An increased tendency in fibrinogen activity and its association with a hypo-fibrinolytic state in early stages after injury in patients without acute traumatic coagulopathy (ATC).

Acute traumatic coagulopathy (ATC) diagnosed by prolongation of APTT and/or PT/INR involves alterations in platelet activity, coagulation and fibrinolysis. However, data showing the haemostatic situation in injured patients without ATC are scarce. To assess whether haemostatic impairment is also present in injured patients without ATC, ten injured patients without ATC and ten normal individuals were examined. The patients were sampled on arrival at the emergency department 0, 2, 12 h after surgical or other intervention. Thrombin generation, fibrin formation and fibrin proteolysis were determined via several laboratory methods, using tissue factor as the coagulation trigger. Thrombograms demonstrated that trauma accelerated both thrombin generation and decay. In the presence of unaffected peak thrombin levels, these two contradictory effects cancelled each other out, leading to the global endogenous thrombin potential (ETP) remaining normal. Under the mediation of normal ETP, fibrin network permeability (Ks) kept the reference levels in the two groups of subjects. Fibrinogen (FBG) activity (Clauss) rose with time from 0 to 2 h and 12 h, which significantly slowed down Clot Lysis Potential as determined by an in vitro method with exogenous t-PA. SUMMARY: the main haemostatic impairment in the present patients concerned an increased tendency in FBG activity. Since an increase in FBG is a biomarker of acute inflammation and also predicts greater fibrin production which down-regulates fibrinolysis, we suggest that during early stages after injury, patients without ATC may suffer from worsening inflammation and confront enhancement of thrombosis risk due to dysfunction of fibrinolysis.

Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) vs. facemask breathing pre-oxygenation for rapid sequence induction in adults: a prospective randomised non-blinded clinical trial.

Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) can prolong apnoea time in adults. Therefore, THRIVE used for pre-oxygenation in rapid sequence induction of anaesthesia could extend safe apnoea time during prolonged laryngoscopy and intubation. In this randomised controlled trial, we compared the lowest peripheral oxygen saturation (SpO2 ) during intubation when pre-oxygenating with either traditional facemask or THRIVE. Eighty adult patients, undergoing rapid sequence induction of anaesthesia for emergency surgery, were randomly allocated to pre-oxygenation with 100% oxygen with facemask or with THRIVE. Median (IQR [range]) lowest SpO2 until 1 min after intubation was 99% (97-100 [70-100]%) for the facemask group vs. 99% (99-100 [96-100]%) for the THRIVE group (p = 0.097). Five patients (12.5%) desaturated below 93% when pre-oxygenated with the facemask vs. none in the THRIVE group (p = 0.019). There were no differences in intubation time or apnoea time between the groups. Median intubation time was 51 (34-66 [22-261]) s in the facemask group vs. 48 (38-63 [10-146]) s in the THRIVE group (p = 0.99). Median apnoea time was 109 (86-142 [37-291]) s and 116 (92-146 [63-249]) s when using facemask and THRIVE, respectively (p = 0.49). No signs of regurgitation of gastric content were detected. The data on desaturation indicate potential benefits of oxygenation with THRIVE for rapid sequence induction compared with facemask pre-oxygenation.

Extracorporeal membrane oxygenation improves coagulopathy in an experimental traumatic hemorrhagic model.

PURPOSE: Hemorrhage is the most common cause of preventable death after trauma. Coagulopathy plays a central role in uncontrolled bleeding and is caused by multiple factors. Extracorporeal Membrane Oxygenation (ECMO) is an established treatment for patients with respiratory failure and has in recent years also been used in severely injured trauma patients with cardiopulmonary failure and coexisting bleeding shock. The aim of this study was to evaluate the effect of ECMO on hypothermia, acidosis, and coagulopathy in a traumatic hemorrhagic rabbit model. METHODS: After anesthesia and tracheostomy, ten New Zealand White rabbits sustained laparotomy, bilateral femur fractures and were hemorrhaged 45% of their estimated blood volume. After 90 min of hemorrhagic shock they were resuscitated with a standard transfusion protocol together with venoarterial ECMO (n = 5) or with a standard transfusion protocol only (n = 5) for 60 min. No systemic heparin was administered. RESULTS: ECMO during 60 min of resuscitation significantly increased heart rate (p = 0.01), mean arterial pressure (p = 0.01), body temperature (p = 0.01) and improved the metabolic acidosis, pH (p = 0.01), and lactate (p = 0.01). ECMO also improved the coagulation capacity measured in vitro by Rotational Thromboelastometry with a significant decrease in clot formation time (p < 0.01). This finding was confirmed in vivo with a significant reduction in the animals' ear bleeding time (p < 0.01) and cuticle bleeding time (p < 0.01); 5/5 animals survived in the ECMO group and 3/5 animals survived in the control group. CONCLUSIONS: Heparin-free ECMO stabilizes circulation, improves coagulation, and may impact short-time survival, during the first 60 min, in an experimental traumatic model with severe hemorrhagic shock.

