The influence of tourniquet use and operative time on the incidence of deep vein thrombosis in total knee arthroplasty

OBJECTIVE: To evaluate the association between tourniquet and total operative time during total knee arthroplasty and the occurrence of deep vein thrombosis. METHODS: Seventy-eight consecutive patients from our institution underwent cemented total knee arthroplasty for degenerative knee disorders. The pneumatic tourniquet time and total operative time were recorded in minutes. Four categories were established for total tourniquet time: <60, 61 to 90, 91 to 120, and >120 minutes. Three categories were defined for operative time: <120, 121 to 150, and >150 minutes. Between 7 and 12 days after surgery, the patients underwent ascending venography to evaluate the presence of distal or proximal deep vein thrombosis. We evaluated the association between the tourniquet time and total operative time and the occurrence of deep vein thrombosis after total knee arthroplasty. RESULTS: In total, 33 cases (42.3%) were positive for deep vein thrombosis; 13 (16.7%) cases involved the proximal type. We found no statistically significant difference in tourniquet time or operative time between patients with or without deep vein thrombosis. We did observe a higher frequency of proximal deep vein thrombosis in patients who underwent surgery lasting longer than 120 minutes. The mean total operative time was also higher in patients with proximal deep vein thrombosis. The tourniquet time did not significantly differ in these patients. CONCLUSION: We concluded that surgery lasting longer than 120 minutes increases the risk of proximal deep vein thrombosis.

Lupus anticoagulant: a marker for stroke and venous thrombosis in primary Sjogren's syndrome

Antiphospholipid antibodies (aPL) and antiphospholipid syndrome (APS) have been described in primary Sjogren's syndrome (pSS) with controversial findings regarding aPL prevalence and their association with thrombotic events. We evaluated 100 consecutive pSS patients (American-European criteria) and 89 age-gender-ethnicity-matched healthy controls for IgG/IgM anticardiolipin (aCL), IgG/IgM anti-beta2-glycoprotein-I (a beta 2GPI), and lupus anticoagulant (LA) (positivity according to APS Sydney's criteria). Clinical analysis followed standardized interview and physical examination assessing thrombotic and nonthrombotic APS manifestations and thrombosis risk factors. aPLs were detected in 16 % patients and 5.6 % controls (p = 0.035). LA was the most common aPL in patients (9 %), followed by a beta 2GPI (5 %) and aCL (4 %). Thrombotic events occurred in five patients [stroke in two, myocardial infarction in one and deep-vein thrombosis (DVT) in four], but in none of controls (p = 0.061). Mean age at time of stroke was 35 years. Three patients with thrombotic events (including the two with stroke) had APS (Sydney's criteria) and were positive exclusively for LA. Comparison of patients with (n = 16) and without (n = 84) aPL revealed similar mean age, female predominance, and ethnicity (p > =0.387). Frequencies of livedo reticularis (25 vs. 4.8 %, p = 0.021), stroke (12.5 vs. 0 %, p = 0.024), and DVT (18.8 vs. 1.2 %, p = 0.013) were significantly higher in APL + patients. Conversely, frequencies of hypertension, dyslipidemia, diabetes, obesity, smoking, sedentarism, and hormonal contraception were similar in patients with or without aPL (p a parts per thousand yenaEuro parts per thousand 0.253). Our study identified LA as an important marker for APS in pSS, particularly for stroke in young patients, warranting routine evaluation of these antibodies and rigorous intervention in modifiable risk factors.

Mycotic aneurysm of the tibioperoneal trunk: a first manifestation of an infected endocarditis

Infrapopliteal mycotic aneurysm resulting from endocarditis is rare, with only a few reported cases. We describe the case of a 28-year-old male patient who was suffering with pain and edema in the right leg. The ultrasound revealed an aneurysm of the right tibioperoneal trunk and a deep vein thrombosis (DVT). The patient was admitted and developed acute congestive heart failure, being diagnosed with possible endocarditis. A pseudo-aneurysm was revealed by arteriography. Aggressive antibiotic treatment was initiated, and open surgery confirmed a mycotic pseudo-aneurysm of the tibioperoneal trunk. To our knowledge, this is the 8th case reported of an infected aneurysm in this particular location.

