Removing the barriers to prehospital blood: a roadmap to success

ABSTRACT

This review describes the necessity, evolution, and current state of prehospital blood programs in the United States. Less than 1% of 9-1-1 Ground Emergency Medical Service agencies have been able to successfully implement prehospital blood transfusions as part of a resuscitation strategy for patients in hemorrhagic shock despite estimates that annually between 54,000 and 900,000 patients may benefit from its use. The use of prehospital blood transfusions as a tool for managing hemorrhagic shock has barriers to overcome to ensure it becomes widely available to patients throughout the United States. Barriers include 1) current state Emergency Medical Services clinicians' scope of practice limitations, 2) program costs and reimbursement of blood products, 3) no centralized data collection process for prehospital hemorrhagic shock and patient outcomes, 4) collaboration between prehospital agencies, blood suppliers, and hospital clinicians and transfusion service activities. The following paper identifies barriers and a proposed roadmap to reduce death due to prehospital hemorrhage.

The U.S. Armed Services Blood Program support to U.S. Central Command 2014-2021: Transformation of combat trauma resuscitation through blood product innovation and expansion of blood availability far forward

BACKGROUND

The United States Armed Services Blood Program (ASBP) faced complex blood supply challenges during two decades of military operations in the U.S. Central Command (CENTCOM) and through an adaptive, responsive, and agile system, gained valuable insights on blood product usage in combat casualty care.

STUDY DESIGN AND METHODS

A retrospective review of blood product introduction and utilization trends was compiled from ASBP data collected during CENTCOM operations from 2014 through 2021.

RESULTS

During the study period, several blood products were introduced to the CENTCOM area of operations including Low Titer O Whole Blood (LTOWB), Cold-Stored Platelets (CSP), Liquid Plasma (LP), and French Freeze Dried Plasma (FDP) manufactured from U.S. sourced donor plasma, all while expanding Walking Blood Bank capabilities. There was a gradual substitution of component therapy for whole blood; blood utilization peaked in 2017. Transfusion of Fresh Whole Blood (FWB) from Walking Blood Banks decreased as fully pre-tested LTOWB was supplied by the ASBP. LTOWB was initially supplied in citrate-phosphate-dextrose (CPD) anticoagulant (21-day shelf life) but was largely replaced with LTOWB in citrate-phosphate-dextrose-adenine (CPDA-1) anticoagulant (35-day shelf life) by 2019. Implementation of prehospital transfusion and expansion of surgical and resuscitation teams led to an increase in the number of sites receiving blood.

DISCUSSION

ASBP introduced new products to its inventory in order to meet changing blood product demands driven by changes in the Joint Trauma System Clinical Practice Guidelines and operational demands. These products were adopted into clinical practice with a resultant evolution in transfusion strategies.

Joint Trauma System, Defense Committee on Trauma, and Armed Services Blood Program consensus statement on whole blood

Hemorrhage is the most common mechanism of death in battlefield casualties with potentially survivable injuries. There is evidence that early blood product transfusion saves lives among combat casualties. When compared to component therapy, fresh whole blood transfusion improves outcomes in military settings. Cold-stored whole blood also improves outcomes in trauma patients. Whole blood has the advantage of providing red cells, plasma, and platelets together in a single unit, which simplifies and speeds the process of resuscitation, particularly in austere environments. The Joint Trauma System, the Defense Committee on Trauma, and the Armed Services Blood Program endorse the following: (1) whole blood should be used to treat hemorrhagic shock; (2) low-titer group O whole blood is the resuscitation product of choice for the treatment of hemorrhagic shock for all casualties at all roles of care; (3) whole blood should be available within 30 min of casualty wounding, on all medical evacuation platforms, and at all resuscitation and surgical team locations; (4) when whole blood is not available, component therapy should be available within 30 min of casualty wounding; (5) all prehospital medical providers should be trained and logistically supported to screen donors, collect fresh whole blood from designated donors, transfuse blood products, recognize and treat transfusion reactions, and complete the minimum documentation requirements; (6) all deploying military personnel should undergo walking blood bank prescreen laboratory testing for transfusion transmitted disease immediately prior to deployment. Those who are blood group O should undergo anti-A/anti-B antibody titer testing.

Civilian walking blood bank emergency preparedness plan

BACKGROUND

The current global pandemic has created unprecedented challenges in the blood supply network. Given the recent shortages, there must be a civilian plan for massively bleeding patients when there are no blood products on the shelf. Recognizing that the time to death in bleeding patients is less than 2 h, timely resupply from unaffected locations is not possible. One solution is to transfuse emergency untested whole blood (EUWB), similar to the extensive military experience fine-tuned over the last 19 years. While this concept is anathema in current civilian transfusion practice, it seems prudent to have a vetted plan in place.

METHODS AND MATERIALS

During the early stages of the 2020 global pandemic, a multidisciplinary and international group of clinicians with broad experience in transfusion medicine communicated routinely. The result is a planning document that provides both background information and a high-level guide on how to emergently deliver EUWB for patients who would otherwise die of hemorrhage.

RESULTS AND CONCLUSIONS

Similar plans have been utilized in remote locations, both on the battlefield and in civilian practice. The proposed recommendations are designed to provide high-level guidance for experienced blood bankers, transfusion experts, clinicians, and health authorities. Like with all emergency preparedness, it is always better to have a well-thought-out and trained plan in place, rather than trying to develop a hasty plan in the midst of a disaster. We need to prevent the potential for empty shelves and bleeding patients dying for lack of blood.

The need for dried plasma - a national issue

Recent studies have demonstrated that early transfusion of plasma or RBCs improves survival in patients with severe trauma and hemorrhagic shock. Time to initiate transfusion is the critical factor. It is essential that transfusion begin in the prehospital environment when transport times are longer than approximately 15 to 20 minutes. Unfortunately, logistic constraints severely limit the use of blood products in the prehospital setting, especially in military, remote civilian, and mass disaster circumstances, where the need can be most acute. US military requirements for logistically supportable blood products are projected to increase dramatically in future conflicts. Although dried plasma products have been available and safely used in a number of countries for over 20 years, there is no dried plasma product commercially available in the United States. A US Food and Drug Administration-approved dried plasma is urgently needed. Considering the US military, disaster preparedness, and remote civilian trauma perspectives, this is an urgent national health care issue.

