Trauma-induced coagulopathy. A narrative review of goal-directed hemostatic resuscitation

Post-traumatic haemorrhage is the leading cause of death in trauma patients. The development of coagulopathy substantially contributes to bleeding severity and to the ensuing unfavourable outcome. Trauma-induced coagulopathy (TIC) can be seen in 10-25% of patients with major trauma, and its early and appropriate therapeutic management leads to considerable reduction of mortality risk. Due to the extreme complexity of TIC pathophysiology, the limitations of conventional coagulation tests (CCTs) have become evident in recent years. Unlike these routine tests, point of care viscoelastic tests (VET) such as thromboelastogram (TEG) or rotational thromboelastography (ROTEM) provide valuable clinical information by real time assessment of changes in viscoelastic properties of blood throughout clot formation. This review was aimed to collect and discuss available evidence on goal-directed hemostatic resuscitation, based on TEG or ROTEM data. We included studies with patients aged 18 years or older, major trauma, and needing massive transfusions. Overall, 6 studies totalling 1533 patients were finally included. A total number of 288 patients died, 98 of whom in the TEG- or ROTEM-guided cohorts (i.e., intervention groups). A 36% reduction of death was observed in the intervention groups (relative risk, 0.641; 95% CI 0.517-0.795; P<0.001). Our results show that VET-guided management is effective to reduce mortality compared to conventional management with CCTs. Except for mortality, all others endpoints were heterogeneous across the studies. This emphasize the need of scheduling new and well-designed trials, aimed to better define the optimal strategy for TIC management

Trauma-induced coagulopathy. A narrative review of goal-directed hemostatic resuscitation

Post-traumatic haemorrhage is the leading cause of death in trauma patients. The development of coagulopathy substantially contributes to bleeding severity and to the ensuing unfavourable outcome. Trauma-induced coagulopathy (TIC) can be seen in 10-25% of patients with major trauma, and its early and appropriate therapeutic management leads to considerable reduction of mortality risk. Due to the extreme complexity of TIC pathophysiology, the limitations of conventional coagulation tests (CCTs) have become evident in recent years. Unlike these routine tests, point of care viscoelastic tests (VET) such as thromboelastogram (TEG) or rotational thromboelastography (ROTEM) provide valuable clinical information by real time assessment of changes in viscoelastic properties of blood throughout clot formation. This review was aimed to collect and discuss available evidence on goal-directed hemostatic resuscitation, based on TEG or ROTEM data. We included studies with patients aged 18 years or older, major trauma, and needing massive transfusions. Overall, 6 studies totalling 1533 patients were finally included. A total number of 288 patients died, 98 of whom in the TEG- or ROTEM-guided cohorts (i.e., intervention groups). A 36% reduction of death was observed in the intervention groups (relative risk, 0.641; 95% CI 0.517-0.795; P<0.001). Our results show that VET-guided management is effective to reduce mortality compared to conventional management with CCTs. Except for mortality, all others endpoints were heterogeneous across the studies. This emphasize the need of scheduling new and well-designed trials, aimed to better define the optimal strategy for TIC management

Dietary habits in women with recurrent idiopathic calcium nephrolithiasis

Nutrition has been widely recognized to influence the risk of kidney stone formation. Therefore the aim of our study was to assess: a) whether usual diet of women with idiopathic calcium nephrolithiasis (ICN) living in Parma (Northern-Italy) is different compared to healthy controls, b) how their diet differs from Italian National guidelines and c) whether it is related to nephrolithiasis clinical course

Is anticoagulant therapy always indicated in "medium-risk" patients with first diagnosed atrial fibrillation? Insights from a real world, 10-year observational study

BACKGROUND: The choice of antithrombotic prophylaxis in the so-called "medium-risk" patients (i.e., CHA2DS2-VASc score\u202f=\u202f1 in males or 2 in females) is one of the major enigmatic issues in clinical management of atrial fibrillation (AF). METHODS: We retrospectively evaluated 30-day and 1-year thromboembolic events in all consecutive medium-risk patients visited for first diagnosed AF in the local Emergency Department during a 10-year period. The main aim was to establish whether anticoagulant or antiplatelet therapy was effective to lower the thromboembolic risk in patients receiving these drugs. Bleeding events, related to anticoagulant or antiplatelet therapy, was defined as secondary end point. RESULTS: The final study population consisted of 6389 (3640 males and 2749 females) patients for whom a complete dataset regarding targeted follow-up was available. Patients were then subdivided into two subgroups, according to performance of cardioversion and spontaneous sinus rhythm restoring. In both genders, no significant difference in thromboembolic or bleeding events was noted between patients who underwent cardioversion and were discharged with oral anticoagulant therapy or antiplatelet treatment versus those who were not treated with antithrombotic drugs. Moreover, no difference was also observed in thromboembolic or hemorrhagic event rate between low risk and "medium-risk" patients. CONCLUSIONS: The results of this study suggest that anticoagulant or antiplatelet therapy would not produce clinical benefits in "medium-risk" AF patients

