This document discusses the use of tranexamic acid (TXA) in trauma patients to reduce hemorrhage and mortality. It summarizes two major studies on TXA - the CRASH-2 trial and the MATTERs study. The CRASH-2 trial found TXA reduced mortality in trauma patients, though some critique the applicability of the results to severely injured patients in developed trauma systems. The MATTERs study in military patients also found reduced mortality with TXA. However, both studies found a potential increased risk of thrombosis with TXA use. Overall, the document examines the evidence for and criticisms of using TXA to reduce hemorrhage in trauma patients.
EVIDENCE OF POSTTRAUMATIC COAGULOPATHY IN CASE OF THE SEVERE COMBINED THORACI...pijans
Early coagulopathy associated with trauma – result of exaggerate activity during the initiation phase of
coagulation. The aim of this study was to determine the diagnostic value of the coagulopathy markers for
metabolic monitoring of the severe combined thoracic trauma and it’s possibly to help in outcome
prediction. This retrospective study was performed on 73 male polytrauma patients from 20 to 68 years
old. The prothrombin time, fibrinogen concentration and β-Naphthol test were estimated on 1-2-d, 3-4-th
and 5-6-th days after trauma. The results suggest that hypocoagulation occurs early in equal extent for
survivals and non-survivals. Coagulation abnormalities are the result of vital functions disturbances rather
than direct tissue injury.
This study analyzed data from the California Patient Discharge Database between 2005-2013 to determine rates of subsequent major amputation after initial minor amputation due to peripheral artery disease (PAD) and/or diabetes mellitus (DM). Patients with combined PAD/DM had the highest rates of major amputation (6.3%) and repeat minor amputation (16%) compared to those with DM or PAD alone. The median time to major amputation was 12.9 months, with no significant differences between groups. Mortality rates were also highest in the PAD/DM group at 49%. Revascularization before subsequent amputation was associated with lower risk of limb loss.
This multicenter study analyzed 111 elderly patients (age 80-89) who underwent radical cystectomy for bladder cancer. The complication rate was high, with 50.4% experiencing early complications and 32% late complications. The perioperative mortality rate was 7.2% and 27.2% of patients were readmitted to the hospital. Tumor progression-free survival at 12 months was lower for patients with ≥pT3 disease (36%) compared to ≤pT1 disease (83.9%). Radical cystectomy in elderly patients carries significant risks given high complication rates, mortality, and readmission rates. Careful patient selection is important to minimize risks and balance benefits against life expectancy.
1. Chemoradiotherapy has become the standard of care for locally advanced head and neck cancers as it allows for organ preservation while maintaining survival compared to surgery.
2. Pivotal studies in the 1980s-1990s established the benefit of adding chemotherapy to radiotherapy, with concurrent chemotherapy demonstrating improved outcomes over induction chemotherapy.
3. Later studies showed concurrent cisplatin and radiation provided the best rates of larynx preservation for advanced laryngeal cancers compared to other approaches.
Reversal of warfarin associated coagulopathy prothrombin complex concentratesTÀI LIỆU NGÀNH MAY
Để xem full tài liệu Xin vui long liên hệ page để được hỗ trợ
: https://www.facebook.com/thuvienluanvan01
HOẶC
https://www.facebook.com/garmentspace/
https://www.facebook.com/thuvienluanvan01
https://www.facebook.com/thuvienluanvan01
tai lieu tong hop, thu vien luan van, luan van tong hop, do an chuyen nganh
Extended criteria donors in liver transplantation Part II reviewing the impac...Balázs Nemes
This document reviews the impact of extended-criteria donors on complications and outcomes of liver transplantation. It finds that extended-criteria donors are associated with higher risks of early allograft dysfunction, especially when donors have moderate to severe steatosis. Extended criteria donors also increase the risk of biliary complications and recurrence of hepatitis C virus. However, with new antiviral regimens, sustained virological response can be achieved in most patients. The use of extended criteria donors reduces long-term survival rates, with 1-year survival rates of 87% for low-risk donors and 40% for high-risk donors. Graft survival is excellent for donors up to a certain risk score but declines significantly above that threshold.
This document summarizes a study that evaluated the effect of substance use on the occurrence and severity of systemic inflammatory response syndrome (SIRS) following trauma. The study found that patients positive for alcohol had more occurrences of SIRS and more severe SIRS than other substance users. Patients positive for cannabis had less severe SIRS than other substance users. Substance use may increase the risk of poor SIRS-related outcomes like sepsis and organ failure after trauma.
Vascular repair after firearm injury is associated with increased morbidity a...anomwiradana
This study analyzed data from 648,662 patients with firearm injuries between 1993-2014 using the National Inpatient Sample database. The key findings were:
1) 9.9% (63,973) of firearm injuries involved a concurrent vascular repair, with these patients more likely to be younger, male, black, on Medicaid, and have lower income.
2) Patients undergoing vascular repair had higher injury severity scores and were more likely to have abdomen/pelvis or extremity injuries from assault.
3) Patients undergoing vascular repair had higher rates of in-hospital mortality (5.51% vs 1.98%), acute renal failure, venous thromboembolic events, pulmonary complications, cardiac complications, sepsis
EVIDENCE OF POSTTRAUMATIC COAGULOPATHY IN CASE OF THE SEVERE COMBINED THORACI...pijans
Early coagulopathy associated with trauma – result of exaggerate activity during the initiation phase of
coagulation. The aim of this study was to determine the diagnostic value of the coagulopathy markers for
metabolic monitoring of the severe combined thoracic trauma and it’s possibly to help in outcome
prediction. This retrospective study was performed on 73 male polytrauma patients from 20 to 68 years
old. The prothrombin time, fibrinogen concentration and β-Naphthol test were estimated on 1-2-d, 3-4-th
and 5-6-th days after trauma. The results suggest that hypocoagulation occurs early in equal extent for
survivals and non-survivals. Coagulation abnormalities are the result of vital functions disturbances rather
than direct tissue injury.
This study analyzed data from the California Patient Discharge Database between 2005-2013 to determine rates of subsequent major amputation after initial minor amputation due to peripheral artery disease (PAD) and/or diabetes mellitus (DM). Patients with combined PAD/DM had the highest rates of major amputation (6.3%) and repeat minor amputation (16%) compared to those with DM or PAD alone. The median time to major amputation was 12.9 months, with no significant differences between groups. Mortality rates were also highest in the PAD/DM group at 49%. Revascularization before subsequent amputation was associated with lower risk of limb loss.
