bluuebunny/crossref_metadata_2025 huggingface dataset:
Critical discourse analysis and nominalization: problem or pseudo-problem?
Authors: Van Dijk Teun A.
Published: October 2008

This reply to Billig's article emphasizes that, as for all discourse, one should not only analyse texts, but also their contexts. The issue is not the primary use or abuse of nominalization or any other feature of discourse in CDA, but the study of the systematic abuse of discursive power by hiding the negative role of elite actors and the consequences of such discourse properties on the mental models of the recipients. CDA scholars do not study nominalizations in isolation, but within the text and context of the discourses studied critically. Of course they know that nominalizations have many other functions beyond these forms of obfuscation. If CDA itself uses nominalizations in its analytical discourse it does so like any scientific discourse. Because in this case there is no question of hiding the negative role of powerful actors, Billig's criticism is pointless, and creates a pseudo-problem. Finally a psychological basis for the description of nominalization is supplied, as Billig expects, but such an explanation cannot be provided by discursive psychology (DP), contrary to what Billig suggests, because DP explicitly rejects such cognitive analyses of language use.
Nominalizing and de-nominalizing: a reply
Authors: Billig Michael
Published: October 2008

In this article, the author replies to the comments made by Van Dijk, Fairclough and Martin on 'The Language of Critical Discourse Analysis'. The author also discusses at greater length the background to his concerns with current styles of academic writing. The author suggests that the problems with 'nominalization' and 'passivization' are wider than particular cases of abuse as Van Dijk suggests. The author discusses how analysts typically use 'nominalization' imprecisely, employing this same word to denote linguistic entities as well as processes of very different kinds. In replying to Fairclough, the author also points out that some linguists use 'nominalization' to refer to supposed linguistic 'processes' which are not, in fact, processes at all. In consequence, the use of technical terminology, far from leading to greater precision, has led to imprecision and to analysts avoiding basic issues. The author argues that it is important to understand what speakers/writers do with language. Technical nominals, which turn actions into 'things', are often poorly equipped for this task, especially when analysts use technical nouns in place of examining precisely what sorts of actions speakers/writers are performing. The author discusses why the current economic conditions of academic life encourage jargon-filled, technical writing and why, for ideological reasons, academics should resist the pressure to use heavy, nominal-based jargon.
Musical evidence regarding trochaic inversion
Authors: Winn Matthew B. , Idsardi William J.
Published: October 2008

This study investigates an unresolved issue in poetic metrics — the trochaic inversion — the apparent substitution of a trochaic foot in place of an iambic foot in an otherwise iambic line of verse. Various theories have been proposed to explain this metrical variation, including specific metrical units, groupings of beats and offbeats, and constrained definitions of metrical units via concepts such as stress maxima. By positing a structural comparison between the verse and music of set poetry, the current project attempts to evaluate theories of poetic metrics using a new empirical methodology. Specifically, musical settings of iambic poetry with trochaic inversion are examined. Our analysis shows that the musical settings predicted from various prevalent theories do not map neatly onto the actual musical settings, which suggests that they do not adequately describe the actual rhythmic effect of the trochaic inversion. The music instead suggests that we regard this metrical pattern not as a trochee in place of an iamb, but rather as a unary stressed foot followed by an anapest.
Between extended metaphor and allegory: is blending enough?
Authors: Crisp Peter
Published: October 2008

Allegory can both be related to and differentiated from extended, linguistic metaphor. From one point of view it is simply a super-extended metaphor; from another however it involves a shift from a consciously apprehended metaphorical blend to a consciously apprehended fictional situation. Understanding the nature of this shift involves the issue of blending. Although almost vacuous in its most general versions, if construed as a theory of specifically figurative forms of thought, blending theory does have content. There is as yet however no evidence from experimental psychology for the occurrence of blending. The only presently available evidence for this is the conscious sense of fusion associated with new, poetic metaphor and related phenomena. In Blake's 'A Poison Tree' an allegorical fiction emerges out of a blend whose setting up is prompted by an extended metaphor, which itself in turn emerges out of a conventional metaphor that, almost certainly, does not involve blending. The analysis of 'A Poison Tree' casts vivid light on the relations between blending, allegory and issues of ontology, truth and reference.
Integrating multimodal analysis and the stylistics of drama: a multimodal perspective on Ian McKellen's Richard III
Authors: McIntyre Dan
Published: October 2008

