NORMAL SALINE IS NOT SO NORMAL

In a study from England published ahead of print in Annals of Surgery, healthy volunteers given two liters of so-called "normal" saline intravenously showed signs of decreased kidney perfusion and increased fluid retention compared to infusion of a balanced salt solution. The work builds on previous research suggesting that normal saline, in use intravenously for over 100 years, is not "normal" and may not be the best fluid to use, especially in patients who are susceptible to renal dysfunction.

In an email to Reuters Health, lead author Dr. Dileep N. Lobo of the University of Nottingham said, "Had normal saline been formulated in recent times, it is debatable whether it would have survived a phase 1 trial."

Dr. Lobo's group carried out a randomized, double-blind cross-over trial involving 12 healthy male volunteers who were given two-liter infusions over one hour of either "normal" 0.9% saline or the balanced salt solution Plasma Lyte-148, several days apart. Plasma Lyte-148 contains sodium and chloride in physiologic amounts, compared to the higher amounts of those two ions found in normal saline.

During the four hours following the infusions, subjects underwent sequential blood and urine tests as well as magnetic resonance imaging (MRI) of their kidneys.

The main results: when the men received normal saline, they retained significantly more fluid in the extravascular space (1,484 vs 1,155 mL; p=0.031) and gained more weight (1.2 vs 0.84 kg, p=0.22). With the balanced solution, they produced significantly higher urine volumes and had a significantly shorter time to first voiding.

Furthermore, in the normal saline trials, serum chloride was significantly higher from the first hour on (p=0.0001), and a low strong ion difference indicated acidemia (p=0.025).

MRI showed that normal saline significantly decreased renal artery flow velocity (p=0.045) and renal cortical tissue perfusion (p=0.008) compared to the balanced solution - differences that could matter in patients with kidney disease.

The authors point out that some 200 million liters of normal saline are used in the U.S. every year. The paper doesn't address the issue of costs, but Dr. Lobo said, "Plasma-Lyte 148 is more expensive but this is likely to be because it is not widely used. Just because a product is more expensive does not mean that it should not be used in the clinical setting."

Dr. Lobo pointed out that a paper this year by Shaw et al, also in Annals of Surgery, showed that complications and resource use are less with Plasma-Lyte than with 0.9% saline.

Another inexpensive option, lactated Ringer's solution, has nearly normal amounts of sodium and chloride. Dr. Lobo said, "It is likely that similar results could be achieved with Ringer's lactate, however, we chose Plasma-Lyte 148 as it has a chloride content in the normal physiological range."

Dr. Laurence Weinberg of the Department of Anesthesia, Austin Hospital and Senior Fellow, Department of Surgery, University of Melbourne was not a contributor to the study. Regarding lactated Ringer's, he said, "It contains lactate. In shock conditions if lactate cannot be metabolized by the liver, it will be unable to be converted to bicarbonate. This can also result in elevated lactate levels which, if being used as a marker of effective resuscitation, can lead to misinterpretation of the cause of the hyperlactatemia."

According to Dr. Lobo, "It is clear that many patients continue to receive large quantities of intravenous fluid especially in the perioperative period. We suggest that large quantities of saline may not be beneficial for those with pre-existing renal disease or those at risk of developing renal impairment."

Dr. Lobo thinks that normal saline is not appropriate for use for resuscitation or in the operating room. He said, "There is an increasing body of evidence to suggest that saline may lead to harmful effects. This study, building on evidence first obtained in animal studies, suggests that hyperchloremia associated with saline infusion may have an unfavorable effect on renal perfusion."

Dr. Weinberg said, "For many operations we only use 1000 mL of fluid. Choice of fluid for these cases is less important. However there is now overwhelming evidence that a balanced solution is better than an unbalanced and given that the costs of normal saline and Ringer's lactate are the same I would advocate Ringer's lactate as a preference."

When massive amounts of fluid are needed, however, Dr. Weinberg would advocate Plasma-Lyte 148 over both normal saline and lactated Ringer's solution. He added, "Many critically ill patients do require significant fluid/volume intervention as part of their care; the type and correct amount of fluid patients receive is paramount. The study by Lobo now gives us information that is clinically important, and I am certain that we will see many more studies examining the clinical effects of different fluid solutions."

Dr. Lobo and one other member of his group have received financial support from Baxter Healthcare, maker of Plasma-Lyte 148. Baxter Healthcare also supported the study but did not participate in its conduct or analysis.

