text:
Advances in resuscitation strategies
Hasan B. Alam*
Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
a r t i c l e i n f o
Received 4 May 2010
Received in revised form
30 July 2010
Accepted 4 September 2010
Available online 15 September 2010
a b s t r a c t
Shock, regardless of etiology is characterized by decreased delivery of oxygen and nutrients to the tissues
and our interventions are directed towards reversing the cellular ischemia and preventing its conse-
quences. The treatment strategies that are most effective in achieving this goal obviously depend upon
the different types of shock (hemorrhagic, septic, neurogenic and cardiogenic). This brief review focuses
on the two leading etiologies of shock in the surgical patients: bleeding and sepsis, and addresses
a number of new developments that have profoundly altered the treatment paradigms. The emphasis
here is on new research that has dramatically altered our treatment strategies rather than the basic
pathophysiology of shock.
Ó 2010 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
1. Hemorrhagic shock
Exsanguination is one of the leading causes of death following
and prompt hemorrhage control along with adequate
ﬂuid resuscitation are the key components of early trauma care.
Similarly, hemorrhage is often encountered in non-trauma patients
as a complication following major surgeries. Despite hemorrhage
being a common problem, the optimal resuscitative strategy
remains controversial, with vigorous ongoing debates about issues
such as the type of ﬂuid, volume, rate, route of administration, and
endpoints of resuscitation.
1.1. Futility of current methods/adverse effects of aggressive
Although it is widely believed that early aggressive ﬂuid resusci-
tation is beneﬁcial, clinical and basic science literature fails to provide
conclusive supporting evidence.3e7
As a matter of fact, the basic
rationale for administering intravenous ﬂuids in patients with
ongoing bleeding has been challenged repeatedly for almost a
Theoretically, ﬂuid resuscitation in the absence of (or prior
to) hemorrhage control can exacerbate bleeding due to the disruption
of early soft thrombus, coagulopathy, and hemodilution.9e12
systematic review of 52 animal trials concluded that ﬂuid resuscita-
tion appeared to decrease the risk of death in models of severe
hemorrhage (RR ¼ 0.48), but increased the risk of death in those with
less severe hemorrhage (RR ¼ 1.86).13
resuscitation (targeting a lower blood pressure), whenever tested,
reduced the risk of death (RR ¼ 0.37). Similarly, a critical review of the
literature failed to ﬁnd any evidence that pre-hospital advanced life
support and improved outcomes in trauma patients.14
In a study that
has generated vigorous debate since its publication in 1994,15
tensive patients with penetrating torso injury were randomized to
routine ﬂuid resuscitation, or resuscitationwas delayed until bleeding
had been surgically controlled. The results of this study demonstrated
a survival advantage in the delayed resuscitation group (70% vs. 62%,
p ¼ 0.04). Despite all the controversy, the most impressive ﬁnding
remains that withholding ﬂuid resuscitation until hemorrhage
control did not increase the mortality. The issue of timing and volume
of ﬂuid resuscitation in bleeding patients has also been addressed by
The Cochrane Database of Systematic Reviews.16
Only six randomized
clinical trials met the inclusion criteria, and a careful review failed to
provide any evidence in support of (or against) early or large volume
intravenous ﬂuid administration in uncontrolled hemorrhage. Based
upon all this information, it is reasonable to conclude that ﬂuid
resuscitation is not a substitute for early hemorrhage control. Low
volume, careful resuscitation is reasonable, especially when trying to
get a dying patient to deﬁnitive care. However, early aggressive ﬂuid
resuscitation, in the absence to hemorrhage control, can’t be justiﬁed.
* Division of Trauma, Emergency Medicine and Surgical Critical Care,
165 Cambridge Street, Suite 810, Boston, MA 02114. Tel.: þ1 617 643 2433.
E-mail address: email@example.com.
Contents lists available at ScienceDirect
International Journal of Surgery
journal homepage: www.theijs.com
1743-9191/$ e see front matter Ó 2010 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
International Journal of Surgery 9 (2011) 5e12
2. In addition to the impact of resuscitation on bleeding, resusci-
tation ﬂuids have profound cellular effects. It is now widely
recognized that resuscitation ﬂuids are not completely innocuous,
and they may actually potentate the cellular injury caused by
This concept of “resuscitation injury” has
steadily gained attention since a report by the Institute of Medicine
(1999) described in detail the wide spectrum of adverse conse-
quences that can follow resuscitative efforts.18
concept of large volume crystalloids resuscitation was a product of
seminal work by Shires, Moyer, Moss and others during the
and it became common practice during the Vietnam
conﬂict. Their work suggested that infusion of large volume
isotonic crystalloids improved survival, and resuscitation ﬂuids
were needed not only to replace the intra-vascular volume loss, but
also to replenish interstitial deﬁcits. Therefore, these investigators
recommended ﬂuid replacement equal to three times the volume of
blood loss (and as high as 8:1 for severe shock). At that time the
emphasis was on restoration of intra-vascular and interstitial ﬂuid
deﬁcits, without much importance attached to the cytotoxic effects
of crystalloid ﬂuids. Isotonic ﬂuids were used widely in Vietnam
and it was during this period that the appearance of “shock lung/Da
Nang lung” (later termed acute respiratory distress syndrome or
ARDS) was ﬁrst described in soldiers that received massive crys-
talloid resuscitation. Today, ARDS and Multiple Organ Dysfunction
Syndrome are major causes of delayed mortality in trauma patients.
An ever-increasing basic science literature supports the new
paradigm that cellular injury is inﬂuenced not only by shock, but
also by our resuscitation strategies. Today, with the easy availability
of advanced cellular research techniques, we can study the effect of
resuscitation ﬂuids on the biological systems in much greater
detail. Review of the literature suggests that commonly used
resuscitation ﬂuids (especially racemic lactated Ringer’s solution)
can exaggerate the post trauma immune activation.23
addition to the immediate side effects (worsening of hemorrhage),
delayed complications of ﬂuid resuscitation such as systemic
inﬂammatory response, ﬂuid overload (leading to compartment
syndromes, pulmonary edema etc), anemia, thrombocytopenia,
electrolyte/acid-base abnormalities, and cardiac and pulmonary
complications must also be kept in mind.24
Excessive ﬂuid resus-
citation increases the chances of developing abdominal compart-
ment syndrome in critically ill surgical/trauma, burn, and medical
Similarly, in a multicenter study of burn patients,
administration of excessive ﬂuids (in excess of 25% of predicted)
increased the odds of ARDS (OR 1.7), pneumonia (OR 5.7), multiple
organ failure (OR 1.6), blood stream infections (OR 2.9), and death
1.2. New development
It is now being appreciated that resuscitation ﬂuids, like other
drugs, have indication for appropriate use, safe therapeutic doses,
potential side effects and complications. Despite a paucity of good
randomized controlled trials (RCT) in this arena, clinical practices
are rapidly changing. In general, large volume aggressive ﬂuid
resuscitation is becoming increasingly rare, and low volume,
carefully guided resuscitation is more common. A few of these
issues are discussed in more detail below:
i. Controlled hypotensive resuscitation: In appropriate patients
(e.g. in young victims of penetrating trauma) limiting the rate
andvolumeofﬂuidresuscitationprior tohemorrhage control is
rapidly becoming routine practice in large trauma centers.
Blunt trauma patients with associated head injury are still
resuscitated to a higher blood pressure, in an attempt to
maintain adequate cerebral perfusion, but early use of blood
products and vasopressors is replacinglarge volume crystalloid
infusion. Prompted by the recommendations of some con-
and due to the unique logistical
challenges of the battleﬁeld, the resuscitation strategies being
utilized by the US military have changed dramatically: resus-
citation is selective, emphasizing low volume and practical
endpoints, and the use of ﬂuids with logistical advantages (e.g.
