This study investigated the incidence of the lethal triad (coagulopathy, hypothermia, and acidaemia) in major burn patients. The study found that 39.3% of patients exhibited coagulopathy on admission. Coagulopathy correlated with increased serum lactate and higher abbreviated burn severity index scores. Early coagulopathy independently predicted higher 28-day mortality. A subgroup of 15 patients exhibited the lethal triad, which was also associated with higher mortality. The study concludes accurate burn assessment and fluid resuscitation are important to limit tissue hypoperfusion and the development of coagulopathy in major burn patients.
An Updated presentation of the management of severe sepsis including best evidence for fluid resuscitation, vasopressors, blood pressure target, steroid replacement, blood transfusion and other moralities.
An Updated presentation of the management of severe sepsis including best evidence for fluid resuscitation, vasopressors, blood pressure target, steroid replacement, blood transfusion and other moralities.
http://www.theheart.org/web_slides/1283563.do
A study on Anglo-Scandinavian Cardiac Outcomes--Lipid Lowering Arm (ASCOT-LLA) designed to assess the effect on risk of normal MI and fatal CHD of two treatment strategies.
http://www.theheart.org/web_slides/1283563.do
A study on Anglo-Scandinavian Cardiac Outcomes--Lipid Lowering Arm (ASCOT-LLA) designed to assess the effect on risk of normal MI and fatal CHD of two treatment strategies.
Beyond 4G: A Venture into Digital Services Firdaus Fadzil
One of the speakers in International IT & Telecommunications Exhibition 2014 held in Phnom Penh on 14-17 November 2014. Here, I highlighted what it means by Digital Services from mobile operators' context, discussed briefly on one of the driving forces behind Digital Services, provided some illustrations on what could the verticals to served, highlighted what could possibly be the route opted by Smart (the sole 4G operator in Cambodia) and highlighted some commercial collaborations/partnerships Smart has with its partners.
Latest addition to Temasya Glenmarie and already sold out. Final release would be a low rise luxury apartment, 6-storey, called Temasya Kasih ("TK"), to be launched in January 2013. Build up ranges between 920sf to 2,900sf. Price to be advised later. Artist impression or image rendering of TK's facade is already out in the pubic domain.
SIM Box and its linked to external frauds affecting leading operators in Cambodia in the form of falling revenues, lower QoS for for International Incoming Calls and inbound roaming services. Arguably, such activity is becoming rampant due to lack of legal framework, poor enforcement and coordination among Government Ministries and Government agencies.
Ponencia realizada el 23 de noviembre de 2022 en CardioTV titulado 'Nuevas fronteras en la reducción del riesgo CV residual. Integrando icosapento de etilo en la práctica clínica' por el Dr. Subodh Verma
Holley analyses the cascade of events in bleeding trauma patients leading to Australia's latest evidenced-based guidelines on transfusion protocols in critical bleeding.
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
1. Sherren PB, Hussey J, Martin R, Kundishora T, Emerson B
Department of Anaesthesia and Intensive Care, St.
Andrew’s Burn Centre
2. The lethal triad
The ‘lethal triad’ is a well described entity in the trauma
population and is associated with significant mortality.
Moore EE. Am J Surg 1996;172:405-410.
Major burn patients are exposed to similar physiological
insults
Little is known about the incidence and effect of the
lethal triad in burns patients.
A lethal triad could impact on early total burn
excision/grafting , CVS stability and septic complications
3.
4. Coagulopathy
Acute traumatic coagulopathy (ATC) is a well
described phenomenon in the trauma population
associated with significant mortality Brohi K et al. J Trauma.
2003;54:1127-1130.
ATC is an impairment of haemostasis involving a
complex dynamic interaction between endogenous
anticoagulants and fibrinolysis
ATC is driven by an endothelial injury and
hypoperfusion, which results in in increased
thrombomodulin expression and APC
An early burn induced coagulopathy has yet to be
demonstrated
5. Hypothermia
Significant problem!
Factors involved
• Large volume fluid resuscitation
• Thermal tissue injury impairs skin’s insulating ability
• Anaesthesia impacts thermoregulation
• Impaired endogenous heat production as a result of
anaerobic metabolism
• Reluctance to warm burn patients by medical
professionals?
6. Acidaemia
Major burns are characterised by
• direct endothelial injury
• systemic hypoperfusion
• hypovolaemia/ haemoconcentration
• myocardial contractility and cellular hypoperfusion.