Multivisceral Transplantation for Diffuse Portomesenteric Thrombosis

Objective: To evaluate the clinical outcomes of multivisceral transplantation (MVT) in the setting of diffuse thrombosis of the portomesenteric venous system. Background: Liver transplantation (LT) in the face of cirrhosis and diffuse portomesenteric thrombosis (PMT) is controversial and contraindicated in many transplant centers. LT using alternative techniques such as portocaval hemitransposition fails to eliminate complications of portal hypertension. MVT replaces the liver and the thrombosed portomesenteric system. Methods: A database of intestinal transplant patients was maintained with prospective analysis of outcomes. The diagnosis of diffuse PMT was established with dual-phase abdominal computed tomography or magnetic resonance imaging with venous reconstruction. Results: Twenty-five patients with grade IV PMT received 25 MVT. Eleven patients underwent simultaneous cadaveric kidney transplantation. Biopsy-proven acute cellular rejection was noted in 5 recipients, which was treated successfully. With a median follow-up of 2.8 years, patient and graft survival were 80%, 72%, and 72% at 1, 3, and 5 years, respectively. To date, all survivors have good graft function without any signs of residual/recurrent features of portal hypertension. Conclusions: MVT can be considered as an option for the treatment of patients with diffuse PMT. MVT is the only procedure that completely reverses portal hypertension and addresses the primary disease while achieving superior survival results in comparison to the alternative options.

Trombose de veia porta no transplante hepático

INTRODUÇÃO: A trombose de veia porta foi considerada contraindicação ao transplante de fígado no passado em razão da elevada morbi-mortalidade. Diversos avanços permitiram melhora dos resultados. OBJETIVO: Revisão dos avanços e das estratégias cirúrgicas utilizadas para realização do transplante de fígado na vigência de trombose de veia porta. MÉTODO: Revisão da literatura nas bases de dados Medline, Scielo, Lilacs cruzando os descritores: portal vein thrombosis, liver transplantation, vascular complications, jump graft, graft failure, multivisceral transplant. Foram estudados a epidemiologia, fatores de risco, classificação, diagnóstico, estratégias cirúrgicas e resultados. CONCLUSÃO: A trombose de veia porta deixou de ser contraindicação para o transplante hepático. O cirurgião dispõe atualmente de uma série de estratégias para realização do transplante, variando conforme o grau da trombose. Apesar de implicar em maior morbidade e taxas de re-trombose, os resultados do transplante na presença de trombose portal são semelhantes aos observados nas séries habituais.

Totally implantable venous catheters: insertion via internal jugular vein with pocket implantation in the arm is an alternative for diseased thoracic walls

Purpose: Insertion of totally implantable catheters via deep vessels that drain into the superior vena cava results in a lower incidence of venous thrombosis and infection as compared to catheters inserted into femoral and arm veins. Superior vena cava obstruction and inadequacy of the thoracic wall are conditions that prevent reservoir implantation in the chest wall. In this article, we describe a technical innovation that enables the pocket to be fixed in the arm while still allowing access to be achieved via the internal jugular vein. Method: The procedure reported maintains the use of the internal jugular vein for access even when the patient's chest is not suited for reservoir implantation, which is localized in the arm. Results: The procedure was successful and no complications occurred. The position of the catheter tip did not alter with arm movement. Conclusion: The implantation of a port reservoir in the arm following venous access via the internal jugular vein is both safe and convenient.

