In vitro factor XIII supplementation increases clot firmness in Rotation Thromboelastometry (ROTEM®)

Factor XIII (F XIII) is an essential parameter for final clot stability. The purpose of this study was to determine the impact of the addition of factor (F)XIII on clot stability as assessed by Rotation Thromboelastometry (ROTEM(R)). In 90 intensive care patients ROTEM(R) measurements were performed after in vitro addition of F XIII 0.32 IU, 0.63 IU, 1.25 IU and compared to diluent controls (DC; aqua injectabile) resulting in approximate F XIII concentrations of 150, 300 and 600%. Baseline measurements without any additions were also performed. The following ROTEM(R) parameters were measured in FIBTEM and EXTEM tests: clotting time (CT), clot formation time (CFT), maximum clot firmness (MCF), maximum lysis (ML), maximum clot elasticity (MCE) and a-angle (aA). Additionally, laboratory values for FXIII, fibrinogen (FBG), platelets and haematocrit were contemporaneously determined. In the perioperative patient population mean FBG concentration was elevated at 5.2 g/l and mean FXIII concentration was low at 62%. The addition of FXIII led to a FBG concentration-dependent increase in MCF both in FIBTEM and EXTEM. Mean increases in MCF (FXIII vs. DC) of approximately 7 mm and 6 mm were observed in FIBTEM and EXTEM, respectively. F XIII addition also led to decreased CFT, increased aA, and reduced ML in FIBTEM and EXTEM. In vitro supplementation of FXIII to supraphysiologic levels increases maximum clot firmness, accelerates clot formation and increases clot stability in EXTEM and FIBTEM as assayed by ROTEM(R) in perioperative patients with high fibrinogen and low FXIII levels

Relative concentrations of haemostatic factors and cytokines in solvent/detergent-treated and fresh-frozen plasma

Background Indications, efficacy, and safety of plasma products are highly debated. We compared the concentrations of haemostatic proteins and cytokines in solvent/detergent-treated plasma (SDP) and fresh-frozen plasma (FFP). Methods Concentrations of the following parameters were measured in 25 SDP and FFP samples: fibrinogen (FBG), factor (F) II, F V, F VII, F VIII, F IX, F X, F XIII, von Willebrand factor (vWF), D-Dimers, ADAMTS-13 protease, tumour necrosis factor-α (TNF-α), interleukin (IL)-1β, IL-6, IL-8, and IL-10. Results Mean FBG concentrations in SDP and FFP were similar, but in FFP, the range was larger than in SDP (P<0.01). Mean F II, F VII, F VIII, F IX, and F XIII levels did not differ significantly. Higher concentrations of F V (P<0.01), F X (P<0.05), vWF (P<0.01), and ADAMTS-13 (P<0.01) were found in FFP. With the exception of F VIII and F IX, the range of concentrations for all of these factors was smaller (P<0.05) in SDP than in FFP. Concentrations of TNF-α, IL-8, and IL-10 (all P<0.01) were higher in FFP than in SDP, again with a higher variability and thus larger ranges (P<0.01). Conclusions Coagulation factor content is similar for SDP and FFP, with notable exceptions of less F V, vWF, and ADAMTS-13 in SDP. Cytokine concentrations (TNFα, IL-8, and IL-10) were significantly higher in FFP. The clinical relevance of these findings needs to be established in outcome studie

Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations.

