Haemodynamics as a determinant of need for pre-hospital application of a pelvic circumferential compression device in adult trauma patients.

INTRODUCTION: Pelvic ring fractures are common following high-energy blunt trauma and can lead to substantial haemorrhage, morbidity and mortality. Pelvic circumferential compression devices (PCCDs) improve position and stability of open-book type pelvic fracture, and can improve haemodynamics in patients with hypovolaemic shock. However, PCCDs may cause adverse outcomes including worsening of lateral compression fracture patterns and routine use is associated with high costs. Controversy regarding indication of PCCDs exists with some centres recommending PCCD in the setting of hypovolaemic shock compared to placement for any suspected pelvic injury. OBJECTIVE: To assess the need for PCCD application based on pre-hospital vital signs and mechanism of injury. METHODS: A retrospective cohort study was conducted in a single adult major trauma centre examining a 2-year period. Patients were sub-grouped based on initial pre-hospital and emergency department observations as haemodynamically normal (heart rate <100 bpm, systolic blood pressure ≥100 mmHg and Glasgow Coma Scale ≥13) or abnormal. Diagnostic accuracy of pre-hospital haemodynamics as a predictor of pelvic fracture requiring intervention within 24 h was assessed. RESULTS: There were 376 patients with PCCD in-situ on hospital arrival. Pelvic fractures were diagnosed in 137 patients (36.4%). Of these, 39 (28.5%) were haemodynamically normal and 98 (71.5%) were haemodynamically abnormal. The most common mechanisms of injury were motor vehicle collision (57.7%) and motorcycle collision (13.8%). Of those with fractures, 40 patients (29.2%) required pelvic intervention within 24 h of admission; of these, 8 (20%) were haemodynamically normal and 32 (80%) were haemodynamically abnormal. As a test for pelvic fracture requiring intervention within 24 h, abnormal pre-hospital haemodynamics had a sensitivity of 0.80 (95% CI 0.64-0.91), specificity of 0.32 (95% CI 0.27-0.38) and negative predictive value (NPV) of 0.93 (95% CI 0.88-0.96). Combined with absence of a major mechanism of injury, normal haemodynamics had a sensitivity 1.00, specificity 0.51 (95% CI 0.36-0.66) and NPV of 1.00 for pelvic intervention within 24 h. CONCLUSION: Normal haemodynamic status, combined with absence of major mechanism of injury can rule out requirement for urgent pelvic intervention. Ongoing surveillance is recommended to monitor for any adverse effects of this change in practice.

A checklist for trauma quality improvement meetings: A process improvement study.

BACKGROUND: Each year approximately five million people die from injuries. In countries where systems of trauma care have been introduced, death and disability have decreased. A major component of developed trauma systems is a trauma quality improvement (TQI) program and trauma quality improvement meeting (TQIM). Effective TQIMs improve trauma care by identifying and fixing problems. But globally, TQIMs are absent or unstructured in most hospitals providing trauma care. The aim of this study was to implement and evaluate a checklist for a structured TQIM. METHODS: This project was conducted as a prospective before-and-after study in four major trauma centres in India. The intervention was the introduction of a structured TQIM using a checklist, introduced with a workshop. This workshop was based on the World Health Organization (WHO) TQI Programs short course and resources, plus the developed TQIM checklist. Pre- and post-intervention data collection occurred at all meetings in which cases of trauma death were discussed. The primary outcome was TQIM Checklist compliance, defined by the discussion of, and agreement upon each of the following: preventability of death, identification of opportunities to improve care and corrective actions and a plan for closing the loop. RESULTS: There were 34 meetings in each phase, with 99 cases brought to the pre-intervention phase and 125 cases brought to the post-intervention phase. There was an increase in the proportion of cases brought to the meeting for which preventability of death was discussed (from 94% to 100%, p = 0.007) and agreed (from 7 to 19%, OR 3.7; 95% CI:1.4-9.4, p = 0.004) and for which a plan for closing the loop was discussed (from 2% to 18%, OR 10.9; 95% CI:2.5-47.6, p < 0.001) and agreed (from 2% to 18%, OR 10.9; 95% CI:2.5-47.6, p < 0.001). CONCLUSION: This study developed, implemented and evaluated a TQIM Checklist for improving TQIM processes. The introduction of a TQIM Checklist, with training, into four Indian trauma centres, led to more structured TQIMs, including increased discussion and agreement on preventability of death and plans for loop closure. A TQIM Checklist should be considered for all centres managing trauma patients.

