Liberal Group Research Articles

Restrictive versus liberal transfusion strategy in upper gastrointestinal bleeding: A randomized controlled trial.

Background:The study aimed at comparing restrictive and liberal transfusion strategy in reducing mortality in patients with upper gastrointestinal bleeding (UGIB).Methods:This was a single-center, prospective, open-label, non-inferiority, randomized controlled trial conducted over two years. Patients presenting with UGIB were randomized into restrictive (hemoglobin (Hb) <7 g/dl) or liberal (Hb <8 g/dl) transfusion strategy groups. Transfusion was given till patients achieved target Hb of 9 g/dl in restrictive and 10 g/dl in the liberal arms. Patients with exsanguinating bleeding, transfusion within 90 days, recent history of trauma or surgery were excluded. Primary outcome was mortality rate and the secondary outcomes were morbidity, re-bleeding episodes and the need for intervention.Results:A total of 224 patients were randomized to 112 patients in each group. Demographic characteristics were comparable. 45-day mortality was similar between the two groups (restrictive vs. liberal; 10/112 vs. 12/112; P = 0.65). The number of in-hospital bleeding episodes (12 vs. 9; P = 0.25), incidence of re-bleeding during the 45-day follow-up (13 vs. 14; P = 0.84), need for endoscopic banding for varices (37/112 vs. 39/112, P = 0.99), mean hospital stay (days) (3.21 ± 2.78 vs. 2.73 ± 1.29; P = 0.10) were similar between the two groups.Conclusion:Restrictive transfusion strategy is non-inferior to liberal transfusion strategy in patients with UGIB.

Effects of Liberal vs Restrictive Transfusion Thresholds on Survival and Neurocognitive Outcomes in Extremely Low-Birth-Weight Infants

Red blood cell transfusions are commonly administered to infants weighing less than 1000 g at birth. Evidence-based transfusion thresholds have not been established. Previous studies have suggested higher rates of cognitive impairment with restrictive transfusion thresholds. To compare the effect of liberal vs restrictive red blood cell transfusion strategies on death or disability. Randomized clinical trial conducted in 36 level III/IV neonatal intensive care units in Europe among 1013 infants with birth weights of 400 g to 999 g at less than 72 hours after birth; enrollment took place between July 14, 2011, and November 14, 2014, and follow-up was completed by January 15, 2018. Infants were randomly assigned to liberal (n = 492) or restrictive (n = 521) red blood cell transfusion thresholds based on infants' postnatal age and current health state. The primary outcome, measured at 24 months of corrected age, was death or disability, defined as any of cognitive deficit, cerebral palsy, or severe visual or hearing impairment. Secondary outcome measures included individual components of the primary outcome, complications of prematurity, and growth. Among 1013 patients randomized (median gestational age at birth, 26.3 [interquartile range {IQR}, 24.9-27.6] weeks; 509 [50.2%] females), 928 (91.6%) completed the trial. Among infants in the liberal vs restrictive transfusion thresholds groups, respectively, incidence of any transfusion was 400/492 (81.3%) vs 315/521 (60.5%); median volume transfused was 40 mL (IQR, 16-73 mL) vs 19 mL (IQR, 0-46 mL); and weekly mean hematocrit was 3 percentage points higher with liberal thresholds. Among infants in the liberal vs restrictive thresholds groups, the primary outcome occurred in 200/450 (44.4%) vs 205/478 (42.9%), respectively, for a difference of 1.6% (95% CI, -4.8% to 7.9%; P = .72). Death by 24 months occurred in 38/460 (8.3%) vs 44/491 (9.0%), for a difference of -0.7% (95% CI, -4.3% to 2.9%; P = .70), cognitive deficit was observed in 154/410 (37.6%) vs 148/430 (34.4%), for a difference of 3.2% (95% CI, -3.3% to 9.6%; P = .47), and cerebral palsy occurred in 18/419 (4.3%) vs 25/443 (5.6%), for a difference of -1.3% (95% CI, -4.2% to 1.5%; P = .37), in the liberal vs the restrictive thresholds groups, respectively. In the liberal vs restrictive thresholds groups, necrotizing enterocolitis requiring surgical intervention occurred in 20/492 (4.1%) vs 28/518 (5.4%); bronchopulmonary dysplasia occurred in 130/458 (28.4%) vs 126/485 (26.0%); and treatment for retinopathy of prematurity was required in 41/472 (8.7%) vs 38/492 (7.7%). Growth at follow-up was also not significantly different between groups. Among infants with birth weights of less than 1000 g, a strategy of liberal blood transfusions compared with restrictive transfusions did not reduce the likelihood of death or disability at 24 months of corrected age. ClinicalTrials.gov Identifier: NCT01393496.

