Fibrinogen levels during trauma hemorrhage, response to replacement therapy, and association with patient outcomes

BACKGROUND

Low fibrinogen levels are known to occur in trauma. However, the extent of fibrinogen depletion during trauma hemorrhage, the response to replacement therapy and association with patient outcomes remain unclear.

OBJECTIVES

The study aims were to: characterize admission fibrinogen level and correlate it with factors associated with injury; describe the time course of fibrinogen depletion and response to replacement therapy; determine the correlation of fibrinogen level with rotational thromboelastography (ROTEM) parameters; evaluate the effect of fibrinogen supplementation ex vivo; and establish the association between fibrinogen level and clinical outcomes.

METHODS

This was a prospective cohort study of 517 patients. Blood samples were drawn on admission and after admistration of every 4 units of packed red blood cells. Fibrinogen levels were determined with the Clauss method, and global hemostatic competence was assessed with thromboelastometry. The effect of fibrinogen supplementation was assessed in a subgroup of coagulopathic patients.

RESULTS

Low admission fibrinogen level was independently associated with injury severity score (P < 0.01), shock (P < 0.001), and prehospital fluid volume (P < 0.001). Fibrinogen supplementation during transfusion maintained but did not augment fibrinogen levels. Administration of cryoprecipitate was associated with improved survival. ROTEM parameters correlated with fibrinogen level, and ex vivo fibrinogen administration reversed coagulopathic ROTEM parameters. Fibrinogen level was an independent predictor of mortality at 24 h and 28 days (P < 0.001).

CONCLUSIONS

Fibrinogen level is decreased in injured patients on admission and is associated with poor outcomes. ROTEM is a rapid means of assessing hypofibrinogenemia. Earlier administration of specific fibrinogen replacement may improve outcomes, and prospective controlled trials are urgently needed.

Shifting attitudes: the National Education Programme for work and health

BACKGROUND

Evidence suggests that general practitioners (GPs) find fitness for work certification and work- related consultations challenging. The Royal College of General Practitioners was commissioned in 2009 to develop and roll out a National Education Programme (NEP) funded by the Department for Work and Pensions for a period of 2 years.

AIMS

To develop and evaluate a face-to-face educational programme that shifts GPs' attitudes to the management of the consultation about work and health.

METHODS

A 3 hour interactive programme that addressed both knowledge and skills for the management of the health and work consultation using behaviour-change principles was developed. Evaluation focused on delegates' confidence in managing the work and health consultation and the importance (priority) they gave to the subject. Questionnaires at three time points were constructed: pre, immediately post and 3 months post training.

RESULTS

A total of 152 workshops were evaluated across the UK between July 2009 and March 2011. A total of 2865 GPs attended the workshops. Questionnaire response rates were 78% pre workshop, 80% post workshop and 14% 3 months post workshop. Evaluation showed a significant increase in GPs' confidence in managing the consultation regarding work and health, and GPs gave higher priority to these types of consultations after the training.

CONCLUSIONS

The NEP has brought the training about health and work to prominence in general practice, and has also influenced policy and practice in other medical specialties.

Development of genetic markers for Ochradenus arabicus (Resedaceae), an endemic medicinal plant of Saudi Arabia

Some species of the genus Ochradenus are difficult to identify based on morphological markers. Similar limitations are found for biochemical markers. We developed genetic markers based on DNA sequences for Ochradenus arabicus, which is an endemic plant to Saudi Arabia, locally utilized as a medicinal shrub. The internal transcribed spacer sequence of nuclear ribosomal DNA and chloroplast (rpoB and rpoC1) markers were more informative than other chloroplast DNA markers. Based on these markers, we were able to discriminate this species from another species of the same genus (O. baccatus) that is widely distributed in Saudi Arabia, despite a high degree of morphological similarity. These genetic markers facilitate its identification, even when acquired in a dried state from local markets.

Protective effect of ω-3 polyunsaturated fatty acids (PUFAs) on sodium nitroprusside-induced nephrotoxicity and oxidative damage in rat kidney

