An educational course including medical simulation for early goal-directed therapy and the severe sepsis resuscitation bundle: An evaluation for medical student training

Objective

Widespread application of early goal-directed therapy (EGDT) and the severe sepsis resuscitation bundle is limited by clinician knowledge, skills and experience. This study evaluated use of simulation-based teaching during medical training to increase future clinician knowledge in the above therapies for severe sepsis and septic shock.

Methods

A prospective cohort study was performed with medical students at all levels of training. A 5-h course including didactic lectures, skill workshops, and a simulated case scenario of septic shock were administered to the participants. A checklist including 21 tasks was completed during the patient simulation. An 18-question pre-test, post-test and 2-week post-test were given. The participants completed a survey at the end of the course.

Results

Sixty-three students were enrolled. There was statistical difference between the pre-test and each of the post-test scores: 57.5 ± 13.0, 85.6 ± 8.8, and 80.9 ± 10.9%, respectively. 20.6% of participants thought the pre-test was too difficult, whereas all participants thought the post-test was either appropriate or too easy. The task performance during the simulated septic shock patient was 94.1 ± 6.0%. The participants noted improvements in their confidence levels at managing severe sepsis and septic shock, and agreed that the course should be a requirement during medical school training.

Conclusions

Medical simulation is an effective method of educating EGDT and the severe sepsis resuscitation bundle to medical students with limited experience in patient care. The results suggest that our course may be of further benefit at increasing clinical experience with this intensive protocol for the management of severe sepsis and septic shock.     

The benefits of a simplified method for CPR training of medical professionals: A randomized controlled study

Objectives

We developed and tested a training method for basic life support incorporating defibrillator feedback during simulated cardiac arrest (CA) to determine the impact on the quality and retention of CPR skills.

Methods

298 subjects were randomized into 3 groups. All groups received a 2 h training session followed by a simulated CA test scenario, immediately after training and at 3 months. Controls used a non-feedback defibrillator during training and testing. Group 1 was trained and tested with an audiovisual feedback defibrillator. During training, Group 1 reviewed quantitative CPR data from the defibrillator. Group 2 was trained as per Group 1, but was tested using the non-feedback defibrillator. The primary outcome was difference in compression depth between groups at initial testing. Secondary outcomes included differences in rate, depth at retesting, compression fraction, and self-assessment.

Results

Groups 1 and 2 had significantly deeper compressions than the controls (35.3 ± 7.6 mm, 43.7 ± 5.8 mm, 42.2 ± 6.6 mm for controls, Groups 1 and 2, P = 0.001 for Group 1 vs. controls; P = 0.001 for Group 2 vs. controls). At three months, CPR depth was maintained in all groups but remained significantly higher in Group 1 (39.1 ± 9.9 mm, 47.0 ± 7.4 mm, 42.2 ± 8.4 mm for controls, Groups 1 and 2, P = 0.001 for Group 1 vs. control). No significant differences were noted between groups in compression rate or fraction.

Conclusions

A simplified 2 h training method using audiovisual feedback combined with quantitative review of CPR performance improved CPR quality and retention of these skills.     

Plasma osteoprotegerin levels increase with the severity of cerebral artery atherosclerosis

Objectives

Osteoprotegerin (OPG) is a member of the tumor necrosis factor receptor superfamily and suggested as a marker of atherosclerosis. We investigated whether plasma OPG levels were associated with the presence and severity of cerebral atherosclerosis.

Design and methods

We used an enzyme-linked immunosorbent assay to measure the plasma OPG levels of 107 patients with acute cerebral infarction. We compared the plasma OPG levels according to the presence and number of arteries with cerebral atherosclerosis (≥ 50% stenosis).

