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1.
Transfusion ; 2020 Jul 21.
Artigo em Inglês | MEDLINE | ID: mdl-32692441

RESUMO

BACKGROUND: Early plasma transfusion is important in the treatment of patients with major hemorrhage. Prolonged shelf life of AB type frozen -80°C and cold-stored (4°C) deep frozen plasma (DFP) will improve strategic stock management, minimize need for resupply, and make pre-hospital implementation more feasible. METHODS AND MATERIALS: Plasma products type AB of different age and origin (-30°C Fresh Frozen [(FFP], -80°C DFP [short (±1 year) and long (±7 year)] stored) were thawed (Day 0), stored at 4°C, and sampled on Days 7 and 14. Additionally, samples of plasma containing blood products (Octaplas LG®, whole blood and platelets) were compared for coagulation factor activity, phospholipid clotting time (PPL), and kaolin TEG during 4°C or 22°C storage. RESULTS: Coagulation profiles of FFP, short- and long-stored -80°C DFP were not significantly different after thaw. Cold storage did not affect fibrinogen, Protein C, and Antithrombin III activities whereas factor V, VII, VIII, and Protein S decreased in all blood products. After 14 days DFP still meets the guidelines for clinical use, except for Protein S (0.4 IU/mL). With exception of Octaplas LG®, phospholipid activity and TEG coagulation were similar between plasma containing blood components during storage. CONCLUSION: AB DFP quality was unaffected by almost 7 years of frozen storage. Quality of thawed 14-day stored AB DFP met, with exception of Protein S, all minimal guidelines which implies that its quality is sufficient for use in the (pre)-hospital (military) environment for treatment of major hemorrhage.

2.
Transfusion ; 2020 Jun 27.
Artigo em Inglês | MEDLINE | ID: mdl-32592423

RESUMO

BACKGROUND: Cryopreserved platelet products can be stored for years and are mainly used in military settings. Following thawing, cryopreserved platelets are activated, resulting in faster clot formation but reduced aggregation in vitro, rendering their efficacy in bleeding unknown. Also, concerns remain on the safety of these products. The aim was to investigate the efficacy and safety of cryopreserved platelets in a rat model of traumatic hemorrhage. STUDY DESIGN AND METHODS: After 1 hour of shock, rats (n = 13/group) were randomized to receive a balanced transfusion pack (1:1:1 red blood cell:plasma:platelet) made from syngeneic rat blood, containing either liquid stored platelets or cryopreserved platelets. Primary outcome was the transfusion volume required to obtain a mean arterial pressure (MAP) of 60 mmHg. Secondary outcomes were coagulation as assessed by thromboelastometry (ROTEM®) and organ failure as assessed by biochemistry and histopathology. RESULTS: The transfusion volume to obtain a MAP of 60 mmHg was lower in animals receiving cryopreserved platelets (5.4 [4.1-7.1] mL/kg) compared to those receiving liquid stored platelets (7.5 [6.4-8.5] mL/kg, p < 0.05). ROTEM® clotting times were shorter (45 [41-48] vs. 49 [45-53]sec, p < 0.05), while maximum clot firmness was slightly lower (68 [67-68] vs. 69 [69-71]mm, p < 0.01). Organ failure was similar in both groups. CONCLUSIONS: Use of cryopreserved platelets required less transfusion volume to reach a targeted MAP compared to liquid stored platelets, while organ injury was similar. These results provide a rationale for clinical trials with cryopreserved platelets in (traumatic) bleeding.

