A randomized prospective analysis of alteration of hemostatic function in patients receiving tranexamic acid and hydroxyethyl starch (130/0.4) undergoing off pump coronary artery bypass surgery

Postoperative hemorrhagic complications is still one of the major problems in cardiac surgeries. It may be caused by surgical issues, coagulopathy caused by the side effects of the intravenous fluids administered to produce plasma volume expansion such as hydroxyl ethyl starch (HES). In order to thwart this hemorrhagic issue, few agents are available. Fibrinolytic inhibitors like tranexamic acid (TA) may be effective modes to promote blood conservation; but the possible complications of thrombosis of coronary artery graft, precludes their generous use in coronary artery bypass graft surgery. The issue is a balance between agents that promote coagulation and those which oppose it. Therefore, in this study we have assessed the effects of concomitant use of HES and TA. Thromboelastogram (TEG) was used to assess the effect of the combination of HES and TA. With ethical committee approval and patient's consent, 100 consecutive patients were recruited for the study. Surgical and anesthetic techniques were standardized. Patients fulfilling our inclusion criteria were randomly allocated into 4 groups of 25 each. The patients in group A received 20 ml/kg of HES (130/0.4), 10 mg/kg of T.A over 30 minutes followed by infusion of 1 mg/kg/hr over the next 12 hrs. The patients in group B received Ringer's lactate + TA at same dose. The patients in the Group C received 20 ml/kg of HES. Group D patients received RL. Fluid therapy was goal directed. Total blood loss was assessed. Reaction time (r), α angle, maximum amplitude (MA) values of TEG were assessed at baseline, 12, 36 hrs. The possible perioperative myocardial infraction (MI) was assessed by electrocardiogram (ECG) and troponin T values at the baseline, postoperative day 1. Duration on ventilator, length of stay (LOS) in the intensive care unit (ICU) were also assessed. The demographical profile was similar among the groups. Use of HES increased blood loss significantly (P < 0.05). Concomitant use of TA reduced blood loss when used along with HES. r value was prolonged at 12 hours in all the groups and α angle was reduced at 12 hours in all the groups, where as MA value was reduced at 12 th hour in the HES group compared to the baseline and increased in TA + HES group. These findings were statistically significant. No significant change in Troponin T values/ECG, duration of ventilation and LOS ICU was observed. No adverse events was noticed in any of the four groups. HES (130/0.4) used at a dose of 20 ml/kg seems to produce coagulopathy causing increased blood loss perioperatively. Hemodilution produced by fluid therapy seems to produce Coagulopathy as observed by TEG parameters. Concomitant use of TA with HES appears to reverse these changes without causing any adverse effects in patients undergoing OPCAB surgery.     

Association Between Gut Microbial Abundance and Sight-Threatening Diabetic Retinopathy

PurposeTo study the association between gut microbial abundance and sight-threatening diabetic retinopathy among patients with a history of type 2 diabetes mellitus.MethodsAn observational case-control study was performed using a sample population of diabetics referred to a tertiary eye institute. Sample subjects were identified as cases if they were diagnosed with sight-threatening diabetic retinopathy and controls if they were not but had at least a 10-year history of diabetes. Fecal swabs for all patients were collected for enumeration and identification of sequenced gut microbes. Statistical analyses were performed to associate the clinically relevant Bacteroidetes to Firmicutes relative abundance ratio (B/F ratio) with sight-threatening diabetic retinopathy and an optimal cutoff value for the ratio was identified using Youden''s J statistics.ResultsA sample size of 58 diabetic patients was selected (37 cases, 21 controls). No statistically significant difference in the relative abundance among the predominant phyla between the groups were found. In our univariate analysis, the B/F ratio was elevated in cases compared to controls (cases, 1.45; controls, 0.94; P = 0.049). However, this statistically significant difference was not seen in our multivariate regression model. Optimal cutoff value of 1.05 for the B/F ratio was identified, and significant clustering of cases above this value was noted in beta diversity plotting.ConclusionsNo difference in gut microbial abundance for any particular phylum was noted between the control and diseased population. Increased gut microbial B/F ratio can be a potential biomarker for the development of sight-threatening diabetic retinopathy among type 2 diabetic patients.     

Prevalence and mechanisms of malnutrition in patients with advanced liver disease, and nutrition management strategies

Malnutrition is prevalent among cirrhotic patients and is an important prognostic factor. Etiologic factors include hypermetabolism, malabsorption, altered nutrient metabolism, and anorexia. It is a challenge to manage nutrition in cirrhotic patients because of alterations to metabolic and storage functions of the liver; use of traditional assessment tools, such as anthropometric and biometric measures, is difficult because of complications such as ascites and inflammation. In addition to meeting macro- and micronutrient requirements, the composition and timing of supplements have been proposed to affect efficacy of nutrition support. Studies have indicated that branched chain aromatic acid can be given as therapeutic nutrients, and that probiotics and nocturnal feeding improve patient outcomes.     