Traditionally, stylistic analyses of drama have tended to concentrate on the analysis of dramatic texts rather than dramatic performances. This has been on the basis that no two performances of the same text are entirely alike, and that accurate critical discussion is therefore impossible unless we can be sure that everyone concerned has seen the particular performance we are analysing (Short, 1981). Nonetheless, some performances of plays incorporate production elements that seem to add substantially to the original play script, and which arguably guide our interpretation of the play. In such cases, a stylistic analysis which ignores these production elements is arguably impoverished and incomplete. There appears, then, to be some tension between being methodologically rigorous and producing a complete stylistic analysis of a play which takes into account production and performance elements. However, in the case of plays which have been filmed this methodological problem can be circumvented, since the film version constitutes a permanent record of a particular production of the play in question. In this article I demonstrate the value of taking into account the multimodal aspects of drama by analysing the soliloquy scene from Ian McKellen's film version of Shakespeare's Richard III. I argue that in order to provide a multimodal analysis of the play that matches a traditional stylistic analysis in terms of level of detail, it is necessary to work from a transcript that incorporates linguistic, paralinguistic and non-linguistic elements of the production. As a result of my analysis, I suggest that the multimodal elements of the production contribute to our interpretation of the play as much as the linguistic elements of the dramatic text.
The Bilingual Mind and Linguistic Creativity
Authors: Bhatia Tej K. , Ritchie William C.
Published: October 2008

The aim of this article is to focus on the two salient aspects of the capacity of the bilingual mind/brain, namely, its ability to maintain both language separation on one hand and language integration on the other. These two types of bilingual capacity result in language mixing, termed Code Mixing (CM) and Code Switching (CS) in socio-linguistic research. The article reveals various facets of bilingual creativity through language mixing as it manifests itself in the day-to-day verbal behaviour of a bilingual and in global advertising. The article argues that language mixing is essentially an ‘optimizing’ strategy which renders a wide variety of new meaning which the separate linguistic systems are incapable of rendering by themselves.
The Use of English in Advertising in Mexican Print Media
Authors: Baumgardner Robert J.
Published: October 2008

This article is an analysis of the use of English in advertising in Mexican newspapers (both classified as well as non-classified advertising in Monterrey's El Norte) and in seven magazines published in the Mexico City. A distinction is made early in the article between the use in advertisements of English borrowings that are an established part of the lexicon of Mexican Spanish as opposed to the use of English as language display (Eastman and Stein 1993). The electronic database of Monterrey's El Norte newspaper is utilized to verify the borrowing frequencies. English as language display in advertisements is analyzed according to the framework of English found in a signature line (product name), attention-getter, slogan, body copy, standing details or illustration (Bhatia 1992, Pillar 2003). As many other studies have shown, this study too shows that advertisers in Mexico use English, which now serves as a worldwide lingua franca, as language display in most structural parts of the advertisements.
English and American Culture Appeal in Russian Advertising
Authors: Ustinova Irina P.
Published: October 2008

The article proposes that Russian advertising discourse offers prospective for examining the changes in Russian language and culture in the context of globalization. It focuses on the use of English in Russian advertising with an analysis of code-mixed samples drawn from recent print, Internet and TV advertisements. Strong evidence emerges that the main source of creativity in Russian advertisements is the mixing of English and Russian. English–Russian language mix is presented in abundance on the levels of words, sentences and phrases in the structural components of Russian advertisements. The proportion of English in advertisements is in alignment with gender and modernity. Nativization and assimilation of English also manifests itself in using Cyrillic script for language transfer. The English usage in the advertisements can be explained by utilitarian reasons, as the brand names and logo in English are promoted all over the world, and by social reasons, as English is a sign of high-quality products, novelty, prestige and even fun. By revealing age-specific English used in advertisements, the attempts are made to redefine a new ethnic identity. The phenomenon is interpreted according to possible ongoing changes of Russian ethnolinguistic identity.
From Linguistic Apartheid to Linguistic Co-habitation
Authors: Kamwangamalu Nkonko M.
Published: October 2008

Apartheid South Africa instituted laws that divided not only the communities but also the languages they spoke. Phenomena such as codeswitching (CS) were an anathema for the apartheid state. Now that apartheid is dead, it is perhaps opportune to explore to what extent the political change from apartheid to democracy has permeated South Africa's other institutions, including language. This article investigates the use of CS in print advertising in the post-apartheid South Africa, with a focus on Zulu English CS. In particular, the article seeks to address the following questions: Why do the marketers in South Africa use CS in advertising? What are the syntactic patterns of their CS behaviour? Are these patterns random or rule-governed? Does their use of CS in the advertisements follow a certain order or hierarchy, such that if English occurs in one part of the advertisement it then spreads to the other parts as well, as suggested in Bhatia's (2001) Structural Domain Dependency (SDD) model?
Accounting and the annual general meeting: the case of the Edinburgh University Tea Club, 1920—45
Authors: Jeacle Ingrid
Published: October 2008

This study investigates the historical role of the annual general meeting (AGM) and, in particular, examines the role of the AGM as an accountability mechanism. Few studies have adopted the context of the AGM, or organizational meetings generally, as a site for studying accounting's role. The specific setting for this study, a ladies tea club, is also novel as a locale for accounting research more generally. In this regard, the article attempts to advance an appreciation of the role of accounting in everyday life. The investigation involves a review of the minutes of the AGM of the Edinburgh University Tea Club for a period of 25 years from the time of its establishment in 1920. Such a review reveals a rich social history of the club's operations and provides a context for a more complete understanding of accounting's role in organizational and social functioning.
The interplay of conceptions of accounting and schools of thought in accounting history
Authors: Gomes Delfina
Published: October 2008

