Aetiology of preoperative anaemia in patients undergoing elective cardiac surgery-the challenge of pillar one of Patient Blood Management.

Preoperative anaemia is common in patients undergoing cardiac surgery. Whilst there is a strong association with increased morbidity and mortality, it is currently unclear whether treatment of anaemia leads to patient benefit. This retrospective study aimed to determine the aetiology of preoperative anaemia in a cohort of patients undergoing elective cardiac surgery over two years at a tertiary hospital. Laboratory data obtained at the preoperative assessment clinic visit were assessed to stratify patients into four groups-iron deficiency anaemia (IDA), possible IDA, anaemia of chronic disease (ACD) and non-anaemic patients with low ferritin according to the 'Preoperative haemoglobin assessment and optimisation template' of the Australian Patient Blood Management (PBM) Guidelines. Of patients with preoperative anaemia, 23.1% had IDA, 6.6% had possible IDA and 70.3% had possible ACD. Of the patients with possible ACD, 30% had a ferritin <100 µg/l, representing limited iron stores or coexisting absolute iron deficiency in the setting of chronic disease. In addition, 46.2% of those with possible ACD had iron studies indicative of functional iron deficiency. Time between assessment and surgery was as little as one day in a third of patients and in only 7% was it more than seven days. Our findings indicate that about one-third of our patients with preoperative anaemia had evidence of iron deficiency, a potentially reversible cause of anaemia. In addition, a significant number had either limited iron stores that may render them iron deficient by surgery, or a functional iron deficiency.

Joint functional impairment and thermal alterations in patients with Psoriatic Arthritis: A thermal imaging study.

BACKGROUND: Functional infrared imaging (fIRI) is used to provide information on circulation, thermal properties and thermoregulatory function of the cutaneous tissue in several clinical settings. OBJECTIVES: This study aims to evaluate the application of fIRI in Psoriatic Arthritis (PsA) assessment, evaluating the thermoregulatory alterations due to joint inflammation in PsA patients both in basal conditions and after a mild functional (isometric) exercise; fIRI outcomes were compared with those provided by Power Doppler Ultrasonography (PWD-US). METHODS: 10 patients with PsA and 11 healthy controls were enrolled in the study. The cutaneous temperature dynamics of 20 regions of interest located on the dominant hand were recorded by means of high-resolution thermal imaging at baseline and after a functional exercise. RESULTS: Higher temperature values and faster temperature variations characterized the PsA group compared to healthy controls, confirming that the PsA-related inflammatory state alters the normal thermal proprieties of the skin overlying inflamed joints. fIRI outcomes correlated with the PWD-US findings. CONCLUSIONS: fIRI applied to the study of the response to a functional stimulus may represent an innovative, non-invasive, and operator-independent method for the assessment of peripheral PsA.

Evaluation of the retinal nerve fibre layer and ganglion cell complex thickness in pituitary macroadenomas without optic chiasmal compression.

PURPOSE: The aim of this prospective study was to measure the thickness of the circumpapillary retinal nerve fibre layer (cpRNFL) and the ganglion cell complex (GCC) using spectral domain optical coherence tomography (SD-OCT) in a cohort of consecutive de novo patients with pituitary macroadenomas without chiasmal compression. PATIENTS AND METHODS: Twenty-two consecutive patients with pituitary macroadenoma without chiasmal compression (16 men, 6 women, aged 45.2±14.6 years, 43 eyes) entered the study between September 2011 and June 2013. Among them, 31.8% harboured a growth hormone-secreting pituitary adenoma, 27.3% a prolactin-secreting pituitary adenoma, 27.3% a corticotrophin-secreting pituitary adenoma, and 13.6% a non-secreting pituitary tumour. Eighteen subjects (nine females, nine males, mean age 36.47±6.37 years; 33 eyes) without pituitary adenoma, with normal ophthalmic examination, served as controls. In both patients and controls, cpRNFL and GCC thicknesses were measured by SD-OCT. RESULTS: Patients were significantly older (P=0.02) than controls. Best corrected visual acuity, intraocular pressure, colour fundus photography, and automatic perimetry test were within the normal range in patients and controls. Conversely, cpRNFL (P=0.009) and GCC (P<0.0001) were significantly thinner in patients than in controls. The average GCC (r=0.306, P=0.046) significantly correlated with the presence of arterial hypertension. OCT parameters did not differ significantly between patients with a tumour volume above the median and those with a tumour volume below the median. CONCLUSION: Pituitary macroadenomas, even in the absence of chiasmal compression, may induce GCC and retinal nerve fibre layer thinning. SD-OCT may have a role in the early diagnosis and management of patients with pituitary tumours.

