Malaria blood stage infection suppresses liver stage infection via host-induced interferons but not hepcidin

Malaria-causing Plasmodium parasites first replicate as liver stages (LS), which then seed symptomatic blood stage (BS) infection. Emerging evidence suggests that these stages impact each other via perturbation of host responses, and this influences the outcome of natural infection. We sought to understand whether the parasite stage interplay would affect live-attenuated whole parasite vaccination, since the efficacy of whole parasite vaccines strongly correlates with their extend of development in the liver. We thus investigated the impact of BS infection on LS development of genetically attenuated and wildtype parasites in female rodent malaria models and observed that for both, LS infection suffered severe suppression during concurrent BS infection. Strikingly and in contrast to previously published studies, we find that the BS-induced iron-regulating hormone hepcidin is not mediating suppression of LS development. Instead, we demonstrate that BS-induced host interferons are the main mediators of LS developmental suppression. The type of interferon involved depended on the BS-causing parasite species. Our study provides important mechanistic insights into the BS-mediated suppression of LS development. This has direct implications for understanding the outcomes of live-attenuated Plasmodium parasite vaccination in malaria-endemic areas and might impact the epidemiology of natural malaria infection.

Molecular detection of Mycoplasma gallisepticum in different poultry breeds of Abbottabad and Rawalpindi, Pakistan

The poultry sector in Pakistan is contributing mainly in bridging gap between demand and supply for protein. Mycoplasma gallisepticum is an emerging bacterium causing serious problems in poultry industry of Pakistan. A cross-sectional study was conducted to evaluate the M. gallisepticum load in poultry populated regions of Pakistan. Total 600 serum and 600 swab samples were collected, 200 from each broiler, layers and breeders poultry in Rawalpindi and Abbottabad districts. Serum samples were analyzed through ELISA for seroprevalence. Swabs were cultured on Frey's medium followed by PCR and partial mgc2 gene sequencing. Results of seroprevalence of M. gallisepticum showed that layers (75%, n=150) are more positive as compared to breeders (70%, n=140) and broilers (50%, n=100). Typical colonies of the M. gallisepticum were observed in breeder (26.5%), followed by layer (21%) and broilers (9%). A total of 37.1% (n=42) samples were identified positive through PCR out of total 113 cultured based positive samples. A total of six M. gallisepticum isolates of current study showed 98-99 percent similarity with previously reported isolates on the basis of mgc2 gene partial sequencing. The M. gallisepticum was found highly prevalent in different poultry breads. Results of this study would add into basic data and provide a direction for livestock sector to strengthen a control strategy for mycoplasmosis in poultry farms.

Food habits of indian crested porcupine (Hystrix indica) (Kerr 1792), in district Bagh, Azad Jammu and Kashmir

The Indian Crested Porcupine (Hystrix indica) is classified as an agricultural pest species. It feeds on plants and crops; hence, it is responsible for massive financial losses worldwide. The current study was conducted to assess the diet composition of Indian Crested Porcupine in District Bagh, Azad Jammu and Kashmir (AJ&K). Thus, fecal samples were collected and examined from different sampling sites. Reference slides of the material collected from the study area were prepared for identification of dietary components in fecal pellets. A total of 80 fecal samples were collected and processed. Percent relative frequencies (P.R.F.) were calculated for each plant species recovered from pellets. Data revealed that Indian Crested Porcupine consumed 31 plant species in its diet, among them Zea mays (34.31±7.76) was the most frequently selected species followed by Rumex obtusifolius (15.32±2.57) and Melia azedarach (12.83±4.79). The study revealed that the greatest diversity of (n=20) plant species were consumed in summer season while minimum (n=13) species were used during winter. Among the parts of plants, stem was highly consumed in spring (57.2%) as compared to seed in fall (36.7%) while spikes and leaf were the least recovered parts from the fecal matter. The Berger-Parker diversity index showed highly diversified food (10.92) in the summer time of the year as compared to the autumn season (2.95). This study provides a baseline for the diet preference of this pest in the study area. Based on current findings, a detailed investigation on damage assessment, exploration, habitat use and management of Indian Crested Porcupine in AJ&K has been recommended.