Paralleling the advent of different conceptions of accounting in the past two decades or so is the distinction between what are now known as the “traditional” and “new” schools of accounting history research. Viewing accounting as a social practice, as opposed to a mere technical practice, orientates the historical researcher firmly into the arena of the new accounting history, which recognizes the pervasive and enabling characteristics of accounting and gives rise to concerns about studying the implications of accounting change on organizational and social functioning. This literature study examines the interplay of conceptions of accounting with schools of thought in the historical accounting literature. It seeks to enhance an understanding of the underlying connections between the conceptions of accounting embraced by researchers of contemporary accounting and the schools of thought adopted by historical accounting researchers. As the state of play in accounting history research appears to have become a little predictable, certain challenges are identified for accounting historians of the future.
“Comparisons are odorous” (Shakespeare): financial performance and management competence at four Scottish colliery companies, 1900—46
Authors: Pitts Marianne , Wale Judith
Published: October 2008

The decline of British industry after 1870 has often been attributed to poor entrepreneurial decisions. This article uses a variety of sources, including published accounts, to compare entrepreneurial performance in four coal-mining companies (Edinburgh Colliery; Lothian Coal; Niddrie and Benhar Coal; Shotts Iron) all of which exploited the coal reserves of the Lothian basin from 1900 to nationalization in 1946. These companies are comparable as they shared local geology, geography, history, markets, technology, customs and labour conditions. Factors for success were found to be conservative financing, good labour relations and a paternal management style.
Complementary and Alternative Medicine Use in Children With Cancer and General and Specialty Pediatrics
Authors: Post-White Janice , Fitzgerald Maura , Hageness Susan , Sencer Susan F.
Published: October 2008

The objective of this survey is to determine the frequency, reasons, and factors influencing use of complementary and alternative medicine (CAM) in general and specialty pediatrics within the same geographic area. Of the 281 surveys completed, CAM use was higher in children with epilepsy (61.9%), cancer (59%), asthma (50.7%), and sickle cell disease (47.4%) than in general pediatrics (36%). Children most often used prayer (60.5%), massage (27.9%), specialty vitamins (27.2%), chiropractic care (25.9%), and dietary supplements (21.8%). Parents who used CAM for themselves (68.7%) were more likely to access CAM for their child. Most parents (62.6%) disclosed some or all of their child's use of CAM to providers. This study confirms that within the same geographic region, children with chronic and life-threatening illness use more CAM therapies than children seen in primary care clinics. Children with cancer use CAM for different reasons than children with non-life-threatening illnesses.
Langerhans Cell Histiocytosis in Children
Authors: Grifo Anne H.
Published: October 2008

Langerhans cell histiocytosis (LCH) is a nonmalignant disease characterized by an accumulation of dendritic cells. The disease can affect multiple organs, and the clinical picture ranges from localized bone lesions or skin disease to multiple organ involvement and severe dysfunction. LCH most commonly affects children, with the peak incidence at 1 to 4 years of age. Prognosis is dependent on the number of organ systems involved, the degree to which normal function of the organ system is affected, and the rate of progression of the disease. In the majority of children, the disease is self-resolving. For patients with multisystem disease, it is most commonly treated with steroids and chemotherapeutic agents including prednisone, vinblastine, and mercaptopurine. Although LCH is not considered a malignancy, the pediatric oncology nurse plays a key role in disease management because these patients are often followed in inpatient and outpatient oncology settings. This article provides nurses with insight about the pathophysiology and treatment modalities of LCH and prepares the nurse to provide confident comprehensive nursing care and to educate patients and families.
The Consequences of Multiracial Contexts on Public Attitudes toward Immigration
Authors: Ha Shang E.
Published: October 2008

This study examines how racial contexts relate to Americans’ opinion toward immigration. Survey data analysis reveals that racial surroundings correspond to public attitudes differently, depending on race and geographic unit. For non-Hispanic white Americans, proximity to Asians correlates with positive attitudes toward immigrants, whereas those living with Hispanics are more likely to harbor negative stereotypes. Conversely, African Americans living with Asians are more likely to be prejudiced against immigrants. Furthermore, the positive effects of racial contexts are more salient in the neighborhoods than in larger areas. These findings suggest the significance of racial integration in alleviating interethnic tension.
Pathophysiology of Postpneumonectomy Pulmonary Edema
Authors: Dietz Niki M.
Published: October 2008

Pulmonary edema is a rare, potentially fatal complica tion associated with major resection of the lung, usually pneumonectomy. Although pulmonary edema in this setting can often be attributed to a variety of causes such as cardiac failure, bacterial pneumonia, and fluid overload, the specific syndrome of postpneumonec tomy pulmonary edema (PPE) occurs in the absence of these factors. PPE remains a diagnosis of exclusion, and its pathophysiology is poorly understood. Overzealous perioperative fluid administration has traditionally been implicated in clinical cases of postpneumonectomy pulmonary edema, but there is a body of evidence suggesting several other potential mechanisms. These include increases in cardiac output secondary to cat echolamine release, interruption of mediastinal lym phatic drainage, endothelial injury secondary to release of humoral factors or stretching of intercellular junc tions, hyperinflation, and other unknown factors.
Thoracic Epidural Analgesia
Authors: Albrecht Ronald F.
Published: October 2008