Association Between Intravenous Fluid Resuscitation and Hospital Mortality in Post Cardiac Arrest Patients: A Retrospective Study.

To assess the role for intravenous fluid (IVF) resuscitation in the postarrest state. Primary outcome was survival to hospital discharge and 30-day mortality. Secondary outcomes were associations with amount of vasopressor use and mechanical ventilation days. Retrospective study design. Single-center tertiary hospital in Philadelphia, Pennsylvania. All patients admitted to the intensive care unit between 2018 and 2019. Patients were divided into two groups based on amount of IVF received within 24 h <30 mL/kg (restricted) and over 30 mL/kg (liberal). A total of 264 patients were included in the study, with 200 included in the restrictive (<30 mL/kg) group and 64 included in the liberal (>30 mg/kg) group. There was no difference in 30-day mortality between the two groups with 146 (73%) deaths in the restrictive groups and 44 (69%) deaths in the liberal group (P = 0.53). There was also no significant difference between those who survived to hospital discharge in the liberal and restrictive groups on Kaplan-Meier analysis (Log-rank = 1.476 P = 0.224). However, there was a significant difference between restrictive and liberal groups with the duration of mechanical ventilation (4 ± 6 days vs. 6 ± 9 days; P = 0.03) and in the rates of two or more vasopressor use (38% vs. 59%; P = 0.002). End-stage renal disease (ESRD) (OR = 2.39; P = 0.03) and volume of fluids in mL/kg/24 h (OR = 1.025; P < 0.0001) were independently associated with higher vasopressor need. Volume of fluid in mL/kg/24 h (P = 0.01), ESRD (P = 0.015), and chronic obstructive pulmonary disease (P = 0.04) were significantly associated with duration of mechanical ventilation, even after adjusting for demographic factors, comorbidities, and mortality. A liberal strategy of IVF used in resuscitation after cardiac arrest is not associated with higher mortality. However, it predicts higher vasopressor use and duration of mechanical ventilation.

Correlation between Intraoperative Fluid Administration and Outcomes of Pancreatoduodenectomy.

Background Intraoperative fluid (IOF) administration plays an important role during major abdominal surgery although increased fluid intake can adversely influence postoperative outcomes. However, the effect of the IOF rate on the outcomes of pancreatoduodenectomy (PD) is unclear. Methods 151 patients, who underwent PD at Binzhou Medical University Hospital between January 2010 and May 2017, were categorized into three groups according to IOF rates (ml/kg/hr): restricted (<10, n = 47), standard (10–15, n = 76), and liberal (>15, n = 28). Results The overall postoperative morbidity was 56.95%. The incidence of postoperative pancreatic fistula (POPF) was 11.26%. The in-hospital mortality rate was 7.28% with the most common cause being grade C POPF and secondary intra-abdominal infections. The patients in the liberal group had significantly higher incidences of POPF (25%) and respiratory complications (21.43%). The other outcome parameters such as recovery of bowel function, hospital stay, and postoperative daily drainage were similar among the groups. Multivariable analysis confirmed the IOF rate to be most strongly associated with POPF (odds ratio: 5.195, confidence interval: 1.142–23.823, P = 0.023) and respiratory complications (odds ratio: 7.302, confidence interval: 0.676–58.231, P = 0.025). Conclusions The IOF rate significantly affects the incidence of POPF and respiratory complications after PD. Careful patient-oriented fluid therapy may help to prevent these complications.

A restrictive versus liberal transfusion strategy to prevent myocardial injury in patients undergoing surgery for fractured neck of femur: a feasibility randomised trial (RESULT-NOF)

