Blood conservation in neonatal and pediatric populations

Blood conservation in infants and children has benefits even beyond those seen with the adult populations. For instance, acquired blood borne diseases such as cytomegalovirus not only cause illness but also can have deleterious effects on the growth and development of infants and children. Decreasing blood transfusions is especially important in preventing sensitization over a lifetime, which may require further transfusion and even organ transplantation. A less striking benefit, but one equally as significant, is decreasing the occurrence of graft-versus-host disease when blood conservation negates the need for multiple transfusions. The limitation of alternative transfusion practices in children and infants increases the benefits of blood conservation. Autologous blood donation may be an alternative to allogeneic transfusion in older children, but is not possible with neonates who may be born anemic and who experience a normal physiologic anemia during the first 2 months of life. Critical care nurses are instrumental in helping blood conservation by understanding blood salvaging techniques, including correct collection techniques, noninvasive monitoring, evaluation of diagnostic sample needs, and administration of erythrocyte-stimulating factors.

Expression of the type 2 metallothionein-like gene MT2 from Arabidopsis thaliana in Zn(2+)-metallothionein-deficient Synechococcus PCC 7942: putative role for MT2 in Zn2+ metabolism

Zn2+ proteins pervade metabolism and are essential for gene expression. However, no proteins have been ascribed the central roles of Zn2+ donation to, or removal from, metalloproteins, or Zn2+ storage in vegetative plant tissue. In animals, such functions have been proposed for metallothioneins. Plants contain multiple metallothionein-like genes but their predicted products, which differ significantly from animal metallothioneins, remain to be isolated from vegetative tissue and their roles are uncertain. The type 2 metallothionein-like gene from Arabidopsis, MT2, was expressed under the control of Zn2+-responsive elements derived from the cyanobacterial metallothionein divergon, smt. Zn2+-dependent expression of MT2 transcripts in Synechococcus PCC 7942 was confirmed by northern analysis. The Arabidopsis MT2 gene partly complemented Zn2+ hypersensitivity in mutants of Synechococcus PCC 7942 which are functionally deficient in an endogenous Zn2+-metallothionein gene, smtA. MT2 was also expressed as a recombinant fusion protein in Escherichia coli, purified and shown to bind Zn2+ in vitro. The mean pH of half displacement of Zn2+ from MT2 was estimated to be 5.05. This suggests that MT2 has a greater affinity for Zn2+ than phytochelatins. The results presented here reveal that MT2 is capable of binding Zn2+ in vitro, conferring tolerance to elevated [Zn2+] in vivo within cyanobacteria and is likely to compete with other polypeptides for cellular Zn2+ in planta.

Shade-stimulated growth and nitrogen uptake by pasture grasses in a subtropical environment

Fibrous feeds constrain voluntary feed intake by ruminants through a complex of interacting animal and plant factors. The animal factors are briefly assessed indicating some control over digesta load in the rumen and that only small particles (<1 mm screen size) achieve ready passage from the rumen. There is evidence that retention of small particles may be prolonged because their movement from the rumen to reticulum may be restricted by their buoyancy and entrapment within the digesta raft in the rumen. Ingestive chewing and rumination effort varies with feed type, is greater for stem than leaf and increases with feed maturity. It is still not clear from animal studies whether passage rate and VFI are limited more by the time to break large particles to small particles or by the hindrance of small particle passage from the rumen. Digestion in rumen decreases the physical grinding energy needed to comminute feed, but it is not readily shown that this makes a difference to efficiency of animal rumination. Anatomical characteristics of leaves and stems of tropical and temperate grasses and legumes are analysed to assess their influence on the ease and pattern of breakdown, and the characteristics of the resultant fibre particles. Epidermal and vascular structures, and microbial digestion, determine the initial breakdown of organs which is fast in leaves of legumes and high quality temperate grasses, but slow in tropical grass leaves. All stems require a high chewing effort to facilitate swallowing of feed and passage of particles from the rumen. Some tissue components directly enter the 'fines' fraction, the rest (vascular strands in isolated or composite form) become the large particle fraction. Rumination is essential to degrade these to small particles. It is hypothesised that inaccessibility of cell walls for microbial attack limits digestive weakening in both large and small particles. A conceptual framework summarizing the breakdown pattern for different feed groups is presented. Potential future opportunities for overcoming these intake constraints associated with modification of rumen microbes and plant anatomical structure are discussed.

