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OBJECTIVES: Management of pain is suboptimal in many prehospital and emergency department settings, and European guidelines are lacking. We carried out the Consensus On Management of PAin Caused by Trauma (COMPACT) Delphi initiative to gain insights into the factors physicians consider important when selecting analgesics for trauma pain. PATIENTS AND METHODS: A pan-European panel of experts in emergency medicine or pain (N = 31) was recruited to participate in the COMPACT Delphi initiative. In round 1, panelists supplied free-text responses to an open question about the attributes of analgesics for emergency pain relief favored by physicians. Common themes were consolidated into factors. In round 2, factors rated important by more than 75% of the panel were taken forward into round 3. In round 3, the point at which the consensus was achieved was defined a priori as at least 75% of panelists agreeing or strongly agreeing that a factor was important. RESULTS: Twenty-nine experts participated, representing 12 European countries and with a mean (SD) of 20 (8.6) years of clinical experience. Most worked in an emergency department (79.3%). The consensus was achieved for 10 factors that were important to consider when selecting analgesics for trauma pain relief. The highest level of consensus was achieved for 'efficacy' (100%), followed by 'safety and tolerability' (96.6%), and 'ease of use' (93.1%). CONCLUSION: These findings may facilitate the development of evidence-based guidelines supporting the provision of pain management in prehospital, emergency department, and critical care settings.
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Analgésicos/uso terapéutico , Servicio de Urgencia en Hospital , Manejo del Dolor , Dolor/etiología , Heridas y Lesiones/complicaciones , Técnica Delphi , Humanos , Dolor/tratamiento farmacológico , Manejo del Dolor/métodos , Manejo del Dolor/normasRESUMEN
There is inconsistent evidence on the efficacy of agriculture programmes at improving women and children's anaemia and nutritional status. The primary aim of this study was to evaluate the impact of a nutrition-sensitive enhanced homestead food production (EHFP) programme on anaemia in women (18-45 years) and children (6-59 months) in rural Cambodia. Secondary outcomes were women's micronutrient status and women and children's anthropometry. In this cluster-randomized controlled trial, 900 households from 90 villages (clusters) were randomized to either (a) home gardens and behaviour change communication (BCC) on nutrition, hygiene, women's empowerment, and marketing (EHFP); (b) home gardens plus fishponds and BCC (EHFP + F); or (c) control (no intervention). Haemoglobin concentration and anthropometry were measured in women and children at baseline and at 22 months. Venous blood samples were collected in a subset of women (n = 450) at baseline and at 22 months. Generalized linear mixed effect models with repeated measures were used to evaluate the difference across groups and the change from baseline to end of study. Ninety clusters, 552 women, and 754 children completed the trial. Compared with control, we found a statistically significant impact on anaemia prevalence in children (-14.0 percentage points; P = 0.02) and retinol binding protein concentrations in women (difference in difference: 0.34; P = 0.02) randomized to EHFP and EHFP + F groups, respectively. No other statistically significant effects on anaemia, nutritional biomarker concentrations, or anthropometry were observed. Future research is needed to examine longer term impacts of EHFP on anthropometry in women and children and into the nutritional causes of anaemia among children in Cambodia.
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Anemia/dietoterapia , Anemia/prevención & control , Dieta/clasificación , Micronutrientes/administración & dosificación , Estado Nutricional , Adolescente , Adulto , Antropometría , Acuicultura , Cambodia/epidemiología , Preescolar , Análisis por Conglomerados , Productos Agrícolas , Femenino , Jardinería , Conductas Relacionadas con la Salud , Humanos , Higiene/educación , Lactante , Fenómenos Fisiológicos Nutricionales del Lactante , Masculino , Fenómenos Fisiologicos Nutricionales Maternos , Micronutrientes/deficiencia , Persona de Mediana Edad , Población Rural , Adulto JovenRESUMEN
Urethral injury in major trauma is infrequent, with complex problems of diagnosis and treatment. The aims of this study are to determine the incidence and epidemiological factors relating to urethral injury in major trauma, as well as determine if any additional prognostic factors are evident within this cohort of patients. A retrospective review of patients sustaining urethral injury following major trauma was made over a 6-year period, from 2010 to 2015. Quantitative analysis was made using the national trauma registry for England and Wales, the Trauma Audit and Research Network (TARN) database, identifying all patients with injury codes for urethral injury. 165 patients with urethral injuries were identified, over 90% were male, most commonly injured during road traffic accidents and with an associated overall mortality of 12%. Urethral injury in association with pelvic fracture occurred in 136 patients (82%), representing 0.6% of all pelvic fractures, and was associated with double the rate of mortality. Urethral injury was associated with unstable pelvic fractures (LC2, LC3, APC3, VS, CM) but not with a specific pelvic fracture type. This study confirms the rare incidence of this injury in major trauma at 1 per 2 million population per year.
