Resuscitative Strategies in the Trauma Patient: The Past, the Present, and the Future.

Over the last decade, trends in fluid resuscitation have changed dramatically as have our practices. Research is driving trauma centers across the globe to initiate modifications in fluid resuscitation of the hemorrhagic trauma patients both in the prehospital and intrahospital arena. This is being done by combining the theory of permissive hypotension and damage control surgery with hemostatic resuscitation as the preferred methods of resuscitation in patients with hemorrhagic shock. The literature illustrates that previous strategies we considered to be beneficial are actually detrimental to the outcomes of these severely injured patients. This complex and continuously changing adaptation in practice must be made without losing our strategic focus of improvement of outcomes and recognition of the morbidity associated with bleeding of the trauma patient. Designating limits on large-volume crystalloid resuscitation will prevent cellular injury. These wiser resuscitation strategies are key in the efforts to reduce mortality and to improve outcomes. This article is to serve as a review of each of the resuscitative fluid strategies as well as new methods of trauma resuscitation.

Unsupportive parenting moderates the effects of family psychosocial intervention on metabolic syndrome in African American youth.

BACKGROUND/OBJECTIVE: Family relationships have been linked to obesity and related disorders in youth, but few studies have provided causal evidence of this association. This study tested the impact of a family psychosocial intervention on components of metabolic syndrome-a condition driven largely by abdominal obesity-in African American youth. In particular, the study tested whether effects were strongest among those who started at highest risk, that is, with high levels of unsupportive parenting at baseline. SUBJECTS/METHODS: Randomized clinical trial of a community sample of 391 African American youth (mean age=11.2 years) conducted in 2001-2002, with follow-up metabolic syndrome assessment in 2014-2015. Participants were assigned either to receive a weekly family intervention or to a control group. The primary study outcome was the number of components of metabolic syndrome that were clinically elevated at age 25, including central adiposity, blood pressure, triglycerides, glucose and low high-density lipoproteins. Unsupportive parenting was measured by questionnaires at baseline. RESULTS: Significant interaction effects were found between group assignment and baseline unsupportive parenting on counts of metabolic syndrome components in youth (beta=-0.17, P=0.03). Among those who started with higher levels of unsupportive parenting at age 11, participation in the family intervention reduced the number of clinically elevated components of the metabolic syndrome at age 25 relative to the control group. No such effect was seen among those who started with good parenting. Mediation analyses suggested that changes in the psychosocial targets of the parenting intervention partially accounted for the effects amongst those high in unsupportive parenting at baseline (effect size=-0.350, s.e.=0.178). CONCLUSIONS: These findings suggest that efforts to improve family relationships may be able to ameliorate the detrimental effects that harsh and unsupportive parenting have on obesity-related outcomes such as metabolic syndrome in youth.

The influence of neighborhood disadvantage, collective socialization, and parenting on African American children's affiliation with deviant peers.

This study focused on hypotheses about the contributions of neighborhood disadvantage, collective socialization, and parenting to African American children's affiliation with deviant peers. A total of 867 families living in Georgia and Iowa, each with a 10- to 12-year-old child, participated. Unique contributions to deviant peer affiliation were examined using a hierarchical linear model. Community disadvantage derived from census data had a significant positive effect on deviant peer affiliations. Nurturant/involved parenting and collective socialization processes were inversely associated, and harsh/inconsistent parenting was positively associated, with deviant peer affiliations. The effects of nurturant/involved parenting and collective socialization were most pronounced for children residing in the most disadvantaged neighborhoods.

Linking parenting processes and self-regulation to psychological functioning and alcohol use during early adolescence.

A longitudinal transactional model was tested linking parenting and youth self-regulation to youths' psychological functioning and alcohol-use behavior. Participants included one hundred twenty 12-year-olds, their mothers, and their fathers from whom three waves of data were collected at 1-year intervals. Teachers provided assessments of self-regulation, and parenting was assessed from multiple perspectives, including youth reports, parent reports, and observer ratings. Youths reported their psychological functioning and alcohol-use behavior. The data supported the model. Parenting and youth self-regulation were stable across time, and self-regulation was linked with changes in harsh-conflicted parenting from Wave 1 to Wave 2. Parenting at Wave 2 was associated with youth self-regulation. Youth self-regulation at Wave 2 mediated the paths from parenting practices at Wave 2 to youth psychological functioning and alcohol use at Wave 3.

Heuristic model linking contextual processes to self-management in African American adults with type 2 diabetes.

PURPOSE: This article examines the influence of various environmental factors on the diabetes self-care practices of African American adults with type 2 diabetes. METHODS: A heuristic model was developed that considers how community barriers and supports, availability and use of insurance, diabetes education, medical provider-patient relationships, extended family processes, and psychological functioning may indirectly affect metabolic control through the patient's ability to regulate diabetes. RESULTS: The proposed model offers a framework to demonstrate the complexity of diabetes management that may be unique to the African American experience. CONCLUSIONS: A comprehensive view of the environmental context will lead to new and more effective approaches in diabetes education and counseling for African American adults with type 2 diabetes.

