Haemodilution-induced profibrinolytic state is mitigated by fresh-frozen plasma: implications for early haemostatic intervention in massive haemorrhage

Background Fibrinolysis contributes to coagulopathy after major trauma and surgery. We hypothesized that progressive haemodilution is responsible, at least in part, for increased fibrinolytic tendency of blood clot. Methods The study was performed in two parts. First, whole blood (WB) samples collected from six healthy, consented volunteers were diluted in vitro with either saline or fresh-frozen plasma (FFP) to 40% and 15% of baseline. We quantified factor levels related to coagulation and fibrinolysis, and measured endogenous thrombin generation in undiluted control plasma samples and in samples diluted with saline or FFP. Additionally, thromboelastometry was used to assess susceptibility to fibrinolysis after adding tissue plasminogen activator in undiluted WB samples and in samples diluted with saline before and after substitution of fibrinogen or FFP. Secondly, as a model of in vivo haemodilution, we evaluated the same parameters before and after operation in nine consented patients undergoing off-pump coronary artery bypass surgery. Results The dilution with saline caused dose-dependent decreases in plasma levels of coagulation and antifibrinolytic factors, and in thrombin generation. In FFP-supplemented samples, factor levels and thrombin generation were maintained within normal ranges. Fibrinolytic tendency was significantly higher after haemodilution with saline independent of fibrinogen substitution compared with FFP. Similarly, increased tendency for fibrinolysis was also observed in the in vivo haemodilution. Conclusions We demonstrated in vitro and in vivo that progressive haemodilution decreases endogenous antifibrinolytic proteins including α2-antiplasmin and thrombin-activatable fibrinolysis inhibitor, resulting in increased fibrinolytic tendency. Therefore, early fluid replacement therapy with FFP might be advantageous after massive haemorrhag

Gunshot energy transfer profile in ballistic gelatine, determined with computed tomography using the total crack length method

By measuring the total crack lengths (TCL) along a gunshot wound channel simulated in ordnance gelatine, one can calculate the energy transferred by a projectile to the surrounding tissue along its course. Visual quantitative TCL analysis of cut slices in ordnance gelatine blocks is unreliable due to the poor visibility of cracks and the likely introduction of secondary cracks resulting from slicing. Furthermore, gelatine TCL patterns are difficult to preserve because of the deterioration of the internal structures of gelatine with age and the tendency of gelatine to decompose. By contrast, using computed tomography (CT) software for TCL analysis in gelatine, cracks on 1-cm thick slices can be easily detected, measured and preserved. In this, experiment CT TCL analyses were applied to gunshots fired into gelatine blocks by three different ammunition types (9-mm Luger full metal jacket, .44 Remington Magnum semi-jacketed hollow point and 7.62 × 51 RWS Cone-Point). The resulting TCL curves reflected the three projectiles' capacity to transfer energy to the surrounding tissue very accurately and showed clearly the typical energy transfer differences. We believe that CT is a useful tool in evaluating gunshot wound profiles using the TCL method and is indeed superior to conventional methods applying physical slicing of the gelatine

Cinematic rendering of a burst sagittal suture caused by an occipito-frontal gunshot wound

The computed tomography (CT) scan of a 19-year-old man who died from an occipito-frontal gunshot wound presented an impressive radiating fracture line where the entire sagittal suture burst due to the high intracranial pressure that arose from a near-contact shot from a 9 mm bullet fired from a Glock 17 pistol. Photorealistic depictions of the radiating fracture lines along the cranial bones were created using three-dimensional reconstruction methods, such as the novel cinematic rendering technique that simulates the propagation and interaction of light when it passes through volumetric data. Since the brain had collapsed, depiction of soft tissue was insufficient on CT images. An additional magnetic resonance imaging (MRI) examination was performed, which enabled the diagnostic assessment of cerebral injuries

Social, cultural and experiential patterning of attitudes and behaviour towards assisted suicide in Switzerland: evidence from a national population-based study.

