The contemporary role of blood products and components used in trauma resuscitation

<p>Abstract</p> <p>Introduction</p> <p>There is renewed interest in blood product use for resuscitation stimulated by recent military experience and growing recognition of the limitations of large-volume crystalloid resuscitation.</p> <p>Methods</p> <p>An editorial review of recent reports published by investigators from the United States and Europe is presented. There is little prospective data in this area.</p> <p>Results</p> <p>Despite increasing sophistication of trauma care systems, hemorrhage remains the major cause of early death after injury. In patients receiving massive transfusion, defined as 10 or more units of packed red blood cells in the first 24 hours after injury, administration of plasma and platelets in a ratio equivalent to packed red blood cells is becoming more common. There is a clear possibility of time dependent enrollment bias. The early use of multiple types of blood products is stimulated by the recognition of coagulopathy after reinjury which may occur as many as 25% of patients. These patients typically have large-volume tissue injury and are acidotic. Despite early enthusiasm, the value of administration of recombinant factor VIIa is now in question. Another dilemma is monitoring of appropriate component administration to control coagulopathy.</p> <p>Conclusion</p> <p>In patients requiring large volumes of blood products or displaying coagulopathy after injury, it appears that early and aggressive administration of blood component therapy may actually reduce the aggregate amount of blood required. If recombinant factor VIIa is given, it should be utilized in the fully resuscitated patient. Thrombelastography is seeing increased application for real-time assessment of coagulation changes after injury and directed replacement of components of the clotting mechanism.</p

Re: Infection control in burn patients: are fungal infections underestimated?

A response to Struck MF. Infection control in burn patients: are fungal infections underestimated? Scand J Trauma Resusc Emerg Med. 2009 Oct 9;17(1):51. [Epub ahead of print] PubMed PMID: 19818134

Handling fairness issues in time-relaxed tournaments with availability constraints

Sports timetables determine who will play against whom, where, and on which time slot. In contrast to time-constrained sports timetables, time-relaxed timetables utilize (many) more time slots than there are games per team. This offers time-relaxed timetables additional flexibility to take into account venue availability constraints, stating that a team can only play at home when its venue is available, and player availability constraints stating that a team can only play when its players are available. Despite their flexibility, time-relaxed timetables have the drawback that the rest period between teams’ consecutive games can vary considerably, and the difference in the number of games played at any point in the season can become large. Besides, it can be important to timetable home and away games alternately. In this paper, we first establish the computational complexity of time-relaxed timetabling with availability constraints. Naturally, when one also incorporates fairness objectives on top of availability, the problem becomes even more challenging. We present two heuristics that can handle these fairness objectives. First, we propose an adaptive large neighborhood method that repeatedly destroys and repairs a timetable. Second, we propose a memetic algorithm that makes use of local search to schedule or reschedule all home games of a team. For numerous artificial and real-life instances, these heuristics generate high-quality timetables using considerably less computational resources compared to integer programming models solved using a state-of-the-art solver

A comparison of clustering and modification based graph anonymization methods with constraints

In this paper a comparison is performed on two of the key methods for graph anonymization and their behavior is evaluated when constraints are incorporated into the anonymization process. The two methods tested are node clustering and node modification and are applied to online social network (OSN) graph datasets. The constraints implement user defined utility requirements for the community structure of the graph and major hub nodes. The methods are benchmarked using three real OSN datasets and different levels of k?anonymity. The results show that the constraints reduce the information loss while incurring an acceptable disclosure risk. Overall, it is found that the modification method with constraints gives the best results for information loss and risk of disclosure.This research is partially supported by the Spanish MEC (projects ARES CONSOLIDER INGENIO 2010 CSD2007-00004 -- eAEGIS TSI2007-65406-C03-02 -- and HIPERGRAPH TIN2009-14560-C03-01)Peer Reviewe

Floquet-engineered quantum state manipulation in a noisy qubit

Adiabatic evolution is a common strategy for manipulating quantum states and has been employed in diverse fields such as quantum simulation, computation and annealing. However, adiabatic evolution is inherently slow and therefore susceptible to decoherence. Existing methods for speeding up adiabatic evolution require complex many-body operators or are difficult to construct for multi-level systems. Using the tools of Floquet engineering, we design a scheme for high-fidelity quantum state manipulation, utilizing only the interactions available in the original Hamiltonian. We apply this approach to a qubit and experimentally demonstrate its performance with the electronic spin of a Nitrogen-vacancy center in diamond. Our Floquet-engineered protocol achieves state preparation fidelity of $0.994 \pm 0.004$, on the same level as the conventional fast-forward protocol, but is more robust to external noise acting on the qubit. Floquet engineering provides a powerful platform for high-fidelity quantum state manipulation in complex and noisy quantum systems

Burn Resuscitation

Fluid resuscitation following burn injury must support organ perfusion with the least amount of fluid necessary and the least physiological cost. Under resuscitation may lead to organ failure and death. With adoption of weight and injury size-based formulas for resuscitation, multiple organ dysfunction and inadequate resuscitation have become uncommon. Instead, administration of fluid volumes well in excess of historic guidelines has been reported. A number of strategies including greater use of colloids and vasoactive drugs are now under investigation to optimize preservation of end organ function while avoiding complications which can include respiratory failure and compartment syndromes. Adjuncts to resuscitation, such as antioxidants, are also being investigated along with parameters beyond urine output and vital signs to identify endpoints of therapy. Here we briefly review the state-of-the-art and provide a sample of protocols now under investigation in North American burn centers

Inhalation injury: epidemiology, pathology, treatment strategies

Lung injury resulting from inhalation of smoke or chemical products of combustion continues to be associated with significant morbidity and mortality. Combined with cutaneous burns, inhalation injury increases fluid resuscitation requirements, incidence of pulmonary complications and overall mortality of thermal injury. While many products and techniques have been developed to manage cutaneous thermal trauma, relatively few diagnosis-specific therapeutic options have been identified for patients with inhalation injury. Several factors explain slower progress for improvement in management of patients with inhalation injury. Inhalation injury is a more complex clinical problem. Burned cutaneous tissue may be excised and replaced with skin grafts. Injured pulmonary tissue must be protected from secondary injury due to resuscitation, mechanical ventilation and infection while host repair mechanisms receive appropriate support. Many of the consequences of smoke inhalation result from an inflammatory response involving mediators whose number and role remain incompletely understood despite improved tools for processing of clinical material. Improvements in mortality from inhalation injury are mostly due to widespread improvements in critical care rather than focused interventions for smoke inhalation. Morbidity associated with inhalation injury is produced by heat exposure and inhaled toxins. Management of toxin exposure in smoke inhalation remains controversial, particularly as related to carbon monoxide and cyanide. Hyperbaric oxygen treatment has been evaluated in multiple trials to manage neurologic sequelae of carbon monoxide exposure. Unfortunately, data to date do not support application of hyperbaric oxygen in this population outside the context of clinical trials. Cyanide is another toxin produced by combustion of natural or synthetic materials. A number of antidote strategies have been evaluated to address tissue hypoxia associated with cyanide exposure. Data from European centers supports application of specific antidotes for cyanide toxicity. Consistent international support for this therapy is lacking. Even diagnostic criteria are not consistently applied though bronchoscopy is one diagnostic and therapeutic tool. Medical strategies under investigation for specific treatment of smoke inhalation include beta-agonists, pulmonary blood flow modifiers, anticoagulants and antiinflammatory strategies. Until the value of these and other approaches is confirmed, however, the clinical approach to inhalation injury is supportive