Joyce A. Smith

Use of recombinant hemoglobin solution in reversing lethal hemorrhagic hypovolemic oxygen debt shock

OBJECTIVE To compare recombinant hemoglobin solution (rHb1.1) with colloid/blood (CB) resuscitation in a hemorrhagic shock (HS) model based on oxygen debt (O2D). METHODS Twenty-two anesthetized canines (weight 23.3 +/- 0.2 kg) were bled to an O2D of 99.9 +/- 2.1 mL/kg over 60 minutes (estimated lethal dose 31%), blood loss 65.9 +/- 2.3% of estimated blood volume, - 199 g hemoglobin (Hgb). Prospectively randomized resuscitation done in 20 minutes with 120% of shed blood volume, either colloid 60%/blood 60% shed blood volume (CB), 118 g Hgb, or 120% shed blood volume as 5% rHb1.1, 85 g Hgb, and fall in O2D was quantified over 80 minutes. Six animals died during HS, one after CB resuscitation (32% actual mortality). Blood lactate (L) and base deficit (BEA) were related to O2D. RESULTS Both lactate (L) and BEA quantified O2D during hemorrhage: L = 0.0671 (O2D) + 1.209; r2 = 0.90, p < 0.0001; BEA = 0.1313 (O2D) + 1.764; r2 = 0.90, p < 0.0001, but L was a better indicator than BEA of fall in O2D during resuscitation (L = 0.069 (O2D) + 1.083; r2 = 0.80). Both groups were followed for 7 days after HS and had normal renal and hepatic function by day 7. However, at equal resuscitation volume, rHb1.1 resuscitation with 41% of Hgb loss produced a more rapid initial fall in O2D than CB at 60% of Hgb loss (p < 0.002). rHb1.1 resuscitation also caused a more complete washout of metabolic acids than CB. CONCLUSIONS Lactate and BEA accurately quantify O2D in HS and resuscitation. rHb1.1 replacement is as good as CB with regard to survival, but leads to a more uniform reperfusion and produces a more complete resolution of ischemic acidosis.

Oxygen debt criteria quantify the effectiveness of early partial resuscitation after hypovolemic hemorrhagic shock.

BACKGROUND The effectiveness of partial resuscitation after hypovolemic hemorrhagic shock with deferment of full resuscitation is critical to successful hypotensive resuscitation. METHODS To quantitatively address this issue, 40 canines were bled under anesthesia to a mean oxygen debt (O(2)D) of 104 +/- 7.6 mL/kg over 60 minutes (mortality, 40%). Animals surviving the shock were then immediately resuscitated with 0%, 8.4%, 15%, 30%, or 120% (full resuscitation) of shed volume as 5% albumin and held for 2 hours postshock, when the remaining portion of full resuscitation volume was given. Animals were followed for 7 days postshock with hepatic and renal function studies, and then, under anesthesia, cardiac output and organ biopsy specimens were taken before the animals were killed. RESULTS By 2 hours postshock, 0% immediate resuscitation had an O(2)D increase of 80 mL/kg above end of shock, but O(2)D at 8.4% immediate resuscitation decreased -30 mL/kg, 15% immediate resuscitation fell -65 mL/kg, 30% immediate resuscitation decreased -80 mL/kg below end of shock, and O(2)D with 120% full resuscitation fell to preshock levels. All decreases in O(2)D were significantly (p < 0.05) below end of shock, but both 15% and 30% immediate resuscitation exceeded the 8.4% immediate resuscitation rate (p < 0.05) throughout the resuscitation, and 120% full resuscitation exceeded these (p < 0.05). The immediate resuscitation O(2)D response correlated significantly (p < 0.001) with base deficit and lactate, but blood pressure was not a significant discriminator. Seven-day biopsies showed return of bowel mucosa but a pattern of cellular injury in heart, liver, and kidney that improved from 8.4% < 15% < 30 < 120% immediate resuscitation. CONCLUSION The data suggest that, compared with 120% postshock immediate resuscitation, 8.4% and 15% immediate resuscitation give poorer results, with 30% immediate resuscitation showing mild, transient, but acceptable changes in organ function allowing for a 2-hour delay until full resuscitation, with complete 7-day recovery. Base deficit and lactate, but not blood pressure, are significant indices of O(2)D.

Study on the use of long-term urinary catheters in community-dwelling individuals.