Results

Of 107 patients, 73 (68.2%) had cerebral atherosclerosis. OPG levels were increased in patients with cerebral atherosclerosis (374.69 ± 206.48 vs 261.17 ± 166.91 pg/mL, p = 0.006). OPG levels showed positive correlation with the number of cerebral arteries with atherosclerosis (Spearman's rho = 0.342, p < 0.001). After adjustment for vascular risk factors, OPG > 229.9 pg/mL was independently associated with the presence [OR 4.61, 95% CI 1.57–13.55, p = 0.005, binary logistic regression] of cerebral atherosclerosis and number [OR 3.20, 95% CI 1.26–8.12, p = 0.014, ordinal logistic regression] of arteries with cerebral atherosclerosis.

Conclusions

Plasma OPG levels were significantly associated with the presence and severity of cerebral atherosclerosis. This finding suggests that plasma OPG might have a role in cerebral atherosclerosis.     

Obstacles delaying the prompt deployment of piston-type mechanical cardiopulmonary resuscitation devices during emergency department resuscitation: A video-recording and time-motion study

Background

The quality of cardiopulmonary resuscitation (CPR) is important to survival after cardiac arrest. Mechanical devices (MD) provide constant CPR, but their effectiveness may be affected by deployment timeliness.

Objectives

To identify the timeliness of the overall and of each essential step in the deployment of a piston-type MD during emergency department (ED) resuscitation, and to identify factors associated with delayed MD deployment by video recordings.

Methods

Between December 2005 and December 2008, video clips from resuscitations with CPR sessions using a MD in the ED were reviewed using time-motion analyses. The overall deployment timeliness and the time spent on each essential step of deployment were measured.

Results

There were 37 CPR recordings that used a MD. Deployment of MD took an average 122.6 ± 57.8 s. The 3 most time-consuming steps were: (1) setting the device (57.8 ± 38.3 s), (2) positioning the patient (33.4 ± 38.0 s), and (3) positioning the device (14.7 ± 9.5 s). Total no flow time was 89.1 ± 41.2 s (72.7% of total time) and associated with the 3 most time-consuming steps. There was no difference in the total timeliness, no-flow time, and no-flow ratio between different rescuer numbers, time of day of the resuscitation, or body size of patients.

Conclusions

Rescuers spent a significant amount of time on MD deployment, leading to long no-flow times. Lack of familiarity with the device and positioning strategy were associated with poor performance. Additional training in device deployment strategies are required to improve the benefits of mechanical CPR.     

Extracorporeal life support as rescue strategy for out-of-hospital and emergency department cardiac arrest

Background

Extracorporeal life support (ECLS) has been utilized as a rescue strategy for patients with cardiac arrest unresponsive to conventional cardiopulmonary resuscitation.

Objective

We sought to describe our institution's experience with implementation of ECLS for out-of-hospital and emergency department (ED) cardiac arrests. Our primary outcome was survival to hospital discharge.

Methods

Consecutive patients placed on ECLS in the ED or within one hour of admission after out-of-hospital or ED cardiac arrest were enrolled at two urban academic medical centers in the United States from July 2007–April 2014.

Results

During the study period, 26 patients were included. Average age was 40 ± 15 years, 54% were male, and 42% were white. Initial cardiac rhythms were ventricular fibrillation or pulseless ventricular tachycardia in 42%. The average time from initial cardiac arrest to initiation of ECLS was 77 ± 51 min (range 12–180 min). ECLS cannulation was unsuccessful in two patients. Eighteen (69%) had complications related to ECLS, most commonly bleeding and ischemic events. Four patients (15%) survived to discharge, three of whom were neurologically intact at 6 months.

Conclusion

ECLS shows promise as a rescue strategy for refractory out-of-hospital or ED cardiac arrest but is not without challenges. Further investigations are necessary to refine the technique, patient selection, and ancillary therapeutics.     