3.
Artigo em Inglês | MEDLINE | ID: mdl-32472443

RESUMO

PURPOSE: Use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) as adjunct for temporary hemorrhage control in patients with exsanguinating torso hemorrhage is increasing. Characteristics of aortic occlusion balloons (AOB) are diverse and evolving as efforts are made to improve the technology. It is important to select a device that fits the requirements of the medical situation to minimize the risk of failure and complications. The aim of this study is to appraise guidance in the choice of an AOB in a specific situation. METHODS: We assessed 29 AOB for differences and outline possible advantages and disadvantages of each. Bending stiffness was measured with a three-point bending device. RESULTS: Diameter of the AOB ranged from 6 (ER-REBOA™) to 10 (Coda®-46) French. However, some need large-bore access sheaths up to 22 French (Fogarty®-45 and LeMaitre®-45) or even insertion via cut-down (Equalizer™-40). Bending stiffness varied from 0.08 N/mm (± 0.008 SD; Coda®-32) to 0.72 N/mm (± 0.024 SD; Russian prototype). Rescue Balloon™ showed kinking of the shaft at low bending pressures. The only non-compliant AOB is REBOA Balloon®. ER-REBOA™, Fogarty®, LeMaitre®, REBOA Balloon®, and Rescue Balloon™ are provided with external length marks to assist blind positioning. CONCLUSION: In resource-limited settings, a guidewire- and fluoroscopy-free, rather stiff device, such as ER-REBOA™, Fogarty®, and LeMaitre®, is warranted. Of these devices, ER-REBOA™ is the only catheter compatible with seven French sheaths and specifically designed for emergency hemorrhage control. Of the over-the-wire devices, Q50® has several features that facilitate use and reduce the risk of malplacement or vessel damage.

4.
World J Surg ; 44(8): 2622-2637, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32377860

RESUMO

BACKGROUND: The Acute Care Surgery (ACS) model was developed as a dedicated service for the provision of 24/7 nontrauma emergency surgical care. This systematic review investigated which components are essential in an ACS model and the state of implementation of ACS models worldwide. METHODS: A literature search was conducted using PubMed, MEDLINE, EMBASE, Cochrane library, and Web of Science databases. All relevant data of ACS models were extracted from included articles. RESULTS: The search identified 62 articles describing ACS models in 13 countries. The majority consist of a dedicated nontrauma emergency surgical service, with daytime on-site attending coverage (cleared from elective duties), and 24/7 in-house resident coverage. Emergency department coverage and operating room access varied widely. Critical care is fully embedded in the original US model as part of the acute care chain (ACC), but is still a separate unit in most other countries. While in most European countries, ACS is not a recognized specialty yet, there is a tendency toward more structured acute care. CONCLUSIONS: Large national and international heterogeneity exists in the structure and components of the ACS model. Critical care is still a separate component in most systems, although it is an essential part of the ACC to provide the best pre-, intra- and postoperative care of the physiologically deranged patient. Universal acceptance of one global ACS model seems challenging; however, a global consensus on essential components would benefit any healthcare system.

5.
Transfus Apher Sci ; 59(3): 102789, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32340813

RESUMO

The Dutch military uses frozen blood products for the treatment of bleeding trauma patients during military deployments. With -80 °C frozen blood products it is possible to follow operational demand while reducing the number of resupply transports and loss of products due to expiration. In this paper lessons learned are described on efficient blood management with -80 °C deep-frozen erythrocytes (DEC).

6.
Diving Hyperb Med ; 50(1): 2-7, 2020 Mar 31.
Artigo em Inglês | MEDLINE | ID: mdl-32187611

RESUMO

INTRODUCTION: The Netherlands Maritime Special Operations Forces use closed circuit oxygen rebreathers (O2-CCR), which can cause pulmonary oxygen toxicity (POT). Recent studies demonstrated that volatile organic compounds (VOCs) can be used to detect POT in laboratory conditions. It is unclear if similar VOCs can be identified outside the laboratory. This study hypothesised that similar VOCs can be identified after O2-CCR diving in operational settings. METHODS: Scenario one: 4 h O2-CCR dive to 3 metres' seawater (msw) with rested divers. Scenario two: 3 h O2-CCR dive to 3 msw following a 5 day physically straining operational scenario. Exhaled breath samples were collected 30 min before and 30 min and 2 h after diving under field conditions and analysed using gas chromatography-mass spectrometry (GC-MS) to reconstruct VOCs, whose levels were tested longitudinally using a Kruskal-Wallis test. RESULTS: Eleven divers were included: four in scenario one and seven in scenario two. The 2 h post-dive sample could not be obtained in scenario two; therefore, 26 samples were collected. GC-MS analysis identified three relevant VOCs: cyclohexane, 2,4-dimethylhexane and 3-methylnonane. The intensities of 2,4-dimethylhexane and 3-methylnonane were significantly (P = 0.048 and P = 0.016, respectively) increased post-dive relative to baseline (range: 212-461%) in both scenarios. Cyclohexane was increased not significantly (P = 0.178) post-dive (range: 87-433%). CONCLUSIONS: VOCs similar to those associated with POT in laboratory conditions were identified after operational O2-CCR dives using GC-MS. Post-dive intensities were higher than in previous studies, and it remains to be determined if this is attributable to different dive profiles, diving equipment or other environmental factors.

