Coagulopathy, Bleeding Events, and Outcome According to Rotational Thromboelastometry in Patients With Acute Liver Injury/Failure

BACKGROUND AND AIMS

Patients with acute liver injury or failure (ALI/ALF) experience bleeding complications uncommonly despite an abnormal hemostatic profile. Rotational thromboelastometry (ROTEM), which assesses clot formation in whole blood, was used to determine the nature of abnormal hemostasis and whether it contributes to bleeding events, illness severity, or survival.

APPROACH AND RESULTS

A total of 200 patients were recruited from sites of the ALF Study Group. Blood collected daily for up to 5 days was analyzed using ROTEM delta devices. Consistent with standard laboratory evidence of hypocoagulability (median international normalized ratio = 2.9 and platelet count = 144 × 109 /L), patients frequently exhibited ROTEM parameters outside the normal range (73% and 62% had abnormalities in clot formation from extrinsic and intrinsic clotting cascades, respectively); however, measures of clot stability were generally normal. Eighteen patients (9%) experienced bleeding events, in whom clot initiation, assembly, and firmness were more severely deranged than patients without bleeding. Abnormal ROTEM parameters were more frequently observed in patients with non-acetaminophen ALI/ALF than those with acetaminophen ALI/ALF (clot initiation [P < 0.001], assembly [P = 0.02], firmness at 10 minutes [P = 0.05], and maximal firmness [P = 0.06]). Patients with more severe systemic complications (high-grade hepatic encephalopathy and need for renal replacement therapy) also had a higher incidence of abnormal ROTEM parameters. Finally, more hypocoagulable ROTEM parameters (clot initiation (P = 0.005), stiffness at 10 minutes (P = 0.05), and maximal stiffness by fibrin assembly (P = 0.004)) were observed in patients who died or underwent liver transplantation than those who survived with their native liver.

CONCLUSIONS

In patients with ALI/ALF, abnormal ROTEM parameters are frequent and proportional to disease severity. Whether the increased bleeding risk associated with abnormal ROTEM indicates hemostatic failure or is a proxy for disease severity requires additional study.

Time intervals between semen production, initiation of analysis, and IUI significantly influence clinical pregnancies and live births

PURPOSE

Does IDEF mapping help monitor the technical process of IUI and explore the potential improvements which might contribute to increased pregnancy and live birth rates?

METHOD

Retrospective analysis of 1729 homologous IUI cycles of couples attending a fertility clinic in a university hospital setting. Standardized conventional semen parameters were analyzed and the semen samples prepared via discontinuous density gradient centrifugation.

RESULTS

There was no significant association between sperm concentration, motility and morphology (analysis phase), and pregnancy outcome. Only female and male ages were significantly associated with the pregnancy outcome. There was a significant difference in the odds on clinical pregnancies and live births when analysis was ≤ 21 min initiated, and < 107 min between sample production and IUI, adjusted for male and female age.

CONCLUSIONS

Adjusting for the couple's age, we could show that time intervals between semen production and analysis and IUI when kept low significantly influenced clinical pregnancies and live births.

[Skills lab from the surgical point of view. Experiences from the Magdeburg Medical School--The University of Magdeburg]

INTRODUCTION

For the acquisition of practical skills, the separate learning atmosphere of a skills lab(oratory) is very suitable. Numerous educational objectives of surgical teaching can be pursued using phantoms, manikins or mutual training among students prior to real practical use during clinical traineeships or internships.

AIM AND METHOD

This article provides a compact, systematic overview of the skills lab concept, based on published aspects in selected and relatively recent topic-related references from PubMed® including our own approaches, as well as comments and experiences with regard to its further development. In particular, the Magdeburg concept to use the local skills lab MAMBA for surgical teaching within the practical training is demonstrated, which has developed step by step from a basically pure bedside teaching and which includes student tutors in practical teaching in surgery.

RESULTS

By founding the Magdeburg educational and training center options for a practical education, in particular, in surgery were created. The great majority of students accepted the conceptual idea and it has so far been well received. As a first step several well selected topics of practical training during human medical studies were increasingly taught by students who received a didactic course of instruction which also included aspects of the educational objectives. For the future tutorials led by students are planned going beyond the teaching contents of the practical courses and can, thus, lead to a networking with educational objectives of other disciplines. There are not only curricular but also facultative courses in MAMBA which have been steadily optimized since the beginning. This Magdeburg's concept is planned to be further developed for which there is enough room for development with regard to organizational aspects (personnel and room).