hetastarch) is preferred. The endpoint of resuscitation is not
a normal BP, but simply a palpable radial pulse and normal
mental status (in the absence of head injury). Thus, IV ﬂuids are
given only selectively, and in much less volumes. Also, early
hemorrhage control is prioritized over aggressive ﬂuid resus-
citation. It is difﬁcult to determine the direct impact of these
new strategies on combat casualty outcomes, but is very
encouraging to note that for the ﬁrst time since the Crimean
War, the killed in action rate has markedly dropped below the
historic 20% to around 10e14%.33
can be performed by infusing ﬂuids to achieve a desired goal
(e.g. target blood pressure), or at a pre-determined ﬁxed rate.
Pre-clinical data shows that resuscitation to target mean arte-
rial pressure (MAP) of 40 mmHg, as opposed to 80 mmHg or
higher notonly results in decreased blood loss but also in better
splanchnic perfusion and tissue oxygenation,34
hemodilution, thrombocytopenia, and coagulopathy,35
eased apoptotic cell death and tissue injury35,36
However, others have shown in large animal
models that prolonged duration (8 h) of hypotension increases
metabolic stress, tissue hypoxia, and mortality37,38
majority of the pre-clinical data favors MAPs between 40 and
60 mmHg or systolic blood pressure (SBP) between 80 and
90 mmHg. Furthermore, in each of these studies, hypotensive
resuscitationwith crystalloids wasbeneﬁcialcompared to non-
resuscitated controls. An alternative means of hypotensive
resuscitation, particularly useful in pre-hospital or austere
environments where accurate blood pressure measurement
may not be feasible,is by ﬂuidinfusionat a pre-determined rate
(carefully selected to avoid over resuscitation). In animal
studies, empiric rates of infusion have shown promise. Slow
infusion rates with crystalloid have been shown to reduce
cause faster recovery of hemorrhage sup-
pressed cell mediated immune function40,41
mortality. Overall, the data suggest that hypotensive resusci-
tation at a ﬁxed rate of 60e80 cc/kg/hour generally maintains
controlled hypotension to a SBP of 80e90 mmHg (MAP of
40e60 mmHg) and that this empiric control of infusion rates is
beneﬁcial in hemorrhagic shock. Regardless of which approach
is selected (goal directed vs. ﬁxed volume), these pre-clinical
data combined with the clinical evidence15,16
against routine large volume crystalloid resuscitation. The best
approach for urban trauma services (short transport times)
appears to be “scoop and run”, where unnecessary ﬁeld inter-
ventions are avoided and the focus is on fast and efﬁcient
transport of the patient to the hospital.42
ii. Hypertonic saline: Another new development is the renewed
interest in hypertonic saline (HTS), not just as a volume
expander but also as an immune modulator. The use of HTS for
resuscitation from hemorrhage was ﬁrst described in 1980,
when Velesco et. al,43
and DeFelippe et. al,44
separate studies that hypersomotic sodium chloride rapidly
expands plasma volume after major blood loss. Because of its
ability to mobilize interstitial ﬂuids into the vascular space,
250 ml of 7.5% saline can achieve results comparable to resus-
citation with 2e3 L of 0.9% saline. Since the original reports,
HTS or hypertonic saline combined with dextran (HSD) have
been tested in a number of RCTs, without showing a clear
H.B. Alam / International Journal of Surgery 9 (2011) 5e126
3. survival advantage.45
A meta-analysis evaluated HSD as the
initial treatment for hypovolemic shock by reviewing the
original records from six trials (and 604 subjects).46
discharge survival rates were better with HSD resuscitation as
compared to conventional resuscitation. HSD resuscitationwas
particularly effective for the sub-group of patients that had
sustained head injury with a discharge survival rate of 38%, as
compared to a rate of 27% for the control group receiving saline.
All of these trials had used HTS as a volume expander, but
a more advantageous effect of HTS administration may be the
attenuation of immune mediated cellular injury. A number of
pre-clinical studies have demonstrated that HTS has the
potential to modulate the immune response, with an overall
attenuation of immune mediated cellular injury.47e56
RCT has also shown that initial treatment of trauma patients
with HSD inhibits neutrophil adhesion molecule expression
and favorably modulates the inﬂammatory response.57
recently established Resuscitation Outcome Consortium
funded by the National Institutes of Health and the US
Department of Defense initiated two multicenter trials of
hypertonic resuscitation in blunt or penetrating trauma
patients in hypovolemic shock, and severe traumatic brain
injury. Both studies were designed to have three randomized
groups comparing hypertonic saline/dextran (7.5% saline/6%
dextran 70, HSD), hypertonic saline alone (7.5% saline, HTS),
and normal saline (NS) as the initial resuscitation ﬂuid for the
pre-hospital setting. In addition to the primary endpoints,
comprehensive data about the immunologic consequences of
hypertonic resuscitation would also be collected. Unfortu-
nately, the interim analysis of the data was not favorable, HTD
treated patients experienced higher early mortality and no
overall beneﬁt compared to the control arm (the full analysis
remain unpublished at the time of this writing).59
much lauded laboratory effects of hypertonic saline, this ﬂuid
has not been the magic bullet hoped for by many researchers.
Based upon these clinical data, HTS cannot be recommended
for resuscitating trauma patients outside an approved trial.
Another ﬂuid that remains controversial is albumin. A recent
report [post hoc analysis of patients from the Saline versus
Albumin Fluid Evaluation (SAFE) study] suggests that albumin
should be avoided in patients with traumatic brain injury, as it
was associated with a signiﬁcant increase in mortality.60
iii. Damage control resuscitation: An idea that is gaining
momentum due to the ongoing war (Iraq and Afghanistan) is
the concept of hemostatic/damage control resuscitation.61
Trauma patients are often coagulopathic due to shock and
tissue injury, and this coagulopathy can be worsened by
resuscitation with crystalloids and packed red blood cells
(PRBC), as both are deﬁcient in clotting factors. Observational
data from civilian trauma centers and the battleﬁeld seem to
suggest that early administration of component therapy con-
taining fresh frozen plasma (FFP) and platelets may be bene-
A recent retrospective analysis of mixed trauma
patients requiring surgery and massive transfusion compared
FFP:PRBC ratios of 1:1 and 1:4, and showed that only 26% of
patients treated with the former ratio died while 87.5% of
patients treated with the latter ratio died (p < 0.0001). In this
high risk group with an overall mortality of 55.5%, a 1:4 ratio of
FFP:PRBC increased the relative risk of dying by 18.9
(p < 0.001) when controlling for all other patient variables.64
Holcomb’s study of trauma patients at 16 trauma centers
who required massive transfusion found that an FFP:PRBC
ratio of 1:2 or higher (n ¼ 252) compared to lower ratios
(n ¼ 214) was associated with improved 30-daysurvival (59.6%
with high ratio vs. 40.4% with low ratio, p < 0.01).65
conclusions have recently been questioned by a study that
suggests that the observed survival differences between
patients receiving high and low ratios in the ﬁrst 24 h may
simply be due to the fact that survivors live long enough to
receive component therapy (survivor bias).66
Based on the
battleﬁeld experience, the US Army has instituted a policy of
using a 1:1:1 ratio of PRBC:FFP:platelets in the battleﬁeld for
those that meet the criteria for massive resuscitation (expec-
ted to receive >10 units PRBC). However, no well-designed
randomized clinical trial has conclusively identiﬁed the
optimal ratios of blood components. Our own institutional
policy is to start FFP infusion as early as possible in massively
bleeding patients, by activating Massive Transfusion Protocols
(MTP) which deliver PRBC:FFP in a ratio of 2:1, and administers
6 units of platelets for 10 units PRBC. Despite an ongoing
debate about the precise ratios, there is general agreement
that the blood products should be administered in the form of
an MTP to optimize the processes of care and to improve
outcomes. The often disorganized process of blood component
transfusion in the face of massive hemorrhagebeneﬁts from an
organized and standardized approach that deliversthe needed
blood products while avoiding their misuse. Despite these
