Epistaxis in anticoagulated patients: Fewer hospital admissions and shorter hospital stays on rivaroxaban compared to phenprocoumon.

OBJECTIVES: Treatment of epistaxis in patients on anticoagulants is challenging and associated with higher admission rates and longer hospital stays compared with patients without anticoagulation. However, there is little information about epistaxis in patients taking new direct oral anticoagulants such as rivaroxaban compared with patients on traditional vitamin K antagonists such as phenprocoumon. DESIGN: Retrospective cohort study. SETTING: The study was conducted at the emergency department of the University Hospital Inselspital, Bern, Switzerland. PARTICIPANTS: All admissions to the emergency department of the University Hospital Inselspital, Bern, Switzerland from 1st July 2012 to 30th June 2016 with non-traumatic epistaxis on anticoagulant therapy with phenprocoumon or rivaroxaban were included. MAIN OUTCOME MEASURES: We compared clinical outcome parameters (admission rates, length of hospital stay and mortality) for both anticoagulant groups. RESULTS: We included 440 patients with epistaxis, 123 (28%) on rivaroxaban and 317 (72%) on phenprocoumon. Fewer hospital admissions and shorter hospital stays were found in patients under rivaroxaban (12 (10.4%) vs 57 (18.0%) patients, P=.033; 0.7±2.2 vs 1.5±3.7 days, P=.011) compared with phenprocoumon. Anterior epistaxis was more common in the rivaroxaban group in contrast to posterior epistaxis in patients on phenprocoumon (74 (60.2%) vs 139 (43.8%) patients, P=.002; 7 (5.7%) vs 39 (12.3%) patients, P=.042). CONCLUSIONS: Our data suggests that epistaxis on direct oral anticoagulation with rivaroxaban is associated with shorter hospital stays and fewer hospital admissions than epistaxis on vitamin K antagonist phenprocoumon.

Bilateral lingual artery stenosis: A rare, late complication of chemoradiotherapy.

INTRODUCTION: Carotid artery stenosis following radiotherapy (RT) is a known risk factor for the development of cerebrovascular disease with a risk of subsequent stroke or transient ischaemic attack. In contrast, small vessel disease in the neck following RT has been more rarely described. CASE REPORT: The authors report the case of a 61-year-old man who developed partial lingual necrosis 4 years after surgery and postoperative chemoradiotherapy for squamous cell carcinoma of the floor of the mouth. Contrast-enhanced CT scan confirmed subtotal to total occlusion of both lingual arteries. Surgical debridement of the necrosis allowed complete cure of the lesions. DISCUSSION: Small vessel disease is a possible complication in patients treated by RT for head and neck cancer. Although the risk of these complications is not directly related to the total radiation dose, higher doses appear to accelerate the development of vascular lesions. Practitioners must be aware of the possibility of these complications, especially in patients surviving more than 5 years.

Genetic algorithm for shift-uncertainty correction in 1-D NMR-based metabolite identifications and quantifications.

MOTIVATION: The analysis of metabolic processes is becoming increasingly important to our understanding of complex biological systems and disease states. Nuclear magnetic resonance spectroscopy (NMR) is a particularly relevant technology in this respect, since the NMR signals provide a quantitative measure of the metabolite concentrations. However, due to the complexity of the spectra typical of biological samples, the demands of clinical and high-throughput analysis will only be fully met by a system capable of reliable, automatic processing of the spectra. An initial step in this direction has been taken by Targeted Profiling (TP), employing a set of known and predicted metabolite signatures fitted against the signal. However, an accurate fitting procedure for (1)H NMR data is complicated by shift uncertainties in the peak systems caused by measurement imperfections. These uncertainties have a large impact on the accuracy of identification and quantification and currently require compensation by very time consuming manual interactions. Here, we present an approach, termed Extended Targeted Profiling (ETP), that estimates shift uncertainties based on a genetic algorithm (GA) combined with a least squares optimization (LSQO). The estimated shifts are used to correct the known metabolite signatures leading to significantly improved identification and quantification. In this way, use of the automated system significantly reduces the effort normally associated with manual processing and paves the way for reliable, high-throughput analysis of complex NMR spectra. RESULTS: The results indicate that using simultaneous shift uncertainty correction and least squares fitting significantly improves the identification and quantification results for (1)H NMR data in comparison to the standard targeted profiling approach and compares favorably with the results obtained by manual expert analysis. Preservation of the functional structure of the NMR spectra makes this approach more realistic than simple binning strategies.

Evaluation of a new point-of-care test for influenza A and B virus in travellers with influenza-like symptoms.

