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The Department of Respiratory Medicine of Nippon Medical School Hospital and the Working Committee of Clinical Simulation Laboratory have held training sessions for chest tube drainage since 2007. The training program consists of the preparation of a training manual, a small-group session, and a review of the process of chest tube drainage using a checklist of steps after the session. A total of 21 medical interns of Nippon Medical School Hospital participated in training sessions from April 2010 through February 2011. A questionnaire survey at the end of the session revealed that most participants rated highly both the explanations given by the instructors and the descriptions in the manual for comprehensibility. Only 3 interns felt that they had successfully acquired the clinical skill, and the other 18 interns felt that they had somewhat acquired the skill. Research after the interns had completed the program of the department showed that 80% of interns had performed chest tube drainage for patients during the rotation. The interns assessed the training program as useful, and some interns felt they could perform the skill with confidence or without anxiety. Other systematic programs of skill training for medical interns are recommended to ensure definite acquisition of basic skills.

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Transfusion for hemorrhagic shock can improve oxygenation, but immunoreactions may induce inflammation. Artificial oxygen carriers have been developed to address clinical concerns of infection and stability, but whether an artificial oxygen carrier might induce inflammation is not well known. To address this question, we compared inflammatory reactions after resuscitation with hemoglobin vesicles (HbVs) or red blood cells (RBCs) in a hemorrhagic shock rat model. Both HbVs and the stored and irradiated rat RBCs deprived of buffy coat were suspended in recombinant human serum albumin [(Hb) = 8.6 g/dL]. Under anesthesia, hemorrhagic shock was induced for 30 min, followed by resuscitation by 20 min transfusion of HbVs or rat RBCs in a volume equivalent to the volume of withdrawn blood. Lungs were excised 2 or 24 h after resuscitation, and mRNA levels of tumor necrosis factor alpha (TNF-alpha), intercellular adhesion molecule-1 (ICAM-1), nitric oxide synthase 2 (iNOS), nitric oxide synthase 3, hypoxia-inducible factor 1 alpha, and heme oxygenase 1 (HO-1) were measured. In rats resuscitated with HbVs, mRNA levels of TNF-alpha and HO-1 2 h after resuscitation were significantly higher than those in the rat RBC group, but the levels at 24 h were similar in both groups. The expression of iNOS and ICAM-1, second messengers of inflammation, was not affected, and inflammatory levels after 24 h with HbVs are similar to rat RBC transfusion. The rat RBC group did not show an expected inflammatory reaction related to a transfusion-induced lung injury, and a clinical relevance concerning this level of transient inflammatory reaction induced by HbVs is not known; however, attention to the early stage of resuscitation in ongoing studies of HbV is required.

DOI： 10.1097/MAT.0b013e3181b17f34

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The aim of the present study was to compare the hypoxic and inflammatory effects of transfusing hemoglobin-vesicles (HbV) or lactated Ringer's (LR) solution on several organs in a hemorrhagic shock model. Hemorrhagic shock was induced in 48 anesthetized rats by withdrawing 28 mL/kg blood. The animals were resuscitated by replacing the blood with an equal volume of HbV solution or three times the volume of LR solution. The heart, lung, liver, kidney and spleen were extracted at different time points following resuscitation, and mRNA expression levels of hypoxia-induced factor 1-alpha (HIF-1alpha) and tumor necrosis factor-alpha (TNF-alpha) were determined. Blood lactate concentrations in the HbV group rapidly returned to baseline levels, whereas elevated lactate concentrations in the LR group were prolonged. There were no significant differences between the two resuscitation groups in terms of HIF-1alpha and TNF-alpha expression in the organs examined. HIF-1alpha and TNF-alpha expression in the lungs was significantly greater than in other organs. Our results suggest that resuscitation from hemorrhagic shock with HbV did not increase hypoxic or inflammatory effects in major organs, compared with resuscitation using LR solution, despite prolonged elevation of blood lactate.

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Several hemoglobin (Hb)-based oxygen carriers are available for use in clinical situations, but their use risks inducing cardiovascular dysfunction as a result of Hb interacting with nitric oxide. Hb vesicles (HbV) are liposome-encapsulated purified human Hb with polyethylene glycol chains at the surface. This study evaluated the effects of HbV on hemodynamics, tissue and systemic oxygenation, and osmotic pressure after fluid resuscitation in an acute hemorrhagic shock model. Hemorrhagic shock was induced in 24 anesthetized mechanically ventilated male rabbits by withdrawing blood to a mean arterial blood pressure (MAP) of 30 to 35 mmHg over 15 min and maintaining this state for 30 min. The animals were resuscitated by replacing the blood with equal volumes of HbV in recombinant human albumin solution (HbV/rHSA), rHSA alone, or Ringer lactated solution (RL), or with three times the withdrawn volume of RL and observed for 2 h. Fluid resuscitation restored MAP, central venous pressure, and cardiac index values, but these fell again within 2 h in rabbits treated with RL. Fluid resuscitation using HbV/rHSA immediately increased MAP and cardiac index but not systemic vascular resistance, maintained a high level of oxygen consumption, and reduced the blood glucose level, which increased after hemorrhage. Fluid resuscitation using HbV/rHSA did not disturb microoxygenation in the brain, kidneys, liver, or muscle; allowed an immediate recovery of tissue oxygenation without decreasing cardiac output or increasing systemic vascular resistance, and increased the oxygen consumption. HbV solution offers the advantages of systemic oxygenation without impairing microcirculation in the treatment of hemorrhagic shock.

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