Evaluation of Enoxaparin Given before and after Operation to Prevent Venous Thromboembolism during Digestive Surgery: Play-the-Winner Designed Study

A total of 316 patients were included in a play-the-winner (PTW) designed study comparing the safety of enoxaprain started preoperatively versus postoperatively as prophylaxis against venous thromboembolism for digestive surgery. In a PTW-designed study the treatment of any next patient depends on the outcome of the previous patient. If successful, the next patient receives the same treatment, if not, the comparative regimen is given. Excessive bleeding according to specified criteria, severe adverse reactions, clinically detected deep venous thrombosis (DVT), or pulmonary embolism (PE) were criteria for classification as “loser.” The PTW design allocates most patients to the superior treatment. The main variable in PTW studies is the number of consecutive patients receiving the same treatment. In this study 163 patients were allocated to postoperatively started and 153 to preoperatively started prophylaxis with enoxaparin. The frequency of “winners” was found to be 82.8% and 78.4% in the post- and preoperatively treated groups, respectively. No significant differences were found between the groups with regard to frequency of “winners” or the number of consecutive patients before change of treatment. The percentile of survival distribution did not detect superiority of any group. Prophylaxis against postoperative venous thromboembolism for digestive surgery using enoxaparin can safely be started preoperatively.     

Analysis of hemostasis alterations in sepsis.

This laboratory study tested new methods to analyze hemostasis alterations in septic patients. Samples of ethylenediamine tetraacetic acid (EDTA) plasma and citrated plasma were collected from 62 patients with clinical diagnosis of sepsis. Additionally, a subset of EDTA-plasma samples from each patient was stabilized 1 + 1 with 2.5 mol/l arginine, pH 8.6, to conserve the real hemostasis activation state. EDTA-arginine plasma, EDTA plasma and citrated plasma samples were tested in duplicate. The patients at admission to the intensive care unit had 36 +/- 26 (normal, 0.8 +/- 0.2) ng/ml global endotoxin reactivity, 188 +/- 66% (normal, 100 +/- 20%) fibrinogen function, 179 +/- 66% (normal, 100 +/- 20%) fibrinogen antigen, 4.0 +/- 3.6 (normal, 0.049 +/- 0.025) microg/ml D-dimer, 313 +/- 307% (normal, 100 +/- 30%) plasmin-antiplasmin complex, 8.7 +/- 11.4 (normal, 1.1 +/- 0.7) U/ml plasminogen activator inhibitor-1, 12.1 +/- 10.5 (normal, 1.3 +/- 0.4) ng/ml thrombin-antithrombin III complex, 173 +/- 62% (normal, 100 +/- 20%) thrombin, 568 +/- 225 (normal, 140 +/- 42) pg/ml tissue factor, and 2.56 +/- 2.48 (normal, 0.19 +/- 0.04) microg/ml soluble intercellular adhesion molecule-1. Endotoxin (lipopolysaccharide and/or beta-glucan) reactivity (EDTA plasma), fibrinogen function + antigen + ratio and plasminogen activator inhibitor-1 (citrated plasma), and D-dimer, soluble intercellular adhesion molecule-1, thrombin activity (EDTA-arginine-stabilized plasma) presented large aberrations in septic patients when compared with normal values and may therefore be particularly interesting as markers of hemostasis alteration. Whether the observed alterations are of clinical significance has to be determined in well defined patient groups.     

Methylprednisolone treatment in acute spinal cord injury: the myth challenged through a structured analysis of published literature.

BACKGROUND CONTEXT: Methylprednisolone has evolved during the 1990s, through the results obtained from the National Acute Spinal Cord Injury Studies NASCIS II and III, as a standard treatment in acute spinal injury. PURPOSE: To evaluate the scientific basic for the use of methylprednisolone in acute spinal cord injury. STUDY DESIGN: Systematic review of the accumulated literature. METHODS: Critical evaluation of the data obtained in the NASCIS II and III studies plus other accumulated literature. RESULTS: Analyses have been made on subgroups of the study populations, and the results were based on statistical artefacts. Furthermore, improved functional recovery shown by these studies was not clinically significant. CONCLUSION: There is insufficient evidence to support the use of methylprednisolone as a standard treatment in acute spinal cord injury.     

Memory loss in persons with HIV/AIDS: assessment and strategies for coping

Although the incidence of HIV-related dementia has decreased significantly in the era of contemporary HAART, the prevalence of memory and cognitive symptoms remains steady in persons with HIV/AIDS. Recognition of which memory symptoms may be specifically related to HIV infection is becoming more and more challenging because of the increased survival and aging of those living with HIV disease. Therefore, numerous age-related causes of memory impairment may need to be ruled out. Depression can often result in subjective memory symptoms but rarely causes objective cognitive impairment. Because of the widespread use of thiamine food supplementation, alcohol is now a less common cause of severe memory impairment. HAART remains the treatment of choice for HIV-related dementia.     