Thoracic epidural analgesia (TEA) offers a unique oppor tunity for the anesthesiologist to enhance postopera tive recovery for the thoracic surgery patient. By deliver ing analgesics to a limited dermatomal distribution, TEA can provide profound segmental analgesia and also serves to modulate neural outflow to improve cardiac and pulmonary parameters. The notable side-effects of hypotension and respiratory depression can be mini mized by using synergistic combinations of local anes thetic and opioids, and by adopting a continuous infu sion strategy. With thoughtful patient selection, careful technique, and a proactive approach to the recognition of the known hemodynamic and respiratory effects of epidural drugs, TEA can be administered safely. The significant benefits of TEA include better pain relief, increased FEV1, earlier extubation, and, perhaps, de creased morbidity and mortality.
Preoperative Evaluation of the Patient for Vascular Surgery in the "Real World"
Authors: Foss Joseph F.
Published: October 2008

Patients presenting for vascular surgery frequently have multiple coexisting diseases. To meet the goal of providing a safe anesthetic with optimum resource use, we must ex amine the impact of each of these conditions on the patient and how the data from a particular evaluation or test will impact our anesthetic plan. Existing guidelines may be valu able if adapted to institution-specific circumstances. Con sultants represent a relatively high-cost resource, which can be optimized when used with clear goals in sight. Finally, we may be able to modify our evaluation based on the antici pated procedure, as these patients are exposed to a range of potential hemodynamic stresses.
Perioperative Treatment of Congestive Heart Failure
Authors: Clark Laura L.
Published: October 2008

Congestive heart failure is a common disease that affects 5 million people and will continue to increase in prevalence as the population ages. Estimates of its prevalence in patients presenting for vascular surgery range up to 50%. It has been consistently shown to be associated with increased mortal ity after vascular surgery. The anesthesiologist's contact with this disease entity will increase as well. Little has changed in the treatment of this disease until recently. Many new developments have occurred in the pathophysiology and the treatment of this age-old disease. This article re views developments in the pathophysiology, which have resulted in a new understanding and a complete revision of the recommendations for the treatment of heart failure as well as some modalities that hold promise for the future.
Update on Transfusion Therapy
Authors: O'Connor Michael F. , Apfelbaum Jeffrey L.
Published: October 2008

The science and technology of transfusion have improved dramatically over the past decade. Improvements in screen ing for viral pathogens have reduced the risk of transfusion transmitted viral infections to historic lows. Newly recog nized entities, including the transfusion transmitted virus and Parvo viruses are being investigated as pathogens. There is increasing appreciation that bacterial infection and parasites may be transmitted via transfusion, and a variety of approaches are being developed to deal with them. Clin ical studies continue to conflict about what the ideal hemo globin for patients with cardiovascular disease should be, but several studies suggest that higher hematocrits may be beneficial. Factor deficiency may play a more important role in massive transfusion than previously believed. The impor tance of autologous predeposit of red cells and hemodilu tion may diminish as the blood supply becomes ever safer, but intraoperative salvage is likely to remain an important technique. Finally, although blood substitutes have been under development for more than 10 years, they have not yet become widely used in medicine. The few remaining products under development are presently in advanced clin ical trials but face a variety of clinical and economic obsta cles before they can rise to their potential.
The Liver and Vascular Surgery
Authors: Daves Suanne M.
Published: October 2008

The anesthesiologist may encounter patients with pre-exist ing liver disease who are scheduled to undergo surgery and anesthesia or may care for patients with postoperative liver dysfunction caused by various intraoperative events. A re view of pre-existing or intraoperative factors that can con tribute to liver dysfunction will enhance the clinician's abil ity to establish a differential diagnosis and course of clinical care. The clinician should become familiar with the prognos tic indicators of perioperative morbidity and mortality in the patient with pre-existing liver disease to carefully weigh the risks and benefits of proceeding with surgery and anesthe sia; the patient and the surgeon should be counseled accord ingly. The first section of this article, on liver dysfunction after vascular surgery, addresses various intraoperative fac tors that may contribute to postoperative hepatic dysfunc tion and reviews the impact of pre-existing liver disease on perioperative morbidity and mortality. Today, more patients undergo transjugular intrahepatic portosystemic shunt (TIPS) procedures than surgical portosystemic shunts. The introduction of liver transplantation into clinical medicine has also reduced surgical portosystemic shunts. The second section of this article, on current status of portosystemic shunts, reviews both surgically and radiographically placed shunts and their current role in caring for patients with portal hypertension.
Aprotinin Use in Pediatric Cardiac Surgery
Authors: Gramlich Lisa A. , Barnes Steve D.
Published: October 2008