Clinical and prognostic role of circulating MMP-2 and its inhibitor TIMP-2 in HCC patients prior to and after trans-hepatic arterial chemo-embolization

Background and aims

Trans-hepatic arterial chemo-embolization is the most commonly used treatment for unresectable hepatocellular carcinoma. The prognostic impact of tumor biomarkers has not therefore been evaluated in this treatment. Imbalance between matrix metalloproteinase-2 and tissue inhibitor metalloproteinase-2 is considered to play an important role in extracellular matrix remodeling and degradation. Higher serum levels of MMP-2 have been shown to predict a poor prognosis and shorter overall survival in HCC after TACE. The objective of this study was to evaluate the serum levels of MMP-2 and TIMP-2 in HCC patients before and after TACE to evaluate their clinical significance and usefulness as prognostic biomarkers.

Methods

MMP-2 and TIMP-2 levels were measured by ELISA in 75 HCC patients and 30 healthy controls. Sera MMP-2 and TIMP-2 were correlated with clinico-pathological features.

Results

The mean serum MMP-2 and TIMP-2 levels of HCC patients before TACE were 1700 ± 71 ng/mL and 89 ± 45 ng/mL respectively, significantly higher than that of the control group: 771 ± 60 ng/mL (p < 0.0001, t-test) and 25.7 ± 20 ng/mL respectively (p < 0.0001, t-test). A significant decrease of MMP-2 levels after 1 and 3 months compared to baseline time was observed (p < 0.0001), while with TIMP-2 a gradual increase in serum before and after TACE (p < 0.01) was detected. No significant correlation between serum MMP-2 levels and other clinico-pathological features was observed. Patients with serum MMP-2 > 1500 ng/mL (median value) had worse overall and recurrence-free survival compared with those with serum MMP-2 levels < 1500 ng/mL before treatment.

Conclusion

Higher serum MMP-2 levels and MMP-2/TIMP-2 ratio could predict poor prognosis after TACE, suggesting prognostic role of these biomarkers in HCC.     

Retrocalcaneal bursitis but not Achilles tendinopathy is characterized by increased pressure in the retrocalcaneal bursa

Background

We questioned whether different forms of Achilles tendon overuse injuries can be differentiated by retrocalcaneal bursa pressure measurement.

Methods

Retrocalcaneal bursa pressure was determined by using invasive pressure measurement in patients suffering from retrocalcaneal bursitis (n = 13) or Achilles tendinopathy (n = 15), respectively. Standardized measurements were taken with the subject lying prone. Initially, the foot and ankle was in a spontaneous, unsupported position. Then passive dorsiflexion was induced by an increasing pressure which was applied in five defined steps against the plantar forefoot.

Findings

Mean pressures found in unloaded position were 30.5 (SD 28.9) mmHg in retrocalcaneal bursitis and − 9.9 (SD 17.2) mmHg in Achilles tendinopathy (p < 0.001). A stepwise increase in passive ankle dorsiflexion was associated with increasing pressure values in both groups. The differences were p = 0.009 to 0.035 when dorsiflexion was initiated with 10, 20, 30, and 40 N, respectively. Dorsiflexion induced by 50 N load resulted in a mean pressure of 113.7 (SD 124.9) mmHg for retrocalcaneal bursitis and 32.5 (SD 48.9) mmHg for Achilles tendinopathy (p = 0,051).

Interpretation

Higher retrocalcaneal bursa pressure values were found in patients suffering from chronic retrocalcaneal bursitis. This result supports the hypothesis that retrocalcaneal bursa hypertension leads to an impingement lesion of the corresponding anterior Achilles tendon.     

Bispectral Index to Predict Neurological Outcome Early After Cardiac Arrest

Aim of the study

To address the value of continuous monitoring of bispectral index (BIS) to predict neurological outcome after cardiac arrest.

Methods

In this prospective observational study in adult comatose patients treated by therapeutic hypothermia after cardiac arrest we measured bispectral index (BIS) during the first 24 hours of intensive care unit stay. A blinded neurological outcome assessment by cerebral performance category (CPC) was done 6 months after cardiac arrest.