Adnexal torsion after gonadotrophin ovulation induction for IVF or ICSI and its conservative treatment

This study was designed to find out the incidence of ovarian torsion in the patients who were in ovulation induction treatment for either In vitro fertilization (IVF) or Intracytoplasmic sperm injection (ICSI). Also operative laparoscopic conservative treatment (detorsion or unwinding the twisted adnex) was tried to perform to all the patients. Among 10,583 cycles 9 ovarian torsion cases had been diagnosed laparoscopically between January 1994 and October 1998. 104 ovarian hyperstimulation syndrome (OHSS) patients were evaluated during that time. From 104 hyperstimulated cases three had torsion of the adnex and two of them were pregnant. Five of the patients were clinically and one was chemically pregnant. First, laparoscopy was done to all the patients and 8 of them could be detorsioned, in one case unwinding performed by laparotomy because of the large size of the ovary. No complications were observed after conservative surgery. These results demonstrate that, in the IVF or ICSI clinics ovarian torsion has to be regarded as one of the major complications especially if the patients are hyperstimulated or pregnant or both. Immediate manipulation is needed conservatively, preserving the ovaries which were very important for those infertile patients.

Conventional in-vitro fertilization versus intracytoplasmic sperm injection in sibling oocytes from couples with tubal infertility and normozoospermic semen

An auto-controlled study was conducted in couples with tubal infertility and normozoospermic semen. The fertilization rates and embryonic development in sibling oocytes treated, using the same semen sample, either by conventional in-vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) at the same time were compared. Sibling oocyte-cumulus complexes (OCC) of 56 different couples with tubal infertility and normozoospermic semen were randomly divided in order of retrieval into two groups inseminated either by conventional IVF or by ICSI. Of the retrieved OCC in the same cohort, 53.0 +/- 31.2 and 62.0 +/- 26.6% showed two distinct pronuclei after conventional IVF and ICSI respectively (not significant). Complete fertilization failure occurred after conventional IVF in 12.5% (7/56 couples). After ICSI, the comparable figure was 3.6% (2/56). The number of cases was too small to apply a statistical test to this difference. Total cleavage rates were quite similar: 86.7 +/- 28.0 and 90.1 +/- 21% of the zygotes developed into transferable embryos after IVF and ICSI respectively (not significant). Similarly, no difference in embryo quality was observed. Although injection and insemination of the oocytes were performed at the same time in the two groups, at 42 h post-insemination more embryos were at the four-cell stage after ICSI (P < 0.001) than after conventional IVF, where more embryos were still at the two-cell stage (P < 0.02). Embryo transfer was possible in all 56 couples, resulting in 16 positive serum human chorionic gonadotrophin tests (28.6% per embryo transfer), from which a clinical pregnancy resulted in 15 couples. The best embryos were selected for transfer independently of the insemination procedure, but preferably from the same origin. There appeared to be no difference in implantation potency of the embryos obtained with either technique after the non-randomized transfers.

Hysteroscopic septum resection in patients with recurrent abortions or infertility

Fifty-seven patients who underwent hysteroscopic septum resection between January 1991 and December 1996 were studied; nine patients presented with recurrent abortions, 46 with infertility (26 primary and 20 secondary), one with dysmenorrhoea and one with an asymptomatic complete septum. Their reproductive history included 78 pregnancies: 69 (88.4%) abortions, two (2.6%) ectopics, two (2.6%) preterm deliveries and five (6.4%) term deliveries. In patients with infertility, the incidence of unexplained infertility was 19.6% and the incidence of endometriosis was 26.1%. After hysteroscopic septum resection, 42 patients were interested in pregnancy. All patients with recurrent abortions conceived spontaneously. Twenty-one (63.6%) infertile patients achieved a pregnancy, 13 (61.9%) of them after treatment with various assisted reproduction techniques. The reproductive outcome after septum resection yielded 44 pregnancies, including three sets of twins and one set of triplets reduced to twins: 11 (25%) abortions, one (2.3%) ectopic pregnancy, two (4.5%) preterm deliveries (both twins), 28 (63.7%) term deliveries and two (4.5%) as-yet ongoing pregnancies. It seems that the hysteroscopic treatment of uterine septum has a beneficial effect on pregnancy outcome. A septate uterus does not seem to be an infertility factor. The achievement of pregnancy is normal in patients with recurrent abortions, while the chances of conception in patients with infertility seem to be similar to those for the general infertile population.

