Comparison of the antithrombotic effects of heparin, enoxaparin and prostacycline in continuous hemofiltration

Continuous anticoagulation is required during haemofiltration to prevent the deposition of fibrin and the formation of thrombus which would lead to early clotting of the haemofilter. This study aimed to compare the efficiencies of 3 different anticoagulation protocol: 150 IU.kg-1.day-1 heparin (group HEP), 1.2 mg.kg-1.day-1 enoxaparin (group ENX), and a combination of 0.8 mg.kg-1.day-1 enoxaparin with 5 ng.kg-1.min-1 prostaglandin I2 (group ENX and PGI2). A flat ANS69S (Hospal) haemofilter was used for continuous venovenous haemofiltration. Antithrombotic efficiency was assessed with a haemofilter permeability index (HPI) including the transmembraneous pressure gradient and the rate of production of ultrafiltrate. The time required for HPI to decrease to 1/3 of its initial value (HPI1/3) was used to compare the 3 protocols. Treatment tolerance was judged by monitoring the usual haemodynamic and haemostatic parameters. No adverse effects (bleeding, thrombosis, hypotension) were observed. HPI1/3 was 15.1 +/- 2.4 h, 18.3 +/- 3.1 h and 28.2 +/- 4.2 h in groups HEP, ENX and ENX and PGI2 respectively. High dose enoxaparin reached antithrombotic efficiency without increasing the risk of haemorrhage. The use of low doses of prostaglandin I2 greatly increased HPI1/3, without any deleterious haemodynamic effects. However, the high cost of prostaglandin I2 needs to be put in the balance with the increase in duration of haemofilter life. Therefore, further investigations are required to evaluate the possible synergy between heparin and prostaglandin I2, as well as the biological parameters which need to be monitored.     

Measurement of post-operative pain and narcotic administration in infants using a new clinical scoring system

We developed a clinical neurologic and behavioral scoring system composed of 10 items to measure the post-operative pain levels in infants: (1) sleep during preceeding hour, (2) facial expression of pain, (3) quality of cry, (4) spontaneous motor activity, (5) Spontaneous excitability, (6) flexion of fingers and toes, (7) sucking, (8) global evaluation of tone, (9) consolability and (10) sociability. Using this system, a group of infants ranging from one to seven months in age and undergoing minor surgical procedures was studied. The infants were randomly assigned to two groups: Group I received Fentanyl intravenously (3 g/kg) prior to surgery, and Group II received a placebo. The infants then were studied post-operatively in the recovery room at 30, 60, 90 and 120 min intervals. Over the entire post-operative observation period, 54% of the infants in Group I had satisfactory analgesia compared to 18% in Group II. There were no significant differences in Group I and Group II in oxygenation, carbon dioxide elimination, blood pressure, heart rate or temperature.     

14. FDG CDET (2D Dual-Head Coincidence Gamma Camera) in the Primary Staging of Oesophageal Cancer. Histopathological Correlation

Purpose: The aim of this study was to evaluate the role of FDG-CDET for the detection of primary oesophageal tumour, lymph node involvement and distant extension before surgery.Methods and patients: In patients fasting for 6h or more, 150-250 MBq of 18F-FDG were injected i.v. and 2D imaging (whole-body scan and at least a tomoscintigram) was started 45 min. later, using a PICKER gamma camera. We studied 14 patients (pts). All of them were operated on (mean time between FDG and surgery: 5.4 +/- 3.8 days) and staging results were correlated with post surgical histology.Results: The primary lesion took up FDG in all cases but one (FN in a 5 mm lesion). The primary NM staging of these 14 pts was negative with FDG-CDET in 7 cases (4 TN and 3 FN corresponding to an invasion of satellite lymph nodes in 2 cases and to a metastatic infracentimetric subdiaphragmatic lymph node in one case) and positive in 7 cases (7 TP corresponding to 10 foci), revealing in 4 cases a sub-diaphragmatic lymph node extension unknown prior to FDG-CDET. One pt referred for characterisation of an oesophageal lesion (failure of multiple biopsies) had an intense focus of FDG uptake in this area (TP confirmed by surgery). The overall sensitivity was 13/14 = 93% on a per patient basis and 21/25 = 84% on a per lesion basis. Specificity on a per lesion basis was 5/5 = 100%.Conclusion: These first results, obtained in an indication of FDG not frequently evaluated even with dedicated PET systems, seem very promising, the oesophageal neoplastic lesions appearing to take up FDG with a high intensity.     