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Traumatismos Abdominales/complicaciones , Fracturas Óseas/complicaciones , Traumatismo Múltiple/fisiopatología , Huesos Pélvicos/lesiones , Uretra/lesiones , Traumatismos Abdominales/diagnóstico por imagen , Adulto , Estudios de Evaluación como Asunto , Femenino , Fracturas Óseas/diagnóstico por imagen , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Traumatismo Múltiple/epidemiología , Huesos Pélvicos/diagnóstico por imagen , Guías de Práctica Clínica como Asunto , Reino Unido/epidemiología , Uretra/diagnóstico por imagen , Uretra/fisiopatologíaRESUMEN
Methoxyflurane is an inhaled analgesic administered via a disposable inhaler which has been used in Australia for over 40 years for the management of pain associated with trauma and for medical procedures in children and adults. Now available in 16 countries worldwide, it is licensed in Europe for moderate to severe pain associated with trauma in conscious adults, although additional applications are being made to widen the range of approved indications. Considering these ongoing developments, we reviewed the available evidence on clinical usage and safety of inhaled analgesic methoxyflurane in trauma pain and in medical procedures in both adults and children. Published data on methoxyflurane in trauma and procedural pain show it to be effective, well tolerated, and highly rated by patients, providing rapid onset of analgesia. Methoxyflurane has a well-established safety profile; adverse events are usually brief and self-limiting, and no clinically significant effects on vital signs or consciousness levels have been reported. Nephrotoxicity previously associated with methoxyflurane at high anesthetic doses is not reported with low analgesic doses. Although two large retrospective comparative studies in the prehospital setting showed inhaled analgesic methoxyflurane to be less effective than intravenous morphine and intranasal fentanyl, this should be balanced against the administration, supervision times, and safety profile of these agents. Given the limitations of currently available analgesic agents in the prehospital and emergency department settings, the ease of use and portability of methoxyflurane combined with its rapid onset of effective pain relief and favorable safety profile make it a useful nonopioid option for pain management. Except for the STOP! study, which formed the basis for approval in trauma pain in Europe, and a few smaller randomized controlled trials (RCTs), much of the available data are observational or retrospective, and further RCTs are currently underway to provide more robust data.
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BACKGROUND: Low-dose methoxyflurane and nitrous oxide (N2O; 50:50 with oxygen) are both self-administered, self-titrated, rapid-acting, nonnarcotic, and noninvasive inhalational agents with similar onset times of pain relief. The aim of this review was to compare the clinical efficacy, safety, and tolerability of these analgesics in emergency care. MATERIALS AND METHODS: A systematic literature search and review according to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were performed using Embase, Medline, the Cochrane Library, several clinical trial registers, and emergency-medicine conference material. RESULTS: Although both compounds have been used for many years in emergency care, the search found only a few controlled studies and no head-to-head trials performed in this setting. Two double-blind, randomized studies comparing their respective study medication (low-dose methoxyflurane or N2O) to placebo were identified that could be compared in an indirect approach by using placebo as a bridging comparator. Both agents provided rapid pain relief to trauma patients, with no significant differences between them; both treatments were generally well tolerated. CONCLUSION: Both low-dose methoxyflurane and N2O are suitable options for the pain treatment of trauma patients in the emergency setting. Due to the ease of administration and portability, inhaled low-dose methoxyflurane, however, may not only offer advantages in emergency situations in remote or difficult-to-reach locations and mass-casualty situations but also be of significant value in urban and rural environments.