PURPOSE The purpose of this study was to determine the incidence and distribution of catheter-related problems in long-term indwelling urinary catheter users. We also sought to assess appropriateness of catheter use and examine relationships among catheter complications and catheter care practices. DESIGN This repeated-measures study involved self-reported data collection by recall at intake and by prospective data collection at 2, 4, and 6 months in long-term urinary catheter users. SUBJECTS AND SETTING Two sampling arms were used: a home care (HC) agency with 10 individuals and the Internet with 33 people having spinal cord injury. METHODS Home visit and follow-up telephone call interviews were used with the participants from the HC agency. Data were self-administered through SurveyMonkey in the Internet sample, and communication was through e-mail, telephone, and postal mail. Analysis included descriptive statistics and generalized estimating equation techniques to adjust for within-subject variation over time. RESULTS All study participants had at least 1 catheter-related problem during 8 months, and many had multiple, recurring problems. Catheter-associated urinary tract infection (CAUTI) was reported by 70%, blockage by 74%, leakage by 79%, and accidental dislodgement by 33%. Key tests of associations (generalized estimating equation) predicted that catheter size contributed to CAUTI, with significant covariates of female gender and younger age. The presence of sediment in the urine on the day of the survey predicted catheter blockage. CONCLUSION The incidence of all complications was higher than expected. Problems associated with long-term indwelling catheter use may contribute to excess healthcare utilization adversely affecting both users and their families.

Inhibition of skeletal muscle protein synthesis in septic intra-abdominal abscess.

Chronic sepsis is always associated with profound wasting leading to increased release of amino acids from skeletal muscle. Net protein catabolism may be due to decreased rate of synthesis, increased rate of degradation, or both. To determine whether protein synthesis is altered in chronic sepsis, the rate of protein synthesis in vivo was estimated by measuring the incorporation of [3H]-phenylalanine in skeletal muscle protein in a chronic (5-day) septic rat model induced by creation of a stable intra-abdominal abscess using an E. coli + B. fragilis-infected sterile fecal-agar pellet as foreign body nidus. Septic rats failed to gain weight at rates similar to control animals, therefore control animals were weight matched to the septic animals. The skeletal muscle protein content in septic animals was significantly reduced relative to control animals (0.18 +/- 0.01 vs. 0.21 +/- 0.01 mg protein/gm wet wt; p less than 0.02). The rate of incorporation of [3H]-phenylalanine into skeletal muscle protein from control animals was 39 +/- 4 nmole/gm wet wt/hr or a fractional synthetic rate of 5.2 +/- 0.5%/day. In contrast to control animals, the fractional synthetic rate in septic animals (2.6 +/- 0.2%/day) was reduced by 50% compared to control animals (p less than 0.005). The decreased rate of protein synthesis in sepsis was not due to an energy deficit, as high-energy phosphates and ATP/ADP ratio were not altered. This decrease in protein synthesis occurred even though septic animals consumed as much food as control animals.(ABSTRACT TRUNCATED AT 250 WORDS)

BARRIERS TO AND CONSEQUENCES OF MANDATED REPORTING OF CHILD ABUSE BY NURSE PRACTITIONERS

INTRODUCTION The objective of this study was to examine the experiences of pediatric nurse practitioners (PNPs) in the identification and management of child abuse, determine the frequency of their reporting, and describe the effects, attitudes, and confidence in reporting child abuse. METHODS A survey based on the 2006 CARES survey was disseminated via e-mail through use of Survey Monkey to 5,764 PNP members of the National Association of Pediatric Nurse Practitioners. The data from this survey were then subjected to statistical analysis, and the resultant findings were compared and contrasted with other similar studies. RESULTS Data analysis revealed that smaller numbers of PNPs in the sample group failed to report suspected child abuse than did their physician colleagues. PNPs and physicians encountered similar perceived barriers to reporting and used similar processes in dealing with them. Both physicians and PNPs with recent child abuse continuing education hours expressed greater confidence in child abuse management skills and were more likely to report suspected cases of abuse. DISCUSSION Much information was learned about PNP reporting practices regarding child abuse. The most significant facts that emerged from this study were that all health care providers require further child abuse education, both in their curriculum preparation and continuing education, to effectively diagnose and manage child abuse.

Finite element aortic injury reconstruction of near side lateral impacts using real world crash data.

Traumatic rupture of the aorta (TRA) remains the second most common cause of death associated with motor vehicle crashes, only less prevalent than brain injury. On average, nearly 8000 people die annually in the United States due to blunt injury to the aorta. It is observed that over 80% of occupants who suffer an aortic injury die at the scene due to exsanguination into the chest cavity. In the current study, eight near side lateral impacts, in which TRA occurred, were reconstructed using a combination of real world crash data reported in the Crash Injury Research and Engineering Network (CIREN) database, finite element (FE) models of vehicles, and the Wayne State Human Body Model - II (WSHBM). For the eight CIREN cases reconstructed, the high strain regions in the aorta closely matched with the autopsy data provided. The peak average maximum principal strains in all of the eight CIREN cases were localized in the isthmus region of the aorta, distal to the left subclavian artery, and averaged at 22 ± 6.2% while the average maximum pressure in the aorta was found to be 117 ± 14.7 kPa.