This decreased oxygen delivery results in a shift to
anaerobic metabolism, lactate production and
metabolic acidaemia
The initial lactate is a strong predictor of mortality in
burns patients. Latenser BA. Crit Care Med. 2009 Oct;37(10):2819-26
7.
8. Aim
The primary aim of this study was to identify a
clinically significant early burn induced coaguloapthy
and a lethal triad in thermal injuries.
We also sought any association with the validated
abbreviated burn severity index (ABSI), fluid
administration and mortality.
10. Methods
Patients with TBSA burns ≥30% from October 2008 to
December 2011 were identified from the metavision
database.
A structured and anonymous metavision review was
conducted.
The database was scrutinised for a predetermined list of
demographics, interventions, admission observations and
investigations.
Exclusion criteria were: associated major trauma, arrival at
the burn centre>12 hours after burn, significant
CO/Cyanide poisoning, pre-existing coagulopathy, any
PRBC/FFP/PCC administration and non-thermal injuries.
11. Definitions
Coagulopathy - PT≥14.7/APTT≥45
seconds (Local lab. reference & Davenport et al. Crit Care Med
2011;39(12):2652-2658)
Hypothermia - Temperature≤35.5°C
Acidaemia - pH≤7.25
12. Lethal Triad
total cases reviewed
(n=205)
excluded
(n=60)
missing data
(n=28)
Lethal triad
Non Triad group
(n=15)
(n=102)
13. Demographics
Lethal Triad
P-value
Present (n=15)
Absent (n=102)
Age in years, mean (SD)
Sex (M/F)
TBSA burn, mean (SD)
Inhalational injury present
Abbreviated burn severity index,
median (IQR)
46 (20.9)
10/5
59.2 (18.7)
13 (86.7%)
12 (9-13)
33.0 (21.9)
65/37
47.9 (18.1)
31 (30.4%)
8.5 (6-10)
0.033*
1
0.027*
<0.0001*
0.0011*
Time from burn to arrival Burn
Centre in minutes, mean (SD)
352 (107.5)
361.5 (160.8)
0.83
Fluid received prior to arrival at
Burns centre. ml, mean (SD)
4783.3 (2140.1)
4167.1 (2910.6)
0.43
Fluid deficit according to Parkland
formula on arrival in Burns centre.
ml, mean (SD)
1903.2 (2095.6)
301.7 (2287.5)
0.012*
10/15 (66.7)
12/102 (11.8)
<0.0001*
Mortality rate at 28 days (%)
14. Coagulopathy
39.3% of the 117 patients were coagulopathic on
admission
There was no significant correlation between the PT and
volume of fluid administered (p - 0.095, r - 0.155)
The 28 day mortality rate for patients with a
coagulopathy of 39.1% was significantly higher than the
8.5% of those with normal coagulation (p-0.0001)
The predictive value of an early coagulopathy in regards
to 28 day mortality was sought using logistic regression
analysis. All components of the ABSI were adjusted for
An earlier coagulopathy was an independent predictor of
28 day mortality, OR 3.42 (1.11-10.56)
15. Incidence of coagulopathy with ABSI
Pearson product moment correlation coefficient r - 0.292 and p - 0.0013
100
90
80
70
Percentage
with
coagulopathy
60
50
40
30
20
10
0
≤7
8 to 9
10 to 11
ABSI
12 to 13
≥ 14
16. PT vs serum lactate
Pearson product moment correlation coefficient, r - 0.292 and p 0.001
8
7
6
5
Serum Lactate 4
(mmol/L)
3
2
1
0
0
5
10
15
20
25
Prothrombin Time (seconds)
30
35
17. Summary
In patients with major thermal injuries there is a
clinically significant early burn induced coagulopathy
This coagulopathy correlates to serum lactate and
ABSI but is unrelated to fluid administration
An
earlier coagulopathy was an independent
predictor of 28 day mortality
A subgroup of major burns patients exhibit the lethal
triad which is associated with an increased mortality
18. Conclusion
In the pre-hospital management of major burns it is
vital to accurately assess the burn area and
resuscitate appropriately to limit tissue
hypoperfusion
An acute burn induced coagulopathy has significant
bleeding implications for any surgical procedures
Ensure temperature conservation
• Highest possible ambient temperature
• Use of Clingfilm, space blankets and layering techniques
• Use of active warming methods such as heat pads and the
En-Flow fluid warmer