BackgroundThe optimum transfusion strategy in patients with fractured neck of femur is uncertain, particularly if there is coexisting cardiovascular disease. MethodsWe conducted a prospective, single-centre, randomised feasibility trial of two transfusion strategies. We randomly assigned patients undergoing surgery for fractured neck of femur to a restrictive (haemoglobin, 70–90 g L−1) or liberal (haemoglobin, 90–110 g L−1) transfusion strategy throughout their hospitalisation. Feasibility outcomes included: enrolment rate, protocol compliance, difference in haemoglobin, and blood exposure. The primary clinical outcome was myocardial injury using troponin estimations. Secondary outcomes included major adverse cardiac events, postoperative complications, duration of hospitalisation, mortality, and quality of life. ResultsWe enrolled 200 (22%) of 907 eligible patients, and 62 (31%) showed decreased haemoglobin (to 90 g L−1 or less) and were thus exposed to the intervention. The overall protocol compliance was 81% in the liberal group and 64% in the restrictive group. Haemoglobin concentrations were similar preoperatively and at postoperative day 1 but lower in the restrictive group on day 2 (mean difference [MD], 7.0 g L−1; 95% confidence interval [CI], 1.6–12.4). Lowest haemoglobin within 30 days/before discharge was lower in the restrictive group (MD, 5.3 g L−1; 95% CI, 1.7–9.0). Overall, 58% of patients in the restrictive group received no transfusion compared with 4% in the liberal group (difference in proportion, 54.5%; 95% CI, 36.8–72.2). The proportion with the primary clinical outcome was 14/26 (54%, liberal) vs 24/34 (71%, restrictive), and the difference in proportion was –16.7% (95% CI, –41.3 to 7.8; P=0.18). ConclusionA clinical trial of two transfusion strategies in hip fracture with a clinically relevant cardiac outcome is feasible. Clinical trial registrationNCT03407573.

The best strategy for red blood cell transfusion in severe burn patients, restrictive or liberal: A randomized controlled trial

IntroductionAlthough blood transfusion is common in burns, data are lacking in appropriate transfusion thresholds. It has been reported that a restrictive blood transfusion policy decreases blood utilization and improves outcomes in critically ill adults, but the impact of a restrictive blood transfusion policy in burn patients is unclear. We decided to investigate the outcome of decreasing the blood transfusion threshold. Material and methodsEighty patients with TBSA > 20% who met our inclusion criteria were included. They were randomly divided into control and intervention groups. The intervention group received packed cells only when Hemoglobin declined to less than 8 g/dL at routine laboratory evaluations. While the control group received packed-cell when hemoglobin was declined to less than 10 g/dl. The total number of the received packed cell before, during and after any surgical procedure was recorded. The outcome was measured by the evaluation of the infection rate and other complications. ResultThe mean hemoglobin level before transfusion was 7.7 ± 0.4 g/dL in the restrictive group and 8.8 ± 0.7 g/dL in the liberal group. The mean number of RBC unit transfusion per patient in the restrictive group was significantly lower than the traditional group (3.28 ± 2.2 units vs. 5.9 ± 3.7 units) (p-value = 0.006). The total number of RBC transfused units varied significantly between the two groups (p-value = 0.014). The number of transfused RBC units outside the operation room showed a significant difference between groups (restrictive: 2.8 ± 1.4 units vs. liberal: 4.4 ± 2.6 units) (p = 0.004). We did not find any significant difference in mortality rate or other outcome measures between groups. ConclusionApplying the restrictive transfusion strategy in thermal burn patients who are highly prone to all kinds of infection, does not adversely impact the patient outcome, and results in significant cost savings to the institution and lower rate of infection. We conclude that the restrictive transfusion practice during burn excision and grafting is well tolerated and effective in reducing the number of transfusions without increasing complications. Clinical Trial Registration ReferenceIRCT20190209042660N1.

Science, Medicine, and the Anesthesiologist

Science, Medicine, and the Anesthesiologist

Fluidoterapia perioperatoria y complicaciones post pancreatectomía distal videolaparoscópica

Despite mortality in pancreatic surgery has decreased over the last decade, morbidity remains high. One of the most important causes is pancreatic fistula. Recent studies have demonstrated the importance of fluid therapy management during the perioperative period in major abdominal surgeries. This finding was observed first in colonic surgery, demonstrating that overload of fluids increases postoperative complications. Objective. To evaluate the impact of fluid management on postoperative complications after laparoscopic distal pancreatectomy. Material and methods. Descriptive, retrospective study of a prospective database of patients whom underwent laparoscopic distal pancreatectomy from November 2011 to September 2018. Thirty patients were evaluated and divided in two groups depending on the fluid management (restrictive, or liberal). The data were collected from the anesthesia protocols and nursery reports (until 3rd postoperative day). Demographics, length of stay, kind of fluid management and complications were analyzed. For statistical analysis SPSS®v.21 was used (p &lt; 0.05 was considered significant). Results. Out of 30 patients, 17% were male, mean age was 55 ± 18 years (r 19-82); 17 patients (57%) were included in the liberal group and 13 (43%) in the restrictive group. Twenty-three patients developed complications; 16 (53%) belonged to liberal group whereas 7 (23%) to restrictive group. (p = 0.01). Fourteen patients of liberal group vs. 6 patients of restrictive group had postoperative pancreatic fistula (p = 0.04). There were 7 patients (23%) in liberal group. and 4 (13%) patients in restrictive group with clinically relevant pancreatic fistula (13%, p = NS). Ninety day-mortality was 3.3, with no differences between groups. Conclusion. After laparoscopic distal pancreatectomy, liberal fluid administration at the perioperative period is associated with an increase in the incidence of complication, specially favoring the development of pancreatic fistula.

