Fresh frozen plasma transfusion in acute variceal haemorrhage: Results from a multicentre cohort study

BACKGROUND

Fresh frozen plasma (FFP) transfusion is often used in the management of acute variceal haemorrhage (AVH) despite best practice advice suggesting otherwise.

OBJECTIVE

We investigated if FFP transfusion affects clinical outcomes in AVH.

DESIGN, SETTING AND PATIENTS

We performed a retrospective cohort study of 244 consecutive, eligible patients admitted to five tertiary health care centres between 2013 and 2018 with AVH.

MAIN OUTCOME MEASUREMENTS

Multivariable regression analyses were used to study the association of FFP transfusion with mortality at 42 days (primary outcome) and failure to control bleeding at 5 days and length of stay (secondary outcomes).

RESULTS

Patients who received FFP transfusion (n = 100) had higher mean Model for End Stage Liver Disease (MELD) score and more severe variceal bleeding than those who did not received FFP transfusion (n = 144). Multivariable analysis showed that FFP transfusion was associated with increased odds of mortality at 42 days (odds ratio [OR] 9.41, 95% confidence interval [CI] 3.71-23.90). FFP transfusion was also associated with failure to control bleeding at 5 days (OR 3.87, 95% CI 1.28-11.70) and length of stay >7 days (adjusted OR 1.88, 95% CI 1.03-3.42). The independent association of FFP transfusion with mortality at 42 days persisted when the cohort was restricted to high-risk patients and in patients without active bleeding.

LIMITATIONS AND CONCLUSIONS

Fresh frozen plasma transfusion in AVH is independently associated with poor clinical outcomes. As this an observational study, there may be residual bias due to confounding; however, we demonstrate no benefit and potential harm with FFP transfusions in AVH.

Cognitive function in early psychosis patients from a low-income country

Background

Cognitive impairments are well established findings in schizophrenia and are associated with significant impairment of social functioning. Episodic memory, working memory and executive function test scores are typically 1 standard deviation below healthy controls. There are reports suggesting the presence of neurocognitive deficits prior to illness onset, opening the possibility of using cognitive profiles as disease markers. Interest in exploring cognitive functioning in early stages schizophrenia has continued to grow, as earlier treatments could possibly lead to improved outcomes.

Methods

This is a cross-sectional assessment of cognitive profiles in patients with early psychosis. A total of 51 patients suffering from psychosis in the age group of 18–65 years were recruited and matched with 51 healthy controls. A wide range of neurocognitive domains were assessed using standardised neuropsychological tests.

Results

There was evidence of statistically significant impairments in cognitive functioning across a broad range of cognitive domains in early-psychosis patients, as compared to healthy controls. More pronounced deficits were seen in executive function tests.

Conclusions

To our knowledge, this is the first study to report cognitive deficits across a range of domains in patients with first episode psychosis from a low-income country. This study found deficits across multiple domains, including language, memory, attention, executive function, and visuospatial function in patients with early psychosis. Evidence of neuropsychological deficits in the early course of the disease may highlight crucial therapeutic windows for both pharmacological treatments and cognitive rehabilitation. This may improve functional outcomes in this patient group in the longer term.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Pathology Image of the Month: Abdominal Pain and Peripheral Eosinophilia

A 69 year-old man presented to his primary care physician with abdominal discomfort. Medical history was notable for diabetes, chronic obstructive pulmonary disease with recent (one week prior) steroid use and hypertension. Surgical history was significant for a remote sigmoid hemicolectomy for diverticulitis with a synthetic mesh abdominal repair. He was admitted to the hospital for suspected gastroparesis. An upper GI series showed a distended stomach with delayed gastric motility. He underwent esophagogastroduodenoscopy and a duodenal biopsy was taken. He remained afebrile but had an elevated white blood cell count of 19.1 x 103/mcL (4.5 - 11.0 x 103/mcL) with 28.8 percent eosinophils on differential. Microscopic images of the duodenal biopsy are shown below.