The immunological perturbations induced by ongoing blood-stage infection during Plasmodium GAP (Genetically Attenuated Parasites) vaccination

Plasmodium sporozoites (SPZ) are transmitted by mosquito bite, infect the liver, grow and differentiate as intrahepatocytic liver stages (LS) and ultimately form the first generation of red blood cell-infectious merozoites, which initiate the symptomatic blood stage infection. Immunization with replication-deficient radiation attenuated SPZ vaccine has shown to confer sterilizing immunity in animal models by preventing parasite growth into the liver before onset of symptomatic blood stage infection. This attenuated SPZ vaccine has undergone clinical testing and it was observed that sterilizing immunity was achieved high in malaria naïve subjects but lower in malaria pre-exposed subjects residing in malaria-endemic regions. Previous studies in rodent models indicate that the ongoing blood stage infection suppresses protection after immunization with replication deficient irradiated SPZ. We have shown that replication competent late liver stage arresting genetically attenuated parasites (RC-GAP) immunization confer superior protection when compared to irradiated SPZ. However, whether the blood stage infection would also affect the RC-GAP parasite vaccine mediated protective immunity by altering specific immune responses remains unknown. Here, we show that ongoing homologous blood stage infection during Plasmodium yoelii RC-GAP immunization suppress the vaccine mediated immunity in Balb/c mice. Our data suggest that the reduction in protection was associated with the perturbations of long-lived Ag specific antibody as well as tissue resident memory CD8 T cell (TRMs) responses generated against pre-erythrocytic SPZ and LS stages.

158 Management of Atrial Fibrillation in Patients with Cerebral Amyloid Angiopathy: Multidisciplinary Neuro-Cardiology Approach

 

We present two cases that highlight the clinical challenge of anti coagulation in patients with intracerebral haemorrhage (ICH) due to Cerebral Amyloid Angiopathy (CAA) and co-existent non-valvular Atrial Fibrillation (AF).

Case 1

78 -Years right-handed functionally independent gentleman presented with right parietal intracerebral haemorrhage (ICH) on Dabigatran that required reversal. He had a background history of hypertension, persistent AF and a previous ICH on warfarin. Post atrial septal defect repair, he had multiple unsuccessful cardioversions for AF, and a failed catheter ablation after the first stroke. Magnetic Resonance Imaging (MRI) brain showed Cerebral Amyloid Angiopathy (CAA), the cause of his recurrent bleeds. Anticoagulation was not started due to severe CAA on imaging and recurrent bleeds. He was referred for left atrial closure device.

Case 2

79-Years female presented with left parietal haemorrhage and new onset atrial fibrillation. Work up for ICH showed normal BP readings and clotting profile. Her MRI brain showed a large lobar bleed with mild small vessel disease and evidence of no other imaging features suggestive of CAA. As optimal timing to start anticoagulation after ICH is unknown, she was suggested to take part in a clinical trial. Her family declined the offer of clinical trial and also anti coagulation due to few falls. Her CHAD-VaSc and HAS-BLED score were 4 and 2 respectively. She was then referred to tertiary centre for left atrial appendage closure device.

Conclusion

Safety and timing to initiate DOAC for AF in this group is not established yet, understanding hemorrhagic risk using Boston Criteria for CAA diagnosis should be considered in addition to HAS-BLED score. Shared decision making and comprehensive discussions with cardiologist are of paramount importance. Non pharmacological intervention studies WATCHMAN and PREVAIL have proven procedural efficacy, however, in elderly population, decision making is complex due to frailty, dementia and co-morbidities.

Superior CD8 T cell-mediated protection against malaria parasite liver stage infection after vaccination with Replication Competent Genetically Attenuated Parasites (RC-GAP) and impact of blood stage infection on immunity