This multicenter study analyzed 111 elderly patients (age 80-89) who underwent radical cystectomy for bladder cancer. The complication rate was high, with 50.4% experiencing early complications and 32% late complications. The perioperative mortality rate was 7.2% and 27.2% of patients were readmitted to the hospital. Tumor progression-free survival at 12 months was lower for patients with ≥pT3 disease (36%) compared to ≤pT1 disease (83.9%). Radical cystectomy in elderly patients carries significant risks given high complication rates, mortality, and readmission rates. Careful patient selection is important to minimize risks and balance benefits against life expectancy.
1. Chemoradiotherapy has become the standard of care for locally advanced head and neck cancers as it allows for organ preservation while maintaining survival compared to surgery.
2. Pivotal studies in the 1980s-1990s established the benefit of adding chemotherapy to radiotherapy, with concurrent chemotherapy demonstrating improved outcomes over induction chemotherapy.
3. Later studies showed concurrent cisplatin and radiation provided the best rates of larynx preservation for advanced laryngeal cancers compared to other approaches.
Reversal of warfarin associated coagulopathy prothrombin complex concentratesTÀI LIỆU NGÀNH MAY
Để xem full tài liệu Xin vui long liên hệ page để được hỗ trợ
: https://www.facebook.com/thuvienluanvan01
HOẶC
https://www.facebook.com/garmentspace/
https://www.facebook.com/thuvienluanvan01
https://www.facebook.com/thuvienluanvan01
tai lieu tong hop, thu vien luan van, luan van tong hop, do an chuyen nganh
Extended criteria donors in liver transplantation Part II reviewing the impac...Balázs Nemes
This document reviews the impact of extended-criteria donors on complications and outcomes of liver transplantation. It finds that extended-criteria donors are associated with higher risks of early allograft dysfunction, especially when donors have moderate to severe steatosis. Extended criteria donors also increase the risk of biliary complications and recurrence of hepatitis C virus. However, with new antiviral regimens, sustained virological response can be achieved in most patients. The use of extended criteria donors reduces long-term survival rates, with 1-year survival rates of 87% for low-risk donors and 40% for high-risk donors. Graft survival is excellent for donors up to a certain risk score but declines significantly above that threshold.
This document summarizes a study that evaluated the effect of substance use on the occurrence and severity of systemic inflammatory response syndrome (SIRS) following trauma. The study found that patients positive for alcohol had more occurrences of SIRS and more severe SIRS than other substance users. Patients positive for cannabis had less severe SIRS than other substance users. Substance use may increase the risk of poor SIRS-related outcomes like sepsis and organ failure after trauma.
Vascular repair after firearm injury is associated with increased morbidity a...anomwiradana
This study analyzed data from 648,662 patients with firearm injuries between 1993-2014 using the National Inpatient Sample database. The key findings were:
1) 9.9% (63,973) of firearm injuries involved a concurrent vascular repair, with these patients more likely to be younger, male, black, on Medicaid, and have lower income.
2) Patients undergoing vascular repair had higher injury severity scores and were more likely to have abdomen/pelvis or extremity injuries from assault.
3) Patients undergoing vascular repair had higher rates of in-hospital mortality (5.51% vs 1.98%), acute renal failure, venous thromboembolic events, pulmonary complications, cardiac complications, sepsis
The document summarizes a panel discussion on cancer of the tongue held at Apollo Hospital Kolkata. It introduces several doctors from Apollo Hospital and other hospitals in Kolkata who specialize in oncology, radiation oncology, surgical oncology and pathology. The panel then discusses the case of a 45-year old male patient with squamous cell carcinoma of the tongue, outlining his diagnosis, investigations, staging and treatment options which include surgery, radiation and chemotherapy.
Kshivets O. Lung Cancer: Optimal Treatment StrategiesOleg Kshivets
This document describes a study examining optimal treatment strategies for non-small cell lung cancer (NSCLC) patients. The study reviewed data from 535 NSCLC patients who underwent complete surgical resection between 1985-2008. Patients received one of three treatments: surgery alone (316 patients), surgery plus postoperative radiotherapy (102 patients), or surgery plus adjuvant chemoimmunoradiotherapy (117 patients). The study found that adjuvant chemoimmunoradiotherapy resulted in significantly higher 5-year survival rates compared to radiotherapy or surgery alone, especially for patients with lymph node involvement. Overall 5-year survival for the entire group was 63.6%, demonstrating the benefit of aggressive surgical resection and adjuvant therapies.
Cuando empeza y cuando parar la profilaxisAnderson David
1) Patients undergoing major orthopedic surgeries like hip or knee replacements are at high risk of developing dangerous blood clots in their legs or lungs.
2) Current guidelines recommend using blood thinners to prevent clots, but there is debate around when to start and how long to continue the medication.
3) This article discusses the timing of increased clot risk after surgery and reviews evidence on balancing clot prevention with bleeding risks of blood thinners at different postoperative times.
Retrospective Analysis of Intra Operative Blood Loss in Pelvic Oncological Su...Premier Publishers
To study intraoperative blood loss and analyse average blood loss and number of transfusions in patients who underwent pelvic oncological surgeries in this oncology centre in South India from January 2012 – December 2018. A retrospective analysis of medical records of 257 patients who had undergone pelvic oncological surgeries in our institute from January 2012 and December 2018 was done and information regarding blood loss and transfusions was analysed with student’s T test. Out of 257 patients, 72 underwent pelvic exenteration of which 18 were operated for primary and 54 were operated for recurrences, 105 underwent Wertheim’s hysterectomy, 19 patients underwent APR, 8 underwent LAR, 5 underwent AR, 36 underwent surgical staging 8 underwent Cystectomy and 4 underwent sacrectomy. In our analysis we found that laparoscopic surgeries had less blood loss (average 354 ml) compared to open surgeries (average 811 ml) and upfront surgeries (531 ml) had less blood loss compared to surgeries done post chemoradiotherapy (668 ml) resulting in less number of transfusions, transfusion reactions, infections and early recovery in laparoscopic and upfront surgeries. Laparoscopic surgery in pelvic oncological surgeries has become a benefit to surgeons because of less intraoperative blood loss, reduced hospital stay and better outcomes. Though laparoscopic surgeries require a learning curve, extensive anatomical knowledge about the procedure during open surgeries made learning curve less steep. Blood loss in upfront cases is less than that of post chemoradiotherapy cases leading to less infection rates, better recovery and with increase in duration of surgery, blood loss is more.