Aprotinin is a serine protease inhibitor that inhibits kal likrein and plasmin. Aprotinin's plasmin inhibition accounts for its antifibrinolytic and platelet-sparing effects, which are important factors for its homeostatic efficacy. The kallikrein inhibition occurs at higher plasma levels and is the mecha nism accounting for its anti-inflammatory actions. Aprotinin has relatively large acquisition costs, but these costs are offset by potential reductions in transfusions and intensive care costs. This review summarizes the pediatric literature and develops generalized recommendations for the effica cious use of aprotinin.
Pediatric Anesthesia for Cardiac Catheterization and Electrophysiology Studies
Authors: Bulleova Slavka , Johnson Calvin
Published: October 2008

In recent years interventional procedures have been intro duced to the field of pediatric catheterization. These proce dures continue to develop and be applied to patients with reduced cardiovascular reserve as an alternative to cardiac surgery or when cardiac surgery with cardiopulmonary by pass is contraindicated. More frequently anesthesiologists are being called on to provide support in sedating, anesthe tizing, or resuscitating these patients. As more compli cated procedures are performed, the anesthetist plays a pivotal role in the management of the patient to prevent mortality and major morbidity in the cardiac catheterization laboratory.
Predicting Postoperative Outcome
Authors: Melendez Jose A. , Fischer Mary E.
Published: October 2008

Pulmonary complications are the main source of postop erative morbidity and mortality, with respiratory failure and pneumonia resulting in 50% of postoperative deaths after lung surgery. Despite the high incidence of postop erative complications, pulmonary resection remains the only effective treatment for lung cancer. Substantial resources are ascribed for the perioperative care of these high-risk patients. Clinical experience would dic tate that predicting outcome could be of immense value in allocating resources. This review will consider the predictive value of preoperative testing, including spi rometry, split lung function, blood gas analysis, carbon monoxide diffusion capacity, pulmonary vascular resis tance, and exercise testing, as well as recent efforts to develop a combined cardiopulmonary index.
Assessment of Right Ventricular Function
Authors: Heerdt Paul M. , Dickstein Marc L.
Published: October 2008

In contrast to studies suggesting that the right ventricle (RV) often functions primarily as a conduit for blood flow from the venous circulation to the lungs, recent data show that the chamber plays a major role in maintenance of global cardiovascular homeostasis un der many conditions. Accordingly, clinicians involved with the perioperative care of surgical patients must be familiar with factors influencing RV performance. Com prised of two embryologically distinct regions, the inflow and outflow tracts, the crescent-shaped RV exhib its characteristics of filling and contraction that are different from those of the left ventricle (LV). Further more, although the basic determinants of ventricular function (rate and rhythm, preload, afterload, and con tractility) are the same for both the LV and RV, the relative contribution of each determinant to overall function of each chamber is somewhat different. This review approaches assessment of RV function from two directions. First, the anatomic and physiological differ ences between the RV and LV are described and used to show why some methods derived for complex character ization of LV function cannot be directly applied to the RV. Second, the application and limitations of methods used for perioperative assessment of RV function are discussed.
Coronary Artery Bypass Graft Patency
Authors: Bidstrup Ben P.
Published: October 2008

The long-term success of myocardial revascularization depends on continued patency of the bypass conduit or the artery treated by angioplasty. Patency after coronary artery bypass graft (CABG) surgery is determined by surgical factors, including the type of conduit used and by pharmacotherapy in the postoperative period. The purpose of this review is to provide an overview of factors that may contribute to improved or decreased coronary artery bypass graft patency.
Endothelial Cell-Blood Interface Actions and the Procoagulant Response
Authors: Spiess Bruce D.
Published: October 2008

Anesthesiologists and surgeons have focused on the problems of hypocoagulability and resulting hemorrhage after cardiopulmonary bypass. Recent work in endothelial cell biology has demonstrated that the interaction of inflammatory processes and coagulation dysfunction with the endothelium may contribute to either hypocoagulability (bleeding) or hypercoagulability (thrombosis). New work with endothelial cell function and intracellular signaling of procoagulant responses may allow for unique therapeutic interventions in the future.
Hypercoagulable States
Authors: Robbins Peter , Forrest Mark , Royston David
Published: October 2008

The hypercoagulable states consist of a group of prothrombotic clinical disorders associated with an increased risk for thromboembolic events. The abnormalities lead to inappropriate thrombus formation. After a review of the coagulation process, inherited disorders (including antithrombin-III deficiency, protein CS system deficiencies, disorders of plasmin generation, dysfibrinogenemias, and homocysteinuria) and acquired disorders (including responses to surgery, cancer, drugs, and the antiphospholipid syndrome) are described. Screening and management methods are discussed. Copyright © 1997 by W. B. Saunders Company.
Intrinsic Anticoagulation: Protein C, Protein S, and Thrombomodulin
Authors: Mac Hale John L. , Nathan Nadia , D'Ambra Michael
Published: October 2008

