Optimal trauma resuscitation with plasma as the primary resuscitative fluid: the surgeon's perspective

Hematology ◽  
2013 ◽  
Vol 2013 (1) ◽  
pp. 656-659 ◽  
Author(s):  
John B. Holcomb ◽  
Shibani Pati
Keyword(s):  
Quality Data ◽  
Past Century ◽  
Trauma Patients ◽  
Blood Products ◽  
Military Operations ◽  
Trauma Outcomes ◽  
The Past ◽  
Civilian Trauma ◽  
Transfusion Ratio ◽  
Injured Patients

Abstract Over the past century, blood banking and transfusion practices have moved from whole blood therapy to components. In trauma patients, the shift to component therapy was achieved without clinically validating which patients needed which blood products. Over the past 4 decades, this lack of clinical validation has led to uncertainty on how to optimally use blood products and has likely resulted in both overuse and underuse in injured patients. However, recent data from both US military operations and civilian trauma centers have shown a survival advantage with a balanced transfusion ratio of RBCs, plasma, and platelets. This has been extended to include the prehospital arena, where thawed plasma, RBCs, and antifibrinolytics are becoming more widely used. The Texas Trauma Institute in Houston has followed this progression by putting RBCs and thawed plasma in the emergency department and liquid plasma and RBCs on helicopters, transfusing platelets earlier, and using thromboelastogram-guided approaches. These changes have not only resulted in improved outcomes, but have also decreased inflammatory complications, operations, and overall use of blood products. In addition, studies have shown that resuscitating with plasma (instead of crystalloid) repairs the “endotheliopathy of trauma,” or the systemic endothelial injury and dysfunction that lead to coagulation disturbances and inflammation. Data from the Trauma Outcomes Group, the Prospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study, and the ongoing Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial represent a decade-long effort to programmatically determine optimal resuscitation practices, balancing risk versus benefits. With injury as the leading cause of death in patients age 1 to 44 years and hemorrhage the leading cause of potentially preventable death in this group, high-quality data must be obtained to provide superior care to the civilian and combat injured.

National temporal variation in major trauma in England, Wales and Northern Ireland

Trauma ◽  
2021 ◽  
pp. 146040862098226
Author(s):  
Will Kieffer ◽  
Daniel Michalik ◽  
Jason Bernard ◽  
Omar Bouamra ◽  
Benedict Rogers
Keyword(s):  
Northern Ireland ◽  
Temporal Variation ◽  
Major Trauma ◽  
Injury Severity ◽  
Research Network ◽  
Trauma Patients ◽  
Trauma Outcomes ◽  
Causes Of Mortality ◽  
Injured Patients ◽  
Time Of Admission

Introduction Trauma is one of the leading causes of mortality worldwide, but little is known of the temporal variation in major trauma across England, Wales and Northern Ireland. Proper workforce and infrastructure planning requires identification of the caseload burden and its temporal variation. Materials and Methods The Trauma Audit Research Network (TARN) database for admissions attending Major Trauma Centres (MTCs) between 1st April 2011 and 31st March 2018 was analysed. TARN records data on all trauma patients admitted to hospital who are alive at the time of admission to hospital. Major trauma was classified as an Injury Severity Score (ISS) >15. Results A total of 158,440 cases were analysed. Case ascertainment was over 95% for 2013 onwards. There was a statistically significant variation in caseload by year (p < 0.0001), times of admissions (p < 0.0001), caseload admitted during weekends vs weekdays, 53% vs 47% (p < 0.0001), caseload by season with most patients admitted during summer (p < 0.0001). The ISS varied by time of admission with most patients admitted between 1800 and 0559 (p < 0.0001), weekend vs weekday with more severely injured patients admitted during the weekend (p < 0.0001) and by season p < 0.0001). Discussion and Conclusion: There is a significant national temporal variation in major trauma workload. The reasons are complex and there are multiple theories and confounding factors to explain it. This is the largest dataset for hospitals submitting to TARN which can help guide workforce and resource allocation to further improve trauma outcomes.

scholarly journals Excitation of Polar Motion

2000 ◽  
Vol 178 ◽  
pp. 411-420 ◽  
Author(s):  
Clark R. Wilson
Keyword(s):  
Polar Motion ◽  
Conceptual Models ◽  
Numerical Models ◽  
Broad Band ◽  
Quality Data ◽  
Past Century ◽  
High Quality Data ◽  
The Past ◽  
Continuum Concept ◽  
The Continuum

AbstractConceptual models of polar motion have evolved over the past century, as improved data revealed signals over progressively wider frequency bands. In the 1890s, Chandler represented polar motion as a sum of discrete components, 14 month and annual terms, and this component model effectively summarized the observations, but did not provide a physical explanation for them. Over time both the search for a physical understanding of polar motion, and the ability to observe the broad band continuum outside the Chandler and annual bands have led to an understanding of polar motion as a continuum of variations, not adequately described by a few discrete components. The continuum concept is now the working model in most studies of polar motion. The transition from component to continuum conceptual models preceded the arrival of high quality data by several decades, and reflected significant contributions from Harold Jeffreys. With modern space geodetic observations and good global numerical models of the atmosphere, oceans, and other climate processes, it is clear that air and water motion and redistribution are the dominant contributors to the excitation continuum.