7.
J Spec Oper Med ; 20(1): 81-86, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32203611

RESUMO

BACKGROUND: Early hemorrhage control using resuscitative endovascular balloon occlusion of the aorta (REBOA) can save lives. This study was designed to evaluate the ability to train Quick Response Team Fire Fighters (QRT-FF) to gain percutaneous femoral artery access and place a REBOA catheter in a model, using a comprehensive theoretical and practical training program. METHODS: Six QRT-FF participated in the training. SOF medics from a previous training served as the control group. A formalized training curriculum included basic anatomy and endovascular materials for percutaneous access and REBOA placement. Key skills included (1) preparation of an endovascular toolkit, (2) achieving vascular access in the model, and (3) placement and positioning of REBOA. RESULTS: QRT-FF had significantly better scores compared with medics using endovascular materials (P = .003) and performing the procedure without unnecessary attempts (P = .032). Basic surgical anatomy scores for QRT-FF were significantly better than SOF medics (P = .048). QRT-FF subjects demonstrated a significantly higher overall technical skills point score than medics (P = .030). QRT-FF had a median total time from start of the procedure to REBOA inflation of 3:23 minutes, and medics, 5:05 minutes. All six QRT-FF subjects improved their procedure times-as did four of the five medics. CONCLUSIONS: Our training program using a task training model can be utilized for percutaneous femoral access and REBOA placement training of QRT-FF without prior ultrasound or endovascular experience. Training the use of advanced bleeding control options such as REBOA, as a secondary occupational task, has the potential to improve outcomes for severely bleeding casualties in the field.


Assuntos
Bombeiros/educação , Hemorragia/prevenção & controle , Aorta , Oclusão com Balão , Cateterismo Periférico , Procedimentos Endovasculares , Estudos de Viabilidade , Artéria Femoral , Humanos , Avaliação de Programas e Projetos de Saúde , Ressuscitação
9.
Injury ; 51(4): 892-896, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32093945

RESUMO

BACKGROUND: Optimal health is demanded for service members in military operations. However, the strains of deployment can result in a deterioration, moreover when combat-related injuries are sustained, affecting level of participation and health related quality of life (HRQOL). Secondary health conditions may occur in time, however existing studies measure coping, level of activity and participation and HRQOL at one point in time. AIM: To assess the change over time concerning coping, mobility, level of participation and HRQOL in Dutch service members with combat-related injuries sustained during operation Task Force Uruzgan (TFU). METHODS: The lower extremity functional scale (LEFS), the cognitive emotion regulation questionnaire (CERQ), the assessment of life habits short version (LIFE-H) and the EuroQol-5D (EQ-5D), measuring HRQOL, were administered in 2010 and 2014. Change of scores between the two time points was tested with the Wilcoxon signed rank test. RESULTS: The response rate was 53% (28/53). The score on the coping strategy self-blame showed a significant increase over time with low scores on both occasions. The coping strategies positive reappraisal and acceptance showed the highest scores. No significant change is shown in mobility, the level of participation or HRQOL. CONCLUSION: service members with combat-related injuries remain stable in level of activity and participation and HRQOL in time and they use adaptive coping strategies.