Lifeline for the front lines: blood products to support the warfighter

BACKGROUND

Hemorrhage is the leading cause of death on the battlefield. Damage control resuscitation guidelines in the US military recommend whole blood as the preferred resuscitation product. The Armed Services Blood Program (ASBP) has initiated low-titer group O whole blood (LTOWB) production and predeployment donor screening to make whole blood more available to military forces.

STUDY DESIGN AND METHODS

ASBP donor centers updated procedures and labeling for LTOWB production. Donors are screened according to US Food and Drug Administration regulations and standard operating procedures. Group O donors are tested for anti-A and anti-B titer levels. Additionally, military personnel notified for pending deployment coordinate with their local ASBP donor center to complete whole blood donor prescreening. The process consists of completing a donor history questionnaire, processing of blood samples for blood group and infectious disease testing, and titer determination for group O personnel.

RESULTS

Since March 2016, 7940 LTOWB units have been manufactured at ASBP donor centers and shipped in support of combat operations. Additionally, ASBP donor centers have screened several thousand service members before deployment. From these screenings, the donor low titer rate was 68% and infectious disease reactive test rate was extremely low (≤0.004).

CONCLUSION

Whole blood is now the preferred blood product for resuscitation of combat trauma patients. The ASBP partnered with combat forces to screen personnel before deployment. Additionally, LTOWB is manufactured and shipped in support of combat operations. These efforts are expanding the availability of LTOWB for the warfighter.

Conducting fresh whole blood transfusion training

Fresh whole blood is the optimal resuscitation fluid for casualties in hemorrhagic shock according to the Committee on Tactical Combat Casualty Care and has demonstrated to improve outcomes in severely wounded patients. Like all medical interventions, fresh whole blood transfusions are not without risks, but similarly can be mitigated through increased training to develop provider knowledge and proficiency. To date, no literature has been published regarding the proper technique to conduct fresh whole blood transfusion training. This article provides a structured foundation to establish a standardized fresh whole blood transfusion training program to increase skill and preparedness for fresh whole blood protocol implementation. Using these techniques in a training environment, providers will be able to provide optimal resuscitation in hemorrhagic shock in austere environments.

NATO Blood Panel perspectives on changes to military prehospital resuscitation policies: current and future practice

The North Atlantic Treaty Organization (NATO) Blood Panel exists to promote interoperability of transfusion practice between NATO partners. However, it has served as an important forum for the development of prehospital transfusion and transfusion in the austere environment. There are synergies with the trauma hemostasis and oxygen research community especially in the areas of innovation and research. Four presentations are summarized together with a review of some scientific principles. The past decade has already seen significant changes in early transfusion support. Sometimes practice has preceded the evidence and has stretched regulatory and logistic constraints. Ethical and philosophical issues are also important and require us to question "should we" and not just "could we." The challenge for the combined communities is to continue to optimize transfusion support underpinned by evidence-based excellence.

Treatment of blood with a pathogen reduction technology using ultraviolet light and riboflavin inactivates Ebola virus in vitro

BACKGROUND

Transfusion of plasma from recovered patients after Ebolavirus (EBOV) infection, typically called "convalescent plasma," is an effective treatment for active disease available in endemic areas, but carries the risk of introducing other pathogens, including other strains of EBOV. A pathogen reduction technology using ultraviolet light and riboflavin (UV+RB) is effective against multiple enveloped, negative-sense, single-stranded RNA viruses that are similar in structure to EBOV. We hypothesized that UV+RB is effective against EBOV in blood products without activating complement or reducing protective immunoglobulin titers that are important for the treatment of Ebola virus disease (EVD).

STUDY DESIGN AND METHODS

Four in vitro experiments were conducted to evaluate effects of UV+RB on green fluorescent protein EBOV (EBOV-GFP), wild-type EBOV in serum, and whole blood, respectively, and on immunoglobulins and complement in plasma. Initial titers for Experiments 1 to 3 were 4.21 log GFP units/mL, 4.96 log infectious units/mL, and 4.23 log plaque-forming units/mL. Conditions tested in the first three experiments included the following: 1-EBOV-GFP plus UV+RB; 2-EBOV-GFP plus RB only; 3-EBOV-GFP plus UV only; 4-EBOV-GFP without RB or UV; 5-virus-free control plus UV only; and 6-virus-free control without RB or UV.

RESULTS

UV+RB reduced EBOV titers to nondetectable levels in both nonhuman primate serum (≥2.8- to 3.2-log reduction) and human whole blood (≥3.0-log reduction) without decreasing protective antibody titers in human plasma.

CONCLUSION

Our in vitro results demonstrate that the UV+RB treatment efficiently reduces EBOV titers to below limits of detection in both serum and whole blood. In vivo testing to determine whether UV+RB can improve convalescent blood product safety is indicated.

Theater Blood Support in the Prehospital Setting

The Army Blood Program (ABP) is charged with the responsibility of supporting the Warfighter on the battlefield, in addition to meeting garrison hospital blood requirements on a daily basis. Blood support concepts developed in response to Operation Iraqi Freedom/Operation Enduring Freedom combat operations are the cornerstone to maintaining current capabilities and shaping future endeavors.. The ABP is actively engaged with research, advanced development of blood products and medical technology to improve blood safety and efficacy for both our conventional and operational forces. The feasibility of frozen/deglycerolized red blood cell use in theater has been demonstrated. The use of Blood Group A plasma in the place of Blood Group AB plasma has been successful. Placement of cryoprecipitate at Role 2 medical facilities and the placement of blood products on MEDEVAC (Vampire Program missions) have proven invaluable in moving transfusion therapy closer to the point of Injury. The improved patient outcomes from earlier transfusion of blood products has driven the requirement for far-forward blood support. Now (more than ever), there are products and processes in place to meet the requirements for blood use in the prehospital setting.