Systematic reviews and meta-analyses comparing mortality in restrictive and liberal haemoglobin thresholds for red cell transfusion: an overview of systematic reviews

BackgroundThere are no overviews of systematic reviews investigating haemoglobin thresholds for transfusion. This is important as the literature on transfusion thresholds has grown considerably in recent years. Our aim was to synthesise evidence from systematic reviews and meta-analyses of the effects of restrictive and liberal transfusion strategies on mortality.MethodsThis was a systematic review of systematic reviews (overview). We searched MEDLINE, Embase, Web of Science Core Collection, PubMed, Google Scholar, and the Joanna Briggs Institute EBP Database, from 2008 to 2018. We included systematic reviews and meta-analyses of randomised controlled trials comparing mortality in patients assigned to red cell transfusion strategies based on haemoglobin thresholds. Two independent reviewers extracted data and assessed methodological quality. We assessed the methodological quality of included reviews using AMSTAR 2 and the quality of evidence pooled using an algorithm to assign GRADE levels.ResultsWe included 19 systematic reviews reporting 33 meta-analyses of mortality outcomes from 53 unique randomised controlled trials. Of the 33 meta-analyses, one was graded as high quality, 15 were moderate, and 17 were low. Of the meta-analyses presenting high- to moderate-quality evidence, 12 (75.0%) reported no statistically significant difference in mortality between restrictive and liberal transfusion groups and four (25.0%) reported significantly lower mortality for patients assigned to a restrictive transfusion strategy. We found few systematic reviews addressed clinical differences between included studies: variation was observed in haemoglobin threshold concentrations, the absolute between group difference in haemoglobin threshold concentration, time to randomisation (resulting in transfusions administered prior to randomisation), and transfusion dosing regimens.ConclusionsMeta-analyses graded as high to moderate quality indicate that in most patient populations no difference in mortality exists between patients assigned to a restrictive or liberal transfusion strategy.Trial registrationPROSPERO CRD42019120503

THE NATIONAL ORGANIZATION FOR WOMEN AND THE DEMOCRATIC PARTY IN REAGAN'S AMERICA

AbstractThis article explores the emergence of women in the United States as a liberal voting group in the 1980s and the impact of this development on the power of liberalism, amid the Reagan revolution – an era often viewed as the apogee of conservatism. As the Republican party shifted in a more conservative direction in the 1980s, gender started to correlate with partisan preference/election outcomes in enough contests to give credence to the belief that women were becoming a decidedly liberal voting bloc. Contemporaneously, the equality-seeking movements of the 1960s and 1970s began institutionalizing their operations and exploiting these demographic shifts, becoming more entrenched than ever within the internal politics of the Democratic party. The National Organization for Women (NOW), the largest liberal women's group, proved to be particularly successful in this respect. Therefore, by presenting substantial archival evidence that liberal politicians and organizations remained a dynamic political force during the 1980s, this article details the growing organizational prowess of NOW and examines how liberals resisted the conservative challenge to fashion a political approach suited to the ‘Reagan Era’.