scholarly journals Optimal Use of Blood Products in Severely Injured Trauma Patients

Hematology ◽  
2010 ◽  
Vol 2010 (1) ◽  
pp. 465-469 ◽  
Author(s):  
John B. Holcomb
Keyword(s):  
The United States ◽  
Outcome Data ◽  
Quality Data ◽  
Optimal Timing ◽  
Trauma Patients ◽  
Blood Products ◽  
Multicenter Studies ◽  
Life Years ◽  
Multicenter Prospective Observational Study ◽  
Trauma Patient Outcome

Abstract Injury is the leading cause of life years lost in the United States, and uncontrolled hemorrhage is the leading cause of potentially preventable death. Traditionally, these patients have been serially resuscitated with large volumes of crystalloid and/or colloids and red blood cells, followed by smaller amounts of plasma and platelets. Transfusion data coming first from the ongoing war in Iraq and Afghanistan and followed by multiple civilian studies have brought into question this tradition-based practice. Numerous recent retrospective single and multicenter studies have associated improved outcomes with earlier and increased use of plasma and platelets. These data have stimulated significant interest in studying massively transfused trauma patients. Most clinicians have concluded that the optimal timing and quantity of blood products in the treatment of hypothermic, coagulopathic, and acidotic trauma patients are unclear. Although there are strongly held opinions and long-standing traditions in their use, there are little quality data within which to logically guide resuscitation therapy. A multicenter prospective observational study is ongoing, and randomized trials are planned. This review will address the issues raised previously and describe recent trauma patient outcome data utilizing predetermined plasma:platelet:red blood cell transfusion ratios, and possibilities for future transfusion products and research.

scholarly journals Evolution of Joint Warfare

2021 ◽  
pp. 1-11
Author(s):  
Edward R. Lucas ◽  
Thomas A. Crosbie
Keyword(s):  
Past Century ◽  
Military Operations ◽  
Basic Premise ◽  
The Past ◽  
Joint Operations

AbstractThe ability to employ force across the physical warfighting domains of air, land, maritime, and space is essential in contemporary conflict. In NATO doctrine, the term “joint operations” refers to military actions “in which elements of at least two services participate.” While doctrinal definitions differ slightly across Western militaries, the basic premise remains that “jointness” in military operations entails significant action in at least two of the physical warfighting domains. This chapter provides an overview of joint warfare, beginning with a brief discussion of its development over the past century. It then turns its attention to the development of joint doctrine and the joint functions. It concludes with a brief discussion of what some military theorists see as the next iteration of joint warfighting: multi-domain operations (MDO).

The zoonotic potential of bat-borne coronaviruses

2020 ◽  
Vol 4 (4) ◽  
pp. 365-381
Author(s):  
Ny Anjara Fifi Ravelomanantsoa ◽  
Sarah Guth ◽  
Angelo Andrianiaina ◽  
Santino Andry ◽  
Anecia Gentles ◽  
...  
Keyword(s):  
Genetic Material ◽  
Field Research ◽  
Sympatric Species ◽  
Animal Origin ◽  
Mammalian Host ◽  
Past Century ◽  
The Past ◽  
Novel Host ◽  
Horseshoe Bat ◽  
Human Infections

Seven zoonoses — human infections of animal origin — have emerged from the Coronaviridae family in the past century, including three viruses responsible for significant human mortality (SARS-CoV, MERS-CoV, and SARS-CoV-2) in the past twenty years alone. These three viruses, in addition to two older CoV zoonoses (HCoV-229E and HCoV-NL63) are believed to be originally derived from wild bat reservoir species. We review the molecular biology of the bat-derived Alpha- and Betacoronavirus genera, highlighting features that contribute to their potential for cross-species emergence, including the use of well-conserved mammalian host cell machinery for cell entry and a unique capacity for adaptation to novel host environments after host switching. The adaptive capacity of coronaviruses largely results from their large genomes, which reduce the risk of deleterious mutational errors and facilitate range-expanding recombination events by offering heightened redundancy in essential genetic material. Large CoV genomes are made possible by the unique proofreading capacity encoded for their RNA-dependent polymerase. We find that bat-borne SARS-related coronaviruses in the subgenus Sarbecovirus, the source clade for SARS-CoV and SARS-CoV-2, present a particularly poignant pandemic threat, due to the extraordinary viral genetic diversity represented among several sympatric species of their horseshoe bat hosts. To date, Sarbecovirus surveillance has been almost entirely restricted to China. More vigorous field research efforts tracking the circulation of Sarbecoviruses specifically and Betacoronaviruses more generally is needed across a broader global range if we are to avoid future repeats of the COVID-19 pandemic.