This document summarizes a study that analyzed data from 499 patients with esophageal cancer who underwent surgery between 1975-2017. The study evaluated different treatment approaches including surgery alone or combined with adjuvant chemoimmunoradiotherapy. Overall survival was 1763 days on average, with 47.3% of patients surviving 5 years and 40.7% surviving 10 years. Adjuvant therapy significantly improved 5-year survival to 67.7% compared to 43.1% with surgery alone. Factors like tumor stage, lymph node involvement, age, adjuvant therapy and others were found to significantly impact long-term survival based on statistical modeling of the data. The study concludes that optimal management of esophageal cancer includes early detection,
Chapter 24.2 lmwh in cancer asso thrombosisNilesh Kucha
The document discusses cancer-associated thrombosis (CAT). It notes that cancer increases the risk of venous thromboembolism (VTE) due to alterations in the coagulation system and inflammatory response to cancer that result in a hypercoagulable state. Several risk assessment scores are used to stratify cancer patients' risk of VTE, with the goal of identifying those who could benefit from thromboprophylaxis. The pathophysiology of CAT involves Virchow's triad of stasis, vessel injury, and hypercoagulability due to factors from cancer cells and cytokines that promote coagulation and clot formation.
1) The document discusses management of advanced prostate cancer, focusing on high risk disease. Treatment options for high risk prostate cancer include radiotherapy, androgen deprivation therapy, surgery, or a combination approach.
2) Studies have shown that dose escalated external beam radiotherapy improves outcomes for high risk prostate cancer when combined with androgen deprivation therapy. Moderate hypofractionation is a reasonable alternative to standard fractionation.
3) For high risk disease, long term androgen deprivation therapy of 2 years or more is superior to short term therapy when combined with radiotherapy. However, reducing the duration of long term androgen deprivation may be considered.
Kshivets O. Expert Systems for Diagnosis and Prognosis of Malignant NeoplasmsOleg Kshivets
This document provides an abstract for a dissertation submitted for the degree of Doctor of Medical Sciences. The research developed five new methodologies for cancer diagnosis and prognosis using both traditional and advanced approaches like expert systems and artificial intelligence. The methodologies include: 1) a technology for early cancer screening, 2) a technology for differential cancer diagnosis, 3) a technology for assessing cancer metastasis, 4) a technology for reliable cancer prognosis, and 5) a technology for evaluating immune system homeostasis in cancer patients. These methodologies have no analogs and are designed to optimize cancer diagnosis and treatment using expert systems and computers.
This study developed a new prognostic index called MIPI for patients with advanced-stage mantle cell lymphoma based on data from 455 patients treated in 3 clinical trials. The MIPI stratified patients into low-, intermediate-, and high-risk groups based on 4 independent prognostic factors: age, performance status, lactate dehydrogenase level, and leukocyte count. Validation showed the MIPI provided better risk stratification than existing indices and may help guide treatment decisions. Proliferation marker Ki-67 also showed strong additional prognostic relevance when included in the index.
Venous thromboembolism in cancer patientsDina Barakat
Venous thromboembolism (VTE) represents a significant cause of morbidity and mortality in cancer patients. The risk of VTE is increased by certain cancer types, advanced or metastatic disease, surgery, chemotherapy, targeted therapy, and hospitalization. Prophylaxis is recommended for cancer patients undergoing surgery, hospitalized with medical conditions, and those receiving chemotherapy or targeted therapy who are at high risk. Prophylaxis involves pharmacological methods like low molecular weight heparins or mechanical methods. Guidelines provide recommendations on assessing risk factors, initiating prophylaxis, and duration of treatment and prophylaxis to balance preventing VTE events and risks of bleeding in cancer patients.
1. Several randomized controlled trials have consistently shown that the addition of neoadjuvant hormonal therapy (NHT) to external beam radiotherapy (EBRT) improves outcomes for men with intermediate-risk or high-risk localized prostate cancer.
2. The optimal timing and duration of NHT is still unclear, but most evidence suggests that 2-3 months of NHT combined with EBRT is adequate for intermediate-risk patients. Longer adjuvant hormonal therapy may benefit high-risk patients.
3. While the sequence of NHT relative to EBRT may impact outcomes, short-term NHT combined with EBRT appears beneficial overall based on multiple randomized trials.
Cryopreserved saphenous vein allografts were evaluated for infragenual bypass surgery in 92 patients with critical limb ischemia over 15 years. Primary and primary assisted patency rates at 1 year were 49.9% and 55.7%, and limb salvage rates at 1, 3, and 5 years were 85%, 70%, and 64%. While allografts are an alternative to prosthetic materials when autologous veins are unavailable, better patient selection and use of statins may improve results, though availability remains limited.
Clinical outcome, proteome kinetics and angiogenic factors in serum after the...Enrique Moreno Gonzalez
Thermoablation is used to treat patients with unresectable colorectal liver metastases (CRLM). We analyze clinical outcome, proteome kinetics and angiogenic markers in patients treated by cryosurgical ablation (CSA) or radiofrequency ablation (RFA).
Use of TEG® in Acute Traumatic Brain Injurykathleenmccann
Acute traumatic coagulopathy complicate 25 – 75% of cases of traumatic brain injury, incidence increasing with severity of injury. The complex processes that cause this are a culmination of the activation of anticoagulant and fibrinolytic pathways. Much has been published about the clinical outcomes of brain injury and the associated coagulopathy with platelet dysfunction. The mechanism, however, is still not understood.
Clinical management of these patients to date relies on traditional serum based screens: PT, INR, PTT, platelet counts, fibrinogen, and D-dimer assays. These values do not reflect whole blood hemostasis nor do they reflect a cell based model of hemostasis. Thromboelastography with platelet mapping, however, provides real-time data on:
Coagulation pathway function
Fibrinogen function
Platelet function
Fibrinolysis
We purport the expanded use of TEG® as a viscoelastic point-of-care test of whole blood which more accurately reflects hemostasis. It determines the hemostatic integrity of whole blood in vitro by giving real-time information on thrombus initiation, amplification, propagation, and termination. It has long been used in management in transplant patients and during cardiac surgery. It has recently become increasingly used in the management of trauma patients, including those presenting with traumatic brain injury.
We show that TEG® is useful not only in guiding treatment, but also in studying the mechanisms underlying acute traumatic coagulopathy and platelet dysfunction in cases of hemorrhagic brain injury, in both the animal model and in the clinical setting.