Plasmodium sporozoites (SPZ) are transmitted by mosquito bite, infect the liver, grow and differentiate as intrahepatocytic liver stages (LS) and ultimately form the first generation of red blood cell-infectious merozoites, which initiate the symptomatic blood stage infection. A vaccine against the clinically silent pre-erythrocytic SPZ and LS stages is attractive as it confers protection against infection before onset of symptomatic blood stage infection. Immunization with replication-deficient attenuated SPZ constitutes a promising vaccination strategy to engender protective humoral and CD8 T cell responses, with tissue resident memory CD8 T cell (TRMs) mediating sterilizing immunity in animal models. Attenuated parasite vaccines have undergone clinical testing and it was observed that sterilizing immunity is high in malaria naïve subjects but lower in malaria pre-exposed subjects residing in malaria-endemic regions. Previous studies in rodent models indicate that the ongoing blood stage infection suppresses protection after immunization with replication-deficient irradiated sporozoites. We have shown that replication competent late liver stage arresting genetically attenuated parasites (RC-GAP) confer superior protection when compared to irradiated sporozoites. We show that this protection is dependent on CD8 TRMs in the liver. However, whether the blood stage infection also suppresses the RC-GAP parasite vaccine mediated protective immunity remains unknown. Here, we examined whether blood stage infection either before or during RC-GAP immunization affects vaccine induced protection in the Plasmodium yoelii/Balb/c mouse model and how this correlated with perturbation of memory T and B cell responses.

Innate immunity limits protective adaptive immune responses against pre-erythrocytic malaria infection

Immunization with whole pre-erythrocytic stage malaria parasites that infect hepatocytes but are unable to cause blood stage infection constitutes one of the most promising strategies to protect against malaria infection. In rodent malaria models, whole parasite vaccines that exhibit substantial replication within hepatocytes engender superior, long-lasting strain- and stage-transcending immunity as compared to replication-deficient whole parasite vaccines. Liver stage infection with replication-competent Plasmodium parasites induces an innate immune response that is dependent on type I Interferon (IFN-1) signaling. However, it remains unknown how this IFN-1 response contributes to vaccine-engendered adaptive immunity. Using a replication-competent genetically attenuated parasite vaccine in an immunization regimen that confers partial protection in wildtype (WT) mice, we examined vaccine efficacy in mice lacking IRF3 or IFNAR. Surprisingly, IRF3−/− and IFNAR−/− mice showed superior protection against an infectious sporozoite challenge when compared to WT mice. Better protection correlated with a greater frequency of liver-resident memory CD8 T cells in immunized IFNAR−/− mice. Furthermore, IFNAR−/− mice exhibited lower levels of the T cell co-inhibitory receptors, PD-1 and LAG-3, a greater percentage of IFNγ-producing CD8 T cells, and eliminated liver stages more effectively. Taken together, we show that the Plasmodium engendered IFN-1 response impairs the generation of an optimal memory T cell response. To our knowledge, this study is the first description of a detrimental role for IFN-1 signaling on malaria vaccine efficacy and as such may necessitate a paradigm shift in rational malaria vaccine design.

Evaporative cooling in late gestation heat-stressed Murrah buffaloes increases efficiency of next reproductive cycle

Evaporative cooling during late gestation period improves post-partum reproductive performance in Murrah buffaloes. To prove this hypothesis, sixteen pregnant dry Murrah buffaloes at sixty days pre-partum were selected and divided into two groups of eight animals each. Group 1 of buffaloes (Cooled/CL) was managed under fan and mist cooling during dry period, whereas second group of buffaloes (non-cooled/NCL) remained without the provision of cooling. After parturition, all the animals were managed under evaporative cooling till the end of experimental period. Reproductive performance in cooled (CL) and non-cooled (NCL) groups, respectively, viz. 1st and 2nd ovulation from calving (48.63 ± 2.41, 69.25 ± 2.34 days and 57.75 ± 3.35, 93.63 ± 2.84 days); calving to conception interval (117.88 ± 4.21 days and 117.88± 4.21 days); conception rate (87.5% ± 2.16% and 57% ± 2.26%); and follicular diameter at the time of 1st and 2nd ovulation (14.84 ± 0.16, 15.75 ± 0.13 mm and 12.65 ± 0.13, 13.35 ± 0.11 mm) varied significantly (p < .05). Total peak oestrogen concentration was significantly (p < .05) higher in cooled (26.7 ± 1.32 pg/ml) relative to non-cooled (20.7 ± 1.22 pg/ml) buffaloes. Time from onset of oestrus to ovulation varied significantly (p < .05) in cooled (32 ± 2.22 hr) and non-cooled (40 ± 2.86 hr) buffaloes. The peak progesterone concentration reached to (4.25 ng/ml) in cooled group and (4.16 ng/ml) in non-cooled group after first ovulation.

