[Respiratory complications after transfusion]. / Les complications respiratoires de la transfusion.

Respiratory complications of blood transfusion have several possible causes. Transfusion-Associated Circulatory Overload (TACO) is often the first mentioned. Transfusion-Related Acute Lung Injury (TRALI), better defined since the consensus conference of Toronto in 2004, is rarely mentioned. French incidence is low. Non-hemolytic febrile reactions, allergies, infections and pulmonary embolism are also reported. The objective of this work was to determine the statistical importance of the different respiratory complications of blood transfusion. This work was conducted retrospectively on transfusion accidents in six health centers in Champagne-Ardenne, reported to Hemovigilance between 2000 and 2009 and having respiratory symptoms. The analysis of data was conducted by an expert committee. Eighty-three cases of respiratory complications are found (316,864 blood products). We have counted 26 TACO, 12 TRALI (only 6 cases were identified in the original investigation of Hemovigilance), 18 non-hemolytic febrile reactions, 16 cases of allergies, 5 transfusions transmitted bacterial infections and 2 pulmonary embolisms. Six new TRALI were diagnosed previously labeled TACO for 2 of them, allergy and infection in 2 other cases and diagnosis considered unknown for the last 2. Our study found an incidence of TRALI 2 times higher than that reported previously. Interpretation of the data by a multidisciplinary committee amended 20% of diagnoses. This study shows the imperfections of our system for reporting accidents of blood transfusion when a single observer analyses the medical records.

Case-control study on the survival of abutment teeth of partially dentate patients.

OBJECTIVES: Due to the scarce amount of data available, a retrospective analysis of patients treated with removable dental prostheses (RDPs) was performed. The aim of the trial was to evaluate the rate of repairs and failures of attachment-retained RDPs (AR-RDPs) compared to clasp-retained RDPs (CR-RDPs) with respect to cofactors (e.g., type of loading). In this respect, two hypotheses were proposed: AR-RDPs are more prone to repairs than CR-RDPs, and AR-RDPs are more prone to fail than CR-RDPs. MATERIALS AND METHOD: Two hundred three patients treated with 135 AR-RDPs and 68 CR-RDPs between 1994 and 2006 were evaluated in this trial. The dental treatment was carried out in the clinical training course of senior students. Kaplan-Meier estimates were calculated for the primary end point (repairs) and for the secondary end point (failures). RESULTS: The survival of CR-RDPs and AR-RDPs did show significant differences regarding repairs (p = 0.034) but not with regard to failures (p = 0.169). Prostheses of the non-axially loaded group showed no significant differences in the frequency of repairs and failures. CONCLUSIONS: Technical complications occurred more frequently in the CR-RDP group. Taking the higher observation time in the AR-RDP group into account, CR-RDPs are more prone to repairs, especially to those with technical background (e.g., fracture of the metal framework). CLINICAL RELEVANCE: The use of crowns with rod attachments on tilted teeth seems to be an appropriate treatment approach in order to simplify removable dental prosthesis design.

Carotenoid biosynthesis structural genes in carrot (Daucus carota): isolation, sequence-characterization, single nucleotide polymorphism (SNP) markers and genome mapping.

Carotenoid pigments are important components of the human diet and carrots are the main dietary sources of the vitamin A precursors alpha- and beta-carotene. Carotenoids play essential biological roles in plants and the genes coding for the carotenoid pathway enzymes are evolutionarily conserved, but little information exists about these genes for carrot. In this study, we utilized published carrot sequences as well as heterologous PCR approaches with primers derived from sequence information of other plant species to isolate 24 putative genes coding for carotenoid biosynthesis enzymes in carrot. Twenty-two of these genes were placed on the carrot genetic linkage map developed from a cross between orange-rooted and white-rooted carrot. The carotenoid genes were distributed in eight of the nine linkage groups in the carrot genome recommending their use for merging maps. Two genes co-localized with a genomic region spanning one of the most significant quantitative trait loci (QTL) for carotenoid accumulation. Carotenoid biosynthesis cDNAs linked to root color mutations and to QTL for carotenoid accumulation may suggest a functional role for them as candidate genes. RACE PCR and reverse transcriptase PCR were used to amplify the full-length transcript for twenty expressed carotenoid biosynthesis genes and sequences were submitted to GenBank. The cloning and sequence information of these genes is useful for PCR-based expression studies and may point toward transgenic approaches to manipulate carotenoid content in carrot.

Seizure induced by ropivacaine.