This document summarizes statistics on prostate cancer incidence and mortality rates in the United States from 1975 to 2009. It also discusses results from several major clinical trials comparing prostate cancer screening to no screening, and radical prostatectomy to observation for localized prostate cancer. The key findings are:
1) Prostate cancer incidence peaked in 1992 but mortality rates have been declining since the 1990s.
2) Large screening trials show screening increases prostate cancer diagnosis but does not reliably decrease prostate cancer mortality.
3) The PIVOT trial found that among men with localized prostate cancer, radical prostatectomy resulted in a 2.9% lower rate of death from any cause and a 2.6% lower rate of death from prostate
Kshivets Oleg Local Advanced Gastric Cancer: Optimization of ManagementOleg Kshivets
This document analyzes treatment plans for patients with locally advanced gastric cancer. 144 patients underwent surgery to remove their stomach and nearby organs. Patients who received adjuvant chemotherapy after surgery had a significantly higher 5-year survival rate of 69.3% compared to 35.1% for patients who only had surgery. Neural network modeling revealed that 5-year survival was most dependent on the extent of lymph node involvement. The optimal management strategies identified were experienced surgeons for complex surgery, complete removal of the tumor and lymph nodes during surgery, precise prediction of prognosis, and adjuvant treatment for high-risk patients.
This document summarizes guidelines for preventing deep vein thrombosis and pulmonary embolism in surgical patients. It discusses the causes of VTE including stasis, intimal injury, and hypercoagulability due to surgery. It also describes methods for assessing patient risk and different prophylaxis options including unfractionated heparin, low molecular weight heparin, and pentasaccharide. The summary provides an overview of dosing and administration for various prophylaxis modalities.
CAN WE MARCH WITH MARCH META-ANALYSIS?Kanhu Charan
Altered fractionation radiotherapy, especially hyperfractionated radiotherapy, provides improved overall survival compared to conventional fractionation for head and neck cancers. The 2017 MARCH meta-analysis update, which included over 11,000 patients, confirmed the benefits of altered fractionation. Specifically, hyperfractionated radiotherapy resulted in an 8.1% absolute improvement in 5-year survival. Concurrent chemotherapy with conventional radiation was found to be better than altered fractionation alone, but hyperfractionated radiotherapy seems comparable to chemotherapy with standard radiation.
The internal educational program (IEP) of Vanderbilt University's Division of Trauma, Emergency Surgery and Surgical Critical Care aims to provide educational opportunities on topics related to trauma care from pre-hospital care to post-discharge requirements. The IEP will outline the care provided to trauma patients from point of injury through completion of care. The trauma team includes surgeons, nurses, and liaisons from emergency medicine, orthopedics, neurosurgery, anesthesia, and radiology, with the shared goal of improving trauma patient care in a consistent and caring manner and preventing injuries in the local region. Participants are asked to review provided materials and complete an evaluation.
The internal educational program (IEP) of Vanderbilt University's Division of Trauma, Emergency Surgery and Surgical Critical Care aims to provide educational opportunities on topics related to trauma care from pre-hospital care to post-discharge requirements. The IEP will explore various areas of interest throughout the year and outline the full continuum of care provided to trauma patients. The IEP involves the trauma team, which consists of physicians, nurses, and other specialists from various departments. The overall goal is to continuously improve trauma patient care and reduce injuries in the local region.
The document summarizes a panel discussion on cancer of the tongue held at Apollo Hospital Kolkata. It introduces several doctors from Apollo Hospital and other hospitals in Kolkata who specialize in oncology, radiation oncology, surgical oncology and pathology. The panel then discusses the case of a 45-year old male patient with squamous cell carcinoma of the tongue, outlining his diagnosis, investigations, staging and treatment options which include surgery, radiation and chemotherapy.
Kshivets O. Lung Cancer: Optimal Treatment StrategiesOleg Kshivets
This document describes a study examining optimal treatment strategies for non-small cell lung cancer (NSCLC) patients. The study reviewed data from 535 NSCLC patients who underwent complete surgical resection between 1985-2008. Patients received one of three treatments: surgery alone (316 patients), surgery plus postoperative radiotherapy (102 patients), or surgery plus adjuvant chemoimmunoradiotherapy (117 patients). The study found that adjuvant chemoimmunoradiotherapy resulted in significantly higher 5-year survival rates compared to radiotherapy or surgery alone, especially for patients with lymph node involvement. Overall 5-year survival for the entire group was 63.6%, demonstrating the benefit of aggressive surgical resection and adjuvant therapies.
Cuando empeza y cuando parar la profilaxisAnderson David
1) Patients undergoing major orthopedic surgeries like hip or knee replacements are at high risk of developing dangerous blood clots in their legs or lungs.
2) Current guidelines recommend using blood thinners to prevent clots, but there is debate around when to start and how long to continue the medication.
3) This article discusses the timing of increased clot risk after surgery and reviews evidence on balancing clot prevention with bleeding risks of blood thinners at different postoperative times.
Retrospective Analysis of Intra Operative Blood Loss in Pelvic Oncological Su...Premier Publishers
To study intraoperative blood loss and analyse average blood loss and number of transfusions in patients who underwent pelvic oncological surgeries in this oncology centre in South India from January 2012 – December 2018. A retrospective analysis of medical records of 257 patients who had undergone pelvic oncological surgeries in our institute from January 2012 and December 2018 was done and information regarding blood loss and transfusions was analysed with student’s T test. Out of 257 patients, 72 underwent pelvic exenteration of which 18 were operated for primary and 54 were operated for recurrences, 105 underwent Wertheim’s hysterectomy, 19 patients underwent APR, 8 underwent LAR, 5 underwent AR, 36 underwent surgical staging 8 underwent Cystectomy and 4 underwent sacrectomy. In our analysis we found that laparoscopic surgeries had less blood loss (average 354 ml) compared to open surgeries (average 811 ml) and upfront surgeries (531 ml) had less blood loss compared to surgeries done post chemoradiotherapy (668 ml) resulting in less number of transfusions, transfusion reactions, infections and early recovery in laparoscopic and upfront surgeries. Laparoscopic surgery in pelvic oncological surgeries has become a benefit to surgeons because of less intraoperative blood loss, reduced hospital stay and better outcomes. Though laparoscopic surgeries require a learning curve, extensive anatomical knowledge about the procedure during open surgeries made learning curve less steep. Blood loss in upfront cases is less than that of post chemoradiotherapy cases leading to less infection rates, better recovery and with increase in duration of surgery, blood loss is more.
