Fellow Designations of Interest to Nurse Leaders.

Achieving fellow designation is commonly a career goal for nurse leaders. The path to achievement can be confusing, and once a goal is set, choosing the right designation is important. This column outlines the background of fellow designation, clarifies differences between fellow designation and other career advancement options, and presents ideas for consideration by nurse leaders as they pursue career advancement through fellow designation.

The Scope of Hospital-Based Simulation.

BACKGROUND: Healthcare simulation has expanded dramatically; however, little is known about the scope of simulation in acute care hospitals. METHODS: A descriptive, cross-sectional online survey was used. Participants included nurse executives from acute care hospitals in California. RESULTS: Most organizations (96%) used simulation primarily for education, 37% used simulation for health system integration and systems testing, 30% used it for error investigation, 15% used it for research, and 15% used it for patient/family education. CONCLUSIONS: Organizations have a substantial opportunity to increase the scope of simulation beyond education to include systems integration, clinical systems testing, and other translational simulation activities. This targeted focus on patient safety and quality will allow hospitals to improve financial performance and maximize scarce resources.

Simulation as a Nursing Education Disrupter.

Simulation as an evidence-based pedagogy began emerging at a time when many constraints were being imposed on clinical experiences for nursing students. As research illuminated the advantages of simulation and standards were developed, educators began to recognize the limitations of the clinical setting, such as the inability to provide experiences in teamwork and delegation, and a focus on tasks. Simulations are crafted to provide an experience that matches content that is being taught in class, and debriefing techniques guide learners in a reflective process that promotes the development of clinical reasoning and judgment. The National Council of State Boards of Nursing study concluded that simulation could be substituted for 50% of clinical hours. Simulation-exposed gaps in the curriculum and its pedagogical principles are now extending to adaptations of its use in the classroom and in clinical postconferences. They are also shaping teacher-student conversations in the office and the hallways. Use of simulation for assessment is beginning to evolve. In a little more than 10 years, it has started a revolution that will continue to have a major impact on all aspects of nursing education in the future.

Exploring Faculty Perceptions about Simulation Training: Influence on Career, Confidence, Knowledge and Skill Acquisition and Competence.

Even with insufficient evidence in the literature regarding the impact of faculty development with simulation education, faculty development is critical to building a successful simulation program. Despite simulation being ubiquitous in nursing education across the United States (US), there is little investigation of the impact of the education and training on job satisfaction, skill development and overall confidence when using simulation to teach nursing students. The purpose of this qualitative study was to investigate how has simulation education and training has influenced faculty career fulfillment, acquisition of knowledge, overall self-confidence and competence? Themes that emerged included the following: competency, professional role change, role acquisition, course learner needs, course impact, skill development, and overall ability and confidence. The study results confirmed that a gap exists where faculty without formal education may not be aware of their lack of competence and what training they need to be effective in facilitating clinical simulation.

Efficacy and Stability of Integrating Fungicide and Cultivar Resistance to Manage Fusarium Head Blight and Deoxynivalenol in Wheat.