Background and purpose - There is a large volume of heterogeneous studies across all Enhanced Recovery After Surgery (ERAS®) components within total hip and total knee replacement surgery. This multidisciplinary consensus review summarizes the literature, and proposes recommendations for the perioperative care of patients undergoing total hip replacement and total knee replacement with an ERAS program.Methods - Studies were selected with particular attention being paid to meta-analyses, randomized controlled trials, and large prospective cohort studies that evaluated the efficacy of individual items of the perioperative treatment pathway to expedite the achievement of discharge criteria. A consensus recommendation was reached by the group after critical appraisal of the literature.Results - This consensus statement includes 17 topic areas. Best practice includes optimizing preoperative patient education, anesthetic technique, and transfusion strategy, in combination with an opioid-sparing multimodal analgesic approach and early mobilization. There is insufficient evidence to recommend that one surgical technique (type of approach, use of a minimally invasive technique, prosthesis choice, or use of computer-assisted surgery) over another will independently effect achievement of discharge criteria.Interpretation - Based on the evidence available for each element of perioperative care pathways, the ERAS® Society presents a comprehensive consensus review, for the perioperative care of patients undergoing total hip replacement and total knee replacement surgery within an ERAS® program. This unified protocol should now be further evaluated in order to refine the protocol and verify the strength of these recommendations

Detection, evaluation, and management of preoperative anaemia in the elective orthopaedic surgical patient: NATA guidelines

Previously undiagnosed anaemia is common in elective orthopaedic surgical patients and is associated with increased likelihood of blood transfusion and increased perioperative morbidity and mortality. A standardized approach for the detection, evaluation, and management of anaemia in this setting has been identified as an unmet medical need. A multidisciplinary panel of physicians was convened by the Network for Advancement of Transfusion Alternatives (NATA) with the aim of developing practice guidelines for the detection, evaluation, and management of preoperative anaemia in elective orthopaedic surgery. A systematic literature review and critical evaluation of the evidence was performed, and recommendations were formulated according to the method proposed by the Grades of Recommendation Assessment, Development and Evaluation (GRADE) Working Group. We recommend that elective orthopaedic surgical patients have a haemoglobin (Hb) level determination 28 days before the scheduled surgical procedure if possible (Grade 1C). We suggest that the patient's target Hb before elective surgery be within the normal range, according to the World Health Organization criteria (Grade 2C). We recommend further laboratory testing to evaluate anaemia for nutritional deficiencies, chronic renal insufficiency, and/or chronic inflammatory disease (Grade 1C). We recommend that nutritional deficiencies be treated (Grade 1C). We suggest that erythropoiesis-stimulating agents be used for anaemic patients in whom nutritional deficiencies have been ruled out, corrected, or both (Grade 2A). Anaemia should be viewed as a serious and treatable medical condition, rather than simply an abnormal laboratory value. Implementation of anaemia management in the elective orthopaedic surgery setting will improve patient outcomes

Vampires in the village Žrnovo on the island of Korčula: following an archival document from the 18th century

Središnja tema rada usmjerena je na raščlambu spisa pohranjenog u Državnom arhivu u Mlecima (fond: Capi del Consiglio de’ Dieci: Lettere di Rettori e di altre cariche) koji se odnosi na događaj iz 1748. godine u korčulanskom selu Žrnovo, kada su mještani – vjerujući da su se pojavili vampiri – oskvrnuli nekoliko mjesnih grobova. U radu se podrobno iznose osnovni podaci iz spisa te rečeni događaj analizira u širem društvenom kontekstu i prate se lokalna vjerovanja.The main interest of this essay is the analysis of the document from the State Archive in Venice (file: Capi del Consiglio de’ Dieci: Lettere di Rettori e di altre cariche) which is connected with the episode from 1748 when the inhabitants of the village Žrnove on the island of Korčula in Croatia opened tombs on the local cemetery in the fear of the vampires treating. This essay try to show some social circumstances connected with this event as well as a local vernacular tradition concerning superstitions