Pathology Image of the Month:Cough and Shortness of Breath in a Noncompliant Patient with HIV/AIDS

A 37- year-old man with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) was admitted to the intensive care unit following a four month history of progressive shortness of breath, productive cough, and flu-like symptoms. His HIV/AIDS was diagnosed at the age of 19 (CD4 count =15; viral load = 294,436 copies/ mL) and was complicated by hemodialysis-dependent, HIV-associated nephropathy, prior Pneumocystis pneumonia and known noncompliance with prescribed antiretroviral therapy. Chest film at admission was interpreted as diffuse bilateral interstitial and airspace opacities with a right sided layering density representative of laminar pleural effusion. Bacterial blood cultures were subsequently negative. A bronchoalveolar lavage was performed and an image from the cytologic cell block is seen above in Figure 1. The patient's respiratory status continued to deteriorate and he was converted to comfort care. Following death, an unlimited autopsy examination was requested by the family and authorized by the coroner. At autopsy, additional gross pathologic findings included 350ml of chylous appearing pleural fluid and serous ascites (700ml). Histopathology revealed intra-alveolar acute fibrinopurulent exudate, chronic pericarditis and end-stage nephropathy. Similar cells to those shown above in Figure 1 were identified in lung epithelium and in pancreatic acinar cells. Special stain for Pneumocystis was negative.

Short-term glucocorticoid intake and metabolic responses during long-lasting exercise

The aim of the study was to evaluate the effects of short-term glucocorticoid treatment on plasma amino acids, free fatty acids, blood glucose, and several hormones in healthy volunteers performing long-lasting exercise. 9 young female subjects exercised 2 h at 50-55% VO₂ max twice, once after placebo (Pla) ingestion and once after prednisone (Cor, 50 mg/day/7 days) ingestion, according to a double-blind and randomized protocol. Blood samples were tat rest and during exercise for measurement of amino acids, free fatty acids, blood glucose, adrenocorticotrophic hormone (ACTH), growth hormone, dehydroepiandrosterone (DHEA), insulin, and glucagon. Both ACTH and DHEA values were significantly decreased by Cor vs. Pla (p < 0.01) throughout exercise, and Cor intake also induced lower growth hormone concentrations vs. Pla (p < 0.05) from 60 min to the end of exercise. No significant difference in glucagon, insulin or free fatty acid values was found between the treatments. Branched-chain amino acids and other essential amino acids were significantly higher after Cor vs. Pla from 60 min to the end of exercise (p < 0.05), whereas blood glucose was significantly higher from 90 min to the end of exercise (p < 0.05). We conclude that short-term glucocorticoid intake induces marked hormonal and metabolic changes during long-lasting exercise. Proteolysis can increase with glucocorticoid during this type of exercise and the related higher plasma amino acid concentrations may contribute as energy substrates. Further studies will be necessary to explore and accurately quantify the mechanisms of proteolysis and glyconeogenesis induced by short-term glucocorticoid intake during this type of exercise.

Serum and saliva adrenocortical hormones in obese diabetic men during submaximal exercise

The aim of this study was to evaluate serum and saliva adrenocortical hormones and their relationships at rest and during submaximal exercise and recovery in 9 obese diabetic middle-aged men (BMI: 35.2 ± 1.6 kg/m (2)). Blood and saliva samples were taken at rest, every 10 min of a 30-min cycling exercise at 70% of maximal heart rate, and after 10 min of recovery in order to analyze cortisol, dehydroepiandrosterone sulfate (DHEA-S) and dehydroepiandrosterone (DHEA). Serum and saliva cortisol increased significantly during recovery (p<0.05), but no significant difference was observed between the rest, exercise, and recovery DHEA-S and DHEA concentrations. A strong correlation was found at rest between both serum and saliva cortisol (r=0.72, p<0.001) and DHEA-S and DHEA (r=0.93, p<0.001). Serum DHEA-S and saliva DHEA remained strongly correlated during and after the submaximal exercise (r=0.81, p<0.001), whereas a weaker but still significant relationship was observed between serum and saliva cortisol during and after the exercise (r=0.52, p<0.001). In conclusion, these results suggest that saliva adrenocortical hormones, and especially saliva DHEA, may offer a practical surrogate for serum concentrations during both rest and exercise in obese diabetic men.