Integration of host resistance and prothioconazole + tebuconazole fungicide application at anthesis to manage Fusarium head blight (FHB) and deoxynivalenol (DON) in wheat was evaluated using data from over 40 trials in 12 U.S. states. Means of FHB index (index) and DON from up to six resistance class-fungicide management combinations per trial (susceptible treated [S_TR] and untreated [S_UT]; moderately susceptible treated [MS_TR] and untreated [MS_UT]; moderately resistant treated [MR_TR] and untreated [MR_UT]) were used in multivariate meta-analyses, and mean log response ratios across trials were estimated and transformed to estimate mean percent control ( ) due to the management combinations relative to S_UT. All combinations led to a significant reduction in index and DON (P < 0.001). MR_TR was the most effective combination, with a of 76% for index and 71% for DON, followed by MS_TR (71 and 58%, respectively), MR_UT (54 and 51%, respectively), S_TR (53 and 39%, respectively), and MS_UT (43 and 30%, respectively). Calculations based on the principle of treatment independence showed that the combination of fungicide application and resistance was additive in terms of percent control for index and DON. Management combinations were ranked based on percent control relative to S_UT within each trial, and nonparametric analyses were performed to determine management combination stability across environments (trials) using the Kendall coefficient of concordance (W). There was a significant concordance of management combinations for both index and DON (P < 0.001), indicating a nonrandom ranking across environments and relatively low variability in the within-environment ranking of management combinations. MR_TR had the highest mean rank (best control relative to S_UT) and was one of the most stable management combinations across environments, with low rank stability variance (0.99 for index and 0.67 for DON). MS_UT had the lowest mean rank (poorest control) but was also one of the most stable management combinations. Based on Piepho's nonparametric rank-based variance homogeneity U test, there was an interaction of management combination and environment for index (P = 0.011) but not for DON (P = 0.147), indicating that the rank ordering for index depended somewhat on environment. In conclusion, although the magnitude of percent control will likely vary among environments, integrating a single tebuconazole + prothioconazole application at anthesis with cultivar resistance will be a more effective and stable management practice for both index and DON than either approach used alone.

Where Are We Now? A Follow-up Survey on Regulation of Simulation Use in United States Prelicensure Nursing Programs.

Background: Approval of simulation in substitution of traditional clinical hours increased in nursing programs during the COVID-19 pandemic, yet these temporary and inconsistent between states. Variability and a return to "pre-pandemic" limits on simulation use amplify questions about consistency of learner outcomes. Methods: Boards of Nursing (BONs) of the United States and District of Columbia (DC) were queried to verify accuracy of simulation regulations posted on the International Nursing Association for Clinical Simulation and Learning (INACSL) regulatory map and to identify factors contributing to regulatory changes. Results: Approximately half of respondents indicated information posted on the INACSL regulatory map is accurate for their state. Almost 30% of respondents indicated information is not accurate. Some states could not confirm accuracy of simulation regulations posted. Conclusions: Many nursing programs expanded the use of simulation during the COVID-19 pandemic. Reverting to "prepandemic" limited simulation use presents a missed opportunity to advance nursing education and align simulation regulation with the growing body of evidence supporting its outcomes.

First Report of Anthracnose Caused by Colletotrichum caudatum on Indiangrass in New York.

Indiangrass or yellow indiangrass (Sorghastrum nutans L.) is a warm-season, perennial grass grown for livestock forage, erosion control, wildlife food and cover, landscaping, and more recently, as a biofuel crop. In August of 2007, foliar lesions were observed on plants within mature stands of a number of cultivars and populations of indiangrass at the USDA-NRCS Plant Materials Center in Big Flats (Chemung County), NY. In subsequent years, similar lesions were observed in both mature and immature (less than 3 years old) stands of indiangrass in Chemung and Tompkins counties. Lesions were elliptical to irregular with distinct or diffuse purple margins often surrounded by tan-to-maroon halos and were sometimes observed on the leaf sheath and stem. Lesions were generally less than 2 cm long, approximately 2 mm wide, and often coalesced when disease was severe. Centers became necrotic and often developed numerous acervuli with black setae. After 2 to 5 days of incubation in moist chambers, symptomatic leaf tissue developed acervuli containing masses of cream-colored spores. Spores streaked onto potato dextrose agar containing streptomycin gave rise to cultures with gray mycelium often accompanied by sporulating avervuli. The fungus was identified as Colletotrichum caudatum (Peck ex Sacc.) Peck on the basis of cultural characteristics and conidial morphology (2). Conidia were one celled, hyaline, fusiform, and falcate with a filiform, caudate appendage. Conidial length averaged 28 µm (21 to 45 µm), width averaged 5 µm (4 to 6 µm), and the appendage averaged 15 µm (5 to 29 µm) long. The sequence of the rDNA internal transcribed spacer (ITS) regions of an isolate from 'Rumsey' indiangrass in Chemung County, NY (Cc004NY07, GenBank Accession No. JF437056) exhibited 98% nucleotide identity to C. caudatum isolates (GenBank Accession Nos. AB042304 and AB042305) collected from bentgrass (Agrostis sp. L.) and cogongrass (Imperata cylindrica L.) in Japan (1). Colletotrichum species from grasses are not discriminated solely on ITS sequence, but the unique caudate appendage is diagnostic of C. caudatum. Pathogenicity of the sequenced isolate plus a second isolate from 'Rumsey' indiangrass (Cc006NY07) was evaluated in greenhouse experiments. Eight-week-old plants of indiangrass population 'PA Ecotype' (Ernst Conservation Seeds, Meadville, PA) were inoculated with conidial suspensions (2 × 106 conidia/ml) of C. caudatum. Twelve plants were sprayed with either inoculum or sterile water (as the control treatment) until runoff with a spray bottle. After inoculum had dried, plants were placed in a mist chamber for 48 h. Plants were then returned to the greenhouse and observed for disease development, which occurred within 1 week of inoculation. No symptoms developed on the control plants. Foliar lesions closely resembled those observed in the field. C. caudatum was reisolated consistently from symptomatic tissue collected from greenhouse experiments. To our knowledge, this is the first report of C. caudatum causing anthracnose on indiangrass in New York, though it has been reported in the adjoining states of New Jersey (2) and Pennsylvania (3). Indiangrass cultivars should be assessed for susceptibility to regional isolates of C. caudatum prior to expanded regional production of indiangrass as a biofuel crop. References: (1) J. Moriwaki et al. J. Gen. Plant Pathol. 68:307, 2002. (2) T. R. Nag Raj. Can. J. Bot. 51:2463, 1973. (3) K. E. Zeiders. Plant Dis. 71:348, 1987.