Results

Forty-six patients (48%) had a good neurological outcome at 6-month, as defined by a cerebral performance category (CPC) 1-2, and 50 patients (52%) had a poor neurological outcome (CPC 3-5). Over the 24 h of monitoring, mean BIS values over time were higher in the good outcome group (38 ± 9) compared to the poor outcome group (17 ± 12) (p < 0.001). Analysis of BIS recorded every 30 minutes provided an optimal prediction after 12.5 h, with an area under the receiver operating characteristic curve (AUC) of 0.89, a specificity of 89% and a sensitivity of 86% using a cut-off value of 23. With a specificity fixed at 100% (sensitivity 26%) the cut-off BIS value was 2.4 over the first 271 minutes. In multivariable analyses including clinical characteristics, mean BIS value over the first 12.5 h was a predictor of neurological outcome (p = 6E-6) and provided a continuous net reclassification index of 1.28% (p = 4E-10) and an integrated discrimination improvement of 0.31 (p = 1E-10).

Conclusions

Mean BIS value calculated over the first 12.5 h after ICU admission potentially predicts 6-months neurological outcome after cardiac arrest.     

Plasma vaspin concentrations are decreased in acute coronary syndrome,but unchanged in patients without coronary lesions

Objective

Previous studies suggested that decreased serum vaspin levels were associated with coronary artery disease (CAD). The present study aimed to investigate the association between plasma vaspin levels and different states of CAD.

Design and methods

A total of 162 patients with coronary angiography (CAG) proved that CAD was enrolled. Additional 103 patients complained with “chest discomfort” with negative CAG, and 60 normal subjects were enrolled in this study. The levels of plasma vaspin, adiponectin, clinical parameters, lipid profile and C reactive protein (CRP) were measured.

Results

The levels of plasma vaspin were significantly lower in the CAD group (0.47 ± 0.63 μg/L) than those in the healthy group and CAG (−) group (all p < 0.001). In CAD group, the pos hoc analysis showed that serum vaspin concentration in acute myocardial infarction group (0.21 ± 0.19 μg/L) was significantly lower than that in the unstable angina pectoris group (0.40 ± 0.37 μg/L) (p = 0.012), and serum vaspin concentration in unstable angina pectoris was significantly lower than that in stable angina pectoris group (0.92 ± 0.94 μg/L) (p = 0.013). The plasma vaspin concentration was also negatively correlated with the severity of CAD (1-vessel: 0.86 ± 0.90 μg/L; 2-vessel: 0.36 ± 0.39 μg/L; 3-vessel: 0.21 ± 0.16 μg/L). The plasma vaspin concentration in CAG (−) group with “chest discomfort” (1.93 ± 2.57 μg/L) was similar to the healthy control group (2.18 ± 3.49 μg/L).

Conclusions

The plasma vaspin concentration correlated to the severity of CAD. Furthermore, plasma vaspin has a value of avoiding patients without CAD from unnecessary CAG.     

Serum levels of pigment epithelium-derived factor (PEDF) are independently associated with procollagen III N-terminal peptide levels in patients with nonalcoholic fatty liver disease

Objectives

Pigment epithelium-derived factor (PEDF) is a glycoprotein that belongs to the superfamily of serine protease inhibitors with complex anti-oxidative, anti-fibrotic, and anti-inflammatory properties, thus being involved in cardiometabolic disorders. Nonalcoholic fatty liver disease (NAFLD) is a hepatic manifestation of the metabolic syndrome as well. However, the pathophysiological role of PEDF in NAFLD remains largely unknown. We studied here the relationship between serum PEDF levels and various clinical markers of NAFLD in humans.

Design and methods

The study involved 194 biopsy-proven NAFLD patients (102 male and 92 female) with a mean age of 51.3 ± 13.8 years. We examined which anthropometric, metabolic and inflammatory variables, and liver steatosis and fibrosis markers are independently associated with serum levels of PEDF.