The Effect of Intra-Operative Plethysmography Variability Index-guided Fluid Therapy on Serum Lactate Levels; A Randomized Double-blinded Clinical Trial

Background: Goal-directed fluid therapy may improve perioperative fluid management. This study aimed to evaluate the effects of Pleth variability index (PVI)-guided fluid therapy on changes in intraoperative serum lactate levels in comparison with liberal fluid therapy. Methods: This study was a randomized double-blinded clinical trial that was conducted in the operating room of a university hospital. Inclusion criteria comprised patients aged 18–60 years and classified as American Society of Anesthesiologists physical status class I and II, who were candidates for elective thyroidectomy. In total, 44 patients meeting the inclusion criteria were enrolled in the study and randomly assigned to two groups: the liberal and PVI groups. In both groups, 5 mL/kg bolus of normal saline was infused prior to the anesthesia induction. In the PVI group, 100 mL bolus of normal saline was administered every 5 min if the PVI remained &gt;13% during the operation. In the liberal group, continuous crystalloid infusion (5–6 mL/kg/h) was administered throughout the surgery. Arterial blood samples were taken, and serum lactate levels were measured following anesthesia induction and just before tracheal extubation. Results: In the PVI group, mean serum lactate decreased at the end of the surgery, with a difference of −0.6 ± 0.13 mmol/L, whereas it increased in the liberal group (0.070 ± 0.3, P&lt;0.05). Conclusion: In conclusion, we found that using intraoperative PVI-guided fluid therapy could decrease serum lactate levels and total fluid administration compared to the liberal method.

Blood Conservation Strategy at Time of Left Ventricular Assist Device Placement Improves Survival

Bleeding is the most common complication of left ventricular assist device (LVAD) placement. However, excessive transfusion has been linked to heart failure, stroke, and alloimmunization. We compared 90-day outcomes in patients receiving a blood conservation (BCS) versus liberal transfusion strategy during surgery and the subsequent 24 hours. 173 LVAD implants at a single center between June 2011 and September 2018 were reviewed. Due to incomplete data, 3 patients were excluded. The BCS (≤1 packed red blood cell (pRBC)) was employed in 56/170 patients. In the liberal group, 41 received 2-5 units, 24 received 6-10 units, 24 received 11-15 units, and 25 received ≥15 units of PRBC. Anti-platelet use was equal across groups whereas anticoagulants were more readily used in the conservative group (55 vs 38%, p=0.04) at implantation. The liberal group had greater use of circulatory support devices (47 vs 29%, p=0.02) whereas the BCS group had larger ventricular size. Pre-operative laboratory values were similar among groups except for hemoglobin g/dL (12.6 conservative vs 11.6 liberal, p=0.02). Both the length of hospital and ICU stay were lower in the BCS group (17 vs 24 days, p<0.001 and 9 vs 12 days, p=0.02). Bleeding events (p-0.02) and reoperation were more frequent in the liberal group (13 vs 32 %, p=0.007). No difference between stroke, infection and right ventricular assist device use rates were seen. 90-day mortality was significantly higher in the liberal group (p=0.03). However, multivariate analysis did not show a significant benefit of the BCS despite trend towards survival with a crude HR 2.23 (0.86-5.82, p=0.10) and adjusted HR 2.21 (0.82-5.75, p=0.10). BCS at time of LVAD implant is associated with improved early survival. Identified transfusion triggers and standardized transfusion protocols for LVAD patients have the potential to reduce blood product utlization.

Disliked but Free to Speak: Cognitive Ability Is Related to Supporting Freedom of Speech for Groups Across the Ideological Spectrum

Freedom of speech for all citizens is often considered as a cornerstone of democratic societies. In three studies, we examined the relationship between cognitive ability and support for freedom of speech for a variety of social groups across the ideological spectrum (N1 varies between 1,373 and 18,719, N2 = 298, N3 = 395). Corroborating our theoretical expectations, although cognitive ability was related to more affective prejudice toward relatively conservative groups and less affective prejudice toward relatively liberal groups (Study 2), people with higher levels of cognitive ability were more in favor of freedom of speech for all target groups (Studies 1–3). The relationship between cognitive ability and freedom of speech support was mediated by intellectual humility (preregistered Study 3). These results indicate that cognitive ability contributes to support for the democratic right of freedom of speech for all social–ideological groups.

The effect of restrictive versus liberal transfusion strategies on longer-term outcomes after cardiac surgery: a systematic review and meta-analysis with trial sequential analysis.