First Report of a Leaf Spot Caused by Bipolaris oryzae on Switchgrass in New York.

Switchgrass (Panicum virgatum L.) is a perennial grass with biofuel potential. From 2007 to 2010, foliar lesions were observed on first year and mature stands of switchgrass in various locations in New York. Foliar lesions were purple, elliptical (up to 1 cm) with either distinct or diffuse margins, and occasionally with yellow halos and/or white necrotic centers. After 2 to 5 days of moist chamber incubation, surface-sterilized, symptomatic leaf tissue produced conidia that when streaked onto potato dextrose agar containing 0.3 g of streptomycin per liter gave rise to cultures with gray-to-black mycelium that developed brown conidia. The fungus was identified as Bipolaris oryzae (Breda de Haan) Shoemaker on the basis of conidial morphology (1,2). Conidiophores were brown, straight, cylindrical, and multiseptate. Conidia were brown, curved, ellipsoidal tapering to rounded ends, with 3 to 14 septa. Conidia averaged 105 µm (54 to 160 µm) long and 16 µm (12 to 20 µm) wide. Sequences of the glyceraldehyde-3-phosphate dehydrogenase (GDP) gene of three isolates from Tompkins County (Cornell Accession and corresponding GenBank Nos.: Bo005NY07 [cv. Cave-in-Rock], JF521648; Bo006NY07 [cv. Kanlow], JF521649; and Bo038NY07 [cv. Shawnee], JF521650) exhibited 100% nucleotide identity to B. oryzae isolates (GenBank Nos. AY277282-AY277285) collected from switchgrass in North Dakota (1). Sequences of the rDNA internal transcribed spacer (ITS) regions of the isolates (Cornell Accession and corresponding GenBank Nos.: Bo005NY07, JF693908; Bo006NY07, JF693909; and Bo038NY07, JF693910) exhibited 100% nucleotide identity to B. oryzae isolates (GenBank Nos. GU222690-GU222693) collected from switchgrass in Mississippi (3). Pathogenicity of two of the sequenced isolates (Bo006NY07 and Bo038NY07) along with one other isolate (Bo116NY09 from 'Cave-in-Rock' in Cayuga County) was evaluated in the greenhouse. Six- to eight-week-old switchgrass plants were inoculated with conidial suspensions (40,000 conidia/ml) of B. oryzae. Inoculum or sterilized water was applied until runoff. There were three plants per treatment of each of 'Blackwell', 'Carthage', 'Cave-in-Rock', 'Kanlow', 'Shawnee', 'Shelter', and 'Sunburst'. After inoculum had dried, plants were placed in a mist chamber for 24 h and then returned to the greenhouse. Symptoms developed 2 to 4 days after inoculation for all cultivars. No symptoms developed on the control plants. Foliar lesions closely resembled those observed in the field. B. oryzae was consistently reisolated from symptomatic tissue collected from greenhouse experiments. B. oryzae was first reported as a pathogen of switchgrass in North Dakota (1) and more recently in Mississippi (3). To our knowledge, this is the first report of B. oryzae causing a leaf spot on switchgrass in New York. Observation of severe leaf spot in several field plots suggests that switchgrass populations should be screened for their reaction to regional isolates of B. oryzae prior to expanded production of switchgrass as a biofuel crop. References: (1) J. M. Krupinsky et al. Can. J. Plant Pathol. 26:371 2004. (2) R. A. Shoemaker. Can. J. Bot. 37:883, 1959. (3) M. Tomaso-Peterson and C. J. Balbalian. Plant Dis. 94:643 2010.