In vitro evaluation of novel low-pressure spark plasma sintered HA–BG composite scaffolds for bone tissue engineering

The low-pressure spark plasma sintering (SPS) technique is adopted to fabricate hydroxyapatite–bioglass (HA–BG) scaffolds while maintaining the physical properties of both components, including their bulk and relative density and hardness. However, prior to their orthopaedic and dental applications, these scaffolds must be validated via pre-clinical assessments. In the present study, scaffolds with different ratios of HA : BG, namely, 100 : 0 (HB 0 S), 90 : 10 (HB 10 S), 80 : 20 (HB 20 S) and 70 : 30 (HB 30 S) were fabricated. These scaffolds were characterized by investigating their physicochemical properties (X-ray diffraction (XRD) and surface wettability), bioactivity in a simulated body fluid (SBF) (field emission scanning electron microscopy (FESEM), Fourier-transform infrared spectroscopy (FTIR) and calcium dissolution), antimicrobial properties, biocompatibility and osteoinduction of human bone marrow-derived mesenchymal stromal cells (hBMSCs) and human monocyte immune cell response. The XRD and surface wettability results confirmed no formation of undesirable phases and the enhanced surface hydrophilicity of the scaffolds, respectively. The bioactivity in SBF indicated the formation of bone-like apatite on the surface of the scaffolds, corresponding to an increase in BG%, which was confirmed through FTIR spectra and the increasing trend of calcium release in SBF. The scaffolds showed inhibition properties against Staphylococcus aureus and Staphylococcus epidermidis. The scanning electron microscopy (SEM) micrographs and Alamar Blue proliferation assay indicated the good attachment and significant proliferation, respectively, of hBMSCs on the scaffolds. Alizarin Red S staining confirmed that the scaffolds supported the mineralisation of hBMSCs. The osteogenic protein secretion (bone morphogenetic protein-2 (BMP2), type-I collagen (COL1) and osterix (OSX)) was significant on the HB 30 S-seeded hBMSCs when compared with that of HB 0 S. The monocyte migration was significantly halted in response to HA–BG-conditioned media when compared with the positive control (monocyte chemoattractant protein-1: MCP-1). In conclusion, the HB 30 S composite scaffold has a greater potential to substitute bone grafts in orthopaedic and dental applications.

HB 30 S composite scaffold inhibits Staphylococcus spp., supports the biocompatibility and osteogenic differentiation of hBMSCs and resists monocyte migration.     

Two-Stage Arthroplasty for Prosthetic Joint Infection : A Systematic Review of Acute Kidney Injury,Systemic Toxicity and Infection Control

Periprosthetic infections of hip and knee joints are now treated by two-stage revision arthroplasty with an infection control rate of 91%. The present systematic review studied the reported incidence of acute kidney injury (AKI) and infection recurrence from January 1989 to June 2012 to assess the risk–benefit ratio of antibiotic spacer use. Ten observational studies (n = 544 patients) with clinical outcomes showed an average incidence of AKI of 4.8%. The average reported persistence or recurrence rate of infection was 11% during a follow-up period that ranged from 13 to 108 months. The risk–benefit ratio presently favors treatment although there appears to be higher complication rates and incidence of AKI than previously reported. Marked heterogeneity in practice and lack of detail in reporting precluded more robust quantitative synthesis. Clinicians need to be aware of the potential risk of AKI, particularly in high-risk patients; practice patterns for the use of antibiotic spacers need to be standardized.     

Nonfunctional Pancreatic Neuroendocrine Tumors <2 cm on Preoperative Imaging are Associated with a Low Incidence of Nodal Metastasis and an Excellent Overall Survival

Background

The optimal surgical management of small nonfunctional pancreatic neuroendocrine tumors (NF-PNETs) remains controversial. We sought to identify (1) clinicopathologic factors associated with survival in NF-PNETs and (2) preoperative tumor characteristics that can be used to determine which lesions require resection and lymph node (LN) harvest.

Methods

The records of all 116 patients who underwent resection for NF-PNETs between 1989 and 2012 were reviewed retrospectively. Preoperative factors, operative data, pathology, surgical morbidity, and survival were analyzed.

Results

The overall 5- and 10-year survival rates were 83.9 and 72.8 %, respectively. Negative LNs (p?=?0.005), G1 or G2 histology (p?=?0.033), and age <60 years (p?=?0.002) correlated with better survival on multivariate analysis. The 10-year survival rate was 86.6 % for LN-negative patients (n?=?73) and 34.1 % for LN-positive patients (n?=?32). Tumor size ≥2 cm on preoperative imaging predicted nodal positivity with a sensitivity of 93.8 %. Positive LNs were found in 38.5 % of tumors ≥2 cm compared to only 7.4 % of tumors <2 cm.

Conclusions

LN status, a marker of systemic disease, was a highly significant predictor of survival in this series. Tumor size on preoperative imaging was predictive of nodal disease. Thus, it is reasonable to consider parenchyma-sparing resection or even close observation for NF-PNETs <2 cm.     

Gamma Knife radiosurgery in the management of brainstem metastases

Background

Metastases to the brainstem portend a poor prognosis and present a challenge in clinical management. Surgical resection is rarely a viable option.

Methods

Post-treatment MRI scans of patients with brainstem metastases treated with radiosurgery were used to determine local control and disease progression. Median survival was calculated using Kaplan–Meier analysis. Univariate and multivariate analyses were performed using log-rank test and Cox proportional hazards model, respectively.

Results

Thirty-two consecutive patients with brainstem metastasis underwent Gamma Knife radiosurgery. Median age was 50 years. Median tumor volume was 0.71 cm³ and median tumor margin dose was 13 Gy. Seventeen of 32 patients received WBRT prior to stereotactic radiosurgery. Median survival was 5.2 months. There was a statistically significant difference in survival based on RTOG recursive partition analysis (RPA) class. Median survival of patients categorized as RPA class I was 19.2 months, RPA class II was 8.4 months, and RPA class III was 1.9 months. The overall local tumor control rate was 87.5%. There were no acute complications following stereotactic radiosurgery and no evidence of radiation necrosis noted on post-treatment MRI scans.

Conclusion

Stereotactic radiosurgery is an effective treatment for brainstem metastases and should be considered especially for patients with good performance status.