The protein C anticoagulant system provides important control over the blood coagulation cascade. Any alteration in this pathway, either hereditary, iatrogenic, or otherwise, may interfere with normal coagulation. In this review, current concepts and understanding of surface-dependent hemostatis are reviewed, effects of deficiencies in the intrinsic anticoagulant system are described, and potentially useful therapeutic strategies are proposed. The importance of protein C, protein S, and thrombomodulin in patients undergoing cardiac surgery is specifically addressed. Further work is required before complex interactions of individual components of the intrinsic anticoagulation pathway are fully understood.
Molecular Genetics of Factor V Leiden: Genetic Origins and Modern DNA-Based Detection Strategies
Authors: Maher Caroline , Wall Carmel , Fanning Séamus
Published: October 2008

It has been acknowledged that a prothrombotic tendency may result from a specific genetic defect. Resistance to activated protein C (APC) (factor V Leiden) is now recognized as the most prevalent cause of increased thrombogenicity, being found in 2% to 5% of the world population. The APC-resistant phenotype arises from a well-characterized transitional mutation, resulting in an arginine(R)-506-glutamine(Q) amino acid substitution. Much remains to be uncovered concerning the importance of this mutation and how it relates to other conditions on a broader basis. Relevant and accurate detection methods that quickly identify the genetic lesion will play a major part in this strategy. This article details recent advances in identifying the factor V Leiden mutation by modern molecular techniques.
Does Hemodilution Enhance or Compromise Blood Coagulation?
Authors: Egli Gabi A. , Spahn Donat R.
Published: October 2008

The reduction in oxygen-carrying capacity during hemodilution is well tolerated by most patients. However, hemodilution not only decreases O2 transport capacity, but also may influence blood coagulation. Advanced hemodilution with crystalloids does not compromise blood coagulation and, with moderate hemodilution, even augmented blood coagulation may develop. In contrast, blood coagulation is compromised during hemodilution with colloids. The effect of human serum albumin and gelatin is relatively modest, but significantly more than during equivalent hemodilution with crystalloids. Dextran and hydroxyethyl starch compromise blood coagulation more. This results from reduction of factor VIII, a decrease in plasmatic coagulation, and an impairment of platelet function. For hydroxyethyl starch, molecular size and degree of substitution are crucial for the effect on blood coagulation, with hydroxyethyl starch (200,000/0.5) having the least effect. Furthermore, accelerated fibrin formation is observed during hemodilution with Dextran, hydroxyethyl starch, and gelatin with an altered fibrin structure. In vitro clot lysis is also increased with all colloids, but there are no reports on augmented in vivo fibrin degradation products. Besides the effect on intraoperative blood coagulation, the hemodynamic effectiveness, duration thereof, effect on microcirculation and edema formation, and, in particular, the effect on the hypercoagulable state in the postoperative period need to be considered in the choice of the replacement fluid during hemodilution and intraoperative blood loss.
Heparin-Induced Thrombocytopenia
Authors: Cummins David , Hill Elaine
Published: October 2008

Heparin's anticoagulation effect makes it the principal component in the immediate treatment of all thrombotic diseases. After hemorrhage, the most important complication of heparin is thrombocytopenia, the decrease in the number of blood platelets. Ten cases of "heparin-induced thrombocytopenia" are described, and guidelines for diagnosing heparin-induced thrombocytopenia in patients who present for cardiac and vascular surgery are given. Methods of treating patients with heparin-induced thrombocytopenia, including use of arachidonic acid derivatives, antiplatelet agents, other anticoagulants, heparinoids, natural and synthetic thrombin inhibitors, hirudin, and defibrinogenation with ancrod, are discussed.
Aprotinin Fifteen Years Later
Authors: Westaby Stephen
Published: October 2008

Aprotinin, the broad-based bovine serine protease inhibitor, was first used as an antidote against the harmful proteases released through complement-induced neutrophil activation in the early 1980s. Since then, the safety and efficacy of aprotinin have been debated. Even now, fifteen years later, aprotinin's precise mechanism of action and clear indications for use have not been defined. This article discusses what aprotinin is, its role in the contact system of blood, how it improves hemostasis, the effect of temperature on it, its use in clinical practice, and which patients should receive it. The article concludes that aprotinin's hemostatic effects are useful in patients who are at increased risk from bleeding, but that it should not be considered a substitute for surgical skill. Early claims of absolute safety were premature. Risks between high- and low-dose regimens vary significantly, and more study is required. Alternatives to aprotinin such as the less expensive antifibrinolytic agent tranexamic acid are now available, but they also require additional study.
Hemostatic Drugs in Prothrombotic or Hypercoagulable States
Authors: Royston David
Published: October 2008