Prognostic factors in advanced pancreatic cancer. Multivariate analysis of predictive survival score. University Surgery Association

STUDY AIM: To identify prognostic factors in advanced pancreatic cancer and to define a predictive score. PATIENTS AND METHOD: One hundred and sixty six patients were included in this multicentre study. Seventeen covariables were prospectively collected for each patient. Covariables associated with survival (p < 0.10) were analysed by a stepwise Cox model. RESULTS: Four prognostic factors were selected on multivariate analysis: pain (RR 1.5; CI: 1.1-2.0), ascites (RR 1.7; CI: 1.0-2.9), weight loss > 10 kg (RR 1.4; CI: 1.0-2.0), and metastases (RR 2.3: CI: 1.6-3.2). A score was defined by attributing a value of one for pain, ascites and weight loss, and two for metastases. Patients with a score > 2 had a median survival of 2 months (SE: 0.5), and patients with a score < or = 2 had a median survival of 6 months (SE: 0.6) (Logrank p < 0.0001). CONCLUSION: The proposed score may be helpful in therapeutic decisions concerning surgery, palliative chemotherapy and/or radiotherapy. However, this score must be validated on an independent series of patients.     

The appropriate use of colonoscopy in the curative management of colorectal cancer

A total of 175 patients who underwent a curative resection for a colonic (n = 130) or a rectal cancer (n = 45) between 1986 and 1992 were entered into a routine clonoscopy program. Colonoscopies were performed 1 year after the operation, and then at 2-year intervals. The findings at colonoscopy, as well as those of preoperative colonoscopy (when performed), were recorded. Eleven anastomotic recurrences were diagnosed at an asymptomatic stage, at a mean follow-up of 14 months. All of them were identified in patients with a stage B or C primary rectosigmoid cancer. Eight patients underwent another potentially curative re-operation. Only perioperative colonoscopy (preoperative colonoscopy; first postoperative colonoscopy in patients for whom the preoperative procedure was incomplete or not performed) allowed diagnosis of second cancers (n = 7) and adenomatous polyps greater than 10 mm (n = 17). Further colonoscopies detected only polyps less than 10 mm. Positive examination rates for successive follow-up colonoscopies were 15, 20 and 23%, respectively; they were significantly higher in patients who had previously had adenomatous polyps than in patients who had not: 30% versus 6% (P<0.025), 46% vs 5% (P<0.005) and 38% vs 11% (P<0.025), respectively. From these data, the following recommendations are made: (1) All colorectal cancer patients should have a total colonoscopy either before (whenever possible) or soon after operation; (2) Based on results of the perioperative colonoscopy, patients: should undergo their first follow-up colonoscopy only 3 yearly (presence of synchronous adenomatous polyps) or 5 yearly (absence of synchronous adenomatous polyps) after resection; (3) In patients with stage B or C primary rectosigmoid cancer, a surveillance of the suture line by rigid proctosigmoidoscopy should be added during the first 2 postoperative years: 6, 15 and 24 months after the operation.     

Inhibition of rat liver fibrogenesis through noradrenergic antagonism

The effect of adrenergic innervation and/or circulating catecholamines on the function of liver fibrogenic cells is poorly understood. Our aim was to investigate the effects of noradrenergic antagonism on carbon tetrachloride (CCl4)-induced liver fibrosis in rats. Two weeks of CCl4 induced an approximately 5-fold increase in the area of fibrosis as compared with controls. The addition of 6-hydroxydopamine (OHDA), a toxin that destroys noradrenergic fibers, decreased fibrosis by 60%. After 6 weeks of CCl4, the area of fibrosis increased about 30-fold in CCl4-treated animals and was decreased by 36% with OHDA. At 2 weeks, OHDA abrogated the CCl4-induced increase in mRNA level of tissue inhibitor of matrix metalloproteinases-1 (TIMP-1), an inhibitor of extracellular matrix degradation, and it greatly reduced it at 6 weeks. Finally, when rats treated with CCl4 for 2 weeks also received prazosin, an antagonist of alpha1-adrenergic receptors, fibrosis was decreased by 83%. In conclusion, destruction of noradrenergic fibers or antagonism of noradrenergic signaling through alpha1 receptors inhibited the development of liver fibrosis. Because adrenoreceptor antagonists have a very sound safety profile, they appear as attractive drugs to reduce liver fibrogenesis.     