Correlation between plasma and saliva adrenocortical hormones in response to submaximal exercise

This study examined the relationships between plasma and saliva adrenocortical hormones in response to long-duration submaximal exercise. In nine healthy, physically active, female volunteers, blood and saliva samples were taken at rest and every 30 min during a 120-min cycling trial at 50-55% VO(2max) for cortisol and dehydroepiandrosterone (DHEA) analysis. Correlation analysis revealed a moderate but significant relationship between plasma and saliva cortisol (r = 0.35, P < 0.02) and plasma and saliva DHEA (r = 0.47, P < 0.001) during the submaximal exercise. When expressed in percent of resting values, the correlations between the plasma and saliva concentrations were higher for both hormones during the exercise (cortisol: r = 0.72; DHEA: r = 0.68, P < 0.001). The results thus suggest that, even under prolonged exercise conditions, non-invasive saliva samples may offer a practical approach to assessing pituitary-adrenal function, especially when compared with individual basal values.

Saliva DHEA and cortisol responses following short-term corticosteroid intake

BACKGROUND

Given the high correlation between the serum and saliva hormone values demonstrated at rest, saliva provides a convenient non-invasive way to determine dehydroepiandrosterone (DHEA) and cortisol concentrations. However, to our knowledge, pituitary adrenal recovery following short-term suppression with corticosteroids has never been investigated in saliva. The aim of this study was therefore to examine how steroid hormone concentrations in saliva are influenced by short-term corticosteroid administration.

MATERIALS AND METHODS

We studied saliva DHEA and cortisol concentrations before, during (day 1-day 7) and following (day 8-day 16) the administration of oral therapeutic doses of prednisone (50 mg daily for 1 week) in 11 healthy recreationally trained women.

RESULTS

Mean saliva DHEA and cortisol concentrations decreased immediately after the start of prednisone treatment (P < 0.05). Three days after concluding prednisone administration, both saliva DHEA and cortisol had returned to pretreatment levels.

CONCLUSIONS

These data are consistent with previous studies on blood samples and suggest that non-invasive saliva samples may offer a practical approach to assessing pituitary-adrenal function continuously during and after short-term corticosteroid therapy.

Salbutamol intake and substrate oxidation during submaximal exercise

In order to test the hypothesis that salbutamol would change substrate oxidation during submaximal exercise, eight recreationally trained men twice performed 1 h at 60% VO(2) peak after ingestion of placebo or 4 mg of salbutamol. Gas exchange was monitored and blood samples were collected during exercise for GH, ACTH, insulin, and blood glucose and lactate determination. With salbutamol versus placebo, there was no significant difference in total energy expenditure and substrate oxidation, but the substrate oxidation balance was significantly modified after 40 min of exercise. ACTH was significantly decreased with salbutamol during the last 10 min of exercise, whereas no difference was found between the two treatments in the other hormonal and metabolic parameters. The theory that the ergogenic effect of salbutamol results from a change in substrate oxidation has little support during relatively short term endurance exercise, but it is conceivable that longer exercise duration can generate positive findings.

The Reflector: a new method for saving anaesthetic vapours

Anaesthesia systems that minimize the use of volatile anaesthetics to reduce cost and pollution are of interest. Closed circuit anaesthesia is the ideal solution, but requires continuous adjustment of fresh gas flow and composition and thus is demanding in routine practice. We describe an alternative system, the Reflector system, which is open in regard to oxygen, nitrogen and N2O, and semiclosed in regard to volatile anaesthetics. The Reflector system is a circle system with a carbon dioxide absorber and an automatic vapour delivery device placed in the inspiratory limb of the circle. A zeolite filter, the Reflector, is placed between the ventilator and the circle. The Reflector functions as a molecular sieve, preventing the volatile anaesthetic from leaving the circle. Isoflurane consumption using the Reflector system in bench tests and an animal study was compared with that of an open system. In bench tests consumption was reduced by 79% and 82%, at a respiratory frequency of 10 and 20 min-1, respectively. The corresponding mean figures from the animal experiment were 65% and 77%.

