Management of bleeding following major trauma: an updated European guideline.

INTRODUCTION Evidence-based recommendations are needed to guide the acute management of the bleeding trauma patient, which when implemented may improve patient outcomes. METHODS The multidisciplinary Task Force for Advanced Bleeding Care in Trauma was formed in 2005 with the aim of developing a guideline for the management of bleeding following severe injury. This document presents an updated version of the guideline published by the group in 2007. Recommendations were formulated using a nominal group process, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) hierarchy of evidence and based on a systematic review of published literature. RESULTS Key changes encompassed in this version of the guideline include new recommendations on coagulation support and monitoring and the appropriate use of local haemostatic measures, tourniquets, calcium and desmopressin in the bleeding trauma patient. The remaining recommendations have been reevaluated and graded based on literature published since the last edition of the guideline. Consideration was also given to changes in clinical practice that have taken place during this time period as a result of both new evidence and changes in the general availability of relevant agents and technologies. CONCLUSIONS This guideline provides an evidence-based multidisciplinary approach to the management of critically injured bleeding trauma patients.

Technologies de procédé et de contrôle pour réduire la teneur en sel du jambon sec et des saucissons

Dans certains pays européens, les produits carnés élaborés peuvent représenter près de 20% de la consommation journalière de sodium. De ce fait, les industries de la viande tentent de réduire la teneur en sel dans les produits carnés pour répondre, d’une part aux attentes des consommateurs et d’autre part aux demandes des autorités sanitaires. Le système Quick‐Dry‐Slice process (QDS®), couplé avec l’utilisation de sels substituant le chlorure de sodium (NaCl), a permis de fabriquer, avec succès, des saucisses fermentées à basse teneur en sel en réduisant le cycle de fabrication et sans ajout de NaCl supplémentaire. Les technologies de mesure en ligne non destructives, comme les rayons X et l’induction électromagnétique, permettent de classifier les jambons frais suivant leur teneur en gras, un paramètre crucial pour adapter la durée de l’étape de salaison. La technologie des rayons X peut aussi être utilisée pour estimer la quantité de sel incorporée pendant la salaison. L’information relative aux teneurs en sel et en gras est importante pour optimiser le processus d’élaboration du jambon sec en réduisant la variabilité de la teneur en sel entre les lots et dans un même lot, mais aussi pour réduire la teneur en sel du produit final. D’autres technologies comme la spectroscopie en proche infrarouge (NIRS) ou spectroscopie microondes sont aussi utiles pour contrôler le processus d’élaboration et pour caractériser et classifier les produits carnés élaborés, selon leur teneur en sel. La plupart de ces technologies peuvent être facilement appliquées en ligne dans l’industrie afin de contrôler le processus de fabrication et d’obtenir ainsi des produits carnés présentant les caractéristiques recherchées.

RED BLOOD CELL MICROPARTICLES: ROLE IN TRANSFUSION MEDICINE?

RésuméLes microparticules sont des vésicules phospholipidiques de moins d‟un micromètre relâchées dans le sang par différents types cellulaires, comme les cellules endothéliales, les plaquettes ou encore les globules blancs et rouges. Elles sont bioactives et impliquées dans de nombreux processus physiologiques incluant l‟hémostase. De plus, un nombre élevé de microparticules circulantes dans le sang a été observé dans différentes pathologies.Dans le domaine de la transfusion, les microparticules de globules rouges ont été détectées dans les concentrés érythrocytaires. Le but de cette recherche était de caractériser les microparticules de globules rouges et d‟évaluer si ces dernières avaient un rôle en transfusion. Pour ce faire, une approche globale utilisant différentes techniques comme la cytométrie de flux, la protéomique, la microscopie ainsi que des tests d‟hémostase de routines, a été adoptée.Le présent travail de thèse a démontré que les microparticules de globules rouges s‟accumulent dans les concentrés érythrocytaires pendant le stockage. Leur bioactivité a été démontrée de part leur rôle actif dans le processus de la coagulation. En effet, lors de test de génération de thrombine, elles peuvent non seulement supporter ce processus de coagulation, mais aussi le déclencher par un mécanisme inconnu sous certaines circonstances. Les microparticules de globules rouges présentent aussi des antigènes de groupes sanguins à leur surface, toutefois, leur implication potentielle dans l‟induction d‟une réponse immunitaire n‟est pas connue. Bien que le mécanisme de formation et d‟émissions des microparticules par les globules rouges ne soit pas complètement élucidé, il a été démontré qu‟elles n‟ont pas toutes le même contenu protéique et donc qu‟elles pourraient avoir des fonctions différentes.Au vu des résultats, notamment par leur implication dans la coagulation, il est fort probable que la présence de microparticules puisse affecter la qualité des produits sanguins, et causer des réactions transfusionnelles.

