Administration of platelets to ruptured abdominal aortic aneurysm patients before open surgery: a prospective, single-blinded, randomised study

BACKGROUND

In patients undergoing open surgery for a ruptured abdominal aortic aneurysm (rAAA), survivors demonstrate a high platelet count, and proactive administration of platelets (and fresh frozen plasma) appears to influence mortality.

OBJECTIVES

This trial investigated the effect of platelets administered before transport to surgery.

METHODS

In a prospective study design, patients were randomised to receive platelets (intervention; n = 61) or no platelets (control; n = 61) before transport to vascular surgery from 11 local hospitals. The study was terminated when one of the vascular surgical centres implemented endovascular repair for rAAA patients.

RESULTS

Thirty days after surgery, mortality was 36% for patients with intervention vs 31% for controls (P = 0·32). Post-operative thrombotic events (14 vs 15; P = 0·69), renal failure (11 vs 10; P = 0·15) and pulmonary insufficiency (34 vs 39; P = 0·15) were similar in the two groups of patients. No adverse reactions to platelet administration were observed. In addition, length of stay in the intensive care unit was unaffected by intervention.

CONCLUSIONS

For patients planned for open repair of a rAAA, we observed no significant effect of early administration of platelets with regard to post-operative complications and stay in the ICU or in hospital and also no significant effect on mortality.

Mosquitoes in Moose Country: A Mosquito Survey of Northern Minnesota

An adult mosquito survey was conducted at 12 sites using carbon dioxide traps in northern Minnesota throughout the summer of 2012. Specimens were counted, identified to species, sorted into pools, and tested for eastern equine encephalitis (EEEV) and West Nile virus (WNV). Our findings extend the known range of Culiseta melanura, Anopheles barberi, and An. quadrimaculatus and document the presence and abundance of 27 other mosquito taxa in the region. None of the pools tested positive for EEEV or WNV.

Isolation of viable Neospora caninum from brains of wild gray wolves (Canis lupus)

Neospora caninum is a common cause of abortion in cattle worldwide. Canids, including the dog and the dingo (Canis familiaris), the coyote (Canis latrans), and the gray wolf (Canis lupus) are its definitive hosts that can excrete environmentally resistant oocysts in the environment, but also can act as intermediate hosts, harboring tissue stages of the parasite. In an attempt to isolate viable N. caninum from tissues of naturally infected wolves, brain and heart tissue from 109 wolves from Minnesota were bioassayed in mice. Viable N. caninum (NcWolfMn1, NcWolfMn2) was isolated from the brains of two wolves by bioassays in interferon gamma gene knockout mice. DNA obtained from culture-derived N. caninum tachyzoites of the two isolates were analyzed by N. caninum-specific Nc5 polymerase chain reaction and confirmed diagnosis. This is the first report of isolation of N. caninum from tissues of any wild canid host.

Anti-inflammatory cytokines and risk of type 2 diabetes

Proinflammatory processes have been investigated extensively in the development of type 2 diabetes, but our knowledge on anti-inflammatory proteins is rather limited. This article summarizes studies that investigated associations between circulating levels of anti-inflammatory cytokines and incident type 2 diabetes preferably in prospective epidemiological studies. Adiponectin is the only known anti-inflammatory protein whose circulating levels are decreased before type 2 diabetes. In contrast, concentrations of interleukin-1 receptor antagonist (IL-1RA), transforming growth factor-β1 (TGF-β1) and growth differentiation factor-15 (GDF-15) are increased and indicate the presence of a compensatory, but eventually futile, counter-regulation of proinflammatory stimuli. Importantly, a proof-of-principle study using recombinant IL-1RA to improve metabolic control in patients with type 2 diabetes demonstrated that a more pronounced upregulation of this protein than that found in the natural course of diabetes development may have clinical relevance. Other interesting candidates like omentin (which shows similar associations with metabolic parameters as adiponectin), interleukin-10 (IL-10) and secreted frizzled-related protein-5 (Sfrp5) are currently less well studied with sometimes conflicting results regarding their association with type 2 diabetes. Thus, further research is required to better understand the causal role of proinflammatory cytokines, hypoadiponectinaemia and the upregulation of anti-inflammatory proteins before the onset of type 2 diabetes.

