Driving pressure during general anesthesia for open abdominal surgery (DESIGNATION) : study protocol of a randomized clinical trial

Background Intraoperative driving pressure (Delta P) is associated with development of postoperative pulmonary complications (PPC). When tidal volume (V-T) is kept constant, Delta P may change according to positive end-expiratory pressure (PEEP)-induced changes in lung aeration. Delta P may decrease if PEEP leads to a recruitment of collapsed lung tissue but will increase if PEEP mainly causes pulmonary overdistension. This study tests the hypothesis that individualized high PEEP, when compared to fixed low PEEP, protects against PPC in patients undergoing open abdominal surgery. Methods The "Driving prESsure durIng GeNeral AnesThesIa for Open abdomiNal surgery trial" (DESIGNATION) is an international, multicenter, two-group, double-blind randomized clinical superiority trial. A total of 1468 patients will be randomly assigned to one of the two intraoperative ventilation strategies. Investigators screen patients aged >= 18 years and with a body mass index <= 40 kg/m(2), scheduled for open abdominal surgery and at risk for PPC. Patients either receive an intraoperative ventilation strategy with individualized high PEEP with recruitment maneuvers (RM) ("individualized high PEEP") or one in which PEEP of 5 cm H2O without RM is used ("low PEEP"). In the "individualized high PEEP" group, PEEP is set at the level at which Delta P is lowest. In both groups of the trial, V-T is kept at 8 mL/kg predicted body weight. The primary endpoint is the occurrence of PPC, recorded as a collapsed composite of adverse pulmonary events. Discussion DESIGNATION will be the first randomized clinical trial that is adequately powered to compare the effects of individualized high PEEP with RM versus fixed low PEEP without RM on the occurrence of PPC after open abdominal surgery. The results of DESIGNATION will support anesthesiologists in their decisions regarding PEEP settings during open abdominal surgery

Een schets van de professionalisering van de wijkverpleging in Nederland in de laatste vijftig jaar (1950-2000)

This article describes home nursing in the Netherlands between 1950 and 2004. The developments in this period are described from the theoretical perspective on professions of Andrew Abbott: 'professions are exclusive occupational groups applying somewhat abstract knowledge to particular cases.' In 1950, home nursing was an all-round profession providing home nursing care and preventive care to all categories of patients, mainly in their own homes. It was - and still is - a profession situated in the 'periphery' of the health care system, where care and support to patients with pain, suffering and disabilities because of age or chronic illness are considered as belonging to a separate task domain, relatively independent of the mainly curative activities that are performed in the 'medical centre' of health care, especially in the academic hospitals. Typical compared to other countries is that an extensive network of private initiatives, in the form of Cross Organisations of different denominational signatures, existed in the Netherlands until 1990, covering the whole country with home nursing services. In that year, the provision of home nursing and home help were integrated and most home nursing organisations merged into large, regional home care organisations. In this article, six main social developments are described, that influenced the development of home nursing and resulted in the profession as it is now: a differentiated profession divided into different levels of care, working in an organisational, largely bureaucratic setting of home care organisations, where managers and external regional assessment organisations (RIO's) decide on the care to be provided. They now find themselves in a transmural setting, where boundaries between different forms of care no longer exist, and co-operation with other professionals, such as home helps, specialist nurses, GPs, and hospital physicians, is frequent. Currently, their professional autonomy and independent decision-making regarding diagnosis and therapy is affected, and elements of bureaucratisation and managementism (for example aspects such as time-writing) affect their daily work. However, home nursing can still be characterised as a relatively exclusive and independent profession, solving particular cases in the homes of patients by performing activities that are based on abstract, methodical knowledge

Identification of hyaluronan as a crystal-binding molecule at the surface of migrating and proliferating MDCK cells

Identification of hyaluronan as a crystal-binding molecule at the surface of migrating and proliferating MDCK cells.BackgroundThe adherence of calcium oxalate crystals to the renal tubule epithelium is considered a critical event in the pathophysiology of calcium nephrolithiasis. Calcium oxalate monohydrate (COM) crystals cannot adhere to the surface of a functional Madin-Darby canine kidney (MDCK) monolayer, but they bind avidly to the surface of proliferating and migrating cells.MethodsTo identify crystal-binding molecules (CBMs) at the surface of crystal-attracting cells, we applied metabolic labeling protocols in combination with differential enzymatic digestion and gel filtration, which was compared with [14C]COM crystal binding and confirmed by confocal microscopy.ResultsThe indication that hyaluronan [hyaluronic acid (HA)] might act as a CBM in subconfluent cultures came from studies with glycosaminoglycan (GAG)-degrading enzymes. Subsequently, metabolic-labeling studies revealed that hyaluronidase cleaved significantly more radiolabeled glycoconjugates from crystal-attracting cells than from cells without affinity for crystals. During wound repair, crystal binding could be prevented by pretreating the healing cultures with hyaluronate lyase, an enzyme that specifically hydrolyzes HA. Binding to immobilized HA provided evidence that COM crystals physically can become associated with this polysaccharide. Finally, confocal microscopy demonstrated that fluorescently labeled HA binding protein (HABP) adhered to the surface of proliferating cells in subconfluent cultures as well as to cells involved in closing a wound, but not to cells in confluent monolayers.ConclusionsThese results identify HA as binding molecule for COM crystals at the surface of migrating and proliferating MDCK cells