obvious attractive features, in a recent review Malone found
only 10 such protocols published worldwide.67
The utility of
MTP (using different ratios of blood components) has already
been veriﬁed in some case controlled studies. Cotton tested
the effectiveness of a Trauma Exsanguination Protocol (1:2:4
ratio of platelets:FFP:PRBC) by comparing patients treated
with the protocol (n ¼ 94 over 18 months) to a cohort of similar
patients admitted during the prior 18 months (n ¼ 117). The
study found that implementation of the protocol reduced 30-
day mortality (51% vs. 66%, p < 0.03), decreased intraoperative
crystalloid administration (4.9 L vs. 6.7 L, p ¼ 0.002), and
reduced post-operative blood product use (2.8 units PRBCs vs.
8.7 units, p < 0.001; 1.7 units FFP vs. 7.9 units, p < 0.001; 0.9
units platelets vs. 5.7 units, p < 0.001).68
a similar study of an MTP (1:1:1 ratio of platelets:FFP:PRBC), by
comparing matched patients during one year period before
and after implementation of protocol (73 protocol, and 84
matched controls). Implementation of the protocol was found
to reduce mortality in the ﬁrst 24 h (17% with MTP vs. 36% pre-
MTP, p ¼ 0.008), and at 30 days (34% vs. 55%, p ¼ 0.04), with
a more pronounced impact in the blunt trauma patients.69
study also showed that MTP patients required fewer overall
transfusions of PRBCs and FFP after the ﬁrst 24 h (2.7 units
PRBCS vs. 9.3 units, p < 0.0001; 3 units FFP vs. 7.5 units,
p < 0.05). While further prospective research is needed to
specify the exact ratios, there is convincing evidence that
implementation of standardized protocols for blood compo-
nent transfusion improves processes of care, reduces overall
use of blood components, and improves outcomes.
iv. Red blood cell substitutes: Although advances in viral
screening have markedly decreased the risks of infectious
transmissions, blood transfusion continues to be associated
with numerous serious side effects. In trauma patients, trans-
fusion of red bloodcells (especiallyafter prolonged storage) has
been shown to disturb the immune system with an early
immune activation resulting in Systemic Inﬂammatory
Response Syndrome (SIRS), anda delayed immune suppression
which predisposes the patients to infections.70
As a matter of
fact, transfusion of PRBC remains an independent risk factor for
increased infections, multiple organ failure, length of hospital
stay, and mortality.71e74
This has prompted many researchers
to focus their attention on testing alternative oxygen carrying
A detailed discussion about the history and the
H.B. Alam / International Journal of Surgery 9 (2011) 5e12 7
4. development of these products is beyond the scope of this
article. However, all of these solutions contain some form of
polymerized hemoglobin molecule and are thus labeled as
hemoglobin-based oxygen carriers (HBOC). A common
problemwith the HBOC relates to the scavengingof nitric oxide
by the free hemoglobin molecule, which results in severe
vasoconstriction, a pro-inﬂammatory response, and end-organ
injury. Different formulations differ in the mammalian source
of the hemoglobin and how it is cross-linked, as well as in
storage and length of shelf-life. Of the HBOCs tested thus far,
only Hemopure or HBOC-201 (13 g/dL glutaraldehyde poly-
merized bovine hemoglobin) has remained in contention for
possible human use, while other formulations such as Poly-
heme (10 g/dL glutaraldehyde polymerized human hemo-
globin) and HemAssist (10 g/dL diaspirin cross-linked human
hemoglobin) have fallen out of favor due to negative phase III
clinical trials. In Sloan’s multicenter randomized clinical trial
(RCT) trauma patients in severe hemorrhagic shock received
either 500 ml of saline (n ¼ 53) or HemAssist (n ¼ 58) within
60 min of presentation. The study found a higher 28-day
mortality in the treatment arm (47% for HemAssist vs. 25% for
saline, p ¼ 0.015).76
In another multicenter RCT, trauma
patients with severe hypovolemic shock were randomized to
standard of care (n ¼ 62) or HemAssist (n ¼ 53) without any-
difference in 5- or 28-day mortality.77
Similar ﬁndings were
reported with Polyheme in a subsequent RCT, where trauma
patients in severe hemorrhagic shock were given either stan-
dard of care (crystalloid and allogenic blood transfusion,
n ¼ 365) or up to 6 units of Polyheme (n ¼ 349). Even after
accounting for numerous protocol violations (17%), there was
no mortality beneﬁt in the treatment arm, and a higher rate of
adverse events (93% for Polyheme vs. 88% for controls,
p ¼ 0.041).78
A 2008 meta-analysis of 16 HBOC trials, including
four trials of trauma patients receiving HemAssistor Polyheme,
raised alarm as patients receiving HBOCs were noted to have
a signiﬁcant risk of myocardial infarction (RR, 2.71; 95% CI,
1.67e4.40), and mortality (RR, 1.30; 95% CI, 1.05e1.61).79
meta-analysis also included a single study data from a 2005
presentationtothe U.S. FoodandDrug Administration (FDA) on
HBOC-201 use in surgical patients. HBOC-201 (Hemopure) has
also been rested in a trauma patient population in South
African study but the ﬁnal results of this trial remain unpub-
HOC 201 hasbeen extensively tested with goodresults
in animal models (and is approved for veterinary use). It has
also been tested in a large phase III clinical trial (n-688) in
elective orthopedic surgical patients, where use of HBOC-201
resulted in less need for PRBC transfusion but a signiﬁcant
increase in serious adverse events.81
A phase II multicenter trial
in trauma patients entitled Restore Effective Survival in Shock
(RESUS) was ﬁrst submitted to the FDA for approval in 2005.
However, after an initial positive response the FDA has
repeatedly refused to allow the clinical trial to proceed due to
concerns about patient safety, despite multiple revisions in the
study protocol. Thus, based upon these current data, the use of
any HBOCs can’t be endorsed at this time outside of well-
designed, thoroughly vetted clinical trials.
2. Septic shock
2.1. Initial resuscitation
As opposed to hemorrhagic shock, early goal directed resuscita-
tion has been shown to improve 28-day mortality in a single center,
Although the exact parameters used to guide
resuscitation in that study have been challenged, the basic concept is
clearly sound, as has been validated by a number of subsequent
For optimal results, the resuscitation protocol must be
initiated as soon as shock is diagnosed and should not be delayed
until admission to the intensive care unit (ICU). Due to venous
dilation, and increased capillary leak, most of these patients require
aggressive ﬂuid resuscitation over the ﬁrst 24 h. During this period,
in addition to ensuring adequate cardiac pre-load (e.g. central
venous pressure, pulmonary artery occlusion pressure), parameters
of tissue perfusion and oxygen delivery (e.g. serum lactate, base
deﬁcit, urine output, central/mixed venous oxygen saturation,
cardiac output) should be carefully monitored. The SAFE study88
shown that albumin and crystalloids are equally safe and effective
(except for patients with traumatic head injury). Surviving Sepsis
Campaign has recently reviewed the literature and published
updated and comprehensive guidelines to guide the resuscitation in
adult and pediatric patients.89
These guidelines also provide
evidence-based recommendations regarding a wide spectrum of
supportive/adjunctive therapies (e.g. glycemic control, steroids,
vasoactive agents, activated protein C etc).
2.2. Vasopressors and inotropes
Within reasonable limits, blood ﬂow through the tissue beds is
more important than blood pressure. However, during septic shock
autoregulation is not normal and perfusion can become linearly
dependent on blood pressure. Thus, after the initial ﬂuid resusci-
tation (or concomitantly) hypotensive patients may require
administration of vasopressors to keep the mean arterial pressure
>65 mmHg (which has been shown to preserve tissue perfu-
Whenever possible, vasopressors should be started after
providing adequate initial ﬂuid resuscitation. There is no compel-
ling, high quality evidence that shows one agent to be superior to
However, Surviving Sepsis Campaign recommends
“norepinephrine or dopamine as the ﬁrst choice vasopressor agent
to correct hypotension in septic shock (Grade IC)”.89
them, norephephrine has some attractive features as it increases
MAP (due to vasoconstriction), with little change in heart rate and
some increase in stroke volume. Dopamine is another good choice,
which increases MAP and stroke volume. However, it also increases
heart rate, which may not be desirable. Other choices have some