Results

Mean serum levels of PEDF were 16.4 ± 5.7 μg/mL. Univariate analysis revealed that age (inversely), male, body mass index, waist circumference, numbers of white blood cells and platelets, aspartate aminotransferase, alanine aminotransferase, fasting plasma glucose, glycated hemoglobin, uric acid, procollagen type III N-terminal peptide (P-III-P), subcutaneous fat areas, visceral fat areas and liver to spleen density ratio in computed tomography, the presence of diabetes and medication for hyperlipidemia were significantly associated with serum levels of PEDF. In multiple stepwise regression analysis, age (p < 0.01, inversely), male (p < 0.05), waist circumference (p < 0.01), white blood cell number (p < 0.05), P-III-P (p < 0.05), and the presence of diabetes (p < 0.05) and medication for hyperlipidemia (p < 0.01), were independently correlated to serum levels of PEDF (R² = 0.285).

Conclusions

The present study reveals that serum levels of PEDF are independently associated with P-III-P levels, suggesting that PEDF level is a novel biomarker of liver fibrosis in patients with NAFLD.     

Preanalytical,analytical (DiaSorin LIAISON) and clinical variables potentially affecting the 25-OH Vitamin D estimation

Background

Vitamin D (25-OHD) physiological functions have been expanded beyond traditional bone health, increasing the importance of its estimation in Laboratory Medicine, which renders validation of available methods mandatory.

Aims and methods

We evaluated some preanalytical and analytical aspects of 25-OHD determination and the effects of potentially confounding clinical variables by using the DiaSorin “LIAISON 25-OH Vitamin D TOTAL”.

Results

25-OHD samples were extremely stable, at least in the short term, without requiring special transport or storage. Precision intervals (CV%) were: within run (7–11%) and total precision (8–11.5%). Mean (SD) recovery was 96 (2)%. The assay was linear on dilution. Comparison with radioimmunoassay (RIA) yielded acceptable correlation (Inter-rater agreement/kappa coefficient = 0.94) and clinical equivalence in the interval from 6 to 55 ng/mL.The assay was evaluated on a general population (N = 476, age: 60 ± 14 years, 65 males). The status of 25‐OHD resulted inversely related to parathyroid hormone levels (r = − 0.21, p < 0.001), and aging (r = − 0.17, p < 0.001), but not to sex. Levels of 25-OHD were found to be sufficient (≥ 30 ng/mL) only in 54 samples (12%). Marked seasonal 25-OHD variations were observed in 13 subjects (p < 0.05). Moreover, a marked seasonal fluctuation was seen in samples collected during the period of February 2010–October 2011 (p ≤ 0.01).Lower 25-OHD concentration was observed in subjects with diabetes (19 ± 9 vs 14 ± 7 ng/mL, p < 0.01) and hypertension (20 ± 9 vs 17 ± 9 ng/mL, p < 0.01). Moreover, 25-OHD inversely correlated with BMI (r = − 0.25, p < 0.001). Conversely, no difference in 25-OHD levels was observed between subjects due to smoking habits and dyslipidemia.In multiple logistic regression models, aging is the only significant independent risk factor for low 25-OHD levels (Odds ratio, 95% confidence intervals: 3.1, 1.3–7.3; p ≤ 0.01).

Conclusions

Results confirm the LIAISON 25-OHD assay as a useful tool for 25-OHD estimation in the clinical practice. Lack of vitamin D is common among Italian adults, and appears associated with several cardiovascular risk factors.     

Does the addition of deep breathing exercises to physiotherapy-directed early mobilisation alter patient outcomes following high-risk open upper abdominal surgery? Cluster randomised controlled trial

Objective

To investigate whether the inclusion of deep breathing exercises in physiotherapy-directed early mobilisation confers any additional benefit in reducing postoperative pulmonary complications (PPCs) when patients are treated once daily after elective open upper abdominal surgery. This study also compared postoperative outcomes following early and delayed mobilisation.

Design

Cluster randomised controlled trial.

Setting

Single-centre study in a teaching hospital.

Participants

Eighty-six high-risk patients undergoing elective open upper abdominal surgery.

Intervention

Three groups: early mobilisation (Group A), early mobilisation plus breathing exercises (Group B), and delayed mobilisation (mobilised from third postoperative day) plus breathing exercises (Group C).

