Life-threatening hemorrhage following subcutaneous heparin therapy

Prophylactic administration of unfractionated heparin is a common practice in a perioperative period. Heparin monitoring with subcutaneous dosing is not recommended; however it becomes important in selected patients. We report a case of massive hemorrhage with subcutaneous heparin administration in an HIV-positive male patient with cachexia and mild liver dysfunction. Prolonged activated plasma thromboplastin time and thrombin time, but normal reptilase time well as response to protamine sulfate point towards the heparin effect. Inhibitor screen was negative and factor VIII activity was normal. All these rule out the possibility of acquired factor VIII inhibitor or any other inhibitor and confirm that this bleeding was due to heparin overdose. We believe that delayed clearance of UH secondary to possible involvement of reticuloendothelial system might have been be responsible for heparin overdose even though inadvertent administration of large dose of heparin intravenously can not be completely ruled out. Administration of unfractionated heparin to a patient with cachexia and abnormal liver function warrants close attention to heparin monitoring or switch to low molecular weight heparin since its mechanism of elimination differs

Classification of Complex Systems Based on Transients

In order to develop systems capable of modeling artificial life, we need to identify, which systems can produce complex behavior. We present a novel classification method applicable to any class of deterministic discrete space and time dynamical systems. The method distinguishes between different asymptotic behaviors of a system's average computation time before entering a loop. When applied to elementary cellular automata, we obtain classification results, which correlate very well with Wolfram's manual classification. Further, we use it to classify 2D cellular automata to show that our technique can easily be applied to more complex models of computation. We believe this classification method can help to develop systems, in which complex structures emerge.Comment: 9 page

Postoperative pulmonary embolism in a three year old with Klippel–Trenaunay syndrome

Massive pulmonary embolism (PE) in a small child is a rare event and unified guidelines for its treatment are missing. Timely diagnosis and management of massive pulmonary embolism is of crucial importance for a good outcome. We describe a unique management of PE causing oxygenation failure using a combination of catheter extraction technique, and regional thrombolysis on top of systemic heparin administration and inferior vena cava filter placement. Pulmonary hypertension was treated with inhaled nitric oxide. We believe that catheter extraction technique and regional thrombolysis is an option to consider provided that resources and expertise are available. Preoperative placement of an inferior vena cava filter should be contemplated in such high risk situations

Spiritual aspects of pedagogy Maria Montessori

HTF - Katedra učitelstvíHusitská teologická fakultaHussite Theological Facult

Analysis of thermal effects in endoscopic nanocarriers-based photodynamic therapy applied to esophageal diseases

In this work we propose a predictive model that allows the study of thermal effects produced when the optical radiation interacts with an esophageal or stomach disease with gold nanoparticles embedded. The model takes into account light distribution in the tumor tissue by means of a Monte Carlo method. Mie theory is used to obtain the gold nanoparticles optical properties and the thermal model employed is based on the bio-heat equation. The complete model was applied to two types of tumoral tissue (squamous cell carcinoma located in the esophagus and adenocarcinoma in the stomach) in order to study the thermal effects induced by the inclusion of gold nanoparticles.This work has been partially supported by the project MAT2012-38664-C02-01 of the Spanish Ministery of Economy and Competitiveness, by the Czech Grant Agency under grant P102/11/1376, by the Czech Ministry of Industry and Trade under grant FR-TI2/705, by the Czech Ministry of Education under grant LD12067, and by the EU COST Action IC1101

Postoperative pain management in children: Guidance from the pain committee of the European Society for Paediatric Anaesthesiology (ESPA Pain Management Ladder Initiative)

The main remit of the European Society for Paediatric Anaesthesiology (ESPA) Pain Committee is to improve the quality of pain management in children. The ESPA Pain Management Ladder is a clinical practice advisory based upon expert consensus to help to ensure a basic standard of perioperative pain management for all children. Further steps are suggested to improve pain management once a basic standard has been achieved. The guidance is grouped by the type of surgical procedure and layered to suggest basic, intermediate, and advanced pain management methods. The committee members are aware that there are marked differences in financial and personal resources in different institutions and countries and also considerable variations in the availability of analgesic drugs across Europe. We recommend that the guidance should be used as a framework to guide best practice

The Society for Pediatric Anesthesia recommendations for the use of opioids in children during the perioperative period

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/149726/1/pan13639_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/149726/2/pan13639.pd

Patient-directed self-management of pain (PaDSMaP) compared to treatment as usual following total knee replacement; a randomised controlled trial

Background Self-administration of medicines by patients whilst in hospital is being increasingly promoted despite little evidence to show the risks and benefits. Pain control after total knee replacement (TKR) is known to be poor. The aim of the study was to determine if patients operated on with a TKR who self-medicate their oral analgesics in the immediate post-operative period have better pain control than those who receive their pain control by nurse-led drug rounds (Treatment as Usual (TAU)). Methods A prospective, parallel design, open-label, randomised controlled trial comparing pain control in patient-directed self-management of pain (PaDSMaP) with nurse control of oral analgesia (TAU) after a TKR. Between July 2011 and March 2013, 144 self-medicating adults were recruited at a secondary care teaching hospital in the UK. TAU patients (n = 71) were given medications by a nurse after their TKR. PaDSMaP patients (n = 73) took oral medications for analgesia and co-morbidities after two 20 min training sessions reinforced with four booklets. Primary outcome was pain (100 mm visual analogue scale (VAS)) at 3 days following TKR surgery or at discharge (whichever came soonest). Seven patients did not undergo surgery for reasons unrelated to the study and were excluded from the intention-to-treat (ITT) analysis. Results ITT analysis did not detect any significant differences between the two groups’ pain scores. A per protocol (but underpowered) analysis of the 60% of patients able to self-medicate found reduced pain compared to the TAU group at day 3/discharge, (VAS -9.9 mm, 95% CI -18.7, − 1.1). One patient in the self-medicating group over-medicated but suffered no harm. Conclusion Self-medicating patients did not have better (lower) pain scores compared to the nurse-managed patients following TKR. This cohort of patients were elderly with multiple co-morbidities and may not be the ideal target group for self-medication