Multiplate and TEG platelet mapping in a population of severely injured trauma patients.

OBJECTIVES: The objectives of this study were to compare thromboelastography platelet mapping (TEG PM) with impedance aggregometry (Multiplate, MP) in a single trauma population and relate their results clinically. BACKGROUND: Platelet function as measured by thromboelastography and impedance aggregometry demonstrates significant reductions that persist for days following traumatic injury. However, no study compares these devices and the correlation between them is not known. METHODS: In level 1 trauma patients, TEG PM and MP were conducted at their initial presentation to the emergency department. Within-device repeatability and between-device association were determined using correlation analyses. Demographic variables, Injury Severity Score, blood product transfusion, laboratory test results and mortality rate were recorded. RESULTS: Ninety-two patients were enrolled. Within-device repeatability was high for TEG PM and MP for arachidonic acid (AA) and adenosine diphosphate (ADP) activation pathways. When comparing TEG PM with MP, results correlated poorly in the ADP pathway (Spearman's rho = 0·11, P = 0·44) and moderately in the AA pathway (Spearman's rho = 0·56, P < 0·0001). TEG PM was predictive of blood product transfusion and correlated with increased base deficit, whereas MP was only predictive of mortality. CONCLUSIONS: Intra-device variability was low for TEG PM and MP, but the two point-of-care devices measuring platelet function correlate poorly with each other in injured trauma patients. Each device also had different clinical associations.

Synchronous bidirectional endoscopy for iron deficiency anaemia: is it appropriate for patients under 50?

BACKGROUND: UK guidelines1 suggest investigation with bidirectional endoscopy (BDE) (upper endoscopy and colonoscopy) in the same sedative episode is a reasonable approach for the investigation of iron deficiency anaemia. There are few data regarding such investigation for iron deficiency anaemia (IDA) in young men. OBJECTIVE: To assess the use of synchronous BDE for IDA in men and in women <50; and to compare the effectiveness of synchronous BDE in the investigation of iron deficiency anaemia in patients <50 years with those >50 years. METHODS: Our endoscopy database was searched for all synchronous bidirectional endoscopies that were undertaken for the indication of iron deficiency anaemia between 2003 and 2009. Age, gender and endoscopic findings were retrieved for each procedure. Significant findings were defined as cancer, grade 3 oesophagitis (Savory Miller classification), oesophageal stricture, Barrett's oesophagus, ulcer, arteriovenous malformation, colitis, and colonic polyps >1 cm. RESULTS: 558 patients underwent synchronous BDE for iron deficiency anaemia between 2003 and 2009. A significant finding in those >50 years was found in 24.6% vs 11.3% of patients <50 years (OR 2.5, 95% CI 1.3 to 5.0). In men under 50 years a significant finding was present in 20.6%. Dual pathology was present in 1.5% of patients over 50 vs 1.3% under 50 years. CONCLUSIONS: Our findings suggest that synchronous BDE is an appropriate means of investigation for iron deficiency anaemia in patients >50 and for men <50 years old.

Effect of carbon monoxide and high oxygen modified atmosphere packaging and phosphate enhanced, case-ready pork chops.

The objective of this study was to evaluate the effects of CO-MAP compared to traditional high oxygen MAP (HiOx-MAP) packaging and enhanced with different phosphate on enhanced pork quality. Pork loins were enhanced to 10.5% over initial weight to contain 0.3% salt and 0.4% phosphate (either sodium tripolyphosphate [STP] or a blend of STP and sodium hexametaphosphate) on a finished weight basis. Chops were cut, packaged in atmospheres containing 0.4% CO/30.0% CO(2)/69.6% N(2) (CO-MAP) or 80% O(2)/20% CO(2) (HiOx-MAP), aged in the dark, then placed in a lighted retail display case for 48h. Chops packaged in CO-MAP were redder (higher Minolta a(∗) values) and darker (lower Minolta b(∗) values) than chops packaged in HiOx-MAP. Based on sensory scores, the CO-MAP chops were pinker than the HiOx chops after cooking. CO-MAP chops also experienced less purge loss than chops in HiOx-MAP. Results indicate that CO-MAP had no effect on flavor or consumer acceptability and only minimal effects on other characteristics.