Main outcomes

PPCs and postoperative outcomes [number of days until discharge from physiotherapy, physiotherapy input and length of stay (LOS)].

Results

There was no significant difference in PPCs between Groups A and B. The LOS for Group A {mean 10.7 [standard deviation (SD) 5.0] days} was significantly shorter than the LOS for Groups B [mean 16.7 (SD 9.7) days] and C [mean 15.2 (SD 9.8) days; P = 0.036]. The greatest difference was between Groups A and B (mean difference −5.93, 95% confidence interval −10.22 to −1.65; P = 0.008). Group C had fewer smokers (26%) and patients with chronic obstructive pulmonary disease (0%) compared with Group B (53% and 14%, respectively). This may have led to fewer PPCs in Group C, but the difference was not significant. Despite Group C having fewer PPCs and less physiotherapy input, the number of days until discharge from physiotherapy and LOS were similar to Group B.

Conclusions

The addition of deep breathing exercises to physiotherapy-directed early mobilisation did not further reduce PPCs compared with mobility alone. PPCs can be reduced with once-daily physiotherapy if the patients are mobilised to a moderate level of exertion. Delayed mobilisation tended to increase physiotherapy input and the number of days until discharge from physiotherapy compared with early mobilisation.     

Serum level and prognostic value of neopterin in patients after ischemic stroke

Background

We hypothesized that serum level of neopterin is significantly predictive of prognostic outcome in patients after acute ischemic stroke (IS).

Methods

Between November 2008 and May 2010, serum levels of neopterin were prospectively collected at 48 h after acute IS in 157 patients.

Results

Serum neopterin levels were substantially higher in patients with severe neurological impairment [National institutes of Health Stroke Scale (NIHSS) score ≥ 12] than in those with NIHSS < 12 (p < 0.008). Furthermore, Spearman's test showed a strongly positive correlation between neopterin level and NIHSS (p = 0.003). Multiple logistic regression analysis demonstrated that serum neopterin level was strongly and independently predictive of NIHSS ≥ 12 (p = 0.002) at 48 h after acute IS and 90-day major adverse clinical outcome (defined as NIHSS ≥ 12, recurrent stroke or death) (p = 0.003).

Conclusion

Serum level of neopterin was notably increased after acute IS. This biomarker was strongly and independently predictive of 90-day unfavorable clinical outcome in patients after acute IS.     

Genetic polymorphisms in Cytochrome P 4501B1 and susceptibility to idiopathic preterm labor in North Indian population

Objective

The etiology of preterm labor (PTL) is still unknown, but it may be related to a possible genetic predisposition together with involvement of environmental factors. We investigated the relation between PTL and polymorphisms in Cytochrome P4501B1 (CYP1B1) gene, which is involved in the metabolism of a wide range of environmental toxins and hormones.

Design and methods

Three hundred (n = 300) cases of PTL and equal number of subjects of full term labor (FTL), after excluding all the known risk factors for PTL were included in the study. A two step allele specific PCR was performed for polymorphic analysis of CYP1B1 gene.

Results

The homozygous variant genotype of CYP1B1*2 (OR = 2.97, 95%CI = 1.08–8.08, p = 0.033) and heterozygous variant of CYP1B1*3 (OR = 2.57, 95%CI = 1.88–3.63, p = 0.001), and CYP1B1*7 (OR = 2.59, 95%CI = 1.85–3.62, p = 0.001) were found to be significantly higher in PTL cases as compared to FTL.

Conclusions

The present study demonstrates the possible association of homozygous variant of CYP1B1*2 and heterozygous variant of CYP1B1*3 and CYP1B1*7 genes with the increased risk of PTL.     

A randomised trial comparing a 4-stage to 2-stage teaching technique for laryngeal mask insertion

Objective

To compare the ‘4-stage’ teaching technique (demonstration, deconstruction, formulation, performance) with the traditional ‘2-stage’ teaching technique (deconstruction, performance) in laryngeal mask airway (LMA) insertion.