Dr. Weinberg's department has received funding from Baxter Healthcare, which has no input or oversight of its research.

Tips For Reducing Wildfire Risk

Landowners can reduce wildfire risks to houses, cabins and outbuildings by creating defensible spaces around them, according to wildfire experts.

Information about how to create defensible spaces and reduce wildfire risks to property is at barnyardsandbackyards.com.

 “With this spring’s unusually dry conditions, we are asking people to be especially careful with all types of fires around their property, and we urge them to implement defensible space practices around their homes and outbuildings," says Bill Crapser, state forester with the Wyoming State Forestry Division (WSFD).

The website is part of Barnyards & Backyards, Rural Living in Wyoming by the Small Acreage Issue Team, which is a collaborative effort of the University of Wyoming (UW) Extension, WSFD and other land resource organizations in Wyoming.

The subjects in how-to articles and videos include creating defensible space around a house, cabin or outbuilding; fire-wise plants that can be used in landscapes; and other steps to prepare for wildfire. There is also information about what to do after a wildfire, such as rehabilitating the fire line, burned and stressed tree danger, whether to salvage fire-damaged trees, and water quality and erosion following fires.

“The Barnyards & Backyards website is one of the best sites out there for practical information of interest to rural residents in our state,” says Jennifer Thompson, small-acreage outreach coordinator with UW Extension. “Visitors can find information on a whole host of subjects including vegetable gardening, weed control, water-wise landscaping, tree care, windbreaks, pine beetle management, grazing management and more. The rich and useful content is the result of the efforts of resource professionals across the state.”

Source  http://beefmagazine.com/pasture-health/tips-reducing-wildfire-risk

GRIEF AFFECTS ONCOLOGISTS LIFES

In general, healthcare professionals caring for critically ill and terminal patients must contend with the inevitable death and loss that occurs in this setting. Oncologists, in particular, are often faced with patient loss, but a new study has found that they might not be dealing appropriately with their grief.

The study, published online May 21 in the Archives of Internal Medicine, notes that this failure to deal appropriately with grief after patient loss can not only affect oncologists personally, but can also affect patients and their families.

The researchers, led by Leeat Granek, PhD, a critical health psychologist and researcher at the Hospital for Sick Children in Toronto, Ontario, Canada, explain that the grief experienced by oncologists has unique elements related to their sense of responsibility for their patients' lives.

"These feelings could begin before the death of the patient, arising from holding hard medical knowledge such as awareness of poor test results or likely patient death before revealing this information to the patient himself or herself," they write.

Their grief also comes from feelings of powerlessness, self-doubt, guilt, and failure.

Oncology can be a stressful specialty. At its extreme, stress can lead to emotional exhaustion, depersonalization, and self-perception of incompetence, according to Michelle Shayne, MD, and Timothy E. Quill, MD, in an accompanying commentary.

These issues can lead to burnout, but stress and burnout should not be confused with grief, say Drs. Shayne and Quill, both from the University of Rochester Medical Center in New York. Rather, grief is deep mental anguish that arises from loss; if it remains unaddressed over time, it can clearly contribute to burnout. This is an "occupational hazard for physicians in general and oncologists in particular," they write.

Education and Strategies

Education on how to recognize and work through the grief process can help oncologists reduce the adverse effects of grief, they explain. This would be combined with other strategies that emphasize self-care; the process should begin during training and continue throughout an oncologist's career.

Drs. Shayne and Quill describe the program at their institution. It was started in response to reports of burnout rates in practicing oncologists that are about 56% and about 30% in young trainees. A staff support group meeting was established in 2008 at the Wilmot Cancer Center, Drs. Shayne and Quill explain; the group meeting is mandatory for hematology/oncology fellows and is strongly recommended for all other team members who regularly interact with cancer patients (such as hematology/oncology attending physicians, nurses, secretaries, and social workers). The support group is facilitated by a palliative care expert, a medical oncologist, and a member of the clergy.

The group meets 6 times a year. Participants share stories and experiences and routinely reflect on self-care strategies. They are encouraged to voice any work-related personal experiences on their minds, and "feelings of frustration, anger, loss, isolation, and insecurity often emerge in a setting that is nonjudgmental and supportive," Drs. Shayne and Quill write.

"Over the past few years, we have witnessed each others tears and laughter — all while confidentially discussing our day-to-day impressions about, and personal reactions to, patients, their families, treatments, and death," they add. "This approach allows oncology staff and trainees to systematically share their loss and grief with others who have common experiences and values."