Size of metastatic deposits affects prognosis in patients undergoing pulmonary metastectomy for colorectal cancer

INTRODUCTION

Pulmonary metastectomy for colorectal cancer (CRC) is a well accepted procedure although data regarding indications and prognostic outcomes are inconsistent. This study aimed to analyse our experience with resection of pulmonary CRC metastases to evaluate clinically relevant prognostic factors affecting survival.

METHODS

A retrospective analysis was undertaken of the records of all patients with pulmonary metastases from CRC who underwent a thoracotomy between 2004 and 2010 at a single surgical centre.

RESULTS

Sixty-six patients with pulmonary metastases from the colon (n=34) and the rectum (n=32) were identified. The 30-day hospital mortality rate was 0%, with 63 patients undergoing a R0 resection and 3 having a R1 resection. The median survival was 45 months and the cumulative 3-year survival rate was 61%. Size of pulmonary metastasis and ASA (American Society of Anesthesiologists) grade were statistically significant prognostic factors (p=0.047 and p=0.009 respectively) with lesions over 20mm associated with a worse prognosis. Sex, age, site, disease free interval (cut-off 36 months), primary tumour stage, hepatic metastases, number of metastases (solitary vs multiple), type of operation (wedge vs lobe resection), hilar lymph node involvement and administration of adjuvant chemotherapy were not found to be statistically significant prognostic factors.

CONCLUSIONS

Pulmonary metastectomy has a potential survival benefit for patients with metastatic CRC. Improved survival even in the presence of hepatic metastases or multiple pulmonary lesions justifies aggressive surgical management in carefully selected patients. In our cohort, size of metastatic deposit was a statistically significant poor prognostic factor.

C-reactive Protein as a Predictor of Adverse outcome in Patients with Acute Coronary Syndrome

Background and Objectives:

The acute-phase reactant C-reactive protein (CRP) has been shown to reflect systemic and vascular inflammation and to predict future cardiovascular events. The objective of this study was to evaluate the prognostic value of CRP in predicting cardiovascular outcome in patients presenting with acute coronary syndromes.

Patients and Methods:

This prospective, single-centered study was carried out by the Department of Pathology in collaboration with the Department of Cardiology, Bolan Medical College Complex Quetta, Balochistan, Pakistan from January 2009 to December 2009. We studied 963 consecutive patients presenting with chest pain to Accident and Emergency Department. Patients were divided into four groups. Group-1 comprised patients with unstable angina; group-2 included patients with acute ST elevation myocardial infarction (STEMI); group-3 comprised patients with Non-ST elevation myocardial infarction (Non-STEMI) and group-4 was the control group. All four groups were followed-up for 90 days for occurrence of cardiovascular events.

Results:

The CRP was elevated (>3 mg/L) among 27.6% patients in Group-1; 70.9% in group- 2; 77.9% in group-3 and 5.3% in the control group. Among cases with elevated CRP, 92.1% had a cardiac event compared to 34.3% among patients with CRP £3 mg/L (P < 0.0001). The mortality was significantly higher (P < 0.0001) in group-2 (8.9%) and group-3 (11.9%) as compared to group-1 (2.1%). There was no cardiac event or mortality in Group-4.

Conclusions:

Elevated CRP is a predictor of adverse outcome in patients with acute coronary syndromes and helps in identifying patients who may be at risk of cardiovascular complications.

Dissatisfaction with Do Not Attempt Resuscitation Orders: A nationwide study of Irish consultant physician practices

The legal/ethical status of Do Not Attempt Resuscitation (DNAR) orders in Ireland has not been clarified, nor have national policies been formulated. We questioned 298 consultant physicians in the Republic of Ireland about DNAR orders. 173 replies were received (58%). 85 expressed unsatisfactory understanding of issues relating to Irish DNAR orders (49%). 116 physicians felt that alert patients preferred not to discuss their own resuscitation (67%). 55 physicians felt that if a competent adult patient is the subject of a DNAR order without the patient's knowledge, the reasons for this decision are "almost never" documented in the patient's medical record (32%). 75 consultants "almost never" had advance discussion of resuscitation preferences with the patient (43%). 47 physicians had experienced advance directives for Irish patients (27%). 102 physicians felt that both they and the patient's next of kin had joint responsibility for deciding resuscitation status for an incapacitated patient with no advance directive (59%). 37 respondents described a formal resuscitation policy in their place of work (21%). We feel that physicians require greater national guidance regarding DNAR order-making, and we advocate more widespread use of resuscitation policies.