This document summarizes a study that analyzed data from 499 patients with esophageal cancer who underwent surgery between 1975-2017. The study evaluated different treatment approaches including surgery alone or combined with adjuvant chemoimmunoradiotherapy. Overall survival was 1763 days on average, with 47.3% of patients surviving 5 years and 40.7% surviving 10 years. Adjuvant therapy significantly improved 5-year survival to 67.7% compared to 43.1% with surgery alone. Factors like tumor stage, lymph node involvement, age, adjuvant therapy and others were found to significantly impact long-term survival based on statistical modeling of the data. The study concludes that optimal management of esophageal cancer includes early detection,
Chapter 24.2 lmwh in cancer asso thrombosisNilesh Kucha
The document discusses cancer-associated thrombosis (CAT). It notes that cancer increases the risk of venous thromboembolism (VTE) due to alterations in the coagulation system and inflammatory response to cancer that result in a hypercoagulable state. Several risk assessment scores are used to stratify cancer patients' risk of VTE, with the goal of identifying those who could benefit from thromboprophylaxis. The pathophysiology of CAT involves Virchow's triad of stasis, vessel injury, and hypercoagulability due to factors from cancer cells and cytokines that promote coagulation and clot formation.
1) The document discusses management of advanced prostate cancer, focusing on high risk disease. Treatment options for high risk prostate cancer include radiotherapy, androgen deprivation therapy, surgery, or a combination approach.
2) Studies have shown that dose escalated external beam radiotherapy improves outcomes for high risk prostate cancer when combined with androgen deprivation therapy. Moderate hypofractionation is a reasonable alternative to standard fractionation.
3) For high risk disease, long term androgen deprivation therapy of 2 years or more is superior to short term therapy when combined with radiotherapy. However, reducing the duration of long term androgen deprivation may be considered.
Kshivets O. Expert Systems for Diagnosis and Prognosis of Malignant NeoplasmsOleg Kshivets
This document provides an abstract for a dissertation submitted for the degree of Doctor of Medical Sciences. The research developed five new methodologies for cancer diagnosis and prognosis using both traditional and advanced approaches like expert systems and artificial intelligence. The methodologies include: 1) a technology for early cancer screening, 2) a technology for differential cancer diagnosis, 3) a technology for assessing cancer metastasis, 4) a technology for reliable cancer prognosis, and 5) a technology for evaluating immune system homeostasis in cancer patients. These methodologies have no analogs and are designed to optimize cancer diagnosis and treatment using expert systems and computers.
This study developed a new prognostic index called MIPI for patients with advanced-stage mantle cell lymphoma based on data from 455 patients treated in 3 clinical trials. The MIPI stratified patients into low-, intermediate-, and high-risk groups based on 4 independent prognostic factors: age, performance status, lactate dehydrogenase level, and leukocyte count. Validation showed the MIPI provided better risk stratification than existing indices and may help guide treatment decisions. Proliferation marker Ki-67 also showed strong additional prognostic relevance when included in the index.
Venous thromboembolism in cancer patientsDina Barakat
Venous thromboembolism (VTE) represents a significant cause of morbidity and mortality in cancer patients. The risk of VTE is increased by certain cancer types, advanced or metastatic disease, surgery, chemotherapy, targeted therapy, and hospitalization. Prophylaxis is recommended for cancer patients undergoing surgery, hospitalized with medical conditions, and those receiving chemotherapy or targeted therapy who are at high risk. Prophylaxis involves pharmacological methods like low molecular weight heparins or mechanical methods. Guidelines provide recommendations on assessing risk factors, initiating prophylaxis, and duration of treatment and prophylaxis to balance preventing VTE events and risks of bleeding in cancer patients.
1. Several randomized controlled trials have consistently shown that the addition of neoadjuvant hormonal therapy (NHT) to external beam radiotherapy (EBRT) improves outcomes for men with intermediate-risk or high-risk localized prostate cancer.
2. The optimal timing and duration of NHT is still unclear, but most evidence suggests that 2-3 months of NHT combined with EBRT is adequate for intermediate-risk patients. Longer adjuvant hormonal therapy may benefit high-risk patients.
3. While the sequence of NHT relative to EBRT may impact outcomes, short-term NHT combined with EBRT appears beneficial overall based on multiple randomized trials.
Cryopreserved saphenous vein allografts were evaluated for infragenual bypass surgery in 92 patients with critical limb ischemia over 15 years. Primary and primary assisted patency rates at 1 year were 49.9% and 55.7%, and limb salvage rates at 1, 3, and 5 years were 85%, 70%, and 64%. While allografts are an alternative to prosthetic materials when autologous veins are unavailable, better patient selection and use of statins may improve results, though availability remains limited.
Clinical outcome, proteome kinetics and angiogenic factors in serum after the...Enrique Moreno Gonzalez
Thermoablation is used to treat patients with unresectable colorectal liver metastases (CRLM). We analyze clinical outcome, proteome kinetics and angiogenic markers in patients treated by cryosurgical ablation (CSA) or radiofrequency ablation (RFA).
Use of TEG® in Acute Traumatic Brain Injurykathleenmccann
Acute traumatic coagulopathy complicate 25 – 75% of cases of traumatic brain injury, incidence increasing with severity of injury. The complex processes that cause this are a culmination of the activation of anticoagulant and fibrinolytic pathways. Much has been published about the clinical outcomes of brain injury and the associated coagulopathy with platelet dysfunction. The mechanism, however, is still not understood.
Clinical management of these patients to date relies on traditional serum based screens: PT, INR, PTT, platelet counts, fibrinogen, and D-dimer assays. These values do not reflect whole blood hemostasis nor do they reflect a cell based model of hemostasis. Thromboelastography with platelet mapping, however, provides real-time data on:
Coagulation pathway function
Fibrinogen function
Platelet function
Fibrinolysis
We purport the expanded use of TEG® as a viscoelastic point-of-care test of whole blood which more accurately reflects hemostasis. It determines the hemostatic integrity of whole blood in vitro by giving real-time information on thrombus initiation, amplification, propagation, and termination. It has long been used in management in transplant patients and during cardiac surgery. It has recently become increasingly used in the management of trauma patients, including those presenting with traumatic brain injury.
We show that TEG® is useful not only in guiding treatment, but also in studying the mechanisms underlying acute traumatic coagulopathy and platelet dysfunction in cases of hemorrhagic brain injury, in both the animal model and in the clinical setting.