Value appropriation in hepatitis C

The European Journal of Health Economics - In 2015, the Swedish government in an unprecedented move decided to allocate 150 million € to provide funding for new drugs for hepatitis C. This...     

The induction of nitric oxide-mediated relaxation of human isolated pulmonary arteries by PACAP

1. The effects of pituitary adenylate cyclase-activating peptide (PACAP) and vasoactive intestinal peptide (VIP) were analysed in human isolated circular segments of pulmonary arteries. Guinea-pig pulmonary arteries were used for comparison. The responses obtained were analysed in relation to the vascular endothelium and the nitric oxide (NO) synthase inhibitor N^G-monomethyl L-arginine (L-NMMA).
2. PACAP and VIP induced concentration-dependent relaxations of precontracted pulmonary arteries. The maximal dilator response (I_max,%) and the potency (pEC₅₀ value) were the same for both peptides, and there were no differences in the effects obtained on human and guinea-pig segments. PACAP and VIP were both more potent that acetylcholine (ACh).
3. Removal of the vascular endothelium abolished the PACAP induced dilator response in pulmonary arteries from both species. The VIP induced dilatation was unaffected, whereas the response to ACh was abolished. L-NMMA given before PACAP inhibited the dilatation. Furthermore, L-NMMA also reversed the dilatation already induced by PACAP and excess concentrations of L-arginine restored the dilator response of the L-NMMA treated arteries.
4. PACAP is a potent dilator of human pulmonary arteries. Although the dilator effect seems to be similar in amplitude to the one induced by VIP, the present results suggest differences in the underlying mechanisms of action (endothelium-dependency) between the two peptides.

     

Effects of prolonged uniocular dark adaptation on the direct-current electroretinogram of pigmented and albino rabbits

The direct-current electroretinogram of seven pigmented and seven albino rabbits was recorded from both eyes for almost 4 h in response to repeated identical light stimuli. Stimulus duration was 10 s, light intensity was 6.8 × 10² lux, and the interval between the beginning of succeeding light stimuli was 3 min. The dark-adaptation period preceding light stimulation was 30 min for one of the eyes (unoccluded eye) and 150 min for the contralateral eye (occluded eye), which was patched during the first part (117 min) of the experiment. In pigmented animals, the b- and c-wave amplitudes of the unoccluded eye slowly increased during the first part of the experiment but not significantly during the second. The a-wave amplitude was not significantly changed. After removal of the cover, the a- and b-wave amplitudes of the occluded eye immediately attained but did not exceed the level of those in the unoccluded eye, irrespective of the light adaptation induced by the stimulus flashes previously presented to the unoccluded eye. (Control experiments on six pigmented rabbits confirmed that stimuli identical to those used in the main part of the study caused a light adaptation, since a decrease in a- and b-wave amplitudes occurred after the first light stimulus following an initial dark-adaptation period of 2 h for both eyes.) In albino rabbits, electroretinogram responses were clearly discernible in the occluded eye also during the first part of the experiment, probably because of transillumination of the head. In other respects, the results were essentially similar to those of pigmented animals. The observation that occluded eyes did not dark adapt better, as judged by the electroretinogram responses, than contralateral eyes given repeated light adaptive stimuli may indicate the presence of a mechanism for transfer of adaptation information between the eyes.     

Haemodynamic consequences and uterine contractions following 0.5 or 1.0 litre crystalloid infusion before obstetric epidural analgesia

Purpose

The efficacy of infusion of 0.5 L and 1.0 L Ringer’s lactate (LR) to prevent hypotension during induction of obstetric analgesia was studied. The effect of the different fluid boluses on fetal heart rate (FHR) and frequency of uterine contractions were also determined.

Methods

Ninety-two ASA 1–2 parturients were randomized to receive 0.5 L (Group 1) and 1.0 L (Group 2) LR immediately before incremental epidural injections with lidocaine to achieve T₁₀ sensory block. Systolic blood pressure (SBP) was measured with an automated BP cuff every two minutes for 30 min after infusion of fluid bolus. Fetal heart rate monitoring and tocometry were used continuously. The number of uterine contractions were recorded 30 min before and 60 min after iv bolus.

Results

The SBP decreased in both groups, but there was no difference between groups in mean SBP or maternal heart rate. The incidence of hypotension (SBP < 90 mmHg or decrease of 20%) was 4% in both groups. The FHR record of a patient in Group 1 showed a single late deceleration, and a decrease in beat-to-beat variability occured in one patient in Group 2. A decrease in the frequency of uterine contractions of two or more contractions per 30 min was noted more frequently in Group 2 (P < 0.05). The duration of iv bolus was longer in Group 2 than Group 1 (18.8 ± 4.3 min vs 12.3 ± 4.5 min, P < 0.01).

Conclusion

Administration of 1.0 L LR iv does not provide added protection against maternal hypotension, and is associated with delay in providing pain relief and a risk of decreasing uterine contraction frequency.