unattractive features. For example epinephrine can cause tachy-
cardia, decreased splanchnic circulation, and hyperlactemia.
Phenylephrine is a pure vasopressor and is least likely to cause
tachycardia, but it decreases stroke volume. Vasopressin has
recently gained popularity for treating refractory hypotension in
septic shock patients, as there is a relative deﬁciency of this
hormone in septic shock.93
However, a recent RCT-Vasopressin and
Septic Shock Trial (VASST), which enrolled 778 patients failed to
show a survival advantage of vasopressin (0.03 units/min) over
norepinephrine, or a reduction in overall rate of serious adverse
In addition to agents that restore the vascular tone,
patients with documented or suspected decrease in cardiac func-
tion (elevated ﬁlling pressures and low cardiac output) should be
given dobutamine as an inotropic agent.89
Administration of these
agents should be guided by serial measurements of markers of
tissue oxygenation, ﬁlling pressures and cardiac output, without
making an attempt to achieve supra-normal levels.89
2.3. Blood products
The optimal hemoglobin level has not been determined for
severely septic patients. Rivers and associates in the early goal
directed therapy trial82
used a target hematocrit of 30% in patients
who continued to show low central venous oxygen saturation. In
a more recent multi-institutional trail of mixed ICU patients (not
H.B. Alam / International Journal of Surgery 9 (2011) 5e128
5. necessarily septic shock patients) hemoglobin levels of 7e9 gm/dL
and 10e12 gm/dL were associated with identical outcomes.95
it is reasonable to aim for target hemoglobin between 7 and 9 gm/
dL if parameters of tissue oxygenation are adequate. But in cases of
depressed tissue oxygenation or in patients with other co-morbid
issues (e.g. coronary artery disease, stroke, etc), hemoglobin levels
can be pushed up to 10e12 gm/dL to optimize the tissue oxygen
delivery. However, this area remains controversial and evidence-
based guidelines have been proposed by experts in the ﬁeld to steer
the transfusion practices in these critically ill patients.96
3. Future directions
A number of new and exciting developments in the arena of
resuscitation research have the potential of radically transforming
clinical care in the near future. Two such areas of research are
3.1. Pharmacologic therapy
Over the years, a number of pharmacologic agents have been
tested as possible adjuncts to ﬂuid resuscitation. These drugs cover
a wide spectrum including neuroendocrine agents, calcium channel
blockers, ATP-pathway modiﬁers, prostaglandins, sex steroids, anti-
oxidants, anti-inﬂammatory agents, and immune-modulators.
Although there is strong laboratory evidence of their beneﬁcial
effects on tissue perfusion, myocardial contractility, reticulo-endo-
thelial function, cell survival, oxidative injury, and immune activa-
tion, majority of these agents are not yet in clinical use as
resuscitative agents. A thorough discussion of the research in this
area is beyond the scope of this article. However, a number of agents
aimed at correcting the circulatory and immunologic derangements
of hemorrhage are worth mentioning as promising pharmacologic
adjunctsto resuscitation. Dr. Chaudry’s group hasextensivelystudied
the role of sex steroids in cytokine responses and neutrophil adhe-
sion after hemorrhage; they have proposed estrogen and its analogs
as possible beneﬁcial treatments.97
Dr. Coimbra’s group has studied
the phosphodiesterase inhibitor, pentoxyfylline, already widely used
for vascular disease due to its rheologic properties, as a treatment for
A Cochrane review recently analyzed data on the opiate antagonist
Naloxone which has been studied based on the ﬁnding that central
Mu, Epsilon, Kappa, and Delta receptors are activated during
hemorrhagic shock and inhibit Caþþ
channels; the data suggested
that further clinical trials are needed to determine if the beneﬁcial
effects on blood pressure by administration of Naloxone result in any
durable improvements in survival.99
A common thread across all of
these potential agents is that they are already in wide clinical use for
other disorders. Thus, there is great hope that with more clinical
evidence, these agents whose safety proﬁle has already been tested
for various non-trauma indications can be rapidly implemented as
adjuncts to ﬂuid resuscitation. Our group has been studying another
group of drugs, also already in wide clinical use for non-trauma
indications, in animal models of shock. Following hemorrhage, the
stress of shock and resuscitation causes an immediate modulation of
genes and proteins involved in a variety of cellular defense pathways
through an alteration in their acetylation status.100,101
sized that histone deacetylase (HDAC) inhibitors such as valproic acid
(VPA) and suberoylanilide hydroxamic acid (SAHA) may have utility
in the treatment of shock through restoration of normal cellular
acetylation. We subsequently have shown that HDAC inhibitors
rapidly reverse shock induced alterations, restore normal histone
acetylation, and improve survival in different models of otherwise
fatal hemorrhagic shock and poly-trauma.102e104
survival improvement was achieved without conventional ﬂuid
resuscitation or blood transfusion, which makes this approach very
appealing for the logistically constrained pre-hospital and battleﬁeld
environments. It appears that HDAC inhibitors rapidly activate
nuclear histones as well as numerous cellular proteins to create
a “pro-survival” phenotype in hemorrhagic and septic shock.105e109
Unpublished data also demonstrate that this approach is very
promising for the treatment of traumatic brain injury. A number of
these HDAC inhibitors are currently being tested in phase I and II
clinical trials (non-traumatic situations). We believe that additional
research in this arena could ultimately lead to a potent pharmaco-
logic adjunct to the treatment of hemorrhagic shock that works by
promoting cell survival during periods of lethal stress.
3.2. Emergency Preservation and Resuscitation (EPR)
Up to 80% of trauma deaths occur in the early post-traumatic
with exsanguination as the dominant etiology.2
shock from blood loss does not respond well to conventional
methods of resuscitation.14
Even when the underlying cause can be
treated and circulation restored, cerebral ischemia lasting 5 min or
longer invariably results in severe brain damage. Often the under-
lying injuries are reparable but the patient dies of irreversible shock
or severe brain damage. In this setting, strategies to maintain cere-
bral and cardiac viability long enough to gain control of hemorrhage
and restore intra-vascular volume could be life saving. This requires
an entirely new approach to the problem, with emphasis on rapid
total body preservation, repair of injuries during metabolic arrest,
and controlled resuscitation: Emergency Preservation and Resusci-
tation (EPR). Currently, hypothermia is the mosteffectivemethod for
preserving cellular viability during prolonged periods of ischemia.
Although, no clinical studies have been conducted to test the ther-
apeutic beneﬁts of hypothermia in trauma patients, numerous well-
designed pre-clinical studies clearly support this concept. It should
be emphasized upfront that induced hypothermia and hypothermia
secondary to shock are very different entities. Induced hypothermia
is therapeutic in nature whereas hypothermia, seen in severely
traumatized patients, is a sign of tissue ischemia and failure of
homeostatic mechanisms to maintain normal body temperature. It
is clear from the literature that rapid induction of deep/profound
hypothermia (<15 C) can improve otherwise dismal outcome after
exsanguinating cardiac arrest.111e113
Depending on the degree of
hypothermia, good outcomes have been achieved with cardiac
arrests of 15, 20, 30 and even 90 min in canine models.114,115
Furthermore, the period of hypothermia can be safely extended to
180 min if blood is replaced with organ preservation ﬂuids and low
ﬂow cardiopulmonary bypass is continued (as opposed to no ﬂow)
during the arrest period.116
Although ground breaking, the clinical
relevance of these original studies was somewhat limited by reliance
on pressure-controlled models of hemorrhagic shock (or no
hemorrhage), an absence of major injuries, and lack of surgical
interventions. To ﬁll these gaps, our team has utilized clinically
realistic large animal models of lethal vascular injuries and soft
tissue trauma to demonstrate that profound hypothermia can be