Diel-scale variation of dissolved inorganic carbon during a rainfall event in a small karst stream in southern China.

Metabolic processes of the submerged aquatic community (photosynthesis and respiration) play important roles in regulating diel cycles of dissolved inorganic carbon (DIC) and sequestering carbon in a karst stream. However, little is known of whether diel DIC cycling occurs during rainfall in a karst groundwater-fed stream, even though this question is critical for the accurate estimation of what may be a major terrestrial carbon sink. Here, we measured diel variations of water chemical composition in a small karst groundwater-fed stream in southwest China during a rainfall event to assess the influences of rainfall and rising discharge on DIC diel cycling and the potential carbon sink produced by in-stream metabolism. Our results show that water chemical composition at the source spring (CK site) is relatively stable due to chemostatic behavior during rising discharge after a rainfall period. This site lacked submerged aquatic vegetation and, thus, had no diel variations in water chemistry. However, diel cycles of all hydrochemical parameters occurred at a site 1.3 km downstream (LY site). Diel variations in pH, DO, and δ13CDIC were inversely related to diel changes in SpC, DIC, Ca2+, and pCO2. These results indicated that diel cycling of DIC due to in-stream metabolism of submerged aquatic community was still occurring during elevated discharge from rainfall. We estimate the carbon sink through the in-stream metabolism of the submerged aquatic community to be 5.6 kg C/day during the studied rainfall event. These results imply that submerged aquatic communities in a karst stream can significantly stabilize carbon originating from the carbonate rock weathering processes in karst areas.

Video-tube thoracostomy in trauma resuscitation: A pilot study.

BACKGROUND: Complications related to incorrect positioning of tube thoracostomy (TT) have been reported to be as high as 30%. The aim of this study was to assess the feasibility of flexible videoscope guided placement of a pre-loaded chest tube, permitting direct intrapleural visualization and placement (Video-Tube Thoracostomy [V-TT]). METHODS: A prospective, single centre, phase 1 pilot study with a parallel control group was undertaken. The population studied were adult thoracic trauma patients requiring emergency TT who were haemodynamically stable. The intervention performed was VTT. Patients in the control group underwent conventional TT. The primary outcome was tube position as defined by a consultant radiologist's interpretation of chest x-ray (CXR) or CT. The trial was registered with ANZCTR.org.au (ACTRN: 12,615,000,870,550). RESULTS: There were 37 patients enrolled in the study - 12 patients allocated to the VTT intervention group and 25 patients allocated to conventional TT. Mean age of participants was 48 years (SD 15) in intervention group and 46 years (SD 15) years in the control group. In the VTT group all patients were male; the indications were pneumothorax (83%), haemothorax (8%) and haemopneumothorax (8%). The median injury severity score was 23 (16-28). There were 1 positional and 1 insertional complications. In the control group 72% of patients were male, the indications were pneumothorax (56%), haemothorax (4%) and haemopneumothorax (40%). The median injury severity score was 24 (14-36). There were 8 (32%) positional complications and no insertional complications. CONCLUSION: V-TT was demonstrated to be a feasible alternative to conventional thoracostomy and merits further investigation.

Structure of the monotopic membrane protein (S)-mandelate dehydrogenase at 2.2 Šresolution.