First Report of Anthracnose Caused by Colletotrichum navitas on Switchgrass in New York.

Switchgrass (Panicum virgatum L.) is a perennial grass with significant potential as a biofuel crop. From 2007 to 2010, foliar lesions were observed in new and mature stands of switchgrass in various locations in New York. Lesions were elliptical with purple margins and white necrotic centers, generally <3 cm long, ~1 mm wide, often coalesced, and containing black setae. Upon incubation, symptomatic leaf tissue developed acervuli with masses of salmon-colored spores. The fungus was identified as Colletotrichum nativas Crouch on the basis of typical cultural characteristics and conidial morphology (1). Conidia were one-celled, hyaline, fusiform, and generally falcate. Conidial length averaged 40 µm (22 to 47 µm) and width averaged 5 µm (4 to 7 µm). Compared with other graminicolous species of Colletotrichum, the conidia were larger and varied from straight to irregularly bent. Sequences of the rDNA internal transcribed spacer (ITS) regions of three isolates (Cornell accession and corresponding GenBank Nos.: Cn071NY08 (from a >20-year-old naturalized stand of switchgrass in Steuben County), JF437053; Cn080NY08 (from 'Pathfinder' in Chemung County), JF437054; and Cn101NY09 (from 'Blackwell' in Chemung County), JF437055) exhibited 100% nucleotide identity to the type isolate of C. nativas (GenBank No. GQ919068) collected from switchgrass selection 'Brooklyn' in New Jersey (1). Pathogenicity of the sequenced isolates along with seven other isolates (Cn105NY09 from 'Sunburst' in Tompkins County; Cn107NY09 from 'Trailblazer' in Tompkins County; Cn109NY09 from 'Forestburg' in Tompkins County; Cn111NY09 and Cn112NY09 from 'Shelter' in Tompkins County; and Cn122NY09 and Cn123NY09 from 'Cave-in-Rock' in Genesee County) was evaluated in greenhouse experiments. Seven- to eight-week-old switchgrass plants were inoculated with conidial suspensions (1 × 106 conidia/ml) of C. nativas. Inoculum or sterilized water was sprayed until runoff. Three plants of each of 'Cave-in-Rock' and 'Kanlow' were sprayed per treatment and the experiment was repeated for 3 of the 10 isolates. Inoculated plants were placed in a mist chamber for 48 h before they were returned to the greenhouse and observed for disease development, which occurred within 1 week of inoculation for both cultivars. No symptoms developed on the control plants. Foliar lesions closely resembled those observed in the field. C. nativas was consistently reisolated from symptomatic tissue collected from greenhouse experiments. Switchgrass anthracnose associated with C. graminicola sensu lata has been reported in many U.S. states (2). On the basis of molecular phylogenetics and distinguishing morphological characters, Crouch et al. erected C. navitas as a novel species distinct from C. graminicola sensu stricto, a taxon restricted to the corn anthracnose pathogen (1). C. nativas was first documented on switchgrass in New Jersey (1) and appears to be the same pathogen causing anthracnose of switchgrass in the adjoining state of Pennsylvania (1,3). To our knowledge, this is the first report of C. nativas causing anthracnose of switchgrass in New York. References: (1) J. A. Crouch et al. Mycol. Res. 113:1411, 2009. (2) D. F. Farr and A. Y. Rossman. Fungal Databases, Systematic Mycology and Microbiology Laboratory, ARS, USDA. Retrieved from http://nt.ars-grin.gov/fungaldatabases/ , May 5, 2011. (3) M. A. Sanderson et al. Agron. J. 100:510, 2008.

