Impact of Preemptive Fibrinogen Concentrate on Transfusion Requirements in Liver Transplantation: A Multicenter, Randomized, Double-Blind, Placebo-Controlled Trial.

We hypothesized that preemptive fibrinogen administration to obtain an initial plasma level of 2.9 g/L would reduce transfusion requirements in liver transplantation. A randomized, multicenter, hemoglobin-stratified, double-blind, fibrinogen-versus-saline-controlled trial was conducted. The primary end point was the percentage of patients requiring red blood cells. We evaluated 51 patients allocated to fibrinogen and 48 allocated to saline; the primary end point was assessed using data for 92 patients because the electronic record forms were offline for three patients in the fibrinogen group and four in the saline group. We injected a median of 3.54 g fibrinogen preemptively in the fibrinogen group. Nine patients in the saline group (20.9%) required fibrinogen at graft reperfusion (compared with one patient [2.1%] in the fibrinogen group; p = 0.005). Blood was transfused to 52.9% (95% confidence interval [CI] 42.5-63.3%) in the fibrinogen group and 42.74% (95% CI 28.3-57.2%) in the saline group (p = 0.217). Relative risk for blood transfusion was 0.80 (95% CI 0.57-1.13). Thrombotic events occurred in one patient (2.1%) and five patients (11.4%) in the fibrinogen and saline groups, respectively. Seven patients (14.6%) in the fibrinogen group and nine (20.3%) in the saline group required reoperation. Preemptive administration of fibrinogen concentrate did not influence transfusion requirements.

Relationships between abstract features and methodological quality explained variations of social media activity derived from systematic reviews about psoriasis interventions.

OBJECTIVES: The aim of this study was to describe the relationship among abstract structure, readability, and completeness, and how these features may influence social media activity and bibliometric results, considering systematic reviews (SRs) about interventions in psoriasis classified by methodological quality. STUDY DESIGN AND SETTING: Systematic literature searches about psoriasis interventions were undertaken on relevant databases. For each review, methodological quality was evaluated using the assessing the methodological quality of systematic reviews tool. Abstract extension, structure, readability, and quality and completeness of reporting were analyzed. Social media activity, which consider Twitter and Facebook mention counts, as well as Mendeley readers and Google scholar citations were obtained for each article. Analyses were conducted to describe any potential influence of abstract characteristics on review's social media diffusion. RESULTS: We classified 139 intervention SRs as displaying high/moderate/low methodological quality. We observed that abstract readability of SRs has been maintained high for last 20 years, although there are some differences based on their methodological quality. Free format abstracts were most sensitive to the increase of text readability as compared with more structured abstracts (Introduction, Methods, Results, and Discussion or eight headings), yielding opposite effects on their quality and completeness depending on the methodological quality: a worsening in low quality reviews and an improvement in those of high quality. Both readability indices and preferred reporting items of systematic reviews and meta-analyses for Abstract total scores showed an inverse relationship with social media activity and bibliometric results in high methodological quality reviews but not in those of lower quality. CONCLUSION: Our results suggest that increasing abstract readability must be specially considered when writing free format summaries of high-quality reviews because this fact correlates with an improvement of their completeness and quality, and this may help to achieve broader social media visibility and article usage.

Wrinkling of a bilayer membrane.

The buckling of elastic bodies is a common phenomenon in the mechanics of solids. Wrinkling of membranes can often be interpreted as buckling under constraints that prohibit large-amplitude deformation. We present a combination of analytic calculations, experiments, and simulations to understand wrinkling patterns generated in a bilayer membrane. The model membrane is composed of a flexible spherical shell that is under tension and that is circumscribed by a stiff, essentially incompressible strip with bending modulus B . When the tension is reduced sufficiently to a value sigma , the strip forms wrinkles with a uniform wavelength found theoretically and experimentally to be lambda=2pi(B/sigma)(1/3). Defects in this pattern appear for rapid changes in tension. Comparison between experiment and simulation further shows that, with larger reduction of tension, a second generation of wrinkles with longer wavelength appears only when B is sufficiently small.

