Fibrinogen concentrate vs. fresh frozen plasma for the management of coagulopathy during thoraco-abdominal aortic aneurysm surgery: a pilot randomised controlled trial.

Major vascular surgery is frequently associated with significant blood loss and coagulopathy. Existing evidence suggests hypofibrinogenaemia develops earlier than other haemostatic deficiencies during major blood loss. The purpose of this study was to assess whether the use of an infusion of fibrinogen concentrate to prevent and treat hypofibrinogenaemia during surgery resulted in satisfactory haemostasis, removing or reducing the need for blood component transfusion. Twenty patients undergoing elective extent-4 thoraco-abdominal aortic aneurysm repair were randomly allocated to receive either fresh frozen plasma or fibrinogen concentrate to treat hypofibrinogenaemia during surgery. Coagulation was assessed during and after surgery by point-of-care and laboratory testing, respectively, and treatment was guided by pre-defined transfusion triggers. Despite blood losses of up to 11,800 ml in the patients who received the fibrinogen concentrate, none required fresh frozen plasma during surgery, and only two required platelet transfusions. The median (IQR [range]) allogeneic blood component administration during surgery and in the first 24 h postoperatively was 22.5 (14-28 [2-41]) units in patients allocated to fresh frozen plasma vs. 4.5 (3-11[0-17]) in patients allocated to fibrinogen concentrate (p = 0.011). All patients in both groups were assessed by the surgeon to have satisfactory haemostasis at the end of surgery. Mean (SD) postoperative fibrinogen concentrations were similar in patients allocated to fresh frozen plasma and fibrinogen concentrate (1.6 (0.3) g.l-1 vs. 1.6 (0.2) g.l-1 ; p = 0.36) but the mean (SD) international normalised ratio and activated partial thromboplastin time ratio were lower in patients allocated to fresh frozen plasma (1.1 (0.1) vs. 1.8 (0.3); p < 0.0001 and 1.1 (0.2) vs. 1.7 (0.5); p = 0.032, respectively). Fibrinogen concentrate may be used as an alternative to fresh frozen plasma in the treatment of coagulopathy during thoraco-abdominal aortic aneurysm repair.

Refractures in patients at least forty-five years old. a prospective analysis of twenty-two thousand and sixty patients.

BACKGROUND: Individuals who sustain a low-energy fracture are at increased risk of sustaining a subsequent low-energy fracture. The incidence of these refractures may be reduced by secondary preventative measures, although justifying such interventions and evaluating their impact is difficult without substantive evidence of the severity of the refracture risk. The aim of this study was to quantify the risk of sustaining another fracture following a low-energy fracture compared with the risk in an age and sex-matched reference population. METHODS: During the twelve-year period between January 1988 and December 1999, all inpatient and outpatient fracture-treatment events were prospectively audited in a trauma unit that is the sole source of fracture treatment for a well-defined local catchment population. During this time, 22,060 patients at least forty-five years of age who had sustained a total of 22,494 low-energy fractures of the hip, wrist, proximal part of the humerus, or ankle were identified. All refracture events were linked to the index fracture in the database during the twelve-year period. The incidence of refracture in the cohort of patients who had sustained a previous fracture was divided by the "background" incidence of index fractures within the same local population to obtain the relative risk of refracture. Person-years at-risk methodology was used to control for the effect of the expected increase in mortality with advancing age. RESULTS: Within the cohort, 2913 patients (13.2%) subsequently sustained a total of 3024 refractures during the twelve-year period. Patients with a previous low-energy fracture had a relative risk of 3.89 of sustaining a subsequent low-energy fracture. The relative risk was significantly increased for both sexes, but it was greater for men (relative risk = 5.55) than it was for women (relative risk = 2.94). The relative risk was 5.23 in the youngest age cohort (patients between forty-five and forty-nine years of age), and it decreased with increasing age to 1.20 in the oldest cohort (patients at least eighty-five years of age). CONCLUSIONS: Individuals who sustain a low-energy fracture between the ages of forty-five and eighty-four years have an increased relative risk of sustaining another low-energy fracture. This increased risk was greater when the index fracture occurred earlier in life; the risk decreased with advancing age. Secondary preventative measures designed to reduce the risk of refracture following a low-energy fracture are likely to have a greater impact on younger individuals.

Excision of a remarkable tumour of the upper jaw in 1834 by Robert Liston.

A series of pre-operative casts of the head, one of plaster of Paris and the other of wax, have recently been discovered in the Department of Anatomy, Edinburgh, of a patient with an immense tumour of the left maxillary antrum which produced an enormous degree of facial distortion. These casts complement a series of engravings published in the contemporary literature. This lady's tumour was successfully excised by Robert Liston in 1834 in the Royal Infirmary of Edinburgh, only a month before he left Edinburgh for London. The tumour was believed to be benign, and was removed without the benefit of anaesthesia. The patient returned the following summer to have a gold palate fitted, and while her voice was initially indistinct, it subsequently recovered.

The Penman case: a re-evaluation.

One of the most remarkable operations carried out in the Royal Infirmary of Edinburgh during the early decades of the 19th century was the surgical excision of an enormous tumour, believed to be an osteosarcoma, of the lower jaw of Robert Penman, that produced severe disfigurement of his face. James Syme, then in his late twenties, was invited to see the patient by Professor Ballingall and Dr John Abercrombie and, in July 1828, he operated, without the benefit of an anaesthetic, to completely remove the tumour. The patient not only survived the operation, but also remained in excellent health for many years afterwards. He emigrated to the United States, but occasionally returned home to Scotland. In 1855, Lord Lister, who noted that his "deformity" had been wonderfully masked by a bushy beard, saw him. This case is re-evaluated in the light of information from the archives in the Royal College of Surgeons of Edinburgh and from the contemporary and more recent literature.