Randomized Controlled Trial of CARE: An Intervention to Improve Outcomes of Hospitalized Elders and Family Caregivers

In this randomized controlled trial we tested the efficacy of an intervention program (CARE: Creating Avenues for Relative Empowerment) for improving outcomes of hospitalized older adults and their family caregivers (FCGs). FCG-patient dyads (n = 407) were randomized into two groups. The CARE group received a two-session empowerment-educational program 1-2 days post-admission and 1-3 days pre-discharge. The attention control group received a generic information program during the same timeframe. Follow-up was at 2 weeks and 2 months post-discharge. There were no statistically significant differences in patient or FCG outcomes. However, inconsistent evidence of role outcome differences suggests that CARE may benefit certain FCG subgroups instead of being a one-size-fits-all intervention strategy. Closer examination of CAREs mechanisms and effects is needed.

Supplemental Nurses Are Just As Educated, Slightly Less Experienced, And More Diverse Compared To Permanent Nurses

In the past three decades, the shortage of nurses willing to work in hospitals has been a persistent challenge in the United States. Hiring supplemental registered nurses-nurses on short-term contracts obtained through an external staffing agency-has been common to fill gaps in nurse staffing. But there has been insufficient evidence about supplemental nurse workforce trends to inform workforce policy. To address this concern, we compared qualifications and characteristics of supplemental nurses with those of permanent nurses during 1984-2008. The two groups shared similar education levels in terms of possessing a baccalaureate or higher degree. Supplemental nurses were somewhat less experienced than permanent nurses, averaging fifteen years of experience in 2008 compared to eighteen years for permanent nurses. The supplemental nurse workforce was more diverse racially and ethnically and more likely to be male than the permanent nurse workforce. These data show that employing supplemental nurses could help meet the challenges of an aging nursing workforce, the projected future shortage of nurses, and an increasingly diverse US population.

An Exploration of the Determinants of Gestational Weight Gain in African American Women: Genetic Factors and Energy Expenditure:

Background: Excessive gestational weight gain (GWG) has a long-term impact on women’s body weight and contributes to the development of obesity in the mother and her child. Many risk factors for GWG have been identified, but to date, only 6–33.8% of the variance in GWG has been explained. The purpose of this study was to evaluate the overall variance of GWG that can be explained by including weight-adjusted resting metabolic rate (aRMR) and a genetic risk score constructed on obesity-related genes in addition to sociodemographic and lifestyle factors. Methods: In this observational study involving 55 African American women, data collected/measured during pregnancy included sociodemographic factors, medical information, lifestyle factors, aRMR, and seven obesity-related genes. Multivariable linear regression was performed to evaluate the variance in GWG explained by the potential risk factors listed above. Results: The mean GWG was 15 kg (±7.5 kg), and 63.6% of women gained more than the Institute of Medicine’s GWG recommendations. The final regression model explained 53.3% of the variance in GWG. Higher genetic risk score, lower aRMR, and higher dietary intake of total energy and percentage of fat were significantly associated with increased GWG (p < .05). These factors explained 18% additional variance in GWG over that explained by significant sociodemographic and lifestyle factors in the analysis (i.e., maternal age, prepregnancy body mass index, parity, illegal drug use, and education). Conclusion: Overall, our results indicate that the genetic risk score, aRMR, and dietary intake have a substantial impact on GWG in African American women.

Opioid Use in the Last Year of Life Among Medicare Beneficiaries With Advanced Illnesses: A Retrospective Cohort Study

The presence of refractory dyspnea is often associated with illness progression to advanced stages. Opioid medications are the first-line pharmacological treatment for the palliation of refractory dyspnea, and indication for this intervention could signal the need for palliative care or hospice. The aims of this study were to describe opioid use and enrollment in hospice care among Medicare beneficiaries with heart failure, chronic obstructive pulmonary disease, or lung cancer during their last year of life. Using Medicare data, we conducted a retrospective cohort study of beneficiaries with heart failure, chronic obstructive pulmonary disease, or lung cancer who died in 2009. Slightly more than one-third of the 110 218 decedents used an opioid medication during the last year of life. Beneficiaries with lung cancer had the most opioid and hospice use. Hospice was initiated in the last month of life, whereas opioids were first prescribed 9 to 12 months before death. Findings suggest that the symptoms experienced by this population in the last year of life may not be well managed. The introduction of an opioid medication to manage refractory dyspnea could be used as an indicator to begin discussions about palliative care or hospice among patients with advanced illnesses.