Expanding perfusion services through mobile point-of-care coagulation monitoring

Current trends in cardiac surgery have challenged perfusionists to seek diversification of services. Point-of-care coagulation (POCC) monitoring represents a desirable area of perfusion service expansion. The purpose of the study was to create a series of hemostatic conditions to assess the functionality of POCC monitors to identify specific coagulopathies with identifiable profiles for algorithm development. Fresh (< 4 h) bovine blood, anticoagulated with anticoagulant citrate dextrose, was adjusted to a hematocrit of 30.0 +/- 2.0%. Hypofibrinogenemia < or = 90 mg/dL), thrombocytopenia (< or = 70,000/mm3), platelet dysfunction (850 microg/mL of nitroglycerin/mL of blood) and hyperfibrinolysis (0.40 units of urokinase/mL of blood) were created. Five POCC devices were used to evaluate activated clotting time, thrombin time, fibrinogen, platelet function, prothrombin time, activated partial thromboplastin time and thromboelastograph. Results are reported as percentage change from control for each test (abtract table). [table: see text] Each test performed showed specificity and sensitivity for certain coagulopathies, however variability amongst monitors was encountered. In conclusion, the development of a mobile cart incorporating POCC monitors with knowledge of specific coagulopathic conditions may expand perfusion service.     

Assessment of diaphragm function after stellate ganglion block using magnetic stimulation

Stellate ganglion block is a procedure frequently used for the management of patients with chronic sympathetically mediated pain affecting the arm, neck or head. We studied the effect of stellate ganglion block on ipsilateral phrenic nerve function, and hence diaphragmatic strength, in 11 adult patients with chronic sympathetically mediated pain. Pre- and post-block forced vital capacity (FVC) measurements were recorded using a pneumotachograph and a Magstim nerve stimulator was used to generate pre- and post-block twitch mouth pressures (P(TWM)). This device can be used to stimulate the phrenic nerves and hence the diaphragm. The resulting change in airway pressure was measured at the mouth and has previously been shown to reflect diaphragm strength. There was no statistically significant difference in FVC or P(TWM) pre- or post stellate ganglion block. In conclusion, a stellate ganglion block has no adverse effect on ipsilateral phrenic nerve function or diaphragm strength in healthy adult patients.     

High-dose chemotherapy followed by reinfusion of selected CD34+ peripheral blood cells in patients with poor-prognosis breast cancer: a randomized multicentre study.

Seventy-one patients with poor-prognosis breast cancer were enrolled after informed consent in a multicentre randomized study to evaluate the use of selected peripheral blood CD34+ cells to support haematopoietic recovery following high-dose chemotherapy. Patients who responded to conventional chemotherapy were mobilized with chemotherapy (mainly high-dose cyclophosphamide) and/or recombinant human granulocyte colony-stimulating factor (rhG-CSF). Patients who reached the threshold of 20 CD34+ cells per microl of peripheral blood underwent apheresis and were randomized at that time to receive either unmanipulated mobilized blood cells or selected CD34+ cells. For patients in the study arm, CD34+ cells were selected from aphereses using the Isolex300 device. Fifteen patients failed to mobilize peripheral blood progenitors and nine other patients were excluded for various reasons. Forty-seven eligible patients were randomized into two comparable groups. CD34+ cells were selected from aphereses in the study group. Haematopoietic recovery occurred at similar times in both groups. No side-effect related to the infusion of selected cells was observed. The frequency of epithelial tumour cells in aphereses was low (8 out of 42 evaluated patients), as determined by immunocytochemistry. We conclude that selected CD34+ cells safely support haematopoietic recovery following high-dose chemotherapy in patients with poor-prognosis breast cancer.     

Captopril treatment reverses erectile dysfunction in male stroke prone spontaneously hypertensive rats

The involvement of antihypertensive therapy in the pathology of hypertension associated male erectile dysfunction is unclear. Stroke prone spontaneously hypertensive rats (SHRSP) were treated chronically with the angiotensin converting enzyme (ACE) inhibitor captopril or placebo, normotensive rats served as controls. Mean arterial and intracavernosal pressure were measured during the induction of erection by autonomic ganglion stimulation. SHRSP-placebo treated rats were hypertensive and had a blunted erectile response. Captopril treatment returned both the blood pressure and erectile response to control levels. Therefore, ACE inhibitor therapy may not be responsible for the erectile dysfunction observed in treated hypertensive subjects.     

Inter- and Intrajudge Reliability for Videofluoroscopic Swallowing Evaluation Measures

Interjudge reliability for videofluoroscopic (VFS) swallowing evaluations has been investigated, and results have, for the most part, indicated that reliability is poor. While previous studies are well-designed investigations of interjudge reliability, few reports of intrajudge reliability are available for VFS measures derived from frame-by-frame analysis that clinicians typically employ. The purpose of this study was to examine the inter- and intrajudge reliability of VFS examination measures commonly used to assess swallowing functions. No training to criteria occurred. VFS examinations were conducted on 20 patients who had suffered a stroke within six weeks and had no structural abnormalities or tracheostomies. Three clinical judges served as subjects and rated the VFS examinations from videotape using frame-by-frame analysis. A clinician's repeated review of measures employed in the 20 examinations indicated high intrajudge reliability for a number of measures, suggesting that an experienced clinician may employ consistent standards for rating certain VFS measures across patients and time. These standards appear to vary among clinicians and yield unacceptable interjudge reliability. The need to train clinicians to criteria to improve interjudge reliability is discussed.     

Compartment syndrome associated with the Lloyd Davies position. Three case reports and review of the literature

The Lloyd Davies position was developed to facilitate access to the pelvis for gynaecological, urological and colorectal procedures. Previous case reports have demonstrated that prolonged adoption (> 4 h) of this position has been associated with the development of bilateral compartment syndrome of the calves. All three patients reported here suffered severe bilateral calf pain despite the use of thoracic epidurals. All three cases required three-compartment fasciotomies and, 6 months after surgery, were all still severely disabled as a consequence of the compartment syndrome. These case reports stress the dangers of use of the Lloyd Davies position for prolonged procedures and demonstrate that some patients are at risk after relatively short periods (< 3 h). Previous case reports and clinical studies have focused on the effect of limb elevation in stirrups on the arterial pressure in the lower limb. We review the pathophysiology of compartment syndrome and consider factors other than a decrease in arterial pressure that may predispose to compartment syndrome during adoption of the Lloyd Davies position.     

Plantar-flexion tarsometatarsal joint injuries in children

We are reporting a series of eight patients ranging in age from 3 to 10 years who sustained plantar-flexion injuries of the foot, resulting in injuries to the tarsometatarsal (TMT) interval. All injuries were identified within 3 days and treated with molded short leg immobilization. We evaluated all patients an average of 32 months after injury with physical examination and the Midfoot Functional Rating (MFR) score. Seven patients had no limitations in their activities of daily living or athletic endeavors. These seven patients had MFR scores of 100. One patient had complaints of midfoot pain with running for >5 min and radiographic evidence of degenerative changes across the TMT interval at 3-year follow-up. These results suggest that although indirect pediatric TMT injuries have a generally favorable prognosis, early degenerative changes can occur and may be responsible for chronic pain and activity limitation. Degenerative changes in this weight-bearing region in a young patient can have lifelong implications. Patients and parents may benefit from discussion of the potential for future midfoot compromise following this injury.