Diagnostic value of serum activin A and follistatin levels in women with peritoneal, ovarian and deep infiltrating endometriosis

Activin A is a growth factor, produced by the endometrium, whose actions are modulated by the binding protein follistatin. Both proteins are detectable in the peripheral serum and their concentrations may be increased in women with endometriosis. The present study was designed to evaluate whether serum levels of activin A and follistatin are altered, and therefore have a potential diagnostic value, in women with peritoneal, ovarian and deep infiltrating endometriosis. We performed a multicenter controlled study evaluating simultaneously serum activin A and follistatin concentrations in women with and without endometriosis. Women with endometriosis (n 139) were subdivided into three groups: peritoneal endometriosis (n 28); ovarian endometrioma (n 61) and deep infiltrating endometriosis (n 50). The control group (n 75) consisted of healthy women with regular menstrual cycles. Blood samples were collected from a peripheral vein and assayed for activin A and follistatin using commercially available enzyme immunoassay kits. The ovarian endometrioma group had serum activin A levels significantly higher than healthy controls (0.22 0.01 ng/ml versus 0.17 0.01 ng/ml, P 0.01). None of the endometriosis groups had serum follistatin levels which were significantly altered compared with healthy controls; however, levels found in the endometrioma group (2.34 0.32 ng/ml) were higher than that in the deep endometriosis group (1.50 0.17 ng/ml, P 0.05). The area under the receiver operating characteristic curve of activin A was 0.700 (95 confidence interval: 0.6050.794), while that of follistatin was 0.620 (95 confidence interval: 0.5100.730) for the diagnosis of ovarian endometrioma. The combination of both markers into a duo marker index did not improve significantly their diagnostic accuracy. The present study demonstrated that serum activin A and follistatin are not significantly altered in peritoneal or deep infiltrating endometriosis and have limited diagnostic accuracy in the diagnosis of ovarian endometrioma.

Macrofaunal succession in sediments around kelp and wood falls in the deep NE Pacific and community overlap with other reducing habitats

Sunken parcels of macroalgae and wood provide important oases of organic enrichment at the deep-sea floor, yet sediment community structure and succession around these habitat islands are poorly evaluated. We experimentally implanted 100-kg kelp falls and 200 kg wood falls at 1670 m depth in the Santa Cruz Basin to investigate (1) macrofaunal succession and (2) species overlap with nearby whale-fall and cold-seep communities over time scales of 0.25-5.5 yr. The abundance of infaunal macrobenthos was highly elevated after 0.25 and 0.5 yr near kelp parcels with decreased macrofaunal diversity and evenness within 0.5 m of the falls. Apparently opportunistic species (e.g., two new species of cumaceans) and sulfide tolerant microbial grazers (dorvilleid polychaetes) abounded after 0.25-0.5 yr. At wood falls, opportunistic cumaceans become abundant after 0.5 yr, but sulfide tolerant species only became abundant after 1.8-5.5 yr, in accordance with the much slower buildup of porewater sulfides at wood parcels compared with kelp falls. Species diversity decreased significantly over time in sediments adjacent to the wood parcels, most likely due to stress resulting from intense organic loading of nearby sediments (up to 20-30% organic carbon). Dorvilleid and ampharetid polychaetes were among the top-ranked fauna at wood parcels after 3.0-5.5 yr. Sediments around kelp and wood parcels provided low-intensity reducing conditions that sustain a limited chemoautrotrophically-based fauna. As a result, macrobenthic species overlap among kelp, wood, and other chemosynthetic habitats in the deep NE Pacific are primarily restricted to apparently sulfide tolerant species such as dorvilleid polychaetes, opportunistic cumaceans, and juvenile stages of chemosymbiont containing vesicomyid bivalves. We conclude that organically enriched sediments around wood falls may provide important habitat islands for the persistence and evolution of species dependent on organic- and sulfide-rich conditions at the deep-sea floor and contribute to beta and gamma diversity in deep-sea ecosystems. (C) 2010 Elsevier Ltd. All rights reserved.