The role of the humoral immune response to Clostridium difficile toxins A and B in susceptibility to C. difficile infection: a case-control study

Antibody levels to Clostridium difficile toxin A (TcdA), but not toxin B (TcdB), have been found to determine risk of C. difficile infection (CDI). Historically, TcdA was thought to be the key virulence factor; however the importance of TcdB in disease is now established. We re-evaluated the role of antibodies to TcdA and TcdB in determining patient susceptibility to CDI in two separate patient cohorts. In contrast to earlier studies, we find that CDI patients have lower pre-existing IgA titres to TcdB, but not TcdA, when compared to control patients. Our findings suggest that mucosal immunity to TcdB may be important in the early stages of infection and identifies a possible target for preventing CDI progression.

High yield expression of biologically active recombinant full length human tuftelin protein in baculovirus-infected insect cells

Tuftelin is an acidic protein expressed at very early stages of mouse odontogenesis. It was suggested to play a role during epithelial-mesenchymal interactions, and later, when enamel formation commences, to be involved in enamel mineralization. Tuftelin was also detected in several normal soft tissues of different origins and some of their corresponding cancerous tissues. Tuftelin is expressed in low quantities, and undergoes degradation in the enamel extracellular matrix. To investigate the structure and function of tuftelin, the full length recombinant human tuftelin protein was produced. The full length human tuftelin cDNA was cloned using Gateway recombination into the Bac-to-Bac system compatible transfer vector pDest10. This vector adds a hexahistidine tag to the N-terminus of the expressed protein, enabling one-step affinity purification on nickel column. The recombinant human tuftelin protein was transposed into the bacmid and expressed in Spodoptera frugiperda (Sf9) insect cells. The yield of the purified, his-tagged recombinant full length human Tuftelin (rHTuft+) was 5-8 mg/L culture. rHTuft+ was characterized by SDS-PAGE, Western blot, ESI-TOF spectrometry, restriction mapping and MS/MS sequencing. The availability of the purified, full length recombinant human tuftelin protein opened up the possibility to investigate novel functions of tuftelin. Application of rHTuft+ agarose beads onto embryonic mouse mandibular explants caused changes in the surrounding epithelial cells, including morphology, orientation and spatial organization. Further studies using DiI labeling, revealed that rHTuft+, placed on the tooth germ region, brought about recruitment of adjacent embryonic mesenchymal cells. These findings support the hypothesis that tuftelin plays an important role during embryogenesis.

Tumour necrosis factor inhibitors in ankylosing spondylitis

Ankylosing spondylitis (AS) is the most common form of spondyloarthropathy. Non-steroidal anti-inflammatory medications and exercise are used to manage the chronic inflammatory spinal pain and stiffness. Up to 20% of patients have a peripheral inflammatory arthritis, which is treated with standard disease-modifying anti-rheumatic drugs especially sulfasalazine and methotrexate. Patients may also have extra-articular manifestations, such as anterior uveitis, psoriasiform skin lesions and inflammatory bowel disease. Anti-tumour necrosis (TNF) therapy has been used with great success in rheumatoid arthritis. There are now good data of the efficacy of anti-TNF therapies in the short and medium terms in AS. Etanercept, infliximab and adalimumab have been shown in randomized placebo-controlled trials of short duration to significantly reduce disease activity, including pain and stiffness as well as improving function, spinal movement and quality of life. It is hoped that long-term therapy will prevent radiologic progression and ankylosis and studies of long-term efficacy are awaited. Anti-TNF therapies are generally well tolerated in AS. It is important to screen for latent tuberculosis before the commencement of anti-TNF therapy. The side-effect profile of anti-TNF therapies in AS does not appear different from that in rheumatoid arthritis. Currently, treatment with anti-TNF therapy in AS is indicated in established disease with radiographic damage. There is evidence that response to therapy is greater in patients with earlier disease and less damage. Future developments may see this therapy extended to patients with pre-radiographic AS.

Effects of probiotic supplementation for the first 6 months of life on allergen- and vaccine-specific immune responses

BACKGROUND

A reduction in microbial burden during infancy when allergen-specific memory is evolving has become a prominent explanation for the allergy epidemic.

OBJECTIVE

We sought to determine whether probiotic dietary supplementation in the first 6 months of life could modify allergen- and vaccine-specific immune responses.

METHODS

Two hundred and thirty-one pregnant women with a history of allergic disease and positive allergen skin prick test (SPT) were recruited into a randomized-controlled trial. The infants received either a probiotic (3 x 10(9)Lactobacillus acidophilus LAVRI-A1; Probiomics) or placebo (maltodextrin alone) daily for the first 6 months of life, given independent of feeding methods. One hundred and seventy-eight children completed the study; blood samples were available from 60 children in the placebo group and 58 children in the probiotic group. Infant cytokine (IL-5, IL-6, IL-10, IL-13, TNF-alpha or TGF-beta) responses to tetanus toxoid (TT), house dust mite (HDM), ovalbumin (OVA), beta-lactoglobulin (BLG), Staphylococcus enterotoxin B (SEB) and phytohaemaglutinin (PHA) were measured at 6 months of age.

RESULTS

Children who received the probiotics showed reduced production of IL-5 and TGF-beta in response to polyclonal (SEB) stimulation (P=0.044 and 0.015, respectively). They also demonstrated significantly lower IL-10 responses to TT vaccine antigen compared with the placebo group (P=0.03), and this was not due to any differences in vaccination. However, there were no significant effects of probiotics on either Type 1 (Th1) or Type 2 (Th2) T helper cell responses to allergens or other stimuli. The only other effects observed were for reduced TNF-alpha and IL-10 responsiveness to HDM allergens in children receiving probiotics (P=0.046 and 0.014, respectively).

CONCLUSIONS

In summary, although we did not see any consistent effects on allergen-specific responses, our study suggests that probiotics may have immunomodulatory effects on vaccine responses. The significance and clinical relevance of this need to be determined in further studies.

Predicting response to recombinant factor VIIa in non-haemophiliac patients with severe haemorrhage

BACKGROUND

Despite increasing use of recombinant factor VIIa (rFVIIa) in non-haemophiliac patients, it is unclear when rFVIIa might be effective.