Perinatal Risks in "Late Motherhood" Defined Based On Parity and Preterm Birth Rate - an Analysis of the German Perinatal Survey (20th Communication)

Aim: "Late motherhood" is associated with greater perinatal risks but the term lacks precise definition. We present an approach to determine what "late motherhood" associated with "high risk" is, based on parity and preterm birth rate. Materials and Methods: Using data from the German Perinatal Survey of 1998-2000 we analysed preterm birth rates in women with zero, one, or two previous live births. We compared groups of "late" mothers (with high preterm birth rates) with "control" groups of younger women (with relatively low preterm birth rates). Data of 208 342 women were analysed. For women with zero (one; two) previous live births, the "control" group included women aged 22-26 (27-31; 29-33) years. Women in the "late motherhood" group were aged > 33 (> 35; > 38) years. Results: The "late motherhood" groups defined in this way were also at higher risk of adverse perinatal events other than preterm birth. For women with zero (one; two) previous live births, normal cephalic presentation occurred in 89 % (92.7 %; 93.3 %) in the "control" group, but only in 84.5 % (90 %; 90.4 %) in the "late motherhood" group. The mode of delivery was spontaneous or at most requiring manual help in 71.3 % (83.4 %; 85.8 %) in the "control" group, but only in 51.4 % (72.2 %; 76.4 %) in the "late motherhood" group. Five-minute APGAR scores were likewise worse for neonates of "late" mothers and the proportion with a birth weight ≤ 2499 g was greater. Conclusion: "Late motherhood" that is associated with greater perinatal risks can be defined based on parity and preterm birth rate.

Adding ketamine to morphine for intravenous patient-controlled analgesia for acute postoperative pain: a qualitative review of randomized trials

In experimental trials, ketamine has been shown to reduce hyperalgesia, prevent opioid tolerance, and lower morphine consumption. Clinical trials have found contradictory results. We performed a review of randomized, double-blinded clinical trials of ketamine added to opioid in i.v. patient-controlled analgesia (PCA) for postoperative pain in order to clarify this controversy. Our primary aim was to compare the effectiveness and safety of postoperative administered ketamine in addition to opioid for i.v. PCA compared with i.v. PCA with opioid alone. Studies were identified from the Cochrane Library 2003, MEDLINE (1966-2009), and EMBASE (1980-2009) and by hand-searching reference lists from review articles and trials. Eleven studies were identified with a total of 887 patients. Quality and validity assessment was performed on all trials included using the Oxford Quality Scale with an average quality score of 4.5. Pain was assessed using visual analogue scales or verbal rating scales. Six studies showed significant improved postoperative analgesia with the addition of ketamine to opioids. Five studies showed no significant clinical improvement. For thoracic surgery, the addition of ketamine to opioid for i.v. PCA was superior to i.v. PCA opioid alone. The combination allows a significant reduction in pain score, cumulative morphine consumption, and postoperative desaturation. The benefit of adding ketamine to morphine in i.v. PCA for orthopaedic or abdominal surgery remains unclear. Owing to huge heterogeneity of studies and small sample sizes, larger double-blinded randomized studies showing greater degree of homogeneity are required to confirm these findings.

One Step Nucleic Acid Amplification (OSNA) for intra-operative detection of lymph node metastases in breast cancer patients

21053

Background: Sentinel lymph node metastasis in breast cancer patients has conventionally been determined by intra- operative histopathological examination of frozen sections followed by definitive post-operative examination of permanent sections. The purpose of this study is to evaluate a more efficient method for intra-operative detection of lymph node metastasis in a clinical setting. Therefore, a new rapid method of detection of CK19 mRNA by One Step Nucleic Acid Amplification (OSNA) and Reverse Transcription Loop Mediated Isothermal Amplification (RT-LAMP) was tested against standard histological techniques. Methods: The clinical study was conducted at two facilities using 188 lymph nodes (46 patients). Lymph nodes from axillary dissected patients with breast cancer were divided into four slices. Alternate slices were used for the new method of CK19 mRNA detection (OSNA) and histopathological examination by hematoxylin & eosin and cytokeratin staining. For the analysis of concordance between both methods, the slices for histopathology were cut in 4 μm sections. For the OSNA method the other 2 slices were homogenised in a short sample preparation step. Afterwards CK19 mRNA was directly amplified from the tissue lysate within 16 minutes. Results: In the clinical study, an overall concordance rate between the OSNA assay and histopathology was 92%. Several discordant results are explainable with the expected uneven distribution of metastases within the lymph nodes. Conclusions: The study indicates that OSNA is a reliable and fast diagnostic tool for the detection of lymph node metastases in breast cancer patients. This method could be beneficial to avoid diagnostic delay for the patient or second surgery based on a post-operatively diagnosed positive lymph node.