Sodium nitroprusside (SNP) a nitric oxide (NO) donor has proven toxic effects. Dietary ω-3 polyunsaturated fatty acid (PUFA) has been shown to reduce the severity of numerous ailments. Present study examined whether intake of fish oil (FO)/flaxseed oil (FXO, Omega Nutrition, St Vancouver, Canada) would have protective effect against SNP-induced toxicity. Male Wistar rats (150 ± 10 g) were used in this study. Initially animals were divided into two groups: one fed on normal diet and the other on 15% FO/FXO for 15 days. On the 16th day, SNP (1.5 mg/kg body weight) was administered intraperitoneally for 7 days daily. After 7 days animals were killed, kidneys were harvested for further analysis. SNP induced nephrotoxicity by increasing serum creatinine and blood urea nitrogen, SNP significantly decreased malate dehydrogenase, glucose-6-phosphatase, fructose-1,6-bisphosphatase and malic enzyme but increased lactate dehydrogenase and glucose-6-phosphate dehydrogenase. Brush border membrane enzymes such as alkaline phosphatase, γ-glutamyl transpeptidase and leucine amino peptidase were also decreased. The activity of catalase and glutathione peroxidase decreased concomitantly with increased lipid peroxidation, indicating that the significant kidney damage has been inflicted by SNP. Feeding of FO and FXO with SNP ameliorated the changes in various parameters caused by SNP. The results of the present study suggest that ω-3 PUFA-enriched FO and FXO from seafoods and plant sources, respectively, are similarly effective in reducing SNP-induced nephrotoxicity and oxidative damage. Thus, vegetarians who cannot consume FO can have similar health benefits from plant-derived ω-3 PUFA.

FZD6 encoding the Wnt receptor frizzled 6 is mutated in autosomal-recessive nail dysplasia

BACKGROUND

Isolated nail dysplasia is rare and has been reported in only a small number of families.

OBJECTIVES

To describe and characterize two Pakistani families with an autosomal-recessive inherited nail dysplasia.

METHODS

Genome-wide linkage analysis; mutation screening of candidate genes by Sanger sequencing; cloning of FZD6 and protein analyses; immunohistochemistry.

RESULTS

We mapped this genodermatosis to chromosome 8q22.3, and identified a homozygous nonsense mutation c.1750G>T (p.E584X) in the frizzled 6 (FZD6) gene in all affected individuals. Immunohistochemical analyses in nail sections from healthy individuals revealed strong expression of FZD6 in the ventral nail matrix and a less pronounced expression of FZD6 in the nail bed.

CONCLUSIONS

FZD6 belongs to a family of proteins that serve as receptors in Wnt signalling pathways, and has been shown to act as a negative regulator of the canonical Wnt/β-catenin signalling cascade and a positive regulator of the noncanonical Wnt or planar cell polarity pathway. The present results therefore suggest that FZD6 plays a pivotal role in the growth and guidance of the nail plate in humans by acting as a molecular switch between different Wnt pathways. Previous studies have identified mutations in the RSPO4 and LMX1B components of the Wnt pathway in patients with the hypoplastic nail disorders anonychia and nail-patella syndrome, respectively. Only recently, FZD6 mutations were identified in isolated nail dysplasia. The present results emphasize the important role of the Wnt pathways in nail development and increase understanding of Wnt-mediated developmental events in general.

The utility of cytodiagnostic urinalysis as a tool to diagnose kidney allograft dysfunction in the era lymphocyte-depleting induction therapy

Cytodiagnostic urinalysis (CDU) has been used to evaluate causes of kidney allograft dysfunction, such as an acute rejection episode (ARE), calcineurin inhibitor (CNI) toxicity, or polyoma virus infection. We examined the concordance between CDU and allograft biopsy in patients with allograft dysfunction. Between 2002 and 2006, 201 patients had CDU performed within 7 days of a biopsy. The cohort was black (73%) with, male preponderance (59.2%), and an overall mean age of 48±13 years with 46% having received a deceased donor kidney. The induction regimen consisted of either antithymocyte globulin or alemtuzumab. CDU results that demonstrated 5 to 10 lymphocytes per high-power field (HPF) and >20 lymphocytes/HPF had 2.5 increased odds of predicting acute rejection (AR) on biopsy (odds ratio [OR] 2.5; 95% confidence interval [CI] 1.12-5.79; P=.025). In the era of antithymocyte globulin induction, a CDU result demonstrating>5 lymphocytes/HPF had a 4.3 increased odds of predicting AR (CI 1.76-10.50; P=.001). This association was lost with alemtuzumab induction. A positive CDU result for calcineurin inhibitor (CNI) toxicity did not predict CNI nephrotoxcity on biopsy, but a positive CDU for polyoma virus infection predicted polyoma virus nephropathy (OR 22.18; CI: 4.41-111.63; P<.001). In conclusion, CDU is an adjunctive diagnostic tool for kidney transplantation.

Combined pedunculopontine-subthalamic stimulation in Parkinson disease

OBJECTIVE

To assess the effect of deep brain stimulation (DBS) in the pedunculopontine nucleus (PPN) and caudal zona incerta (cZi)-both separately and in combination-on motor symptoms and regional cerebral blood flow (rCBF) in patients with Parkinson disease (PD).