The Importance and Impact of Nurse Leader Engagement With State Nursing Workforce Centers: Lessons From the COVID-19 Pandemic.

The COVID-19 pandemic caused unparalleled morbidity and mortality across the globe. Health care agencies, public health departments, and academic institutions experienced widespread disruption to usual operations. These events had an adverse impact on the nursing workforce. Nurse leaders in California rallied to identify and remediate the effects of COVID-19 on the nursing workforce. This article describes the strategy and interventions. Nurse leaders should invest resources in state workforce centers to ensure the health and supply of a strong nursing workforce.

The development of evidence-based clinical simulation scenarios: guidelines for nurse educators.

Clinical simulation has been recognized as a teaching method using learning exercises that closely mimic real-life situations. The development of evidence-based clinical simulation scenarios and guidelines for nurses is an important step in redesigning nursing education. These scenarios are created for students to learn in a safe environment. Simulated clinical experience requires immersing students in a representative patient-care scenario, a setting that mimics the actual environment with sufficient realism to allow learners to suspend disbelief. The purpose of this article is to discuss the Bay Area Simulation Collaborative's development of guidelines for effective evidence-based scenarios for use in hospitals and nursing schools. Six scholarly articles were reviewed and evaluated to determine whether evidence-based guidelines for scenario development exist and whether consensus in the literature regarding best practice is evident.

The doctor of nursing practice degree: my journey.

The Doctor of Nursing Practice (DNP) degree is a new terminal degree for nursing. This article reviews the essentials of the DNP degree as published by the American Association of Colleges of Nursing and describes the author's personal journey toward completion of the DNP degree in December 2008.

Diagnostic procedures for catheter malfunction in programmable implantable intraperitoneal insulin infusion devices.

OBJECTIVE: To evaluate the roles of 1) abdominal radiography, 2) a pressure diagnostic procedure (PDP) using a standardized diluent infusion into the catheter sideport, and 3) radiocontrast imaging of the catheter lumen as procedures for diagnosing catheter malfunction in diabetic patients implanted with a programmable intraperitoneal infusion device. RESEARCH DESIGN AND METHODS: Sixteen type I diabetic patients implanted with Infusaid programmable intraperitoneal insulin pumps were studied. The ability of the above three procedures to assist diagnosis of catheter malfunction and distinguish between occlusion and catheter breakage was retrospectively analyzed. Glycated hemoglobin was measured to determine the clinical importance of catheter malfunctions and decreases in pump flow due to insulin aggregation in the pump chamber. RESULTS: Mean glycated hemoglobin levels increased significantly from 8.0 +/- 0.3 to 9.0 +/- 0.4% (P < 0.05) before and after catheter malfunction, but not during pump flow slowdowns. Mean peak pressure during PDP was 1.96 +/- 0.14 psi (P < 0.01 vs. normal) in reversibly occluded catheters and 1.86 +/- 0.35 psi (P < 0.05 vs. normal) in broken catheters, compared with 1.32 +/- 0.23 psi in normal catheters. Decay times during PDP were > 50 s for both reversibly occluded and broken catheters (P < 0.001 vs. normal of 3.6 +/- 0.82 s). Abdominal radiographs and sideport injections of contrast material were used to distinguish the types of broken catheters. CONCLUSIONS: Catheter breakage and occlusion are complications in implantable insulin infusion systems and result in metabolic deterioration. The presence of a sideport allows pressure data and radiographic procedures to assist in determining the cause of catheter malfunction. A diagnostic algorithm was generated to improve efficiency in investigating catheter problems.