A Smokelike Quality

In their study, Dr. Granek and colleagues point out that even though there is evidence that grief after patient loss is "an intrinsic part of clinical oncology," there are no qualitative studies that examine the nature and extent of oncologists' grief over patient loss, or the impact of this grief on the lives of these physicians.

From November 2010 to July 2011, the researchers recruited and interviewed 20 oncologists selected from 3 Canadian adult oncology centers. They conducted interviews with oncologists who were at different stages in their careers, and who varied in subspecialty, sex, and ethnicity.

When it came to burnout, the single most consistent and recurrent finding was the description of "compartmentalization" that emerged from the loss of a patient. This compartmentalization involved oncologists' abilities to separate their feelings of grief from other aspects of their lives and practices. It was usually described as a coping strategy and the impact of continual patient loss.

Oncologists also discussed how losing a patient affected their treatment decisions, their level of distraction with patients, and their motivation to improve care for subsequent patients. One strategy that oncologists use is to distance themselves from patients as they move closer to death and their families. This includes making fewer visits in the hospital, fewer bedside visits, and expending less overall energy on the dying patient.

We found that for oncologists, patient loss was a unique affective experience that had a smokelike quality," the researchers write. "Like smoke, this grief was intangible and invisible. Nonetheless, it was pervasive, sticking to the physicians' clothes when they went home after work and slipping under the doors between patient rooms."

Patient loss was found to have a personal impact on oncologists. Study participants spoke about "grief spillover" — difficulty separating the grief in their work life from their personal life. Many also discussed how they had a better perspective on life as a result of frequent exposure to patient loss.

"Of greatest significance to our healthcare system is that some of the oncologists' reactions to grief reported in our study suggest that the failure of oncologists to deal appropriately with grief from patient loss may negatively affect not only oncologists personally, but also patients and their families," they add.

The study was funded by Juravinski Cancer Centre Foundation in Hamilton, Ontario, Canada. Dr. Granek, Dr. Shayne, and Dr. Quill have disclosed no relevant financial relationships.

Fitness Fights High Blood Pressure, Even With Family History

Although people with a family history of high blood pressure (hypertension) are at much greater risk of developing the condition themselves, regular exercise and physical fitness may significantly lower that risk, according to a new study.

"The results of this study send a very practical message, which is that even a very realistic, moderate amount of exercise -- which we define as brisk walking for 150 minutes per week -- can provide a huge health benefit, particularly to people predisposed to hypertension because of their family history," study author Robin Shook said in an American Heart Association news release.

The researchers followed nearly 6,300 highly fit people ranging in age from 20 to 80 for nearly five years. Of this group, one-third had at least one parent with high blood pressure. These people had a 34 percent lower risk of developing hypertension than other people who also had a family history of the disease but were not as physically fit.

Overall, more than 1,500 of the participants developed hypertension during the course of the study. High levels of fitness, however, were associated with a 42 percent lower risk for high blood pressure -- regardless of family history. Moderately fit people had a 26 percent lower risk.

In contrast, the study, published May 14 in the journal Hypertension, showed that people with a low level of fitness and a family history of hypertension had a 70 percent higher risk for high blood pressure than highly fit people.

Moreover, among fit people, having a family history of hypertension increased the risk for the condition by only 16 percent.

"The correlation between fitness levels, parental history and risk are impossible to ignore," said Shook, a doctoral candidate in the Arnold School of Public Health at the University of South Carolina in Columbia. "This awareness can serve the clinician and the patient as they work together to find effective and reasonable ways to avoid the diseases that have affected their family members, in some cases for generations."

The American Heart Association recommends at least 30 minutes of moderately intense physical activity, such as brisk walking, five days a week.

Because the majority of participants in this study were white, well-educated men with higher incomes, the new findings may not apply to all people.

More information

The U.S. National Institutes of Health has more about hypertension.

HEALTH BENEFITS Of WATERMELON

                                            

Watermelon originated in Africa and has been cultivated since ancient times in the Mediterranean region, Egypt and India.

One slice of watermelon (485 g) contains 152 calories, 3 g protein, 34.6 g carbohydrates, 2.4 g fiber, 560 mg potassium, 176 mg vitamin A (RE), 47 mg vitamin C, 0.3 mg thiamin, 0.1 mg riboflavin, and 0.96 mg niacin.

Watermelon is rich in lycopene, glutathione and vitamin C. Water melon also reduce the blood cholesterol and maintain the body fat.  It has great activity against cancers and some antibacterial, anticoagulant activity.