Thrombin generation during cardiopulmonary bypass: the possible role of retransfusion of blood aspirated from the surgical field

BACKGROUND: In spite of using heparin-coated extracorporeal circuits, cardiopulmonary bypass (CPB) is still associated with an extensive thrombin generation, which is only partially suppressed by the use of high dosages of heparin. Recent studies have focused on the origins of this thrombotic stimulus and the possible role of retransfused suctioned blood from the thoracic cavities on the activation of the extrinsic coagulation pathway. The present study was designed to find during CPB an association between retransfusion of suctioned blood from the pericardium and pleural space, containing activated factor VIIa and systemic thrombin generation. METHODS: Blood samples taken from 12 consenting patients who had elective cardiac surgery were assayed for plasma factor VIIa, prothrombin fragment 1+2 (F1+2), and thrombin-antithrombin (TAT) concentrations. Blood aspirated from the pericardium and pleural space was collected separately, assayed for F1+2, TAT, and factor VIIa and retransfused to the patient after the aorta occlusion. RESULTS: After systemic heparinization and during CPB thrombin generation was minimal, as indicated by the lower than base line plasma levels of F1+2, and TAT after correction for hemodilution. In contrast, blood aspirated from the thoracic cavities had significantly higher levels of factor VIIa, F1+2, and TAT compared to the simultaneous samples from the blood circulation (P < 0.05). Furthermore, after retransfusion of the suctioned blood (range, 200-1600 mL) circulating levels of F1+2, and TAT rose significantly from 1.6 to 2.9 nmol/L (P = 0.002) and from 5.1 to 37.5 μg/L (P = 0.01), respectively. The increase in both F1+2, and TAT levels correlated significantly with the amount of retransfused suctioned blood (r = 0.68, P = 0.021 and r = 0.90, P = 0.001, respectively). However, the circulating factor VIIa levels did not correlate with TAT and F1+2 levels. CONCLUSIONS: These data suggest that blood aspirated from the thoracic cavities during CPB is highly thrombogenic. Retransfusion of this blood may, therefore, promote further systemic thrombin generation during CPB.     

Resident-oriented care in nursing homes: effects on nurses

Background.  In a resident-oriented care model the assignment of patients to primary nurses takes place. These primary nurses are responsible for the total nursing care of their patients and make use of the nursing process. According to job demand-control models, these enlarged and enriched jobs can be described in terms of autonomy, job demands and social support, and the presence of these work characteristics has a positive influence on workers' psychological and behavioural outcomes.
Aims.  This paper reports a study to investigate the extent to which the various features of resident-oriented care were implemented and its effects nurses' on work characteristics and on psychological and behavioural outcomes in three Dutch nursing homes.
Methods.  In a quasi-experimental design, experimental and control groups were followed over 22 months, using a pretest and two post-tests with questionnaires, interviews and qualitative observations.
Results.  The quantitative data showed significant increases in resident assignment, the two variables measuring the nursing process and, in the psycho-geriatric experimental group, on resident-oriented tasks. The qualitative data showed that a partly task-oriented division of labour was still used and that the planned delegation of coordination tasks to primary nurses was not fully achieved. Effects on work perceptions were limited. After implementation of the new system, the experimental group showed an increase in job autonomy.
Conclusions.  The intervention appeared to be only partly successful. Most of the expected results regarding work characteristics and psychological and behavioural outcomes did not materialize. Theoretical and methodological reflections are presented in the light of these findings.     

Peptidoglycan increases firm adhesion of monocytes under flow conditions and primes monocyte chemotaxis

The Toll-like receptor (TLR) 2/nucleotide-binding oligomerization domain ligand peptidoglycan (PG) has been shown to be present in macrophage-rich regions within atherosclerotic lesions, and stimulation of TLR2 promotes atherosclerotic plaque and intima formation in in vivo mouse models. We determined the effect of a PG preparation and Pam(3)Cys-SK(4), a synthetic TLR2 activator, on (1) adhesion molecule expression by flow cytometry; (2) monocyte adhesion under flow conditions, and (3) monocyte migration. The total adhesion (rolling and firm adhesion) of the PG-preparation-stimulated monocytes to L cells, constitutively expressing ICAM-1 (intercellular adhesion molecule-1) and E-selectin, was decreased. This was most likely due to the L-selectin shedding, since monocyte incubation with a blocking L-selectin antibody resulted in a comparable number of adherent monocytes as PG-stimulated cells. The PG preparation induced an increased percentage of firmly adherent, polarized cells and a beta(2)-integrin-dependent binding to ICAM-1-coated beads. Interestingly, the PG preparation induced a priming of the monocytes for increased migration towards the chemoattractant C5a which was TLR2 and beta(2)-integrin dependent. Pam(3)Cys-SK(4) gave comparable results to the PG preparation in all assays tested. This study demonstrates that PG activation of monocytes results in an increase in adhesive and migratory capacities of these cells. This might be a mechanism by which PG promotes atherosclerotic disease in vivo.     