Randomized comparison of metabolic control achieved by intraperitoneal insulin infusion with implantable pumps versus intensive subcutaneous insulin therapy in type I diabetic patients.

OBJECTIVE: To compare intraperitoneal implantable insulin infusion (IP) to subcutaneous (SC) intensive insulin therapy. RESEARCH DESIGN AND METHODS: Twenty-one insulin-dependent (type I) diabetic patients aged 24-61 yr underwent a 3-mo treatment optimization using multiple SC daily injections or external pumps. Patients were then randomized (time 0 mo) to IP infusion using Infusaid-programmable pumps or continuation on SC intensive insulin for 6 mo. RESULTS: No differences were noted between study and control group data. However, longitudinal within-group comparisons from baseline showed that glycosylated hemoglobin improved to near-normal in both groups: IP, 9.0 +/- 0.5 vs. 7.8 +/- 0.6% (P less than 0.05) and SC, 8.4 +/- 0.5 vs. 7.5 +/- 0.3% (P less than 0.5) at 0 and 4 mo, respectively (normal less than 6.9%). The percentage of blood glucose tests greater than 11 mM at 0 and 6 mo was 28 +/- 5 vs. 16 +/- 4% in the IP group (P less than 0.05) and 22 +/- 5 vs. 24 +/- 7% in the SC group (NS). At 0 and 6 mo, the standard deviation of blood glucose values, an index of glycemic fluctuations, was 4.3 +/- 0.4 vs. 3.2 +/- 0.5 mM in the IP group (P less than 0.05) and 3.7 +/- 0.3 vs. 4.0 +/- 0.4 mM in the SC group (NS). Weight, insulin dosages, circulating lipid levels, and the frequency of severe hypoglycemic reactions and biochemical hypoglycemias were similar and did not change in the two groups. CONCLUSIONS: IP-implantable pumps compared with SC intensive insulin therapy have similar effects on most metabolic variables and are equally effective at achieving near-normal glycemic levels. Only longitudinal data suggest that IP treatment may be more effective at limiting glycemic fluctuations.

Insulin antibody responses after long-term intraperitoneal insulin administration via implantable programmable insulin delivery systems.

OBJECTIVE: To determine whether insulin antibodies are generated in diabetic patients after short- and long-term intraperitoneal insulin use and, if so, whether they are of potential clinical interest. Insulin antibodies commonly develop in diabetic patients who use subcutaneous human insulin, although their clinical significance remains controversial. Few data are available regarding insulin antibody responses to intraperitoneal insulin. RESEARCH DESIGN AND METHODS: We studied insulin antibody levels and clinical diabetes control in 25 type 1 diabetic patients treated for 3-6 years with intraperitoneal surfactant-stabilized porcine modified human insulin delivered by implantable programmable insulin delivery systems. RESULTS: All patients had preimplantation insulin antibody levels < 20 microU/ml, with a mean value of 2 +/- 2 microU/ml (1 SD). Mean antibody levels increased throughout the study period to a mean maximum of 197 +/- 326 microU/ml (P < 0.02) with 11 of 25 (44%) patients' levels exceeding 20 microU/ml (insulin responders). The mean time to significant antibody development was 21.8 +/- 4.4 months. Of the 11 responder patients, 4 had clinical syndromes that consisted of increasing daily insulin requirements and/or nocturnal hypoglycemia despite minimal nighttime basal insulin infusion rates associated with peak antibody levels > 200 microU/ml. None of the nonresponder patients (antibody levels < 20 microU/ml) had these clinical findings. CONCLUSIONS: Our results indicate that insulin antibody levels observed during intraperitoneal administration of human insulin are 1) similar to those reported during subcutaneous administration; although the rise in antibody level may be delayed compared with subcutaneous human insulin, 2) associated with a patient subset who are insulin antibody responders after switching from subcutaneous to intraperitoneal human insulin, 3) associated with a decrease in levels among responder patients regardless of whether they discontinue or continue pump use, and 4) associated with increased insulin needs and/or nocturnal hypoglycemia despite minimal basal rate insulin infusion at nighttime when antibody levels exceed 200 microU/ml.