Genetics of calcium homeostasis in humans: continuum between monogenic diseases and continuous phenotypes

Extracellular calcium participates in several key physiological functions, such as control of blood coagulation, bone calcification or muscle contraction. Calcium homeostasis in humans is regulated in part by genetic factors, as illustrated by rare monogenic diseases characterized by hypo or hypercalcaemia. Both serum calcium and urinary calcium excretion are heritable continuous traits in humans. Serum calcium levels are tightly regulated by two main hormonal systems, i.e. parathyroid hormone and vitamin D, which are themselves also influenced by genetic factors. Recent technological advances in molecular biology allow for the screening of the human genome at an unprecedented level of detail and using hypothesis-free approaches, such as genome-wide association studies (GWAS). GWAS identified novel loci for calcium-related phenotypes (i.e. serum calcium and 25-OH vitamin D) that shed new light on the biology of calcium in humans. The substantial overlap (i.e. CYP24A1, CASR, GATA3; CYP2R1) between genes involved in rare monogenic diseases and genes located within loci identified in GWAS suggests a genetic and phenotypic continuum between monogenic diseases of calcium homeostasis and slight disturbances of calcium homeostasis in the general population. Future studies using whole-exome and whole-genome sequencing will further advance our understanding of the genetic architecture of calcium homeostasis in humans. These findings will likely provide new insight into the complex mechanisms involved in calcium homeostasis and hopefully lead to novel preventive and therapeutic approaches. Keyword: calcium, monogenic, genome-wide association studies, genetics.

The role of the vascular endothelium in arenavirus haemorrhagic fevers.

Viral haemorrhagic fevers (VHF) caused by arenaviruses are among the most devastating emerging human diseases. The most important pathogen among the arenaviruses is Lassa virus (LASV), the causative agent of Lassa fever that is endemic to West Africa. On the South American continent, the New World arenavirus Junin virus (JUNV), Machupo (MACV), Guanarito (GTOV), and Sabia virus (SABV) have emerged as causative agents of severe VHFs. Clinical and experimental studies on arenavirus VHF have revealed a crucial role of the endothelium in their pathogenesis. However, in contrast to other VHFs, haemorrhages are not a salient feature of Lassa fever and fatal cases do not show overt destruction of vascular tissue. The functional alteration of the vascular endothelium that precede shock and death in fatal Lassa fever may be due to more subtle direct or indirect effects of the virus on endothelial cells. Haemorrhagic disease manifestations and vascular involvement are more pronounced in the VHF caused by the South American haemorrhagic fever viruses. Recent studies on JUNV revealed perturbation of specific endothelial cell function, including expression of cell adhesion molecules, coagulation factors, and vasoactive mediators as a consequence of productive viral infection. These studies provided first possible links to some of the vascular abnormalities observed in patients, however, their relevance in vivo remains to be investigated.

Le coup de chaleur d'exercice [Exertional heatstroke].

Exertional heatstroke is defined by an increase of core body temperature above 40 degrees C and neurological symptoms in association with exercise. It is related to excessive heat production, which overwhelms the endogenous mechanisms of thermoregulation. It is observed during intense physical activity in a hot and humid environment, most commonly in untrained subjects poorly adapted to such conditions. Clinical manifestations of exertional heatstroke are related to the induction of a systemic inflammatory response and a disseminated intravascular coagulation triggered by heat stress, which may lead to multiorgan dysfunction and death. Early management through rapid cooling is mandatory to prevent the devastating consequences of exertional heatstroke.