No significant financial relationships to disclose.

Relationship between nocturnal hypoxaemia, tachycardia and myocardial ischaemia after major abdominal surgery

BACKGROUND

Episodic hypoxaemia, cardiac arrhythmias, and myocardial ischaemia may be related after major abdominal surgery.

METHODS

We studied 52 patients on the second and third nights after major abdominal operations, using continuous pulse oximetry and Holter ECG. We recorded the amount of time spent with oxygen saturation values less than 90, 85, and 80% during the night, and noted episodes of hypoxaemia, tachycardia, bradycardia, and ST-segment changes.

RESULTS

In 87 study nights there were 2403 (individual range 1-229) episodes of hypoxaemia, 3509 (individual range 1-234) episodes of tachycardia, and 265 (individual range 1-73) episodes of ST segment deviation. Of the 52 patients, 50 had episodes of hypoxaemia and tachycardia, and 19 patients had one or more episodes of ST segment deviation. For 38% of the episodes of ST deviation, there was an episode of hypoxaemia at the same time and in 16% there was an episode of tachycardia. ST deviation was only noted in 4% of the episodes of hypoxaemia and in 1% of the episodes of tachycardia.

CONCLUSION

Episodes of hypoxaemia and tachycardia frequently occur together after surgery but are rarely associated with ST deviation. Hypoxaemia or tachycardia is often present at the same time as ST deviation occurs.

High-dose chemotherapy with autologous hematopoietic stem-cell support compared with standard-dose chemotherapy in breast cancer patients with 10 or more positive lymph nodes: first results of a randomized trial

PURPOSE

Investigation of high-dose chemotherapy (HD-CT) followed by autologous hematopoietic stem-cell support compared with standard-dose chemotherapy (SD-CT) as adjuvant treatment in patients with primary breast cancer and 10 or more positive axillary lymph nodes.

PATIENTS AND METHODS

Between November 1993 and September 2000, 307 patients were randomized to receive (following four cycles of epirubicin 90 mg/m(2) and cyclophosphamide 600 mg/m(2), intravenously every 21 days) either HD-CT of cyclophosphamide 1500 mg/m(2), thiotepa 150 mg/m(2), and mitoxantrone 10 mg/m(2), intravenously for 4 consecutive days followed by stem-cell support; or SD-CT in three cycles of cyclophosphamide 500 mg/m(2), methotrexate 40 mg/m(2), and fluorouracil 600 mg/m(2) intravenously on days 1 and 8, every 28 days. The primary end point was event-free survival.

RESULTS

After a median follow-up of 3.8 years, 144 events with respect to event-free survival have been observed (HD-CT: 63 events; SD-CT: 81 events). The first event of failure (HD-CT v SD-CT) was an isolated locoregional recurrence (nine v 11), a distant failure (52 v 68), and death without recurrence (two v two). The estimated relative risk of HD-CT versus SD-CT was 0.75 (95% CI, 0.54 to 1.06; P =.095). Overall survival showed no difference (HD-CT: 40 deaths; SD-CT: 49 deaths).

CONCLUSION

There was a trend in favor of HD-CT with respect to event-free survival, but without statistical significance. Further follow-up and a meta-analysis of all randomized studies will reveal the effect of HD-CT as compared with SD-CT as adjuvant treatment in high-risk primary breast cancer.

Beneficial effects of a soy-based dietary supplement on lipid levels and cardiovascular risk markers in type 2 diabetic subjects

OBJECTIVE

Consumption of soy protein has recently been shown to improve the blood lipid levels in nondiabetic subjects. The purpose of this study was to evaluate if a dietary supplement of soy protein, isoflavones, and cotyledon fiber (Abalon) affects cardiovascular risk markers, blood glucose, and insulin levels in type 2 diabetic subjects.

RESEARCH DESIGN AND METHODS

Twenty type 2 diabetic subjects participated in a crossover trial. They were randomized to double-blind supplementation for 6 weeks with Abalon (soy protein [50 g/day] with high levels of isoflavones [minimum 165 mg/day] and cotyledon fiber [20 g/day]) or placebo (casein [50 g/day] and cellulose [20 g/day]), separated by a 3-week wash-out period.