induced through an emergency thoracotomy approach for total
body protection, with excellent long-term survival and no neuro-
logical damage or signiﬁcant organ dysfunction.117
In a follow up
study, it was established that lethal vascular injuries, above and
below the diaphragm, can be repaired under hypothermic arrest
with 75% long-term survival.118
More importantly, it was shown
that hypothermia could be used successfully even after 60 min of
normothermic shock (transport time), and that the surviving
animals were not only neurologically intact but also had normal
cognitive functions. Subsequent studies have determined that to
achieve the best results, profound hypothermia must be induced
rapidly (2 C/min) and reversed at a slower rate (0.5 C/min).119,120
H.B. Alam / International Journal of Surgery 9 (2011) 5e12 9
6. Induction of hypothermia has been shown to preserve various cell
types in the central nervous system, while providing some immu-
nological advantages, and modulating cell survival pathways.121e123
The optimal depth of hypothermia is 10 C, and decreasing the
temperature to ultra-profound levels (5 C) may actually worsen the
If done appropriately, the safe duration of total body
preservation in poly-trauma is about 60 min,125
and it results in no
increase in post-operative bleeding or septic complications.126
Technically it is now feasible to induce hypothermia using small,
battery operated, portable equipment (suitable for austere settings
and pre-hospital environment).127
This is associated with excellent
“total body preservation” which may have signiﬁcant implications
not only for treatment of traumatic injuries but also for preserving
organs for transplant.128
Induction of hypothermia not only modu-
lates metabolism but also inﬂuences a vide variety of cellular and
including alteration in transcription of
numerous beneﬁcial genes,130
the down-stream effects of which
persists long after hypothermia. There is also some data from small
animal models to suggest that similar metabolic arrest (and tissue
preservation) can be achieved with other methods, such as inhaled
It may sound futuristic, but the expertise to
preserve the viability of key organs during repair of otherwise lethal
injuries is now available,132
and a prospective multi-institutional
clinical trial is scheduled to start later this year.133
Treatments of shock have evolved over the last 50 years, but the
changes over the last decade have been especially dramatic.134e136
Based upon contemporary data, early goal directed ﬂuid resuscita-
tion should be considered the standard of care for septic shock, along
with additional supportive measures as advocated by the Surviving
The optimal approach for hemorrhagic shock is
not as clear due to a relative paucity of level-1 evidence. However,
according to my personal opinion the existing literature strongly
supports some common sense recommendations for the treatment
of hemorrhagic shock.137
First, resuscitation is not a substitute for
early hemorrhage control. From the moment of injury, all efforts to
provide deﬁnitive control of hemorrhage as expeditiously as
possible must be aggressively pursued. Second, large volume crys-
talloid resuscitation is deleterious and should be abandoned. Fluid
resuscitation can be safely withheld in patients who have adequate
cerebral perfusion (normal mental status in the absence of head
injury) and a palpable radial pulse, especially if the pre-hospital
transport time is expected to be brief. For situations where the time
to deﬁnitive care is longer than 15e20 min, initiation of limited
volume resuscitation is supported by the literature. Speciﬁcally, the
goals should be to maintain either a SBP approximating
80e90 mmHg, or clear mental status (in the absence of head injury)
and a palpable radial pulse. At present, it seems that infusion of
lactated Ringer’s solution (containing only the L-isomer of lactate) is
the best option in the pre-hospital setting, whereas early use of
blood products should be strongly considered once the patient
reaches the hospital.18,23,137
While the ideal ratio of blood compo-
nents is under investigation, there is a strong trend in favor of
starting component therapy early and to administer higher ratios of
FFP and platelets to PRBC. Newer methods for blood component
preservation have improved their logistical proﬁle, which may yield
shelf-stable products for pre-hospital use in the near future.138,139
The evidence strongly suggests that applying these ratios through
an institutional protocol improves delivery of care and outcomes.
When blood products are not an option, blood substitutes may have
a role. However, at present, the data on blood substitutes are far too
mixed to recommend their use outside of trials. Finally, pharmaco-
logic adjuncts to resuscitation may ultimately play a role is reducing
the deleterious immunologic and cellular effects of hemorrhage and
resuscitation. This is an exciting area of future research but their use
remains to be validated in robust clinical trials. For now, early and
expeditious control of hemorrhage and modest, goal directed
resuscitation should be the standard of care.
Conﬂict of interest
Sources of funding
National Institutes of Health and US Department of Defense.
The author would like to acknowledge research support
provided by numerous grants by the Ofﬁce of Naval Research, US
Army Medical Research and Materiel Command, Defense Advanced
Research Projects Agency, and National Institutes of Health.
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110. Demetriades D, Murray J, Charalambides K, Alo K, Velmahos G, Rhee P, et al.
Trauma fatalities: time and location of hospital deaths. J Am Coll Surg
111. Tisherman SA, Safar P, Radovsky A, Peitzman A, Sterz F, Kuboyama K. Ther-
apeutic deep hypothermic circulatory arrest in dogs: a resuscitation modality
for hemorrhagic shock with irreparable injury. J Trauma 1990;30:836e47.
112. Tisherman SA, Safar P, Radovsky A, et al. Profound hypothermia (10
compared with deep hypothermia (15
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dogs after two hours circulatory arrest induced to enable resuscitative
surgery. J Trauma 1991;31:1051e62.
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recovery after normothermic hemorrhagic shock and profound hypothermic
circulatory arrest of 60 min in dogs. J Trauma 1996;40:388e95.
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Rapid hypothermic aortic ﬂush can achieve survival without brain damage
after 30 min cardiac arrest in dogs. Anesthesiology 2000;93:1491e9.
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death of 60e120 min in dogs using suspended animation by profound
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solution for life without blood: asanguineous low-ﬂow perfusion of a whole
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rewarming from profound hypothermic arrest inﬂuences the outcome in
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profound hypothermia modulates the immune/inﬂammatory response in
a swine model of lethal hemorrhage. Resuscitation 2005;66(2):209e16.
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hypothermia preserves neurons and astrocytes, and protects cognitive func-
tions in a swine model of lethal hemorrhage. J Surg Res 2005;126:172e81.
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hypothermia decreases cardiac apoptosis through Akt survival pathway. J Am
Coll Surg 2009;209(1):89e99.
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hypothermia is superior to ultra-profound hypothermia in improving survival
in a swine model of lethal injuries. Surgery 2006;140:307e14.
125. Alam HB, Duggan M, Li Y, et al. Putting life on hold-for how long? profound
hypothermic cardiopulmonary bypass in a swine model of complex vascular
injuries. J Trauma 2008;64:912e22.
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Profound hypothermic cardiopulmonary bypass facilitates survival without
a high complication rate in a swine model of complex vascular, splenic and
colon injuries. J Am Coll Surg 2007;204:642e53.
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lines casualty management system. Artif Organs 2005;29:557e63.
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profound hypothermic cardiac arrest. Transplant Proc 2005;37:303e7.
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or a foe? Scand J Trauma Resusc Emerg Med 2009 Dec 23;17(1):65 [Epub ahead
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H.B. Alam / International Journal of Surgery 9 (2011) 5e1212