Blood transfusions are frequently administered in cardiac surgery. Despite a large number of published studies comparing a "restrictive" strategy with a "liberal" strategy, no clear consensus has emerged to guide blood transfusion practice in cardiac surgery patients. The purpose of this study was to identify, critically appraise, and summarize the evidence on the overall effect of restrictive transfusion strategies compared with liberal transfusion strategies on mortality, other clinical outcomes, and transfusion-related outcomes in adult patients undergoing cardiac surgery. We searched MEDLINE (OvidSP), EMBASE (OvidSP) and Cochrane CENTRAL (Wiley) from inception to 1December 2017 and queried clinical trial registries and conference proceedings for randomized-controlled trials of liberal vs restrictive transfusion strategies in cardiac surgery. From 7,908 citations, we included ten trials (9,101 patients) and eight companion publications. Overall, we found no significant difference in mortality between restrictive and liberal transfusion strategies (risk ratio [RR], 1.08; 95% confidence interval [CI], 0.76 to 1.54; I2 = 33%; seven trials; 8,661 patients). The use of a restrictive transfusion strategy did not appear to adversely impact any of the secondary clinical outcomes. As expected, the proportion of patients who received red blood cells (RBCs) in the restrictive group was significantly lower than in the liberal group (RR, 0.68; 95% CI, 0.64 to 0.73; I2 = 56%; 5 trials; 8,534 patients). Among transfused patients, a restrictive transfusion strategy was associated with fewer transfused RBC units per patient than a liberal transfusion strategy. In adult patients undergoing cardiac surgery, a restrictive transfusion strategy reduces RBC transfusion without impacting mortality rate or the incidence of other perioperative complications. Nevertheless, further large trials in subgroups of patients, potentially of differing age, are needed to establish firm evidence to guide transfusion in cardiac surgery. PROSPERO (CRD42017071440); registered 20 April, 2018.

Women’s Activism in Pakistan: Role of Religious Nationalism and Feminist Ideology Among Self-Identified Conservatives and Liberals

AbstractThis paper explores women’s activism and political engagement in contemporary Pakistan. In this exploration with self-identified liberal and conservative groups of women, emerged their experiences and narratives about Feminism and Nationalism with a common moderator being religious affiliations. In this qualitative and phenomenological exploration, the informants belonged to various self-identified liberal and conservative women-led organizations. To this end, 20 women (age-range 23-48 years) were interviewed. Results indicated that gender roles and feminism were seen very differently between the two groups; gender and national identity were closely associated with Islamic values and there was a negative association between nationalism and feminist ideology. Women from liberal organizations, mostly feminists, emphasized pro-public-sphere engagement of women, rebelling against religious fundamentalism. On the contrary, many self-reported conservative women proclaimed nationalist, anti-feminists (they did not identify as Islamic feminists) and pro-private-sphere engagement of women. Many of the liberal informants complained about Pakistan’s misogynistic society and hurdles they faced in demanding equal opportunities for women. This research has implications for gender equality and female identity in the context of nationalism, women’s mobility and entitlement to the public sphere. The study also has applied significance for prejudices and stereotypes that make it difficult for women, to break away from fixed categories of gender role expectations. This paper informs academics and practitioners on socially and politically engaged Pakistani women’s views regarding these narratives. The study concluded that women’s activism is influenced by their religious views and their religious interpretation of feminism and nationalism in Pakistani society.

In search for a haemoglobin threshold in myelodysplastic syndromes.

In search for a haemoglobin threshold in myelodysplastic syndromes.

Sepsis-related anemia in a pediatric intensive care unit: transfusion-associated outcomes.

Pediatric patients with sepsis in intensive care units are at high risk of developing anemia, which might have adverse effects on their prognosis. This study aimed to evaluate the impact of red blood cell (RBC) transfusion on the outcomes of patients admitted to a pediatric intensive care unit (PICU) with sepsis. We conducted a prospective randomized clinical trial, enrolling 67 children, aged 2 to 144 months who were admitted to a PICU with a new episode of sepsis from November 2017 to April 2018. Patients were allocated randomly to two groups: Group 1, liberal transfusion strategy group, including 33 patients who had initial hemoglobin (Hb) between 7 or greater and less than 10 g/dL and received an RBC top-up transfusion to 12 g/dL; and Group 2, restrictive strategy group, including 34 patients who had the same Hb range and did not receive RBCs. Patients with Hb less than 7 or greater than 10 g/dL were excluded. Of 33 patients who received liberal transfusions, 31 (93.94%) required ventilation, and 29 (87.88%) had multiorgan dysfunction. They had a significantly lengthier hospital stay and a higher incidence of acute respiratory distress syndrome and acute lung injury. Moreover, mortality was significantly higher in the liberal transfusion group (42.4% vs. 17.6%). Compared to the restrictive transfusion strategy, liberal transfusion might be associated with a worse outcome. However, the possible role of other known and unknown confounding factors and minor protocol violations should be taken into consideration. We recommend minimizing factors worsening anemia in PICU patients to reduce the need for transfusion.