Fine needle aspiration versus open biopsy for testicular sperm recovery: a controlled study in azoospermic patients with normal spermatogenesis

This retrospective controlled study aimed at comparing two techniques for recovering testicular spermatozoa in azoospermic patients undergoing intracytoplasmic sperm injection (ICSI). 102 men suffering from infertility because of obstructive azoospermia had ICSI using testicular spermatozoa recovered either by open excisional biopsy (n = 51), or by fine needle aspiration (FNA) (n = 51). A higher average number of spermatozoa were recovered after open biopsy than after FNA, but no significant differences in either fertilization rates or cleavage rates were observed after ICSI with spermatozoa retrieved by the two techniques. Neither was there any significant difference in ongoing pregnancy and implantation rates: in the FNA group, these figures were respectively 19.6% per cycle and 7.8% per embryo transferred and in the open biopsy group 21.6 and 7.1%. We conclude that ICSI with testicular spermatozoa recovered by FNA yields results comparable to those obtained with spermatozoa recovered by open biopsy in azoospermic patients with normal spermatogenesis. However a prospective study is needed to confirm the present results and to assess recovery rates and patient comfort for the two methods.

The role of transvaginal ultrasonography in the detection of pelvic pathologies in the infertility workup

To assess the efficiency of transvaginal ultrasonography (TVUS) in the screening of pelvic pathologies in the initial workup of infertile women, we carried out a prospective comparison of sonographic diagnosis with laparoscopic and pathological findings. Between February 1994 and April 1995, 133 premenopausal non-pregnant women underwent TVUS on the day before laparoscopy. The efficiency of TVUS in detecting pelvic pathologies was 90.2% with a sensitivity of 86.2%, a specificity of 97.8% and positive and negative predictive values of 98.6 and 78.8% respectively. If the six false-negative cases with a histological diagnosis of minimal endometriosis were defined as 'normal pelvis', sensitivity and specificity could be corrected to 92.5 and 98.6% respectively. Endometriomas were diagnosed by TVUS with an efficiency of 96.4%, with a sensitivity and a specificity of 90 and 96.7 % and with positive and negative predictive values of 75 and 99.1% respectively. The sensitivity of vaginal sonographic characterization of pelvic adhesions was 61.1% with a specificity and positive predictive value of 98.2 and 84.6%. The negative predictive value of TVUS was 94.1%. These data suggest that it is not possible to characterize pelvic adhesions, especially filmy adhesions, with acceptable accuracy. However, in the initial workup of infertile women, if the patient is young, if both hysterosalpingography and TVUS are negative, laparoscopy could be postponed. In couples with severe male factor infertility and for whom in-vitro fertilization or intracytoplasmic sperm injection is the treatment of choice, laparoscopy might be avoided where the TVUS is negative.

Ectopic pregnancy: let's cut! Strict laparoscopic approach to 194 consecutive cases and review of literature on alternatives

From March 1989 to December 1995, 194 cases of ectopic pregnancy were diagnosed in our centre and treated following a strict laparoscopic protocol. A total of 193 cases was treated surgically and only one case was treated medically, because general anaesthesia was contraindicated. Altogether, eight laparotomies (4.1%) had to be performed; three primary and five secondary, due to uncontrollable haemorrhage (n = 3) and too large pregnancy size (n = 2). Peri- or postoperative complications were encountered in 24 cases (12.4%). Residual disease occurred in 14 cases (7.2%), all after a technically successful operative laparoscopic procedure. These cases received adjuvant therapy, either systemic administration of methotrexate or a second intervention. The overall laparoscopic cure rate was 88.1% (171/194). Conclusive follow-up data could be obtained concerning 110 cases with an active desire for pregnancy. Overall conception rate was 77.3%, with an ongoing pregnancy rate of 81.2% and a recurrency rate of 10.6%. A critical overview of the available data on non-surgical approaches is made, while the reported results are evaluated according to published data. It is concluded that at this stage a surgical approach by means of operative laparoscopy should remain the gold standard in treating ectopic pregnancies.