[Neuraxial analgesia during labor in a patient with Arnold-Chiari type I malformation and syringomyelia]. / Malformación de arnold-chiari tipo I con siringomielia, trabajo de parto y analgesia neuroaxial.

Chiari type I malformation is a caudal displacement of the cerebellum with tonsillar herniation through the foramen magnum, frequently associated with syringomyelia, a syndrome characterized by cyst-like cavities in the spinal cord; each of the conditions leads to characteristic neurologic abnormalities. Pregnant patients with these types of malformation are considered to have an increased risk of brainstem compression and/or progression of the disease during labor. We present the case of a patient in labor with a diagnosis of syringomyelia associated with Chiari type I malformation and describe the anesthetic management. The patient revealed during labor that she had syringomyelia associated with Chiari type I malformation, after having made no mention of it in previous history taking. Finally, we review the pathology observed in these patients.

[Neuromyelitis optica spectrum disorders: profile of a cohort according to the 2015 diagnostic criteria]. / Espectro de neuromielitis optica: descripcion de una cohorte segun los criterios diagnosticos de 2015.

INTRODUCTION: The new 2015 criteria for neuromyelitis optica spectrum disorders (NMOSD) have been recently incorporated in the study of different international cohorts. AIM: To describe clinical-radiological characteristics and prognostic factors in patients with NMOSD according to the 2015 criteria. PATIENTS AND METHODS: Retrospective analysis of 36 patients diagnosed with NMOSD according to serologic AQP4 status (positive, negative, unknown and negative + unknown). Clinical and radiological characteristics were compared and possible disability prognostic factors were evaluated. RESULTS: AQP4 were positive in 7 patients, negative in 12 and unknown in 17. Age of presentation was 36.6 ± 16 years, with higher female proportion (4:1). Mean disease duration was 7.4 ± 7.6 years. Most frequent presenting symptoms were acute myelitis (61%), optic neuritis (33%) and area postrema syndrome (11%). Most frequent MRI lesion was longitudinally extensive transverse myelitis (75%). All patients received acute treatment during attacks, and preventive treatment was used in 81% (azathioprine and rituximab mostly prescribed). Median EDSS was 2.0 at the end of follow-up. No differences were observed in any of the variables comparing serologic status. Age of first attack was prognostic, with direct correlation with EDSS. First attack in < 30 years was protective, meanwhile > 50 years old patients had increased risk of disability. CONCLUSIONS: The 2015 criteria allow the description and classification of NMOSD patients within different cohorts. Age of first attack seems to be a prognostic factor for developing disability.

TITLE: Espectro de neuromielitis optica: descripcion de una cohorte segun los criterios diagnosticos de 2015.Introduccion. Los nuevos criterios diagnosticos de 2015 del espectro de neuromielitis optica (NMO) estan comenzando a utilizarse en diferentes poblaciones en el mundo. Objetivo. Describir las caracteristicas clinicorradiologicas y pronosticas de pacientes diagnosticados de NMO con los criterios de 2015. Pacientes y metodos. Analizamos retrospectivamente 36 pacientes diagnosticados de NMO con los actuales criterios. Se generaron cuatro grupos segun la serologia de antiacuaporina 4 (positivos, negativos, desconocidos y negativos mas desconocidos agrupados). Se compararon sus caracteristicas clinicorradiologicas y se evaluaron posibles variables pronosticas de discapacidad. Resultados. Encontramos siete pacientes seropositivos, 12 negativos y 17 desconocidos. La edad de inicio fue de 36 ± 16 años, con mayor proporcion de mujeres (4 a 1). La duracion de la enfermedad fue de 7,4 ± 7,6 años. Los sintomas iniciales mas frecuentes fueron mielitis (61%), neuritis optica (33%) y sindrome del area postrema (11%). La lesion mas frecuente en la resonancia magnetica fue la mielitis longitudinalmente extensa (75%). Todos los pacientes recibieron tratamiento agudo, y el preventivo se utilizo en el 81%; la azatioprina y el rituximab fueron los que mas se usaron. La mediana de la Expanded Disability Status Scale (EDSS) fue de 2 al final del seguimiento. No hubo diferencias significativas en las variables clinicorradiologicas entre los distintos grupos de pacientes. La edad de inicio fue pronostica y presenta correlacion directa con la EDSS. El inicio antes de los 30 años fue protector y, despues de los 50 años, un factor de riesgo para mayor discapacidad. Conclusiones. Los actuales criterios permiten describir diferentes cohortes. La edad de inicio parece ser un factor pronostico para desarrollar discapacidad.