Cyclodextrin-grafted cellulose: physico-chemical characterization.

Cyclodextrins (CDs) can form inclusion complexes with a wide variety of molecules making them very attractive in different areas, such as pharmaceutics, biochemistry, food chemistry and textile. In this communication we will report on the physico-chemical characterization of cellulose modified with CDs by means of infra-red spectroscopy (FTIR), cross polarization magic angle spinning solid state nuclear magnetic resonance (CP-MAS NMR), polarized optical microscopy (POM) and thermal gravimetric analysis (TGA). Both CP-MAS NMR and FTIR indicate that CDs are chemically attached to cellulose backbone through the formation of ester bonds. Furthermore, the CD-grafted cellulose was dissolved in a "superphosphoric" acid solution but, despite the increase of hydrophilicity due to the modification, POM revealed that grafted cellulose was less soluble when compared to the unmodified polymer. The formation of a complex CD-cellulose network is suggested.

Insights into the interplay between molecular structure and diffusional motion in 1-alkyl-3-methylimidazolium ionic liquids: a combined PFG NMR and X-ray scattering study.

We report on how the local structure and the diffusional motion change upon increasing the alkyl chain length in 1-alkyl-3-methylimidazolium cation ionic liquids. This study has been performed by combining pulse field gradient (PFG) nuclear magnetic resonance (NMR) spectroscopy and small angle X-ray scattering (SAXS) experiments. The cationic side chain length varies from ethyl (n = 2) to hexadodecyl (n = 16), while the anion is always bis(trifluoromethanesulfonyl)imide (TFSI). We find that the self-diffusivity of the individual ionic species is correlated to the local structure in the corresponding ionic liquid, namely the nano-segregation into polar and non-polar domains. In agreement with previous results, we observe that for relatively short alkyl chains the cations diffuse faster than the anions; however we also note that this difference becomes less evident for longer alkyl chains and a cross-over is identified at n ≈ 8 with the anions diffusing faster than the cations. Our results indicate that this controversial behavior can be rationalized in terms of different types of cation-cation and anion-anion orderings, as revealed by a detailed analysis of the correlation lengths and their dispersion curves obtained from SAXS data. We also discuss the validity of the Stokes-Einstein relation for these ionic liquids and the evolution of the extrapolated cationic radius that was found to depend non-strictly linearly on n, in agreement with the cation-cation correlation lengths.

Decreased risk of alcohol dependence and/or misuse in women with high self-assertiveness and leadership abilities.

AIMS: To analyse dimensions of gender identity and its association to psychiatric disorders and alcohol consumption. METHODS: The study was performed in two stages: an initial screening (n = 8335) for alcohol consumption, followed by a structured psychiatric interview (n = 1054). The Masculinity/Femininity-Questionnaire was used as an indicator of gender identity. The final study group included 836 women. RESULTS: Leadership, caring, self-assertiveness and emotionality were dimensions of gender identity found in a factor analysis. Low self-assertiveness, high emotionality and to some extent low leadership were associated with increased odds for having bipolar disorders, severe anxiety disorders and alcohol dependence and misuse. Low self-assertiveness and high emotionality were not only associated with alcohol dependence and misuse, but also with high episodic drinking. CONCLUSIONS: There was an association between some of the dimensions of gender identity and psychiatric disorders and alcohol consumption. Further attention is needed in both clinical work and research.

An outcome study of severe traumatic head injury using the "Lund therapy" with low-dose prostacyclin.