Effects of ibotenic acid lesions of the ventral striatum and the medial prefrontal cortex on ethanol consumption in the rat

The purpose of this study was to to assess the effect on ethanol drinking of ibotenic acid lesions in the medial prefrontal cortex and the ventral striatum of female rats with continuous access to water and a 6% ethanol solution. Ibotenic acid infusions in the prefrontal cortex did not affect ethanol intake at any time, but a significant increase in water intake was observed on the third postoperative week. Ventral striatal lesions significantly increased ethanol intake during the first 2 postoperative weeks. On the third week consumption was not significantly different from vehicle-infused controls. Apparently, then, severe excitoxic injury to the ventral striatum is compatible with normal, or increased, intake of ethanol; in contrast, similar lesions reduce the intake of other drugs of abuse such as psychostimulants and opioids.

Metyrapone-induced suppression of corticosterone synthesis reduces ethanol consumption in high-preferring rats

The fluid intake of male Wistar rats with simultaneous access to water and 6% ethanol was determined between 0900 and 1500 h. In high-preferring males (normally covering > 60% of their daily fluid consumption in the form of ethanol), two injections with the corticosterone synthesis inhibitor metyrapone (50 mg/kg) at 0900 h and 1200 h for 4 consecutive days significantly reduced ethanol preference such that they preferred water over alcohol. Treatment with corticosterone (0.6 mg/kg) 2 h before each metyrapone injection partially cancelled this effect of the synthesis inhibitor. By contrast, there was no significant effect of metyrapone treatment on the drinking of ethanol in low-preferring rats (normally covering < 30% of their daily fluid consumption in the form of ethanol). These results suggest that the adrenal secretion of corticosterone directly or indirectly modulates the intake of alcohol in high-preferring rats.

Taste reactivity to ethanol in rats: influence of adrenalectomy or ipsapirone

The affective mimetic responses of male Wistar rats with prior access to 6% ethanol in their home cages were observed during intraoral infusions of an equivalent alcohol solution. Ethanol preference in the home cage appeared unrelated to measures of aversion and ingestion in the taste reactivity tests in normal rats. Adrenalectomy, which significantly reduced home cage ethanol preference, failed to influence the taste reactions elicited by ethanol or water. On the other hand, treatment of intact rats with the 5-HT1A receptor agonist ipsapirone (2.5 mg/kg), a drug that also decreases ethanol drinking in two-bottle intake tests, did increase the duration of aversive groomings, whereas measures of ingestion remained unaffected. These results suggest that ipsapirone, but not adrenalectomy, may alter the palatability of ethanol; this perceptual change may partly underlie the ability of ipsapirone to reduce home cage alcohol drinking in the rat.

Clinical experience with minimal flow xenon anesthesia

Xenon is a more potent anesthetic than nitrous oxide, and give more profound analgesia. This investigation was performed to assess the potential of xenon for becoming an anesthetic inspite of its high manufacturing cost. Seven ASA I-II patients undergoing cholecystectomy (n = 4), hernia repair (n = 2), or mammoplasty (n = 1) were studied. Denitrogenation by 15-20 min of oxygen breathing under propofol anesthesia was followed by fentanyl-supplemented xenon anesthesia administered via an automatic minimal flow system which held the oxygen concentration at 30%. Xenon anesthesia lasted 76-228 min and 8-14 l of xenon (ATPD) was used, of which 5.6-8.1 l was expended during the first 15 min. Anesthesia appeared to be satisfactory, and the patients woke up rapidly after xenon was discontinued. The automatic system made minimal flow xenon anesthesia easy to administer, but nitrogen accumulation is still a problem. Assuming a xenon price of 10 US$ per litre, the average cost for xenon was about 65 US$ for the first 15 min and then about 25 US$ for each subsequent hour of anesthesia.