Plant and animal constraints to voluntary feed intake associated with fibre characteristics and particle breakdown and passage in ruminants

Effects of artificial shading to 50% sunlight of nitrogen (N) limited tropical pastures of different grass species on a high (clay loam) and low (granitic loam) fertility soil type were evaluated in a semi-arid. subtropical environment over 3 years. The hypothesis was tested that shade can stimulate shoot growth by providing a modified environment more conducive to organic matter breakdown leading to increased mineralisation and availability of soil N, and the ability of tropical grasses to take advantage of this effect was examined. Unfertilised pastures of green panic (Panicum maximum var. trichoglume), buffel (Cenchrus ciliaris). rhodes (Chloris gayana), and speargrass (Heteropogon contortus) in full sun or shaded by sarlon cloth were sampled on 9 occasions. Additional green panic plots on both soils were irrigated for the first 2 years, and all other plots were dependent on natural rainfall. Shoot and root dry matter and N yield, and soil nitrate and ammonia N, were measured. In one set of green panic plots on each soil, canopy. litter, and surface soil temperatures were monitored continuously, and soil moisture at different depths was measured fortnightly. Shade stimulated shoot dry matter yield over the 3 years by up to 37% in green panic. 22% in rhodes, and 9% in speargrass. Shade decreased buffel yield on the clay soil but had no effect on the granitic soil. Relative increases in yield of shoot N were similar to those for shoot dry matter, except for buffel on the granitic soil where N yield was increased by 39% with no increase in shoot growth. Positive shade responses occurred in all 3 years but were reduced by extreme drought in year 3, particularly on the clay soil. Irrigation gave a greater shade response on the clay but not on the granitic soil. Root mass was lower under shade than in full sun. but there was no long-term trend of progressive decrease. and the change in N yield of roots did not appear to explain the gain in shoot N of the shaded pastures. Nitrogen percentage in the youngest expanded leaf was higher in the shade than the sun leaves only after about 2 to 2 5 months of shading. Surface soil nitrate and ammonia concentrations tended to be higher under shade for most harvests. Shade lowered temperature extremes of surface soil and litter by up to 10-12�C, and improved soil water status. compared with the sun plots. Soil water data were analysed to separate effects on plant water stress and soil microbial activity. The consistent positive response of shoot N yield to shade across grass species. weeds, and soil type. the delay in it becoming evident, and its longevity all support the hypothesis that shade enhances organic matter breakdown and N cycling. Harsh surface temperatures and low soil moisture in open sun pastures appear inimical to high microbial activity. Implications for pasture management are discussed. with the caveat that the outlined benefits of artificial shade may not necessarily arise with tree canopies.

Self-esteem, compliance, and cervical screening

A computerized version of the semantic differential was administered to 57 respondents and 43 nonrespondents to invitations for a cervical smear test. 26 concepts pertaining to emotional, social, parental, and health-related domains were tested. The semantic differential was followed by a personal questionnaire. Analysis indicated that fear, worry, and embarrassment were negatively correlated with the decision to have a cervical smear test. Respondents seemed to have higher self-esteem and better relationships with their husbands than nonrespondents.

Synaptic inputs to single neurons in the lateral geniculate nuclei of normal and monocularly deprived squirrel monkeys

Neurons in the dorsal lateral geniculate nucleus (dLGN) of normal and monocularly lid-sutured squirrel monkeys were recorded electrophysiologically, and some were injected intracellularly with horseradish peroxidase (HRP) to examine and compare their synaptic inputs. Limited tests of the receptive field properties did not show any differences between the normal, nondeprived, or deprived neurons. Sixteen injected neurons were examined at the light microscopic level with most of these located in the P-laminae (n = 14). Ten of these were either from normal monkeys (n = 9) or received input from the nondeprived eye of a monocularly deprived monkey (n = 1). The remaining six neurons received input from the deprived eye. The dendritic trees of deprived neurons did not differ from those of normal or nondeprived neurons. Three normal and five deprived neurons from the P-laminae were examined at the electron microscopic level. Afferent distributions were not significantly different between normal and deprived neurons. Retinal, cortical, and gamma aminobutyric (GABA)ergic afferents accounted for nearly all inputs (avg., 42%, 23%, and 32%, respectively) and selectively contacted proximal, distal, or all parts of the dendrites. Overall, synaptic densities (synapses per length of dendrite) were high proximally and decreased with distance from the soma. However, the synaptic densities onto deprived neurons were higher at all distances compared to those onto normal neurons. Furthermore, HRP-filled deprived neurons received an average of 25 synapses onto their somata compared with only an average of 7 somal synapses on the HRP-filled normal neurons. Most of the increase in the number of synapses onto the deprived neurons was from GABAergic type profiles. This abnormality of the deprived neurons of the dLGN could be the underlying cause of their lesser responses compared with normal or nondeprived dLGN neurons. It could also be the initial stage that causes blindness in monocularly lid-sutured primates.

