Rheological behaviour of red blood cells suspended in hemoglobin solutions. In vitro study comparing dextran-benzene-tetra-carboxylate hemoglobin, stroma free hemoglobin and plasma expanders

Circulating volume expansion for intentional hemodilution and/or resuscitation of hemorrhagic shock can be performed with hemoglobin-based oxygen carriers (HBOC) which, in addition to oxygen transport, have vasoactive effects through poorly documented mechanisms. Among these, the effects of HBOC on red blood cell (RBC) rheology are relatively unknown. The aim of the present in vitro study was to measure the rheological effects of human hemoglobin bound to benzene-tetracarboxylate substituted dextran (Dex-BTC-Hb) as an example of chemically modified hemoglobin. The viscosity was assessed with a capillary and a rotational viscometer for shear rates of 0.5-128 s-1. Erythrocyte aggregation was determined by analysis of the red light backscattered in a RBC suspension and with a rheoscope. The deformability was determined by the pressure-flow relationship of the RBC suspensions passed through polycarbonate filters. At hematocrit of 0.35 l/l and at low shear rates, the viscosity of RBC was higher in the presence of Dex-BTC-Hb as compared to free Hb, Dex-BTC, Dextran 40 (Plasmacair), modified fluid gelatin (MFG-Plasmion) or hydroxyethyl starch (HEA-Elohes). The effect on erythrocyte aggregation of Dex-BTC-Hb was greater than that of standard solutions, but close to that of MFG or HEA. There was no apparent change in RBC deformability. Dex-BTC-Hb, unlike free Hb, has a hyperaggregating effect on RBC, similar to that of some clinically used volume expanders. This hyperaggregating effect could influence the in vivo rheological behavior of substituted Hb by increasing shear stress.     

Prognostic value of nocturnal Cheyne-Stokes respiration in chronic heart failure

BACKGROUND: Nocturnal Cheyne-Stokes respiration (CSR) occurs frequently in patients with chronic heart failure (CHF), and it may be associated with sympathetic activation. The aim of the present study was to evaluate whether CSR could affect prognosis in patients with CHF. METHODS AND RESULTS: Sixty-two CHF patients with left ventricular ejection fraction /=30/h and left atria >/=25 cm2. CONCLUSIONS: The AHI is a powerful independent predictor of poor prognosis in clinically stable patients with CHF. The presence of an AHI >/=30/h adds prognostic information compared with other clinical, echocardiographic, and autonomic data and identifies patients at very high risk for subsequent cardiac death.     

Low Density Lipoprotein Apheresis by Membrane Differential Filtration (Cascade Filtration)

Membrane differential filtration (MDF) is an apheresis technique with which atherogenic lipoproteins can be eliminated from plasma on the basis of particle size. In 52 patients (REMUKAST Study, 1,702 treatments), low density lipoprotein (LDL) cholesterol was decreased by 61%, high density lipoprotein (HDL) cholesterol by 42%, and fibrinogen by 54%. Our own results in 3 patients show decreases of 62%, 31%, and 59%, respectively; lipoprotein (a) (Lp[a]) was reduced by 58%. The elimination of atherogenic lipoproteins was accompanied by a loss of macromolecules (IgM: 55%, IgG: 27%, α₂-macroglobulin: 49%) resulting in improved hemorrheologic parameters. Although HDL is eliminated with each apheresis session, pretreatment concentrations of HDL cholesterol increased by 24% during regular apheresis for 1 year (26 patients, REMUKAST Study). However, preapheresis concentrations of other macroglobulins such as immunoglobulins remained decreased compared to concentrations obtained before the first apheresis session (IgM: 34%, IgG: 23%, and IgA: 16%). We conclude that MDF apheresis is an effective method to lower elevated concentrations of atherogenic lipoproteins. The concomitant loss of other macromolecules transiently improves hemorrheology but demands a close monitoring of immunoglobulin concentrations as a safety parameter.     

Meta-analyses in systematic reviews of randomized controlled trials in perinatal medicine: comparison of fixed and random effects models.

There is a need for empirical work comparing the random effects model with the fixed effects model in the calculation of a pooled relative risk in the meta-analysis in systematic reviews of randomized controlled trials. Such comparisons are particularly important when trial results are heterogeneous. We considered 84 independent meta-analyses in which each trial included a set of different women/newborns. These meta-analyses were included in systematic reviews published in the Cochrane Library's pregnancy and childbirth module. Twenty-one of these 84 meta-analyses demonstrated statistical heterogeneity at p<0.10. The random effects model estimates showed wider confidence intervals, particularly in those meta-analyses showing heterogeneity in the trial results. The summary relative risk for the random effects model tended to show a larger protective treatment effect than the fixed effects model in the heterogeneous meta-analyses. In this set of meta-analyses, statistical evaluation of publication bias cannot be shown to account for heterogeneity. Our empirical conclusion is that there may be opposing effects if the random effects model is used in the meta-analysis of clinical trials showing heterogeneity in the results: stronger treatment effects reflected in the summary relative risk, but wider confidence intervals about this summary measure.     

