Effect of fibronectin-rich human cryoprecipitate on fluid volume requirements in sheep during postoperative sepsis

Septic surgical patients often require fluid administration to maintain cardiovascular stability due, in part, to the sepsis-induced increase in vascular permeability and associated plasma volume depletion. Plasma fibronectin deficiency exists in such septic patients. We determined if maintenance of fibronectin levels by administration of fibronectin-rich human plasma cryoprecipitate would lower the resuscitative fluid volume needed for support of arterial pressure in septic postoperative sheep which were experimentally depleted of plasma fibronectin. Following a 2-hr postoperative baseline period, denatured collagen (gelatin, 8.7 mg/kg), which has a high affinity for fibronectin, was infused into both control and experimental sheep in order to acutely deplete plasma fibronectin. Sheep were then challenged both intraperitoneally and intravenously with live Pseudomonas (5 x 10(10) bacteria IP; 5 x 10(9) bacteria IV). Experimentals were given fresh plasma cryoprecipitate intravenously at a dose of 4 units bolus, followed by 3 units/hr for 5 hr. Controls received plasma cryoprecipitate selectively depleted of fibronectin by affinity chromatography. Bacterial challenge rapidly resulted in severe systemic hypotension. Ringer's lactate was infused intravenously into both groups at a rate sufficient to maintain a systemic arterial pressure of approximately 50 mm Hg with a maximum pulmonary artery wedge pressure of 15-18 mm Hg. Its rate of infusion was periodically adjusted to maintain this hemodynamic status. Comparison was made of the volume of Ringer's lactate required to maintain an arterial pressure of 50 mm Hg in both groups. Net fluid requirement was significantly (p less than 0.05) less in postoperative septic sheep (47.4 +/- 6.2 mg/kg/hr) treated with fibronectin-rich cryoprecipitate compared to the fluid requirement (71.7 +/- 4.7 mg/kg/hr) for postoperative septic sheep receiving fibronectin-deficient cryoprecipitate. Thus elevation of plasma fibronectin concentration lowers the fluid requirements needed for hemodynamic support in postoperative Gram-negative sepsis.     

Assessment of global and regional left ventricular function and volumes with 64-slice MSCT: a comparison with 2D echocardiography.

BACKGROUND: In patients with coronary artery disease (CAD), LV function and volumes are important parameters for long-term prognosis. Multislice computed tomography (MSCT) allows noninvasive assessment of the coronary arteries, but the accuracy of 64-slice MSCT for the assessment of left ventricular (LV) volumes and function is unknown. METHODS AND RESULTS: A head-to-head comparison between 64-slice MSCT and 2-dimensional (2D) echocardiography was performed in 40 patients with known or suspected CAD. The LV end-diastolic volume (LVEDV) and LV end-systolic volume (LVESV) were determined and the LV ejection fraction (LVEF) was derived. Regional wall motion was assessed visually using a 17-segment model. A 3-point scoring system was used to assign to each segment a wall motion score: 1 = normokinesia, 2 = hypokinesia, 3 = akinesia or dyskinesia. Two-dimensional echocardiography served as the gold standard. MSCT agreed well with 2D echocardiography for assessment of LVEDV (r = 0.97; p < .0001) and LVESV (r = 0.98; p < .0001). An excellent correlation between MSCT and 2D echocardiography was shown for the evaluation of LVEF (r = 0.91; p < .0001). Agreement for the assessment of regional wall motion was excellent (96%, kappa = 0.82). CONCLUSIONS: An accurate assessment of global and regional LV function and volumes is feasible with 64-slice MSCT.     

Abundance of Ixodes scapularis (Acari: Ixodidae) after the complete removal of deer from an isolated offshore island, endemic for Lyme Disease

Monhegan is an isolated 237-ha island lying 16 km off the coast of Maine. Introduced to the island in 1955, white-tailed deer, Odocoileus virginianus Zimmerman, reached a density of approximately 37/km2 by the mid-1990s. Black-legged ticks, Ixodes scapularis Say, first noticed in the late 1980s, flourished thereafter. Norway rats (Rattus norvegicus Berkenhout) on Monhegan are highly infected with Borrelia burgdorferi Johnson, Schmidt, Hyde, Steigerwalt, and Brenner, the agent of Lyme disease. By 1996, 13% of year-round residents had contracted the disease. The community's subsequent decision to eliminate deer from the island provided a unique opportunity to monitor the abundance of vector ticks in response to the complete and permanent removal of the primary hosts of their reproductive stage. With the exception of humans and their dogs and cats, there are no other potential hosts for adult I. scapularis on Monhegan. From November 1996 to March 1999, all deer were removed from the island. Previous annual fall flagging of vegetation from 1990 to 1998 produced 6-17 adult ticks/h, of which 24-41% were infected with the Lyme disease spirochete. During this same period, up to 18 larvae and 4 nymphs were removed per Norway rat live-trapped on the island each July. With the absence of deer in the fall of 1999, both the density of host-seeking adult ticks and infection prevalence rose substantially to 28/h and 75.0%, respectively. By the summer of 2003, however, no sub-adult ticks were found on rats, and that fall, only 0.67 adult ticks/h were flagged. Of the 68 adults collected from 2002 to 2003, 20 (29.4%) were infected. Over this same period, adult tick abundance on a deer-populated, reference island continued to gradually increase.     

The effects of calcium and magnesium on inhibitory junctional transmission in smooth muscle of guinea pig small intestine

Summary The membrane potential of smooth muscle cells in the circular layer of the guinea pig ileum was recorded using intracellular electrodes. Transmural stimulation, in the presence of atropine, caused a transient hyperpolarization, an inhibitory junction potential (IJP). IJP's are thought to result from the action of transmitter released from intramural inhibitory nerves. It has been reported that, in the guinea pig jejunum, the amplitude of the IJP resulting from field stimulation is not altered by changes in the calcium and magnesium ion concentration in the bathing solution. Experiments reported here have shown that the IJP amplitude decreased markedly on reducing the calcium ion concentration and or increasing the magnesium ion concentration. Indirect evidence is presented suggesting that the decrease in amplitude of the IJP is due to a decrease in the amount of transmitter released.     

Death and the health professional: organization and defense in health care

Organizational and technological developments within the health care system have helped consolidate a power structure that dehumanizes clients and fosters defensive-ness in professionals. Frequent exposure to death renders health professionals vulnerable to severe anxiety, which they may try to avoid through death denial, leaving them psychologically unable to support dying clients. Professional education, attitudes equating death with professional failure, organizational coping strategies among nurses, and staff burnout interact to perpetuate this atmosphere. As a model for learning, this article analyzes a pediatric case study to illuminate the manifestations of professional defensiveness. Finally, I consider three specific problem-solving strategies: improving morale, opening communication, and expanding professional education to include death studies and psychological study of the health organization. Bringing humanity back into the health care environment is possible to the extent that both the organization and its members are responsive and open to change.     

Methadone: old problems for new programmes

The present paper is concerned with factors which compromise the effective delivery of programmes incorporating methadone. Current clinical practices and programme characteristics are reviewed and policy issues regarding the role of methadone are considered, especially within the context of containing the spread of HIV infection. These issues are discussed in relation to empirical outcome studies, local prescribing trends and clinical case material. The authors conclude that there is an urgent need for: (1) an evaluation of the outcome of private practitioner methadone dispensation versus comprehensive agency-based therapy; (2) the accreditation of staff in all programmes incorporating methadone; and (3) the development of monitoring mechanisms, including on-site clinical audits of programmes.