Methods

Using a prospective randomised study design, participants were taught LMA insertion on a manikin by either the ‘2-stage’ or ‘4-stage’ teaching method. Subjects were eligible if they had never inserted a LMA. Skill acquisition was assessed immediately following training, and skill retention assessed a number of weeks later. The primary outcome was LMA insertion on a manikin, with successful ventilation within 30 s. Other outcomes included overall time to LMA insertion, and number of errors. Assessors were blinded to the teaching method used for each subject.

Results

A total of 120 participants were randomised between the two teaching groups (60 subjects in each group). Mean time to LMA insertion at acquisition was 39.7 s for 2-stage and 34.7 s for 4-stage (p > 0.05), and proportion completing within 30 s was 41.67% for 2-stage and 48.33% for the 4-stage teaching group (p > 0.05). With skill retention assessment, mean time to LMA insertion was 44.3 s for 2-stage and 42.5 s for the 4-stage teaching group (p > 0.05). Proportion completing task within 30 s was 34.0% for 2-stage and 41.67% for 4-stage group (p > 0.05). Overall, there was no significant difference found in skill acquisition or in skill retention between the 2 or 4-stage teaching method.

Conclusion

The 2-stage teaching technique is not statistically different to the 4-stage teaching method in efficacy of LMA insertion skill acquisition or retention.     

Efficacité thérapeutique de l’autologous conditioned plasma (ACP™) : analyse de sa composition cellulaire et revue de la littérature

Purpose

To analyze the platelet counts of autologous conditioned plasma (ACP™) in a group of patients compared to that of whole blood and to determine the value of ACP™ based on a literature review.

Methods

In 2011, a prospective study was performed in a continuous series of patients presenting with chronic tendinopathies. Three 9 μL venous blood samples were obtained from each patient: the first to perform a full blood count and the second and third to prepare two doses of ACP™, one which was injected into the patient and the other which underwent biological testing. A bibliographic search was performed on PubMed with the key words “autologous conditioned plasma”. All studies both clinical and experimental, in English and in French, were included.

Results

The series included 14 male patients mean age 39 ± 14 years. The mean platelet count was 230,538.5 ± 23,663/μL in whole blood and 377,153.8 ± 69,169.9/μL in ACP™, P = 0.00015. The mean “ACP™ platelet count/whole blood platelet count” ratio was 1.64 ± 0.30. The number of red and white blood cells was below the detection thresholds. The systematic review identified eight studies: three in animals and five in human of which two clinical studies.

Conclusion

The preparation technique for ACP™ was rapid and easy to use. ACP™ had a platelet count that was significantly higher than that of whole blood and did not contain any red or white blood cells. The review of the literature did not clearly confirm the therapeutic efficacy of ACP™. Randomized clinical studies comparing ACP™ to placebo are needed.

Level of evidence

IV.     

Urinary ketone is associated with the heart failure severity

Objectives

To test the hypothesis that urinary metabolites characterizing heart failure (HF) are associated with the magnitude of echocardiographic measurements and ultimately the severity of HF.

Design/methods

Patients with systolic HF (n = 46) and control subjects (n = 32) participated in this study. Patients with type 2 diabetes mellitus were excluded. Echocardiographic measurements were performed, and selected urinary metabolites were quantified.

Results

Urinary levels of acetate (p < 0.05), acetone (p < 0.01), cytosine (p < 0.001), methylmalonate (p < 0.001), and phenylacetylglycine (p < 0.01) were significantly higher, while 1-methylnicotinamide (p < 0.05) were significantly lower in HF patients than in controls. There were significant differences in E/E′ (p < 0.05), urinary levels of acetate (p < 0.005), acetoacetate (p < 0.05), acetone (p < 0.05) and ketones (p < 0.01) according to the New York Heart Association (NYHA) classification in HF patients. Multiple linear regression analysis revealed that urinary ketones were found to be independent factors for both left ventricular ejection fraction and E/E′ after adjusting for confounders.