Macrofaunal abundance and composition on the West Antarctic Peninsula continental shelf: Evidence for a sediment `food bank` and similarities to deep-sea habitats

To assess the impact and fate of the summer phytoplankton bloom on Antarctic benthos, we evaluated temporal and spatial patterns in macrofaunal abundance and taxonomic composition along a transect crossing the West Antarctic Peninsula (WAP) continental shelf As part of the FOODBANCS project, we sampled three sites at 550-625 m depths during five cruises occurring in November 1999, February-March 2000, June 2000, October 2000 and March 2001. We used a combination of megacore and box-core samplers to take 81 samples, and collected over 30,000 macrofaunal individuals, one of the largest sampling efforts on the Antarctic shelf to date. Comparison of the two sampling methodologies (box core and megacore) indicates similar macrofaunal densities, but with significant differences in taxonomic composition, a reflection of the different spatial scales of sampling. Macrorfaunal abundances on the WAP shelf were relatively high compared to other Antarctic shelf settings. At two of the three sampling sites, macrofaunal abundance remained constant throughout the year, which is consistent with the presence of a sediment `food bank`. Differences were observed in taxonomic composition at the site closest to the coast (Station A), driven by higher abundances of subsurface-deposit feeders. A significant temporal response was observed in the ampharetid polychaetes at Station A, with an abundance peak in the late fall post-bloom period; this may have resulted from juvenile recruitment during the summer bloom. Familial composition of macrofaunal polychaetes on the WAP shelf is more closely related to deep-sea abyssal fauna than to other shelf regions, and we hypothesize that this is a result of both local ecological conditions (low temperatures) and a reflection of historical processes such as extinctions on the Antarctic shelf during previous glacial maxima followed by recolonization from the deep sea. (C) 2008 Elsevier Ltd. All rights reserved.

The Oligocene-Neogene deep-sea Columbia Channel system in the South Brazilian Basin: Seismic stratigraphy and environmental changes

The Columbia Channel (CCS) system is a depositional system located in the South Brazilian Basin, south of the Vitoria-Trindade volcanic chain. It lies in a WNW-ESE direction on the continental rise and abyssal plain, at a depth of between 4200 and 5200 m. It is formed by two depocenters elongated respectively south and north of the channel that show different sediment patterns. The area is swept by a deep western boundary current formed by AABW. The system has been previously interpreted has a mixed turbidite-contourite system. More detailed study of seismic data permits a more precise definition of the modern channel morphology, the system stratigraphy as well as the sedimentary processes and control. The modern CCS presents active erosion and/or transport along the channel. The ancient Oligo-Neogene system overlies a ""upper Cretaceous-Paleogene"" sedimentary substratum (Unit U1) bounded at the top by a major erosive ""late Eocene-early Oligocene"" discordance (D2). This ancient system is subdivided into 2 seismic units (U2 and U3). The thick basal U2 unit constitutes the larger part of the system. It consists of three subunits bounded by unconformities: D3 (""Oligocene-Miocene boundary""), D4 (""late Miocene"") and D5 (""late Pliocene""). The subunits have a fairly tabular geometry in the shallow NW depocenter associated with predominant turbidite deposits. They present a mounded shape in the deep NE depocenter, and are interpreted as forming a contourite drift. South of the channel, the deposits are interpreted as a contourite sheet drift. The surficial U3 unit forms a thin carpet of deposits. The beginning of the channel occurs at the end of U1 and during the formation of D2. Its location seems to have been determined by active faults. The channel has been active throughout the late Oligocene and Neogene and its depth increased continuously as a consequence of erosion of the channel floor and deposit aggradation along its margins. Such a mixed turbidite-contourite system (or fan drift) is characterized by frequent, rapid lateral facies variations and by unconformities that cross the whole system and are associated with increased AABW circulation. (C) 2009 Elsevier B.V. All rights reserved.