OBJECTIVE: To report development of a seizure after administration of ropivacaine. CASE SUMMARY: A 26-year-old woman was scheduled for a cesarean section because of a stagnation of the uterine neck dilatation after 4.5 hours. After peridural administration of 279 mg of ropivacaine (total dose) over five hours, she presented with oculogyric movements and slurred speech that preceded convulsions of the face and of the upper limbs. DISCUSSION: Convulsions are well-known complications of local anesthetics. Ropivacaine, a relatively new agent, is considered safer for the central nervous system. Currently, there are only four published reports that implicate ropivacaine as being associated with convulsions. The likelihood that ropivacaine caused the seizure in our patient was possible based on the Naranjo probability scale. CONCLUSIONS: Clinicians should be aware of the possibility of seizures as an adverse effect of ropivacaine.

Riluzole series. Synthesis and in vivo "antiglutamate" activity of 6-substituted-2-benzothiazolamines and 3-substituted-2-imino-benzothiazolines.

Two series of analogues of riluzole, a blocker of excitatory amino acid mediated neurotransmission, have been synthesized: monosubstituted 2-benzothiazolamines and 3-substituted derivatives. Of all the compounds prepared in the first series, only 2-benzothiazolamines bearing alkyl, polyfluoroalkyl, or polyfluoroalkoxy substituents in the 6-position showed potent anticonvulsant activity against administration of glutamic acid in rats. The most active compounds displaying in vivo "antiglutamate" activity were the 6-OCF(3) (riluzole), 6-OCF(2)CF(3), 6-CF(3), and 6-CF(2)CF(3) substituted derivatives with ED(50) values between 2.5 and 3.2 mg/kg i.p. Among the second series of variously substituted benzothiazolines, compounds as active as riluzole or up to 3 times more potent were identified in two series: benzothiazolines bearing a beta-dialkylaminoethyl moiety and compounds with an alkylthioalkyl chain and their corresponding sulfoxides and sulfones. The most potent derivatives were 2-imino-3-(2-methylthio)- and 2-imino-3-(2-methylsulfinyl)-ethyl-6-trifluoromethoxybenzothiazolines (61 and 64, ED(50) = 1.0 and 1.1 mg/kg i.p., respectively). In addition, intraperitoneal administration of some of the best benzothiazolines protected mice from mortality produced by hypobaric hypoxia.

A comprehensive school-based clinic: university and community partnership.

PURPOSE: To describe the evolution and current status of a university and community partnership engaged in operating an urban elementary school-based clinic (SBC) POPULATION: The children at the school who are eligible to receive care at the SBC include 500 elementary students and 200 adolescents who attend a magnet junior high school housed in the same building. The vast majority of the children attending the school are from families whose incomes are below the national poverty level. Eighty-five percent of the children are black. Fifteen percent are Hispanic, non-white. CONCLUSIONS: A variety of services and programs are offered to the children and their families for the promotion of health and the prevention of mental disorders. Service, education, and research occur simultaneously to achieve the multiple goals of the partners and participants. PRACTICE IMPLICATIONS: Advanced practice nurses can provide quality health and mental health care services for school-age children and their families through SBCs. Institutional partnerships, capitalizing on each other's strengths, can expand the availability of SBC offerings.

Effect of neostigmine at different levels of mivacurium-induced neuromuscular blockade.

The effectiveness of neostigmine 40 micrograms/kg for antagonism of two different levels of neuromuscular blockade, induced by a bolus dose of mivacurium 0.15 mg/kg, was studied in 45 patients. The patients were anaesthetized with thiopentone, fentanyl, nitrous oxide in oxygen, and enflurane. Neostigmine was administered at either 10% recovery of the twitch height (TH10) at the adductor pollicis muscle (n = 14) or upon reappearance of the first response at the orbicularis oculi muscle (OO1) after train-of-four (TOF) stimulation (n = 16), the latter representing a deeper degree of neuromuscular blockade. Fifteen of the 45 patients did not receive neostigmine (control group). Neostigmine administration at OO1 rather than at TH10 at the adductor pollicis muscle caused reversal of neuromuscular blockade to occur 8 min earlier and shortened the time to reach 25% recovery of the twitch height (TH25) at the adductor pollicis muscle by about 5 min, compared with the control group. However, the time needed to reach a T4/T1 ratio > or = 0.8 was similar in both the early and late neostigmine administration groups, being 9 min faster than in the control group. It can be concluded that there is no advantage in administering neostigmine at profound neuromuscular blockade to achieve clinically adequate recovery (T4/T1 ratio > or = 0.8). However, the time between injection of mivacurium and TH25 may be shortened by using neostigmine at profound neuromuscular blockade, a procedure which may be useful in case of unpredictably difficult intubation, since diaphragmatic movements usually reappear at TH25.

