Rotational thrombelastometry: a step forward to safer patient care?

Purpose – This article aims to analyse the discourse about khat in the Swedish newspaper media and to present the concept of moral entrepreneurship as a useful analytical tool for understanding mobilisation against khat use in the Somali diaspora.Design/methodology/approach – The material analysed consists of daily newspaper articles about khat published between 1986 and 2012. The method of analysis is inspired by the critical discourse analysis framework developed by Norman Fairclough. Drawing on Howard S. Becker's concept of moral entrepreneur, the article focuses on anti-khat campaigners who speak out against khat in the media. These are often representatives from Somali voluntary associations or organisations, who sometimes employ moral entrepreneurship. The article discusses these actors' role in framing khat use as a tangible threat to the Somali community in Sweden.Findings – When employing moral entrepreneurship, anti-khat campaigners spread a certain type of knowledge about khat that is presented to the general public via the media. The key issues that repeatedly are of concern are how khat destroys Somali families and how the use might spread to other groups. In this manner khat use is constructed as a threat to Somali social cohesion. The knowledge produced could potentially influence policy makers to introduce stricter punishments for possession, sale and use of khat, thereby possibly increasing stigma and marginalisation in relation to the Somali immigrant community.Originality/value – The literature about khat has pointed to the centrality of Somali organisations mobilising against khat in the diaspora. This article presents moral entrepreneurship as a theoretical tool to further the understanding of the mobilisation against khat and its use

The Edge of Unknown: Postoperative Critical Care in Liver Transplantation

Perioperative care of patients undergoing liver transplantation (LT) is very complex. Metabolic derangements, hypothermia, coagulopathy and thromboses, severe infections, and graft dysfunction can affect outcomes. In this manuscript, we discuss several perioperative problems that can be encountered in LT recipients. The authors present the most up-to-date information regarding predicting and treating hemodynamic instability, coagulation monitoring and management, postoperative ventilation strategies and early extubation, management of infections, and ESLD-related pulmonary complications. In addition, early post-transplant allograft dysfunction will be discussed

Elevated Pre- and Postoperative ROTEM™ Clot Lysis Indices Indicate Reduced Clot Retraction and Increased Mortality in Patients Undergoing Liver Transplantation

Background: The ROTEM™ clot lysis index, describing the decrease in firmness of a clot with time, predicts mortality in various settings. The variability of the clot lysis index in surgical procedures and the involved pathophysiological mechanisms are unknown. We therefore compared pre- and postoperative clot lysis indices in liver transplantation (LTX) procedures, determined the eventual association with mortality, and investigated the mechanisms underlying decreased clot lysis index using inhibitors of fibrinolysis and clot retraction, respectively. Methods: In this retrospective cohort study, data on pre- and post-transplant ROTEM™ findings as obtained with EXTEM (tissue factor activation), INTEM (intrinsic system activation), FIBTEM (extrinsic system activation and inhibition of clot retraction), APTEM (extrinsic system activation and fibrinolysis inhibition), conventional laboratory coagulation tests, blood loss, transfusion of blood products, and outcome were registered. Results: Pre-transplant clot lysis indices showed a broad distribution ranging from 75% to 99% independent of the activator used (EXTEM, INTEM). During the surgical procedure, median clot lysis index values markedly increased from 92% to 97% (EXTEM) and 93% to 98% (INTEM), respectively (p < 0.0001 each). Aprotinin had no effect on either pre- or postsurgical clot lysis indices. Inhibition of platelet clot retraction with cytochalasin D (FIBTEM) markedly increased the preoperative clot lysis index. High pre- and post-transplantation clot lysis indices were associated with increased mortality irrespective of the activator used (EXTEM, INTEM) and the inhibition of fibrinolysis (APTEM). Inhibition of clot retraction (FIBTEM) abolished the association of clot lysis index with mortality in both pre- and post-transplantation samples. Conclusion: Both pre- and postoperative ROTEM™ clot lysis indices predict mortality in patients following liver transplantation. Inhibitor experiments reveal that the clot lysis index is not an indicator of fibrinolysis, but indicates platelet clot retraction. The marked increase of clot lysis index during liver transplantation is caused by a decrease in clot retraction with eventual consequences for clot stability, retraction of wound margins, and reperfusion of vessels in case of thrombosis