Dissociation between peak exercise oxygen consumption and hemodynamic dysfunction in potential heart transplant candidates

OBJECTIVES

The purpose of this study was to determine how often peak exercise oxygen consumption (VO2) misclassifies the severity of cardiac dysfunction in potential heart transplant candidates.

BACKGROUND

Cardiopulmonary exercise testing is being used to help select heart transplant candidates on the basis of the assumption that a low peak exercise VO2 indicates severe hemodynamic dysfunction and a poor prognosis. However, noncardiac factors, such as muscle deconditioning, can also influence exercise capacity. Therefore, peak exercise VO2 may overestimate the severity of cardiac dysfunction in some patients.

METHODS

Hemodynamic and respiratory responses to maximal treadmill exercise were measured in 64 sequential patients undergoing evaluation for heart transplantation, all of whom had an ejection fraction < 35% and reduced peak exercise VO2 levels (mean [+/- SD] 13.3 +/- 2.7 ml/min per kg).

RESULTS

Twenty-eight (44%) of 64 patients exhibited a reduced cardiac output response to exercise and pulmonary wedge pressure > 20 mm Hg at peak exercise, consistent with severe hemodynamic dysfunction. Twenty-three patients (36%) exhibited a normal cardiac output response to exercise but a wedge pressure > 20 mm Hg at peak exercise, suggesting moderate hemodynamic dysfunction. Thirteen patients (20%) exhibited a normal cardiac output and wedge pressure < 20 mm Hg at peak exercise, suggesting mild hemodynamic dysfunction. Despite these markedly different hemodynamic responses, all three groups exhibited similar peak exercise VO2 levels (mild dysfunction 14.2 +/- 3.5 ml/min per kg, moderate dysfunction 13.9 +/- 2.7 ml/min per kg, severe dysfunction 12.4 +/- 2.1 ml/min per kg). A peak exercise VO2 level < 14 ml/min per kg, considered to reflect severe hemodynamic dysfunction, was observed in 18 of the patients with a normal cardiac output response to exercise, whereas 7 patients with severe hemodynamic dysfunction had a peak VO2 level > 14 ml/min per kg.

CONCLUSIONS

More than 50% of potential heart transplant candidates with a reduced peak exercise VO2 level exhibit only mild or moderate hemodynamic dysfunction during exercise. Hemodynamic responses to exercise should be directly measured in potential transplant candidates to confirm severe circulatory dysfunction.

Sources of subcortical afferents to the macaque's dorsal lateral geniculate nucleus

BACKGROUND

The dorsal lateral geniculate nucleus (dLGN) is the thalamic region responsible for transmitting retina signals to cortex. Brainstem pathways to this nucleus have been described in several species and are believed to control the retinocortical pathway depending on the state of the animal (awake, asleep, drowsy, etc.). The purpose of this study was to determine all of the subcortical sources of afferents to the dLGN in a higher primate, the macaque monkey, whose visual system is similar to that of humans.

METHODS

Injections of horseradish peroxidase (HRP), with or without conjugation to wheat germ agglutinin, were made into the dLGNs of seven macaque monkeys, followed by perfusion, brain sectioning, and analyses of neurons in the brainstem, thalamus, and hypothalamus that contained the retrogradely transported marker.

RESULTS

The reticular nucleus of the thalamus, pedunculopontine nucleus, parabigeminal nucleus, pretectal nucleus of the optic tract, superior colliculus, dorsal raphe nucleus, and tuberomammillary region of the hypothalamus contained many retrogradely labeled neurons ipsilateral to the injections. In the contralateral brainstem, HRP-labeled cells were found only in the pedunculopontine nucleus, nucleus of the optic tract, and dorsal raphe nucleus. The number of labeled neurons on the contralateral side was about one-half of that in corresponding ipsilateral nuclei. The locus coeruleus contained no labeled neurons in four of the macaques that had injections limited to the dLGN.

