Guidance for diagnosis and treatment of DIC from harmonization of the recommendations from three guidelines

Three guidelines have recently been published for the diagnosis and treatment of disseminated intravascular coagulation (DIC) in adults. This communication seeks to harmonize the recommendations in these guidelines using a modified GRADE system. The scoring system for diagnosis of DIC using global coagulation tests is known to correlate with key clinical observations and outcomes (Moderate quality). The cornerstone of DIC treatment is the treatment of the underlying condition (Moderate quality). In general, transfusion of platelets or plasma (components) in patients with DIC should be reserved for patients who are bleeding (Low quality). Therapeutic doses of heparin should be considered in cases of DIC where clinical features of thrombosis predominate. Heparin is not recommended in those patients with a high risk of bleeding, (Moderate quality). However, prophylactic doses of unfractionated heparin or low molecular we ight heparin is recommended in critically ill and non-bleeding patients with DIC for prevention of venous thromboembolism (Moderate to High quality). Although further prospective evidence from randomized controlled trials is required, administration of antithrombin or recombinant thrombomodulin may be considered in certain patients with DIC. In general, patients with DIC should not be treated with antifibrinolytic agents (Low quality). However those who present with severe bleeding, that is characterized by a markedly hyperfibrinolytic state such as leukemia (Low quality) and trauma (Moderate quality), may be treated with antifibrinolytic agents. © 2013 International Society on Thrombosis and Haemostasis.

Physical properties of self-assembled monolayers of Mercapto Oligo (ethylene oxide) methyl ether on gold

Physical properties (chemical adsorption rate, viscoelasticity, thickness, and conformation) for self-assembled monolayers (SAMs) of mercapto oligo (ethylene oxide) methyl ethers on gold were determined by quartz crystal microbalance (QCM). The values of thickness, shear viscosity and elastic shear modulus of SAMs increase with unit number of oligo (ethylene oxide) segment. However, the chemical adsorption rate determined by a Langmuir isotherm does not show such a unit number regularity. Those results suggest that difference in unit number of oligo (ethylene oxide) segment can significantly affects physical properties of SAMs.

Stenotrophomonas maltophilia infection in hematopoietic SCT recipients: high mortality due to pulmonary hemorrhage

To clarify the clinical features and outcome of Stenotrophomonas maltophilia infection among hematopoietic SCT (HCT) recipients, we retrospectively reviewed the records of 1085 consecutive HCT recipients and identified 42 episodes in 31 HCT recipients with S. maltophilia infection. We compared these recipients with 30 non-HCT patients with S. maltophilia infection. The mortality rate in HCT recipients was significantly higher than that in non-HCT patients (relative risk 5.7, P=0.04), and we identified seven patients with pulmonary hemorrhage due to S. maltophilia, exclusively in the HCT cohort. Six of these latter seven patients died within 1 day from the onset of hemorrhage and the isolate was identified after death in most cases; one patient, who received empiric therapy for S. maltophilia and granulocyte transfusion, survived for more than 2 weeks. The patients with pulmonary hemorrhage had a more severe and longer duration of neutropenia, persistent fever despite of the use of broad-spectrum antibiotics, complication by pneumonia and higher C-reactive protein levels than those without pulmonary hemorrhage. In conclusion, S. maltophilia was associated with fulminant and fatal pulmonary hemorrhage in HCT recipients. Empiric therapy with antibiotics before the onset of pulmonary hemorrhage may be effective in HCT recipients who carry the conditions identified.

Comparison of actual tidal volume in neonatal lung model volume control ventilation using three ventilators

In neonates, small changes in tidal volumes (V(T)) may lead to complications. Previous studies have shown a significant difference between ventilator-measured tidal volume and tidal volume delivered (actual V(T)). We evaluated the accuracy of three different ventilators to deliver small V(T) during volume-controlled ventilation. We tested Servo 300, 840 ventilator and Evita 4 Neoflow ventilators with lung models simulating normal and injured neonatal lung compliance models. Gas volume delivered from the ventilator into the test circuit (V(TV)) and actual V(T) to the test lung were measured using Ventrak respiration monitors at set V(T) (30 ml). The gas volume increase of the breathing circuit was then calculated. Tidal volumes of the SV300 and PB840 in both lung models were similar to the set V(T) and the actual tidal volumes in the injured model (20.7 ml and 19.8 ml, respectively) were significantly less than that in the normal model (27.4 ml and 23.4 ml). PB840 with circuit compliance compensation could not improve the actual V(T). V(TV) of the EV4N in the normal and the injured models (37.8 ml and 46.6 ml) were markedly increased compared with set V(T), and actual V(T) were similar to set V(T) in the normal and injured model (30.2 ml and 31.9 ml, respectively). EV4N measuring V(T) close to the lung could match actual V(T) to almost the same value as the set V(T) however the gas volume of the breathing circuit was increased. If an accurate value for the patient's actual V(T) is needed, this V(T) must be measured by a sensor located between the Y-piece and the tracheal tube.

Comparison of Actual Tidal Volume in Neonatal Lung Model Volume Control Ventilation using Three Ventilators

In neonates, small changes in tidal volumes (VT) may lead to complications. Previous studies have shown a significant difference between ventilator-measured tidal volume and tidal volume delivered (actual VT). We evaluated the accuracy of three different ventilators to deliver small VT during volume-controlled ventilation.

