Essentials
Pregnancy is a risk factor for thrombosis.
Management of thrombosis risk in pregnancy remains a challenge.
Prophylaxis needs to be personalized.
Our score may be a helpful tool for the ...management of pregnancies at high risk of thrombosis.
Summary
Background
Patients with thrombophilia and/or a history of venous thromboembolism (VTE) are at risk of thrombosis during pregnancy. A risk score for pregnancies with an increased risk of VTE was previously described by our group (Lyon VTE score).
Objectives
The aim of this prospective study was to assess the efficacy and safety of our score‐based prophylaxis strategy in 542 pregnancies managed between 2005 and 2015 in Lyon University Hospitals.
Patients/Methods
Of 445 patients included in the study, 36 had several pregnancies during the study period. Among these 445 patients, 279 had a personal history of VTE (62.7%), 299 patients (67.2%) had a thrombophilia marker, and 131 (29.4%) thrombophilic women had a personal history of VTE. During pregnancy, patients were assigned to one of three prophylaxis strategies according to the risk scoring system.
Results
In the antepartum period, low molecular weight heparin (LMWH) prophylaxis was prescribed to 64.5% of patients at high risk of VTE. Among them, 34.4% were treated in the third trimester only, and 30.1% were treated throughout pregnancy. During the postpartum period, all patients received LMWH for at least 6 weeks. Two antepartum‐related VTEs (0.37%; one with a score of < 3 and the other with a score of > 6) and four postpartum‐related VTEs (0.73%; three with scores of 3–5 and one with a score of > 6) occurred. No case of pulmonary embolism was observed during the study period. The rate of bleeding was 0.37%. No serious bleeding requiring transfusions or surgery occurred during the study period.
Conclusion
The use of a risk score may provide a rational decision process to implement safe and effective antepartum thromboprophylaxis in pregnant women at high risk of VTE.
Background
The first dermatology‐specific proxy health‐related quality of life (HRQoL) instrument for children 0–4 years old with skin diseases, the Infants and Toddlers Dermatology Quality of Life ...(InToDermQoL), was recently developed. In order to avoid the problem of cross‐cultural inequivalence focus groups work and pilot tests were organized simultaneously in all national centres of the project. The InToDermQoL showed good comprehensibility, clarity and acceptance.
Objective
To validate the InToDermQoL questionnaire during international field tests.
Methods
Internal consistency, test–retest reliability, convergent and discriminant validity of the InToDermQoL questionnaire were checked during international field tests.
Results
Parents of 473 children with skin diseases filled in the national language versions of the InToDermQoL questionnaire. All three age‐specific versions of the InToDermQoL questionnaire with 10, 12 and 15 items, respectively, showed high internal consistency (Cronbach's α 0.90–0.93), good test–retest reliability (correlation coefficients > 0.9), significant correlations with the most widely used atopic dermatitis‐specific proxy instrument, the Infants Dermatitis Quality of Life Index (correlation coefficients 0.68–0.79). The InToDermQoL versions for children <3 years old well correlated with the atopic dermatis severity measure Scoring of Atopic Dermatitis (correlation coefficients 0.66 and 0.86 for 10 and 12 items versions, respectively). The InToDermQoL questionnaire discriminated well among different diagnoses and disease severity levels.
Conclusion
Our field tests confirmed internal consistency, test–retest reliability, convergent and discriminant validity of the InToDermQoL questionnaire. Development and validation of the InToDermQoL questionnaire make it possible to assess dermatology‐specific aspects of HRQoL in youngest children with skin diseases. There are many reasons to assess HRQoL in dermatologic clinical practice, and we hope that our new instrument will be used internationally in paediatric dermatology for research and practical needs.
