16,5% poseían certificado HONcode, la mayoría fue de la OMS (33,3%), la principal fuente de información fue "académica-profesional" (30,0%). Además, el 33,0% de las páginas web eran peruanas, siendo mayormente de tipo gubernamental (42,4%), pero ninguna tenía certificado HONcode. Conclusiones: Solo una de cada seis páginas web proporcionaba información sanitaria confiable sobre la COVID-19. Además, se distingue la presencia de las páginas web de la OMS en proveer información sanitaria sobre la COVID-19 en Google. Si bien este estudio destaca las páginas web de organismos internacionales, se requiere fortalecer la comunicación desde las páginas web gubernamentales peruanas.

Introduction: The COVID-19 pandemic has generated an increase in information about this disease, so it is essential to ensure the credibility and reliability of the web pages that provide this information. Objective: To evaluate the reliability of health information in Spanish on COVID-19 in the Google search engine considering the criteria of the HONcode tool. Material and methods: Observational cross-sectional study. Google web pages were analyzed in December 2020 from Lima-Peru, using 4 search terms. The reliability of the health information on the web pages was assessed using the HONcode tool (version 3.1.3). They were classified according to the source of information and its provenance. Statistical analysis was performed for a significance level of p<0.05. Results: 200 web pages in Spanish were evaluated, 16.5% were HONcode certified, most of them were from the WHO (33.3%), the main source of information was "academic-professional" (30.0%). In addition, 33.0% of the web pages were Peruvian, being mostly governmental (42.4%), but none had HONcode certificate. Conclusions: Only one out of six web pages provided reliable health information on COVID-19. In addition, the presence of WHO web pages in providing health information about COVID-19 on Google stands out. Although this study highlights the web pages of international organizations, there is a need to strengthen communication from Peruvian governmental web pages.

Analysis of posts and comments about ivermectin on Facebook during the COVID-19 pandemic in Peru / Análisis de publicaciones y comentarios sobre la ivermectina en Facebook durante la pandemia del COVID-19 en Perú

This research was carried out with the objective of analyzing the posts and perceptions of users, through their comments, about the drug ivermectin on Facebook during the COVID-19 pandemic in Peru. The pots and their comments were selected by manual search using the terms: "ivermectina" and "#ivermectina" in July 2020. The analysis of posts and their comments was made by conventional content analysis with an inductive process and supported by scientific bibliography. There were 17 posts made between May 18 and July 7, 2020, and were classified into 5 topics: rumors (58.8%), based on scientific evidence (11.8%), precaution (11.8%), production of the drug (11.8%) and confrontation (5.9%). Surprisingly, 70.0% of the rumors were offered by media pages. Regarding the comments, these were classified identifying the perceptions of users towards ivermectin into four topics: ivermectin as an "effective cure" (64.8%), request for information on ivermectin (25.3%), against the consumption of ivermectin (6.3%) and other treatments (3.6%). In conclusion, it was identified that more than half of the information about ivermectin that circulates through Facebook posts was classified as "rumors", and most of them were originates from media pages; regarding the analysis of the comments, the perception of users who consider ivermectin as the "effective cure" against COVID-19 stands out over other perceptions.

Esta investigación se realizó con el objetivo de analizar las publicaciones y percepciones de los usuarios, a través de sus comentarios, sobre el fármaco ivermectina en Facebook durante la pandemia del COVID-19 en Perú. Las publicaciones y sus comentarios fueron seleccionados mediante búsqueda manual utilizando los términos: "ivermectina" y "#ivermectina" en julio del 2020. La interpretación de las publicaciones y sus comentarios se efectuó por análisis de contenido cualitativo convencional con proceso inductivo y apoyado por literatura científica. Se encontraron 17 publicaciones realizadas entre el 18 de mayo y 7 de julio del 2020, clasificándose en 5 temáticas: rumores (58,8%), basada en evidencia científica (11,8%), precaución (11,8%), producción del fármaco (11,8%) y confrontación (5,9%). Paradójicamente, el 70,0% de los rumores fueron ofrecidos por páginas de medios de comunicación. En cuanto a los comentarios, estos se clasificaron identificando las percepciones de los usuarios hacia la ivermectina en cuatro temas: ivermectina como "cura efectiva" (64,8%), solicitud de información sobre ivermectina (25,3%), en contra del consumo de ivermectina (6,3%) y otros tratamientos (3,6%). En conclusión, se identificó que más de la mitad de la información sobre ivermectina que circula mediante publicaciones en Facebook se clasifican como "rumores", y en su mayoría son originadas por páginas de medios de comunicación; en cuanto al análisis de los comentarios se destaca la percepción de los usuarios que consideran a la ivermectina como la "cura efectiva" contra la COVID-19.

Utility of an Anterior Tibial Perforator for Skin Paddle Viability in Through-and-Through Defects of the Mandible.