Aminoglycoside and vancomycin serum concentration monitoring and mortality due to neonatal sepsis in Saudi Arabia

OBJECTIVE

To assess the effectiveness of monitoring of serum concentration of aminoglycosides in neonates.

METHOD

A retrospective evaluation of serum concentration monitoring of aminoglycosides (gentamicin and amikacin) and vancomycin in neonates treated for sepsis in a maternity and children hospital in Jeddah, Saudi Arabia, over the period 1998-2000.

RESULTS

The total number of requests for monitoring increased sixfold in 1999 and 12-fold in 2000 relative to 1998. For aminoglycosides, the incidence of both subtherapeutic peak and toxic trough serum levels decreased significantly (P < 0.05) in 1999 and 2000 compared with 1998. Furthermore, the rate of neonatal mortality caused by sepsis showed reduction in both 1999 (34%) and 2000 (35%) in comparison with 1998 (45%). Vancomycin trough (effective) concentration monitoring revealed no change in the incidence (30%) of levels at subtherapeutic values (<5.0 microg/mL) between the compared years. Furthermore, the rate of toxic levels (>10 microg/mL) increased in both 1999 (31%) and 2000 (39%) relative to 1998 (25%).

CONCLUSION

Therapeutic drug monitoring of vancomycin needs re-evaluation in the hospital to explain why existing methods are ineffective.

Vestibular schwannomas: clinical presentation, management and outcome

OBJECTIVE

To review the demographic trends clinical spectrum, diagnosis, management and out come of patients with vestibular Schwannoma and to identify areas where improvements are needed.

METHODS

All patients with vestibular schwannoma admitted to the Aga Khan University Hospital over the past 11 years were reviewed retrospectively.

RESULTS

The age range of majority of 22 patients analyzed, was 41-50 years (23%). Hearing loss was the most common presenting symptom (96%). Other clinical features included cranial nerve palsies (59%) and headache (55%). Fifty percent had signs of raised intracranial pressure. Neuroimaging revealed "Stage IV b" (tumor distorting the brainstem and compressing the 4th ventricle) in 50% cases. Neurosurgical intervention was carried out in 86%; mainly using the retrosigmoid approach. Postoperative complications included facial nerve palsy in 13 (65%) and hydrocephalus in 5 (25%) patients. Hearing determined clinically was preserved in three patients (14%). One patient died during the inpatient stay.

CONCLUSION

Presentation of these patients is late and the outcome is poor.

Clinical spectrum of systemic lupus erythematosus at the Aga Khan University Hospital

BACKGROUND

Systemic lupus erythematosus is a disease of unknown etiology, which at onest may involve only one organ system or be multisystemic. The aim of our study is to determine the clinical presentation of SLE patients presenting to AKUH to establish whether guidelines laid down about this disease are in agreement with our experience.

METHODS

A retrospective log review was carried out at AKUH, based on data obtained from 165 files of individuals admitted to the hospital over a period of 12 years with a confirmed diagnosis of SLE.

RESULTS

From the sample size of 165, 143 (86.7%) were females and 22 (13.3%) males. The mean age of diagnosis was 30.9 years. Frequency of symptomatology was observed to be in the following order: systemic 78.8%, musculoskeletal 63% and hematological 60.6%. Oninvestigation ANA levels were positive in 112 patients.

CONCLUSION

Our result lead us to conclude that the classification set forth by the American Rheumatological Association is applicable to patients presenting with SLE in our setting.

'Near PVS': a new medico-legal syndrome?

This paper addresses the current medico-legal issues surrounding PVS (Permanent Vegetative State), including: the lack of a unified definition of the acronym PVS, the varying criteria for diagnosis of PVS, and the issue of patients who maintain a minimal degree of consciousness and cannot be categorized as PVS patients. First, we analyse the differing medical definitions and criteria for diagnosis in vegetative conditions. We also ask what part 'consciousness' plays in treatment decisions made by the family, the healthcare team, and the courts, by analysing a unique Irish case of a patient in a state deemed by the courts as 'near PVS'. The paper demonstrates that there is now a legal dichotomy in vegetative patients. However, the manner in which the court treated these patients is the same. Underlying this discussion we hope to demonstrate how medical practice is subject to legal decisions and thus the importance of establishing uniform medical guidelines to assist the non-medical professional.