Abstract Background We sought to compare the association of whole-blood lactate kinetics with survival in patients with septic shock undergoing early quantitative resuscitation. Methods This was a ...preplanned analysis of a multicenter, ED-based, randomized, controlled trial of early sepsis resuscitation. Inclusion criteria were suspected infection, two or more systemic inflammation criteria, either systolic BP< 90 mm Hg after a fluid bolus or lactate level > 4 mM, two serial lactate measurements, and an initial lactate level > 2.0 mM. We calculated the relative lactate clearance, rate of lactate clearance, and occurrence of early lactate normalization (decline to < 2.0 mM in the first 6 h). Area under the receiver operating characteristic curve (AUC) and multivariate logistic regression were used to determine the lactate kinetic parameters that were the strongest predictors of survival. Results The analysis included 187 patients, of whom 36% (n = 68) normalized their lactate level. Overall survival was 76.5% (143 of 187 patients), and the AUC of initial lactate to predict survival was 0.64. The AUCs for relative lactate clearance and lactate clearance rate were 0.67 and 0.58, respectively. Lactate normalization was the strongest predictor of survival (adjusted OR, 5.2; 95% CI, 1.7–15.8), followed by lactate clearance ≥ 50% (OR, 4.0; 95% CI, 1.6–10.0). Lactate clearance ≥ 10% (OR, 1.6; 95% CI, 0.6–4.4) was not a significant independent predictor in this cohort. Conclusions In patients in the ED with a sepsis diagnosis, early lactate normalization during the first 6 h of resuscitation was the strongest independent predictor of survival and was superior to other measures of lactate kinetics. Trial registry ClinicalTrials.gov ; No.: NCT00372502 ; URL: clinicaltrials.gov
Non-equilibrium effects in Brownian coagulation at particle number densities that are large in comparison to that of the background gas are analysed theoretically and through computer experiments. ...With increasing rarefaction of the suspending gas there is a point, when the particle relaxation time becomes longer than the characteristic coagulation time. At that point the average velocity of particles will decrease due to mutual inelastic collisions and will fall below the value predicted by the energy equipartition theorem for there is insufficient time between the collisions to restore the thermal equilibrium. This reduced particle velocity results in a lower coagulation rate than predicted by the classical coagulation theory and this effect is shown through first principle computer experiments using the Langevin dynamics methodology developed in our previous studies on the particle crowding effects, as well as through the novel application of the kinetic Monte Carlo method with the majorant kernel proposed in this work. A theoretical model quantifying the effect of the coagulation rate suppression is formulated by introducing the concept of a thermalization number, which is defined as the reduced mean kinetic energy of particle motion. An expression for this quantity is derived and used to extend the classical coagulation theory to this new non-equilibrium regime of coagulation by following, and extending further, the methodology that we proposed previously to describe the concentration enhancement effects in coagulation. A closed-form, analytical formula for the coagulation kernel is obtained and shown to be applicable for all particle sizes and a wide range of concentrations. Close agreement is demonstrated between the predictions from this formula and the results from first principle simulations in the monodisperse case and this agreement can be improved further still, as well as extended to the polydisperse case, if a single model parameter is allowed to be adjusted from its theoretically derived value.
Brownian coagulation kernel: particle crowding and thermal non-equilibrium effects at high concentrations. Display omitted
•Thermal non-equilibrium develops when coagulation rate outpaces particle relaxation.•Collisional cooling leads to slow down of coagulation process.•Theoretical model for the non-equilibrium coagulation regime is given.
This report reviews the study of open heavy-flavour and quarkonium production in high-energy hadronic collisions, as tools to investigate fundamental aspects of Quantum Chromodynamics, from the ...proton and nucleus structure at high energy to deconfinement and the properties of the Quark–Gluon Plasma. Emphasis is given to the lessons learnt from LHC Run 1 results, which are reviewed in a global picture with the results from SPS and RHIC at lower energies, as well as to the questions to be addressed in the future. The report covers heavy flavour and quarkonium production in proton–proton, proton–nucleus and nucleus–nucleus collisions. This includes discussion of the effects of hot and cold strongly interacting matter, quarkonium photoproduction in nucleus–nucleus collisions and perspectives on the study of heavy flavour and quarkonium with upgrades of existing experiments and new experiments. The report results from the activity of the SaporeGravis network of the I3 Hadron Physics programme of the European Union 7
th
Framework Programme.