Stroke management in a general internal medicine department: results of a survey regarding practice

PURPOSE: The incidence of strokes in the general population and the insufficient numbers of centers specialized in their management has led to the increased hospitalization of patients in general, internal medicine departments. The prognosis for patients is related to the relevance of the initial diagnostic and therapeutic measures. To optimize management of stroke patients outside of specialized units, a survey concerning practice was conducted in internal medicine departments in western France, and a meeting was held to define guidelines. METHODS: Data sheets were mailed to practitioners in internal medicine departments prior to the survey. The following data were recorded for each patient hospitalized during the two-week study: age, sex, clinical characteristics of stroke, risk factors, investigations performed, and initial and subsequent medical management. On the basis of the results, management guidelines were considered and defined. RESULTS: Patients hospitalized for a stroke in internal medicine departments have a similar profile to those hospitalized in neurology departments. CT-scan and EKG recordings were performed in most patients whereas other investigations (cervical ultrasound, echocardiography, MRI) were used less frequently. The use of rehabilitation and therapeutic strategies for secondary stroke prevention were not always performed according to current guidelines. CONCLUSION: Internal medicine departments are frequently involved in the care of stroke patients. The present study of clinical practice may help to improve stroke management in these non-specialized departments.     

Genotype-related changes of ganglioside composition in brain regions of transgenic mouse models of Alzheimer's disease

In this study, brain gangliosides of different transgenic mouse models of Alzheimer's disease (AD) were analyzed and compared with age-matched wild-type mice. Gangliosides were analyzed in cerebral cortex, a region with extensive Aβ plaques, and cerebellum, a non-vulnerable region with no Aβ containing plaques. There was a marked increase in simple gangliosides GM2 and GM3 only within the cortex of all mice expressing APP^SL. Additionally, loss of complex “a” gangliosides (GT1a, GD1a and GM1) was recorded in APP/PS1Ki model, whereas in APP^SL and APP/PS1 mice, the complex “b” gangliosides (GQ1b, GT1b and GD1b) moderately decreased. Surprisingly, expression of either mutant PS1^M146L or PS1 mutant FAD (Ki model) alone tended to lower the levels of both GM2 and GM3 within the cortex. Conversely, only slight changes of the ganglioside pattern were found in the cerebellum. Because ganglioside alterations occurring in APP transgenic mice were similar to those observed in human AD brain, these transgenic models would represent valuable tools to further investigate the role of altered ganglioside metabolism in the pathogenesis of AD.     

Thirty-Day Post-Discharge Outcomes Following COVID-19 Infection

BackgroundThe clinical course of COVID-19 includes multiple disease phases. Data describing post-hospital discharge outcomes may provide insight into disease course. Studies describing post-hospitalization outcomes of adults following COVID-19 infection are limited to electronic medical record review, which may underestimate the incidence of outcomes.ObjectiveTo determine 30-day post-hospitalization outcomes following COVID-19 infection.DesignRetrospective cohort studySettingQuaternary referral hospital and community hospital in New York City.ParticipantsCOVID-19 infected patients discharged alive from the emergency department (ED) or hospital between March 3 and May 15, 2020.MeasurementOutcomes included return to an ED, re-hospitalization, and mortality within 30 days of hospital discharge.ResultsThirty-day follow-up data were successfully collected on 94.6% of eligible patients. Among 1344 patients, 16.5% returned to an ED, 9.8% were re-hospitalized, and 2.4% died. Among patients who returned to the ED, 50.0% (108/216) went to a different hospital from the hospital of the index presentation, and 61.1% (132/216) of those who returned were re-hospitalized. In Cox models adjusted for variables selected using the lasso method, age (HR 1.01 per year [95% CI 1.00–1.02]), diabetes (1.54 [1.06–2.23]), and the need for inpatient dialysis (3.78 [2.23–6.43]) during the index presentation were independently associated with a higher re-hospitalization rate. Older age (HR 1.08 [1.05–1.11]) and Asian race (2.89 [1.27–6.61]) were significantly associated with mortality.ConclusionsAmong patients discharged alive following their index presentation for COVID-19, risk for returning to a hospital within 30 days of discharge was substantial. These patients merit close post-discharge follow-up to optimize outcomes.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-021-06924-0.KEY WORDS: COVID-19, mortality, re-admission, discharge