Certain drug therapies, such as heparin, warfarin, and aspirin, are associated with prothrombotic or hypercoagulable states. If these agents that are administered to prevent thrombosis have been associated with its opposite effect, then agents that are specifically given to inhibit bleeding may produce a deleterious hypocoagulable effect. This article evaluates the risks presented by serine protease inhibitors (ie, aprotinin), lysine analog antifibrinolyics (ie, epsilon aminocaproic acid [Amicar, Wyeth-Ayerst, Philadelphia, PA] and tranexamic acid), and desmopressin acetate (DDAVP, Rhone-Poulenc Rorer, Collegeville, PA). It focuses on their mechanisms of action, particularly their effect on microvascular tone and endothelial function, coagulation factors, platelet function, and the fibrinolytic pathway. It discusses their use in the presence of known thrombin production or fibrinogen conversion and whether certain vascular beds are more prone to drug-related thrombosis.
The Utility of Nitric Oxide in the Postoperative Period
Authors: Body Simon C. , Shernan Stanton K.
Published: October 2008

Inhaled nitric oxide (iNO) is a pulmonary-selective vaso dilator with minimal bronchodilator activity in humans. NO also inhibits platelet and neutrophil activation and adhesion and inhibits ischemia-reperfusion injury. The pulmonary vasodilatory property of iNO causes a reduc tion in pulmonary vascular resistance and improvement in arterial oxygenation in a wide spectrum of diseases characterized by pulmonary hypertension and hypox emia. Promising examples of diseases for which NO may provide beneficial physiologic effects are primary and secondary pulmonary hypertension, right ventricu lar failure, cardiac transplantation, pulmonary embo lism, protamine reactions, acute respiratory distress syndrome, lung transplantation and, perhaps, chronic obstructive airways disease. The usefulness of iNO may be improved by concomitant therapy with pulmonary- selective intravenous vasoconstrictors (eg, Almitrine; Vectarian, Neuilly, France) and cGMP phosphodiester ase V inhibitors (eg, Zaprinast; Research Biochemicals International, Natick, MA). Almitrine improves oxygen ation, synergistically with iNO, and may be useful in disease states characterized primarily by hypoxemia. Zaprinast may be useful for weaning iNO and avoidance of rebound pulmonary hypertension.
The Use of Echocardiography in the Intensive Care Unit
Authors: Koch Colleen Gorman
Published: October 2008

Echocardiography is a powerful diagnostic tool that has become an indispensable part of intensive care medi cine. There is a broad clinical application for the noninva sive real-time structural and functional assessment of the critically ill patient. The echocardiograph provides on-line visual information and software for data manipu lation at the intensive care bedside without significant discomfort or risk. Assessment of ventricular function, hemodynamics, pericardial pathology, valvular status, and the outcomes of cardiac surgical interventions are naturally suited to this modality. Transesophageal echo cardiography is an important adjunct to the standard transthoracic examination, particularly in those pa tients with inadequate precordial images. Anatomic, physiologic, and hemodynamic findings can be corre lated in a variety of clinical conditions to make and confirm diagnoses and to direct management in a manner complementary to routine intensive care. Indi cations for echocardiography in the intensive care unit at this institution included assessment of ventricular function, valvular function, endocarditis, complications of surgery, abnormal hemodynamics, evaluation of intra cardiac source of embolus, and echocardiographic- guided endomyocardial biopsy. In this review, the tech niques, indications, and clinical applications of transthoracic and transesophageal echocardiography in the intensive care setting are explored, with a focus on experience in the cardiac surgical patient.
Ethical Issues in the Postoperative Intensive Care Unit
Authors: Baldyga Andrea P.
Published: October 2008

Ethical principles are the foundation of the practice of medicine. The intensive care unit (ICU) has always been a fertile ground for ethical dilemmas and today is further impacted by many conflicting forces, including the emphasis on patient autonomy, the medical eco nomic climate and the rise of managed care, and the wide availability of life-extending technologies. This article will address three specific ethical concerns that are particularly seen in the ICU to help physicians clarify the ethical issues present in their day-to-day practice. Advance directives were developed in an attempt to make the area of end-of-life decision-making less com plex and more responsive to patient autonomy, but the uses and limitations of these documents must be under stood to use them most effectively. Futility is a signifi cant concern as lives are extended by recent medical advances and technology. The question then becomes, when is it appropriate to withdraw these therapies, and how then to proceed in a caring and ethical manner. Finally, as patients begin to use advance directives more frequently, there will be more cases of patients with preexisting Do Not Resuscitate (DNR) orders com ing to the operating room for surgery for an unrelated disease or palliative procedures. The conduct of care in these cases needs to be based on a well-understood ethical framework.
Management of the Organ Donor
Authors: Abel Mark , Bronheim David
Published: October 2008

Advances in immunosuppressive therapy have led to increased use of organ transplantation to treat end- organ failure. This has led to a consistent shortage of transplantable organs, with many patients dying while awaiting heart, liver, or lung transplantation. Traditional donor criteria are expanding and increase the pool of available donor organs. The organ procurement process often begins with the diagnosis of brain death, which must be made by clinical criteria and is usually con firmed by clinical testing. Because brain-dead patients suffer a variety of hemodynamic, cardiac, endocrine, respiratory, and hematologic abnormalities, manage ment in the intensive care unit demands meticulous attention and expertise. Living and, occasionally, non- heart-beating donors are also a source of donor organs. Management of the various types of donors in the operating room requires specific skills and knowledge. The persistent need for donor organs requires that poten tial organ donors be recognized and appropriately man aged to maximize the pool of available organs for the ever- increasing number of potential organ recipients.
Anesthesia for Renal Transplantation
Authors: Chapin James W. , Bruda Nancy , Snider Sandra
Published: October 2008