Glutamine metabolism in healthy adult men: response to enteral and intravenous feeding.

To assess the effect of feeding on glutamine kinetics, six healthy men received 4-h intravenous infusions of L-[2-15N]glutamine and L-[1-13C]leucine on 3 separate days: 1) in the postabsorptive state, 2) over the course of an 8-h nasogastric infusion of a small peptide-based nutrient mixture, and 3) during an 8-h isonitrogenous, isoenergetic intravenous infusion (1.5 g amino acid.kg-1.d-1; 130 kJ.kg-1.d-1, or 31 kcal.kg-1.d-1; 58% carbohydrate and 42% fat). Regardless of the route, nutrition increased leucine appearance rate (Ra) and oxidation, stimulated protein synthesis, and improved leucine balance; apparent rates of protein breakdown decreased during enteral nutrition only. Glutamine Ra increased 16.8% (NS) and 26.2% (P < 0.01) with parenteral and enteral feeding, respectively, over postabsorptive values. The present findings are consistent with a major role of glutamine in interorgan nitrogen transport in the fed state and further suggest that increased availability of precursors may stimulate glutamine synthesis de novo, and enteral infusion of peptide-bound amino acids may be an effective route to provide free glutamine to the rest of the body.

Leg warming minimizes core hypothermia during abdominal surgery.

The efficacy of leg skin warming in preventing hypothermia and shivering was evaluated in two separate prospective, randomized trials in patients undergoing abdominal surgery. In the first trial, 22 patients were randomized to receive no hypothermia prevention (control group) or active warming with an electric warming blanket (electric blanket group). In the second trial 33 patients were randomized to receive no hypothermia prevention (control group) or forced-air warming (Bair Hugger group) or forced-air warming with insulation of the air blanket from the environment (insulated Bair Hugger group). The core and skin temperatures were measured and changes in body heat content calculated. In the first trial, core temperature was 34.6 +/- 0.3 degrees C at the end of surgery in the control group vs 36.4 +/- 0.1 degrees C in the electric warming blanket group (P < 0.001). Shivering occurred in nine control patients and in one warmed patient (P < 0.05). In the second trial, core temperature was 35.1 +/- 0.2 degrees C at the end of surgery in the control group, 36.3 +/- 0.1 degrees C in the Bair Hugger group (P < 0.01) and 37.1 +/- 0.1 degrees C in the insulated Bair Hugger group (P < 0.01 versus control; P < 0.05 versus Bair Hugger). Shivering occurred in one patient of each warmed group and in seven of the control group (P < 0.05). Skin-surface warming limited to the legs provides sufficient heat (ranging 34 to 43 watts) to counterbalance heat losses during abdominal surgery.

Prevention of intraoperative hypothermia by preoperative skin-surface warming.

BACKGROUND: Intraoperative hypothermia initially results from internal redistribution of heat facilitated by anesthesia-induced vasodilation. Preinduction skin-surface warming minimizes postinduction hypothermia in anesthetized volunteers. However, its efficacy might be reduced in surgical situations, because of multiple sources of heat loss. METHODS: Intraoperative core and mean skin temperatures were measured during total hip arthroplasty in 16 patients, randomly assigned to be covered preoperatively with a warming blanket for > or = 90 min (prewarmed group) or not covered (unwarmed group). RESULTS: During the first hour of anesthesia, core temperature decreased more than twice as much in the unwarmed group (-0.7 +/- 0.1 degree C; mean +/- SE) than in the prewarmed patients (-0.3 +/- 0.1 degree C). At the end of surgery, core temperature was 36.3 +/- 0.1 degree C in the prewarmed group and 35.2 +/- 0.2 degree C in the unwarmed group. During recovery, seven patients obviously shivered in the unwarmed group and none in the prewarmed group. CONCLUSIONS: Preanesthetic skin-surface warming reduces the initial postinduction hypothermia in surgical patients, preventing intraoperative hypothermia and postoperative shivering even for procedures lasting 3 h or longer.

Oxygen uptake during recovery following naloxone. Relationship with intraoperative heat loss.