METHODS

A single centre review of consecutive non-haemophiliac patients receiving rFVIIa for the management of severe haemorrhage. Treatments with rFVIIa were at a dose of 90 mug kg(-1) repeated at three hourly intervals at the clinicians' discretion.

RESULTS

Eighteen patients received rFVIIa. Six patients survived to discharge and 12 patients died in hospital. The median (range) Sequential Organ Failure Assessment (SOFA) score at the time of administration of rFVIIa for the group that survived was 8.0 (5-12) compared with the group that died 12.0 (7.0-14.0) (P=0.03). One of the patients who survived (17%) had organ failure at the time of rFVIIa administration compared with 11 of those who died (92%) (P=0.004). Fifteen patients survived long enough to consider a second dose of rFVIIa, one patient who survived to discharge needed more than one dose (1/6, 17%), compared with seven of those who later died in hospital (7/9, 78%) (P=0.04). The survivors had a significant reduction in blood product requirements after rFVIIa, while patients who died did not. Neither the prothrombin time nor the activated partial thromboplastin time before or after rFVIIa predicted survival.

CONCLUSIONS

High SOFA score and failure to respond to one adequate dose of rFVIIa appear to identify patients with poor prognosis. These observations may help in determining when rFVIIa treatment is likely to be futile.

Single-dose metronidazole vs 5-day multi-drug antibiotic regimen in excision of pilonidal sinuses with primary closure: a prospective, randomized, double-blinded pilot study

AIM

To compare infection-related wound complications following excision of pilonidal sinuses with primary closure using either single-dose intravenous (i.v.) administration of metronidazole preoperatively or a broad-spectrum multi-drug regimen.

PATIENTS AND METHODS

This is a double-blinded study wherein 50 patients were randomized into receiving either single-drug (metronidazole 500 mg i.v.) prophylaxis preoperatively or multi-drug cover (cefuroxime 1.5 g i.v. and metronidazole 0.5 g i.v. preoperatively, and co-amoxiclav 375 mg orally 8-hourly postoperatively for 5 days). They were reviewed at 1, 2 and 4 weeks postoperatively. Wounds were graded as follows: I, healthy; II, redness and swelling of edges; III, abscess in relation to a suture; IV, spreading wound infection; and V, wound breakdown. Other factors considered were the distance from the lowest wound margin to the anal verge and previous local surgery.

RESULTS

Fifty patients (38 men and 12 women, mean age 27 years) underwent pilonidal sinus surgery. At week 1, there was no difference in wound infection rates (p=0.9). However, there were significantly more wound infections in the single-drug group at week 2 (p<0.0001) and week 4 (p=0.03). Seventy-two per cent of all patients had complete wound healing at week 4. Distance from the anal verge and previous surgery did not affect wound infection rates (p> or =0.2). Treating such complications costs 73,219.20 dollars per 100 patients.

CONCLUSION

A broad-spectrum 5-day regimen is superior to 'single-shot' antibiotic prophylaxis in preventing infection-related wound complications. However, this study needs to be conducted in a larger number of patients to have statistical power.

Exercise capacity in pediatric heart transplant candidates: is there any role for the 14 ml/kg/min guideline?

A peak oxygen consumption (VO2) of < 14 ml/kg/min has been identified as a predictor of l-year mortality in adults with congestive heart failure (CHF) and is used as a criterion for listing for cardiac transplantation (OHT). The role of VO2 measurement in children awaiting OHT has not been thoroughly evaluated. We sought to assess the degree of exercise impairment and the clinical applicability of the 14 ml/kg/min rule in children awaiting OHT. Cardiopulmonary exercise test (CPT) and cardiac catheterization data in all patients listed for OHT during the period of 1995-2003 were reviewed. Fourteen patients with a mean age of 15.5 +/- 2.9 years underwent CPT with no serious adverse events at an interval of 6.6 +/- 5.1 months prior to OHT. The etiology of CHF was multifactorial. Patients had impaired aerobic capacity with a mean peak VO2 of 20.4 +/- 6.8 ml/kg/min. Eleven of 14 patients (79%) had a peak VO2 higher than the adult cutoff value of 14 ml/kg/min. Pediatric ambulatory patients with CHF can safely undergo CPT. Because of age-related differences in oxygen consumption and varied etiologies of CHF a peak VO2 of < 14 ml/kg/min is not a useful criterion for listing for OHT in this population.

Left ventricular diastolic dysfunction in children and young adults with Marfan syndrome

Adults with Marfan syndrome (MFS) demonstrate abnormal aortic elastic properties manifest by decreased aortic distensibility and increased aortic stiffness. Left ventricular (LV) diastolic dysfunction has been reported in adults with MFS. The objective of this study was to assess the frequency of LV diastolic dysfunction in a group of children and young adults with MFS and to determine whether diastolic dysfunction is associated with hemodynamic alterations of the aorta. Review of echocardiographic findings in 40 patients with MFS was performed to assess LV size, systolic function, isovolumic relaxation time (IVRT), mitral inflow velocities, deceleration time (DT) of mitral E wave, and aortic root dimension. No patient had significant valvar disease or was on any cardiac medication at the time of study. A group of 40 age and sex-matched healthy subjects undergoing echocardiography served as controls. Significant differences in LV diastolic function were found between MFS patients and controls. MFS patients had prolonged DT and IVRT and decreased mitral E/A ratio, suggesting impaired LV relaxation. No relationship between aortic root dimension and diastolic performance was identified. Left ventricular diastolic dysfunction may be an early marker of myocardial involvement in young MFS patients occurring independently of aortic root dilatation.

Effects of n-3 polyunsaturated fatty acid supplementation in pregnancy on maternal and fetal erythrocyte fatty acid composition

OBJECTIVE

The aim of this study was to assess the effects of fish oil supplementation in pregnancy on maternal erythrocyte fatty acid composition at different stages of pregnancy and in the post-partum period, and on neonatal erythrocyte fatty acid composition.

DESIGN

A double-blind, randomised, placebo-controlled study.

SETTING

: Subiaco, Western Australia.

SUBJECTS

In all, 98 women booked for delivery at St John of God Hospital, Subiaco, were recruited from private rooms of obstetricians. In total, 83 women and their healthy full-term babies completed the study.