Prospective trial of supranormal values of survivors as therapeutic goals in high-risk surgical patients.

Survivors of high-risk surgical operations were previously observed to have significantly higher mean CI, DO2, and VO2 than nonsurvivors. The hypothesis was proposed that increased CI and DO2 are circulatory compensations for increased postoperative metabolism. We tested this hypothesis in two series. In series 1, prospectively allocated by services, mortality and morbidity of the control group were significantly greater than those of the protocol group. In series 2, patients who fulfilled previously defined high-risk criteria were preoperatively randomized to one of three monitoring/treatment groups: CVP-control group, PA-control group and PA-protocol group. Postoperative mortalities in the CVP-control and PA-control groups were not statistically significantly different, but PA-protocol group mortality was significantly reduced compared with its control group. The PA-protocol group had reduced complications, duration of hospitalization, duration in ICU, and mechanical ventilation, and reduced costs when the PA catheter was placed preoperatively and used to augment circulatory responses.

Pentoxifylline improves tissue oxygenation after hemorrhagic shock.

This randomized and blinded study was performed to determine whether pentoxifylline significantly improves tissue oxygenation after hemorrhagic shock. Hepatic surface oxygen tension was measured in anesthetized rats before and after hemorrhage. Rats were then randomly assigned to either a placebo group (n = 21) receiving 1 ml of intravenous saline solution or to a treatment group (n = 23) receiving intravenous 25 mg/kg of pentoxifylline in 1 ml of saline solution. Investigators were blinded as to which solution was injected. Five minutes after injection of pentoxifylline, there was significant increase in hepatic surface oxygen tension; this increase persisted throughout 1 hour of observation and was significantly greater than in placebo-treated animals. Further study of the effects of pentoxifylline on tissue perfusion and oxygenation after hemorrhagic shock is warranted.

Physiologic responses to massive intraoperative hemorrhage.

In five patients who had massive, sudden, intraoperative hemorrhage, defined as loss of more than 1 L of blood in less than ten minutes, mean arterial pressure was initially maintained, and there were early increases in both systemic and pulmonary vascular resistance; however, cardiac output and oxygen delivery decreased. During control of hemorrhage and replacement of blood, wedge pressure and central venous pressure increased, and mean arterial pressure was maintained; however, cardiac output and oxygen delivery decreased, and oxygen consumption decreased below prehemorrhage levels. Three patients died postoperatively of multiple organ failure. The data indicate that anesthesia and operation affect both cardiopulmonary performance and peripheral oxygen transport, such that the ordinary physiologic response to hemorrhage are lessened. The absence of compensatory increase in oxygen consumption after resuscitation may have contributed to the high postoperative mortality.

Is early prediction of outcome in severe head injury possible?

To determine whether the outcome of patients with severe head injury could be predicted early after presentation to the hospital, the records of 306 trauma patients with head injury and Glasgow Coma Scale scores of 10 or less were reviewed. There was poor correlation between initial scores at patient arrival and eventual outcome, while scores 6 hours after presentation correlated better with eventual outcome. Many patients with scores as low as 3 had good neurologic recovery. Patient age, associated injuries, blood pressure, mechanism of injury, presence of spontaneous ventilation, and computed tomographic findings all affected survival. However, considering even these parameters, statistical analysis could not provide sensitive prediction of outcome, which we defined as identifying those patients who eventually had good recovery. We conclude that initial therapy should be aggressive for patients with severe head injury, regardless of initial neurologic status, because accurate prediction of outcome within 6 hours of presentation is impossible.