Attributions in marriage: examining the entailment model in dyadic context.

The entailment model of attributions is examined for the first time using a dyadic approach and longitudinal data. In a sample of 229 married partners with children, causal attributions were distinguished empirically from responsibility attributions and, consistent with the entailment model, the effect of causal attributions on conflict was mediated through attributions of responsibility. Only 1 path was influenced by spouse gender. Examination of cross-spouse effects revealed significant effects and provided a better fit than a model with no cross-spouse effects. The importance of including cross-spouse effects in attributional models is discussed.

African American single mothers and children in context: a review of studies on risk and resilience.

This paper presents a comprehensive review of research linking single-parent family structure to parenting processes, maternal well-being, and child developmental outcomes among African Americans. The approaches used to study these families, related methodological and conceptual concerns, and the factors linked to maternal well-being, effective parenting processes, family functioning, and child outcomes are addressed. Much work remains to be done on conceptualizing and assessing parenting processes among African Americans in general and single African American mothers in particular. Researchers must examine more carefully the circumstances that foster or impede successful parenting among these mothers. Studies also are needed to disentangle the interactions between economic stress and parenting behavior and to determine the extent to which the findings can be applied to middle-income single African American parents.

Protection and vulnerability processes relevant for early onset of substance use: a test among African American children.

This research tested predictions from a self-regulation model of factors relevant for early onset of tobacco and alcohol use with a community sample of 889 African American children (mean age = 10.5 years). Criterion variables were peer substance use, willingness to use substances, and resistance efficacy (intention to refuse substance offers). Structural modeling indicated effects of temperament dimensions were mediated through self-control and risk-taking constructs, which were related to school involvement, life events, and perceived vulnerability to harmful effects of substances. Peer use was predicted by life events, poor self-control, and parent-child conflict; willingness was predicted by life events, risk taking, and (inversely) parental support; and resistance efficacy was predicted by perceived vulnerability and (inversely) poor self-control. Findings are discussed with reference to theoretical models of early protection and vulnerability processes.

Fragile self-esteem in children and its associations with perceived patterns of parent-child communication.

We examined the extent to which 11- to 12-year-old children's (N = 174) self-esteem (SE) stability and level related to their perceptions of various aspects of parent-child communication. Compared to children with stable SE, children with unstable SE reported that their fathers were more critical and psychologically controlling, and less likely to acknowledge their positive behaviors or to show their approval in value-affirming ways. Likewise, children with low SE reported that their fathers exhibited these qualities to a greater extent than did children with high SE. In addition, fathers of children with stable high SE were viewed as especially good at problem solving. Children's SE level related to perceptions of mothers' communication styles very similarly to how it did with fathers'; with respect to SE stability, however, relationships were generally less consistent and frequently absent. Discussion centered on the role of parent-child communication in promoting unstable SE.

Child resiliency in inner-city families affected by HIV: the role of family variables.

This study examined the role of family variables in child resiliency within a sample of African-American, inner-city children whose mothers are HIV-infected. Variables from three dimensions of the family were included: family structural variables, maternal variables, and mother-child (parenting) variables. The participants were 82 children between the ages of 6 and 11 and their HIV-infected mothers. Correlational analyses indicated that resiliency was associated only with three parenting variables: parent-child relationship, parental monitoring, and parental structure in the home. Hierarchical regression analyses indicated a multiplicative relationship between parental monitoring and parent-child relationship and between parental monitoring and parental structure in the home, suggesting that parenting variables potentiate each other. Clinical implications of the findings are considered.

A new model for experimental tendon adhesions in the chicken.

A minimally invasive model using a manual abrader to induce adhesions in the chicken's central digit is described. The flexor synovial sheath and the profundus tendon were abraded with access through small flaps at the level of the proximal and distal phalanges of the avian long toes. The birds were divided into two groups according to the severity of the induced trauma. Group I birds received an abrasion injury and were euthanized to allow biomechanical testing 5 weeks postoperatively. Group II birds had a more severe abrasion and were euthanized similarly and tested 5 weeks after surgery. Results were compared with nonsurgical controls. Long toe function was evaluated weekly by measuring (1) the range of active flexion of each interphalangeal joint, resolved to total angular range; (2) the grasping ability on graded-diameter perches; and (3) the flexion deficit of the long toe. Postmortem biomechanical properties of the adhesions were measured. There was a significant difference between the unoperated controls and abraded digits of both groups in all parameters (p < 0.001). There was, in addition, a marked change in most of the measured parameters between groups I and II. In group I digits the functional and biomechanical deficit was less than group II. In summary, this animal model of long-segment abrasive injury to the tendon and sheath is a simple and reproducible method to generate adhesions and can be used for the evaluation of treatment modalities for adhesion prevention.

Breast cancer stage at diagnosis and survival among patients with prior breast implants.