Chronic neuropathic pain and its control by drugs.

The medical treatment and some currently known aspects of the aetiology of five neurogenic pain states are discussed. Neurogenic pain can be described as pain resulting from noninflammatory dysfunction of the peripheral or central nervous system without nociceptor stimulation or trauma. The enormity of the field has limited this review to post-herpetic neuralgia, complex regional pain syndromes, phantom pain, trigeminal neuralgia and diabetic neuralgia. Evidence suggests that many neurogenic pain states are not effectively controlled. This may be due in part to a lack of understanding of the aetiology of these conditions and to the lack of high quality studies evaluating existing treatments. A compact review of the literature is presented with some treatment options and possible future directions. Where appropriate surgical management and physical therapy have been discussed; however, a thorough appraisal of nondrug treatments was not the main priority of this review.

Transferrin receptors and transferrin iron uptake by cultured human blood monocytes.

Transferrin receptors have been previously found on human macrophages and it has also been shown that transferrin iron is taken up by these cells. It has therefore been inferred that the uptake is receptor mediated and involves an endocytic pathway. The subject was addressed directly in the present study in which the transferrin-iron-receptor interaction was characterized in cultured human blood monocytes. Specific, saturable diferric transferrin binding was demonstrated, with a kDa of 3.6 X 10(-8) M and a calculated receptor density of 1.25-2.5 X 10(5) receptors per cell. Incubation at 4 degrees C markedly reduced transferrin binding and completely inhibited iron uptake. Chase experiments confirmed progressive cellular loading of iron, with concomitant loss of transferrin. Inhibitors of endocytic vesicle acidification (ammonium chloride and 2,4-dinitrophenol) inhibited iron unloading from endocytosed diferric transferrin, while microtubular inhibitors (colchicine and vindesine) and a microfilament inhibitor (cytochalasin B) reduced diferric transferrin uptake but had little effect on the iron unloading pathway. A similar effect was noted with a calcium ion antagonist (verapamil) and with 2 calmodulin antagonists (chlorpromazine and imipramine). These latter findings suggest the importance of cytoskeleton-membrane interactions via a calcium, calmodulin and protein kinase C mediated system. Endocytosed iron accumulated progressively as ferritin within the cultured monocytes.

Transferrin iron interactions with cultured hepatocellular carcinoma cells (PLC/PRF/5).

Hepatocellular carcinoma cells of the PLC/PRF/5 cell line had 1.9 x 10(5) transferrin receptors per tumor cell with a Kd of 1.5 x 10(-8) M. At high concentrations of transferrin the binding was not saturable. Transferrin internalization by hepatoma cells was shown by time and temperature-dependent binding studies and by pronase experiments. Transferrin recycling was confirmed by the demonstration of a progressive increase in the cellular molar ratios of iron to transferrin and by chase experiments. Ammonium chloride interfered with iron unloading. The vinca alkaloid vincristine inhibited iron and transferrin uptake. The hepatocarcinoma cells appeared to lack asialoglycoprotein receptors and therefore internalized partially desialated transferrin by the regular route. Iron uptake from transferrin was markedly inhibited by the hydrophobic ferrous chelator 2,2' bipyridine but was relatively unaffected by the hydrophilic ferric chelator desferroxamine. The implication that ferrous iron was involved in postendocytic transvesicular membrane iron transport was supported by a study in which hepatoma cells were shown to take up large amounts of ferrous iron suspended in 270 mM sucrose at pH 5.5. The interaction at this pH between surface labeled hepatoma cell extracts and ferrous iron on a Sephacryl S-300 column suggested that the postendocytic transvesicular transport of iron through the membrane was in part protein mediated. The endocytosed iron in hepatoma cells was found in association with ferritin (33%), transferrin (31%) and a low molecular weight fraction (21%).

Curry powder as a vehicle for iron fortification: effects on iron absorption.