Results of microsurgical epididymal sperm aspiration (MESA) ans testicular sperm extraction (TESE) in azoospermic men using intracytoplasmic sperm injection (ICSI)

The rationale and results of using epididymal and testicular spermatozoa with intracytoplasmic sperm injection (ICSI) for zoospermic patients are reviewed. A total of 128 consecutive ICSI/MESA cycles and a total of 120 consecutive ICSI/TESE cycles were performed up to December 1994. The two-pronuclei fertilization rate per intact oocyte (observed after the injection) was 58% and 60%, respectively, when epididymal and testicular spermatozoa were used. The embryo transfer rate was similar for the two procedures (91% after ICSI/MESA and 90% after ICSI/TESE). Fifty women became pregnant (positive HCG) when epididymal spermatozoa were used (39% per cycle and 40% per embryo transfer). These results are comparable to those obtained when ejaculated spermatozoa are used.

'To bathe or not to bathe' during the first stage of labor

OBJECTIVE

Does a warm tub bath relieve labor pain? How is it experienced by the parturient?

METHODS

DESIGN

prospective randomised trial.

SETTING

labor ward of a teaching hospital with a uniform active labor management.

PARTICIPANTS

one hundred and ten nulliparous low risk women, at term, in true spontaneous labor. Fifty-four women had a bath, 56 women served as controls.

MEAN OUTCOME MEASURES

labor pain (assessed by means of a visual analogue scale) and post partum patients' bathing experience (by means of a self-made questionnaire).

RESULTS

The study group and the control group were comparable with respect to maternal age, weight, length, duration of gestation, cervical status and labor pain sensation before randomisation. Absolute values of labor pain were not statistically different between the two groups, yet this latter progressed differently: in the bathing group the initial pain sensation (V.A.S.) was 6.8, and this remained stable during the first 25 minutes (V.A.S. = 6.7) and then rose to 8.2 after a mean of 53 minutes. In the control group, labor pain rose progressively from 6.3 to 7.3 after 25 min and to 8.7 after a mean of 52 min (p < 0.01, Student t-test). There was no difference in the use of epidural analgesia. There were no differences in labor duration nor in the frequencies of either operative deliveries or neonatal complications. Eighty percent of the bathers experienced soothing of the pain and all but one reported body relaxation. Ninety percent wanted to bathe again during a next labor.

CONCLUSION

Bathing provided no objective pain relief. It had, however, a temporal pain stabilizing effect possibly mediated through the improved ability to relax in between contractions. No side effects were found. It gives great satisfaction to users. Bathing, in conjunction with other forms of analgesia, is recommended.

Sparteine and mephenytoin oxidation: genetic polymorphisms in east and west Greenland

The oxidation of sparteine and mephenytoin was examined in a group of subjects living in Greenland: 300 in East Greenland and 171 in West Greenland. The distribution of the ratio between the chromatographic peak areas of S- and R-mephenytoin in the urine, the S/R ratio was clearly bimodal in both populations. Thus 9.3% of the East Greenlanders had S/R ratios of 0.9 or more and were phenotyped as poor metabolizers of mephenytoin. In the West Greenlanders, 2.9% of the sample had S/R ratios of 0.90 or more and were accordingly phenotyped as poor metabolizers. The intraethnic difference with regard to the frequency of the mephenytoin poor metabolizer is probably attributable in part to a much higher proportion of admixed Caucasian genes in the West Greenlanders than in the East Greenlanders. In both the East and the West Greenlanders, the sparteine metabolic ratio displayed marked interindividual differences without a clear bimodal distribution. Poor metabolizers arbitrarily defined as subjects with an metabolic ratio of 20 or more made up 3.3% of the East Greenlanders and 2.3% of the West Greenlanders, but the difference between the two groups was not statistically significant.