domain: health


text:
Carved Wooden Boxes are hand crafted and intricately carved wooden boxes inlay in pewter or brass made in India. All products, gifts and handbags are unique, handmade, handcrafted by artisans of the Fair Trade Organizations.
Handcrafted Carved Mango Wood Open Box - Noahs Ark (B)
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Handmade Small Lattice Cutwork Wood Box - Matr Boomie (B)

domain: design


How would I go about dedicating more ram to the GPU? I feel like is just too low. It’s an integrated graphics solution and as such has no dedicated memory but rather takes some from system RAM and it’s usually too low. How do I increase the dedicated video memory on an HP laptop? Hi, set it to MB or MB. You’ll find some version of the chip in most laptops, even those equipped with discrete graphics. The term “integrated” graphics means that the GPU is embedded on the same die as the processor and shares available system memory.
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What you might try at this point is run a dxdiag https: Have you tried this Amazon trick?
Is there any way to enable that option? Refer to the table below for the recommended amount of video memory based intel hd graphics 128mb the amount of RAM you have:. If it does, then you will be able to insert a dedicated video card in it, but most probably a low profile one, because the case of this particular desktop is tiny.
Please visit the new Overwatch community forums at https: Pavel 218mb March 23, at Omar Medhat February 8, at 5: For intel hd graphics 128mb information check out my article about how to improve Intel HD Graphics performance.
How many monitors can I power with Intel graphics? Luckily, this tool can help you outsmart the marketplace.
Right now I only have mb of dedicated video ram and I think that may be an issue with over mb of available VRam intel hd graphics 128mb one stick of 8 gb ram. You can disable dynamic itel for a pretty good FPS boost if I remember the topic from a few months ago right.
Hi, unfortunately on laptops the setting to increase the memory allocated to Intel HD Intel hd graphics 128mb is rarely available. My laptop shows a low memory error. It’d be dead in an hour if I left it unplugged. Another possible solution for desktops is to simply insert a dedicated video card.
How to Increase Intel HD Graphics Dedicated Video Memory
Submit any pending changes before refreshing traphics page. Still have a question? Your laptop most likely has integrated graphics with dynamic allocation. I recommend you try the following:. Here are more ways to improve Intel HD Graphics performance.
Graphic Issues with a BRAND NEW Laptop – Overwatch Forums
Hi, you should check if there”s a BIOS update grahpics your laptop that allows allocating more memory to Intel HD Graphics or contact your laptop’s manufacturer Asus in your case for more information. It is provided for general information only and should not be relied upon as complete intel hd graphics 128mb accurate.
The price Amazon shows isn’t always the lowest. Intel hd graphics 128mb amount reported can be modified or disabled if desired by graphocs the following registry value: Hello, i have intel i3, intel graphics, 6gbRAM, when i enter bios, there is no such a thing to change dedicated video memory.
Intel HD Graphics Guide
Before taking any actions, let’s check out how much “dedicated” memory your Intel HD Graphics is currently using. Then Your PC restarts and get into ‘Start up’ window. I have not yet found a way to set the min memory for the GPU but I just started looking. Idle Gibblet July 31, at 6: I just think that I should be able to squeeze intel hd graphics 128mb little more out of this computer. Related Questions More Answers Below How do I increase dedicated video memory of intel hd graphics and is there any harm in it?
Do you think Uber and Lyft drivers are compensated fairly? Unfortunately, some games are coded to require a specific amount intel hd graphics 128mb dedicated video memory and if not present in the system they refuse to start, although they may be perfectly playable on Intel HD Graphics.