Transient global amnesia

Transient Global Amnesia (TGA) is a clinical syndrome characterized by temporary inability to form new memories described as anterograde amnesia. It is associated with retrograde amnesia and repetitive questioning. During the attack patients remain conscious and communicative and personal identity is preserved. Focal neurological symptoms and epileptic features are absent and general conditions appear intact. The ability to store new memories gradually recovers and subjects return to normal conditions except for a substantial amnestic gap for the duration of the attack. TGA has an incidence of 3-8 per 100 000 people per year. It usually affects patients between the ages of 50 and 70 years, at an average age of 61 years; occurrence in patients younger than 40 years of age is rare. The rate of recurrence is between 6% and 10% per years. No gender prevalence has been recorded. The patients with definite TGA have a very good prognosis; their rate of subsequent major vascular events is less than 1% per year

Exacerbations of severe asthma: a focus on steroid therapy

Bronchial asthma remains one of the most common chronic diseases in the world; approximately 10% of patients shows exacerbations severe enough to be judged life-threatening, whereas around 2-20% of patients are admitted to the Intensive Care Unit (ICU). Acute severe asthma is a dangerous condition where the deterioration of the asthmatic exacerbation usually progresses over days or weeks, although in a few patients over hours or even minutes. Morbidity and mortality are mainly related to the underestimation of the severity of the exacerbation, delay in referring to hospital and inadequate emergency treatment. The cornerstone measures of therapy for acute severe asthma are oxygen supplementation, as to achieve arterial saturation >90%, and repetitive or continuous administration of bronchodilators (short-acting inhaled β2-agonists and ipratropium bromide) and corticosteroids. Despite extensive clinical experience in treatment of chronic asthma with steroids, there is considerable uncertainty about the accurate use of these agents for treatment of acute severe asthma in emergency settings

Neutrophil gelatinase-associated lipocalin (NGAL): a promising biomarker for the early diagnosis of acute kidney injury (AKI)

Acute kidney injury (AKI) is a common complication that occurs in a broad spectrum of clinical settings. Cardiac surgery-associated AKI continues to be a well-recognized complication of cardiac surgery with high morbidity and mortality. The lack of early biomarkers has for long prevented timely interventions to mitigate the effects of AKI. Serum creatinine is not a timely marker of AKI, so that it cannot be used to set potentially effective therapies to treat AKI in patients during phases when the injury is still potentially reversible. Neutrophil gelatinase-associated lipocalin (NGAL) has been identified as a promising biomarker for early detection of AKI. Several studies have shown that NGAL levels significantly increase in AKI patients 24 to 48 hours before a detectable increase of serum creatinine. Recent studies also suggest that measurements of urinary NGAL levels in patients at risk for cardiac surgery-associated AKI may facilitate its early diagnosis and allow clinicians to implement therapeutic adjustments that have the potential to reverse renal cellular damage and minimize further kidney injury

Indapamide therapy and hypercalciuric idiopathic calcium nephrolithiasis recurrences

Background – Idiopathic calcium nephrolithiasis (ICN) is a high-prevalence disease characterized by high recurrence rate. Hypercalciuria (>4 mg/kg/24h) is the main urinary risk factor. Indapamide, a thiazide-like diuretic, can be an effective treatment for lowering calcium excretion, although some subjects may still experience recurrences. The reasons of these therapeutical failures are still poorly known. Aims – Our aim was to evaluate urinary factors linked to kidney stone recurrences on indapamide therapy, the minimum effective indapamide dose and the effect of concurrent therapies. Methods – At the Stone Clinic of Parma University Hospital, Italy, we retrospectively evaluated all the clinical records from 1987 to 2012 of patients with ICN, hypercalciuria, at least one stone relapse, treated with indapamide and subdued to a full urinary profile of lithogenic risk (comprehensive of 24-hour urinary calcium, sodium, oxalate, phosphorus, ammonium, citrate and potassium excretion) before and after treatment. We collected urinary data, concurrent therapies (i.e. potassium citrate or allopurinol), indapamide dose (2.5 mg/day or 1.5 mg/day) and possible follow-up recurrences. Data were analyzed with multivariate statistic, binary logistic regression and discriminating analysis where appropriate. Results –68 patients (48M, age 46±10) responded to inclusion criteria. Mean follow-up period was 13 months. 11 patients (6M) had recurrences during follow-up, showing significantly higher values of ammonium (46±12 vs 37±11 mEq/24h, p=0.023) and sodium (208±62 vs 167±75 mEq/24h, p=0.045) excretion than non-recurrent patients in the follow-up lithogenic profile. Discriminating analysis confirmed that high follow-up sodiuria and ammoniuria are predictive of recurrences on indapamide therapy (standardized canonical coefficient >0.2, p=0.007). Concurrent treatment with potassium citrate or allopurinol did not affect the risk of recurrence. Indapamide was equally effective in lowering calciuria both at high doses (2.5 mg/day, 23 patients, calciuria 462 ± 145 vs 301 ± 155 mg/24h, p<0.001) and at low doses (1.5 mg/day, 45 patients, calciuria 453±116 vs 293±119 mg/24h, p<0.001). Conclusions – A high urinary ammonium and sodium excretion, indexes respectively of animal protein and salt intake, can be major predictors of recurrence in patients with ICN and hypercalciuria on indapamide therapy. Indapamide is anyway an effective therapy for lowering calcium excretion in recurrent ICN at any dosage