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BACKGROUND: There is no consensus on reporting nonmortality trauma complications in a graded manner. The Clavien-Dindo scale of complications was originally for elective surgery and requires adaptation to provide meaningful data for trauma patients. In particular, the original score does not account for those treated without surgery. We report an adapted Clavien-Dindo in trauma (ACDiT) scale and apply it to patients managed operatively and nonoperatively. METHODS: A combined prospective and retrospective international multicenter observational study was undertaken to apply the ACDiT scale to 484 trauma patients at three university teaching hospitals (Birmingham, England (n = 303); Houston, Texas (n = 113); and Glasgow, Scotland (n = 68)). These included both intensive care unit (ICU) and non-ICU-managed patients. The Clavien-Dindo scoring system was adapted for trauma patients based on consensus amongst an international collaboration of trauma specialists at these sites. Data included whether initial patients were managed operatively or nonoperatively. Complication grades were compared with hospital-free and ICU-free days as other outcome measures of patient morbidity. RESULTS: Two hundred seventeen (44.8%) of 484 patients experienced complications, of whom 61 (28.1%) of 217 died (grade V). The remainder consisted of grades I (n = 20), II (n = 60), III (n = 24), and IV (n = 52). There was a strong association between higher ACDiT grade category and lower number of hospital-free and ICU-free days (p < 0.01). Eighty-eight patients with complications did not require surgery, validating the score's usefulness in patients managed nonoperatively. CONCLUSION: The ACDiT scale can be used to grade the severity of posttrauma complications in patients managed both operatively and nonoperatively. It provides clinically meaningful data for morbidity and mortality meetings and other quality improvement exercises. LEVEL OF EVIDENCE: Prognostic, level IV.
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Índices de Gravedad del Trauma , Heridas y Lesiones/complicaciones , Heridas y Lesiones/mortalidad , Adulto , Causas de Muerte , Recolección de Datos/estadística & datos numéricos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Reproducibilidad de los Resultados , Estudios Retrospectivos , Análisis de Supervivencia , Centros Traumatológicos/estadística & datos numéricos , Heridas y Lesiones/clasificación , Heridas y Lesiones/terapia , Adulto JovenRESUMEN
Proximal femoral fractures are a major public health concern with estimated annual direct and social costs amounting to £2 billion and average 30-day mortality risk of 7.5%. In response to the recent debate over out-of-hours hospital provision we investigated the 'weekend effect' at a major trauma centre, caring for acute injuries. A single centre, multi-surgeon review of 2060 patients performed. The distribution of patient and treatment variables compared in patients admitted on a weekday or the weekend. Fewer patients met performance indicators during weekend admission, time to surgery (63 vs. 71%) and time to geriatric review (86 vs. 91%). Weekend admission 30-day mortality was marginally lower than weekday (9.7% vs. 10.2%, OR 0.94, 95% CI 0.67 to 1.32, p = 0.7383). Increasing age, female gender, co-morbidities and confusion increased mortality risk. Binary regression analysis including these variables found no significant 'weekend effect'. Despite the unit observing an increasing workload in the last five years, with meticulous workforce planning, senior doctor provisions and careful use of resources, it is possible to provide a seven-day fracture neck of femur service with no variation in thirty-day mortality by the day of admission.
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Fracturas de Cadera/mortalidad , Admisión del Paciente , Humanos , Medición de Riesgo , Factores de Riesgo , Análisis de Supervivencia , Centros TraumatológicosRESUMEN
The need for prehospital resuscitative hysterotomy/perimortem caesarean section is rare. The procedures can be daunting and clinically challenging for practitioners. Maternal death can be averted by swift and decisive action. This guideline serves to inform prehospital practitioners about conducting maternal resuscitation following cardiac arrest, provides an evidence-based framework to support decision making and highlights areas for improvement in prehospital care.