INTERVENTION

Women received either 4 g of fish oil (n=52) (56% docosahexaenoic acid (DHA) and 28% eicosapentaenoic acid (EPA) or placebo (olive oil) (n=46) per day from 20 weeks gestation until delivery.

MAIN OUTCOME MEASURES

Erythrocyte phospholipid fatty acids were measured in maternal peripheral blood at 20, 30 and 37 weeks of pregnancy and at 6 weeks post partum, and from cord blood collected at birth.

RESULTS

Compared to the control group, maternal EPA and DHA were significantly higher in the fish oil group at 30 and 37 weeks gestation, and remained elevated at 6 weeks post partum (P<0.001). The proportions of n-6 polyunsaturated (arachidonic acid, 22:3n-6 and 22:4n-6) were significantly lower in the fish oil supplemented group at the same time periods (P<0.001). Similarly, the proportions of EPA and DHA were significantly higher (P<0.001), and those of n-6 polyunsaturated fatty acids arachidonic acid, 20:3n-6, 22:3n-6 and 22:4n-6 were significantly lower (P<0.001), in erythrocytes from neonates in the fish oil group, compared to those in the control group.

CONCLUSION

Fish oil supplementation from 20 weeks of pregnancy until birth is an effective means of enhancing n-3 fatty acid status of both mothers and neonates. Furthermore, the changes in maternal erythrocyte fatty acid composition are retained until at least 6 weeks post partum. It is essential to assess the effects of concomitant decreases in arachidonic acid status before any dietary recommendations can be made.

SPONSORSHIP

The study was supported by grants from the NH & MRC and Raine Medical Research Foundation, Australia.

Training on a visual task improves the outcome of optic nerve regeneration

Optic nerve regeneration in a lizard, Ctenophorus ornatus, is dysfunctional despite survival of most retinal ganglion cells and axon regeneration to the optic tectum. The regenerated retino-tectal projection at 6 months has crude topography but by 1 year is disordered; visually-elicited behavior is absent via the experimental eye. Here, we assess the influence of training on the outcome of optic nerve regeneration. Lizards were trained to catch prey presented within the monocular field of either eye. One optic nerve was then severed and visual stimulation resumed throughout regeneration. In the trained group, presentation was restricted to the eye undergoing optic nerve regeneration; for the untrained group, the unoperated eye was stimulated. Pupil responses returned in trained but not in untrained animals. At 1 year, trained animals oriented to and captured prey; untrained animals demonstrated minimal orienting and failed to capture prey. Regenerated retino-tectal projections were topographic in the trained but not in the untrained group as assessed by in vitro electrophysiological recording and by carbocyanine dye tracing. In vitro electrophysiological recording during application of neurotransmitter antagonists to the tectum revealed that the level of GABAergic inhibition was modest in trained animals but elevated in the untrained group; responses were mainly AMPA-mediated in both groups. We conclude that training improves the behavioral outcome of regeneration, presumably by stabilizing and refining the transient retino-tectal map and preventing a build-up of tectal inhibition. The results suggest that for successful central nerve regeneration to occur in mammals, it may be necessary to introduce training to complement procedures stimulating axon regeneration.

Maternal fish oil supplementation in pregnancy reduces interleukin-13 levels in cord blood of infants at high risk of atopy

BACKGROUND AND OBJECTIVES

The epidemiological association between higher dietary n-3 polyunsaturated fatty acids (PUFA) and lower prevalence of asthma, has led to interest in the role of early dietary modification in allergic disease prevention. In this study we examined the effects of maternal n-3 (PUFA)-rich fish oil supplementation on cord blood (CB) IgE and cytokine levels in neonates at risk of developing allergic disease.

METHODS

In a randomized double-blind, placebo-controlled trial, 83 atopic pregnant women received either fish oil capsules (n = 40) containing 3.7 g n-3 PUFA/day or placebo capsules (n = 43) from 20 weeks gestation until delivery. CB cytokine levels (IL-4, IL-5, IL-6, IL-10, IL-12, IL-13, TNF-alpha and IFN-gamma) and total IgE levels were measured and compared between the two groups. Fatty acid composition of red cell membranes was analysed by gas chromatography and the relationships among PUFA, cytokine and IgE levels were examined.

RESULTS

Maternal fish oil supplementation resulted in a significant increase in n-3 PUFA levels (P < 0.001) in neonatal erythrocyte membranes. Neonates whose mothers had fish oil supplementation had significantly lower plasma IL-13 (P < 0.05) compared to the control group. There was also a significant inverse relationship between levels of n-3 PUFA in neonatal cell membranes and plasma IL-13. There was no difference in levels of IgE and the other cytokines measured.

CONCLUSIONS

This study provides preliminary evidence that increasing neonatal n-3 PUFA levels with maternal dietary supplementation can achieve subtle modification of neonatal cytokine levels. Further assessment of immune function and clinical follow-up of these infants will help determine if there are any significant effects on postnatal immune development and expression of allergic disease.

Day-case ureteroscopy: an observational study

OBJECTIVE

To evaluate the outcome after day-case ureteroscopy (used in diagnosing and managing ureteric disease, primarily urolithiasis), as awareness of reduced resources has resulted in increasing pressure to undertake procedures in a day-surgery setting.

PATIENTS AND METHODS

All patients presenting to the unit and requiring ureteroscopy between May 1995 and May 2000 were considered for a day-surgery procedure. The assessment of suitability comprised anaesthetic and social factors; no urological criteria precluded a day-surgery procedure. Outcomes after day-case ureteroscopy, including immediate or delayed admissions and subsequent inpatient management, were reviewed retrospectively.

RESULTS

Sixty-three day-case ureteroscopies were performed on 56 patients (mean age 47 years, range 19-78); eight procedures were diagnostic. Therapeutic ureteroscopies included one balloon dilatation of a ureteric stricture and 54 procedures for urolithiasis, with 98% stone clearance. Most patients were discharged with a JJ stent in situ. Of nine patients requiring immediate admission, seven were for pain control; eight were discharged on the following day. Seven patients required delayed admission 1-13 days after the procedure, three for stent-related symptoms and three for infection. No significant predictors of immediate or delayed admission were identified, although antibiotic prophylaxis was associated with a reduced admission rate.