10.
J Vasc Surg ; 71(2): 682-692.e1, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-32040434

RESUMO

BACKGROUND: Diabetic foot ulcers (DFUs) are frequently associated with peripheral arterial occlusive disease (PAOD) and may ultimately lead to amputations of the lower extremity. Adjuvant hyperbaric oxygen treatment (HBOT) might foster better wound healing and lower amputation rates in patients with DFU and PAOD. A systematic review was conducted to assess the effects of HBOT as an adjunctive therapy to standard treatment for patients with DFUs with PAOD. METHODS: Systematic review using the MEDLINE, EMBASE, and Cochrane CENTRAL databases (from inception to October 2018). All original, comparative studies on the effect of HBOT on DFUs with PAOD were eligible. The primary outcome measures were amputation rate, amputation-free survival, complete ulcer healing, and mortality. RESULTS: Eleven studies, totaling 729 patients, were included for analysis, including 7 randomized clinical trials, 2 controlled clinical trials, and 2 retrospective cohorts. Four were used for quantitative synthesis. Meta-analysis showed a significantly fewer major amputations in the HBOT group (10.7% vs 26.0%; risk difference, -15%; 95% confidence interval [CI], -25 to -6; P = .002; number needed to treat, 7; 95% CI, 4-20). No difference was found for minor amputations (risk difference, 8%; 95% CI, -13 to 30; P = .46). Three studies reporting on complete wound healing showed contrasting results. No significant difference was found for mortality or amputation-free survival. CONCLUSIONS: Current evidence shows that adjuvant HBOT improves major amputation rate, but not wound healing, in patients with DFUs and PAOD. Given the wide range of patients included in the trials, better patient selection may help define which patients with DFUs and PAOD benefit most from HBOT as standard adjunctive treatment.


Assuntos
Arteriopatias Oclusivas/complicações , Pé Diabético/complicações , Pé Diabético/terapia , Oxigenação Hiperbárica , Doença Arterial Periférica/complicações , Humanos
11.
Wound Repair Regen ; 28(2): 266-275, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31667898

RESUMO

Diabetic foot ulcers are a common complication of diabetes, which affects 25% of patients and may ultimately lead to amputation of affected limbs. Research suggests hyperbaric oxygen therapy improves healing of these ulcers. However, this has not been reflected in previous reviews, possibly because they did not differentiate between patients with and without peripheral arterial occlusive disease. Therefore, we performed a systematic review of published literature in the MEDLINE, Embase, and Cochrane CENTRAL databases on nonischemic diabetic foot ulcers with outcome measures including complete ulcer healing, amputation rate (major and minor), and mortality. Seven studies were included, of which two were randomized clinical trials. Two studies found no difference in major amputation rate, whereas one large retrospective study found 2% more major amputations in the hyperbaric oxygen group. However, this study did not correct for baseline differences. Two studies showed no significant difference in minor amputation rate. Five studies reporting on complete wound healing showed no significant differences. In conclusion, the current evidence suggests that hyperbaric oxygen therapy does not accelerate wound healing and does not prevent major or minor amputations in patients with a diabetic foot ulcer without peripheral arterial occlusive disease. Based on the available evidence, routine clinical use of this therapy cannot be recommended. However, the available research for this specific subgroup of patients is scarce, and physicians should counsel patients on expected risks and benefits. Additional research, focusing especially on patient selection criteria, is needed to better identify patients that might profit from this therapy modality.

12.
Injury ; 51(1): 70-75, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31400810

RESUMO

BACKGROUND: Recent terrorist attacks and mass shooting incidents in major European and North American cities have shown the unexpected influx of large volumes of patients with complex multi-system injuries. The rise of subspecialisation and the low violence-related penetrating injuries among European cities, show the reality that most surgical programs are unable to provide sufficient exposure to penetrating and blast injuries. The aim of this study is to describe and create a collaborative program between a major South African trauma service and a NATO country military medical service, with synergistic effect on both partners. This program includes comprehensive cross-disciplinary training & teaching, and scientific research. METHODS: This is a retrospective descriptive study. The Pietermaritzburg hospital and Netherlands military trauma register databases were used for analysing patient data: Pietermaritzburg between September 2015 and August 2016, Iraq between May and July 2018 and Afghanistan from 2006 to 2010. Interviews were held to analyse the mutual benefits of the program. RESULTS: From the Pietermaritzburg study, mutual benefits focus on social responsibility, exchange of knowledge and experience and further mutual exploration. The comparison showed the numbers of surgical procedures over a one-month period performed in Iraq 12.7, in Afghanistan 68.8 and in Pietermaritzburg 152. CONCLUSION: This study has shown a significant volume of penetrating trauma in South Africa, that can provide substantial exposure over a relatively short period. This help to prepare civilian and military surgeons and deployable military medical personnel for casualties with blast - and/or penetrating injuries. The aforementioned findings and the willingness to shape the mutual benefits, create a platform for trauma electives, research, education and training.