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Servicios Médicos de Urgencia/métodos , Histerotomía/métodos , Paro Cardíaco Extrahospitalario/cirugía , Complicaciones del Embarazo/cirugía , Heridas y Lesiones/cirugía , Adulto , Algoritmos , Cesárea/métodos , Cesárea/mortalidad , Femenino , Humanos , Histerotomía/mortalidad , Recién Nacido , Laparotomía/métodos , Paro Cardíaco Extrahospitalario/complicaciones , Paro Cardíaco Extrahospitalario/etiología , Embarazo , Resucitación/métodos , Heridas y Lesiones/complicaciones , Heridas y Lesiones/mortalidadRESUMEN
OBJECTIVE: Prehospital emergency amputation is a rare procedure, which may be necessary to free a time-critical patient from entrapment. This study aimed to evaluate four techniques of cadaveric lower limb prehospital emergency amputation. METHOD: A guillotine amputation of the distal femur was undertaken in fresh frozen self-donated cadavers. A prehospital doctor conducted a surgical amputation with Gigli saw or hacksaw for bone cuts and firefighters carried out the procedure using the reciprocating saw and Holmatro device. The primary outcome measures were time to full amputation and the number of attempts required. The secondary outcomes were observed quality of skin cut, soft tissue cut and CT assessment of the proximal bone. Observers also noted the potential risks to the rescuer or patient during the procedure. RESULTS: All techniques completed amputation within 91â s. The reciprocating saw was the quickest technique (22â s) but there was significant blood spattering and continuation of the cut to the surface under the leg. The Holmatro device took less than a minute. The quality of the proximal femur was acceptable with all methods, but 5â cm more proximal soft tissue damage was made by the Holmatro device. CONCLUSIONS: Emergency prehospital guillotine amputation of the distal femur can effectively be performed using scalpel and paramedic shears with bone cuts by the Gigli saw or fire service hacksaw. The reciprocating saw could be used to cut bone if no other equipment was available but carried some risks. The Holmatro cutting device is a viable option for a life-threatening entrapment where only firefighters can safely access the patient, but would not be a recommended primary technique for medical staff.
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Amputación Quirúrgica/instrumentación , Tratamiento de Urgencia , Extremidad Inferior/lesiones , Extremidad Inferior/cirugía , Instrumentos Quirúrgicos , Cadáver , Fémur/cirugía , Humanos , Tomografía Computarizada por Rayos XRESUMEN
OBJECTIVE: To understand the epidemiology of pregnancy and obstetric complications encountered in the management of pregnant trauma patients. METHODS AND DESIGN: Retrospective analysis of national trauma registry for recording of pregnancy status or obstetric complication in cases of trauma. Sub-division of patient cohort by severity of trauma and stage of pregnancy. Comparison of data sets between pregnant trauma patients and age-matched non-pregnant female trauma patients to determine patterns of injury and impact upon clinical outcomes. SETTINGS: National registry data for the United Kingdom. OUTCOME: For the five year period between 2009 and 2014, a total of 15,140 female patients, aged between 15 years old and 50 years old were identified within the trauma registry. A record of pregnancy was identified in 173 patients (1.14%) from within this cohort. Mechanisms of injury within the cohort of pregnant trauma patients saw increased rate of vehicular collision and interpersonal violence, especially penetrating trauma. Higher abbreviated injury scores were recorded for the abdominal region in pregnancy than in the non-pregnant cohort. Maternal mortality rates were seen to be higher, when compared with the non-pregnant trauma patient. Foetal survival rate from this series was 56% following trauma. Foetal death in pregnant trauma patients most frequently occurred in the 2nd trimester. No cases of isolated foetal survival were recorded following maternal trauma. CONCLUSIONS: Trauma to pregnant patients is rare in the United Kingdom, encountered in 1% of female trauma patients of child bearing age. Observations in altered mechanisms of injury and clinical outcomes were recorded. This provides useful information regarding the clinical management of pregnant trauma patients and offers potential areas to investigate to optimise their care, as well as to focus injury prevention measures. LEVEL OF EVIDENCE: IV--Case series.