The x-ray structure of the monotopic membrane protein (S)-mandelate dehydrogenase (MDH) from Pseudomonas putida reveals an inherent flexibility of its membrane binding segment that might be important for its biological activity. The surface of MDH exhibits a concentration of the positive charges on one side and the negative charges on the other side. The putative membrane binding surface of MDH has a concentric circular ridge, formed by positively charged residues, which projects away from the protein surface by ∼4 Å; this is an unique structural feature and not observed in other monotopic membrane proteins to our knowledge. There are three α-helixes in the membrane binding region. Based on the structure of MDH, it is possible to propose that the interaction of MDH with the membrane is stabilized by coplanar electrostatic interactions, between the positively charged concentric circular ridge and the negatively charged head-groups of the phospholipid bilayer, along with three α-helixes that provide additional stability by inserting into the membrane. The structure reveals the possible orientation of these helixes along with possible roles for the individual residues which form those helixes. These α-helixes may play a role in the enzyme's mobility. A detergent molecule, N-Dodecyl-ß-maltoside, is inserted between the membrane binding region and rest of the molecule and may provide structural stability to intra-protein regions by forming hydrogen bonds and close contacts. From the average B-factor of the MDH structure, it is likely that MDH is highly mobile, which might be essential for its interaction in membrane and non-membrane environments, as its substrate (S)-mandelate, is from the cytoplasm, while its electron acceptor is a component of the membrane electron transport chain.

Early start of the West Nile fever transmission season 2018 in Europe.

In Europe, surveillance indicates that the 2018 West Nile fever transmission season started earlier than in previous years and with a steeper increase of locally-acquired human infections. Between 2014 and 2017, European Union/European Economic Area (EU/EEA) and EU enlargement countries notified five to 25 cases in weeks 25 to 31 compared with 168 cases in 2018. Clinicians and public health authorities should be alerted to ensure timely implementation of prevention measures including blood safety measures.

Management of injured patients who were Jehovah's Witnesses, where blood transfusion may not be an option: a retrospective review.

INTRODUCTION: Management of major haemorrhage as a result of trauma is particularly challenging when blood is not an option (BNAO). Evidence on therapeutic strategies in this situation is limited. The aim of this study was to evaluate the management and outcomes of patients who identified themselves as Jehovah's Witnesses (who usually refuse blood products) with traumatic haemorrhage at an Australian major trauma centre. METHODS: A retrospective review of patients from The Alfred Trauma Registry was conducted, including patients who were Jehovah's Witnesses presenting between January 2010 and January 2017. We examined demographics, injury characteristics, clinical progress, therapeutic interventions and outcomes at hospital discharge. RESULTS: There were 34 patients meeting inclusion criteria, with 50% suffering major trauma. Anaemia was a clinical problem for 13 (38·2%) patients, with haemoglobin levels reaching a nadir of 69·7 g/l (95% CI: 56·7-82·7) on average 5·1 days (95% CI: 2·5-7·7) post admission. Various strategies were employed to reduce blood loss including six (46·2%) patients receiving tranexamic acid, nine (29·2%) patients receiving oral or intravenous iron and five (38·5%) receiving erythropoietin. Three patients received packed red cells, and two patients received synthetic haemoglobin-based oxygen carriers. CONCLUSIONS: Numerous therapeutic strategies were employed inconsistently in this unique population of patients. Augmenting circulatory volume with an oxygen carrier acceptable to JW patients presents a novel approach to be considered in adjunct to other strategies. An international resource centre would assist clinicians faced with anaemia and BNAO.

A novel approach to improving the interpretation of CT brain in trauma.