Survey of hemostasis management and transfusion in liver transplantation.

OBJECTIVE: To determine the management of haemostasis and transfusion practice in the field of liver transplantation in Spain. METHODS: A questionnaire was developed for physicians in anaesthesiology of all centres performing liver transplantation in Spain. The information required made reference to the 12 months prior to its distribution, from January 1 to December 31, 2011. RESULTS: Data were collected from 24 centres in which liver transplantation is performed in Spain. Only 46% reported that they had protocols or practice guidelines for the management of haemostasis, and 83% of hospitals responded that they knew the percentage of transfused patients, but only 57% knew the mean transfusion. Regarding the degree of satisfaction with the management of haemostasis/coagulation, 50% said they were not satisfied. Thromboelastometry was used as an additional method of preoperative monitoring in only 8% of the centres and intra-operatively in one-third. Less than half (46%) of the centres performed preoperative correction of coagulation deficits based on conventional tests. The mean number of packed red cells used was ≤4 in 57% of centres. Consumption of fresh frozen plasma was highly variable, while 100% of centres consumed less than 4 pools of platelets per patient. CONCLUSIONS: There is a wide variability in the management of haemostasis and transfusion practice among Spanish centres. There are no guidelines or they are not widely used. The mean use of transfused blood products remain high. There was a decrease in centres using new methods of monitoring.

A single-puncture arthrocentesis technique, using a peripheral intravenous catheter.

Arthrocentesis is a technique used for lavage of the inflammatory content of the supradiscal space and lysis of the fibrous strands attaching the articular disc to the superior compartment of the temporomandibular joint (TMJ). The most widely accepted and classical manner in which this technique is performed is through two-needle access to the superior joint space. Nevertheless, it has been reported in the literature that this technique is challenging and has several limitations. Thus, the use of a single-puncture approach has been proposed, which represents a less traumatic and easier to perform technique. The single-puncture approach may have several advantages over the classical two-needle approach in regard to completion time, tolerability, stabilization of the needle, and retention of the intra-articular medication. A single-puncture technique is described herein, which uses an intravenous catheter to provide simultaneous inflow/outflow for low or high volume irrigation of the TMJ. The feasibility and low cost of this technique are primary advantages; peripheral intravenous catheters are one of the most widely used devices for vascular access in the primary and hospital healthcare settings.

Migraine, but not subarachnoid hemorrhage, is associated with differentially increased NPY-like immunoreactivity in the CSF.

To test whether migraine and subarachnoid hemorrhage (SAH) are associated with increased sympathetic tone, we compared the neuropeptide Y-like (NPY-LI) and chromogranin A-like immunoreactivities (LI) of cerebrospinal fluid (CSF) from migraneurs and SAH patients with those from control subjects. Increased sympathetic tone was expected to produce higher co-release of these co-stored peptides and concordant changes in their CSF levels. In addition, we investigated a possible disturbed nitric oxide homeostasis by measuring CSF nitrites (NO). More than 70% of CSF NPY-LI corresponded to the chromatographic peak (HPLC) for the intact molecule in all three groups. Migraneurs had 64% higher CSF NPY-LI, but no significant difference in CSF chromogranin A-LI, as compared to controls. In contrast, SAH patients had 74% less CSF chromogranin A-LI and a trend to lower NPY-LI, as compared to controls. No differences in CSF NO were detected among groups. These results argue against an increased sympathetic tone in patients with either migraine or SAH, and suggest that the higher CSF NPY-LI of migraneurs probably originates from central neurons. Furthermore, our findings in SAH patients argue in favor of a decreased sympathetic tone; this could be a homeostatic response to counterbalance vasoconstriction mediated by other mechanisms.