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Traumatismos Abdominales/mortalidad , Accidentes de Tránsito/mortalidad , Cesárea/estadística & datos numéricos , Servicios Médicos de Urgencia/estadística & datos numéricos , Complicaciones del Embarazo/mortalidad , Violencia/estadística & datos numéricos , Heridas Penetrantes/mortalidad , Escala Resumida de Traumatismos , Traumatismos Abdominales/complicaciones , Accidentes de Tránsito/estadística & datos numéricos , Adulto , Femenino , Muerte Fetal , Monitoreo Fetal , Humanos , Puntaje de Gravedad del Traumatismo , Mortalidad Materna , Guías de Práctica Clínica como Asunto , Embarazo , Complicaciones del Embarazo/etiología , Resultado del Embarazo , Estudios Retrospectivos , Reino Unido/epidemiología , Heridas Penetrantes/complicacionesRESUMEN
A young mother presented to a major trauma centre following a road traffic collision. Her admission CT traumagram demonstrated liver and renal lacerations, spinal and pelvic fractures with no abnormalities of the ovarian veins. Her inpatient course was uncomplicated other than a sustained, isolated raised C reactive protein. CT of the abdomen 1 week after injury demonstrated stable solid organ injuries and the additional, unexpected finding of a right ovarian vein thrombosis (OVT). A pragmatic approach was taken towards the management of the OVT given the haemorrhagic risk from her traumatic injuries. A multidisciplinary, consultant-led plan was made to slowly increase enoxaparin to a therapeutic dose under close surveillance and to then switch to warfarin following an outpatient consultation with a consultant haematologist. A MR venogram was performed after 3 months of anticoagulation, and this demonstrated complete resolution of the OVT and normal appearances of the ovary.
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Accidentes de Tránsito , Ovario/irrigación sanguínea , Venas , Trombosis de la Vena/tratamiento farmacológico , Anticoagulantes/uso terapéutico , Enoxaparina/uso terapéutico , Femenino , Humanos , Traumatismo Múltiple/tratamiento farmacológico , Traumatismo Múltiple/etiología , Ovario/lesiones , Grupo de Atención al Paciente , Trombosis de la Vena/etiología , Warfarina/uso terapéutico , Adulto JovenRESUMEN
Iron is a natural element found in food, water and soil and is essential for human health. Our aim was to determine the levels of iron and 25 other metals and trace elements in groundwater from 22 households in Prey Veng, Cambodia. Water analyses were conducted using inductively coupled plasma-mass spectrometry and optical emission spectrometry. Compared to the 2011 World Health Organization guidelines for drinking water quality, aluminum, iron and manganese exceeded maximum levels (in 4.5, 72.7 and 40.9% of samples, respectively). Compared to the 2004 Cambodian drinking water quality standards, iron and manganese exceeded maximum levels (in 59.1 and 36.4% of samples, respectively). We found no evidence of arsenic contamination. Guidelines for iron were established primarily for esthetic reasons (e.g. taste), whereas other metals and elements have adverse effects associated with toxicity. Iron in groundwater ranged from 134 to 5,200 µg/L (mean â¼1,422 µg/L). Based on a daily consumption of 3 L groundwater, this equates to â¼0.4-15.6 mg iron (mean â¼4.3 mg/day), which may be contributing to high iron stores and the low prevalence of iron deficiency anemia in Prey Veng women. Elevated levels of manganese in groundwater are a concern and warrant further investigation.