CONCLUSION

Ureteroscopy can be used successfully as a planned day-case procedure in a dedicated day-surgery unit, with few patients requiring hospitalization. Implementation of analgesia protocols and routine antibiotic prophylaxis may reduce admission after day-case ureteroscopy.

SERMs, ethnicity, and clinical trials: opportunities and challenges

Selective estrogen receptor modulators (SERMs) are an exciting new class of pharmacotherapeutics that may have application in a wide variety of disease states. The science, both basic and clinical, that would guide the usage of these agents is in some respects at a relatively early developmental stage. Thus, the research community has an opportunity, before their use becomes widespread, to structure clinical trials such that the most complete profiles of benefits and risks are described. Tamoxifen is the SERM that has been most extensively studied and for which there are indications for both treatment and prevention of breast cancer based on trials involving more than 50,000 women. Despite this seemingly adequate sample size, an extremely important question remains unanswered--namely, whether there are ethnic differences in benefit and adverse effects of SERMs. It has generally been the case that new pharmacologic agents are tested in relatively small numbers of subjects, often only male, in North America and western Europe. While the populations are multi-ethnic, clinical trial subjects are most often not representative of the ethnic variability of these areas. Guidelines for usage of new drugs based on data from small, ethnically limited population groups are then generalized to other population groups, without consideration that differences in drug metabolism and/or responsiveness might exist.

Race and the decision to refer for coronary revascularization: the effect of physician awareness of patient ethnicity

OBJECTIVES

We sought to assess whether there were differences, relative to racial ethnicity, in coronary revascularization recommendations made by a panel that had no knowledge of the patients' ethnicity.

BACKGROUND

Coronary revascularization is employed less frequently in African American than in white patients. It is unclear whether this utilization pattern is driven by clinical differences between the two populations or by nonclinical factors.

METHODS

Data were reviewed from 938 (26.5% African American, 73.5% white) consecutive cardiac catheterizations done between 1993 and 1995. Revascularization recommendations were made by cardiologists and cardiothoracic surgeons provided with the patients' clinical and angiographic data, but without knowledge of their ethnicity. Revascularization recommendations were compared between African American and white patients and correlated with clinical characteristics.

RESULTS

No difference was noted in the percentage of African American and white patients recommended for revascularization, without reference to whether the recommendation was for percutaneous transluminal coronary angioplasty (PTCA) or for coronary artery bypass graft surgery (CABG) 40 vs. 46%, p = NS). African Americans were recommended more frequently for PTCA (22 vs. 18%, p = NS), whereas CABG was recommended for more white patients (28 vs. 18%, p = 0.002). Significantly fewer African Americans had disease in the left main or left anterior descending coronary artery or in multiple arteries. After adjusting for age, co-morbidity, left ventricular dysfunction and the extent of coronary disease, African Americans were more likely to have a recommendation for PTCA (odds ratio [OR] 1.42, 95% confidence interval [CI] 0.96 to 2.11, p = 0.08) and less likely to have a recommendation for CABG (OR 0.59, 95% CI 0.37 to 0.94, p = 0.02).

CONCLUSIONS

This study suggests that when only clinical factors are considered, the rates of recommendations for revascularization will be similar for white and African American patients; but the type of revascularization procedure may differ by ethnicity and may depend, in part, on clinical factors.

Relationship between 24-H blood pressure and sleep disordered breathing in a normotensive community sample

Sleep disordered breathing (SDB) and hypertension are commonly associated. In this study, we assessed how longitudinal measures of SDB predict a 24-h ambulatory blood pressure monitoring (ABPM) profile. Participants (n = 82) were recruited from a community-based urban (26% African American) sample and included family members of patients with laboratory diagnosed SDB (cases) and family members of neighborhood control subjects evaluated at baseline and at 5 years. Nearly all participants were normotensive and were not receiving therapy for SDB. During both examinations, the respiratory distress index (RDI) was assessed with overnight in-home polysomnography. Seated blood pressure (BP) was assessed at a baseline examination (t,) and after a 5-year follow-up period (t5), when 24-h ABPM also was performed. The change in RDI (t5-t1) over 5 years was significantly associated with 24-h mean systolic blood pressure (SBP) (P = .04), 24-h maximum diastolic blood pressure (DBP) (P = .03), sleep mean SBP (P = .05), sleep mean DBP (P < .05), and sleep maximum SBP (P = .02). Regression analysis revealed that average 24-h mean arterial pressure (MAP) and mean 24-h DBP were each best predicted by change in RDI, explaining 5% of the variance in these 24-h BP readings, and by current smoking status. After accounting for these variables, BP was not predicted by any of the other potential confounders (all P > .10). Mean RDI (averaged between t5 and t1) was associated with mean MAP, mean SBP, and maximal SBP measured during sleep. This study documents for the first time the association between changes in sleep apnea activity and BP and in a community-based normotensive sample. Further long-term evaluation of the effects of these findings and the long-term consequences of hypertension are needed.

Percutaneous endoscopic gastrostomy in patients with ventriculoperitoneal shunts

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) may be required in neurosurgical patients with a persistently depressed neurological status or severe lower cranial nerve palsies. Such patients may have a coexisting hydrocephalus requiring cerebrospinal fluid (CSF) diversion. Despite the risk of infection resulting from exposure to oropharyngeal flora by the pull-through PEG technique and the secondary pneumoperitoneum seen in one-third of patients, simultaneous peritoneal placement of CSF shunt catheters with PEG is the current practice. The aim of the study was to determine the frequency of CSF diversionary procedures in neurosurgical patients undergoing PEG insertion and the occurrence of infective complications in patients with simultaneous placement of a PEG and a ventriculoperitoneal (VP) shunt.

METHODS

This was a retrospective review of all neurosurgical patients undergoing PEG. The presence of hydrocephalus, mode of CSF diversion and the development of subsequent infection in those having coexistent distal peritoneal catheter placement and PEG were determined.