PCSK9 inhibition for LDL lowering and beyond – implications for patients with peripheral artery disease

VASA ◽  
2018 ◽  
Vol 47 (3) ◽  
pp. 165-176 ◽  
Author(s):  
Katrin Gebauer ◽  
Holger Reinecke
Keyword(s):  
Cardiovascular Risk ◽  
Risk Reduction ◽  
Ldl Receptor ◽  
Density Lipoprotein ◽  
Past Century ◽  
Pcsk9 Inhibitors ◽  
Cardiovascular Risk Reduction ◽  
Simultaneous Application ◽  
The Past ◽  
Pcsk9 Inhibition

Abstract. Low-density lipoprotein cholesterol (LDL-C) has been proven to be a causal factor of atherosclerosis and, along with other triggers like inflammation, the most frequent reason for peripheral arterial disease. Moreover, a linear correlation between LDL-C concentration and cardiovascular outcome in high-risk patients could be established during the past century. After the development of statins, numerous randomized trials have shown the superiority for LDL-C reduction and hence the decrease in cardiovascular outcomes including mortality. Over the past decades it became evident that more intense LDL-C lowering, by either the use of highly potent statin supplements or by additional cholesterol absorption inhibitor application, accounted for an even more profound cardiovascular risk reduction. Proprotein convertase subtilisin/kexin type 9 (PCSK9), a serin protease with effect on the LDL receptor cycle leading to its degradation and therefore preventing continuing LDL-C clearance from the blood, is the target of a newly developed monoclonal antibody facilitating astounding LDL-C reduction far below to what has been set as target level by recent ESC/EAS guidelines in management of dyslipidaemias. Large randomized outcome trials including subjects with PAD so far have been able to prove significant and even more intense cardiovascular risk reduction via further LDL-C debasement on top of high-intensity statin medication. Another approach for LDL-C reduction is a silencing interfering RNA muting the translation of PCSK9 intracellularly. Moreover, PCSK9 concentrations are elevated in cells involved in plaque composition, so the potency of intracellular PCSK9 inhibition and therefore prevention or reversal of plaques may provide this mechanism of action on PCSK9 with additional beneficial effects on cells involved in plaque formation. Thus, simultaneous application of statins and PCSK9 inhibitors promise to reduce cardiovascular event burden by both LDL-C reduction and pleiotropic effects of both agents.

Archaeology in the Past Century

1901 ◽  
Vol 51 (1309supp) ◽  
pp. 20976-20977
Author(s):  
W. M. Flinders Petrje
Keyword(s):  
Past Century ◽  
The Past

Catholicism and Cosmopolitanism: the Confluence of Three Catholic Scholars and the Cosmopolitan Democrats on State Sovereignty and the Future of Global Governance

2016 ◽  
Vol 3 (2) ◽  
pp. 37-51
Author(s):  
Matthew Bagot
Keyword(s):  
Global Governance ◽  
State Sovereignty ◽  
Current Debate ◽  
Past Century ◽  
Jacques Maritain ◽  
The Past ◽  
Technological Advances ◽  
The Future ◽  
Cosmopolitan Democracy ◽  
Catholic Tradition

One of the central questions in international relations today is how we should conceive of state sovereignty. The notion of sovereignty—’supreme authority within a territory’, as Daniel Philpott defines it—emerged after the Treaty of Westphalia in 1648 as a result of which the late medieval crisis of pluralism was settled. But recent changes in the international order, such as technological advances that have spurred globalization and the emerging norm of the Responsibility to Protect, have cast the notion of sovereignty into an unclear light. The purpose of this paper is to contribute to the current debate regarding sovereignty by exploring two schools of thought on the matter: first, three Catholic scholars from the past century—Luigi Sturzo, Jacques Maritain, and John Courtney Murray, S.J.—taken as representative of Catholic tradition; second, a number of contemporary political theorists of cosmopolitan democracy. The paper argues that there is a confluence between the Catholic thinkers and the cosmopolitan democrats regarding their understanding of state sovereignty and that, taken together, the two schools have much to contribute not only to our current understanding of sovereignty, but also to the future of global governance.

Aftershocks

2017 ◽  
Author(s):  
Seva Gunitsky
Keyword(s):  
Twentieth Century ◽  
Regime Change ◽  
International System ◽  
Political Legitimacy ◽  
Great Powers ◽  
Past Century ◽  
The Past ◽  
Sudden Rise ◽  
The World ◽  
National Borders

Over the past century, democracy spread around the world in turbulent bursts of change, sweeping across national borders in dramatic cascades of revolution and reform. This book offers a new global-oriented explanation for this wavelike spread and retreat—not only of democracy but also of its twentieth-century rivals, fascism, and communism. The book argues that waves of regime change are driven by the aftermath of cataclysmic disruptions to the international system. These hegemonic shocks, marked by the sudden rise and fall of great powers, have been essential and often-neglected drivers of domestic transformations. Though rare and fleeting, they not only repeatedly alter the global hierarchy of powerful states but also create unique and powerful opportunities for sweeping national reforms—by triggering military impositions, swiftly changing the incentives of domestic actors, or transforming the basis of political legitimacy itself. As a result, the evolution of modern regimes cannot be fully understood without examining the consequences of clashes between great powers, which repeatedly—and often unsuccessfully—sought to cajole, inspire, and intimidate other states into joining their camps.

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