Transfusion medicine during the summer of 2006: lessons learned in northern Israel

In July 2006 a Hizballah attack erupted at the Lebanon-Israel border. Reported here is the experience of the Rambam Health Care Campus--a level I trauma center--during 33 days of warfare. Two hundred ninety-five soldiers and 209 civilians were admitted to the emergency department (ED). Forty-eight wounded soldiers (16%) and 12 civilians (6%) had transfusion. Twenty soldiers and 1 civilian had massive transfusions. The ratio between packed red blood cells and fresh frozen plasma (FFP) used for patients who had massive transfusion was 3:2. In these patients, the median prothrombin time international normalized ratio and partial thromboplastin time increased during the first 2 hours after admission from 1.29 to 1.51 and from 33.6 to 39 seconds, respectively. Twenty patients who had massive transfusion survived. Patients with an injury severity score of at least 16 had a higher need for blood products than others, with a lower severity score, with a mean packed red blood cells unit transfusion of 7 vs 4 (P = .03) and FFP transfusion of 13 vs 1.5 (P = .002), respectively. In conclusion, we observed that early transfusion of FFP to casualties with penetrating wounds requiring massive transfusion is needed to overcome the coagulopathy present. The presence of a transfusion service representative on-site in the ED is recommended to ensure proper identification and labeling of blood samples. Real-time consultations provided by a transfusion medicine physician in the operation theater was also found to be essential.     

Letter position coding in attentional dyslexia

We report data from experiments on orthographic and phonological coding in two patients with attentional dyslexia following bilateral parietal damage. Two experiments required the patients to carry out lexical decisions and we varied whether the nonwords were orthographically or phonologically similar to real words. Experiment 1 showed that the patients were sensitive to the orthographic relations between nonwords and words, as they tended to accept as words nonwords whose letters could migrate within the string to form a word. There were no effects of phonological similarity between the nonwords and the words. Experiment 2 demonstrated that the patients were less likely to accept nonwords as words if the word had to be formed by transposing the first two letters in the string. The data suggest that attentional dyslexics are primarily sensitive to orthographic similarity between words and nonwords, and also that the first letters have privileged coding of their locations, despite the patients being poor at coding letter positions. The implications for theories of visual word recognition are discussed.     

Is idiopathic atrial fibrillation caused by occult thyrotoxicosis? A study of one hundred consecutive patients with atrial fibrillation

In this study we evaluated the possible relationship between idiopathic atrial fibrillation and occult thyrotoxicosis, diagnosed by lack of response of thyroid stimulating hormone to administration of thyrotropin releasing hormone. Three groups were compared: 25 patients with idiopathic atrial fibrillation; 52 with cardiovascular atrial fibrillation; and 27 with sinus rhythm. Patients were excluded with any clinical evidence of thyrotoxicosis or with elevated serum FT₄ level, as well as those with diseases or on medications known to be associated with a diminished response to administration of the releasing hormone. A flat test (lack of response) was found in only 4% of the patients. There was no significant difference among the 3 groups. Based on these data we believe that there is no relationship between idiopathic atrial fibrillation or any other type of atrial fibrillation and occult thyrotoxicosis.     

<Emphasis Type="Italic">One operator’s experience</Emphasis> of ultrasound guided lumbar plexus block for paediatric hip surgery

Lumbar plexus block has been shown to be effective for providing postoperative analgesia after major hip surgeries in children. The goal of the study was to evaluate the feasibility of ultrasound guidance during lumbar plexus block in children undergoing hip surgery for congenital hip dislocation. After obtaining local institutional ethical committee approval and parental informed consent, ASA I or II, 1–6 years old children undergoing hip surgery were included into the study. Lumbar plexus block was performed after general anaesthesia using ultrasound guided Shamrock Method. Bupivacaine 0.25 % was used during block performance. Dose of the local anaesthetic was 1 ml/kg and the maximum dose was limited to 20 ml. In the postoperative period pain was assessed using modified CHEOPS (Children’s Hospital Eastern Ontario Pain Scale) pain score. If pain score in the postoperative period exceeded 3, patients received IV paracetamol 15 mg/kg^?1. Morphine 0.1 mg/kg^?1 IV was planned to administer if pain scores were still higher than 3 despite paracetamol treatment. 75 patients whose mean age was 47 months were enrolled into the study. All blocks were performed successfully and without complications. Mean time for the first analgesic is found as 10 h after surgery. Only one patient required morphine in the recovery unit and 23 patients received paracetamol. US guided lumbar plexus block using Shamrock Method is an effective technique for providing postoperative analgesia after hip surgeries in children and it’s effect lasts for 8–12 h after surgery.     

Effects of Carvacrol on Survival,Mesenteric Blood Flow,Aortic Function and Multiple Organ Injury in a Murine Model of Polymicrobial Sepsis