METHODS

Four patients with bilateral cZi and PPN DBS electrodes were rated with the Unified Parkinson's Disease Rating Scale motor subscale (UPDRS-III) when taking and withdrawn from medication. A block of 16 [(15)O]-H(2)O PET resting measurements of rCBF were performed in 4 different states with patients withdrawn from medication: 1) no stimulation, 2) cZi stimulation alone, 3) PPN stimulation alone, 4) combined PPN/cZi stimulation.

RESULTS

When patients were medicated, combined PPN/cZi stimulation produced a statistically significant improvement in UPDRS-III score compared to cZi stimulation alone. In the "off" medication state, the clinical effect of combined stimulation was not significantly different from that induced by cZi stimulation alone. Concomitant PPN/cZi stimulation had a cumulative effect on levels of rCBF, effectively combining subcortical and cortical changes induced by stimulation of either target in isolation.

CONCLUSIONS

These findings suggest that concomitant low frequency stimulation of PPN and cZi regions induces additive brain activation changes and provides improved control of PD symptoms when medicated.

CLASSIFICATION OF EVIDENCE

This study provides Class IV evidence that concomitant low frequency stimulation of PPN and cZI improves motor symptoms in patients with PD on dopamine replacement. It provides Class III evidence that concomitant low frequency stimulation of PPN and cZi induces additive rCBF changes in motor areas of brain.

Nutritional evaluation of distillery sludge and its effect as a substitute of canola meal on performance of broiler chickens

The study was conducted to investigate the chemical composition of distillery yeast sludge and its inclusion in broiler diets to replace canola meal. Raw distillery yeast sludge was washed with water using water and sludge in the ratio 6:1, respectively. Proximate analysis of raw distillery yeast sludge and washed distillery sludge was carried out for crude protein (CP), true protein (TP), ether extract (EE), ash, acid insoluble ash and nitrogen free extract (NFE) determination. Mineral contents and amino acid profile of raw distillery yeast sludge and washed distillery sludge were also determined. After chemical evaluation, four iso-caloric and iso-nitrogenous broiler starter and finisher diets were prepared in mash form using 0 (control), 4, 8 and 12% levels of washed distillery sludge replacing canola meal. One hundred and twenty day-old broiler chicks were randomly distributed into 12 experimental units in such a way that each diet was offered to three experimental units, each comprising of 10 chicks. It was observed that washing affected the nutrients either by decreasing or increasing their concentration. It decreased the total mineral contents whereas CP, TP, EE and NFE contents increased. Washing also increased amino acid profile. Average feed intake and weight gain were higher in birds fed diet containing 8% washed distillery sludge and lower in birds fed diet containing 0% washed distillery sludge. Feed cost per kg live weight gain decreased significantly as the level of washed distillery sludge was increased in the diet. Average heart, liver and pancreas weights decreased with increased level of washed distillery sludge in the diet. The study revealed that after washing, distillery yeast sludge can be used successfully in broiler diets up to the level of 8% without any adverse effect on broiler’s performance.

Assessing the problem of counterfeit medications in the United Kingdom

Counterfeit medicines pose an ever-increasing threat to public health, although precise tracking of illegal counterfeit prescription drug activity is difficult. Available data indicate that all types of medications have been targeted. Adverse health effects, including death, have resulted from using counterfeit medications; consumers who self-medicate without appropriate interactions with the healthcare system rarely receive adequate healthcare. The Internet provides a large, convenient route for counterfeiters to reach potential buyers with unregulated, often dangerous, products. The majority of medicines purchased via unverified Internet sites are counterfeit; often, these products lack the purported drug compound or have variable concentrations of active ingredients and sometimes contain dangerous toxins. Although many consumers acknowledge some degree of risk with purchasing medications via the Internet, speed, convenience and cost often prompt these purchases. Counterfeit medications also have been detected in the legitimate supply chain, but represent a significantly smaller proportion of sales than those purchased via the Internet. Pilot programmes in Europe have demonstrated that product verification systems prevent penetration of counterfeit products into the legitimate supply chain. Significant EU legislation, including stronger penalties for counterfeiting, is in development. In the United Kingdom, the Medicines and Healthcare Products Regulatory Agency (MHRA) launched an initiative against counterfeit medication. Healthcare professionals should report suspected cases of counterfeit medication to the MHRA, be alert to threats to the medicine supply, and provide practical advice to patients about ordering medications online, including avoiding unregulated Internet pharmacies, and being suspicious of sites offering substantial discounts and prescription-only medication without a prescription.