RESULTS

PEGs were placed in 42 neurosurgical patients (9.3 per cent of all PEGs inserted), of whom 21 had a coexisting hydrocephalus. Eight of 16 shunts with distal catheter placement in the peritoneal cavity developed infection requiring revision. Infections occurred with greater frequency in patients with a tracheostomy. There were no shunt infections requiring revision in a second group of 21 patients who had a coexisting shunt and tracheostomy without PEG.

CONCLUSION

Simultaneous placement of a PEG and a VP shunt should be avoided in the acute phase of a patient's hospital admission.

Effect of gender on fast-track recovery after coronary artery bypass graft surgery

OBJECTIVE

To examine the effects of gender on time to extubation after coronary artery bypass graft (CABG) surgery and intensive care unit and hospital length of stay.

DESIGN

Retrospective study comparing outcomes as related to gender.

SETTING

Tertiary care university teaching hospital.

PARTICIPANTS

Consecutive patients (n = 561; 376 men, 185 women) undergoing CABG surgery between January 1995 and December 1997.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Early extubation was possible in 74% of men versus 64% of women (p = 0.03); length of stay was < or =5 days in 60% of men versus 48% of women (p = 0.008); overall postoperative length of stay was 5.7 days for men versus 6.5 days for women (p = 0.003); morbidity and mortality were not significantly different between groups.

CONCLUSION

Women undergoing CABG surgery with a standardized fast-track protocol have longer intubation times, intensive care unit length of stay, and hospital length of stay than their male counterparts.

A role for syndecan-1 in coupling fascin spike formation by thrombospondin-1

An important role of cell matrix adhesion receptors is to mediate transmembrane coupling between extracellular matrix attachment, actin reorganization, and cell spreading. Thrombospondin (TSP)-1 is a modulatory component of matrix expressed during development, immune response, or wound repair. Cell adhesion to TSP-1 involves formation of biochemically distinct matrix contacts based on stable fascin spikes. The cell surface adhesion receptors required have not been identified. We report here that antibody clustering of syndecan-1 proteoglycan specifically transduces organization of cortical actin and fascin bundles in several cell types. Transfection of COS-7 cells with syndecan-1 is sufficient to stimulate cell spreading, fascin spike assembly, and extensive protrusive lateral ruffling on TSP-1 or on syndecan-1 antibody. The underlying molecular mechanism depends on glycosaminoglycan (GAG) modification of the syndecan-1 core protein at residues S45 or S47 for cell membrane spreading and on the VC2 region of the cytoplasmic domain for spreading and fascin spike formation. Expression of the VC2 deletion mutant or GAG-negative syndecan-1 showed that syndecan-1 is necessary in spreading and fascin spike formation by C2C12 cells on TSP-1. These results establish a novel role for syndecan-1 protein in coupling a physiological matrix ligand to formation of a specific matrix contact structure.

Cystic fibrosis transmembrane conductance regulator facilitates ATP release by stimulating a separate ATP release channel for autocrine control of cell volume regulation

These studies provide evidence that cystic fibrosis transmembrane conductance regulator (CFTR) potentiates and accelerates regulatory volume decrease (RVD) following hypotonic challenge by an autocrine mechanism involving ATP release and signaling. In wild-type CFTR-expressing cells, CFTR augments constitutive ATP release and enhances ATP release stimulated by hypotonic challenge. CFTR itself does not appear to conduct ATP. Instead, ATP is released by a separate channel, whose activity is potentiated by CFTR. Blockade of ATP release by ion channel blocking drugs, gadolinium chloride (Gd(3+)) and 4,4'-diisothiocyanatostilbene-2,2'disulfonic acid (DIDS), attenuated the effects of CFTR on acceleration and potentiation of RVD. These results support a key role for extracellular ATP and autocrine and paracrine purinergic signaling in the regulation of membrane ion permeability and suggest that CFTR potentiates ATP release by stimulating a separate ATP channel to strengthen autocrine control of cell volume regulation.

Developing a public policy response to the tobacco industry's targeting of women and girls: the role of the WHO Framework Convention on Tobacco Control

More than 1 billion people smoke worldwide, and 200 million of them are women. The prevalence of tobacco use among women is rising, as is the tobacco-related disease burden. Recently released tobacco industry documents unequivocally establish that the tobacco industry has made a practice of targeting women and girls for decades in an effort to cultivate what it considers an underexploited market. This article discusses the importance of strategies to limit the growth of the tobacco pandemic and describes the World Health Organization's Framework Convention on Tobacco Control, which may have important implications for preventing the further spread of tobacco use among women.

Nucleotides regulate NaCl transport in mIMCD-K2 cells via P2X and P2Y purinergic receptors

Extracellular nucleotides regulate NaCl transport in some epithelia. However, the effects of nucleotide agonists on NaCl transport in the renal inner medullary collecting duct (IMCD) are not known. The objective of this study was to determine whether ATP and related nucleotides regulate NaCl transport across mouse IMCD cell line (mIMCD-K2) epithelial monolayers and, if so, via what purinergic receptor subtypes. ATP and UTP inhibited Na(+) absorption [measured via Na(+) short-circuit current (I(Na)(sc))] and stimulated Cl(-) secretion [measured via Cl(-) short-circuit current (I(Cl)(sc))]. Using selective P2 agonists, we report that P2X and P2Y purinoceptors regulate I(Na)(sc) and I(Cl)(sc). By RT-PCR, two P2X receptor channels (P2X(3), P2X(4)) and two P2Y G protein-coupled receptors (P2Y(1), P2Y(2)) were identified. Functional localization of P2 purinoceptors suggest that I(Cl)(sc) is stimulated by apical membrane-resident P2Y purinoceptors and P2X receptor channels, whereas I(Na)(sc) is inhibited by apical membrane-resident P2Y purinoceptors and P2X receptor channels. Together, we conclude that nucleotide agonists inhibit I(Na)(sc) across mIMCD-K2 monolayers through interactions with P2X and P2Y purinoceptors expressed on the apical plasma membrane, whereas extracellular nucleotides stimulate I(Cl)(sc) through interactions with P2X and P2Y purinoceptors expressed on the apical plasma membrane.