Limited ovarian stimulation results in the recovery of mature oocytes in polycystic ovarian disease patients: a preliminary report

This pilot study including five patients, examined the feasibility of obtaining oocytes from partially stimulated ovarian follicles in patients with polycystic ovarian disease (PCOD). We evaluated oocyte maturity, and fertilization potentials. The diagnosis of PCOD was based on ultrasound findings and endocrine criteria. The long protocol of pituitary ovarian axis down-regulation was used and follicles were stimulated with daily injections of human menopausal gonadotropin (HMG), until the mean diameter of the leading follicle reached 12 mm. A full dose of HCG (10000 I.U.) was administered and oocytes were collected 36 h later. The mean number of oocytes collected per patient was 12.6+/-4.9, the mean number of MII oocytes was 8.8+/-4.4, with fertilization rate of 70.5% following intracytoplasmic sperm injection (ICSI). To our knowledge this is the first report in the literature documenting the recovery of mature oocytes following limited stimulation of the ovaries. The potentials of this novel approach open a new dimension in the management of patients with PCOD.

Cerebral effects of resuscitation with hypertonic saline and a new low-sodium hypertonic fluid in hemorrhagic shock and head injury

OBJECTIVES

A 2400-mOsm/L hypertonic solution (isosal) with a lower sodium content, compared with conventional 7.5% hypertonic saline, was formulated using a mixture of sodium chloride, glucose, and mixed amino acids. This solution was developed to minimize hypernatremia during resuscitation. We assessed the effects of isosal on hemodynamics, brain edema, and plasma sodium concentration after head injury associated with hemorrhagic shock. DESIGN. Prospective, randomized laboratory study.

SETTING

University research laboratory.

SUBJECTS

Twenty-one adult female Suffolk sheep, weighing 39 to 49 kg.

INTERVENTIONS

Animals were subjected to a 2-hr period of hemorrhagic shock to a mean arterial pressure (MAP) of 40 to 45 mm Hg in the presence of a freeze injury to the cerebral cortex. The hemorrhagic shock/head injury phase was followed by 2 hrs of resuscitation with isosal, a new 2400-mosm/L low-sodium hypertonic fluid, 2400 mosm/L of 7.5% hypertonic saline, or lactated Ringer's solution. Initial resuscitation was with a bolus injection of 8 mL/kg of the study solution; subsequent resuscitation in all three groups was with lactated Ringer's solution as needed to maintain baseline cardiac output.

MEASUREMENTS AND MAIN RESULTS

Serial hemodynamics, intracranial pressure, electrolytes, and osmolarity were measured. AT the end of resuscitation, the animals were killed and brain water content (mL H2O/g dry weight) of the injured and uninjured areas was determined. Resuscitation volumes were significantly lower in the isosal (19 +/- 5 mL/kg) and 7.5% hypertonic saline (14 +/- 2 mL/mg) groups compared with the lactated Ringer's solution (35 +/- 5 mL/kg) group. Intracranial pressure after 2 hrs of resuscitation was significantly lower in the isosal (7 +/- 1 mm Hg) and hypertonic saline groups (4 +/- 1 mm Hg). Water content in all areas of the brain was significantly lower in the hypertonic saline group compared with the lactated Ringer's solution group. Brain water content in the isosal group was lower than in the lactated Ringer's solution group only in the cerebellum. Plasma sodium content was lower in the isosal group than in the hypertonic saline group.

CONCLUSIONS

After combined head injury and shock, isosal and 7.5% hypertonic saline have similar effects on hemodynamics and intracranial pressure. Hypertonic saline induces a greater degree of brain dehydration; isosal resuscitation results in smaller increases in plasma sodium.

Intraosseous resuscitation of hemorrhagic shock in a pediatric animal model using a low sodium hypertonic fluid

OBJECTIVE

To study the efficacy of a low sodium hypertonic resuscitation fluid for resuscitation of severe hemorrhage in a pediatric animal, using the intraosseous route.

DESIGN

Prospective, randomized, controlled animal study.

SETTING

University physiology laboratory.

SUBJECTS

Seventeen immature (6- to 9-wk-old) piglets, weighing 10.6 +/- 0.4 kg, were studied under anesthesia.

