Early management of open tibial fractures

No Abstract

Understanding sexuality following a voluntary termination of pregnancy.

Although much research has been conducted on termination of pregnancy, there is a paucity of information regarding women’s sexuality after such a procedure, and in particular, how a woman understands her sexuality following a termination of pregnancy or what influences such an understanding. This research aimed to investigate how women understand their sexuality following a voluntary termination of pregnancy through the examination of the interaction between personal and broader social views on sexuality. Seven women who had undergone the procedure at two private termination clinics in Johannesburg were interviewed, using a semi-structured, open-ended interview schedule. The data was analysed according to thematic analytic methods. Based on the results, it was clear that the way in which women understand their sexuality following a termination of pregnancy is complex and multi-faceted. Particular themes emerged that were in line with the debates raised in the current literature. It became evident that these views were intricate and multi-faceted. Heteronormativity and heterosexuality proved particularly influential in how women understand their sexuality following a termination of pregnancy, and which further related to points raised throughout the literature. It was clear through the analysis that each theme could be seen to stand alone, or alternatively be represented through other themes and sub-themes

The malignant epidemic-changing patterns of trauma

Objectives and Setting. The worldwide burden of trauma is increasing, but is unequally distributed between nations. Trauma in South Africa targets the young and productive in society and imposes a major burden on the health infrastructure. We undertook a review of injury trends among patients attending the Johannesburg Hospital Trauma Unit (JHTU) and the Johannesburg Medicolegal Laboratory (JMLL) in order to document the evolution in patterns of trauma over a 17-year period of great social and political change. Design, subjects and outcome measures. This was a retrospective review of all priority-one patients attending the JHTU from January 1985 to December 2001. The JHTU trauma database was used to retrieve information on patient demographics, wound mechanism and injury severity. The database at the JMLL, maintained since 1996, was examined and the manner and place of death were analysed.Results. The JHTU has seen an unprecedented increase in the number of trauma patients over the last 17 years. The patients' demographic profiles have altered and injury is now predominantly due to interpersonal violence. Unnatural deaths examined at the JMLL have declined by 19% since 1996; however, the proportion of those deaths due to gunshot wounds has risen.Conclusions. The social and political changes in South Africa in recent years have led to changes in the injury profiles seen at the JHTU. Part of the increase can be explained by desegregation and a reduction in the provision of local hospital services; however, the impact of urbanisation within South Africa, cross-border migration and the high incidence of substance abuse are recognised. Evidence supports the implementation of legislative, environmental, social and behavioural interventions to contain and reduce the incidence and impact of violence and injury. Concerted efforts must be made at all levels to curb South Africa's  trauma  epidemic

Recombinant activated factor VII as an adjunctive therapy for bleeding control in severe trauma patients with coagulopathy: subgroup analysis from two randomized trials

INTRODUCTION: We conducted a post-hoc analysis on the effect of recombinant factor VIIa (rFVIIa) on coagulopathic patients from two randomized, placebo-controlled, double-blind trials of rFVIIa as an adjunctive therapy for bleeding in patients with severe trauma. METHODS: Blunt and penetrating trauma patients were randomly assigned to rFVIIa (200 + 100 + 100 μg/kg) at 0, 1, and 3 hours after transfusion of 8 units of red blood cells (RBCs) or to placebo. Subjects were monitored for 48 hours post-dosing and followed for 30 days. Coagulopathy was retrospectively defined as transfusion of fresh frozen plasma (FFP) (>1 unit of FFP per 4 units of RBCs), FFP in addition to whole blood, and transfusion of platelets and/or cryoprecipitate. RESULTS: Sixty rFVIIa-treated and 76 placebo subjects were retrospectively identified as being coagulopathic. No significant differences were noted in baseline characteristics. The rFVIIa-treated coagulopathic subgroup consumed significantly less blood product: RBC transfusion decreased by 2.6 units for the whole study population (P = 0.02) and by 3.5 units among patients surviving more than 48 hours (P < 0.001). Transfusion of FFP (1,400 versus 660 ml, P < 0.01), platelet (300 versus 100 ml, P = 0.01), and massive transfusions (29% versus 6%, P < 0.01) also dropped significantly. rFVIIa reduced multi-organ failure and/or acute respiratory distress syndrome in the coagulopathic patients (3% versus 20%, P = 0.004), whereas thromboembolic events were equally present in both groups (3% versus 4%, P = 1.00). CONCLUSION: Coagulopathic trauma patients appear to derive particular benefit from early adjunctive rFVIIa therapy