[Preliminary experience with dexmedetomidine treatment of confusional state and hyperadrenergic states at an intensive care unit]. / Experiencia preliminar del tratamiento con dexmedetomidina del estado confusional e hiperadrenergia en la unidad de cuidados intensivos.

Delirium (confusion) is an acute, reversible and fluctuating compromise of awareness and cognitive function, a state that can increase morbidity and mortality. We describe four patients with delirium associated with agitation and hyperadrenergic states refractory to haloperidol but responsive to dexmedetomidine.

Is "intra-operating room" thromboelastometry useful in liver transplantation? A case-control study in 303 patients.

Coagulation monitoring during liver transplantation (LT) is, even today, fundamental to reduce blood loss during surgery. Thromboelastometry (TEM) is a proven technique for controlling the various parameters that influence coagulation. However, there are no studies linking "intra-operating room" TEM (orTEM) with LT outcomes. We describe a case-control study in 303 liver graft recipients analyzing variables associated with operative complications and long-term LT outcomes. The results showed that orTEM reduced the use of blood products in patients with Model for End-Stage Liver Disease scores of ≥ 21, retransplantation, and high surgical difficulty and important intraoperative bleeding. In addition, results in survival and postoperative complications were better when orTEM was used. In conclusion, we confirm that use of orTEM is associated with less use of blood products and a lower rate of complications after LT.

Factor XII C46T gene polymorphism and the risk of cerebral venous thrombosis.

BACKGROUND: The TT genotype of a functional factor XII (FXII) C46T gene polymorphism was shown to be a risk factor for peripheral venous thrombosis. We tested whether this genetic variant also increases the risk for cerebral venous thrombosis (CVT). METHODS: We performed a case-control study including 78 consecutive patients with proven CVT and 201 healthy population controls from South Germany. The FXII C46T genotype was assessed using a PCR technique. RESULTS: The TT genotype of the FXII C46T polymorphism was more common in patients (16.7%) than in controls (5.5%). A strong association of the TT genotype with CVT was found, which was independent of covariables (adjusted odds ratio 4.57; 95% CI 1.55 to 13.41; p = 0.006). CONCLUSION: The TT genotype of the functional factor XII C46T gene polymorphism may be a new independent risk factor for cerebral venous thrombosis (CVT). Our finding warrants confirmation in an independent study before this genetic variant should be added to the panel of established risk factors for CVT.

Reversible nitrous oxide myelopathy and a polymorphism in the gene encoding 5,10-methylenetetrahydrofolate reductase.

We present a case of a patient who received nitrous oxide on two occasions within a period of 8 weeks and who subsequently developed a diffuse myelopathy, characterized by upper extremity paresis, lower extremity paraplegia and neurogenic bladder. Laboratory testing revealed hyperhomocysteinaemia and low levels of vitamin B(12). Because of this uncommon clinical presentation, we analysed the patient's DNA, and found a polymorphism in the MTHFR gene that is associated with the thermolabile isoform of the 5,10-methylenetetrahydrofolate reductase enzyme, which explained the myelopathy experienced by the patient after being exposed to nitrous oxide. Soon after initiating supplementary therapy with folic acid and vitamin B(12), the neurological symptoms subsided.