Renal transplantation is the preferred mode of replace ment therapy for most patients with end-stage renal disease (ESRD) and accounts for nearly 60% of all organ transplants in the United States. While as many as 35,000 people remain on the list waiting to receive a cadaveric kidney, living-related renal transplantation offers a shorter waiting period and greater survival. Maximization of the health of the kidney recipient before transplantation can improve ultimate outcome. Proper anesthetic management is facilitated by under standing the physiology and pharmacology of ESRD. Maintaining intraoperative blood volume is a key to good graft function, especially the living-related pediat ric kidney recipient. Recent improvements in combined immnosuppression therapy have improved the overall outcome in transplant recipients. The average 3-year survival is nearly 75%.
Anesthesia and Kidney-Pancreas Transplantation
Authors: McSweeney Mary E. , Kreul John F.
Published: October 2008

Normoglycemia is the treatment goal for patients with diabetes mellitus. Currently, pancreas transplantation can offer this ideal, but at the cost of lifelong immuno suppression and the accompanying side effects of anti rejection drugs. Pancreas transplantation alone is per formed in some cases but is typically offered in combination with kidney transplantation. The authors review several issues concerning kidney-pancreas trans plantation and anesthetic management. Patient selec tion, donor selection, surgical technique, immunosup pression, antimicrobial prophylaxis and surgical complications are discussed. Anesthetic preoperative evaluation includes special attention to the diabetic patient's airway and the risk of aspiration, as well as cardiovascular and neurologic compromise common in this patient population. Preoperative, intraoperative and postoperative anesthetic management focuses on the disease process as well as the procedure.
Intensive Care of the Intra-Abdominal Organ Transplant Recipient
Authors: Plevak David J. , De Ruyter Martin L.
Published: October 2008

The postoperative care of a patient who receives an intra-abdominal organ transplant is in some ways simi lar to that of any major intra-abdominal procedure. However, certain features unique to organ transplanta tion, such as the variable functional status of the newly transplanted graft, complications that are specific to the organ transplanted, and the side effects from immuno suppressive drugs, suggest that transplantation inten sive care is a distinct subspecialty in critical care medicine. Today, the majority of patients receiving an intra-abdominal transplant will have a relatively uncom plicated postoperative course. However, preoperative disposition, intraoperative misadventure, or immediate postoperative difficulty will require the availability of an intensivist experienced in transplantation. The future of intra-abdominal transplantation will be highly depen dent on progress in immunotherapy. Newer, more spe cific immunomodulators with fewer nonimmune toxici ties should result in improved organ receptance, less graft dysfunction, and improved patient survival.
Pharmacologic Management of Acute Heart Failure: A Review
Authors: Vroom Margreeth B.
Published: October 2008

Because of improved social and medical standards in the western world, the average age of the population continues to increase. This altering demographic profile has its impact on the surgical population, resulting in a dramatic increase in the number of patients with exten sive cardiovascular disease, presenting for either car diac or noncardiac surgery. As a result, the incidence of perioperative acute congestive heart failure (CHF) is a major clinical problem at the present time. For the pharmacologic management of acute CHF, the β-adreno ceptor agonists continue to be the mainstay of therapy, due to their short duration of action and hemodynamic controlability by continuous intravenous infusion. Mono therapy with the phosphodiesterase type III (PDE) inhibi tors appears to be the treatment of choice in selected patients with high systemic vascular resistance or re sidual β-adrenoceptor blockade. Combination therapy especially deserves attention, because this approach allows the enhancement of contractile force, possibly without the side effects associated with the administra tion of high concentrations of one agent alone. New developments including ultrashort-acting PDE inhibi tors, calcium-dependent calcium sensitizers, and cal cium promotors are anxiously awaited.
Influence of Vasodilator Drugs on Perioperative Blood Pressure
Authors: van der Stroom Johanna G.
Published: October 2008

Survey results are given of the incidence and the etiology of perioperative hypertension in patients sub jected to coronary artery surgery. Over the years, numer ous types of antihypertensives have been used for intravenous administration with the aim of preventing or treating perioperative hypertension. Nitrovasodilator compounds such as sodium nitroprusside and nitroglyc erin (NTG), a few calcium antagonists (nifedipine, nicar dipine and isradipine), the short-acting β-blocker esmo lol, clonidine, and the multifactorial compounds labetalol and ketanserin are discussed in detail. Perioperatively, there is an increasing level of plasma catecholamines, causing α-adrenoceptor stimulation. This indicates that α-adrenoceptor blockade with appropriate antagonists is a logical approach for the treatment of perioperative hypertension. For this reason, the multifactorial agent urapidil, which is an α-adrenoceptor blocker and a 5-HT1Aagonist, is discussed extensively.