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Agua Subterránea/química , Hierro/química , Hierro/metabolismo , Cambodia , Femenino , Filtración/instrumentación , Filtración/métodos , Humanos , Metales/química , Oligoelementos/químicaRESUMEN
Biodiversity is changing at unprecedented rates, and it is increasingly important that these changes are quantified through monitoring programmes. Previous recommendations for developing or enhancing these programmes focus either on the end goals, that is the intended use of the data, or on how these goals are achieved, for example through volunteer involvement in citizen science, but not both. These recommendations are rarely prioritized.We used a collaborative approach, involving 52 experts in biodiversity monitoring in the UK, to develop a list of attributes of relevance to any biodiversity monitoring programme and to order these attributes by their priority. We also ranked the attributes according to their importance in monitoring biodiversity in the UK. Experts involved included data users, funders, programme organizers and participants in data collection. They covered expertise in a wide range of taxa.We developed a final list of 25 attributes of biodiversity monitoring schemes, ordered from the most elemental (those essential for monitoring schemes; e.g. articulate the objectives and gain sufficient participants) to the most aspirational (e.g. electronic data capture in the field, reporting change annually). This ordered list is a practical framework which can be used to support the development of monitoring programmes.People's ranking of attributes revealed a difference between those who considered attributes with benefits to end users to be most important (e.g. people from governmental organizations) and those who considered attributes with greatest benefit to participants to be most important (e.g. people involved with volunteer biological recording schemes). This reveals a distinction between focussing on aims and the pragmatism in achieving those aims. Synthesis and applications. The ordered list of attributes developed in this study will assist in prioritizing resources to develop biodiversity monitoring programmes (including citizen science). The potential conflict between end users of data and participants in data collection that we discovered should be addressed by involving the diversity of stakeholders at all stages of programme development. This will maximize the chance of successfully achieving the goals of biodiversity monitoring programmes.
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The tapasin-related protein TAPBPR is a novel component of the antigen processing and presentation pathway, which binds to MHC class I coupled with ß2-microglobulin. We describe six alternatively spliced TAPBPR transcripts from the TAPBPL gene and investigate three of these at a protein level. TAPBPR transcripts lacking exon 5 result in loss of the membrane proximal IgC domain and loss of ability to bind to MHC class I. Alternative acceptor and donor splice sites in exon 4 of TAPBPR altered the reading frame in the IgV domain and produced a truncated TAPBPR product. An additional exon in the TAPBPL gene was identified that encodes extra residues in the cytoplasmic tail of TAPBPR. This longer TAPBPR protein interacted with MHC class I but was attenuated in its ability to down-regulate surface expression of MHC class I. The abundance of these alternative transcripts in peripheral blood mononuclear cells and dendritic cells suggests an important role of TAPBPR isoforms in vivo.
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Antígenos de Histocompatibilidad Clase I/inmunología , Inmunoglobulinas/inmunología , Proteínas de la Membrana/inmunología , Células Dendríticas/citología , Células Dendríticas/inmunología , Células HeLa , Humanos , Inmunoglobulinas/genética , Proteínas de la Membrana/genética , Isoformas de Proteínas/genética , Isoformas de Proteínas/inmunologíaRESUMEN
A series of improvements to the standard solid phase peptide synthesis (SPPS) process allowing for significant gains in product purity along with only a 4 min standard cycle time and a 90% reduction in total waste produced is reported. For example, syntheses of the well-known (65-74)acyl carrier protein (ACP) and (1-42)ß-amyloid peptides were accomplished with 93 and 72% purity (UPLC-MS) in only 44 and 229 min, respectively.
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Proteína Transportadora de Acilo/síntesis química , Péptidos beta-Amiloides/síntesis química , Oligopéptidos/síntesis química , Fragmentos de Péptidos/síntesis química , Proteína Transportadora de Acilo/química , Péptidos beta-Amiloides/química , Estructura Molecular , Oligopéptidos/química , Fragmentos de Péptidos/química , Técnicas de Síntesis en Fase SólidaRESUMEN
Tapasin is an integral component of the peptide-loading complex (PLC) important for efficient peptide loading onto MHC class I molecules. We investigated the function of the tapasin-related protein, TAPBPR. Like tapasin, TAPBPR is widely expressed, IFN-γ-inducible, and binds to MHC class I coupled with ß2-microglobulin in the endoplasmic reticulum. In contrast to tapasin, TAPBPR does not bind ERp57 or calreticulin and is not an integral component of the PLC. ß2-microglobulin is essential for the association between TAPBPR and MHC class I. However, the association between TAPBPR and MHC class I occurs in the absence of a functional PLC, suggesting peptide is not required. Expression of TAPBPR decreases the rate of MHC class I maturation through the secretory pathway and prolongs the association of MHC class I on the PLC. The TAPBPR:MHC class I complex trafficks through the Golgi apparatus, demonstrating a function of TAPBPR beyond the endoplasmic reticulum/cis-Golgi. The identification of TAPBPR as an additional component of the MHC class I antigen-presentation pathway demonstrates that mechanisms controlling MHC class I expression remain incompletely understood.