Encuesta sobre el manejo perioperatorio de la hemostasia y transfusión en el trasplante hepático / Survey of hemostasis management and transfusion in liver transplantation

Objetivo. Conocer el manejo de la hemostasia y la práctica transfusional entre los anestesiólogos españoles en el ámbito del trasplante hepático. Método. Se elaboró un cuestionario dirigido a los facultativos especialistas en anestesiología y reanimación de todos los centros que realizan trasplante hepático en España. Los datos requeridos hacían referencia a los 12 meses previos a su distribución, desde el 1 de enero al 31 de diciembre de 2011. Resultados. Se recogieron datos de los 24 centros. Solo el 46% respondieron disponer de protocolos o guías de actuación para el manejo de la hemostasia. El 83% de los centros respondieron conocer el porcentaje de pacientes transfundidos, pero solo el 57% conocía la media de hemoderivados. La mitad respondió estar nada satisfecho con el manejo realizado. La tromboelastometría fue utilizada como método adicional de monitorización en el preoperatorio solo en el 8% de los centros y en un tercio durante el intraoperatorio. El 46% de los centros realizó corrección preoperatoria de los déficits de coagulación basados en test convencionales. En cuanto al consumo de hemoderivados, en el 57% de los centros la media de transfusión de concentrados de hematíes fue ≤ 4. El consumo de plasma fresco congelado fue muy variable, mientras que en el 100% de los centros se consumieron menos de 4 pools de plaquetas por paciente. Conclusiones. Existe una amplia variabilidad en el manejo de la hemostasia y en la práctica transfusional entre los centros españoles. No existen guías de manejo perioperatorio o no son utilizadas ampliamente. Las medias de hemoderivados transfundidos siguen siendo elevadas. Se aprecia un descenso en los centros que utilizan los nuevos métodos de monitorización (AU)

Objective. To determine the management of haemostasis and transfusion practice in the field of liver transplantation in Spain. Methods. A questionnaire was developed for physicians in anaesthesiology of all centres performing liver transplantation in Spain. The information required made reference to the 12 months prior to its distribution, from January 1 to December 31, 2011. Results. Data were collected from 24 centres in which liver transplantation is performed in Spain. Only 46% reported that they had protocols or practice guidelines for the management of haemostasis, and 83% of hospitals responded that they knew the percentage of transfused patients, but only 57% knew the mean transfusion. Regarding the degree of satisfaction with the management of haemostasis/coagulation, 50% said they were not satisfied. Thromboelastometry was used as an additional method of preoperative monitoring in only 8% of the centres and intra-operatively in one-third. Less than half (46%) of the centres performed preoperative correction of coagulation deficits based on conventional tests. The mean number of packed red cells used was ≤ 4 in 57% of centres. Consumption of fresh frozen plasma was highly variable, while 100% of centres consumed less than 4 pools of platelets per patient. Conclusions. There is a wide variability in the management of haemostasis and transfusion practice among Spanish centres. There are no guidelines or they are not widely used. The mean use of transfused blood products remain high. There was a decrease in centres using new methods of monitoring (AU)

Anaesthesiological airway management in Denmark: assessment, equipment and documentation.

BACKGROUND: Failed intubation remains one cause of anaesthesia-related morbidity and mortality. In a recent survey in Denmark, 20% of respondents reported preventable mishaps in airway management. METHODS: Assessment of the airway, and its documentation, as well as the availability of various equipment to manage a difficult airway, and the existence of a failed intubation plan were surveyed by mailing a questionnaire to the clinical directors of all 69 anaesthesia departments in Denmark. RESULTS: Fifty-six departments (81%) returned the questionnaire. Pre-operative airway evaluation is performed in 90% of the departments. The tests included the mouth-opening test (77%), Mallampati score (48%), lower jaw protrusion (34%), neck mobility (63%), the measurement of the thyromental (11%) and sternomental distance (4%). The result of the tests are documented by 38% of the departments in the anaesthetic chart (96%), in the record (54%), on a card given to the patient (23%), in a letter sent to the patient's general practitioner (2%) or in a database (13%). The patients are personally informed in 82% of the departments. Only 54% of the departments have a failed intubation plan readily available. CONCLUSION: The preoperative assessment of the airways and its documentation is still unsatisfactory, as is communicating with the patient after a case of a difficult/impossible intubation. The adoption of internationally recognized recommendations might improve airway management and teaching to the best standard possible in the already well-equipped Danish anaesthetic departments.

