Prolonged low-volume resuscitation with HBOC-201 in a large-animal survival model of controlled hemorrhage

BACKGROUND: Military guidelines call for two 500-mL boluses of Hextend for resuscitation in far-forward environments. This study compared a hemoglobin-based oxygen carrier (HBOC-201; Hemopure) to Hextend when used to treat hemorrhagic shock in situations of delayed definitive care military operations. METHODS: Yorkshire swine (55-65 kg) were hemorrhaged to a mean arterial blood pressure (MAP) of 30 mmHg. Hypotension was maintained for 45 minutes followed by resuscitation with either Hextend (HEX) (n = 8) or HBOC-201 (HBOC) (n = 8). Over 8 hours, animals received up to 1,000 mL of either fluid in an effort to sustain an MAP of 60 mmHg. At the end of 8 hours, HEX animals received 2 L of lactated Ringer's solution followed by shed blood. HBOC animals received 4 L of lactated Ringer's solution only. Animals were killed and necropsied on postprocedure day 5. Hemodynamic data were collected during shock and resuscitation. Complete blood counts, amylase, lactate, coagulation studies, and renal and liver function were measured throughout the experiment. RESULTS: Equivalent volumes were hemorrhaged from each group (HBOC, 44.3 +/- 2.2 mL/kg; HEX, 47.4 +/- 3.0 mL/kg). The HBOC group achieved the goal MAP (HBOC, 60.0 +/- 2.3 mmHg; HEX, 46.4 +/- 2.3 mmHg; p < 0.01) and required less volume during the initial 8 hours (HBOC, 12.4 +/- 1.4 mL/kg; HEX, 17.3 +/- 0.3 mL/kg; p < 0.01). The HBOC group had lower SvO2 (HBOC, 46.3 +/- 2.4%; HEX, 50.7 +/- 2.5%; p = 0.12) and cardiac output (HBOC, 5.8 +/- 0.4 L/min; HEX, 7.2 +/- 0.6 L/min; p = 0.05), but higher systemic vascular resistance (HBOC, 821.4 +/- 110.7 dynes . s . cm-5; HEX, 489.6 +/- 40.6 dynes . s . cm-5; p = 0.01). Base excess, pH, lactate, and urine output did not differ between groups. HEX group survival was 50% (four of eight) versus 88% for the HBOC group (seven of eight). All animals survived the initial 8 hours. Animals surviving 5 days displayed no clinical or laboratory evidence of organ dysfunction in either group. CONCLUSION: HBOC-201 more effectively restored and maintained perfusion pressures with lower volumes, and allowed for improved survival. These data suggest that hemoglobin-based oxygen carriers are superior to the current standard of care for resuscitation in far-forward military operations.     

Knowledge about hepatitis and previous exposure to hepatitis viruses in immigrants and refugees from the Mekong Region

OBJECTIVE: Infection with hepatitis B (HBV) and hepatitis C (HCV) viruses is relatively common throughout South-East Asia and chronic infection can lead to severe consequences. This study assesses knowledge about HBV and HCV and estimates the seroprevalence of markers for these viruses in immigrants from Laos and Cambodia. METHODS: Ninety-five Laotian (aged 18-82 years) and 234 Cambodian (15-92 years) immigrants participated in separate community-based surveys conducted during 1998 and 2002, respectively. Participants completed a questionnaire on health status and level of knowledge about viral hepatitis. Blood samples were collected and tested for the presence of HBV and HCV markers. RESULTS: Nine per cent of Laotian and 8% of Cambodian participants were infected with HBV. While 49% of Laotian and 64% of Cambodian participants showed evidence of previous exposure to HBV, 30% and 9%, respectively, were vulnerable to infection. The seroprevalence of antibodies to HCV was 3% in the Laotian and 8% in the Cambodian participants. Between one-fifth and one-third of the Laotians and Cambodians who had heard of HBV and HCV knew of possible transmission routes for the viruses. Most of those with HBV or HCV infection were unaware they were infected. CONCLUSIONS: These findings indicate a significant prevalence of undetected HBV and HCV infections and an urgent need for the provision of culturally relevant information about viral hepatitis in immigrants of South-East Asian origin.     

Treatment of splenic injury during laparoscopic nephrectomy with BioGlue, a surgical adhesive

Splenic laceration is a recognized complication of both open and laparoscopic renal surgery. Laparoscopic renal surgery continues to become the new standard of care, and this potentially problematic complication may be encountered during mobilization to gain access to the retroperitoneum. We present 2 cases of splenic injury managed with BioGlue, a new surgical adhesive, during one hand-assisted and one pure laparoscopic nephrectomy. Application of the BioGlue adhesive resulted in satisfactory hemostasis for both injuries without the need for further intervention. These preliminary observations suggest that BioGlue may be a useful addition to the urologic armamentarium to achieve hemostasis in laparoscopic surgery.     

Beyond appearances: perspectives on identity in later life and some implications for method

Two areas of controversy are examined in this article, arising from contemporary debate on identity in later life. The first centers on whether adults are essentially similar regardless of age or whether different stages of life confer different life priorities. The second addresses the management of self in later life, with special attention being given to alternative interpretations of the relationship between interior and exterior experience. An increasing awareness of diversity in life-course patterns suggests that issues concerning uniformity, distinctiveness, and the uses of masquerade in intergenerational contexts should be revisited. Here, the influence of simple and complex states of mind is examined as a factor in intergenerational power, and the expression of agency in later life is discussed. These issues not only propel us forward in our understanding of gerontological phenomena, they also point to potential sources of research bias associated with specifically intergenerational contexts. Finally, suggestions are made with respect to research training.     

School Water Fluoridation

In areas lacking public water supplies and where fluoride is not naturally present in the well water, school fluoridation programs have been shown to be effective and safe. Reductions of up to 38.9% in the rate of dental decay have been reported. Higher levels of fluoride are used in the school water than in public water because of the limited time the children are in school. The relatively low cost of the necessary equipment and chemicals can easily be justified by taking into account the amount of dental decay that can be prevented. Interested parents, teachers, or administrators should contact their state health department for technical assistance.     

A cognitive typology of alcoholism: implications for treatment outcome

The present study related patterns of alcohol-related cognitive deficits to the adjustment of the alcoholic at 2-year posttreatment follow-up. Patterns of cognitive control, based on the extent to which the individual utilized information concerning contemplated action (i.e., internal scanning), were studied within a sample of 42 male alcoholics shortly after the beginning of treatment. Adjustment scores at 2-year follow-up were determined by the subject's level of functioning in a variety of life-functioning domains (based on phone interviews with subjects and collateral sources). More effective internal scanning proved to be predictive of better adjustment 2 years following the assessment. In addition, alcoholics less aware of internal cues, defined as narrow internal scanners, more often reported drinking to reduce tension than did broad scanning alcoholics. The narrow internal scanning alcoholics also were slower learners at an electromyographic biofeedback training task than were the broad internal scanning alcoholics. These findings are interpreted in the context of a cognitive typology of alcoholism based on relative skills/deficits in internal cue processing. Factors relating to differential responsivity to treatment are discussed, and concomitant implications for treatment are noted.     

Nortriptyline pharmacokinetics and plasma levels: implications for clinical practice

The pharmacokinetics of TCAs are reviewed with particular emphasis on nortriptyline, the agent most extensively studied. The clinical uses of TCA plasma level-response studies are discussed in relationship to rational dosage adjustment to increase response rates and avoid iatrogenic toxicity. Other important topics discussed include the issue of active metabolites, single-dose prediction studies, and special considerations in treating the elderly and the medically ill.