Perioperative fluid managment and postoperative complications after laparoscopic distal pancreatectomy

Presenter: Pablo Barros | Hospital Universitario Fundación Favaloro Background: Despite mortality in pancreatic surgery has decreased over the last decade, morbidity still remains high. One of the most important causes for this is the occu pancreatic fistula. Recent studies have demonstrated the importance of fluid management during the post-operative period in major abdominal surgeries. This finding was observed in colonic surgery as well, demonstrating that the overcharge of fluids increases post-operative complications. We aime to evaluate the impact of fluid management on post-operative complications after videolaparoscopic distal pancreatectomy (VDP). Methods: Descriptive, retrospective study of a prospective database of patients who underwent VDP from November 2011 to September 2018. Thirty patients were evaluated and divided into two different groups according to the fluid management protocol used (restrictive or liberal). The data were collected from the anesthesia`s protocols and nursery reports (until 3rd post-operative day). Demographics, length of stay, kind of fluid management and complications were analyzed. For statistical analysis SPSS®v.21 was used (p= < 0.05 was considered significant) Results: Out of 30 patients, 17 (%) were male, mean age was 55 years(r 19-82); 17 patients (57%) were included in liberal group (LG) and 13 (43%) in restrictive group (RG). Twenty-three patients developed complications;16 (53 %) belonged to LG whereas7 (23 %) to RG(p=0,01). Fourteen patients of LG vs. 6 patients of RG had post-operative pancreatic fistula (p=0.04). There were 7 patients (23 %) in LG and 4 (13 %) patients in RG with POPF-CS (13 %, p=ns). 90-day-mortality was 3.3 % Conclusion: After videolaparoscopic distal pancreatectomy, liberal fluid administration at the perioperative period is associated with an increase in the incidence of complication, specially the development of POPF.

Prevalence of anemia among pediatric critical care survivors and impact of restrictive transfusion strategy on it: A study from North India

BACKGROUND: Anemia occurs frequently in critically ill patients and it can impact on long-term outcome more so after a critical illness. Very little data are available about anemia in pediatric critical care survivors. Recent randomized control trials in children support the use of restrictive transfusion strategy in critically ill children.OBJECTIVES: This study aims to estimate the prevalence of anemia in pediatric critical care survivors, its causative factors and impact of restrictive transfusion strategy on its resolution.PATIENTS AND METHODS: In this retrospective observational study, patients who got discharged from pediatric intensive care unit (PICU), their clinical course, serial hemoglobin (Hb) level, and transfusion history were collected. Patients were divided into two groups according to transfusion strategy (restrictive and liberal group). Patients with anemia were followed up and persistence of anemia was noted monthly.RESULTS: In 54 cases enrolled in the study, 35 children had anemia (prevalence 35/54 = 64.8%). Statically significant difference between anemic and nonanemic groups was found in terms of duration of PICU stay and development of infection and no significant difference in age, gender, diagnosis, and requirement of mechanical ventilation. Among the 35 anemic children, restrictive transfusion strategy was followed in 21 and in 14 children liberal transfusion strategy was followed. Ten children were lost to follow-up. Anemia got resolved in 18 children (18/25 = 72%) and 7 children (7/25 = 20%) had persistent anemia. Among 25 children, 4 children in restrictive group (4/15 = 26.6%) and 3 children in liberal group (3/10 = 30%) had persistent anemia (statistically not significant; P > 0.05).CONCLUSIONS: A large proportion of PICU survivor children is anemic at discharge, this could be due to long duration PICU stay or acquired infection during hospital stay or following restrictive transfusion strategy but on a long-term follow-up no statistically significant difference was noted between two groups.

Mirror of Competing Claims: Antisemitism and Citizenship in Vormärz Germany

The Haber Affair of 1843 became a cause célèbre within German society as it pitted the traditional elites against more liberal groups who sought inclusion of outsiders and a fundamental re-organization of society along bourgeois lines. Caught between these groups was Moritz von Haber, the son of an ennobled court banker. These groups viewed the Haber Affair through their personal views of Haber and his perceived transgressions, but ultimately as a litmus test of the limits of Jewish integration and whether or not German Jews deserved full emancipation. The Haber Affair also demonstrated how latent Jew-hatred could be re-activated quickly in society and how the German State participated in fomenting this violence.