BACKGROUND: There are two independent head injury outcome studies using the "Lund concept", and both showed a mortality rate of about 10%, and a favourable outcome (Glasgow outcome scale, GOS 4 and 5) of about 70%. The Lund concept aims at controlling intracranial pressure, and improving microcirculation around contusions. Intracranial pressure is controlled by maintaining a normal colloid osmotic pressure and reducing the hydrostatic capillary pressure. Microcirculation is improved by ensuring strict normovolaemia and reducing sympathetic discharge. The endogenous substance prostacyclin with its antiaggregatory/antiadhesive effects may further improve microcirculation, which finds support from a microdialysis-based clinical study and an experimental brain trauma study. The present clinical outcome study aims at evaluating whether the previously obtained good outcome with the Lund therapy can be reproduced, and whether the addition of prostacyclin has any adverse side-effects. METHODS: All 31 consecutive patients with severe head injury, Glasgow coma scale (GCS) < or = 8, admitted to the University Hospital of Umeå during 1998 were included. The Lund therapy including prostacyclin infusion for the first three days at a dose of 0.5 ng kg(-1) min(-1). Outcome was evaluated according to the GOS >10 months after the injury. RESULTS: One patient died, another suffered vegetative state and 7 severe disability. Of the 22 patients with favourable outcome, 19 showed good recovery and 3 moderate disability. No adverse side-effects of prostacyclin were observed. CONCLUSION: The outcome results from previous studies using the Lund therapy were reproduced, and no adverse side-effects of low-dose prostacyclin were observed.

Hyperbaric bradycardia and hypoventilation in exercising men: effects of ambient pressure and breathing gas.

We sought to determine whether hydrostatic pressure contributed to bradycardia and hypoventilation in hyperbaria. Eight men were studied during exercise at 50, 150, and 250 W while breathing 1) air at 1 bar, 2) helium-oxygen (He-O(2)) at 5.5 bar, 3) sulfur hexafluoride-oxygen (SF(6)-O(2)) at 1.3 bar, and 4) nitrogen-oxygen (N(2)-O(2)) at 5.5 bar. Gas densities were pairwise identical in 1) and 2), and 3) and 4), respectively. Increased hydrostatic pressure to 5.5 bar resulted in a modest but significant relative bradycardia on the order of 6 beats/min, in both the absence [1) vs. 2), P = 0. 0015] and presence [3) vs. 4), P = 0.029] of gases that are both denser than normal and mildly narcotic. In contrast, ventilatory responses appeared not to be influenced by hydrostatic pressure. Also, the combined exposure to increased gas density and mild-to-moderate inert gas narcosis at a given hydrostatic pressure [1) vs. 3), 2) vs. 4)] caused bradycardia (P = 0.032 and 0.061, respectively) of similar magnitude as 5.5-bar hydrostatic pressure. At the same time there was relative hypoventilation at the two higher workloads. We conclude that heart rate control, but not ventilatory control, is sensitive to relatively small increases in hydrostatic pressure.

Slowing and attenuation of baroreflex heart rate control with nitrous oxide in exercising men.

The objective of the present study was to determine whether mild inert-gas narcosis impairs cardiovascular control mechanisms and contributes to the relative bradycardia that occurs in humans exercising in a hyperbaric environment. Eight healthy subjects were exposed to a normoxic 30% nitrous oxide (N(2)O) mixture and an air control during dynamic exercise of 100-W intensity. Beat-by-beat heart rate (HR) and invasive arterial blood pressure measurements were made. The sensitivity and the response latency of the arterial-cardiac-chronotropic baroreflex were determined from repeated blood pressure and HR transients induced by rapid tilts between the upright and supine posture. A significant increase (37%, P

Arterial baroreflex control during mild-to-moderate nitrous oxide narcosis.

We hypothesized that light-to-moderate inert gas narcosis might play a role in bradycardia in divers by altering sensitivity or response dynamics of arterial baroreflexes. Carotid-cardiac and carotid-mean arterial pressure (MAP) baroreflex response curves were generated by applying multiple levels of neck pressure and suction. Seven healthy volunteers were studied during air breathing (control) and during inhalation of 39% nitrous oxide (N2O). Baseline (pre-stimulus) heart rate (HR) and MAP were not altered by N2O. Range, threshold level, saturation level, and delay of responses did not differ between conditions. For hypertensive stimuli, sensitivity of responses did not differ between air control and N2O inhalation, but for hypotensive stimuli, maximal response gain for HR tended to be reduced with N2O inhalation (P = 0.054). Our results speak against inert gas narcosis as a primary mechanism for hyperbaric bradycardia, but it remains possible that an attenuation of tachycardic responses to hypotensive stimuli plays a role.