This document summarizes statistics on prostate cancer incidence and mortality rates in the United States from 1975 to 2009. It also discusses results from several major clinical trials comparing prostate cancer screening to no screening, and radical prostatectomy to observation for localized prostate cancer. The key findings are:
1) Prostate cancer incidence peaked in 1992 but mortality rates have been declining since the 1990s.
2) Large screening trials show screening increases prostate cancer diagnosis but does not reliably decrease prostate cancer mortality.
3) The PIVOT trial found that among men with localized prostate cancer, radical prostatectomy resulted in a 2.9% lower rate of death from any cause and a 2.6% lower rate of death from prostate
Kshivets Oleg Local Advanced Gastric Cancer: Optimization of ManagementOleg Kshivets
This document analyzes treatment plans for patients with locally advanced gastric cancer. 144 patients underwent surgery to remove their stomach and nearby organs. Patients who received adjuvant chemotherapy after surgery had a significantly higher 5-year survival rate of 69.3% compared to 35.1% for patients who only had surgery. Neural network modeling revealed that 5-year survival was most dependent on the extent of lymph node involvement. The optimal management strategies identified were experienced surgeons for complex surgery, complete removal of the tumor and lymph nodes during surgery, precise prediction of prognosis, and adjuvant treatment for high-risk patients.
This document summarizes guidelines for preventing deep vein thrombosis and pulmonary embolism in surgical patients. It discusses the causes of VTE including stasis, intimal injury, and hypercoagulability due to surgery. It also describes methods for assessing patient risk and different prophylaxis options including unfractionated heparin, low molecular weight heparin, and pentasaccharide. The summary provides an overview of dosing and administration for various prophylaxis modalities.
CAN WE MARCH WITH MARCH META-ANALYSIS?Kanhu Charan
Altered fractionation radiotherapy, especially hyperfractionated radiotherapy, provides improved overall survival compared to conventional fractionation for head and neck cancers. The 2017 MARCH meta-analysis update, which included over 11,000 patients, confirmed the benefits of altered fractionation. Specifically, hyperfractionated radiotherapy resulted in an 8.1% absolute improvement in 5-year survival. Concurrent chemotherapy with conventional radiation was found to be better than altered fractionation alone, but hyperfractionated radiotherapy seems comparable to chemotherapy with standard radiation.
The internal educational program (IEP) of Vanderbilt University's Division of Trauma, Emergency Surgery and Surgical Critical Care aims to provide educational opportunities on topics related to trauma care from pre-hospital care to post-discharge requirements. The IEP will outline the care provided to trauma patients from point of injury through completion of care. The trauma team includes surgeons, nurses, and liaisons from emergency medicine, orthopedics, neurosurgery, anesthesia, and radiology, with the shared goal of improving trauma patient care in a consistent and caring manner and preventing injuries in the local region. Participants are asked to review provided materials and complete an evaluation.
The internal educational program (IEP) of Vanderbilt University's Division of Trauma, Emergency Surgery and Surgical Critical Care aims to provide educational opportunities on topics related to trauma care from pre-hospital care to post-discharge requirements. The IEP will explore various areas of interest throughout the year and outline the full continuum of care provided to trauma patients. The IEP involves the trauma team, which consists of physicians, nurses, and other specialists from various departments. The overall goal is to continuously improve trauma patient care and reduce injuries in the local region.
This document discusses optimal fluid therapy for patients with traumatic hemorrhagic shock. It begins by noting that hemorrhage is a leading cause of preventable trauma deaths. Advances in treatment of hemorrhagic shock have often occurred during times of war. The document then reviews patient evaluation, massive transfusion protocols, and damage control resuscitation, which emphasizes early use of plasma over crystalloids. Large volumes of crystalloids are associated with worse outcomes for patients with hemorrhagic shock, and even small amounts may be harmful. Plasma should be the primary means of volume expansion in resuscitation of trauma patients with hemorrhagic shock.
Trauma-Induced coagulopathy: Methods, Trigger and Mechanism of Early TIC
< a href="http://www.emergency-live.com
">read on Emergency Live</a>
Trauma is the leading cause of death among people under the age of 44. Hemorrhage is a major contributor to deaths related to trauma in the first 48 h.
This study aimed to determine factors influencing the stabilization of intracranial hemorrhage within 72 hours of traumatic brain injury. The study analyzed 127 patients with brain injury requiring neurosurgery. Logistic regression identified several significant predictors of hemorrhage stabilization within 72 hours: male sex increased likelihood by 3 times; each additional year of age decreased likelihood by 4%; minor brain injury based on Glasgow Coma Scale score increased likelihood by 23 times compared to severe injury. Contusion size was also a marginally significant predictor. No significant differences in stabilization time were found between neurosurgical treatment groups.
Correlation of Base-Line Trough Tacrolimus Level With Early RejectionCrimsonpublisherssmoaj
The study was done at Muljibhai Patel Urological Hospital, Nadiad, Gujarat. It is a tertiary health care centre, for nephrology, with a well established hemodialysis unit. We have done about 1950 renal transplantation so far. Acute rejection is the most significant risk factor for chronic rejection and potential surrogate for long-term graft failure. Aim of our study was to analyze the association between the baseline through (C0) tacrolimus level in the first day post transplant, with early rejection in living donor transplants [1-10].
1) Several clinical trials are underway to evaluate new trauma interventions such as viscoelastic-guided protocols, lyophilized plasma, tranexamic acid, fibrinogen concentrate, cryopreserved platelets, and cold-stored platelets.
2) Traditional clinical trials in trauma face challenges like patient heterogeneity and dichotomous outcomes like mortality, requiring very large sample sizes. Alternative outcomes being explored include longer term functional outcomes and biological surrogates.
3) Notable ongoing trials include iTACTIC evaluating lyophilized plasma, RePHILL and PATCH-Trauma evaluating tranexamic acid, FEISTY evaluating fibrinogen concentrate, CRYOSTAT-2 evaluating cryoprecipitate, and
Treatment and early outcome of 11 children with hepatoblastoma.Dr./ Ihab Samy
Fouad A. Fouad saleep MD., Ihab samy Fayek MD.
Department of Surgical Oncology – National Cancer Institute – Cairo University - Egypt.