The prevalence of anaemia, hypochromia and microcytosis in preoperative cardiac surgical patients.

This retrospective study aimed to determine the prevalence of preoperative anaemia, hypochromia and microcytosis in cardiac surgery patients. Data was analysed for 943 patients (over a two-year period) undergoing coronary artery bypass graft, valve or combined coronary artery bypass graft and valve surgery at a tertiary hospital in South Australia. Overall prevalence of preoperative anaemia was 25.2%, greater in males than females (27.6 vs 19.9%, P <0.01). Of patients with preoperative anaemia, 19.3% had reduced red cell indices (mean corpuscular haemoglobin and/or mean corpuscular volume) compared to 4% of patients without anaemia. The proportion of anaemic patients with low red cell indices was significantly higher in women <50 years and 50-65 years, compared to those >65 years of age (P=0.003). Anaemic patients with low red cell indices had lower preoperative haemoglobin than anaemic patients without low red cell indices (median haemoglobin 112 vs 120 g/l, P=0.008). Compared to non-anaemic patients, anaemic patients had higher transfusion rates (79.8 vs 46.4%, P <0.0001), which were greater in those with reduced red cell indices compared to those with normal red cell indices (93.5 vs 76.6%, P=0.01). This study demonstrated a high prevalence of preoperative anaemia, microcytosis and hypochromia in cardiac surgical patients.

Propofol infusion syndrome.

The clinical features of propofol infusion syndrome (PRIS) are acute refractory bradycardia leading to asystole, in the presence of one or more of the following: metabolic acidosis (base deficit > 10 mmol.l(-1)), rhabdomyolysis, hyperlipidaemia, and enlarged or fatty liver. There is an association between PRIS and propofol infusions at doses higher than 4 mg.kg(-1).h(-1) for greater than 48 h duration. Sixty-one patients with PRIS have been recorded in the literature, with deaths in 20 paediatric and 18 adult patients. Seven of these patients (four paediatric and three adult patients) developed PRIS during anaesthesia. It is proposed that the syndrome may be caused by either a direct mitochondrial respiratory chain inhibition or impaired mitochondrial fatty acid metabolism mediated by propofol. An early sign of cardiac instability associated with the syndrome is the development of right bundle branch block with convex-curved ('coved type') ST elevation in the right praecordial leads (V1 to V3) of the electrocardiogram. Predisposing factors include young age, severe critical illness of central nervous system or respiratory origin, exogenous catecholamine or glucocorticoid administration, inadequate carbohydrate intake and subclinical mitochondrial disease. Treatment options are limited. Haemodialysis or haemoperfusion with cardiorespiratory support has been the most successful treatment.

Joint and Soft Tissue Injection

Injection techniques are helpful for diagnosis and therapy in a wide variety of musculoskeletal conditions. Diagnostic indications include the aspiration of fluid for analysis and the assessment of pain relief and increased range of motion as a diagnostic tool. Therapeutic indications include the delivery of local anaesthetics for pain relief and the delivery of corticosteroids for suppression of inflammation. Side effects are few; but may include tendon rupture; infection; steroid flare; hypopigmentation; and soft tissue atrophy. Injection technique requires knowledge of anatomy of the targeted area and a thorough understanding of the agents used. In this overview; the indications; contraindications; potential side effects; timing; proper technique; necessary materials; pharmaceuticals used and their actions; and post-procedure care of patients are presented

Diagnostic and Therapeutic Injection of the Shoulder Region

The shoulder is the site of multiple injuries and inflammatory conditions that lend themselves to diagnostic and therapeutic injection. Joint injection should be considered after other therapeutic interventions such as non-steroidal anti-inflammatory drugs; physical therapy; and activity-modification have been tried. Indications for glenohumeral joint injection include osteoarthritis; adhesive capsulitis; and rheumatoid arthritis. For the acromioclavicular joint; injection may be used for diagnosis and treatment of osteoarthritis and distal clavicular osteolysis. Subacromial injections are useful for a range of conditions including adhesive capsulitis; subdeltoid bursitis; impingement syndrome; and rotator cuff tendinosis. Scapulothoracic injections are reserved for inflammation of the involved bursa. Persistent pain related to inflammatory conditions of the long head of the biceps responds well to injection in the region. The proper technique; choice and quantity of pharmaceuticals; and appropriate follow-up are essential for effective outcomes

Grade III acromioclavicular joint injury in Australian Rules Football.