Epilepsy and employment: literature review

OBJECTIVE: The aim of this review is to increase understanding of the factors that affect the regular employment positions of people with epilepsy by means of the World Health Organization International Classification of Functioning, Disability, and Health (ICF) model. METHOD: Thirty-four primary research articles describing factors associated with employment for people with epilepsy are reviewed. RESULTS: People with epilepsy may face a number of complex and interacting problems in finding and maintaining employment. Stigma, seizure severity, and psychosocial variables such as low self-esteem, passive coping style, and low self-efficacy have been implicated as factors that play an important role in predicting employment. Findings demonstrate the need for specific employment training programs. CONCLUSION: We recommend specific training interventions that focus on increasing the self-efficacy and coping skills of people with epilepsy so that these individuals will be able to accept their disorder and make personal and health-related choices that help them to achieve better employment positions in society.     

The potential of molecular diagnosis of cutaneous ectopic schistosomiasis

A 28-year-old woman presented with extensive erythematous lesions on her back after visiting Malawi. Skin biopsies showed ova, which could belong to Schistosoma spp. Sequencing of the Schistosoma 28S rRNA gene, extracted and amplified from paraffin biopsies, identified DNA of Schistosoma haematobium. Cutaneous ectopic schistosomiasis can present with extensive lesions and should be considered in the differential diagnosis of skin lesions in returning travelers. Microscopy and serology are the classical methods to obtain a diagnosis. Alternatively, molecular methods can be a valuable new tool for diagnosis and species determination.     

A family-specific use of the Measure of Processes of Care for Service Providers (MPOC-SP)

OBJECTIVE: To examine the validity and utility of the Dutch Measure of Processes of Care for Service Providers (MPOC-SP) as a family-specific measure. DESIGN: A validation study. SETTING: Five paediatric rehabilitation settings in the Netherlands. MAIN MEASURES: The MPOC-SP was utilized in a general (reflecting on services provided for all clients and clients' families) and family-specific way (filled out in reference to a particular child and his or her family). SUBJECTS: Professionals providing rehabilitation and educational services to children with cerebral palsy. METHODS: For construct validity, Pearson's product-moment correlation coefficients (r ) between the scales were calculated. The ability of service providers to discriminate between general and family-specific ratings was examined by exploration of absolute difference scores. RESULTS: One hundred and sixteen service professionals filled out 240 family-specific MPOC-SPs. In addition, a subgroup of 81 professionals filled out a general MPOC-SP. For each professional, family-specific and general scores were paired, resulting in 151 general-family-specific MPOC-SP pairs. The construct validity analyses confirmed the scale structure: 21 items (77.8%) loaded highest in the original MPOC-SP factors, and all items correlated best and significantly with their own scale score (r 0.565 to 0.897; P<0.001). Intercorrelations between the scales ranged from r = 0.159 to r = 0.522. In total, 94.4% of the mean absolute difference scores between general and family-specific scale scores were larger than the expected difference. CONCLUSION: Service providers were able to discriminate between general and family-specific MPOC-SP item ratings. The family-specific MPOC-SP is a valid measure that can be used for individual evaluation of family-centred services and can be the impetus for family-related quality improvement.     

The division of labour in vision care: professional competence in a system of professions

The provision of vision care services by ophthalmologists, general practitioners, orthoptists, optometrists and opticians in the Netherlands was investigated. We assessed their division of labour, task boundary conflicts, and consensus on professional domains. Analysis of six patient cases indicated considerable overlap in the services provided by these professions. Only general practitioners and orthoptists were content with their current role. Ophthalmologists preferred to delegate cases, optometrists and opticians to expand their services.
The results revealed important differences in inter-professional status, more or less fixed-status hierarchies and dissatisfaction with the existing division of labour. Preferences of the professions did not point to increased inter-professional co-ordination; this could probably only be achieved by means of external intervention.     

Prenatal follow-up of hypophosphatasia by ultrasound: case report

Hypophosphatasia with lung hypoplasia forms a lethal combination. A case with an a priori risk of 25% is reported in which the diagnosis was made by ultrasound.