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Synopsis of recommendations

The Italian Society for Thrombosis and Haemostasis (SISET: Società Italiana per lo Studio dell’ Emostasi e della Trombosi) promoted the development of a series of guidelines which would adopt evidence-based medicine methodology on clinically relevant problems in the field of haemostasis and thrombosis.The objective of the present guidelines is to provide recommendations for the pre-operative and pre-procedural assessment of the bleeding risk with the aim of reducing the incidence of preventable bleeding complications and limiting laboratory tests to the those necessary.The predictive value of haemostatic tests for bleeding complications after surgery or invasive procedures has been evaluated in prospective or retrospective cohort studies only. All retrieved studies were of low methodological quality with a high potential for bias because none conducted a blinded outcome assessment. In addition, different criteria for the severity of bleeding events and different reference values of the laboratory tests were adopted. The low methodological quality limits the validity of the results of these studies. Some of the clinical queries proposed by the working group were not addressed by the studies available in the literature. The areas with evidence, although of low quality, are the following: general surgery in adults (for history, PT, APTT, platelet count and bleeding time), neurosurgery in adults (for history, PT, APTT, platelet count), adenotonsillectomy in children (for history, PT, APTT, platelet count and bleeding time), invasive procedures in adults (for PT, APTT, platelet count), dental extractions (for the bleeding time only), cataract extraction (for platelet count). No studies are available in children for major surgery other than adenotonsillectomy, neurosurgery and invasive procedures.
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1-All recommendations by the multidisciplinary working group (MWG) are of grade D, as they are derived from expert consensus obtained with the RAND corporation method. The following criteria were considered for each consensus: prudential attitude for the necessity of a baseline value in case of subsequent unexpected abnormal bleeding, possibility to detect bleeding disorders especially in children.
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2-The MWG recommended that a detailed personal and family history for bleeding, preferably with locally designed structured questionnaires, and physical examination should be considered good practice procedures before any surgical or invasive intervention.
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3-The MWG consistently recommended that PT, APTT and platelet count should be performed routinely before surgery or invasive procedures (except for diagnostic endoscopies) both in adults and children even in case of a negative history of bleeding. This recommendation differs from those of previously published guidelines which did not recommend pre-operative haemostatic tests in subjects with a negative history of bleeding, although with a grade C. The MWG of this guideline ascribed a relatively higher value to preventing bleeding events and a relatively limited value to cost.
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4-The MWG consistently recommended that the bleeding time, plasma fibrinogen, PFA -100, thromboelastography and platelet aggregation tests should not be performed routinely before surgery or invasive procedures either in adults or children with a negative history of bleeding.
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Objective

To identify complications of mastocytosis that impact the nervous system across a large cohort.

Patients and methods

In this retrospective series, we reviewed the electronic medical records of adult patients with a diagnosis of mastocytosis who were referred to a Neurologist at Mayo Clinic in Rochester, MN from January 1, 1999 to December 31, 2008.

Results

Thirty patients were identified who presented to a Neurologist with symptoms potentially related to the mast cell disease. Twelve of these patients presented with complex spells involving syncope, which frequently preceded a formal diagnosis of mastocytosis. Nine individuals presented with acute back pain which was ultimately deemed symptomatic of vertebral compression fractures. One individual experienced spinal cord compression from a vertebral mast cell infiltrate. Headaches were reported in 78/223 (35%) total patients with mastocytosis. Although details of headaches were insufficiently ascertained to diagnose most, the five individuals in our referral cohort met International Headache Society (IHS) criteria for migraine. Finally, three individuals (1.3%) were identified with multiple sclerosis occurring at variable times after the mast cell diagnosis.

Conclusion

Symptoms related to mastocytosis may be encountered by neurologists and mimic many common, often idiopathic syndromes including, syncopal spells, back pain, and headache. In our cohort, multiple sclerosis may be over-represented. Mastocytosis should be considered in patients with these presentations, especially when also accompanied by flushing, abdominal cramping or diarrhea.  相似文献   

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Objective

Posttraumatic stress disorder (PTSD) is associated with abnormal information processing. The P300 component of event-related potentials (ERPs) is known to be a useful marker of information processing. The purposes of this study were to determine the P300 current source density in PTSD patients, and its relationship with symptom severity.