Postoperative comfort in paediatric outpatient surgery.

Postoperative conditions in hospital and at home were evaluated in 200 paediatric daycase patients by using questionnaires and telephone interviews. Pain was assessed by behaviour observation or a faces rating scale depending on age. Anaesthetic methods, nausea/vomiting, analgesics and parents' aspects were also recorded. Seventy per cent of the patients received regional anaesthesia. Immediate postoperative analgesia was satisfactory in 75% of the children. When the effects of intraoperatively administered analgesics wore off at home almost half the children rated higher than mild pain. The increased degree of pain at home was especially pronounced after regional anaesthesia. The total incidence of nausea/vomiting was 28% and fentanyl caused nausea and vomiting in a significantly higher proportion of cases. The study points out that immediate postoperative comfort obtained by prophylactic analgesia needs to be followed by analgesics given on a continuous basis for the first days after surgery.

Responses of respiratory drive and breathing pattern to inspiratory loading during nitrous oxide and isoflurane sedation.

BACKGROUND: Increased inspiratory resistance in combination with mild gas narcosis is common during recovery after a general anesthesia, but there are only few previous studies on inspiratory loading during subanesthetic gas narcosis. METHODS: Responses of respiratory drive (central inspiratory activity, P0.1) and ventilatory pattern to an inspiratory threshold load of -6 cm H2O were studied in 16 healthy subjects during mild subanesthetic gas narcosis. One group (n = 9) was exposed to 13, 26 and 39% nitrous oxide (N2O) and air control (Group N). Another group (n = 7) was exposed to 0.1, 0.2 and 0.3% isoflurane and air control (Group I). Measurements were done after 1 min adaptation to the load. RESULTS: Nitrous oxide and isoflurane had no effect on respiratory drive and VT either during unloaded breathing or during inspiratory threshold loading. Across all gas concentrations (including 0% control), inspiratory threshold loading resulted in significant P0.1 increases, amounting to 62% in group N and 38% in group I. At the same time VT decreased by 11 and 12%, respectively. A significantly increased end-expired CO2 and decreased minute volume compared to air control was found during isoflurane inhalation but could be ascribed to normalization of the hyperventilation in the control situation. CONCLUSIONS: It is concluded that the steady-state ventilatory responses to loading, consisting of increased P0.1 and decreased VT, are maintained during inhalation of subanesthetic doses of N2O (0.13-0.38 MAC) and isoflurane (0.09-0.26 MAC).

Relative narcotic potency and mode of action of sulfur hexafluoride and nitrogen in humans.

Impairments of psychomotor, perceptual, and cognitive abilities were determined in nine male subjects exposed to inhaled SF6 partial pressures of 0, 52, 104, and 156 kPa and to inhaled N2 partial pressures of 103, 575, 825, and 1,075 kPa. Also data from a previous study with inhaled N2O partial pressures of 0, 13, 26, and 39 kPa were included. With the highest gas concentrations, performances were reduced by 41-57%. Effective doses for a 20% performance impairment were 830, 97, and 21.5 kPa for N2, SF6, and N2O, respectively, yielding relative narcotic potencies of 1.0:8.5:39. The order of narcotic potencies is the same as for the lipid solubility of the three gases. In contrast, the order of increasing tendency for hydrate formation (decreasing hydrate dissociation pressure) for the three gases is N2, N2O, and SF6. Thus, mild to moderate inert gas narcosis in humans shows the same positive relationship to lipid solubility as was shown in previous animal models that utilized much deeper levels of anesthesia.

Effects of sulphur hexafluoride on psychomotor performance.