13.
Emerg Med J ; 37(2): 65-72, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31831587

RESUMO

OBJECTIVES: Massive transfusion protocols (MTPs) may improve survival in patients with uncontrolled haemorrhage. An MTP was introduced into the Dutch transfusion guidelines in 2011, the ninth edition of the advanced trauma life support course in 2012 and the third version of the European guideline in 2013. This is the first survey of MTPs in Dutch trauma centres. METHODS: The aim of the study was to compare MTP strategies in level 1 trauma centres in The Netherlands, and with (inter)national guidelines. A contact in each government assigned level 1 trauma centre in The Netherlands and the Dutch Ministry of Defence was approached to share their MTPs and elucidate their protocol in a survey and oral follow-up interview. RESULTS: All 11 level 1 trauma centres responded. The content of the packages and transfusion ratios (red blood cells/plasma/platelets) were 3:3:1, 5:5:1, 5:3:1, 2:3:1, 4:4:1, 5:2:1, 2:2:1 and 4:3:1. Tranexamic acid was used in all centres and an additional dose was administered in eight centres. Fibrinogen was given directly (n=4), with persistent bleeding (n=3), based on Clauss fibrinogen (n=3) or rotational thromboelastometry (n=1). All centres used additional medication in patients in the form of anticoagulants, but their use was ambiguous. CONCLUSION: MTPs differed between institutes and guidelines. The discrepancies in transfusion ratios can be explained by (inter)national differences in preparation and volume of blood components and/or interpretation of the '1:1:1' guideline. We recommend updating MTPs every year using the latest guidelines and evaluating the level of evidence for treatment during massive transfusion.

14.
Diving Hyperb Med ; 49(4): 283-290, 2019 Dec 20.
Artigo em Inglês | MEDLINE | ID: mdl-31828747

RESUMO

INTRODUCTION: Hearing loss (HL) is common in the adult working population. It is widely assumed that diving is a risk factor for HL. However, studies with sufficient follow-up comparing HL in divers to non-divers are limited. This study aimed to assess the hearing threshold (HT) of Royal Netherlands Navy divers who had been diving for more than 15 years and to compare it to the ISO standard 7029:2017 reference table. METHODS: In this 25-year retrospective cohort study the Royal Netherlands Navy Diving Medical Centre audited the medical records of 1,117 Navy divers. Yearly dive medical assessments were performed according to professional standards, including audiometry. HTs were compared to the ISO 7029:2017 reference table, including Z-distribution, using paired t-tests. RESULTS: Thirty-five divers were included who had been diving for 15 years or longer. The HT increased significantly in nine of the 16 measured frequencies, while the Z-score decreased significantly in nine of the 16 tested frequencies (eight in both ears). In the 25-year follow-up the pattern was more obvious, with one significantly increased HT, and 10 significantly decreased Z-scores. DISCUSSION: The absolute HT increases after 15 years of military diving, but less than would be expected from normal age-related deterioration. Moreover, when comparing Z-scores, this sample of divers actually hear better than non-divers. We conclude that military diving is not an increased risk for HL compared to regular occupational hazards and suggest withdrawing the requirement for routine yearly audiometric evaluation as part of a dive medical examination.


Assuntos
Mergulho , Transtornos da Audição , Perda Auditiva , Militares/estatística & dados numéricos , Adulto , Audiometria , Limiar Auditivo/fisiologia , Mergulho/efeitos adversos , Audição/fisiologia , Transtornos da Audição/etiologia , Perda Auditiva/etiologia , Humanos , Países Baixos , Estudos Retrospectivos
15.
BMJ Case Rep ; 12(12)2019 Dec 02.
Artigo em Inglês | MEDLINE | ID: mdl-31796454

RESUMO

Pyogenic liver abscess (PLA) formation is a rare complication of Crohn's disease (CD). As symptoms often mimic a CD exacerbation, diagnosis can be delayed leading to severe disease. The current case report describes a case of a patient with a history of CD that was admitted with multiple PLAs, which persisted despite percutaneous drainage combined with antibiotics. After a sigmoid resection, the liver abscesses diminished rapidly.