We have reviewed fourteen Australian Rules Football players who were seen consecutively by a single surgeon with grade III acromioclavicular joint injuries between January 1993-June 1997. After discussion at initial consultation eight players elected for non-operative management and six for operative management. Two players in the non-operative group subsequently underwent surgical reconstruction after failure of non-operative treatment. The mean return time to non-contact training was 2.4 weeks (range 1-4, S.D. 1.52) in the non-operative group and 6.3 weeks (range 3.5-10, S.D. 2.99) in the operative group. However return to sports specific training (contact training) was at a mean of 20.8 weeks (range 10-32. S.D. 8.56) in the non-operative group and 13.6 weeks (range 6-24. S.D. 7.06) in the operative group. Return to competitive football matches for the non-operative group was at a mean of 26.2 weeks (range 10-34,S.D. 8.84) and 18.8 weeks (9.5-28. S.D. 8.05) for those treated operatively. These results were not statistically significant. At final follow up the subjective scores for the current overall condition of the shoulder when compared to the uninjured side, were 72.5 (range 20-100, S:D.24.9) for the non operative group and 87.3 (range 75-100, S:D.10.61) for the operative group and this difference was also not statistically significant. Conclusions in this study are limited by small numbers and lack of statistically significant results. The results show a trend towards faster return to ARF and a more satisfactory outcome for patients undergoing surgery compared to their non operative cohorts.

A family of centromeric satellite DNAs from the European brown frog Rana graeca italica.

Digestion of Rana graeca italica DNA with Asp 718I produces highly repetitive fragments of 281 and 385 bp that were cloned and sequenced. The shorter fragment corresponds to the unit repeat (RgiS1b) of a satellite DNA. The longer fragment was found to be part of a 494-bp repeat of another satellite DNA (RgiS1a) that was cloned intact as an EcoRV fragment. RgiS1b is 97% homologous to RgiS1a, from which it seems to be derived by a single deletion. Among all species tested, only the related brown frog Rana dalmatina contained homologous repetitive DNA. The overall number of RgiS1a and RgiS1b repeats per R. graeca italica haploid genome was estimated to be 2.7 x 10(5). RgiS1a and RgiS1b repeats are organized in separate arrays, but repetitive units formed by various combinations of the two repeats were also observed on Southern blots. The amount of these extra repeats varies greatly among animals from the same population, representing a rare case of individual variability in the satellite DNA organization. FISH with probes specific for both satellites, or for RgiS1a only, labeled the centromeric and pericentromeric heterochromatin of all chromosomes. This indicated that RgiS1a and RgiS1b are interspersed within the same heterochromatic regions of the chromosomes.

Hierarchical order in a satellite DNA from the European brown frog Rana dalmatina.

We have cloned and sequenced a 341 bp EcoRV fragment of a repetitive DNA from the European brown frog Rana dalmatina. This fragment contained 11 copies in tandem of the 31 bp long repeat of a satellite DNA, that was named RdS2. RdS2 is species-specific, is not A+T rich and represents about 0.24% of the frog genome (3.5 x 10(5) copies of repeats per haploid genome). Southern blots of Rana dalmatina. DNA partially digested with EcoRV and RsaI indicated that RdS2 also contains high-order repeats with periodicities varying from 10 to 26 copies of the 31 bp unit repeat. Thus, RdS2 appears to have a hierarchical order like a number of satellite DNAs from other vertebrate and invertebrate genomes.

Cloning and preliminary characterization of two satellite-like DNA sequences from the brown frog Rana graeca.

Two repetitive DNA sequences of about 0.29 Kb and 0.39 Kb have been isolated from Rana graeca genomic DNA by digestion with Asp718I and have been cloned in pTZ18R. Hybridization data obtained with DNA probes derived from these clones indicate that: i) both sequences are highly repetitive and species-specific; ii) the two sequences are partially homologous; iii) the 0.29 Kb sequence is present in the frog genome with the typical tandem organization of satellite DNA; iv) the 0.39 Kb sequence is presumably part of a longer repetitive sequence of satellite DNA.