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Presentación de Antígeno/inmunología , Antígenos de Histocompatibilidad Clase I/inmunología , Inmunoglobulinas/metabolismo , Proteínas de la Membrana/metabolismo , Presentación de Antígeno/efectos de los fármacos , Calnexina/metabolismo , Calreticulina/metabolismo , Retículo Endoplásmico/efectos de los fármacos , Retículo Endoplásmico/metabolismo , Aparato de Golgi/efectos de los fármacos , Aparato de Golgi/metabolismo , Células HEK293 , Antígenos HLA-A/metabolismo , Células HeLa , Humanos , Interferón gamma/farmacología , Cinética , Proteínas de Transporte de Membrana/metabolismo , Péptidos/inmunología , Unión Proteica/efectos de los fármacos , Proteína Disulfuro Isomerasas/metabolismo , Multimerización de Proteína/efectos de los fármacos , Transporte de Proteínas/efectos de los fármacos , Microglobulina beta-2/metabolismoRESUMEN
Massive haemorrhage still accounts for up to 40% of mortality after traumatic injury. The importance of limiting blood loss after injury in order to prevent its associated complications has led to rapid advances in the development of dressings for haemostatic control. Driven by recent military conflicts, there is increasing evidence to support their role in the civilian prehospital care environment. This review aims to summarise the key characteristics of the haemostatic dressings currently available on the market and provide an educational review of the published literature that supports their use. Medline and Embase were searched from start to January 2012. Other sources included both manufacturer and military publications. Agents not designed for use in prehospital care or that have been removed from the market due to significant safety concerns were excluded. The dressings reviewed have differing mechanisms of action. Mineral based dressings are potent activators of the intrinsic clotting cascade resulting in clot formation. Chitosan based dressings achieve haemostasis by adhering to damaged tissues and creating a physical barrier to further bleeding. Acetylated glucosamine dressings work via a combination of platelet and clotting cascade activation, agglutination of red blood cells and local vasoconstriction. Anecdotal reports strongly support the use of haemostatic dressings when bleeding cannot be controlled using pressure dressings alone; however, current research focuses on studies conducted using animal models. There is a paucity of published clinical literature that provides an evidence base for the use of one type of haemostatic dressing over another in humans.
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Vendajes , Servicios Médicos de Urgencia , Exsanguinación/terapia , Técnicas Hemostáticas , Hemostáticos/administración & dosificación , Heridas y Lesiones/terapia , HumanosRESUMEN
Fault trees have long been used to estimate failure risk in earthquakes, especially for nuclear power plants (NPPs). One interesting application is that one can assess and manage the probability that two facilities - a primary and backup - would be simultaneously rendered inoperative in a single earthquake. Another is that one can calculate the probabilistic time required to restore a facility to functionality, and the probability that, during any given planning period, the facility would be rendered inoperative for any specified duration. A large new peer-reviewed library of component damageability and repair-time data for the first time enables fault trees to be used to calculate the seismic risk of operational failure and downtime for a wide variety of buildings other than NPPs. With the new library, seismic risk of both the failure probability and probabilistic downtime can be assessed and managed, considering the facility's unique combination of structural and non-structural components, their seismic installation conditions, and the other systems on which the facility relies. An example is offered of real computer data centres operated by a California utility. The fault trees were created and tested in collaboration with utility operators, and the failure probability and downtime results validated in several ways.