Carvacrol (CRV) has strong cytoprotective, antioxidant, and anti-inflammatory properties. We aimed to demonstrate the possible protective effects of CRV on survival, mesenteric artery blood flow (MBF), vascular reactivity, and oxidative and inflammatory injuries in a murine model of polymicrobial sepsis induced by cecal ligation and puncture (CLP). Wistar rats were allocated into the following four groups: Sham, CLP, Sham + CRV, and CLP + CRV. The animals were orally administered with CRV (80 mg/kg/day) or vehicle (corn oil; 1 mL/kg/day) for 7 days. At the eighth day, Sham or CLP procedure was applied. Twenty hours after the operations, MBF and contractile responses of isolated aortic preparations to phenylephrine were measured. Tissue samples were obtained for biochemical and histopathological assessments. Additionally, survival rates were recorded throughout 96 h. CRV administration improved the mesenteric perfusion, contractile function of aorta, and survival after CLP. CRV substantially prevented the elevations in the levels of LDH, BUN, Cr, and inflammatory cytokines (tumor necrosis factor-alpha, interleukin-1 beta and interleukin-6) but could not prevent the elevations of AST and ALT after CLP. The decreased liver, kidney, and spleen glutathione levels and increased liver, kidney, lung, and spleen malondialdehyde levels induced by CLP were substantially restored by CRV. Also, histopathological protective effects of CRV on multiple organ damage due to CLP were observed. CRV possesses strong ameliorative effects on sepsis due to its protective effects on mesenteric perfusion and aortic function and its antioxidative and anti-inflammatory effects.     

Foxp3+ regulatory T‐cell homeostasis quantitatively differs in murine peripheral lymph nodes and spleen

Regulatory T (Treg) cells are essential for maintaining self‐tolerance and modulating inflammatory immune responses. Treg cells either develop within the thymus or are converted from CD4⁺ naive T (Tnaive) cells in the periphery. The Treg‐cell population size is tightly controlled and Treg‐cell development and homeostasis have been intensively studied; however, quantitative information about mechanisms of peripheral Treg‐cell homeostasis is lacking. Here we developed the first mathematical model of peripheral Treg‐cell homeostasis, incorporating secondary lymphoid organs as separate entities and encompassing factors determining the size of the Treg‐cell population, namely thymic output, homeostatic proliferation, peripheral conversion, transorgan migration, apoptosis, and the Tnaive‐cell population. Quantitative data were collected by monitoring Tnaive‐cell homeostasis and Treg‐cell rebound after selective in vivo depletion of Treg cells. Our model predicted the previously unanticipated possibility that Treg cells regulate migration of Tnaive cells between spleen and peripheral lymph nodes (LNs), whereas migration of Treg cells between these organs can largely be neglected. Furthermore, our simulations suggested that peripheral conversion significantly contributed to the maintenance of the Treg‐cell population, especially in LNs. Hence, we provide the first estimation of the peripheral Treg‐cell conversion rate and propose additional facets of Treg‐cell‐mediated immune regulation that may previously have escaped attention.     

Fear and C-reactive protein cosynergize annual pulse increases in healthy adults

Recent international terror outbreaks notably involve long-term mental health risks to the exposed population, but whether physical health risks are also anticipated has remained unknown. Here, we report fear of terror-induced annual increases in resting heart rate (pulse), a notable risk factor of all-cause mortality. Partial least squares analysis based on 325 measured parameters successfully predicted annual pulse increases, inverse to the expected age-related pulse decline, in approximately 4.1% of a cohort of 17,380 apparently healthy active Israeli adults. Nonbiased hierarchical regression analysis among 27 of those parameters identified pertinent fear of terror combined with the inflammatory biomarker C-reactive protein as prominent coregulators of the observed annual pulse increases. In comparison, basal pulse primarily depended on general physiological parameters and reduced cholinergic control over anxiety and inflammation, together indicating that consistent exposure to terror threats ignites fear-induced exacerbation of preexisting neuro-immune risks of all-cause mortality.Recent international terror outbreaks involve mass psychological trauma, leading to long-term mental health risks in the exposed population (1, 2). Fear-induced reactions involve cortical and limbic brain regions that together enhance threat-predictive sensory stimuli (3) by interacting with cholinergic signaling pathways (4) in the hippocampus (5), the central amygdala (6), and the prefrontal cortex, especially in adults (7). Imminent fear may even cause immediate cardiac death [e.g., after an earthquake (8)]. However, whether fear exposure elevates cardiac risks of death to otherwise healthy civilians, and if so, what are the causes of such risks, remains unknown.Pulse is a promising modifiable predictor of cardiovascular and all-cause mortality. Elevated pulse associates with increased systemic inflammation and endothelial dysfunction in older adults (9) and predicts increased risk of death from ischemic heart disease (10). Changes in basal pulse and pulse variability are tightly associated with sudden cardiac death and all-cause mortality, also in asymptomatic men (11). Pulse reflects a complex trait, determined by multiple genetic, environmental, and other endogenous factors that play a substantial role in population variation (12). These include excessive inflammation, shown to associate with pulse increases (13), to be controlled by cholinergic imbalance (decreased vagal tone or increased sympathetic activity) (14), and to increase mortality (15). However, whether specific psychological factors determine the basal pulse and annual pulse changes in active adults is still unknown, perhaps because the intensity of psychological phenomena largely depends on external sources and is highly variable.Although fear of terror (FOT) is universal, Israel has been exposed to the repeated stress of multiple wars and terror attacks for more than 60 y, with a major impact on the entire society (16). To approach the health risks involved in FOT, we therefore explored the parameters determining resting heart rate (pulse) and its annual change in the Israeli population.     

Transcaval invasion of right atrium by thymoma: resection via transient cava-pulmonary shunt

Transcaval extension of the thymoma to the right atrium has very rarely been reported, and cardiopulmonary bypass is recommended for successful resection. An invasive thymoma with intravascular invasion of the superior vena cava, and the left innominate vein extending into the right atrium was presented. Intra-atrial extension was resected through a transient external shunt from the inferior vena cava to the main pulmonary artery. We discussed the feasibility of this surgical technique and possible advantages of cardiopulmonary bypass avoidance.