Curry powder was investigated as a vehicle for targeted iron (Fe) fortification, and especially for NaFeEDTA, by assessing its acceptability to consumers and its effects on Fe absorption. A random survey in an Indian community in the Republic of South Africa, indicated that fortified premixed curry powder was acceptable in terms of color, palatability, and stability. The effect of curry powder on Fe absorption from a potato meal was assessed in 64 Indian housewives. Curry powder caused a significant though modest rise in Fe absorption in two of the studies (t = 2.716, p less than 0.05 and t = 3.126, p less than 0.025) but, in the third, the effect was noted only in the more Fe-depleted subjects. There was no enhancement of Fe absorption from a dhal soup of low-Fe bioavailability (t = 0.224, p greater than 0.1). The results of both the human and animal studies suggested that curry powder's overall mild enhancing effect on Fe absorption was due to its capacity to stimulate gastric acid secretion.

Inhibitory effect of nuts on iron absorption.

The effects on iron absorption of nuts, an important source of dietary protein in many developing countries, were measured in 137 Indian women. When the absorption from bread and nut meals (walnuts, almonds, peanuts, and hazelnuts) was compared with that from bread meals, the overall geometric mean absorption from the nut meals (1.8%) was significantly less than from the bread meals alone (6.6%, t = 9.8, p less than 0.0005). In contrast, coconut did not reduce absorption significantly. All the nuts tested contained significant amounts of two known inhibitors of Fe absorption (phytates and polyphenols) but the amounts in coconut were significantly less than in the other nuts. Fifty milligrams ascorbic acid overcame the inhibitory effects of two nuts that were tested (Brazil nuts and peanuts). This is different from that found previously for soy protein, another potent inhibitor of Fe absorption.

Effect of traditional oriental soy products on iron absorption.

The effect of a variety of traditional oriental unfermented and fermented soy products on iron absorption was evaluated in 242 Indian women. When compared with a soy-flour meal containing an equal amount of protein, iron absorption was found to be significantly improved with silken tofu, natto, tempeh, rice miso, barley miso, and soybean miso. This improvement could not be adequately explained except with reference to changes in the protein composition of the products. The protein fraction profiles of the soy products were obtained by size-exclusion high-performance liquid chromatography. An inverse relationship between food iron absorption and the high-molecular-weight fraction of the soy products was demonstrated (r = 0.66, p = 0.01). However, anomalous results obtained with three products (sufu, tempeh, and fully hydrolyzed isolated soy protein) did not make it possible to reach firm conclusions concerning the effect of the protein fraction of soy on iron bioavailability.

Ascorbic acid prevents the dose-dependent inhibitory effects of polyphenols and phytates on nonheme-iron absorption.

The effects of maize-bran phytate and of a polyphenol (tannic acid) on iron absorption from a white-bread meal were tested in 199 subjects. The phytate content was varied by adding different concentrations of phytate-free and ordinary maize bran. Iron absorption decreased progressively when maize bran containing increasing amounts of phytate phosphorous (phytate P) (from 10 to 58 mg) was given. The inhibitory effect was overcome by 30 mg ascorbic acid. The inhibitory effects of tannic acid (from 12 to 55 mg) were also dose dependent. Studies suggested that greater than or equal to 50 mg ascorbic acid would be required to overcome the inhibitory effects on iron absorption of any meal containing greater than 100 mg tannic acid. Our findings indicate that it may be possible to predict the bioavailability of iron in a diet if due account is taken of the relative content in the diet of the major promoters and inhibitors of iron absorption.

A quantitative analysis of matrix alignment in ligament scars: a comparison of movement versus immobilization in an immature rabbit model.