Volutrauma activates the clotting cascade in the newborn but not adult rat.

Coagulopathy and alveolar fibrin deposition are common in sick neonates and attributed to the primary disease, as opposed to their ventilatory support. Hypothesizing that high tidal volume ventilation activates the extrinsic coagulation pathway, we air ventilated newborn and adult rats at low (10 ml/kg) or high (30 ml/kg) tidal volume and compared them with age-matched nonventilated controls. Blood was collected at the end of the experiment for measurement of clot time, tissue factor, and other coagulation factor content. Similar measurements were obtained from lung lavage material. The newborn clot time (44+/-1) was lower and plasma tissue factor content higher (103.4+/-0.4) than adults (88+/-4 s and 26.6+/-1.4 units; P<0.01). High, but not low, tidal volume ventilation of newborns for as little as 15 min significantly reduced clot time and increased plasma tissue factor content (P<0.01). High volume ventilation increased plasma factor Xa (0.1+/-0.1 to 1.6+/-0.4 nM; P<0.01) and thrombin (1.3+/-0.2 to 2.2+/-0.4 nM; P<0.05) and decreased antithrombin (0.12+/-0.01 to 0.05+/-0.01; P<0.01) in the newborn. Lung lavage material of high volume-ventilated newborns showed increased (P<0.01) factor Xa and thrombin. No changes in these parameters were observed in adult rats that were high volume ventilated for up to 90 min. Compared with adults, newborn rats have a greater propensity for volutrauma-activated intravascular coagulation. These data suggest that mechanical ventilation promotes neonatal thrombosis via lung tissue factor release.

BrainCheck - a very brief tool to detect incipient cognitive decline: optimized case-finding combining patient- and informant-based data.

INTRODUCTION: Optimal identification of subtle cognitive impairment in the primary care setting requires a very brief tool combining (a) patients' subjective impairments, (b) cognitive testing, and (c) information from informants. The present study developed a new, very quick and easily administered case-finding tool combining these assessments ('BrainCheck') and tested the feasibility and validity of this instrument in two independent studies. METHODS: We developed a case-finding tool comprised of patient-directed (a) questions about memory and depression and (b) clock drawing, and (c) the informant-directed 7-item version of the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE). Feasibility study: 52 general practitioners rated the feasibility and acceptance of the patient-directed tool. Validation study: An independent group of 288 Memory Clinic patients (mean ± SD age = 76.6 ± 7.9, education = 12.0 ± 2.6; 53.8% female) with diagnoses of mild cognitive impairment (n = 80), probable Alzheimer's disease (n = 185), or major depression (n = 23) and 126 demographically matched, cognitively healthy volunteer participants (age = 75.2 ± 8.8, education = 12.5 ± 2.7; 40% female) partook. All patient and healthy control participants were administered the patient-directed tool, and informants of 113 patient and 70 healthy control participants completed the very short IQCODE. RESULTS: Feasibility study: General practitioners rated the patient-directed tool as highly feasible and acceptable. Validation study: A Classification and Regression Tree analysis generated an algorithm to categorize patient-directed data which resulted in a correct classification rate (CCR) of 81.2% (sensitivity = 83.0%, specificity = 79.4%). Critically, the CCR of the combined patient- and informant-directed instruments (BrainCheck) reached nearly 90% (that is 89.4%; sensitivity = 97.4%, specificity = 81.6%). CONCLUSION: A new and very brief instrument for general practitioners, 'BrainCheck', combined three sources of information deemed critical for effective case-finding (that is, patients' subject impairments, cognitive testing, informant information) and resulted in a nearly 90% CCR. Thus, it provides a very efficient and valid tool to aid general practitioners in deciding whether patients with suspected cognitive impairments should be further evaluated or not ('watchful waiting').