Abstract Purpose Side-stream dark-field microscopy is currently used to directly visualize sublingual microcirculation at the bedside. Our experience has found inherent technical challenges in the ...image acquisition process. This article presents and assesses a quality assurance method to rate image acquisition quality before analysis. Materials and Methods We identified 6 common image capture and analysis problem areas in sublingual side-stream dark-field videos: illumination, duration, focus, content, stability, and pressure. We created the “Microcirculation Image Quality Score” by assigning a score of optimal (0 points), suboptimal but acceptable (1 point), or unacceptable (10 points) to each category (for further details, go to http://www.MicroscanAnalysis.blogspot.com ). We evaluated 59 videos from a convenience sample of 34 unselected, noncritically ill emergency department patients to create a test set. Two raters, blinded to each other, implemented the score. Any video with a cumulative score of 10 or higher (range, 0-60) was considered unacceptable for further analysis. Results We created the Microcirculation Image Quality Score and applied it to 59 videos. For this particular set of 59 videos, the mean (SD) passing quality score was 1.68 (0.90), and the mean (SD) failing quality score was 15.74 (6.19), with 27 of 59 passing the quality score less than 10. Highest failure occurred from pressure artifact. The interrater agreement for acceptability was assessed using Cohen κ for each category: illumination ( κ = 1.0), duration ( κ = 1.0), focus ( κ = 0.91), content ( κ = 0.76), stability ( κ = 0.71), and pressure ( κ = 0.82) and overall pass-fail rates (score > 10) ( κ = 0.66). Conclusion Our Microcirculation Image Quality Score addresses many of the common areas where video quality can degrade. The criteria introduced are an objective way to assess the quality of image acquisition, with the goal of selecting videos of adequate quality for analysis. The interrater reliability results in our preliminary study suggest that the Microcirculation Image Quality Score is reasonably repeatable between reviewers. Further assessment is warranted.
Study objective Abnormal (both low and high) central venous saturation (ScvO2 ) is associated with increased mortality in emergency department (ED) patients with suspected sepsis. Methods This was a ...secondary analysis of 4 prospectively collected registries of ED patients treated with early goal-directed therapy–based sepsis resuscitation protocols from 4 urban tertiary care hospitals. Inclusion criteria were sepsis, hypoperfusion defined by systolic blood pressure less than 90 mm Hg or lactate level greater than or equal to 4 mmol/L, and early goal-directed therapy treatment. ScvO2 levels were stratified into 3 groups: hypoxia (ScvO2 <70%); normoxia (ScvO2 71% to 89%); and hyperoxia (ScvO2 90% to 100%). The primary exposures were initial ScvO2 and maximum ScvO2 achieved, with the primary outcome as inhospital mortality. Multivariate analysis was performed. Results There were 619 patients who met criteria and were included. For the maximum ScvO2 , compared with the mortality rate in the normoxia group of 96 of 465 (21%; 95% confidence interval CI 17% to 25%), both the hypoxia mortality rate, 25 of 62 (40%; 95% CI 29% to 53%) and hyperoxia mortality rate, 31 of 92 (34%; 95% CI 25% to 44%) were significantly higher, which remained significant in a multivariate modeling. When the initial ScvO2 measurement was analyzed in a multivariate model, only hyperoxia was significantly higher. Conclusion The maximum ScvO2 value achieved in the ED (both abnormally low and high) was associated with increased mortality. In multivariate analysis for initial ScvO2 , the hyperoxia group was associated with increased mortality, but not the hypoxia group. This study suggests that future research aimed at targeting methods to normalize high ScvO2 values by therapies that improve microcirculatory flow or mitochondrial dysfunction may be warranted.
Study objective To study early microcirculatory perfusion indices in patients with severe sepsis/septic shock, compare early microcirculatory indices in sepsis survivors versus nonsurvivors, and ...identify systemic hemodynamic/oxygen transport variables that correlate with early microcirculatory perfusion indices. Methods This prospective observational study used orthogonal polarization spectral imaging to directly visualize the sublingual microcirculation in patients with severe sepsis/septic shock treated with early goal-directed therapy. We performed initial imaging within 6 hours of early goal-directed therapy initiation and late follow-up studies at 24-hour intervals until death or resolution of organ dysfunction. We imaged 5 sublingual sites and analyzed the data offline in a blinded fashion. We calculated 3 microcirculatory perfusion indices: flow velocity score, flow heterogeneity index, and capillary density. We analyzed early data to compare survivors versus nonsurvivors and examine correlations with systemic hemodynamic measurements. We used a linear mixed-effects model for longitudinal analyses. Results We performed 66 orthogonal polarization spectral studies in 26 sepsis patients. Early microcirculatory indices were more markedly impaired (lower flow velocity and more heterogeneous perfusion) in nonsurvivors compared with survivors. These same early indices, flow velocity and heterogeneity, were also more markedly impaired with increasing severity of systemic cardiovascular dysfunction (lower arterial pressure or increasing vasopressor requirement). Conclusion Early microcirculatory perfusion indices in severe sepsis and septic shock are more markedly impaired in nonsurvivors compared with survivors and with increasing severity of global cardiovascular dysfunction.
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