Conclusion

Our results showed that urinary levels of ketone bodies are associated with the magnitude of echocardiographic parameters.     

Plasma neutrophil gelatinase-associated lipocalin levels are markedly increased in patients with non-transfusion-dependent thalassemia: Lack of association with markers of erythropoiesis,iron metabolism and renal function

Background

Neutrophil Gelatinase-Associated Lipocalin (NGAL) (known as NGAL, Lipocalin 2, Siderocalin, Uterocalin, proteinase-3 and 24p3) is a mammalian small 25-kD peptide that belongs to the lipocalin superfamily, which consists of about 20 small lipoproteins. NGAL was initially discovered as an antibacterial factor of natural immunity and an acute-phase protein. NGAL is also an iron trafficking protein, a member of the non-transferrin-bound iron (NTBI) pool and an alternative to the transferrin-mediated iron-delivery pathway. Of note, NTBI, which is elevated in thalassemic patients, induces cellular toxicity. In this study we investigated the possible association of NGAL with parameters of erythropoiesis, iron metabolism and renal injury in patients with non-transfusion-dependent thalassemia (thalassemia intermedia or TI).

Patients and methods

Thirty-five patients with TI, 13 men and 22 women, aged 8–63 years, were included in the study, while, 20 healthy individuals served as controls. Plasma NGAL levels were determined using an immunoenzymatic technique. Erythroid marrow activity was estimated by measuring soluble transferrin receptors (sTfR) levels with a turbidimetric technique. NTBI levels were determined using electrothermal atomic absorption spectrometry. Cystatin C, β2-microglobulin and hs-CRP concentrations were measured by means of immunonephelometric techniques.

Results

The main results of the study showed: a) NGAL levels were significantly higher in patients with TI compared to controls (139.1 ± 86.1 vs 51.2 ± 11.8 μg/L, p < 0.0001), without significant effect of splenectomy or hydroxyurea on NGAL levels. Only 4 patients had NGAL levels within the control group range, b) no correlation was found between NGAL levels and either the parameters of erythropoiesis Hb, Hb F, reticulocytes and sTfR (p > 0.66, p > 0.67, p > 0.63 and p > 0.81 respectively), or with those of iron metabolism ferritin and NTBI (p > 0.90 and p > 0.95 respectively).

Conclusions

The increased NGAL levels reported for the first time in TI patients in this study are in agreement with the elevated expression of NGAL observed in TI mouse models. We postulate that the induction of NGAL in these patients may represent either a survival response, facilitating the survival of the less damaged thalassemic erythroid precursors, or a consequence of the abnormal iron regulation in TI.     

Facteurs de risque intrinsèques de tendinopathie patellaire chez le volleyeur. Étude prospective de 29 cas

Background

Patellar tendinopathy is a common and disabling injury among athletes, especially in sports with jumps such as volleyball.

Objective

The aim of this study was to determine intrinsic risk factors of patellar tendinopathy among young volleyball players.

Methods

This prospective study was conducted from August 2012 to April 2013. It included a clinical examination, ultrasound, muscle isokinetic assessment and tests of jumps at the beginning of the season, and then only a clinical examination at the end of the season. Athletes who developed patellar tendinopathy were compared to healthy subjects.

Results

Patellar tendinopathy (PT) group athletes (6) were older (17.2 ± 0.4 years vs 16.2 ± 0.9 years, P = 0.02) and had a stiffness of hamstrings higher (popliteal angle of 24 ± 12° vs 14 ± 9°, P = 0.04) than healthy athletes (16). They had an eccentric quadriceps peak torque at slow speed (30°/s) lower than healthy athletes (2.7 ± 0.2 Nm/kg vs 3.2 ± 0.5 Nm/kg, P = 0.05).

Conclusion

Age, stiffness of hamstrings and an eccentric strength deficit of quadriceps at slow speed (30°/s) would be intrinsic risk factors of PT among young volleyball players.