Evaluation of Recombinant Factor VIIa Treatment for Massive Hemorrhage in Patients with Multiple Traumas

Background: Recent studies and case reports have shown that recombinant factor VIIa (rFVIIa) treatment is effective for reversing coagulopathy and reducing blood transfusion requirements in trauma patients with life-threatening hemorrhage. The purpose of this study is to evaluate the effect of rFVIIa treatment on clinical outcomes and cost effectiveness in trauma patients. Methods: Between January 2007 and December 2010, we reviewed the medical records of patients who were treated with rFVIIa (N=18) or without rFVIIa (N=36) for life-threatening hemorrhage due to multiple traumas at the Emergency Department of Pusan National University Hospital in Busan, Korea. We reviewed patient demographics, baseline characteristics, initial vital signs, laboratory test results, and number of units transfused, and then analyzed clinical outcomes and 24-hr and 30-day mortality rates. Thromboembolic events were monitored in all patients. Transfusion costs and hospital stay costs were also calculated. Results: In the rFVIIa-treated group, laboratory test results and clinical outcomes improved, and the 24-hr mortality rate decreased compared to that in the untreated group; however, 30-day mortality rate did not differ between the groups. Thromboembolic events did not occur in both groups. Transfusion and hospital stay costs in the rFVIIa-treated group were cost effective; however, total treatment costs, including the cost of rFVIIa, were not cost effective. Conclusions: In our study, rFVIIa treatment was shown to be helpful as a supplementary drug to improve clinical outcomes and reduce the 24-hr mortality rate, transfusion and hospital stay costs, and transfusion requirements in trauma patients with life-threatening hemorrhage

Guideline for the assessment of trauma centres for South Africa

INTRODUCTION: Trauma is a well-known leading cause of unnatural death and disability in South Africa. Internationally the trend is moving toward systematised care. AIM: To revise the Trauma Centre Criteria of the Trauma Society of South Africa and align these with the terminology and modern scope of emergency care practice, using best-care principles as a prelude to the development of trauma systems in South Africa. METHODOLOGY: Revision of existing documents of the Trauma Society of South Africa, the Emergency Medicine Society of South Africa and the Critical Care Society of Southern Africa, where these are relevant to the care of trauma. The committee attempted to harmonise these criteria with the goals of the World Health Organization essential trauma care guidelines for trauma centres and trauma systems. Wide expert consultation was undertaken to refine the criteria before final compilation. RESULTS AND RECOMMENDATIONS: Four levels of trauma care facility are outlined, with the criteria focusing on the trauma-specific requirements of the facilities and their place in the greater trauma system. Accreditation of hospitals according to the criteria will allow for appropriate transfer and designation of patient destination for trauma patients and will improve the quality of care provided. The criteria address structural, process and human resource requirements and medical aspects for the accreditation of various level of trauma centre. CONCLUSION: There is a great opportunity to apply best practice criteria to improve the care of trauma in South Africa and improve patient outcome

Recombinant factor VIIa for the prevention and treatment of bleeding in patients without haemophilia