RESULTS

The results are expressed as means +/- SD. The percentage mean treatment difference between Abalon and placebo demonstrated significantly lower mean values after Abalon for LDL cholesterol (10 +/- 15%, P < 0.05), LDL/UHDL ratio (12 +/- 18%, P < 0.05), apolipoprotein (apo) B100 (30 +/- 38%, P < 0.01), triglycerides (22 +/- 10%, P < 0.05), and homocysteine (14 +/- 21%, P < 0.01), whereas the total cholesterol value tended to be less significant but still lower (8 +/- 15%, P < 0.08). No change occurred in HDL cholesterol, apo B100/apo A1 ratio, plasminogen activator inhibitor 1, factor VIIc, von Willebrand factor, fibrinogen, lipoprotein(a), glucose, HbA1c, or 24-h blood pressure.

CONCLUSIONS

These results indicate beneficial effects of dietary supplementation with Abalon on cardiovascular risk markers in type 2 diabetic subjects. This improvement is seen even in individuals with near-normal lipid values.

Is carbohydrate deficient transferrin a useful marker of harmful alcohol intake among surgical patients?

OBJECTIVE

To find out whether the biological marker, carbohydrate deficient transferrin (CDT), was helpful in the detection of alcoholic patients in a surgical unit.

DESIGN

Prospective open study.

SETTING

Teaching hospital, Denmark.

SUBJECTS

286 men and 248 women admitted to the department of surgical gastroenterology between March and July 1996.

MAIN OUTCOME MEASURES

Specific interview about drinking and correlation with CDT concentration.

RESULTS

31 men (13%) and 10 women (3%) were alcoholic and at special risk of operation. The correlation between intake and CDT:transferrin ratio was 0.63 for men and 0.53 for women. The correlation between consumption and CDT was better, being 0.77 and 0.58, respectively. Younger women had the lowest correlation (0.33). Sensitivity of CDT for men and women was 100% and 80%, respectively; the specificity was 97% and 96%; the positive predictive value 82% and 44%; and the negative predictive value 97% and 99%.

CONCLUSION

CDT is a valid marker of harmful alcohol intake among surgical patients, except among younger women.

Input impedance of the lower abdominal aorta in chronically instrumented fetal sheep

Five fetal sheep (gestational age, 118 to 125 days) were instrumented to measure impedances of the lower abdominal aorta. Four days after surgery, flow and pressure pulses were recorded during control conditions and during infusion of norepinephrine (0.3 to 3 micrograms.min-1.kg-1 body weight) or angiotensin II (0.2 to 3 micrograms.min-1.kg-1). The protocol was repeated after injection of hexamethonium (10 mg.kg-1). Moduli and phases of impedances for the first ten harmonics were calculated by fast Fourier transformation. During control, input resistance was 4300 +/- 940 dyne.s.cm-5 (mean +/- SD) at a mean blood flow of 13.3 +/- 2.4 cm3.s-1 and pressure of 54,960 +/- 6980 dyne.cm-2. Moduli fell to 50% of input resistance between 2 and 3 Hz and, declining continuously, reached a minimum of 20% near 10 to 12 Hz, then increased slightly to 30% at about 30 Hz. At the first three harmonics, flow was always leading pressure. Infusion of angiotensin or norepinephrine increased impedance moduli significantly. Resistance increase was largest with angiotensin (19,800 +/- 11,370 dyne.s.cm-5), but no difference was detectable between angiotensin and norepinephrine when related to the same increase of input resistance. The position of the minimum seemed to be unchanged at high resistance values, but relative impedance moduli were smaller than during control, and low-frequency phases were significantly more negative. An analog of inertance, compliance, and resistance to steady flow was used to simulate impedances, and the effect of resistance increases on flow waveforms in the fetal abdominal aorta was calculated.(ABSTRACT TRUNCATED AT 250 WORDS)

Fetal sheep temperatures in utero during cooling and application of triiodothyronine, norepinephrine, propranolol and suxamethonium