Rotation thromboelastometry (ROTEM®) stability and reproducibility over time

Background: Thromboelastometry is a whole blood assay performed to evaluate the viscoelastic properties during blood clot formation and lysis. Rotation thromboelastography (ROTEM((R)), Pentapharm GmbH, Munich, Germany) has overcome some of the limitations of classic thromboelastography. So far, no clinical validation on reproducibility (inter- and intra-assay variability) and sample stability over time has been published. Methods: To evaluate the pre-analytic aspects, sample stability over time was assessed in 48 patients in eight age groups. Citrated blood was stored at room temperature. Tests measured every 30min from T 0min up to T 120min on two ROTEM((R)) devices were INTEM (ellagic acid activated intrinsic pathway), EXTEM (tissue factor-triggered extrinsic pathway) and FIBTEM (with platelet inhibitor (cytochalasin D) evaluating the contribution of fibrinogen to clot formation). Precision by intra- and inter-assay variability was evaluated at two points of time in 10 volunteers. Finally, reference intervals and effect of age and sex were evaluated. Results: Blood was stable over 120min and no significant differences in ROTEM((R)) results were found. Maximum clot firmness measurements had a coefficient of variation of <3% for EXTEM, <5% for INTEM and <6% for FIBTEM. For clot formation time, the coefficient of variation was <4% for EXTEM and <3% for INTEM. Coefficient of variation for angle alpha was <3% for EXTEM and <6% for INTEM. The coefficient of variation for clotting time was <15% for both EXTEM and INTEM. Small but significant differences between ROTEM((R)) devices were found for maximum clot firmness in FIBTEM and INTEM as well as clot formation time and alpha angle in INTEM. Conclusions: ROTEM((R)) yields stable results over 120min with a minimal variability on the same ROTEM((R)) device. However, small but significant differences between ROTEM((R)) devices were observed. Analysis should be performed on the same ROTEM((R)) device if small differences are of importance for treatment

Analysis of Ocular Firework-Related Injuries and Common Eye Traumata: a 5-year Clinical Study

Background A comparative study of eye injuries related to fireworks or acts of violence around New Year's Eve and the Swiss National Day on August 1st. The two groups were compared with respect to the overall numbers of eye accidents within the period of review. Patients and Methods Retrospective analysis of emergency consultations at the Department of Ophthalmology, University Hospital Zurich with eye accidents around the Swiss National Day on August 1st and New Year's Eve over the last 5 years. Two subgroups were formed: (1) Firework-related eye traumata, (2) Eye injuries due to acts of violence. The groups were analysed by age, gender, active participant or bystander, eye involved, severity of trauma (from clinical findings), surgical interventions, time of follow-up and visits, visual acuity and outcome. Results The study included 97 patients (100 eyes) with 74 male (76 %) and 23 female (24 %) victims. After filtering out 67 common traumata cases (all unilateral), 17 patients (18 eyes) with firework-related injuries and 13 patients (15 eyes) with damage due to an act of violence remained. Firework injuries accounted for 18 % of cases (65 % men); eye injuries caused by an act of violence accounted for 15 % of cases (92 % men). In the fireworks group, women were significantly older than men (mean age men 32 ± 14 years versus women 38 ± 16 years, p = 0.002). 65 % of cases were bystanders. The two subgroups contained 30 patients (33 eyes) with 22 left eyes (67 %, p < 0.001). The anterior segment was most frequently involved (79 %), significantly more often than the posterior part of the eye (p < 0.001). The posterior segment was injured more often in the fireworks group (28 %), than in the violence group (13 %). 87 % of the victims in the group of common traumata were mild trauma, 10 % moderate and 3 % severe. In the fireworks group the distribution was 53 % mild, 12 % moderate and 35 % severe, in the violence group 46 %, 23 % and 31 % respectively. Severe trauma cases occurred significantly more often around the New Year, with 36 % versus August 1st with 18 % (p = 0.0028). They are more often related to firework injuries than caused by violence (40 % versus 33 %). In summary, 7 victims (23 %) needed 8 interventions, with 3 having additional issues with their intraocular pressure. Full final visual acuity was noted in 88 %, which was alike in the two subgroups. On the contrary common traumata happened significantly more often around August 1st (66 %) than New Year (34 %; p < 0.001). Conclusions The number of injured eyes in the two subgroups of fireworks and violence was twice as high around New Year's Eve than around the Swiss National Day. If the two events were combined, eye injuries were caused by an act of violence in 45 % and by fireworks in 55 % of cases. Injuries from fireworks can be decreased by professional fireworks. Both types of accident can be decreased by public awareness