BACKGROUND: Computed tomography of the brain (CTB) has a fundamental role in the diagnosis and management of traumatic brain injury (TBI). There may be substantial discordance between initial CTB interpretation by emergency clinicians and the final radiology report. This study aimed to assess the utility of a structured reporting template in improving the accuracy of CTB interpretation by emergency clinicians. METHOD: A prospective pre- and post-intervention cohort study was undertaken using a study population of emergency medicine trainees. The CTB reporting template was created with consultation from radiology, emergency medicine and trauma specialists. Participants reported on a set of randomly selected trauma CTBs first without, and then with, the reporting template. Each case was independently assessed for concordance with the radiology report by two blinded assessors (including a radiologist) and the proportion of concordant reports in each phase calculated. RESULTS: There were 26 participants recruited to the study who reported on a total of 320 CTBs. In the pre-intervention phase, 121 (76%) cases were concordant with the radiology report compared to 147 (92%) post-intervention (p<0.01). The AUROC was 0.84 (95% CI: 0.78-0.89) pre-intervention and improved to 0.94 (95% CI: 0.88-0.99) with the intervention (p=0.01). A higher level of baseline accuracy was observed in advanced trainees (78%) compared to basic trainees (72%), but both improved to a similar level of 92% with the use of the CTB reporting template. There was a marked reduction in false negative errors, with increased identification of critical diagnoses such as cerebral herniation and diffuse axonal injury. CONCLUSION: The use of the CTB reporting template significantly increased the accuracy of emergency medicine trainees and reduced the number of missed critical diagnoses. Reporting templates may represent an effective strategy to improve CTB interpretation and enhance the initial care of head injured patients.

River sequesters atmospheric carbon and limits the CO2 degassing in karst area, southwest China.

CO2 fluxes across water-air interfaces of river systems play important roles in regulating the regional and global carbon cycle. However, great uncertainty remains as to the contribution of these inland water bodies to the global carbon budget. Part of the uncertainty stems from limited understanding of the CO2 fluxes at diurnal and seasonal frequencies caused by aquatic metabolism. Here, we measured surface water characteristics (temperature, pH, and DO, DIC, Ca2+ concentrations) and CO2 fluxes across the air-water interface at two transects of Guijiang River, southwest China to assess the seasonal and diurnal dynamics of fluvial carbon cycling and its potential role in regional and global carbon budgets. The two transects had differing bedrock; DM transect is underlain by carbonate and detrital rock and PY is underlain by pure carbonate. Our results show that the river water both degasses CO2 to and absorbs CO2 from the atmosphere in both summer and winter, but the degassing and absorption varied between the two transects. Further, CO2 fluxes evolve through diurnal cycles. At DM, the river evaded CO2 from early morning through noon and absorbed CO2 from afternoon through early morning. At PY in summer, the CO2 evasion decreased during the daytime and increased at night while in winter at night, CO2 uptake increased in the morning and decreased in the afternoon but remained relatively stable at night. Although the river is a net source of carbon to the atmosphere (~15mMm-2day-1), the evasion rate is the smallest of all reported world's inland water bodies reflecting sequestration of atmospheric carbon through the carbonate dissolution and high primary productivity. These results emphasize the need of seasonal and diurnal monitoring of CO2 fluxes across water-air interface, particularly in highly productive rivers, to reduce uncertainty in current estimates of global riverine CO2 emission.

In-stream metabolism and atmospheric carbon sequestration in a groundwater-fed karst stream.