This review is published as a Cochrane Review in the Cochrane Database of Systematic Reviews 2012, Issue 3. Cochrane Reviews are regularly updated as new evidence emerges and in response to comments and criticisms, and the Cochrane Database of Systematic Reviews should be consulted for the most recent version of the Review.BACKGROUND: Recombinant factor VIIa (rFVIIa) is licensed for use in patients with haemophilia and inhibitory allo-antibodies and for prophylaxis and treatment of patients with congenital factor VII deficiency. It is also used for off-license indications to prevent bleeding in operations where blood loss is likely to be high, and/or to stop bleeding that is proving difficult to control by other means. This is the third version of the 2007 Cochrane review on the use of recombinant factor VIIa for the prevention and treatment of bleeding in patients without haemophilia, and has been updated to incorporate recent trial data. OBJECTIVES: To assess the effectiveness of rFVIIa when used therapeutically to control active bleeding or prophylactically to prevent (excessive) bleeding in patients without haemophilia. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and other medical databases up to 23 March 2011. SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing rFVIIa with placebo, or one dose of rFVIIa with another, in any patient population (except haemophilia). Outcomes were mortality, blood loss or control of bleeding, red cell transfusion requirements, number of patients transfused and thromboembolic adverse events. DATA COLLECTION AND ANALYSIS: Two authors independently assessed potentially relevant studies for inclusion, extracted data and examined risk of bias. We considered prophylactic and therapeutic rFVIIa studies separately. MAIN RESULTS: Twenty-nine RCTs were included: 28 were placebo-controlled, double-blind RCTs and one compared different doses of rFVIIa. In the 'Risk of bias' assessment, most studies were found to have some threats to validity although therapeutic RCTs were found to be less prone to bias than prophylactic RCTs.Sixteen trials involving 1361 participants examined the prophylactic use of rFVIIa; 729 received rFVIIa. There was no evidence of mortality benefit (risk ratio (RR) 1.04; 95% confidence interval (CI) 0.55 to 1.97). There was decreased blood loss (mean difference (MD) -297 mL; 95% CI -416 to -178) and decreased red cell transfusion requirements (MD -261 mL; 95% CI -367 to -154) with rFVIIa treatment; however, these values were likely overestimated due to the inability to incorporate data from trials (four RCTs in the outcome of blood loss and three RCTs in the outcome of transfusion requirements) showing no difference of rFVIIa treatment compared to placebo. There was a trend in favour of rFVIIa in the number of participants transfused (RR 0.85; 95% CI 0.72 to 1.01). However, there was a trend against rFVIIa with respect to thromboembolic adverse events (RR 1.35; 95% CI 0.82 to 2.25).Thirteen trials involving 2929 participants examined the therapeutic use of rFVIIa; 1878 received rFVIIa. There were no outcomes where any observed advantage or disadvantage of rFVIIa over placebo could not have been observed by chance alone. There was a trend in favour of rFVIIa for reducing mortality (RR 0.91; 95% CI 0.78 to 1.06). However, there was a trend against rFVIIa for increased thromboembolic adverse events (RR 1.14; 95% CI 0.89 to 1.47).When all trials were pooled together to examine the risk of thromboembolic events, a significant increase in total arterial events was observed (RR 1.45; 95% CI 1.02 to 2.05). AUTHORS' CONCLUSIONS: The effectiveness of rFVIIa as a more general haemostatic drug, either prophylactically or therapeutically, remains unproven. The results indicate increased risk of arterial events in patients receiving rFVIIa. The use of rFVIIa outside its current licensed indications should be restricted to clinical trials

Pharmacokinetics of recombinant activated factor VII in trauma patients with severe bleeding

INTRODUCTION: Recombinant activated factor VII (rFVIIa) has been used as adjunctive therapy in trauma patients with severe bleeding. However, its pharmacokinetics profile remains unknown. METHODS: In two placebo-controlled studies in patients with blunt and penetrating trauma, the pharmacokinetics of rFVIIa given at an initial dose of 200 μg.kg(-1 )after transfusion of eight red blood cell units, followed by additional doses of 100 μg.kg(-1), one and three hours later, have been studied, based on the FVII coagulant activity assay. Both non-compartment and population pharmacokinetic analyses were performed. A two-compartment, population pharmacokinetic model was used to estimate a population profile for the rFVIIa dosing regimen. Data are population means (percent coefficient of variation (CV)). RESULTS: Based on the two-compartment population model, the estimated pharmacokinetic parameters were: clearance 40 (30% CV) ml.kg(-1).h(-1); central volume of distribution 89 (32% CV) ml.kg(-1); inter-compartmental clearance 24 ml.kg(-1).h(-1); and peripheral compartment volume 31 ml.kg(-1). Baseline FVII coagulant activity was estimated at 0.29 (39% CV) U.ml(-1), initial half-life was 0.6 (34% CV) hours, and terminal half-life 2.4 (50% CV) hours. High intra- and inter-patient variability was noted in volume of distribution and clearance, which was in part correlated with the transfusion requirements as the single significant covariate. The non-compartmental analysis led to almost identical estimates of key parameters. CONCLUSION: A high intra- and inter-patient variability was noted in the volume of distribution and clearance of rFVIIa in trauma patients with severe bleeding, mainly related with the transfusion requirements and thus blood loss and/or bleeding rate