Kasr el-aini medical journal Volume 18, No.4, October 2012.
dvt prophylaxis, in icu, deep venous thrombosis prophylaxis ,gagan brar
Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE), is extraordinarily common in hospitalized patients. Risk factors for VTE include immobilization, surgery, trauma, cancer, and thrombophilia. Prediction models can help assess patient risk, though require validation. Primary prophylaxis is preferred to prevent VTE and includes mechanical methods like intermittent pneumatic compression and graduated compression stockings, as well as pharmacologic agents like unfractionated heparin, low molecular weight heparins, and fondaparinux. These options aim to reduce the risk of VTE complications while minimizing bleeding risks.
This document summarizes a retrospective study examining the physiological changes in patients with maxillofacial trauma compared to a control group. The study found several significant differences in complete blood counts and vital signs between the two groups within 24 hours of injury. Specifically, trauma patients had higher hemoglobin, red blood cell count, and white blood cell count levels. They also had lower diastolic blood pressure, oxygen saturation, and higher temperature and pulse rate compared to controls. The authors conclude that while the changes were within normal ranges, they reflect the body's compensatory mechanisms to stabilize after injury and extrapolate these findings to better understand the metabolic response to trauma.
This document summarizes a retrospective study examining the physiological changes in patients with maxillofacial trauma compared to a control group. The study found several significant differences in complete blood counts and vital signs between the two groups within 24 hours of injury. Specifically, trauma patients had higher hemoglobin, red blood cell count, and white blood cell count levels. They also had lower diastolic blood pressure, oxygen saturation, and higher temperature and pulse rate compared to controls. These changes are consistent with the body's metabolic response to injury, including hemoconcentration and activation of the immune response. While the values remained within normal ranges, the study suggests maxillofacial surgeons should be sensitive to minor variations in physiological parameters after trauma.
Assists with airway management and ventilation.
3. Doctor 1 (Emergency Physician or Surgeon)
Assesses and manages circulation.
4. Doctor 2
Assists with primary survey and resuscitation.
5. Nurse 1 (ED Nurse, ‘Airway’)
Assists with airway management and ventilation.
6. Nurse 2 (ED Nurse, ‘Circulation)
Assists with circulation assessment and management.
7. Scribe (ED Nurse, Paramedic, Health Care Assistant)
Records details of assessment, treatment and monitoring.
8. Radi
Assists with airway management and ventilation.
3. Doctor 1 (Emergency Physician or Surgeon)
Assesses and manages circulation.
4. Doctor 2
Assesses and manages disability.
5. Nurse 1 (ED Nurse, ‘Airway’)
Assists with airway management and ventilation.
6. Nurse 2 (ED Nurse, ‘Circulation)
Assists with circulation assessment and management.
7. Scribe (ED Nurse, Paramedic, Health Care Assistant)
Records details of assessment, treatment and timings.
8. Radiographer
This document summarizes two cases of radiation therapy accidents and their consequences. Case 1 involved a miscalculation of treatment time in Costa Rica in 1996 that led to an overexposure and the deaths of 17 patients. Case 2 occurred in Panama in 2000 when a treatment planning system incorrectly calculated treatment times after a change in data entry, overexposing 28 patients and killing 5. Accidental underexposure can lead to tumor mismanagement while overexposure causes early complications like necrosis and late complications in slowly-dividing tissues. Establishing quality assurance programs, training, and safety protocols can help prevent such accidents.
1. A randomized trial compared restrictive (transfuse if Hb <7 g/dL) vs liberal (transfuse if Hb <9 g/dL) transfusion strategies in critically ill cancer patients with septic shock.
2. At 28 days, all-cause mortality was not significantly different between groups. However, at 90 days mortality was significantly higher in the restrictive group.
3. Secondary outcomes including ventilation, renal replacement therapy, inotropes, and length of stay showed no significant differences.
4. The results suggest a liberal transfusion strategy may be preferable for critically ill cancer patients with septic shock, as a restrictive strategy was associated with higher 90-day mortality.
Inflammatory cytokines released after trauma cause a hypercoagulable state combined with endothelial injury and venous stasis, completing the Virchow Triad and contributing to venous thrombosis. Both chemical and mechanical thromboprophylaxis have been shown to decrease rates of venous thromboembolism (VTE) in trauma patients, with pharmacologic prophylaxis being more effective than mechanical methods. While thromboprophylaxis reduces VTE risk in orthopedic trauma patients, the risk is not eliminated and regular communication between services is important to promptly initiate prophylaxis when possible.
Major Trauma Management and Trauma Team RolesSCGH ED CME
This document discusses major trauma management and trauma team roles. It defines major trauma as injury affecting more than one body system with an Injury Severity Score of over 15. The trauma network in Western Australia is described, with trauma accounting for a significant percentage of deaths and hospitalizations in Australia. When a major trauma code is called, the trauma team prepares and activates to receive the patient. Key roles on the trauma team include having the right people, equipment, drugs prepared and specialties notified. Hemostatic resuscitation principles are outlined, focusing on blood products over crystalloids to limit bleeding and following ratios like 1-2 units of red blood cells for every unit of plasma and platelets. Tranexamic acid should also
This document summarizes a study on the presentation and management of thoracic trauma patients at a tertiary care hospital in Pakistan. The study included 143 patients with thoracic trauma seen over a one year period. It found that most patients were male (83%) between the ages of 21-50 years. The majority of injuries were due to blunt trauma (87.4%) from road traffic accidents (72%), with rib fractures being the most common chest injury (74% of patients). Tube thoracostomy was the most common intervention (45% of patients). The mortality rate was 11.88%. The study concludes that thoracic trauma is an important cause of hospitalization and mortality in younger populations in Pakistan, with road traffic
Fifteen Years Experience of Managing Penetrating Extra-Peritoneal Rectal Inju...Crimsonpublisherssmoaj
This document summarizes a study examining 15 years of experience managing penetrating extra-peritoneal rectal injuries at Aga Khan University Hospital in Karachi, Pakistan. The study reviewed 15 patients who sustained such injuries. All patients underwent fecal diversion via colostomy. Overall post-operative morbidity was 40%, including two patients who developed necrotizing faciitis and one with an intra-abdominal abscess. The study concludes that drainage with fecal diversion is the most common management for extra-peritoneal rectal injuries, and delayed or inadequate drainage can lead to serious complications.
Strategies for Effective Upskilling is a presentation by Chinwendu Peace in a Your Skill Boost Masterclass organisation by the Excellence Foundation for South Sudan on 08th and 09th June 2024 from 1 PM to 3 PM on each day.