Assuntos
Diverticulite/complicações , Abscesso Hepático Piogênico/etiologia , Doenças do Colo Sigmoide/complicações , Colectomia , Doença de Crohn/complicações , Doença de Crohn/tratamento farmacológico , Diverticulite/diagnóstico por imagem , Diverticulite/patologia , Diverticulite/cirurgia , Humanos , Imunossupressores/uso terapêutico , Abscesso Hepático Piogênico/diagnóstico por imagem , Abscesso Hepático Piogênico/patologia , Masculino , Pessoa de Meia-Idade , Tomografia Computadorizada com Tomografia por Emissão de Pósitrons , Doenças do Colo Sigmoide/diagnóstico por imagem , Doenças do Colo Sigmoide/patologia , Doenças do Colo Sigmoide/cirurgia
16.
BMJ Case Rep ; 12(11)2019 Nov 12.
Artigo em Inglês | MEDLINE | ID: mdl-31722869

RESUMO

A 44-year-old man with a 9-day-old left displaced midshaft clavicle fracture was initially treated conservatively. The patient experienced an increase of pain with tickling and cold sensation in the left upper extremity. CT angiography showed left subclavian artery occlusion over 3 cm at the level of the fracture. At surgical repair, a subclavian-brachial bypass was constructed and fracture fixation was done with an eight-hole locking compression plate. Follow-up at 6 months showed full range of motion of the left shoulder, an open bypass and fracture consolidation.


Assuntos
Arteriopatias Oclusivas/diagnóstico por imagem , Arteriopatias Oclusivas/etiologia , Clavícula/lesões , Fraturas Ósseas/complicações , Artéria Subclávia/diagnóstico por imagem , Adulto , Arteriopatias Oclusivas/cirurgia , Placas Ósseas , Fixação Interna de Fraturas , Fraturas Ósseas/cirurgia , Humanos , Masculino , Artéria Subclávia/cirurgia
17.
Metabolites ; 9(12)2019 Nov 22.
Artigo em Inglês | MEDLINE | ID: mdl-31766640

RESUMO

Exposure to oxygen under increased atmospheric pressures can induce pulmonary oxygen toxicity (POT). Exhaled breath analysis using gas chromatography-mass spectrometry (GC-MS) has revealed that volatile organic compounds (VOCs) are associated with inflammation and lipoperoxidation after hyperbaric-hyperoxic exposure. Electronic nose (eNose) technology would be more suited for the detection of POT, since it is less time and resource consuming. However, it is unknown whether eNose technology can detect POT and whether eNose sensor data can be associated with VOCs of interest. In this randomized cross-over trial, the exhaled breath from divers who had made two dives of 1 h to 192.5 kPa (a depth of 9 m) with either 100% oxygen or compressed air was analyzed, at several time points, using GC-MS and eNose. We used a partial least square discriminant analysis, eNose discriminated oxygen and air dives at 30 min post dive with an area under the receiver operating characteristics curve of 79.9% (95%CI: 61.1-98.6; p = 0.003). A two-way orthogonal partial least square regression (O2PLS) model analysis revealed an R² of 0.50 between targeted VOCs obtained by GC-MS and eNose sensor data. The contribution of each sensor to the detection of targeted VOCs was also assessed using O2PLS. When all GC-MS fragments were included in the O2PLS model, this resulted in an R² of 0.08. Thus, eNose could detect POT 30 min post dive, and the correlation between targeted VOCs and eNose data could be assessed using O2PLS.

18.
Wound Repair Regen ; 27(6): 687-692, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31298805

RESUMO

Hemodialysis patients are at high risk for foot ulceration. The aim of this prospective study was to describe the prevalence and risk factors for foot ulcers in hemodialysis-dependent patients. From 2012 until 2015, all hemodialysis patients (n = 66) above18 years of age, treated at the Alrijne Hospital (Leiderdorp, the Netherlands), were included. Demographics and medical history were collected and the quality of life was measured. Data were collected on common risk factors for foot ulceration: peripheral arterial disease, peripheral neuropathy with or without foot deformities, diabetes mellitus (DM), hypertension, smoking, previous foot ulcer, edema, pedicure attendance, and orthopedic footwear. Sixty-six hemodialysis patients were evaluated; the prevalence of foot ulcer was 21/66 (31.8%). Risk factors were history of foot ulceration in 27/66 (40.9%), ankle-brachial index (ABI) <0.9, and toe pressure < 80 mmHg in 38/66 (57.6%). The percentage of DM in the group of foot-ulcers was higher 13/21 (61.9%) vs. 20/45 (44.4%) in the non-ulcer group, this was not significant (p = 0.183). No differences were found in ABI, toe pressure, peripheral neuropathy and foot deformity, between the DM and non DM group. The mortality between ulcer vs. no ulcer was significant different: 13/21 (61.9%) vs. 11/45 (24.4%) (p = 0.003). Approximately, one-third of hemodialysis patient have a foot ulcer 21/66 (32%). Arterial insufficiency is associated with an increased risk of foot ulcers. In patients with a foot ulcer, survival is significantly lower than in patients without a foot ulcer; interventions to reduce foot ulceration should be implemented for all hemodialysis patients and include frequent inspection, and prompt treatment. Further research should focus on the prevention of foot ulcers in dialysis-dependent patients.