Atmospheric carbon sequestered in karst systems through dissolution of carbonate minerals is considered to have no net effect on long-term regional and global carbon budgets because precipitation of dissolved carbonate minerals emits CO2 back to the atmosphere. Even though recent studies have implied that rapid kinetics of carbonate dissolution coupled with the aquatic photosynthetic uptake of dissolve inorganic carbon (DIC) could facilitate a stable atmospheric C sink in karst rivers and streams, little is known about the magnitudes and long-term stability of this C sink. To assess in-stream biogeochemical processes and their role on stream C cycling, we measured diel cycles of water characteristics and chemical composition (temperature, pH, DO, SpC, DIC, Ca2+, δ13CDIC) in a groundwater-fed karst stream in southwest China. Our results show no diel variations at the groundwater discharge point (CK site) due to the absence of a sub-aquatic community (SAC). However, all hydrochemical parameters show significant diel cycle 1.3km downstream (LY site). Diel variations in pH, DO, and δ13CDIC were inversely related to diel changes in SpC, DIC, Ca2+ and pCO2. This result indicates that in-stream metabolism (photosynthesis and respiration) of SAC controls diel variations in stream water chemistry. Significant diel cycles of net ecosystem production (NEP) influences in-stream diel fluctuation of pH, DO, SIc, DIC, pCO2, Ca2+ and δ13CDIC, with gross primary production (GPP) dominating in day and ecosystem respiration (ER) dominating at the night. Absence of in-stream metabolism at CK enhances CO2 degassing from stream to the atmosphere, which is estimated to be 3-5 times higher than at LY. We estimate the carbon sink through in-stream metabolism of SAC to be 73tCkm-2a-1, which is around half the rate of the oceanic biological pump. These results imply in-stream photosynthesis sequesters DIC originating from karst weathering and controls CO2 evasion.

Partnered pharmacist charting on admission in the General Medical and Emergency Short-stay Unit - a cluster-randomised controlled trial in patients with complex medication regimens.

WHAT IS KNOWN AND OBJECTIVE: Patients admitted to general medical units and emergency short-stay units are often complex with multiple comorbidities, polypharmacy and at risk for drug-related problems associated with increased morbidity and mortality. The aim of this study was to evaluate the effectiveness of a partnered pharmacist charting model completed at the time of admission to prevent medication errors. METHODS: We conducted an unblinded cluster randomized controlled trial comparing partnered pharmacist charting to standard medical charting among patients admitted to general medical units and emergency short-stay units with complex medication regimens or polypharmacy. This trial was conducted at an adult major referral hospital in metropolitan Melbourne, Australia, with an annual emergency department attendance of approximately 60 000 patients. The evaluation included patients' medication charts written in the period of 16 March 2015 to 27 July 2015. Patients randomized to the intervention were managed using the partnered pharmacist charting model. The primary outcome variable was a medication error identified by an independent assessor within 24 h of admission, who was not part of the patient's admission process. RESULTS: Of the 473 patients who received standard medical staff charting during the study period, 372 (78·7%) had at least one medication error identified compared to 15 patients (3·7%) on the partnered pharmacist charting arm (P < 0·001). The relative risk of an error with standard medical charting was 21·4 (95% CI: 13·0-35·0) with a number needed to treat (NNT) to prevent one error of 1·3 (95% CI: 1·3-1·4), and the relative risk of a high or extreme risk error with standard medical charting was 150·9 (95% CI: 21·2-1072·9) with a NNT to prevent one high or extreme error of 2·7 (95% CI 2·4-3·1). WHAT IS NEW AND CONCLUSION: Partnering between medical staff and pharmacists to jointly chart initial medications on admission significantly reduced inpatient medication errors (including errors of high and extreme risk) among general medical and emergency short-stay patients with complex medication regimens or polypharmacy.

Management of haemodynamically stable patients with penetrating abdominal stab injuries: review of practice at an Australian major trauma centre.

INTRODUCTION: The management of haemodynamically stable patients who present following a penetrating abdominal injury (PAI) remains variable between mandatory surgical exploration and more selective non-operative approaches. The primary aim of this study was to assess compliance with an algorithm guiding selective non-operative management of haemodynamically stable patients with PAI. The secondary aim was to examine the association between compliance and unnecessary laparotomies. METHODS: This was a retrospective cohort study involving all patients with PAI that presented to a major trauma centre from January 2007 to December 2011. Data were extracted from the trauma registry and patients' electronic medical records. RESULTS: There were 189 patients included in the study, of which 79 (41.8 %) patients complied with the algorithm. The laparotomy rate in the setting of algorithm compliance was significantly lower than algorithm non-compliance (12.7 vs. 68.2 %; p < 0.01) as were unnecessary laparotomy rates (0 vs. 33.3 %; p = 0.03). CONCLUSION: Among haemodynamically stable patients presenting with PAI, compliance with an algorithm guiding selective non-operative management was low, but associated with lower laparotomy and lower unnecessary laparotomy rates. Improved compliance with algorithms directed towards selective non-operative management of PAI should be encouraged with stringent vigilance towards patient safety.