The Multiscenario Multienvironment BioSecure Multimodal Database (BMDB)

A new multimodal biometric database designed and acquired within the framework of the European BioSecure Network of Excellence is presented. It is comprised of more than 600 individuals acquired simultaneously in three scenarios: 1) over the Internet, 2) in an office environment with desktop PC, and 3) in indoor/outdoor environments with mobile portable hardware. The three scenarios include a common part of audio/video data. Also, signature and fingerprint data have been acquired both with desktop PC and mobile portable hardware. Additionally, hand and iris data were acquired in the second scenario using desktop PC. Acquisition has been conducted by 11 European institutions. Additional features of the BioSecure Multimodal Database (BMDB) are: two acquisitionsessions, several sensors in certain modalities, balanced gender and age distributions, multimodal realistic scenarios with simple and quick tasks per modality, cross-European diversity, availability of demographic data, and compatibility with other multimodal databases. The novel acquisition conditions of the BMDB allow us to perform new challenging research and evaluation of eithermonomodal or multimodal biometric systems, as in the recent BioSecure Multimodal Evaluation campaign. A description of this campaign including baseline results of individual modalities from the new database is also given. The database is expected to beavailable for research purposes through the BioSecure Association during 2008.

Concrete Paving Notes Construction No.1, 2005

This booklet will help developers, consultants, and engineers planning concrete pavement construction projects, superintendents and supervisors who want a basic training aid and reference, and crew members new to the concrete paving industry. It provides a general description of current concrete pavement construction practices, from establishing preconstruction control mechanisms to sealing joints. It also provides a quick troubleshooting reference.

Managing Storm Damaged Woodlands, August 1998

Strong winds, ice, snow and tornadoes are natural occurrences in Iowa forests. When severe, storms can cause extensive damage to forests by uprooting, wounding, bending and breaking trees. Storm damage management should involve a quick assessment to determine the extent of the damage, the need and potential for salvage, and woodland management efforts to return the woodland to a productive status.

Immunoturbidometrisen fibriinimonomeerimäärityksen menetelmätestaus

Fibriinimonomeerejä syntyy fibrinogeenistä veren hyytyessä. Fibriinimonomeerit muodostavat liukoisia komplekseja, joiden olemassaolo voidaan osoittaa plasmasta silloin, kun niitä esiintyy veressä suuria määriä, kuten disseminoituneen intravaskulaarisen koagulaation (DIK) yhteydessä. HUSLABin Meilahden sairaalan laboratoriossa fibriinimonomeerien olemassaolo todetaan tällä hetkellä hemagglutinaatioon perustuvalla kvalitatiivisella testillä, jossa tulos tulkitaan silmämääräisesti. Diagnostica Stago on tuonut markkinoille uuden kvantitatiivisen STA® - Liatest® FM immunoturbidometrisen testin, joka perustuu monoklonaaliseen fibriinimonomeerivasta-aineeseen. Uusi testi on automatisoitavissa, mikä helpottaa testin suoritusta. Työssäni testasin immunoturbidometrisen menetelmän analyyttisiä suorituskykyominaisuuksia määrittämällä Blood Coagulation System (BCS) -analysaattorilla sarjan sisäisen ja sarjojen välisen toistuvuuden sekä lineaarisuuden. Tulosten perusteella menetelmä toimii toistettavasti, mutta lineaarisuus ei ole optimaalinen. Vertasin myös nykyisen ja uuden menetelmän tuloksia 40:stä potilasnäytteestä. Kaikki näytteet olivat agglutinaatiotestissä negatiivisia. Osa näistä antoi kuitenkin positiivisia tuloksia immunoturbidometrisellä testillä. Tulosten perusteella immunoturbidometrinen menetelmä ei mittaa ainoastaan fibriinimonomeerejä. Lisäksi tarkastelin fibriinimonomeeritulosten korrelaatiota saman näytteen fibrinogeeni- ja D-dimeerituloksiin. Fibriinimonomeeritulokset eivät korreloineet fibrinogeenitulosten kanssa, mutta D-dimeeritulosten kanssa korrelaatio oli voimakasta ja tilastollisesi merkitsevää. D-dimeeri mahdollisesti ristireagoi menetelmässä. Jos menetelmä halutaan ottaa käyttöön, se edellyttää lisätutkimuksia.