19.
Diving Hyperb Med ; 49(2): 127-136, 2019 Jun 30.
Artigo em Inglês | MEDLINE | ID: mdl-31177519

RESUMO

BACKGROUND: Physiological changes are induced by immersion, swimming and using diving equipment. Divers must be fit to dive. Using medication may impact the capacity to adapt to hyperbaric conditions. The aim of this systematic review is to assess the interaction of diving/hyperbaric conditions and medication and to provide basic heuristics to support decision making regarding fitness to dive in medicated divers. METHODS: This was a systematic review of human and animal studies of medications in the hyperbaric environment. Studies were subdivided into those describing a medication/hyperbaric environment interaction and those concerned with prevention of diving disorders. Studies without a relation to diving with compressed air, and those concerning oxygen toxicity, hyperbaric oxygen therapy or the treatment of decompression sickness were excluded. RESULTS: Forty-four studies matched the inclusion criteria. Animal studies revealed that diazepam and valproate gave limited protection against the onset of the high-pressure neurological syndrome. Lithium had a protective effect against nitrogen-narcosis and losartan reduced cardiac changes in repetitive diving. Human studies showed no beneficial or dangerous pressure-related interactions. In prevention of diving disorders, pseudoephedrine reduced otic barotrauma, vitamins C and E reduced endothelial dysfunction after bounce diving and hepatic oxidative stress in saturation diving. DISCUSSION AND CONCLUSIONS: Animal studies revealed that psycho-pharmaceuticals can limit the onset of neurologic symptoms and cardiovascular protective drugs might add a potential protective effect against decompression sickness. No evidence of significant risks due to changes in pharmacologic mechanisms were revealed and most medication is not a contraindication to diving. For improving decision making in prescribing medicine for recreational and occupational divers and to enhance safety by increasing our understanding of pharmacology in hyperbaric conditions, future research should focus on controlled human studies.


Assuntos
Doença da Descompressão , Mergulho , Oxigenação Hiperbárica , Narcose por Gás Inerte , Animais , Humanos , Natação
20.
BMJ Open Sport Exerc Med ; 5(1): e000532, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31191976

RESUMO

Objectives: To assess the outcome of conservative treatment for chronic exertional compartment syndrome (CECS) as it relates to the reduction in surgical fasciotomy and return to active duty in a military population. Methods: Historic cohort. From 2015 to 2018, 75 surgically eligible patients with pressure-positive anterior CECS (Group 1), or with positive pressures and associated medial tibial stress syndrome (Group 2), underwent a conservative treatment programme emphasising gait retraining of running and marching. Treatment success was defined as return to duty, without surgery. Fifty patients from 2015 to 2017 were surveyed to assess mid-term outcomes. Results: The average duration of conservative treatment was 144.9 (±59.6) days. Initially, 65% (49/75) were able to return to duty; 28% (21/75) were referred for surgery and 7% (5/75) left the armed forces. There was no difference in outcomes between Group 1 and Group 2. Survey response rate, on average after 742 days (SD 267, range 381-1256), was 84% (42/50); 57% (24/42) had continued duty, without surgery; of them, 43% were at the same military specialty, 57% in a physically less demanding job. Conclusion: A conservative treatment programme for anterior CECS was able to return 65 % of patients to active duty, without surgery. At 2 years, the success rate decreased slightly, but remained positive at 57%. In this high-risk group, initiating a conservative treatment protocol with an emphasis on gait retraining can significantly reduce the need for surgical fasciotomy. For those that fail conservative treatment, surgical release may still be indicated.

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