Triaging the right patient to the right place in the shortest time.

Trauma systems have been successful in saving lives and preventing disability. Making sure that the right patient gets the right treatment in the shortest possible time is integral to this success. Most trauma systems have not fully developed trauma triage to optimize outcomes. For trauma triage to be effective, there must be a well-developed pre-hospital system with an efficient dispatch system and adequately resourced ambulance system. Hospitals must have clear designations of the level of service provided and agreed protocols for reception of patients. The response within the hospital must be targeted to ensure the sickest patients get an immediate response. To enable the most appropriate response to trauma patients across the system, a well-developed monitoring programme must be in place to ensure constant refinement of the clinical response. This article gives a brief overview of the current approach to triaging trauma from time of dispatch to definitive treatment.

Elucidating the clinical characteristics of patients captured using different definitions of massive transfusion.

BACKGROUND AND OBJECTIVES: The type and clinical characteristics of patients identified with commonly used definitions of massive transfusion (MT) are largely unknown. The objective of this study was to define the clinical characteristics of patients meeting different definitions of MT for the purpose of patient recruitment in observational studies. MATERIALS AND METHODS: Data were extracted on all patients who received red blood cell (RBC) transfusions in 2010 at three tertiary Australian hospitals. MT patients were identified according to three definitions: ≥10 units RBC in 24 h (10/24 h), ≥6 units RBC in 6 h (6/6 h) and ≥5 units RBC in 4 h (5/4 h). Clinical coding data were used to assign bleeding context. Data on in-hospital mortality were also extracted. RESULTS: Five hundred and forty-two patients met at least one MT definition, with 236 (44%) included by all definitions. The most inclusive definition was 5/4 h (508 patients, 94%) followed by 6/6 h (455 patients, 84%) and 10/24 h (251 patients, 46%). Importantly, 40-55% of most types of critical bleeding events and 82% of all obstetric haemorrhage cases were excluded by the 10/24 h definition. Patients who met both the 5/4 h and 10/24 h definitions were transfused more RBCs (19 vs. 8 median total RBC units; P < 0·001), had longer ventilation time (120 vs. 55 h; P < 0·001), median ICU (149 vs. 99 h; P < 0·001) and hospital length of stay (23 vs. 18 h; P = 0·006) and had a higher in-hospital mortality rate (23·3% vs. 16·4%; P = 0·050). CONCLUSION: The 5/4 h MT definition was the most inclusive, but combination with the 10/24 h definition appeared to identify a clinically important patient cohort.

Effect of cold application in combination with Indomethacin suppository on chest tube removal pain in patients undergoing open heart surgery.

BACKGROUND: Chest tube removal is a painful procedure. The goal of this study was to evaluate the effect of cold application in combination with Indomethacin suppository on chest tube removal pain in patients undergoing open heart surgery. MATERIALS AND METHODS: This single-blind, double-group clinical trial was performed on 66 patients aged 18-68 years with the chest tube in pleural space. The Indomethacin suppository (100 mg) was administered 1 h before the chest tub removal in both groups. In the intervention group, we applied a 4°C cold pack in the chest tube side for 20 min. In the placebo group, the applied pack was at room temperature. Pain intensity was measured by Visual Analog Score 20 min before, immediately after, and 15 min after the chest tube removal. RESULTS: Immediately after the CTR, the mean pain score was 2.67 ± 0.79 and 3.9 ± 0.76 in the intervention and placebo groups, respectively. The pain scores measured before and 15 min after the CTR were not statistically different between the two groups. CONCLUSION: Application of cold in combination with Indomethacin suppository during the CTR was a suitable, low-risk, and easy method for pain control in open heart patients.