Point-of-care (POC) tests for influenza facilitate clinical case management, and might also be helpful in the care of travellers who are at special risk for influenza infection. To evaluate influenza POC testing in travellers, a new assay, the ImmunoCard STAT! Flu A and B, was used to investigate travellers presenting with influenza-like symptoms. Influenza virus infection was diagnosed in 27 (13%) of 203 patients by influenza virus-specific PCR and viral culture. The POC test had sensitivity and specificity values of 64% and 99% for influenza A, and 67% and 100% for influenza B, respectively. Combined sensitivity and specificity were 67% and 99%, respectively, yielding positive and negative predictive values of 95%, and positive and negative likelihood ratios of 117 and 0.34, respectively. The convenient application, excellent specificity and high positive likelihood ratio of the POC test allowed rapid identification of influenza cases. However, negative test results might require confirmation by other methods because of limitations in sensitivity. Overall, influenza POC testing appeared to be a useful tool for the management of travellers with influenza-like symptoms.

Sensitivity and specificity of a new commercial enzyme-linked immunoassay kit for detecting Entamoeba histolytica IgG antibodies in serum samples.

The study presented here was conducted to evaluate the performance of the newly available RIDASCREEN Set (R-Biopharm AG, Darmstadt, Germany) for the detection of immunoglobulin G antibodies against Entamoeba histolytica. The sensitivity and specificity of this new enzyme-linked immunosorbent assay were evaluated using a panel of sera from 239 individuals. The assay was positive for 43 of 44 patients with invasive amebiasis, including all 18 patients with amebic liver abscess, while it was negative for 190 of 195 adult controls who were either healthy individuals or patients with other parasitic diseases. The kit was found to be highly specific (97.4%) and sensitive (97.7%) for detecting antibodies against E. histolytica in humans. Although antibody titers in patients with amebic liver abscess tend to be higher on average than in patients with invasive amebiasis, it is not possible to distinguish the two forms solely based on the results of this commercial test.

Desflurane inhibits platelet function in vitro similar to halothane.

BACKGROUND AND OBJECTIVE: The effects of the volatile anaesthetic desflurane on platelet activation in vitro were studied and compared to those of halothane. METHODS: Platelet-rich plasma was exposed to 2 MAC of desflurane or halothane, or air only and stimulated by platelet agonists ADP (2.5, 5 and 10 micromol L(-10) and collagen (10 microg m(L-1)). Platelet response was measured by Born aggregometry (maximum aggregation response, area under the curve) and flow cytometry (mean channel fluorescence, percentage of CD62P-positive cells, index of platelet activation for positive platelets). RESULTS: Aggregation response was significantly reduced in platelets exposed to desflurane or halothane; the inhibitory effect was more pronounced when the areas under the curve were analysed: values ranged from 37.5% to 73.3% of control samples for ADP stimulation and 77.1% to 79.8% for collagen stimulation. CD62P expression before and after stimulation with receptor agonists was not statistically different in platelets exposed to desflurane, halothane or air. CONCLUSIONS: By impairing platelet aggregation while not affecting alpha-degranulation desflurane has a differential effect on various aspects of platelet activation similar to halothane. Our results are compatible with the hypothesis of an impairment of platelet thromboxane receptor signalling by halothane. We suggest a similar mechanism for desflurane.

Pseudocholinesterase-activity reduction during cardiopulmonary bypass: the role of dilutional processes and pharmacological agents.

UNLABELLED: 1. Pseudocholinesterase (ChE) activity is a determinant of the elimination kinetics of several drugs used in anesthesia. The time course of ChE activity was investigated in 16 patients undergoing cardiosurgery for a cardiopulmonary bypass (CPB) in normothermia or hypothermia. 2. The onset of the CPB was accompanied by a decrease in ChE activity (-37%) (P<0.05) and protein concentration (-24%) (P<0.05). The quotient ChE activity/protein concentration was numerically reduced to a smaller extent (-15%) (P>0.05). After the CPB was finished, ChE activity and the protein concentration remained low for the remaining operation time. 3. There was no difference in ChE activity, measured in vitro at 37 degrees C, between the normothermic and hypothermic group (P>0.05). 4. There was no correlation between heparin concentration in serum and reduction of ChE activity in vitro (P>0.05). In vitro, the ChE activity was not affected by either heparin in doses as high as 10,000 U/ml or aprotinin in doses as high as 10,000 U/ml (P>0.05). 5. CONCLUSIONS: (1) ChE activity is reduced by CPB mainly by hemodilution and (2) the pharmacological agents used in the present anesthetic technique (heparin, aprotinin, midazolam, fentanyl, propofol and mivacurium) do not inhibit ChE activity at therapeutic serum concentrations.