This investigation quantified the alignment of fibrillar matrix in normal rabbit medial collateral ligaments (MCLs) and in healing MCLs from animals treated with or without knee immobilization. Twenty-four immature female rabbits were given complete midsubstance injuries to their right MCLs. Fifteen of them had that knee pin immobilized in flexion, while the remaining nine were allowed unrestricted cage activity. Animals were sacrificed in groups of three at intervals of 3, 6, or 14 weeks after injury, and both healing MCLs and unoperated contralateral controls were fixed in situ for subsequent removal, freeze-fracture, and preparation for scanning electron microscopy (SEM). A random sampling of SEM photographs followed by automated, statistically validated image processing was used to quantify alignment of matrix in all samples. Results showed that nonimmobilized MCL scars in this model do remodel over 14 weeks of healing, returning to normal alignment values in that time. Surprisingly, MCL scars in immobilized knees were even better, with mean matrix alignments falling statistically within normal MCL limits at all healing intervals studied. If not due to an unknown sampling or fixation artifact, these results suggest that gross knee flexion and extension is not a prerequisite for scar matrix alignment in this immature model of ligament healing.

Endoscopic retrograde cholangiography in the diagnosis and endoscopic management of biliary complications after liver transplantation.

OBJECTIVE: Biliary reconstruction in orthotopic liver transplantation is increasingly being performed without T tube drainage. This increases the difficulty of diagnosing subsequent biliary tract problems, with a greater reliance placed on endoscopic retrograde cholangiopancreatography (ERCP) for the diagnosis of biliary tract complications. The usefulness of ERCP was evaluated in patients who underwent liver transplant where biliary reconstruction was not done with T tube drainage. DESIGN AND PARTICIPANTS: A retrospective study of the case notes of 90 patients who underwent liver transplantation, and in whom the biliary reconstruction was by end to end choledochocholedochostomy without T tube splintage. RESULTS: ERCP was performed as the primary procedure to investigate a suspected biliary complication in 30 patients (33%). The procedure was successful in 26 patients (87%), and showed a biliary stricture in 12 patients and a bile leak in six patients. ERCP was normal in seven patients and demonstrated dilated ducts alone in one patient. Six of the biliary strictures were successfully dilated endoscopically (50%), but none of the bile leaks resolved with endoscopic drainage. CONCLUSION: This study confirms the diagnostic role of ERCP post liver transplant. The therapeutic role requires clearer evaluation with a controlled trial.

Effect of lupines, a protein-rich legume, on iron absorption.

The absorption of iron from lupines, a protein-rich legume, was assessed in 35 parous Indian women. Iron bioavailability was shown to be as low for lupines as soybeans (geometric mean absorptions 0.9 and 1.7 per cent respectively, P less than 0.005). The addition of 30 mg of ascorbic acid moderately improved the geometric mean iron absorption from 1.0 to 5.3 per cent (P less than 0.0001), and 60 mg ascorbic acid from 0.7 to 6.9 per cent (P less than 0.0001). The phytate and polyphenol content of lupines was negligible. The demonstration of poor iron bioavailability from a legume of otherwise rich nutritional potential has important implications in nutritional planning programmes for developing countries.

The promotive effect of soy sauce on iron absorption in human subjects.

The effects on iron absorption of a traditionally fermented Japanese soy sauce added to soy and rice meals were assessed. The addition of soy sauce to a soy flour meal could not overcome the strong inhibition of iron absorption (geometric mean absorption 7.2 per cent with soy sauce vs. 8.7 per cent without, P = 0.5). However, soy sauce added to a rice meal instead of soy flour significantly improved the geometric mean iron absorption (13.9 per cent with soy sauce vs. 5.2 per cent with soy flour, P = 0.002) and had a promotory effect on absorption from a rice meal alone (11.4 per cent with soy sauce vs. 3.5 per cent without, P = 0.0002). Although soy sauce contains appreciable amounts of organic acids, the addition of 340 mg lactic acid to rice did not enhance iron absorption (3.1 per cent with lactic acid vs. 2.2 per cent without, P = 0.11). The promotory effect of soy sauce on iron absorption appears to be due not only to its lack of soy protein content but may also be due to the presence of fermentation products other than organic acids.

Reversible blockade of retrograde axonal transport in the rat sciatic nerve by vincristine.