Methods

ERPs were recorded in 30 PTSD patients and 33 healthy controls while participants were performing the auditory oddball task. We compared P300 current source density data - obtained by standardized low-resolution brain electromagnetic tomography (sLORETA) - between the two groups. The correlation between P300 current source density and clinical symptoms (as evaluated using the Korean version of the Structured Interview for PTSD — K-SIPS and Davidson Trauma Scale — K-DTS) was conducted.

Results

In PTSD patients, the current source density of P300 is significantly reduced in the inferior frontal gyrus, precentral gyrus, insula, and anterior cingulate compared to healthy controls. Total K-DTS scores were correlated with the P300 current source density in the posterior cingulate gyrus. The K-SIP B items (re-experiencing) and K-SIB D items (increased arousal) were positively correlated with P300 current source densities in several brain regions located in the frontal, parietal, and temporal lobe (p < 0.05). Conversely, the K-SIP C items (avoidance and numbing) were negatively correlated with P300 current source densities in the superior and middle frontal gyri in the frontal lobes (p < 0.05).

Conclusion

The P300 current source densities reflected the pathophysiology of PTSD patients. PTSD symptoms were related to different neural activities, depending on their symptom characteristics.  相似文献   

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Context

In 2004, the American Psychiatric Association's Committee on Research on Psychiatric Treatments appointed a subcommittee to investigate the status of empirical evidence with regard to psychodynamic psychotherapy.

Objective

As a part of this effort, the committee developed a rating scale designed to assess the quality of randomized controlled trials (RCTs) of psychotherapy.

Data Sources

A 25-item RCT of Psychotherapy Quality Rating Scale was generated by expert consensus. Interrater reliability, internal consistency, and validity testing were undertaken using 7 trained raters.

Study Selection

A PubMed search was conducted to locate all RCTs of psychotherapies identified by their authors as being “psychodynamic” or “psychoanalytic” in origin and implementation.

Data Extraction

A total of 69 RCTs were independently rated by 2 raters.

Data Synthesis

The scale was found to have good interrater reliability (total score intraclass correlation = 0.76), internal consistency (Cronbach α = .87), and external validity.

Conclusions

This scale establishes a new standard for the design and execution of psychotherapy RCTs and provides a systematic empirical method for evaluating the quality of published RCTs.  相似文献   

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The mode of morphine uptake into brain slices   总被引:1,自引:0,他引:1  
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Objectives

White matter abnormalities are one of the most consistently reported findings in neuroimaging studies of bipolar disorder (BD). We conducted an anatomical likelihood estimation meta-analysis of BD whole-brain diffusion tensor imaging (DTI) studies, with the aim of identifying statistically consistent fractional anisotropy (FA) changes reflecting microstructural modifications to white matter in BD.

Methods

We performed online searches of the PUBMED and EMBASE databases in January 2011. Studies were considered for inclusion if they used diffusion tensor MRI, compared a group of subjects with BD with healthy controls and involved whole-brain white matter analysis of FA. The analyses were conducted in Talairach space, using the activation likelihood estimation technique. We carried out a meta-analysis restricted to studies reporting a lower FA in patients with BD than in healthy controls.

Results

Ten studies were included. We identified two significant clusters of decreased FA on the right side of the brain. The first was located in the right white matter, close to the parahippocampal gyrus. Four of the ten studies included contributed to this cluster. The second cluster was located close to the right anterior and subgenual cingulate cortex. These two clusters of decreased FA in BD are crossed by several white matter tracts.

Conclusions

These two clusters of altered FA may underlie the abnormal emotional processing and altered functional limbic connectivity in BD. Explorations based on DTI-based tractography are required to identify the tracts involved in the pathophysiology of BD.  相似文献   

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