We tested Servo 300, 840 ventilator and Evita 4 Neoflow ventilators with lung models simulating normal and injured neonatal lung compliance models. Gas volume delivered from the ventilator into the test circuit (VTV) and actual VT to the test lung were measured using Ventrak respiration monitors at set VT (30 ml). The gas volume increase of the breathing circuit was then calculated.

Tidal volumes of the SV300 and PB840 in both lung models were similar to the set VT and the actual tidal volumes in the injured model (20.7 ml and 19.8 ml, respectively) were significantly less than that in the normal model (27.4 ml and 23.4 ml). PB840 with circuit compliance compensation could not improve the actual VT. VTV of the EV4N in the normal and the injured models (37.8 ml and 46.6 ml) were markedly increased compared with set VT, and actual VT were similar to set VT in the normal and injured model (30.2 ml and 31.9 ml, respectively). EV4N measuring VT close to the lung could match actual VT to almost the same value as the set VT, however the gas volume of the breathing circuit was increased.

If an accurate value for the patient's actual VT is needed, this VT must be measured by a sensor located between the Y-piece and the tracheal tube.

Cesarean section and primary pulmonary hypertension: the role of intravenous dexmedetomidine

Primary pulmonary hypertension is a fatal disease that frequently becomes evident in pregnancy. The management of pregnant women with primary pulmonary hypertension poses a number of difficult problems, especially where regional anesthesia is considered to be contraindicated. A 30-year-old woman who developed primary pulmonary hypertension at 23 weeks of pregnancy was transferred to our hospital. Systolic pulmonary artery pressure and plasma brain natriuretic peptide levels were markedly elevated. Nitric oxide inhalation and prostacyclin prevented the progression of cardiac failure and reduced both plasma brain natriuretic peptide and pulmonary artery pressure. Cesarean section was performed at 32 weeks under general anesthesia. A combination of nitric oxide, prostacyclin, nitroglycerin, and dobutamine were administered during surgery. Intravenous dexmedetomidine was specifically used during emergence and recovery from anesthesia. This provided effective pain relief and hemodynamic stability. Throughout the clinical course, brain natriuretic peptide levels was monitored and used as an indicator of cardiac failure.

Intensive glucose control after allogeneic hematopoietic stem cell transplantation: a retrospective matched-cohort study

Some studies have shown that intensive glucose control (IGC) improves outcome in the intensive care unit setting. However, it is the benefit of IGC in hematopoietic SCT (HSCT) that is not well defined. Between June 2006 and May 2007, IGC was maintained prospectively after allogeneic HSCT and clinical outcomes were compared with a cohort matched for conditioning regimen, source of stem cells, age and relation to donor. A stratified Cox regression model was used. There were no significant differences in baseline clinical characteristics. The median age was 43.5 years in both groups. The primary diagnosis was a hematologic malignancy. Patients in the IGC group had a lower glucose level (least-square mean, 116.4 vs 146.8 mg per 100 ml, P<0.001) compared to the standard glucose control group. The incidences of documented infections and bacteremia were significantly lower in the IGC group (14 vs 46%, P=0.004, 9 vs 39%, P=0.002, respectively). IGC tended to reduce the incidence of renal dysfunction (19 vs 37%, P=0.36) and the elevation of C-reactive protein (18 vs 38%, P=0.13). This study suggests that IGC has may have a beneficial effect after HSCT. IGC should be evaluated further in a large prospective, randomized study.

PROC, PROCR and PROS1 polymorphisms, plasma anticoagulant phenotypes, and risk of cardiovascular disease and mortality in older adults: the Cardiovascular Health Study

BACKGROUND AND OBJECTIVES

Genes encoding protein C anticoagulant pathways are candidates for atherothrombotic and other aging-related disorders.

METHODS

Using a tagSNP approach, and data from the Cardiovascular Health Study (CHS), we assessed associations of common polymorphisms of PROC, PROS1 and PROCR with: (i) plasma protein C, soluble protein C endothelial receptor (sEPCR) and protein S levels measured in a subsample of 336 participants at study entry; and (ii) risk of incident clinical outcomes [coronary heart disease (CHD), stroke, and mortality] in 4547 participants during follow-up. Secondarily, we explored associations between plasma protein C, protein S and sEPCR levels and other candidate genes involved in thrombosis, inflammation, and aging.

RESULTS

The PROCR Ser219Gly polymorphism (rs867186) was strongly associated with higher sEPCR levels, explaining 75% of the phenotypic variation. The PROCR Ser219Gly variant was also associated with higher levels of circulating protein C antigen. An IL10 polymorphism was associated with higher free protein S levels. The minor alleles of PROC rs2069901 and PROS1 rs4857343 were weakly associated with lower protein C and free protein S levels, respectively. There was no association between PROCR Ser219Gly and risk of CHD, stroke, or mortality. The minor allele of another common PROCR tagSNP, rs2069948, was associated with lymphoid PROCR mRNA expression and with increased risk of incident stroke and all-cause mortality, and decreased healthy survival during follow-up.

CONCLUSIONS

A common PROCR variant may be associated with decreased healthy survival in older adults. Additional studies are warranted to establish the role of PROCR variants in ischemic and aging-related disorders.