Switzerland has the longest history of the legal practice of non-physician assisted suicide of any country. Assisted suicide is not very tightly regulated in Switzerland, and almost all assisted suicides are supported by a right-to-die organisation. Our study investigates older adults’ attitudes and behaviour towards assisted suicide, and the associations of these with the individuals’ sociodemographic and cultural characteristics, as well as with their own health status and healthcare-related experiences in Switzerland. We performed weighted prevalence and multivariable logistic regression estimation on a nationally representative sample of adults aged 55 and over from wave 6 (2015) of the Survey of Health, Ageing and Retirement in Europe (SHARE) in Switzerland (n = 2168). Overall, 81.7% of respondents supported the legality of assisted suicide, as is currently the case in Switzerland, and 60.9% stated that they would potentially consider asking for assisted suicide under certain circumstances; 28.2% of respondents reported either that they are already or that they are likely to become a member of a right-to-die organisation, with 4.9% of respondents reporting to already be a member of such an organisation at the time of the survey. Higher levels of education and previous experience as a healthcare proxy were positively associated with more favourable attitudes and behaviour towards assisted suicide. Compared to individuals aged 55–64, adults aged 65–74 generally showed more favourable attitudes and behaviour towards assisted suicide. By contrast, religious persons displayed more negative attitudes and behaviour towards assisted suicide. Attitudes towards assisted suicide were also more negative in the oldest age group (75+) in comparison to adults aged 55–64, and among persons living in French- and Italian-speaking Switzerland compared to those living in German-speaking Switzerland. While approval for assisted suicide is high overall in Switzerland, more vulnerable population groups, such as older or less educated individuals, have less favourable attitudes towards assisted suicide. In addition, cultural sensitivities to and personal experiences with death and dying are likely to shape the approval or rejection of assisted suicide as it is currently implemented in Switzerland

Illustrated argument for CT-scanning a whole car for the forensic investigation of projectile holes, defects, fragments and possible trajectories

Contemporary documentation of a car with bullet defects after a shooting incident can secure the usual tracks and gunshot residue, take photographs, and use trajectory rods and probes. Since the advent of the ”XXL-CT -Scanner” (Fraunhofer Institute, Germany), we have wondered if the advantages of volume scanning CT, already noted for forensic pathology, could be applied to cars. To this end, we damaged a small 3D-printed car model with an electric drill and added CT -dense material with a soldering iron, simulating linearly configured defect morphologies with metal particles. This model was CT -scanned and the resulting data visualized to illustrate how these visualizations can support reconstructive visualization of trajectories. Performing a real XXL-CT scan of a bullet-riddled car requires extensive preparation, transportation, and other logistical measures that are costly and time-consuming. Nonetheless, we suggest that this is a worthwhile research direction to explore

Promoting hospital-based smoking cessation services at major Swiss hospitals: a before and after study.

Whether a 1-year nationwide, government supported programme is effective in significantly increasing the number of smoking cessation clinics at major Swiss hospitals as well as providing basic training for the staff running them. We conducted a baseline evaluation of hospital services for smoking cessation, hypertension, and obesity by web search and telephone contact followed by personal visits between October 2005 and January 2006 of 44 major public hospitals in the 26 cantons of Switzerland; we compared the number of active smoking cessation services and trained personnel between baseline to 1 year after starting the programme including a training workshop for doctors and nurses from all hospitals as well as two further follow-up visits. At base line 9 (21%) hospitals had active smoking cessation services, whereas 43 (98%) and 42 (96%) offered medical services for hypertension and obesity respectively. Hospital directors and heads of Internal Medicine of 43 hospitals were interested in offering some form of help to smokers provided they received outside support, primarily funding to get started or to continue. At two identical workshops, 100 health professionals (27 in Lausanne, 73 in Zurich) were trained for one day. After the programme, 22 (50%) hospitals had an active smoking cessation service staffed with at least 1 trained doctor and 1 nurse. A one-year, government-supported national intervention resulted in a substantial increase in the number of hospitals allocating trained staff and offering smoking cessation services to smokers. Compared to the offer for hypertension and obesity this offer is still insufficient