Altered axoplasmic transport has been implicated as a contributing factor in neuropathic pain states. Treatments which produce transient axoplasmic transport blockade have shown initial promise as therapeutic procedures in the management of chronic neuropathic pain. The present study evaluated the capacity of the vinca alkaloid, vincristine to produce reversible blockade of retrograde axoplasmic transport. Results indicated that intraneural administration of 10(-5)M vincristine resulted in blockade of retrograde axoplasmic transport of [3H]leucine 24 h following administration. Importantly, the effect reversed over the next four days and axoplasmic transport was re-instated fully at day five. The implications of these results are discussed in relation to the potential use of axoplasmic transport blocking agents in the management of chronic neuropathic pain.

Effect of oral propranolol on the anerobic threshold and maximum exercise performance in normal man.

The effect of propranolol on the anaerobic threshold was studied in six healthy male volunteers. The subjects exercised on a cycle ergometer in a progressive exercise test to exhaustion with propranolol or no drug. Power output was increased by 30 W ever 2 min. Propranolol caused a significant reduction of heart rate by 20-45 beats per minute at all power outputs. In light and moderate exercise, no differences in oxygen uptake, ventilation, or blood lactate were observed in the propranolol and no-drug tests. The anaerobic threshold was not different between the no-drug (2.32 +/- 0.19 L O2/min, mean +/J- SD) and the propranolol (2.83 +/- 0.27 L O2/min) test; however, the heart rate at the anaerobic threshold was significantly lower in the propranolol (143 +/- 13 beats per minute) than the no-drug (187 +/- 9 beats per minute) tests. Above the anaerobic threshold, oxygen uptake was similar at a given power output but it reached a lower peak value (p less than 0.02) in the propranolol (3.16 +/- 0.16 L O2/min) versus the no-drug (3.64 +/- 0.39 L O2/min) tests. It was concluded that propranolol caused no change in anaerobic threshold in this specific progressive exercise protocol. The results suggest that a training intensity for endurance exercise bases on the anaerobic threshold does not need to be modified for subjects on propranolol medication.

Colonoscopy services in the United Kingdom.

BACKGROUND AND STUDY AIMS: Provision of a reasonable colonoscopy service requires approximately 160 procedures per 100000 population per year. The aim of the present study was to document current levels of colonoscopy service, the use of guidelines in surveillance practice and the capacity for expansion in endoscopy units throughout the United Kingdom. MATERIAL AND METHODS: A postal questionnaire was sent to 294 endoscopy units. RESULTS: Replies were received from 164 units (60 %). Of the units, 49 % have reached the calculated target figure. In units not meeting the target, 22% have only one colonoscopist, and 31% have one colonoscopy session a week. Overall, 50 % of units are working at full capacity. Out of all units, 70 % are unable to expand their service further, because of lack of nursing support in 81%, non-availability of endoscopist in 72 % and lack of physical space in 51%. Guidelines for surveillance colonoscopy were a problem: 51% of units reported that guidelines were available for surveillance of ulcerative colitis, 28 % for Crohn's disease, 59 % for polyp follow-up, and 44 % for follow-up of resected colorectal cancer. The majority of units (>70%) had no protocols for their surveillance practice. Nonetheless, 92% of units performed surveillance colonoscopy for ulcerative colitis, 34% for Crohn's disease, and 76% for resected colorectal cancer. CONCLUSIONS: The colonoscopy service has expanded, but there are constraints on further growth. There is a pressing need for national guidelines on surveillance colonoscopy.

Analysis of a protocol for an autologous blood transfusion program for total joint replacement surgery.

This retrospective study analysed an autologous blood transfusion program for total joint replacement surgery. A group of 99 patients receiving autologous blood transfusion was compared with a control group of 55 patients. One-unit phlebotomies were done 14 and 7 days before surgery. The whole blood was transfused intraoperatively. Preoperative hemoglobin values were within the normal range for all patient groups except the female autologous blood group for which the mean value was 122 +/- 11.3 g/L. Due to perioperative hemodilution, the postoperative hemoglobin values were substantially lower than preoperative values for all groups. Mean intraoperative blood loss was similar for the autologous and control groups (650 to 750 ml). No adverse reactions were associated with the autologous transfusions and 74% of the autologous group received autologous blood only. From this analysis a 3-week, three-unit preoperative collection was proposed for future use. A standardized protocol will allow logistical ease and implementation of the program for various surgical procedures.