Serum lipase for assessment of pancreatic trauma.

PURPOSE: Pancreatic enzymes are routinely measured during reception of trauma patients to assess for pancreatic injury despite conflicting evidence on their utility. The aim of this study was to investigate the utility of routine initial serum lipase measurement for the diagnosis of acute pancreatic trauma. MATERIALS AND METHODS: Lipase measurements were introduced as part of the trauma pathology panel and requested on all patients who presented to an adult major trauma service and met trauma call-out criteria. Clinical records of these patients were extracted from the trauma registry and retrospectively reviewed. The performance of an initial serum lipase level measured on presentation to detect pancreatic trauma was determined. RESULTS: There were 2,580 patients included in the study, with 17 patients diagnosed with pancreatic trauma. An elevated lipase was recorded in 390 patients. Statistically significant associations were observed for elevated lipase in patients with pancreatic trauma, head injury, acute alcohol ingestion and massive blood transfusion. As a test for pancreatic trauma, an abnormal serum lipase result had a specificity of 85.3 % (95 % CI 83.8-86.6), sensitivity of 76.5 % (95 % CI 49.8-92.2), positive predictive value of 3.3 % (95 % CI 1.8-5.8) and negative predictive value of 99.8 % (95 % CI 99.4-99.9). Higher cut-offs of serum lipase did not result in better performance. CONCLUSIONS: A normal serum lipase result can be a useful adjunct to exclude pancreatic injury. A positive lipase result, regardless of the cut-off used, was not reliably associated with pancreatic trauma, and should not be used to guide further assessment.

Quantitative microscopy approach for shape-based erythrocytes characterization in anaemia.

Anaemia is one of the most common diseases in the world population. Primarily anaemia is identified based on haemoglobin level; and then microscopically examination of peripheral blood smear is required for characterizing and confirmation of anaemic stages. In conventional approach, experts visually characterize abnormality present in the erythrocytes under light microscope, and this evaluation process is subjective in nature and error prone. In this study, we have proposed a methodology using machine learning techniques for characterizing erythrocytes in anaemia associated with anaemia using microscopic images of peripheral blood smears. First, peripheral blood smear images are preprocessed based on grey world assumption technique and geometric mean filter for reducing unevenness of background illumination and noise reduction. Then erythrocyte cells are segmented using marker-controlled watershed segmentation technique. The erythrocytes in anaemia, such as, tear drop, echinocyte, acanthocyte, elliptocyte, sickle cells and normal erythrocytes cells have been characterized and classified based on their morphological changes. Optimal subset of features, ranked by information gain measure provides highest classification performance using logistic regression classifier in comparison with other standard classifiers.

Chicken domestication: an updated perspective based on mitochondrial genomes.

Domestic chickens (Gallus gallus domesticus) fulfill various roles ranging from food and entertainment to religion and ornamentation. To survey its genetic diversity and trace the history of domestication, we investigated a total of 4938 mitochondrial DNA (mtDNA) fragments including 2843 previously published and 2095 de novo units from 2044 domestic chickens and 51 red junglefowl (Gallus gallus). To obtain the highest possible level of molecular resolution, 50 representative samples were further selected for total mtDNA genome sequencing. A fine-gained mtDNA phylogeny was investigated by defining haplogroups A-I and W-Z. Common haplogroups A-G were shared by domestic chickens and red junglefowl. Rare haplogroups H-I and W-Z were specific to domestic chickens and red junglefowl, respectively. We re-evaluated the global mtDNA profiles of chickens. The geographic distribution for each of major haplogroups was examined. Our results revealed new complexities of history in chicken domestication because in the phylogeny lineages from the red junglefowl were mingled with those of the domestic chickens. Several local domestication events in South Asia, Southwest China and Southeast Asia were identified. The assessment of chicken mtDNA data also facilitated our understanding about the Austronesian settlement in the Pacific.