The increased metabolic and respiratory demand during naloxone recovery from opioid-based anesthesia could be related to the return of thermoregulation in hypothermic patients and thus be avoided by preventing intraoperative hypothermia. In this study, we measured O2 uptake (VO2) during naloxone-induced recovery in two groups of patients to determine the effect of intraoperative heat loss on postoperative VO2 changes. In seven patients, intraoperative hypothermia was prevented (normothermic group), whereas hypothermia was allowed to develop in seven other patients (hypothermic group). Core and skin temperatures were measured throughout the study to calculate changes in body heat content. Before naloxone antagonism of fentanyl-supplemented anesthesia, core temperature (mean +/- SEM) was 36.8 +/- 0.1 degrees C in the normothermic group and 34.2 +/- 0.2 degrees C in the hypothermic group (P less than 0.001). After titrated administration of naloxone during recovery, VO2 and minute ventilation (VE) increased in the hypothermic group, by 114 +/- 37% and 97 +/- 52% respectively (P less than 0.05), with a three-fold increase in four patients. In the normothermic group, VO2 increased significantly less (25 +/- 5%), without any significant change in VE. The change in VO2 and VE was significantly greater in patients who were hypothermic. VO2 was integrated throughout the recovery period to calculate recovery energy expenditure. Recovery energy expenditure and intraoperative heat loss were highly correlated (r = 0.88; P less than 0.01). This study demonstrates that the metabolic and respiratory stresses associated with naloxone-induced recovery from opioid-based anesthesia depend on the intraoperative heat loss and can therefore be reduced by preventing intraoperative hypothermia.

Oral nutrition in patients receiving home cyclic parenteral nutrition: pattern of substrate utilization.

Patients receiving cyclic home parenteral nutrition (PN) often have a significant oral caloric intake. This study describes the metabolic use of fuels, as assessed by indirect calorimetry, in eight stable, ambulatory, noncancerous, adult patients receiving glucose-based PN with (PN + oral) or without (PN only) a self-selected oral intake. Patients' weight was 91 +/- 2% (mean +/- SE) of ideal body weight, and fat mass was 22 +/- 5 and 31 +/- 2% of actual body weight in males and females, respectively. Under the PN-only regimen, providing 104 +/- 5% of predicted basal energy expenditure (BEE), patients were in equilibrium for energy and nitrogen balances. Oral supplementation (absorbed oral intake 80 +/- 5% of BEE) was associated with positive energy and nitrogen balances but also with nearly continuous net fat synthesis. We conclude that the glucose-based PN + mixed oral regimen enables the patients to face the increased energy requirements of everyday ambulatory life but is not associated with an optimal body composition in long-term PN patients.

Glutamine metabolism after small intestinal resection in humans.

Glutamine and leucine kinetics were measured using stable isotopes in five enterectomized patients (residual small bowel, 80 +/- 25 cm [mean +/- SE]) who were in a near normal nutritional status at distance from surgery. While parameters of leucine metabolism were normal, rates of whole body glutamine utilization were reduced by 20% in the patients. The data suggest that the small intestine plays a prominent role in glutamine utilization in vivo in humans.

Use of a ventilated canopy for assessment of [13C]leucine oxidation in patients receiving total parenteral nutrition.

Rates of oxidation of infused 13C-labeled substrates are calculated from CO2 production and 13C enrichment in breath CO2. Breath sampling through a mouthpiece is not appropriate in severely ill patients; the authors therefore validated the use of direct air sampling from the ventilated canopy of an indirect calorimeter for measuring the oxidation of 13C-labeled substrates. Infusions of H13CO3Na or L-[1-13C]leucine were performed in four healthy postabsorptive adults and six malnourished patients receiving total parenteral nutrition (TPN). At each sampling point, air was collected from the canopy to compare with breath air sampled through a mouthpiece and 13CO2 enrichment determined by isotope ratio mass spectrometry. Despite five-fold dilution of expired air by room air within the canopy (a dilution required to maintain safe CO2 levels in inspired air): (1) Breath 13CO2 enrichment was accurately predicted using samples from the canopy, with a correction taking into account the measured CO2 fractions in canopy and room air; (2) the precision in isotopic determination was similar with both methods (SD/mean of 12 determinations = 2.5 +/- 1.0% vs 3.0 +/- 1.0%). These data demonstrate that the use of a ventilated canopy allows for combined assessment of energy expenditure and rates of oxidation of 13C-labeled substrates even in sick, debilitated patients receiving total parenteral nutrition.