Acquired Hemophilia A: A Permanent Challenge for All Physicians

Acquired hemophilia A (AHA) is a rare disease with a prevalence in Europe of 1.5 per million. This diagnosis is significantly delayed in about one-third of all cases, leading to deferred treatment. The main signs of AHA are spontaneous bleeding seen in about two-thirds of all patients. AHA can be lethal in 20% of all symptomatic cases. This patient population’s main standard laboratory finding is a prolonged aPTT (activated prothrombin Time) with otherwise normal coagulation results. In addition, antibodies against FVIII (in Bethesda Units) and a quantitative reduction of FVIII activity are necessary to confirm AHA. The therapy of acute bleeding related to AHA is based on the following main principles: Pharmacologic control of the bleeding is of absolute importance. It can be achieved by administering either recombinant activated FVIIa “bypass therapy”; activated prothrombin complex; or Emicizumab, a bispecific monoclonal antibody. Eradication of the FVIII antibodies should be initiated simultaneously. The combination of steroids with cyclophosphamide leads to the highest eradication rates. Causes of AHA may be related to neoplasms, autoimmune diseases, and pregnancy. We report on a patient who underwent four surgical procedures before the diagnosis of AHA was established

Aspergillus Tracheobronchitis Causing Subtotal Tracheal Stenosis in a Liver Transplant Recipient

Invasive aspergillosis is recognized as one of the most significant opportunistic infections after liver transplantation. Diagnosis of invasive aspergillosis in transplant recipients has been proven to be challenging, and optimal approach to the treatment of invasive aspergillosis is still controversial. We here present an unusual case of Aspergillus tracheobronchitis in the setting of liver transplantation. A 47-year-old female patient with persistent dry cough after liver transplantation developed respiratory insufficiency and was readmitted to the intensive care unit 55 days after liver transplantation. A CT scan revealed subtotal tracheal stenosis; bronchoscopy was performed, and extended white mucus coverings causative of the tracheal stenosis were removed. Microbiological assessment isolated Aspergillus fumigatus. The diagnosis was obstructive Aspergillus tracheobronchitis. The patient was started on a treatment of voriconazole 200 mg orally twice daily, adjusted to a trough level of 1–4 mg/L. For further airway management, a tracheal stent had to be implanted. The patient is alive and well 28 months after liver transplantation. Invasive aspergillosis should be considered a possible etiology in liver transplant patients presenting with unspecific symptoms such as persistent dry cough. Optimal strategies for improved and early diagnosis as well as prophylaxis need to be defined

Limits and pitfalls of haemodynamic monitoring systems in liver transplantation surgery.

Cardiac output (CO) and other hemodynamic variables measured during liver transplantation are often obtained by pulmonary artery catheter (PAC) and in many centers by the transthoracic thermodilution method and/or intraop- erative transesophageal echocardiography (TEE). Newer non-invasive technology, such as the PiCCO\uae system, the LiDCO\uae Plus monitor, and the FloTrac/Vigileo\uae, have been proposed as more reflective of ongoing hemodynamic response to intraoperative manoeuvres. In contrast to the standard \u201csemicontinuous\u201d thermodilution method, which gives information over a set period of time, the new monitoring systems use a different time period or measure over a running several beat average. It has been stated that algorithms based on arterial pulse contour analysis can poten- tially facilitate rapid diagnosis and prompt therapeutic interventions. However, as the use of these technologies has spread, so has the understanding of their limitations. This has led to an increased scepticism among the previously enthusiastic \u201cpioneering\u201d practitioners. Given the poor agreement reported in various studies on liver transplant surgery between PAC and the new \u201ccalibrated\u201d and \u201cuncalibrated\u201d-derived measurements, multicenter trials aiming at evaluating the performance of the non-invasive methods in different hemodynamic conditions and dedicated monitoring-driven treatment protocols are necessary