Using CPS120 (curved position-sensitive detector covering 120°) powder diffraction data in Rietveld analysis. The dehydration process in the zeolite thomsonite

A powder diffractometer (CPS120 by INEL) equipped with a position-sensitive detector covering 120° in 2θ has been tested and the data have been successfully used with the Rietveld method. The detector was found to have a characteristic variation in linearity of ±1.5%. A calibration compound with well known 2θ values was used to determine a cubic spline calibration function to describe the 2θ versus channel-number function, which was then incorporated in the Rietveld analysis program. A procedure is also described to correct for air and capillary scattering, taking sample absorption into account. The methods have been applied to a structure refinement of quartz and to a study of the dehydration process of the zeolite thomsonite. Quartz: Rp = 11.0%, Rw = 14.0% and RB = 7.9%, based on 10 < 2θ < 116.3° in 3470 steps, λ = 1.540598 Å. Space group P312, Z = 3, a = 4.91201 (7), c = 5.40301 (5) Å, x(Si) = 0.4702 (3), B ave(Si) = 0.77 (6) Å2, x(O) = 0.4112 (6), y(O) = 0.2712 (5), z(O) = −0.2811 (4) and B ave(O) = 1.0 (1) Å2. Thomsonite: Rp = 8.18%, Rw = 11.04% and RB = 3.33%, based on 10 < 2θ < 110° in 3270 steps. Space group Pncn, Z = 4, a = 13.0778 (3), b = 13.0398 (3) and c = 13.1970 (3) Å. The unit cell changes continuously with increasing dehydration temperatures up to 523 K, at which a = 12.9725 (3), b = 12.9537 (3) and c = 13.2288 (3) Å. In this first dehydration step, the W3 and W4 molecules coordinated to the Ca/Na site are lost and the Ca/Na and W1 sites are shifted approximately 0.3 Å from their original positions towards the framework O atoms. After dehydration at 573 K, the mode of unit-cell variations is changed: a = 12.908 (3), b = 13.039 (3) and c = 13.034 (3) Å. In this dehydration step, W1 is lost. The W2 site appears unaffected by the dehydration below 573 K. On dehydration above 573 K, the diffraction intensities decrease as the compound becomes amorphous.

A minimal-flow system for xenon anesthesia

We described a minimal-flow system for xenon anesthesia during controlled ventilation. A computer maintained oxygen concentration in the anesthesia circle within +/- 2% of the value set by the anesthesiologist. The ventilator and the circle were connected via a large dead space, through which oxygen from the ventilator entered the circle but which prevented xenon from escaping. This arrangement simplified the computer program. The system was tested on a lung model and in six pigs (37-39 kg). The xenon expenditure and the amount of xenon washed out from the pigs after the anesthetic were measured. Additional experiments with nitrous oxide were made in three pigs. The xenon expenditure during 2 h of xenon anesthesia was 7.6 +/- 0.8 l (mean +/- 1 standard deviation). The corresponding expenditure of nitrous oxide was 16.5 +/- 2.7 l. About 75% of the xenon expenditure was in the 1st h of anesthesia; thereafter 20-40 ml.min-1 was needed to maintain oxygen concentration at 30%. Nitrogen concentration in the circle increased to 12-16% during the xenon anesthetic, although it was preceded by a 20 min denitrogenation period. During the washout phase after the xenon anesthesia, mean expired xenon concentration decreased to below 2% within 4 min. Subsequently, washout was slower and the expired concentration remained above 0.1% for more than 90 min. The estimated total amount of xenon washed out from the lungs and body tissues during 4 h of oxygen breathing was about 4 l. We conclude that xenon anesthesia via a fully automated minimal-flow system is feasible.(ABSTRACT TRUNCATED AT 250 WORDS)

A reflection filter for isoflurane and other anaesthetic vapours

A new way of saving anaesthetic vapours is described. The method is analogous to the heat-moisture exchanger principle: the vapour is trapped in a filter during expiration and is returned to the patient during the subsequent inspiration. Fresh vapour is supplied on the patient side of the filter. A small container with 60 ml of a hydrophobic zeolite (an inorganic material) was used as filter. In model lung tests, this reduced the isoflurane consumption by 51% at a tidal volume of 300 ml, by 57% at 600 ml and by 51% at 930 ml. Neither isoflurane nor halothane yielded any degradation products when brought in contact with the zeolite.