Objective: The present report describes an alternative technique of using a flow- through, double-paddle, fibular, osteocutaneous free flap based on one perforator from the peroneal system and one perforator from the anterior tibial system for a through-and-through mandibular defect. Methods: The patient was a 65-year-old man who underwent a composite resection of the floor of the mouth, mandible, and chin pad due to recurrent oral cavity squamous cell carcinoma. The fibula was harvested with one posterior-lateral septal perforator from the peroneal system and with a second skin perforator from the anterior tibial system to perfuse a 15 × 14 cm skin island. The anterior tibial perforator was anastomosed to the distal end of the peroneal artery in a flow-through technique, and the area between the peroneal and tibial perforators was de-epithelialized to reconstruct separately the floor of mouth and cutaneous defects. Results: Good inflow and outflow of both skin islands were noted at the end of the procedure, and the patient recovered successfully without any fistulas or donor site morbidity. Conclusions: Perforators from the anterior tibial system should be considered for large, through-and-through mandibular defects when using 2 perforators from the peroneal system is not possible. In addition, we believe the flow-through technique can be useful in patients with vessel-depleted necks and provides a suitable match for vessel size between an anterior tibial perforator and the distal end of the peroneal system.

Indications and Outcomes of Single-Pedicle vs 2-Pedicle Thigh Free Flaps in Head and Neck Reconstruction.

IMPORTANCE: Flap choice and design are crucial to the success of free flap reconstruction of the head and neck. These are dependent on donor and recipient site characteristics. OBJECTIVE: To demonstrate indications and outcomes of a single-pedicle anterolateral thigh flap (standard ALT flap) vs a thigh free flap with 2 pedicles in head and neck reconstruction. DESIGN, SETTING, AND PARTICIPANTS: A retrospective case series of consecutive patients treated in a tertiary academic care center between October 2011 and June 2017 by a single reconstructive microsurgeon was carried out. Eighty-one patients underwent reconstruction of a cutaneous and/or mucosal defect of the head and neck. Patients with a composite mandibular defect who received both a fibular flap and a thigh flap were excluded. Those with less than 6 months of follow-up were excluded. MAIN OUTCOMES AND MEASURES: Patient characteristics and clinical variables, including age, sex, primary diagnosis/indication for reconstruction, type of flap, dimensions of flap, and number of perforators in the flap, were collected. Optimal cutoff values to quantitate the differences in length and width between the standard ALT and 2-pedicle thigh flaps were determined using receiver operating characteristic (ROC) curve analysis and the Youden Index. The types of flap were compared to determine any difference in flap complications including flap loss, venous congestion, and poor wound healing. RESULTS: Of the 81 patients (mean [SD] age, 58.2 [15.9] years; 62 [76.5%] men), 57 and 18 patients were reconstructed with a standard ALT flap and a thigh flap with 2 pedicles, respectively. Six patients underwent multiple simultaneous thigh (MST) flaps. Defect size (width ≥12 cm, standard ALT: 95% CI, 7.6-9.7; thigh flap with 2 pedicles: 95% CI, 7.0-17.4; P = .02; length ≥17 cm, standard ALT: 95% CI, 11.9-15.2; thigh flap with 2 pedicles: 95% CI, 13.6-30.0; P = .001), the presence of divergent mucosal defects, and through-and-through oral cavity/pharyngeal defects were associated with the use of 2 pedicles. Within groups of thigh flaps with 2 pedicles and MST flaps, there were no flap complications (ie, partial loss, venous congestion, or wound healing issues from poor perfusion). CONCLUSIONS AND RELEVANCE: Harvesting a thigh flap with 2 pedicles has the potential to reduce flap complications and should be considered for divergent and wide or long defects. Width and length measurements respectively of 12 cm and 17 cm are reasonable numbers to initially consider when deciding whether to include a second pedicle. LEVEL OF EVIDENCE: 3.

Surgical management of a nasal AVM in a pediatric patient: A case report.

Arteriovenous malformations (AVMs) are a type of high-flow vascular malformation that are characterized by abnormal capillary communications between the arterial and venous systems. While they are most commonly located in the head and neck region, their appearance in the nose is considerably rare, resulting in a paucity of literature regarding the surgical management of these lesions. We present the case of a 13-year-old male with a 6.5 × 6 cm AVM of the nose with a history of frequent nosebleeds since early childhood, often requiring aggressive measures, such as silver nitrate cauterization for control. Use of nasal decongestants and aminocaproic acid provided only transient improvement. After determination of arterial supply, AVM was approached with a combination of preoperative selective embolization and surgical excision with subsequent forehead flap defect coverage. Due to the size and complexity of this AVM, extra precautions were taken to avoid severe intraoperative bleeding, and femoral sheaths were placed prior to excision. The patient tolerated the procedure well, and with subsequent debulking surgery and Laser Hair Removal achieved an acceptable cosmetic outcome.

Customized Titanium Implant for Chest Wall Reconstruction in Complex Poland Syndrome.

SUMMARY: This report describes a new method for the surgical repair of the chest wall deformity encountered in complex Poland's syndrome. In this report, we describe the use of a customized titanium implant that was used to replace the missing second through fifth ribs and to provide chest wall stabilization before breast reconstruction. This approach might be considered an alternative to autologous rib grafting in patients who have reached skeletal maturity. It avoids the morbidity and risk associated with rib grafts and improves chest wall symmetry.