Fetal sheep (n = 13) were chronically instrumented to measure temperatures in the maternal femoral artery (MAT), the amniotic fluid (AFT), the fetal brown adipose tissue (BFT) and the fetal arterial blood (DAT). Cooling loops were inserted into the amniotic cavity. In 4 fetuses osmotic minipumps delivering triiodothyronine (T3) were implanted subcutaneously. One to seven days after surgery the following results were obtained: 1) During control DAT was 0.59 +/- 0.2 degrees C (SD), BFT 0.60 +/- 0.24 degrees C and AFT 0.38 +/- 0.31 degrees C higher than MAT. T3 levels in treated fetuses were 3.4 +/- 1.5 micrograms/l. 2) Infusion of norepinephrine (NE) (5.2 +/- 0.9 micrograms/min per kg fetal body weight) with phentolamine (26.1 +/- 4.3 micrograms/min per kg) into a fetal vein did not change temperatures. 3) During cooling (-53 +/- 15 W) MAT decreased 0.45 +/- 0.3 degrees C, DAT 1.9 +/- 0.39 degrees C, BFT 1.61 +/- 0.52 degrees C and AFT 4.2 +/- 1.8 degrees C. 4) The amniotic fluid was cooled until steady state temperatures were achieved. Then propranolol (26.1 +/- 4.3 micrograms/min per kg) or suxamethonium (3 +/- 1 mg/kg) were introduced into the fetal vein. No consistent and significant changes of temperatures could be detected. It is concluded that 1) lowering the fetal core temperature by 1.6 - 1.9 degrees C and its ambient temperature (AFT) by 4.2 degrees C does not induce shivering or non-shivering thermogenesis suppressible by pharmacologic agents, 2) thermogenesis in fetal brown adipose tissue cannot be induced by NE (with or without supplemention of T3).(ABSTRACT TRUNCATED AT 250 WORDS)

[Prenatal diagnosis and therapy of fetal hemolytic disease with Rh incompatibility]

Between 1966 to 1984 a total of 636 intrauterine foetal transfusions were performed at the Hamburg University Hospital on 280 foetuses suffering from severe erythroblastosis. 54.6% of these foetuses survived. Ascitic fluid was found in 29,6% of the foetuses at the beginning of therapy. The survival rate improved to 22%.

[Prenatal diagnosis and therapy of hemolytic disease of the newborn]

From 1966 to 1983 a total of 586 intra-uterine fetal transfusions on 268 fetuses suffering from severe Rh-erythroblastosis were performed at the Hamburg university hospital. 149 (56%) fetuses survived. 29% of 268 fetuses exhibited ascitic fluid at the beginning of therapy. The survival rate improved to 63% in the last five years. The diagnostic and therapeutic procedures are explained in detail. The amniotic fluid analysis has been improved. In addition to Rh-antibodies, it is important to detect other blood group antibodies such as anti-Jk(a) and anti-Fy(a), that can diminish the survival rate of the donor erythrocytes in the fetus.

Congenital malformation syndromes and elevation of amniotic fluid alpha-fetoprotein

Fetal malformations may introduce complications of maternal pregnancy. A polyhydramnios represents one such complication during pregnancy. We want to report five abnormal pregnancies which were marked by acute polyhydramnios and/or premature labor due to an amniotic band syndrome associated with cerebral herniation in two cases, malignant oral teratoma in one case, bilateral cystic hygromas associated with generalized fetal hydrops in one case, and multiple internal malformations in one case alpha-fetoprotein (AFP) values between the 25th and 34th week of gestation were elevated 3.5 to 44 times the normal median value. Since all fetuses showed severe malformations incompatible with life our observations indicate the necessity to determine AFP in cases of acute polyhydramnios independent of the week of gestation. Conversely, elevated AFP levels in amniotic fluid obtained during prenatal diagnosis in the 16th week of gestation may also suggest rare fetal malformations outlined above.

Evidence for a specific transport of D-hexoses across the human term placenta in vitro

Isolated cotylidons of human term placentas are perfused artificially on the fetal and maternal side. The relative transfer rates of radioactive labelled D-glucose, L-glucose, D-mannose and D-mannitol across the placenta are measured and the inhibition of these transports by phloretin is studied: 1. Transfer rates of D-glucose and D-mannose exceed that of L-glucose about 1.5-4 times. 2. Phloretin (10(-3) mol/l) decreases the transports of D-hexoses, whereas the transport of L-GLUCOSE REMAINS UNAFFECTED. 3. If the concentration of D-glucose is increased, the transport of D-mannose is inhibited competitively. 4. L-glucose and D-mannitol equal in transfer rates. These results show, that D-hexoses cross the human placenta by a specific carrier and by simple diffusion.