Representation of the Weddell Sea deep water masses in the ocean component of the NCAR-CCSM model

We examine Weddell Sea deep water mass distributions with respect to the results from three different model runs using the oceanic component of the National Center for Atmospheric Research Community Climate System Model (NCAR-CCSM). One run is inter-annually forced by corrected NCAR/NCEP fluxes, while the other two are forced with the annual cycle obtained from the same climatology. One of the latter runs includes an interactive sea-ice model. Optimum Multiparameter analysis is applied to separate the deep water masses in the Greenwich Meridian section (into the Weddell Sea only) to measure the degree of realism obtained in the simulations. First, we describe the distribution of the simulated deep water masses using observed water type indices. Since the observed indices do not provide an acceptable representation of the Weddell Sea deep water masses as expected, they are specifically adjusted for each simulation. Differences among the water masses` representations in the three simulations are quantified through their root-mean-square differences. Results point out the need for better representation (and inclusion) of ice-related processes in order to improve the oceanic characteristics and variability of dense Southern Ocean water masses in the outputs of the NCAR-CCSM model, and probably in other ocean and climate models.

Deep chlorophyll maximum and upper ocean structure interactions: Case of the Guinea Thermal Dome

Deep Chlorophyll Maximum (DCM) modifies the upper ocean heat capture distribution and thus impacts water column temperature and stratification, as well as biogeochemical processes. This energetical role of the DCM is assessed using a 1 m-resolution 1D physical-biogeochemical model of the upper ocean, using climatological forcing conditions of the Guinea Dome (GD). This zone has been chosen among others because a strong and shallow DCM is present all year round. The results show that the DCM warms the seasonal thermocline by +2 degrees C in September/October and causes an increase of heat transfer from below into the mixed layer (ML) by vertical diffusion and entrainment, leading to a ML warming of about 0.3 degrees C in October. In the permanent thermocline, temperature decreases by up to 2 degrees C. The result is a stratification increase of the water column by 0.3 degrees C m(-1) which improves the thermocline realism when compared with observations. At the same time, the heating associated with the DCM is responsible for an increase of nitrate (+300%, 0.024 mu M), chlorophyll (+50%, 0.02 mu g l(-1)) and primary production (+45%: 10 mg C m(-2) day(-1)) in the ML during the entrainment period of October. The considered concentrations are small but this mechanism could be potentially important to give a better explanation of why there is a significant amount of nitrate in the ML. The mechanisms associated with the DCM presence, no matter which temperature or biogeochemical tracers are concerned, are likely to occur in a wide range of tropical or subpolar regions; in these zones a pronounced DCM is present at least episodically at shallow or moderate depths. These results can be generalized to other thermal dome regions where relatively similar physical and biogeochemical structures are encountered. After testing different vertical resolutions (10 m, 5 m, 2.5 m, 1 m and 0.5 m), we show that using at least a 1 to vertical resolution model is mandatory to assess the energetical importance of the DCM.

Biogeochemistry of a deep-sea whale fall: sulfate reduction, sulfide efflux and methanogenesis

Deep-sea whale falls create sulfidic habits Supporting chemoautotrophic communities, but microbial processes underlying the formation Of Such habitats remain poorly evaluated. Microbial degradation processes (sulfate reduction, methanogenesis) and biogeochemical gradients were studied in a whale-fall habitat created by a 30 t whale carcass deployed at 1675 m depth for 6 to 7 yr on the California margin. A variety of measurements were conducted including photomosaicking, microsensor measurements, radio-tracer incubations and geochemical analyses. Sediments were Studied at different distances (0 to 9 in) from the whale fall. Highest microbial activities and steepest vertical geochemical gradients were found within 0.5 m of the whale fall, revealing ex situ sulfate reduction and in vitro methanogenesis rates of up to 717 and 99 mmol m(-2) d(-1), respectively. In sediments containing whale biomass, methanogenesis was equivalent to 20 to 30%, of sulfate reduction. During in vitro sediment studies, sulfide and methane were produced within days to weeks after addition of whale biomass, indicating that chemosynthesis is promoted at early stages of the whale fall. Total sulfide production from sediments within 0.5 m of the whale fall was 2.1 +/- 3 and 1.5 +/- 2.1 mol d(-1) in Years 6 and 7, respectively, of which similar to 200 mmol d(-1) were available as free sulfide. Sulfate reduction in bones was much lower, accounting for a total availability of similar to 10 mmol sulfide d(-1). Over periods of at least 7 yr, whale falls can create sulfidic conditions similar to other chemosynthetic habitats Such as cold seeps and hydrothermal vents.