text:
I’d guess that about half of my time in South-East Asia was spent kicking around the market. Whether in a tiny mountain town, an ocean-side village, or the big cities, I could count on finding an open-air market full of strange and exotic foods. As early as four a.m the morning market is already filling up with fresh produce, warm soy milk, and tasty breakfast treats. In a larger town multiple markets will pop up throughout the day and even the smallest villages support some kind of market again in the evening so that I could often spend the entire day investigating the cornucopia of fresh fruits, endless rice confections, and assorted animal bits. Chicken feet, buffalo stomach, and toads on a stick, while novel, often did not seem worth the risk of actually consuming. However, I made it a goal to try every kind of fruit I came across.
Tropical regions support a wide variety of exotic, foreign, and down-right strange looking and tasting fruits. From the noxious odor of the durian
to the alien seed pod appearance of the rambutan
, I thought I’d seen and tasted about everything the world of fruits could offer when I was walking through the streets of Vientiane
and saw a street cart full of what looked like small, pink pineapples. So I bought a dragonfruit and hurried back to the hotel to dissect it and hopefully find something edible.
Under the large, green-tipped, pink scales the fruit is all meat, white in color and flecked throughout with black seeds. The texture is somewhat like a watermelon but with no stringy fibers. The seeds are soft, flavorless, and edible, which is a good thing as it would be practically impossible to pick them out. The meat is light and crisp with a subtle flavor something like watermelon and something like kiwi. It is very juicy and I ended up slicing mine in half and eating it with a spoon right out of the shell.
I’ve been looking for dragonfruit in the states since my return with no luck. But I have found out a lot about the fruit.
There is a lot of confusion as to where dragonfruit comes from. Many sources, including gourmetnews.com, claim it is from South-East Asia. Vietnam and Malaysia are both producing dragon fruit as an export and it is also available in Thailand, Laos, and Cambodia. The Vietnamese name for the fruit is “trai thanh long”.
The true origin appears to be South America where the fruit has another name that has multiple spellings. Pitaya, Pithaya, Pitahaya, and Pitaja, all derivitives of the Ta’no
word meaning scaly fruit, refer to the fruit of a cactus family plant called Hylocereus. There are two varieties of this genus. Hylocereus Undatus with white flesh like the one I bought is the most common in South-East Asia and supposedly a bit more tart than its sweeter, red-fleshed sister Hylocereus Polyrhizus. These two have a cousin with bright yellow, bumpy skin with white flesh with the scientific name Selenicereus Megalanthus. All are referred to by the same common name. ilovepitaya.com/ claims that Americans brought the dragon fruit or Pitaya, which has a third common name of strawberry pear, to South-East Asia during the Vietnam War. This seems a bit odd considering that dragonfruit is not common at all in North America, but it did find its way from its Andean home in Columbia
(the major South American exporter), Venezuela
, to South-East Asia and now most of the tropical world. California and Australia are also working to develop dragonfruit farms.
This fruit is definitely best fresh out of the rind. Slice it open, grab a spoon and dig in. Many people claim it makes a fantastic milk shake and it is 83% liquid so you can get a lot of delicious juice out of it. The juice is used in mixed drinks in South America, including “panther piss
” which is a mix of rum and dragonfruit juice. The unopened flower buds of the plant can be used as a vegetable (much like banana flowers) in stews, curries, or salads. Dragonfruit extract is beginning to be used in more commercial foods in the west like Snapple’s “Fire” drink and one of the “Stash” brand herbal teas. Like many other exotic fruit flavors, these manufactured products reflect little if any of the flavor of the actual fruit.
Canadians and Australians may have better luck finding the fruit than Americans as it appears that there are import regulations that keep this fruit out of the USA. That may vary by region and the best place to look for it is at a major cities Chinatown.
ilovepitaya.com/ also makes a few health claims about dragon fruit. It supposedly aides digestion, prevents colon cancer and diabetes, and reduces cholesterol and high blood pressure. However these claims are made about many herbs, fruits, and veggies, especially by marketers like ilovepitaya.com. So I wouldn’t expect any medical miracles from dragonfruit.
The cactus also has a beautiful and fragrant flower, which only blooms at night and normally for one night only. In that short period of time it must be pollinated (usually by the hawk moth
) in order for the fruit to set. If the fruit does set it generally takes a 40-45 days to mature. It produces year round in tropical climates yielding fruit four or five times per year. It is possible to order seeds or start a new plant from a clipping, but don’t expect much fruit if you are growing outside tropical climates.

domain: food


text:
“I have hardly begun to think of the Unity before the Trinity bathes me in its splendour: I have hardly begun to think of the Trinity before the Unity seizes hold of me again.
When one of the Three presents himself to me, I think it is the whole, so full to overflowing is my vision, so far beyond me does he reach. There is no room left in my mind, it is too limited to understand even one. When I combine the Three in one single thought, I see only one great flame without being able to subdivide or analyse the single light.” Gregory Nazianzen Or. 49 on Baptism
Fr. Eric’s Trinity Sunday homily expresses Gregory’s disposition. He introduces two terms that sparkle with meaning: perichoresis and circumincession. Staying grounded Fr. Eric is sublime.
If you still want more, try John of the Cross’ poetic description using three streams of a river as metaphor:

domain: artistic


The Rolling Stones are getting closer to the end of their Rolling Stones’ 60th Anniversary Tour. Here’s a review of the main moments that defined the shows and a focus on Milan, where the band arrived after five years.
A long awaited date for Rolling Stones’ Italian fans
Before the date in Milan, The Rolling Stones last played in Italy only with a concert in Lucca in 2018 and at the Circus Maximus in Rome in 2014. It was 16 years since the last time performed in Milan.
However, people from all over the county came to the venue: British, Germans and French were only some of the guests that attended the show. People from the entire the peninsula came as well. From children to elders, the show united a huge variety of fans who came to attend the only date in the country.
At the end of the night, 57 thousand people joined the band in San Siro Stadium.
Mick Jagger starting the stadium up
At the age of 79, Jagger has never been as energetic as he is now. Not even Covid could stop Jagger, who got infected 7 days before the event.
Not only the artist proved to be one of the best performers around still, but he did it with laud. Together with his famous moves, he even ran along the entire stage, cheered by fans who were shocked but not surprised by the energy of the singer and leader.
Fans couldn’t be any more satisfied after the performance of the band. When you decide to attend a Stones’ concert, you do always get what you want.
The set list
The set list for the shows includes classics Gimme Shelter, Paint It Black, Jumpin’ Jack Flash, Tumbling Dice, (I Can’t Get No) Satisfaction, Start Me Up and many more hits.
The concert began with a surprising Street Fighting Man. Immediately, Jagger proved his undoubted recovery from Covid, running around the stage and dancing his iconic moves.
The most evocative scene comes with Wild Horses, for which the entire stadium was filled with lights.
On the other hand, for hits like Miss You, Start Me Up, Jumping Jack Flash and (I Can’t Get No) Satisfaction, the band gave the audience a unique energy, with Jagger jumping from one side of the stage to the other. As for Gimme Shelter, the audience was speechless in front of Chanel Haynes’ incredible voice on the verse. During the song, the band also referenced support for Ukraine with the representation of the white and yellow flag on the screens. The song proved to be still extremely prevailing today.
A night and a tour dedicated to Charlie
The recent loss of the one and only drummer Charlie Watts on August 24, 2021 harshly affected both the band and fans.
The 60th Anniversary Tour is the first time that Jagger, Richards and Wood take to the road without drummer. Steve Jordan is playing drums on the band’s tour.
However, the band members lovingly remembered their friend and companion. In fact, the concert began with a video in honour of the drummer.
One of the sentences pronounced in Italian by the singer also included a recollection of his friend. “We miss him so much,” he said.


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The Academy Summer Show 2017
July 22–23, 2017
Performances: Saturday 2pm and 5pm and Sunday at 2pm
Box Office: 07568 150759 or email@example.com
The Academy was established in 2015 by Sara Bispham and offers classes in Drama, Screen Acting, Singing and Dance for ages 5-18 years. This showcase is full of high energy singing and dancing featuring songs from West End Musicals and the latest pop charts!
Come and see some of Bushey & Watford's finest young talent !
For more information please visit: www.theacademywatford.com
Performances: Saturday 5 pm and Sunday at 2 pm and 5 pm

domain: entertainment


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text:
So it's no secret that I tend to be lucky with the giveaways. But lately...well, my hot streak has gotten even hotter.
A few months ago I won a Free Fabric Friday giveaway on Sew, Mama, Sew! I chose this fabric from Michael Miller's Hedgehog and the Big E. Cause it's awesome.
Then I won this bundle of lilac loveliness all the way from Sardana Creations in Austria.
I was also the lucky recipient of this super cool pattern from Carolina Patchworks. Can't wait to try this one.
I heard from Andrea that I won this little stuffie pattern from Wee Wonderfuls (did you see that Hillary's book is out now? Must have.)
Why am I embarrassed? It's not my fault Mr. Random Number Generator likes me.
I got this stack of floral goodness in the mail today after winning a giveaway on The Quilt Nook.
Fat quarters of Lecien's Flower Sugar 2.
This is just fueling my burgeoning polka dot obsession.
Cara sent along this cute pattern too.
But, wait, there's more!
I heard today that I won a gift certificate to Downstairs Designs. I'm looking forward to spending it.
Okay, now I'm feeling a bit sheepish. And very, very lucky! I suppose the only thing left to do is have a little giveaway of my own. Stay tuned...
spring quilt market 2017
7 hours ago