The narcotic influence of sulphur hexafluoride on mental and psychomotor performance has been studied in 9 subjects at normal atmospheric pressure. Control experiments were performed with air and with nitrous oxide. Psychomotor, perceptual and cognitive abilities were assessed using a computerized test battery. Subjects were exposed to air and six different normoxic gas mixtures: 13, 26, and 39% N2O, and 39, 59, and 79% SF6. Significant performance impairments were found with 13% N2O and gradual further impairment with 26, and 39% N2O. During exposure to 39, 59, and 79% SF6 over-all performance was impaired by 5, 10, and 18%, respectively. Impairment was significant with 59 and 79% SF6. The results indicate that the relative narcotic potency of SF6: N2O is about 1:4 in humans. It is concluded that a normoxic SF6-O2 mixture can be inhaled for lung function studies without any harmful effects and that the short-lasting narcotic effect, although detectable with a test battery, would not impair the ability of the subject to perform simple breathing procedures.

Cueing effects of anxiolytic benzodiazepines (DZP and Ro 11-3128): stereospecificity and antagonism by the convulsant benzodiazepine Ro 5-3663.

Two groups of gerbils were trained in a T-maze to discriminate between the vehicle condition (4 ml/kg) and either of the benzodiazepine (BDZ) agonists diazepam (DZP) and Ro 11-3128; administration (5.6 mg/kg) was IP 5 min prior to training onset. Once trained, novel doses and drugs were assessed in test sessions interposed between the regular training days. A dose-related generalization effect occurred with both compounds (range 0.1-5.6 mg/kg), the effect being similar at both the 5 and 15 min test intervals; the two intervals were evaluated after a single injection. The lack of generalization of Ro 11-3624 (range 5.6-56 mg/kg) indicates a stereoisomeric separation of BDZ agonist activity. Ro 5-4864 (range 17.5-56 mg/kg), an agent chemically/structurally related to DZP, did not produce DZP responding at either of the two test inverals; clear-cut convulsant activity occurred at the 15 min interval. The convulsant BDZ compound Ro 5-3663 (3 and 10 mg/kg) antagonized the DZP stimulus irrespective of whether Ro 5-3663 was given either prior to, simultaneously with, or shortly after the DZP injection.

Alterations in liver mitochondrial function as a result of fasting and exhaustive exercise.

The effect of exercise upon liver mitochondria structure and function was examined in fasted and fed rats, following a single run to exhaustion on a motor-driven treadmill. Exercise alone and exercise coupled with fasting both produced a significant decrease in the amount of hexokinase bound to the mitochondria, as well as reduction in the ADP/O ratio and acceptor control index measured in the presence of succinate. The mitochondria of the exercised animals, when exposed to freeze-fracture analysis while in state 3, displayed fewer deflections in the fracture plane between the inner and outer membrane than those isolated from control animals. This suggests that fewer contacts existed between the two membranes. Measurements based upon the binding of 8-anilinonaphthalene 1-sulphonate indicated that there was an increase in the net negative charge on the surface of the mitochondrial membranes of the exercised animals. All of these effects could be mimicked by incubation of mitochondria from control animals with free fatty acids. This fact, coupled with the observation that washing of the mitochondria with a solution comprising 5% (w/v) albumin could reverse all of the consequences of exercise, suggests that these alterations in mitochondrial structure and function may be the result of the increase in plasma free fatty acids that accompanies long-term exercise. Furthermore, the observation that the exercise-induced changes are dynamic and readily reversible indicates that the mitochondria were not necessarily damaged, but rather that the coupling of oxidative phosphorylation may be subject to physiological regulation.

The binding of glycerol kinase to the outer membrane of rat liver mitochondria: its importance in metabolic regulation.

Glycerol kinase was found to associate with the hexokinase binding protein. The binding of glycerol kinase has a high specificity as illustrated by the fact that the magnitude of binding was reduced by glycerophosphate and antibodies against the hexokinase binding protein. A possible function of glycerol kinase binding to the mitochondria with respect to metabolic regulation is proposed for the following reasons: (i) Glycerol kinase seems to bind to the same binding protein as hexokinase. (ii) Both kinases were observed to be reversibly bound to the mitochondria in different metabolic situations, i.e., 10% of total cellular activity from both kinases is bound in starved rats whereas no activity of glycerol kinase and 30% of hexokinase become bound in fed rats. (iii) The kinetic properties of the associated glycerol kinase change in an analogous manner to those known for structure-bound hexokinase. (iv) With the binding of glycerol kinase to the mitochondria, it is possible to propose a metabolic pathway for glycerol oxidation to dihydroxyacetone phosphate by a combined action involving the enzyme, glycerol phosphate oxidase, and oxidative phosphorylation.