Effectiveness of a thrombin-gelatin flowable for treating severe liver bleeding: an experimental study.

BACKGROUND: Current scientific evidence has pointed out the relevance of hemostatic products for improving clinical outcomes in liver trauma, including increased survival rates and reductions in bleeding-related complications. The purpose of this study was to compare the use of the gelatin-thrombin flowable (Flowable) versus the standard technique of Packing in a new experimental liver injury model. METHODS: Twenty-four swine were prospectively randomized to receive either Flowable or standard packing technique. We used a novel severe liver injury model, in which the middle and left suprahepatic veins were selectively injured, causing an exsanguinating hemorrhage. The main outcome measure was the percentage of lost blood volume. RESULTS: The median total percentage of total blood volume per animal lost, from injury to minute 120, was significantly lower in the Flowable group (15.2%; interquartile range: 10.7-46.7%) than in the Packing group (64.9%; Interquartile range: 53.4-73.0%) (Hodges-Lehmann median difference: 41.1%; 95% CI: 18.9-58.0%, p = 0.0034). The 24-hour survival rate was significantly higher in the Flowable group (87.0%) than in the Packing group (0.0%) (Hazard ratio (HR) 0.08; 95% confidence interval 0.102 to 0.27; p < 0.0001). Mean-arterial pressure was significantly lower at minute 60 and 120 in the Flowable group than in the packing group (p = 0.0258 and p = 0.0272, respectively). At minute 120, hematocrit was higher in the Flowable than in the packing group (Hodges-Lehmann median difference: 5.5%; 95%CI: 1.0 to11.0, p = 0.0267). Finally, the overall-surgical-procedure was significantly shorter with Flowable than with Packing (Hodges-Lehmann median difference: 39.5 s, 95% CI: 25.0 to 54.0 s, p = 0.0004). CONCLUSIONS: The use of the Flowable was more effective in achieving hemostasis, reducing blood loss, and improving survival rates than standard packing in a severe porcine-liver bleeding model.

Comparison of a gelatin thrombin versus a modified absorbable polymer as a unique treatment for severe hepatic hemorrhage in swine.

There are many surgical techniques (packing, Pringle maneuver, etc.) and hemostatic agents to manage hepatic bleeding in trauma surgery. This study compares the effectiveness of two different types of hemostatic agents, one is an active flowable hemostat and the other is a passive hemostat made of modified absorbable polymers [MAP]. Both surgical technique and hemostatic agents can be used together as a means of controlling bleeding. We have hypothesized that a single hemostatic agent might be as effective as a unique hemostatic surgical technique. Twenty swine were prospectively randomized to receive either active Flowable (Floseal) or passive MAP powder (PerClot) hemostatic agents. We used a novel severe liver injury model that caused exsanguinating hemorrhage. The main outcome measure was total blood loss volume. The total volume of blood loss, from hepatic injury to minute 120, was significantly lower in the Flowable group (407.5 cm3; IqR: 195.0-805.0 cm3) compared to MAP group (1107.5 cm3; IqR: 822.5 to 1544.5 cm3) (Hodges-Lehmann median difference: - 645.0 cm3; 95% CI: - 1144.0 to - 280.0 cm3; p = 0.0087). The rate of blood loss was significantly lower in the flowable group compared with the MAP group as measured from time of injury to minutes 3, 9, 12, and 120 (except for 6 min). The mean arterial pressure gradually recovered in the flowable group by 24 h, whereas in the MAP group, the mean arterial pressure was consistently stayed below baseline values. Kaplan-Meier survival analysis indicated similar rates of death between study groups (Logrank test p = 0.3395). Both the flowable and the MAP hemostatic agents were able to effectively control surgical bleeding in a novel severe liver injury model, however, the flowable gelatin-thrombin agent provided quicker and better bleed control.

Construction and validation of a novel and severe hepatic injury model in swine focuses on research and training. Observational study.

Some hepatic wound models have been developed in pigs with the aim of reproducing liver injury; however, the wound shape, severity, and outcome differ among them. The novel injury profile employed in this study differed from that used elsewhere for standardized, repeatable, reproducible, incising-penetrating, vascular, and severe injury in swine. It is made with a cutting object that penetrates deep into the hepatic parenchyma, always affecting the two suprahepatic veins at the point where they merge into the common trunk. The primary outcome was reproducibility and replicability of the surgical method. The secondary outcome was the analysis of some variables (blood loss, survival, and flow) to validate the model. •This novel method of liver injury provides a liver injury with the following characteristics: standardized, incise-penetrated, deep, bloody, and severe.•This model can be used for research (trauma, hepato-bilio-pancreatic, pharmaceutical) and training (damage control surgery).•Method name: Incising-Penetrating, Vascular and Severe Liver Injury Model in Swine.

Utility of microporous polysaccharide hemospheres in severe hepatic trauma: Experimental study of hemostatic strength and ease of use.