Efficacy of oral iron supplementation is not enhanced by additional intravenous iron during autologous blood donation.

BACKGROUND: The study compared the efficacy of oral iron combined with intravenous iron supplementation to that of oral iron supplementation alone in increasing the preoperative production of hemoglobin (Hb) in autologous blood donors with normal iron stores. STUDY DESIGN AND METHODS: One hundred eight iron-replete patients who were scheduled for donation of 3 units of autologous blood at weekly intervals were randomly assigned to receive, in a double-blind fashion, no iron supplementation (placebo, Group 1), oral iron supplementation (285.6 mg of elemental iron/day, Group 2), or oral iron plus intravenous iron supplementation (285.6 mg of elemental iron/day orally plus 102.5 mg of elemental iron/week intravenously, Group 3). The amount of Hb produced during the 21-day study period was determined by the total amount of Hb donated minus the change in the amount of circulating Hb between the first donation (Day 0) and the poststudy examination (Day 21). RESULTS: Hb production did not differ significantly in the two iron-supplemented groups (oral iron, 85 +/- 36 g; oral plus intravenous iron, 74 +/- 43 g). The patients in the oral iron group produced a significantly greater amount of Hb than those in the placebo group (85 +/- 36 g vs. 52 +/- 41 g, p < 0.01). CONCLUSION: Oral iron supplementation increased the production of Hb in autologous blood donors more than placebo did. Additional intravenous iron did not lead to a further increase in preoperative Hb production.

Confocal analysis of hepatocellular long-chain fatty acid uptake.

Transmembrane transport and cytosolic accumulation of fatty acids were investigated using confocal laser scanning microscopy (cLSM). A Zeiss LSM 310 system was used to determine the uptake of the fluorescent fatty acid derivative 12-(N-methyl)-N-[(7-nitrobenz-2-oxa-1,3- diazol-4-yl)amino]octadecanoic acid (12-NBD stearate) (C18) in single rat hepatocytes. Uptake was a saturable process with a Michaelis-Menten constant value of 68 nM. Initial uptake velocity was dependent on extracellular presence of albumin and beta-lactoglobulin. Absence of albumin reduced uptake to 32 +/- 16% (P < 0.01) of control values. In the presence of unlabeled stearate, uptake of 12-NBD stearate was lowered to 49 +/- 12% (P < 0.01). Ion substitution experiments showed no sodium dependency of uptake. Increase in membrane potential led to a pronounced accumulation of the fatty acid derivative within the plasma membrane and in the adjacent cytoplasmic compartment, whereas membrane depolarization had no effect on uptake rates. In separate experiments line scans through representative hepatocytes were analyzed to generate "x-t" plots. 12-NBD stearate showed a fluorescence pattern with prominent staining of the area of the plasma membrane and the adjacent cytoplasm, dependent on the presence of extracellular albumin. For the hepatocellular cytosolic accumulation process of 12-NBD stearate a diffusion constant of 22.2 +/- 6.2 x 10(-9) cm2/s was calculated. In contrast to the long-chain fatty acid derivative 12-NBD stearate, short (C5)- and medium (C11)-chain fatty acids revealed no membrane interaction with hepatocytes. Erythrocytes also lacked a membrane interaction process for 12-NBD stearate. In conclusion, it was demonstrated that cLSM is capable of directly evaluating the cellular fatty acid uptake process at a subcellular level.

The influence of various anesthetics on the release and metabolism of thyroid hormones: results of two clinical studies.

Normal functioning of the thyroid gland during surgery is important, but few data are available on the possible interactions between anesthesia and thyroid hormones. In two independent studies we examined the influence of different types of general anesthesia on the plasma levels of the thyroid hormones. They revealed an intraoperative increase of free thyroxine (fT4) and total thyroxine (tT4) in plasma to approximately 150% of preanesthesia levels when enflurane was used. No increase in thyroid-stimulating hormone (TSH) secretion was noted prior to this. The increase was not due to a quantitative change in the binding proteins. The plasma levels of fT4 and tT4 returned to normal postoperatively; however, no accompanying increase in plasma triiodothyronine levels was observed. Hence we assume the increase to be due to hormone release from thyroid and/or extrathyroidal stores--an intercompartmental shifting.

Corticotropin-releasing hormone enables weaning from ventilator in a neurosurgical patient under long-term controlled mechanical respiratory support.