Lufaxin, a Novel Factor Xa Inhibitor From the Salivary Gland of the Sand Fly Lutzomyia longipalpis Blocks Protease-Activated Receptor 2 Activation and Inhibits Inflammation and Thrombosis In Vivo

Objective-Blood-sucking arthropods' salivary glands contain a remarkable diversity of antihemostatics. The aim of the present study was to identify the unique salivary anticoagulant of the sand fly Lutzomyia longipalpis, which remained elusive for decades. Methods and Results-Several L. longipalpis salivary proteins were expressed in human embryonic kidney 293 cells and screened for inhibition of blood coagulation. A novel 32.4-kDa molecule, named Lufaxin, was identified as a slow, tight, noncompetitive, and reversible inhibitor of factor Xa (FXa). Notably, Lufaxin's primary sequence does not share similarity to any physiological or salivary inhibitors of coagulation reported to date. Lufaxin is specific for FXa and does not interact with FX, Dansyl-Glu-Gly-Arg-FXa, or 15 other enzymes. In addition, Lufaxin blocks prothrombinase and increases both prothrombin time and activated partial thromboplastin time. Surface plasmon resonance experiments revealed that FXa binds Lufaxin with an equilibrium constant approximate to 3 nM, and isothermal titration calorimetry determined a stoichiometry of 1:1. Lufaxin also prevents protease-activated receptor 2 activation by FXa in the MDA-MB-231 cell line and abrogates edema formation triggered by injection of FXa in the paw of mice. Moreover, Lufaxin prevents FeCl3-induced carotid artery thrombus formation and prolongs activated partial thromboplastin time ex vivo, implying that it works as an anticoagulant in vivo. Finally, salivary gland of sand flies was found to inhibit FXa and to interact with the enzyme. Conclusion-Lufaxin belongs to a novel family of slow-tight FXa inhibitors, which display antithrombotic and anti-inflammatory activities. It is a useful tool to understand FXa structural features and its role in prohemostatic and proinflammatory events. (Arterioscler Thromb Vasc Biol. 2012;32:2185-2196.)

Molecular phylogeny and morphometric analyses reveal deep divergence between Amazonia and Atlantic Forest species of Dendrophryniscus

Dendrophryniscus is an early diverging clade of bufonids represented by few small-bodied species distributed in Amazonia and the Atlantic Forest. We used mitochondrial (414 bp of 12S, 575 bp of 16S genes) and nuclear DNA (785 bp of RAG-1) to investigate phylogenetic relationships and the timing of diversification within the genus. These molecular data were gathered from 23 specimens from 19 populations, including eight out of the 10 nominal species of the genus as well as Rhinella boulengeri. Analyses also included sequences of representatives of 18 other bufonid genera that were publically available. We also examined morphological characters to analyze differences within Dendrophryniscus. We found deep genetic divergence between an Amazonian and an Atlantic Forest clade, dating back to Eocene. Morphological data corroborate this distinction. We thus propose to assign the Amazonian species to a new genus, Amazonella. The species currently named R. boulengeri, which has been previously assigned to the genus Rhamphophryne, is shown to be closely related to Dendrophryniscus species. Our findings illustrate cryptic trends in bufonid morphological evolution, and point to a deep history of persistence and diversification within the Amazonian and Atlantic rainforests. We discuss our results in light of available paleoecological data and the biogeographic patterns observed in other similarly distributed groups. (C) 2011 Elsevier Inc. All rights reserved.