BACKGROUND: Animal studies confirm the utility of hemostatics against standard packing following severe liver injury. We investigated the efficacy and ease of use of novel microporous polysaccharide hemosphere (MPH) compounds (Perclot®, Baxter) in the treatment of severe hepatic hemorrhage in pig. METHODS: Pigs were randomized to one of two equal treatment groups: MPH compounds (n=12) and Standard Packing (n=12). All animals underwent standardized surgical devascularization of the suprahepatic veins (grade V) to induce severe hepatic injury. Measures relating to the hemostatic success were monitored at 12, 60, 120 minutes and 24 hours post injury. RESULTS: Animals allocated to treatment with MPH compounds were associated with higher survival rates at 24 hours than those undergoing standard packing: 66.7% vs, 0%, respectively (p=0.001). At 120 minutes MPH compounds were also associated with reduced blood loss, median (IQR) 1.16 (0.60) vs. 10.19 (5.77) mL/Kg, respectively: p<0.001) as well as higher invasive mean arterial pressures (iMAP) median (IQR) 39.12 (11.29) vs. 25.75 (14.28) mmHg, respectively: p=0.14) and hemoglobin levels median (IQR) 5.45 (2.50) vs. 6.45 (1.73) g/dL, respectively p=0.127). Overall, the application of MPH compounds required nearly half the time of standard packing median (IQR) 32.92 (6.51) vs. 67.75 (14.66) sec, respectively: p<0.001). CONCLUSIONS: The data suggests that the use of MPH works in a severe hemorrhage in the liver of pigs, improving many variables in comparison to standard packing, including survival, blood loss and speed of application and we conclude that this offers a potential alternative for the treatment of hepatic injury. Further work is needed to corroborate these findings.

How Methylation Modifies the Photophysics of the Native All- trans-Retinal Protonated Schiff Base: A CASPT2/MD Study in Gas Phase and in Methanol.

A comparison between the free-energy surfaces of the all- trans-retinal protonated Schiff base (RPSB) and its 10-methylated derivative in gas phase and methanol solution is performed at CASSCF//CASSCF and CASPT2//CASSCF levels. Solvent effects were included using the average solvent electrostatic potential from molecular dynamics method. This is a QM/MM (quantum mechanics/molecular mechanics) method that makes use of the mean field approximation. It is found that the methyl group bonded to C10 produces noticeable changes in the solution free-energy profile of the S1 excited state, mainly in the relative stability of the minimum energy conical intersections (MECIs) with respect to the Franck-Condon (FC) point. The conical intersections yielding the 9- cis and 11- cis isomers are stabilized while that yielding the 13- cis isomer is destabilized; in fact, it becomes inaccessible by excitation to S1. Furthermore, the planar S1 minimum is not present in the methylated compound. The solvent notably stabilizes the S2 excited state at the FC geometry. Therefore, if the S2 state has an effect on the photoisomerization dynamics, it must be because it permits the RPSB population to branch around the FC point. All these changes combine to speed up the photoisomerization in the 10-methylated compound with respect to the native compound.

Theoretical study of the competition between intramolecular hydrogen bonds and solvation in the Cys-Asn-Ser tripeptide.

A study of the competition between intra- and intermolecular hydrogen bonds and its influence on the stability of the Cys-Asn-Ser tripeptide in aqueous solution was performed by using the averaged solvent electrostatic potential from molecular dynamics method (ASEP/MD). The model combines a DFT-B3LYP/6-311+G(d) quantum treatment in the description of the solute molecule with NVT molecular dynamics simulations in the description of the solvent. In gas phase, the most stable structure adopts a C5 conformation. Somewhat higher in energy are found the PP(II) and C7eq structures. In solution, the stability order of the different conformers is reversed: the PP(II) structure becomes the most stable, and the C5 structure is strongly destabilized. The conformational equilibrium is shifted toward conformations in which the intramolecular hydrogen bonds (IHB) have been substituted with intermolecular hydrogen bonds with the water molecules. The solvent stabilizes extended structures without IHBs that are not stable in vacuum. The effect of the protonation state on the conformational equilibrium was also analyzed.

Rotura traumática del diafragma derecho y lesión iatrogénica por drenaje torácico correctamente colocado / No disponible

No disponible

[Clinical value of the ankle-brachial index in patients at risk of cardiovascular disease but without known atherothrombotic disease: VITAMIN study]. / Valor de la determinación del índice tobillo-brazo en pacientes de riesgo vascular sin enfermedad aterotrombótica conocida: estudio VITAMIN.