Three linked vasculopathic processes characterize Kawasaki disease: a light and transmission electron microscopic study.

BACKGROUND: Kawasaki disease is recognized as the most common cause of acquired heart disease in children in the developed world. Clinical, epidemiologic, and pathologic evidence supports an infectious agent, likely entering through the lung. Pathologic studies proposing an acute coronary arteritis followed by healing fail to account for the complex vasculopathy and clinical course. METHODOLOGY/PRINCIPAL FINDINGS: Specimens from 32 autopsies, 8 cardiac transplants, and an excised coronary aneurysm were studied by light (n=41) and transmission electron microscopy (n=7). Three characteristic vasculopathic processes were identified in coronary (CA) and non-coronary arteries: acute self-limited necrotizing arteritis (NA), subacute/chronic (SA/C) vasculitis, and luminal myofibroblastic proliferation (LMP). NA is a synchronous neutrophilic process of the endothelium, beginning and ending within the first two weeks of fever onset, and progressively destroying the wall into the adventitia causing saccular aneurysms, which can thrombose or rupture. SA/C vasculitis is an asynchronous process that can commence within the first two weeks onward, starting in the adventitia/perivascular tissue and variably inflaming/damaging the wall during progression to the lumen. Besides fusiform and saccular aneurysms that can thrombose, SA/C vasculitis likely causes the transition of medial and adventitial smooth muscle cells (SMC) into classic myofibroblasts, which combined with their matrix products and inflammation create progressive stenosing luminal lesions (SA/C-LMP). Remote LMP apparently results from circulating factors. Veins, pulmonary arteries, and aorta can develop subclinical SA/C vasculitis and SA/C-LMP, but not NA. The earliest death (day 10) had both CA SA/C vasculitis and SA/C-LMP, and an "eosinophilic-type" myocarditis. CONCLUSIONS/SIGNIFICANCE: NA is the only self-limiting process of the three, is responsible for the earliest morbidity/mortality, and is consistent with acute viral infection. SA/C vasculitis can begin as early as NA, but can occur/persist for months to years; LMP causes progressive arterial stenosis and thrombosis and is composed of unique SMC-derived pathologic myofibroblasts.

Predicting massive blood transfusion using clinical scores post-trauma.

BACKGROUND AND OBJECTIVES: Early prediction of massive transfusion (MT) post-trauma may reduce mortality by earlier delivery of blood products. A clinical prediction tool (PWH score) for this purpose was developed at the Prince of Wales Hospital, Hong Kong. The aims of this study were to apply this tool to major trauma patients in Victoria, Australia and compare the score to the Assessment of Blood Consumption (ABC) score and the Trauma-Associated Severe Haemorrhage (TASH) score. METHODS: A retrospective review of patients entered into the The Alfred Trauma Registry between January 2006 and December 2009 was conducted. The performance of the PWH score to predict MT defined by 5 units of packed red blood cells in 4 h was compared with the ABC and TASH scores. Included patients presented to the Emergency & Trauma Centre from the scene and had had complete datasets with respect to the components of the three scores. RESULTS: There were 1234 patients included in the study with 195 (15·8%) receiving a MT and an overall mortality of 14·0%. The PWH score had an area under the receiver operating characteristics (ROC) curve of 0·842 (95% CI: 0·820-0·862). The area under the ROC curve of the PWH score was significantly less than that of the TASH score (χ(2)=19·8, P<0·001) and significantly greater than that of the ABC score (χ(2)=9·3, P=0·002). CONCLUSIONS: The PWH score performs with similar accuracy when applied to an Australian population as in its derivation population. The relative simplicity of the PWH score makes it a viable tool for clinical use, although utility of such tools may be more suited for research in determining inclusion or exclusion criteria for comparative outcome studies.