Rapid screening tests for determining in vitro susceptibility of herpes simplex virus clinical isolates.

The susceptibility of human herpes simplex virus (HSV) to acyclovir (ACV) was determined with the use of a single dose of the drug (1 and 2 micrograms of ACV per ml for HSV-1 and HSV-2, respectively) in two rapid assays: a rapid cytopathic effect inhibitory assay (Rapid CIA) and a rapid dye uptake assay (Rapid DUA). These tests allow the simultaneous determination of virus titer and susceptibility to ACV at a determined viral concentration (100 50% tissue culture infective doses and 100 50% dye uptake units). These tests were compared with a conventional susceptibility assay (dye uptake assay) and showed similar results. Indeterminate results with the Rapid CIA appeared in 3 of 30 samples. With the use of both Rapid CIA and Rapid DUA, we were able to determine the susceptibility of 100% of the isolates. The rapid tests, unlike conventional assays, are able to provide susceptibility results within 3 days after the virus has been isolated from a clinical specimen and could thus play a direct role in therapeutic decisions.

[Diabetic neuropathy: thermal sensation and metabolic control in non-insulin-dependent diabetics]. / Neuropatía diabética: sensibilidad térmica y control metabólico en diabéticos no insulinodependientes.

BACKGROUND: The early detection of peripheral neuropathy in diabetics is important since it is the main risk factor for lower limb trophic lesions in diabetics. AIM: To assess the relationship between feet thermal sensation threshold and metabolic control in ambulatory non-insulin-dependent diabetics. PATIENTS AND METHODS: A random sample of 34 non-insulin-dependent diabetics followed for more than five years in a special clinic, out of 368 patients, was selected. Warmth sensation thresholds were measured in the dorsum of both feet using a MSTP-III thermostimulator. The average value of all glycosylated hemoglobins obtained during the 9.7 +/- 5.3 years of follow up for each patient was calculated. A multiple stepwise regression analysis was performed between thermal sensation as the dependent variable and glycosylated hemoglobin, fasting blood glucose, age and diabetes duration. RESULTS: The regression model disclosed glycosylated hemoglobin as the only independent predictor of warmth sensation threshold (partial r = 0.385; p = 0.043). Fifteen diabetic patients with good metabolic control, defined as those with a mean glycosylated hemoglobin of less than 9.5%, had a warmth sensation threshold of 35.6 +/- 3.7 degrees C, whereas 19 diabetics with a had control (glycosylated hemoglobin > or = 9.5%) had a threshold of 39 +/- 3.8 degrees C (p = 0.017). CONCLUSIONS: In this group of diabetics, there is a relationship between the severity of distal polyneuropathy and the metabolic control, assessed with glycosylated hemoglobin levels.

[Cardiovascular risk factors in Chilean university students]. / Factores de riesgo cardiovascular en estudiantes universitarios chilenos.

OBJECTIVE: To study the prevalence of cardiovascular risk factors in asymptomatic university students of both sexes, aged 18 to 25 years. MATERIAL AND METHODS: Serum lipid levels were measured in a subsample of 293 subjects, using a Hitachi 717 chemical analyzer. Obesity was classified using body mass index (BMI) measurements. A self-applied questionnaire was used to collect data on sedentary life style, family history of cardiovascular disease and cigarette smoking. Statistical associations of lipid levels with lipidic and non-lipidic risk factors were assessed using Pearson's chi-square test and multiple regression. RESULTS: We found lipid risk levels in 29.2% for total cholesterol (CT), 16.2% for low-density lipoproteins (C-LDL) and 5% for high-density lipoproteins (C-HDL). The main non-lipidic factors were smoking (46.1%) and sedentarism (60.8%). Obesity, hypertension and parental history of myocardial infarction were present in 1.9%, 4.6% and 11%, respectively. We observed an association of a lipid risk profile with obesity, cigarette smoking and family history. CONCLUSIONS: The results show that sedentarism and smoking are associated with a lipid risk profile. These results call for the need to develop appropriate behavior strategies for the successful prevention of cardiovascular disease.