CONCLUSION

There are seven subcortical regions that send afferents to the dLGNs of macaque monkeys. Except for the locus coeruleus, these are the same as observed for other species, such as the cat and rat, and indicate the possible sources of subcortical control over the dLGNs of humans.

Clenbuterol: a substitute for anabolic steroids?

Clenbuterol is a recently popular drug used by athletes in many sports for its purported anabolic effects and reduction of subcutaneous fat. It is a beta-2 (beta 2) agonist prescribed overseas as a bronchodilator, but not approved for use in this country. It is on the banned substance list of the United States Olympic Committee. To avoid any erosion of confidence, physicians caring for athletes need accurate information regarding clenbuterol. Such information is unavailable within the routine medical environs. A review of the literature of animal husbandry reveals that this drug, when administered in doses far greater than those required for bronchodilation, does indeed increase the deposition rate of lean mass and retard adipose gain. There are no human studies available. Animal studies were conducted on laboratory and slaughter stock. No investigation into long-term cardiovascular side effects has been undertaken. The rate of extrapolation from animal studies to unsupervised human usage is alarming. If this category of drugs does preserve lean mass in humans, there are legitimate medical applications. Trials of efficacy and safety are needed.

Dissociation between exertional symptoms and circulatory function in patients with heart failure

BACKGROUND

Patients with heart failure frequently report exertional dyspnea and fatigue. These symptoms are usually attributed to circulatory dysfunction and therefore are typically treated with cardiovascular medications. Serial assessment of exertional symptoms has also become the principal method used to assess drug efficacy in heart failure. Nevertheless, the relation between exertional symptoms in heart failure and circulatory dysfunction remains uncertain.

METHODS AND RESULTS

This study was undertaken to investigate the relation between exertional symptoms, ventilatory and skeletal muscle dysfunction, and circulatory function in patients with heart failure. To this end, 52 ambulatory patients with heart failure underwent hemodynamic monitoring during maximal treadmill exercise testing. During exercise, the severity of dyspnea and fatigue was evaluated on a scale of 6 to 20 (Borg scale). The level of perceived exercise intolerance during daily activities was evaluated with the Minnesota Living With Heart Failure Questionnaire and the Yale Dyspnea-Fatigue Index. Maximal treadmill exercise increased the VO2 to 13.4 +/- 2.8 mL.min-1.kg-1, the dyspnea score to 15.7 +/- 2.3, the fatigue score to 14.8 +/- 3.4, the pulmonary wedge pressure to 28 +/- 11 mm Hg, and the pulmonary artery lactate concentration to 34.5 +/- 16.3 mg/dL and decreased the pulmonary artery hemoglobin oxygen saturation to 30 +/- 9%. The level of perceived dyspnea had no relation to the pulmonary wedge pressure and correlated only minimally with the level of excessive ventilation (r = 39). The level of perceived fatigue correlated only weakly with blood lactate concentration (r = .55). Eleven patients (21%) exhibited a normal cardiac output and wedge pressure < 20 mm Hg during exercise, 22 (42%) exhibited a normal cardiac output but wedge pressure > 20 mm Hg during exercise, and 19 (37%) exhibited reduced cardiac output and wedge pressure > 20 mm Hg during exercise. Despite these markedly different hemodynamic responses, all three groups exhibited similar levels of fatigue and dyspnea at comparable workloads and had comparable total scores for the Minnesota Living With Heart Failure Questionnaire and the Yale Dyspnea-Fatigue Index. There was no relation between the Living With Heart Failure Questionnaire and peak exercise VO2 and only a weak correlation between the Dyspnea-Fatigue Index and peak VO2 (r = .48).

CONCLUSIONS

The level of exercise intolerance perceived by patients with heart failure has little or no relation to objective measures of circulatory, ventilatory, or metabolic dysfunction during exercise. In patients who report severe exertional symptoms, it may be desirable to directly measure hemodynamic response to exercise to ensure that these symptoms are due to circulatory dysfunction.