INTRODUCTION AND OBJECTIVES: Detecting peripheral arterial disease by measuring the ankle-brachial index can help identify asymptomatic patients with established disease. We investigated the prevalence of peripheral arterial disease (i.e., an ankle-brachial index <0.9) and its potential clinical and therapeutic impact in patients with no known arterial disease who were seen at internal medicine departments. METHODS: This multicenter, cross-sectional, observational study included patients at risk of cardiovascular disease who were selected on the basis of age, gender and the presence of conventional risk factors. No patient was known to have arterial disease. RESULTS: The study included 493 patients, 174 (35%) of whom had diabetes, while 321 (65%) did not. Only 16% were in a low-risk category according to their Framingham score. An ankle-brachial index <0.9 was observed in 27.4%, comprising 37.9% of those with diabetes and 21.3% of those without. Multiple logistic regression analysis showed that the risk factors associated with an ankle-brachial index <0.9 were age, diabetes, and hypercholesterolemia. There was a significant relationship between the ankle-brachial index and Framingham risk categories. Therapeutically, only 21% of patients with an ankle brachial index <0.9 were taking antiplatelet drugs. Overall, 20% had a low-density lipoprotein cholesterol concentration <100 mg/dl and 52% had a concentration <130 mg/dl. Some 42% had arterial blood pressures below 140/90 mm Hg. CONCLUSIONS: Asymptomatic peripheral arterial disease was detected in a high proportion of patients with an intermediate or high cardiovascular disease risk. The ankle-brachial index should be measured routinely in patients at risk of cardiovascular disease who are seen at internal medicine departments.

Treatment results in localized primary gastric lymphoma: data of patients registered within the German multicenter study (GIT NHL 02/96).

PURPOSE: In the prospective study 02/96 on primary GI lymphoma, we have collected data on histology, clinical features, and treatment results. In particular, in stages I and II localized primary gastric lymphoma (PGL), our objectives were to reduce treatment intensity and to confirm our hypothesis from study 01/92, which maintained that an organ-preserving approach is not inferior to primary surgery. PATIENTS AND METHODS: Patients receiving radiotherapy and/or chemotherapy were stratified for histologic grade, stage, and whether surgery had been carried out or not (as decided by each participating center). Patients with aggressive PGL received six cycles of CHOP-14 (cyclophosphamide, doxorubicin, vincristine, and prednisone) followed by involved-field radiotherapy (40 Gy). Patients with indolent PGL (including patients experiencing treatment failure with antibiotic therapy for Helicobacter pylori) were treated with extended-field radiotherapy. The volume depended on stage. The irradiation dose was 30 Gy, followed by a boost of 10 Gy (the latter omitted after complete resection) to the tumor region. RESULTS: Seven hundred forty-seven patients were accrued. Of these patients, 393 with localized PGL were treated with radiotherapy and/or chemotherapy only or additional surgery between December 1996 and December 2003. The survival rate at 42 months for patients treated with surgery was 86% compared with 91.0% for patients without surgery. CONCLUSION: In this nonrandomized study (02/96), we reproduced the previous results of study 01/92 showing no disadvantage for an organ-preserving treatment. Therefore, primary stomach resection should be questioned.

[Late infectious complications after high-dose therapy and autologous blood stem cell transplantation]. / Späte infektiöse Komplikationen nach Hochdosistherapie und autologer Blutstammzelltransplantation.

AIM: Only a few data on frequency and character of late infectious complications after high-dose therapy (HDT) and autologous blood stem cell transplantation (ASCT) have been published. This prospective study was carried out to identify potential predictive factors for late infections (occurring after discharge following HDT) and to clarify the usefulness of prophylactic measures. PATIENTS AND METHODS: Clinical data of 192 consecutive patients treated with HDT and ASCT in a single hospital were analyzed on late infectious complications. After discharge following HDT, the 166 evaluable patients (84 with hematologic malignancies, 82 with solid tumors) had been examined and interviewed on infections every 4-12 weeks after ASCT. For Pneumocystis carinii prophylaxis, inhalation with pentamidine or oral cotrimoxazole was used for 3-4 months following ASCT. RESULTS: In the first 6 months following ASCT (after discharge) we saw on average one infectious episode per patient (median, range 0-6), usually light infections (mostly banal upper airway infections). 17 patients had to be treated in hospital for infectious (15 of whom with hematologic malignancies), three of whom (only with hematologic malignancies) died in spite of intensive care as a result of pneumonias due to opportunistic causative agents (mainly Pneumocystis carinii [PcP]). In the second half of the year after ASCT, five patients (with hematologic malignancies) had to be hospitalized due to infections. No further infection-related death occurred. Early documented infections (pneumonia, bacteremia or Clostridium difficile colitis) were associated with an increased risk for late serious infections. Zoster occurred in 18% of patients within 12 months, more frequently after increased pretreatment (25% vs. 11% after less pretreatment), most frequently in patients with relapsed lymphomas (32%). CONCLUSIONS: Significant late infectious complications after ASCT are uncommon. Patients with hematologic malignancies have a significantly increased risk of more serious infections and should be observed carefully. For risk patients with hematologic malignancies and possibly solid tumors, a strict PcP prophylaxis is required. Patients with relapsed lymphomas could possibly be treated preventively against zoster with low-dose aciclovir to reduce the extent of zoster disease. Each patient should be informed carefully that early signs of zoster require an effective zoster treatment as soon as possible.