A patient with recurrent hemorrhage into the posterior fossa leading to loss of central respiratory drive is described. Repeated i.v. application of corticotropin-releasing hormone over a period of 24 days enabled weaning from long-term controlled mechanical ventilation by reinstitution and maintenance of spontaneous respiration.

Lesions of the sensorimotor region: somatosensory evoked potentials and ultrasound guided surgery.

In 10 patients with lesions of the sensorimotor cortex cortical SEP were registered to identify the postcentral gyrus, and intra-operative ultrasound sonography served to locate the lesion. The combination of both techniques helped to find the optimal approach to the lesion. Postoperative results were considered favourable, as only one patient suffered transient postoperative deterioration, six were unchanged and in three patients the pre-operative motor deficits were improved. The combination of intra-operative ultrasound and neurophysiological identification of the sensorimotor cortex is concluded as being useful in surgery within this region.

[Sudden deafness and the craniocervical transition]. / Hörsturz und kraniozervikaler Ubergang.

Morphological alterations of the cranio-cervical junction as a basilar impression, a ponticulus posterior, an atlas assimilation, an intervertebral narrowing, and spondylosis deformans were found radiologically. There was no difference to a healthy population. This means there are no correlations between static morphological changes of the craniocervical junction and sudden deafness. However, there was a statistically significant reduced mobility in the upper cervical spine in patients suffering from sudden deafness. Especially very high standard deviations in the atlanto-occipital and the atlanto-dental joint are interpreted as hypermobile as well hypomobile atlas joints. These results indicate a correlation between sudden deafness and functional pathology of the craniocervical junction.

[Heparin elimination and free hemoglobin following cell separation and washing of autologous blood with Cell Saver 4]. / Heparin-Elimination und freies Hämoglobin nach Zellseparation und Waschen autologen Blutes mit dem Cell-Saver 4.

Haemoseparation is used for recovery of autologous blood following cardiac surgery protecting patients from various hazards accompanying homologous blood transfusion. Former studies demonstrated that autotransfusion did not increase blood loss after cardiac surgery despite reduced plasma and platelets following centrifugation and washing of oxygenator content. The purpose of our study was to determine the content of heparin and unbound haemoglobin in autologous packed red cells. METHODS. 10 consenting patients undergoing cardiac surgery (table 1) were investigated. Immediately after termination of bypass blood samples were collected from the oxygenator and from autologous blood following concentration and washing with saline solution in the Haemonetics Cell-Saver 4. Contents of haemoglobin, haematocrit, heparin - with and without addition of antithrombine III - and unbound haemoglobin were analysed. RESULTS. Mean duration of extracorporeal circulation was 100.4 minutes. The oxygenators' volume averaged 2089.9 ml blood with a haemoglobin content of 6.7 g/dl and a haematocrit of 20.4%. This was reduced to 660.8 ml autologous blood with a haemoglobin content of 17.9 g/dl and a haematocrit of 57.2% (table 2). The heparin content of the oxygenator blood was 0.47 U/ml without AT III, and with AT III 0.87 U/ml. Autologous blood contained 0.009 U/ml without AT III; with AT III we measured 0.41 U/ml heparin. Unbound haemoglobin content amounted to 11.4 mg/dl in the oxygenator blood and 71.8 mg/dl in the autologous blood (table 3). CONCLUSIONS. Our results demonstrate that autologous blood following concentration and washing of the oxygenator blood with a Haemonetics Cell-Saver 4 contains heparin, but the amount of heparin is not enough to provoke bleeding after retransfusion.(ABSTRACT TRUNCATED AT 250 WORDS)

[Effect of nimodipine on plasma catecholamines and perioperative endocrine stress parameters]. / Der Einfluss von Nimodipin auf Plasma-Katecholamine und perioperative endokrine Stress-Parameter.

The influence of nimodipine on plasma-catecholamines, ADH, ACTH and cortisol during standardized, modified neurolept-anaesthesia was investigated in 20 patients for major abdominal and thoracic surgery. The application of nimodipine led to an intra- and postoperative increase in both adrenaline and noradrenaline. No influence could be demonstrated on ADH, ACTH or cortisol. Group-levels of MAP were lower in the nimodipine-group. No statistical differences became obvious for HR, glucose, lactate and free glycerol. The increases in adrenaline and noradrenaline can be attributed to a cardiocirculatory rebound-phenomenon due to the vasodilative properties of the substance. Under the conditions of adequate fentanylanalgesia, no influence of nimodipine on ADH, ACTH or cortisol was found.