An alternative oxygen supply technique for the difficult patient

A modified oxygen delivery system was developed for a patient too claustrophobic for the monoplace chamber or the hood in the multiplace chamber. The adaptation delivered O2 through the patient's tracheostomy by means of a soft cervical collar, a pediatric tracheostomy cuff, and a T-tube.

Contribution of potassium to exercise-induced vasodilation in humans

It has been postulated that skeletal muscle release of potassium contributes to exercise-induced vasodilation of skeletal muscle arterioles. To determine whether potassium produces muscle arteriolar vasodilation in humans, we measured plethysmographic forearm blood flow and brachial venous potassium concentrations during brachial arterial infusion of potassium (0.6, 3, 6, 15, and 30 mueq.min-1.100 ml forearm volume-1) in nine normal subjects. Infusion of potassium decreased forearm vascular resistance, with an increase in brachial venous potassium of 1 meq/l decreasing forearm vascular tone by 25-30%. We then measured plasma potassium concentrations during forearm and upright bicycle exercise in 15 normal subjects. Forearm exercise at 0.6 W decreased forearm vascular resistance by 83%, whereas brachial venous potassium increased by only 0.5 +/- 0.2 meq/l (both P < 0.05). Maximal bicycle exercise increased systemic potassium concentrations by 1.2 +/- 0.2 meq/l. These findings indicate that potassium produces muscle arteriolar vasodilation in humans and therefore supports the hypothesis that potassium release from exercising muscle contributes to exercise-induced vasodilation. The relatively small change in venous potassium noted during forearm exercise despite marked forearm vasodilation suggests that local potassium release is only a small contributor to exercise-induced vasodilation. However, potassium release during maximal exercise may have significant vasodilatory effects on arterioles both in exercising and nonexercising tissues.

Validation of near-infrared spectroscopy in humans

Near-infrared (NIR) spectroscopy is a noninvasive technique that uses the differential absorption properties of hemoglobin to evaluate skeletal muscle oxygenation. Oxygenated and deoxygenated hemoglobin absorb light equally at 800 nm, whereas at 760 nm absorption is primarily from deoxygenated hemoglobin. Therefore, monitoring these two wavelengths provides an index of deoxygenation. To investigate whether venous oxygen saturation and absorption between 760 and 800 nm (760-800 nm absorption) are correlated, both were measured during forearm exercise. Significant correlations were observed in all subjects (r = 0.92 +/- 0.07; P < 0.05). The contribution of skin flow to the changes in 760-800 nm absorption was investigated by simultaneous measurement of skin flow by laser flow Doppler and NIR recordings during hot water immersion. Changes in skin flow but not 760-800 nm absorption were noted. Intra-arterial infusions of nitroprusside and norepinephrine were performed to study the effect of alteration of muscle perfusion on 760-800 nm absorption. Limb flow was measured with venous plethysmography. Percent oxygenation increased with nitroprusside and decreased with norepinephrine. Finally, the contribution of myoglobin to the 760-800 nm absorption was assessed by using 1H-magnetic resonance spectroscopy. At peak exercise, percent NIR deoxygenation during exercise was 80 +/- 7%, but only one subject exhibited a small deoxygenated myoglobin signal. In conclusion, 760-800 nm absorption is 1) closely correlated with venous oxygen saturation, 2) minimally affected by skin blood flow, 3) altered by changes in limb perfusion, and 4) primarily derived from deoxygenated hemoglobin and not myoglobin.

Aberrant reinnervation following hypoglossal nerve damage

Hypoglossal nerve damage is a known complication of carotid endarterectomy, occurring in approximately 5% of endarterectomies. The vast majority of these patients recover without functional disability from this injury even if the tongue remains hemiplegic. We report 2 patients who suffered hypoglossal nerve section during neck surgery. Although they were initially mildly symptomatic, they developed increasingly severe dysarthria and dysphagia beginning 4 months after surgery. EMG revealed abnormal coactivation of the genioglossus and styloglossus muscles on the affected side, suggesting aberrant reinnervation. Aberrant reinnervation is a well-known complication of facial nerve injury, but has not been previously recognized in hypoglossal nerve injury. Like the face, the tongue is composed of many muscles that must perform complex movements. Normally, injury to one hypoglossal nerve causes little or no disability, but when aberrant reinnervation occurs, the tongue no longer moves in a coordinated manner, and significant dysarthria ensues.