INTERVENTIONS

A new 2400 mosm/L hypertonic fluid, "Isosal" was formulated with reduced (3.45%) sodium content compared with a 2400-mosm/L (7.5%) hypertonic saline solution. This formulation was accomplished by substituting glucose and mixed amino acids for sodium. Piglets were subjected to 1 hr of hemorrhage, reducing the cardiac output to 50% of baseline value. Resuscitation was carried out through the intraosseous route with an initial 6 mL/kg bolus of either hypertonic saline, Isosal, or lactated Ringer's solution. After the initial bolus, additional test fluid was given to maintain the cardiac output at baseline value for a 2-hr period.

MEASUREMENTS AND MAIN RESULTS

Total resuscitation volumes, hemodynamic variables, and electrolytes were measured. Intraosseous vascular access was easily established in all animals, and fluid resuscitation was carried out effectively through this route. Resuscitation volumes were significantly lower for both of the hypertonic fluids (12.7 +/- 1.2 mL/kg for hypertonic saline, and 12.5 +/- 1.7 mL/kg for Isosal solution) compared with lactated Ringer's solution (75.3 +/- 11.6 mL/kg) (p = .01). Both hypertonic saline and Isosal solution resulted in an immediate supranormal response in cardiac output that lasted 20 mins. In contrast, when lactated Ringer's solution was used, multiple boluses were required over a 20-min period to normalize cardiac output. Serum sodium was significantly higher in the hypertonic saline group compared with the Isosal or lactated Ringer's groups (p = .001).

CONCLUSIONS

Isosal solution was as effective as hypertonic saline in "small volume" resuscitation of severe hemorrhagic shock in a pediatric animal model through the intraosseous route, and produced significantly less hypernatremia when compared with hypertonic saline.

Medical management of extensive spinal epidural hematoma in a child with factor IX deficiency

We report an unusual case of extensive spinal epidural hematoma in a seven-year-old male with severe factor IX deficiency. Despite evidence of extensive spinal epidural hematoma on the magnetic resonance imaging scan, aggressive replacement therapy resulted in complete neurologic recovery without the need for surgical decompression. This case also points to the usefulness of serial magnetic resonance imaging scans to monitor progress of the disease.

Emergency department thoracotomy in children: rationale for selective application

Although emergency department (ED) thoracotomy is performed only in selected adult trauma victims, it continues to be widely used in children. To evaluate if use of this liberal policy is justified in children, the charts of 23 pediatric trauma victims who underwent ED thoracotomy at our institution in the past 5 years were reviewed. Mechanism of injury was blunt trauma in 65% and penetrating injury in 35%. Optimal field care was provided, with the majority (74%) of these patients having had intubation and vascular access achieved in the field and transported within 10 minutes to the trauma center. Thoracotomy and open cardiac massage were performed within 5 minutes of arrival in the ED. Despite this aggressive management, only one child (4.4%) survived to discharge, although transient restoration of spontaneous circulation (RSC) was achieved in four (17.4%) children. There were no survivors in the blunt trauma group. All patients with penetrating trauma who had no vital signs in the field died. The cost of ED thoracotomy was $2,740 +/- $214; however, the total hospitalization charges per patient averaged $14,848 +/- $1,724. Forty-six percent of total charges were reimbursed, and financial loss to the hospital per patient was $6,448 +/- $1,441. This study demonstrates that children who arrive at the ED following blunt or penetrating trauma with no cardiac rhythm are unsalvageable and should not undergo ED thoracotomy. The burden of unreimbursed care for this procedure is not trivial. Indications for ED thoracotomy in pediatric trauma victims should therefore be the same as those currently used for adult trauma victims.

Short-term treatment of phobia through eidetic imagery

This paper presents a relatively new approach to the treatment of phobia. The technique is based on the special attributes of eidetic images. A discussion of relevant eidetic concepts and eidetic methodology is followed by two case histories that illustrate the therapeutic use of eidetic imagery.

Use of mental imagery in psychotherapy: a critical review

The paper presents arguments in favor of the use of mental imagery for therapeutic purposes. Several existing imagery approaches to psychotherapy are critically examined and suggestions for future inquiry are offered. The intimate relation between imagery and the affective-somatic processes is stressed.