Longstanding concern exists regarding the potential for women with breast implants to experience delayed detection of breast cancer. Furthermore, survival among cosmetic breast implant patients who subsequently develop breast cancer is a concern. Since 1976, this institution has monitored cancer incidence in a cohort of 3182 women who underwent cosmetic breast augmentation between 1959 and 1981. The distributions of stage at diagnosis and survival of the 37 women who subsequently developed in situ or invasive breast cancer were compared with the observed population distributions. The distribution of stage at diagnosis for cosmetic breast implant patients who subsequently developed breast cancer was virtually identical to that of all breast cancer patients in Los Angeles County who were of the same age and race, and were diagnosed during the same time period. Furthermore, the 5-year survival rate of the 37 patients did not differ from that which would be expected based on rates established by the U.S. National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program. These results suggest that cosmetic breast implant patients are not at increased risk of delayed detection of breast cancer, nor do they suffer a poorer prognosis when breast cancer does occur. Although the number of breast cancer patients in this study is small, the results are highly consistent with the existing epidemiologic evidence related to breast cancer detection and survival among breast implant patients. Although breast implant patients should continue appropriate breast cancer screening behavior, there seems to be no cause for alarm.

Linking maternal efficacy beliefs, developmental goals, parenting practices, and child competence in rural single-parent African American families.

With a sample of 139 rural, single-parent African American families with a 6- to 9-year-old child, we traced the links among family financial resource adequacy, maternal childrearing efficacy beliefs, developmental goals, parenting practices, and children's academic and psychosocial competence. A multimethod, multiinformant design was used to assess the constructs of interest. Consistent with the hypothesized paths, financial resource adequacy was linked with mothers' sense of childrearing efficacy. Efficacy beliefs were linked with parenting practices indirectly through developmental goals. Competence-promoting parenting practices were indirectly linked with children's academic and psychosocial competence through their association with children's self-regulation.

Effects of residential instability on Head Start children and their relationships with older siblings: influences of child emotionality and conflict between family caregivers.

This study examined the influence that residential dislocations have on child behavior problems, depression, peer competence, cognitive competence, and the quality of sibling relations in a sample of 70 Head Start children, aged 32 to 67 months, and their older brothers and sisters, aged 48 to 155 months. This was the first study to investigate the sibling relationship in the context of high residential mobility. Information on child characteristics was obtained from mothers and teachers. Sibling data (warmth/harmony and conflict) were obtained from coding videotaped interactions. Child emotionality was found to be an important moderator of the effects of residential mobility on young, poor children and their siblings; caregiver conflict was a less powerful moderator of these effects. Residential instability seemed to compromise the warmth/harmony of the sibling relationship. It was concluded that the effects of residential instability are complex and cannot be understood without considering child characteristics, such as temperament, and the family context in which the child lives.

Women who are HIV infected: the role of religious activity in psychosocial adjustment.

The role of religious activity in the psychosocial adjustment of 205 inner-city African-American women, one-half of whom are HIV infected, was examined. Those who were HIV infected reported praying more but viewed prayer as less effective in coping with a chronic illness. Frequency of prayer predicted optimism about the future, whereas religious activity was not related to current depressive symptoms.

Parent-child relationships, child temperament profiles and children's alcohol use norms.

OBJECTIVE: The purpose of this study was to examine the contributions of child temperament, parents' alcohol use norms for their children and parent-child relationship quality to children's alcohol use norms. METHOD: Observational and self-report data on these variables were gathered from mothers, fathers and target children during home visits to a purposive random sample of 171 intact white families with a 10- to 12-year-old child, 85 with girls and 86 with boys. RESULTS: Liberality in children's norms was associated with active, sensation-seeking temperament, liberality in parents' norms and poor parent-child relationship quality. Positive parent-child, particularly father-child, relationships were associated with less liberal child norms even when parents' norms were liberal and children's temperaments were active and sensation oriented. CONCLUSIONS: Positive parent-child relationships have a conventionalizing effect on children's alcohol use norms that moderates the effects of temperament and parental norms. The development of alcohol use norms is best described by transactional models.

Tissue plasminogen activator for acute stroke in everyday clinical practice.

Thrombolysis for acute ischemic stroke has become a reality. The aim of our study was to assess the opportunity and practicality of establishing acute stroke treatment in a hospital that did not participate in acute stroke treatment trials, as well as to prospectively analyze 2 groups of patients who reached the Emergency Department (ED) within 3 hours who were either treated or not treated with tissue plasminogen activator (t-PA). The average score for severity of neurological deficits for the patients who received t-PA was 14 on the National Institute of Health Stroke Scale (NIHSS). We compare this group with 18 patients who did not receive t-PA but had similar NIHSS scores (13.9 average). Both groups were matched for age and other comorbidity factors. We concluded that the establishment of an acute stroke treatment algorithm is possible de novo in a hospital that is equipped with computed tomography (CT) and neurosurgery services. The number of patients who can receive t-PA treatment is limited by the strict inclusion and exclusion criteria. Prolonged door-to-needle time was caused by delays in CT interpretation, processing of laboratory results, and stabilization of blood pressure. Patients who received t-PA had a shorter length of stay, were more independent, and had a better survival rate after 1 year. Our findings were in agreement with the National Institute of Neurological Disorders and Stroke (NINDS) Stroke Study that led to the approval of the use of t-PA in the treatment of acute ischemic stroke.