domain: hobby


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Pseudomonas aeruginosa is a Gram negative, aerobic, rod shaped bacterium with unipolar motility (Ryan et al., 2004). It is a common bacterium which can cause disease in human and animals, mostly found in soil, water, and most man-made environments throughout the world. It thrives not only in normal atmospheres, but also with little oxygen, and has thus colonized in many natural and artificial environments. Because it thrives on moist surfaces, this bacterium is also found on and in medical equipment’s including catheters, causing cross infections in hospitals and clinics. P. aeruginosa is a slender Gram negative bacillus, 1.53Hm x 0.5Hm, actively motile by a polar flagellum. Clinical isolates are often piliated. It is non-capsulated but many strains have a mucoid slime layer. A mucoid strains, particularly isolates from cystic fibrosis patients have an abundance of extracellular polysaccharides composed of alginate polymers. This forms a loose capsule in which micro colonies of the bacillus are enmeshed and protected from host defences (Ananthanarayan et al., 2000).
The Enterobacteriaceae are a large, heterogeneous group of gram-negative rods whose natural habitat is the intestinal tract of humans and animals. The family includes many genera ( Escherichia, Shigella, Salmonella, Enterobacter, Klebsiella, Serratia, Proteus, and others). Some enteric organisms, such as Escherichia coli, are part of the normal microbiota. (Funke et al., 2009). E.coli bacteria may give rise to infection in wound, urinary tract, and abnormal cavity. This organism may cause septicemia and hemorrhagic diarrhea.( Madigan et al., 2006). An E. coli infection may also rise due to environmental exposure. Infection with this type of bacteria pose a serious threat to public health with outbreak rising from food and water that has been conterminated with human or animal feces sewage. This type of bacteria has been used as a biological indicator for safety of drinking water since the 1860s.
2.2. MORPHOLOGY AND IDENTIFICATION OF PSEUDOMONAS AEROGENOSA
AND ESCHERICHIA COLI
Pseudomonas aerogenosa is a motile organism (polar flagella) and is rod in shaped, is about (0.6 × 2 ?m)in length . It is gram negative and occurs as single bacteria, in pairs, and occasionally in short chains. The best known are pyocyanin (blue-green), pyoverdine (yellow-green, flourenscent). It is commonly found free living in moist environments and is also pathogen of plants, animals, and humans.
Pseudomonas aerugenosa is often preliminarily identified by its typical odor in vitro. The smell is described as grape-like, tortilla-like. It is not an active fermenter of carbonhydrate and produces acid, but no gas, in glucose and is lactose-negative. The oxidase and catalase test for P. aerugenosa are positive. (Wikipedia).
The multiply slowly in anaerobic environment if nitrate is present as a hydrogen acceptor. It is able to grow at 42?. The combination of pyocyanin production and the ability to grow at 42? is sufficient to distinguish P.aerogenosa from other Pseudomonas spp. e.g., P.fluorenscens, P.putida, P.stutzeri, P.putrefaciens), certain strains of P.aerugenosa may not produce pyocyanin (Wikipedia).
Escherichia coli and most of the other enteric bacteria form circular, convex, smooth colonies with distinct edges. Enterobactercolonies are similar but somewhat more mucoid. Klebsiellacolonies are large and very mucoid and tend to coalesce with prolonged incubation. Th e salmonellae and shigellae produce colonies similar to E. coli but do not ferment lactose. Some strains of E coli produce hemolysis on blood agar.
Escherichia—E coli typically produces positive test results for indole, lysine decarboxylase, and mannitol fermentation and produces gas from glucose. An isolate from urine can be quickly identified as E coli by its hemolysis on blood agar, typical colonial morphology with an iridescent “sheen” on differential media such as EMB agar, and a positive spot indole test result. More than 90% of E coli isolates are positive for ?-glucuronidase using the substrate 4-methylumbelliferyl-?-glucuronide (MUG). Isolates from anatomic sites other than urine, with characteristic properties (above plus negative oxidase test results) often can be confirmed as E coli with a positive MUG test result.

domain: medical


Dissolved organic matter (DOM) plays a significant role in freshwater and marine aquatic ecosystems including its effects on nutrients and carbon cycling and trace metal and contaminant availability. The colored fraction of DOM, CDOM, directly affects the quantity and spectral quality of available light, thereby impacting both primary production and UV exposure in aquatic ecosystems. Measuring the DOM absorption coefficient in situ is difficult because it requires prefiltration of the sample. From measurements made in inland, riverine, estuarine and coastal environments, we show that using the WETStar fluorometer (WET Labs), good estimates of dissolved absorption can be obtained from DOM fluorescence (DOM-FL) measured in situ on unfiltered samples. DOM-FL measured with the in situ fluorometer compare very well to values obtained on filtered samples using more sophisticated laboratory spectrofluorometers. Acquisition of high frequency, long-term data series or high-resolution profiles is feasible and artifacts resulting from filtration or sample storage can be avoided when measurements are made using the WETStar DOM fluorometer. The utility of high-resolution DOM-FL profiles for biogeochemical studies is illustrated by in situ data obtained in the East Siberian Sea.
ASJC Scopus subject areas
- Aquatic Science


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LEGAL & COMPLIANCE: SEC Adopts Reforms to Prime Money Market Funds
The U.S. Securities and Exchange Commission approved a measure today to require prime money market funds to move from a stable $1 per share net asset value, to a floating NAV. The adopted rules (summarized in an attached document) will also allow fund boards to lower redemption “gates” and fees in times of market stress. Regulators say the new rules, adopted in a 3-2 vote, with Republican SEC Commissioner Michael Piwowar and Democrat Kara Stein dissenting, are designed to curb the risk of investor runs on money market funds. A run on one fund during the 2008 financial crisis nearly toppled the $2.6 trillion industry before the Treasury Department stepped in to backstop it.
Industry opponents argue that the changes will destroy the appeal of money funds for corporate and large institutional investors, who have come to rely on money market funds to manage cash. Additionally, opponents argue that the floating share price will result in complex tax reporting requirements for investors, unless tax rules regarding the recognition of gains and losses are changed or waived with respect to money market fund redemptions.
The SEC, in response to that criticism, said the Treasury Department and the Internal Revenue Service will release two types of tax guidance that will simplify the process for tracking gains and losses under the new floating share system. The new rules, which were just issued and are attached below, would allow floating net asset value (NAV) money market fund investors “to use a simplified tax accounting method to track gains and losses that could be used beginning today,” according to the SEC release.
“The proposed regulation will eliminate the need to track individual purchase and sale transactions for tax reporting purposes.” The second item to be issued, according to the SEC, is a revenue procedure providing “relief from the ‘wash sale' rules for any losses on shares of a floating NAV money market fund,” the commission said.
FACT SHEET - Money Market Fund Reform
Treasury MMF Guidance

domain: news