Epithelial P2X purinergic receptor channel expression and function

P2X purinergic receptor (P2XR) channels bind ATP and mediate Ca(2+) influx--2 signals that stimulate secretory Cl(-) transport across epithelia. We tested the hypotheses that P2XR channels are expressed by epithelia and that P2XRs transduce extracellular ATP signals into stimulation of Cl(-) transport across epithelia. Electrophysiological data and mRNA analysis of human and mouse pulmonary epithelia and other epithelial cells indicate that multiple P2XRs are broadly expressed in these tissues and that they are active on both apical and basolateral surfaces. Because P2X-selective agonists bind multiple P2XR subtypes, and because P2X agonists stimulate Cl(-) transport across nasal mucosa of cystic fibrosis (CF) patients as well as across non-CF nasal mucosa, P2XRs may provide novel targets for extracellular nucleotide therapy of CF.

Operative management of Haglund's deformity in the nonathlete: a retrospective study

Haglund's deformity, or "pump bump," is a common cause of posterior heel pain. Management of the condition usually consists of nonoperative therapy. This study presents a retrospective study of 65 cases (53 patients), with symptomatic Haglund's deformity in nonathletes (13 male and 40 female), who presented during a 4-year period (1989-1994). Sixty-five percent (39 heels) of these patients failed to respond to nonoperative therapy for an average of 62 weeks, (range, 4-260 weeks). This group of patients went on to operative treatment. Surgical management consisted of excision of the posterior calcaneal tuberosity through a medial longitudinal incision with debridement, reattachment of the Achilles tendon using bone anchors, and 4 weeks of postoperative immobilization. Thirty-nine patients (74%) were contacted for follow-up. The average follow-up period for these patients was 155 weeks, (range, 92-335 weeks). There were 50% excellent results, 47% good results, 3% fair results (1 patient), and no poor results. The Maryland Foot Score for operated heels was an average of 67/100 preoperative and an average of 92/100 postoperative. On unoperated heels the score was an average of 81/100 at first evaluation and an average of 86/100 at final evaluation. Complications included one recurrence of painful prominence, one wound infection, and one incisional neuroma. The outcome of these cases demonstrated that in those patients who fail nonoperative treatment, surgical treatment of Haglund's deformity produces a predictably good surgical result when performed using the technique described.

Bioluminescence detection of ATP release mechanisms in epithelia

Autocrine and paracrine release of and extracellular signaling by ATP is a ubiquitous cell biological and physiological process. Despite this knowledge, the mechanisms and physiological roles of cellular ATP release are unknown. We tested the hypothesis that epithelia release ATP under basal and stimulated conditions by using a newly designed and highly sensitive assay for bioluminescence detection of ATP released from polarized epithelial monolayers. This bioluminescence assay measures ATP released from cystic fibrosis (CF) and non-CF human epithelial monolayers in a reduced serum medium through catalysis of the luciferase-luciferin reaction, yielding a photon of light collected by a luminometer. This novel assay measures ATP released into the apical or basolateral medium surrounding epithelia. Of relevance to CF, CF epithelia fail to release ATP across the apical membrane under basal conditions. Moreover, hypotonicity is an extracellular signal that stimulates ATP release into both compartments of non-CF epithelia in a reversible manner; the response to hypotonicity is also lost in CF epithelia. The bioluminescence detection assay for ATP released from epithelia and other cells will be useful in the study of extracellular nucleotide signaling in physiological and pathophysiological paradigms. Taken together, these results suggest that extracellular ATP may be a constant regulator of epithelial cell function under basal conditions and an autocrine regulator of cell volume under hypotonic conditions, two functions that may be lost in CF and contribute to CF pathophysiology.

Reference centile charts for measures of disease activity, functional impairment, and metrology in ankylosing spondylitis

OBJECTIVE

To construct reference centile charts for validated measures of disease activity, functional impairment, and metrology (the Bath Ankylosing Spondylitis Disease Activity Index [BASDAI], Bath Ankylosing Spondylitis Functional Index [BASFI], and Bath Ankylosing Spondylitis Metrology Index [BASMI]) in a population of patients with AS, and to explore the potential application of these charts in patient care and clinical research.

METHODS

We collected BASDAI and BASFI data on 2,979 patients with AS from the Royal National Hospital for Rheumatic Diseases (RNHRD) database and BASMI data on 393 patients at RNHRD. Data on age, sex, and duration of AS were also obtained. Centile charts were constructed for the BASDAI, BASFI, and BASMI in both males and females, with duration of AS as the time-dependant variable. Where necessary, BASDAI, BASFI, and BASMI raw scores were transformed to ensure that the indices were normally distributed over the range of disease duration, and allowance was made for change in variability of the indices.

RESULTS

Linear models were fitted to the mean and standard deviations of BASDAI, BASFI, and BASMI scores in males and females as a function of disease duration. A standard deviation score plot confirmed goodness of fit of the models, and fitted centiles were derived. Charts showing the 5th, 10th, 25th, 50th, 75th, 90th, and 95th centiles were constructed. The charts confirmed that AS remains active after 40 years' duration (mean BASDAI score 2.22 and 2.99 in males and females, respectively). The charts also demonstrated that females have greater disease activity and more functional impairment than males, despite better metrology.

CONCLUSION

The use of centile reference charts for disease activity, functional impairment, and metrology in AS will allow physicians and patients to interpret index scores relative to a reference population and will provide the opportunity to assess change over time and response to therapeutic interventions, to improve definition of disease status, and to enhance patients' involvement in their care.

Scleromyxoedema associated with synovitis and myopathy

Scleromyxoedema is a rare skin disease characterized by the deposition of hyaluronic acid in the papillary dermis and often associated with the presence of a monoclonal para protein. Patients with this disorder may also have systemic manifestations. A case of a patient with biopsy proven scleromyxoedema who, in addition to the skin changes had a steroid responsive myopathy and polysynovitis is presented.

Developing guidelines for local use: algorithms for cost-efficient outpatient management of cardiovascular disorders in a VA Medical Center

Local use of practice guidelines requires paying close attention to the concerns of the patient within the framework of society, to the professional and educational needs of the provider, and to the realities of cost. One Veterans Affairs facility took the challenge of balancing these factors and developed their own algorithms for three cardiovascular disorders.