Move to the head of the class: developing staff nurses as teachers.

Nurses, while clinical experts in their specific fields, rarely have an opportunity to learn and practice teaching skills needed in an educator role. Clinical experts experience anxiety when asked to make the transition from a clinical environment to the teaching role. This article describes a 4-hour program developed to train nurses to become teachers. Adult learning principles, learning styles, and curriculum development were included to demonstrate the skills necessary to help nurses become proficient teachers.     

Durable power of attorney: nursing implications.

Written, witnessed advance directives such as Durable Powers of Attorney and Living Wills communicate patients' care preferences. The critical care nurse must be knowledgeable about these legal documents to be able to effectively uphold the specific care requests. The authors define advance directives and outline the role of the nurse in execution of these directives.     

The Safe Medical Device Act: nursing implications.

The Safe Medical Device Act places a legal responsibility on health care practitioners to assess and report malfunctioning medical equipment. As a result of this law, the Food and Drug Administration (FDA) will for the first time have direct regulatory authority over hospitals. Today's complex and technological critical care setting requires that the nurse understand the legal and professional responsibilities imposed by this Act.     

Factors affecting the incidence of hypertension.

The incidence of hypertension was determined among 10,173 patients of general practices in southwestern Ontario studied from 1978 to 1982. For both sexes the incidence of hypertension rose with increasing age. The incidence was higher among men than among women until age 50, after which it was similar for the two sexes. Obesity was positively associated with incidence for both sexes. In men this association diminished significantly with increasing age. The similar trend in women fell just short of statistical significance. In men but not women heavy alcohol consumption was positively related to the incidence of hypertension. However, the broad definition of this variable may have obscured a relation in women. Among men the effect of obesity on the incidence of hypertension was less for heavy drinkers than for light drinkers. Smoking was not related to the incidence of hypertension in either sex.     

In vivo rheologic studies of plasma substitutes]

The aim of this study was to compare in 60 ASA1 patients, the rheological effects of a 500 ml plasma substitute infusion at induction of general anaesthesia. The 60 patients were allocated into 6 groups of 10. Each group received either albumin 4%, or dextran 40 3.5%, or dextran 60 6%, or hydroxyethylstarch (HES) 200 6%, or modified fluid gelatin or Ringer lactate. The infusion extended over 30 minutes. In blood samples obtained before infusion, immediately after the end, three and 24 hours after the end of infusion, osmotic pressure, oncotic pressure, proteins and fibrinogen concentration were measured. Following rheological parameters were also assessed: plasma viscosity, blood viscosity at two shear rates (0.5 and 128 s-1), erythrocyte aggregation by primary and final aggregation times as well as total and partial dissociation thresholds. The determinations were carried out at haematocrit corrected to 40%. At intergroup analysis of the different substitutes compared to albumin 4%, with the exception of Ringer lactate, there was no significant modification of osmotic and oncotic pressures or fibrinogen concentrations. Only gelatin and dextran 60 modified the rheological parameters. The intragroup comparison did not demonstrate significant variations of osmotic and oncotic pressures. Fibrinogen concentrations remained unchanged up to the 24th hours, where they increased as a reaction to surgery. Similar changes of rheological parameters occurred for Ringer lactate, albumin 4% and dextran 40: decrease of plasma viscosity (< 10%) and blood viscosity (< 20% at shear rate of 0.5 s-1), increase of primary aggregation time (30-50%) with decrease of total dissociation threshold (10-20%). These changes ended 24 hours after infusion. Dextran 60 and gelatin elicited a modification of blood rheology until the 24th hour after the end of infusion. Such modifications did not occur with HES. It is concluded that when a rheological effect is required albumin 4% or dextran 40 3.5% should be used.     

A comparison of methods for testing homogeneity of proportions in teratologic studies

We consider teratologic studies in which the aim is to compare the survival rate of animals in a treatment group to the corresponding rate in a control group. The design of such studies often involves the allocation of intact litters of animals to treatment, invalidating the application of standard statistical methods. We review the strengths and weaknesses of several approaches for dealing with this problem including methodology recently developed for the analysis of clustered binary data. A simulation study is conducted in which litter sizes are generated from a distribution having specified mean and degree of imbalance. It is recommended on the basis of this study and on theoretical considerations that the choice of method should depend on whether the comparison of interest is experimental or observational. For experimental comparisons, involving the random assignment of litters to different treatment groups, methods based on the adjustment of standard chi-square statistics are recommended unless the number of litters in each group is very large.