This presentation was provided by Steph Pollock of The American Psychological Association’s Journals Program, and Damita Snow, of The American Society of Civil Engineers (ASCE), for the initial session of NISO's 2024 Training Series "DEIA in the Scholarly Landscape." Session One: 'Setting Expectations: a DEIA Primer,' was held June 6, 2024.
How to Setup Warehouse & Location in Odoo 17 InventoryCeline George
In this slide, we'll explore how to set up warehouses and locations in Odoo 17 Inventory. This will help us manage our stock effectively, track inventory levels, and streamline warehouse operations.
বাংলাদেশের অর্থনৈতিক সমীক্ষা ২০২৪ [Bangladesh Economic Review 2024 Bangla.pdf] কম্পিউটার , ট্যাব ও স্মার্ট ফোন ভার্সন সহ সম্পূর্ণ বাংলা ই-বুক বা pdf বই " সুচিপত্র ...বুকমার্ক মেনু 🔖 ও হাইপার লিংক মেনু 📝👆 যুক্ত ..
আমাদের সবার জন্য খুব খুব গুরুত্বপূর্ণ একটি বই ..বিসিএস, ব্যাংক, ইউনিভার্সিটি ভর্তি ও যে কোন প্রতিযোগিতা মূলক পরীক্ষার জন্য এর খুব ইম্পরট্যান্ট একটি বিষয় ...তাছাড়া বাংলাদেশের সাম্প্রতিক যে কোন ডাটা বা তথ্য এই বইতে পাবেন ...
তাই একজন নাগরিক হিসাবে এই তথ্য গুলো আপনার জানা প্রয়োজন ...।
বিসিএস ও ব্যাংক এর লিখিত পরীক্ষা ...+এছাড়া মাধ্যমিক ও উচ্চমাধ্যমিকের স্টুডেন্টদের জন্য অনেক কাজে আসবে ...
How to Make a Field Mandatory in Odoo 17Celine George
In Odoo, making a field required can be done through both Python code and XML views. When you set the required attribute to True in Python code, it makes the field required across all views where it's used. Conversely, when you set the required attribute in XML views, it makes the field required only in the context of that particular view.
ISO/IEC 27001, ISO/IEC 42001, and GDPR: Best Practices for Implementation and...PECB
Denis is a dynamic and results-driven Chief Information Officer (CIO) with a distinguished career spanning information systems analysis and technical project management. With a proven track record of spearheading the design and delivery of cutting-edge Information Management solutions, he has consistently elevated business operations, streamlined reporting functions, and maximized process efficiency.
Certified as an ISO/IEC 27001: Information Security Management Systems (ISMS) Lead Implementer, Data Protection Officer, and Cyber Risks Analyst, Denis brings a heightened focus on data security, privacy, and cyber resilience to every endeavor.
His expertise extends across a diverse spectrum of reporting, database, and web development applications, underpinned by an exceptional grasp of data storage and virtualization technologies. His proficiency in application testing, database administration, and data cleansing ensures seamless execution of complex projects.
What sets Denis apart is his comprehensive understanding of Business and Systems Analysis technologies, honed through involvement in all phases of the Software Development Lifecycle (SDLC). From meticulous requirements gathering to precise analysis, innovative design, rigorous development, thorough testing, and successful implementation, he has consistently delivered exceptional results.
Throughout his career, he has taken on multifaceted roles, from leading technical project management teams to owning solutions that drive operational excellence. His conscientious and proactive approach is unwavering, whether he is working independently or collaboratively within a team. His ability to connect with colleagues on a personal level underscores his commitment to fostering a harmonious and productive workplace environment.
Date: May 29, 2024
Tags: Information Security, ISO/IEC 27001, ISO/IEC 42001, Artificial Intelligence, GDPR
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Main Java[All of the Base Concepts}.docxadhitya5119
This is part 1 of my Java Learning Journey. This Contains Custom methods, classes, constructors, packages, multithreading , try- catch block, finally block and more.
This document provides an overview of wound healing, its functions, stages, mechanisms, factors affecting it, and complications.
A wound is a break in the integrity of the skin or tissues, which may be associated with disruption of the structure and function.
Healing is the body’s response to injury in an attempt to restore normal structure and functions.
Healing can occur in two ways: Regeneration and Repair
There are 4 phases of wound healing: hemostasis, inflammation, proliferation, and remodeling. This document also describes the mechanism of wound healing. Factors that affect healing include infection, uncontrolled diabetes, poor nutrition, age, anemia, the presence of foreign bodies, etc.
Complications of wound healing like infection, hyperpigmentation of scar, contractures, and keloid formation.
How to Manage Your Lost Opportunities in Odoo 17 CRMCeline George
Odoo 17 CRM allows us to track why we lose sales opportunities with "Lost Reasons." This helps analyze our sales process and identify areas for improvement. Here's how to configure lost reasons in Odoo 17 CRM
Chapter wise All Notes of First year Basic Civil Engineering.pptxDenish Jangid
Chapter wise All Notes of First year Basic Civil Engineering
Syllabus
Chapter-1
Introduction to objective, scope and outcome the subject
Chapter 2
Introduction: Scope and Specialization of Civil Engineering, Role of civil Engineer in Society, Impact of infrastructural development on economy of country.
Chapter 3
Surveying: Object Principles & Types of Surveying; Site Plans, Plans & Maps; Scales & Unit of different Measurements.
Linear Measurements: Instruments used. Linear Measurement by Tape, Ranging out Survey Lines and overcoming Obstructions; Measurements on sloping ground; Tape corrections, conventional symbols. Angular Measurements: Instruments used; Introduction to Compass Surveying, Bearings and Longitude & Latitude of a Line, Introduction to total station.
Levelling: Instrument used Object of levelling, Methods of levelling in brief, and Contour maps.
Chapter 4
Buildings: Selection of site for Buildings, Layout of Building Plan, Types of buildings, Plinth area, carpet area, floor space index, Introduction to building byelaws, concept of sun light & ventilation. Components of Buildings & their functions, Basic concept of R.C.C., Introduction to types of foundation
Chapter 5
Transportation: Introduction to Transportation Engineering; Traffic and Road Safety: Types and Characteristics of Various Modes of Transportation; Various Road Traffic Signs, Causes of Accidents and Road Safety Measures.
Chapter 6
Environmental Engineering: Environmental Pollution, Environmental Acts and Regulations, Functional Concepts of Ecology, Basics of Species, Biodiversity, Ecosystem, Hydrological Cycle; Chemical Cycles: Carbon, Nitrogen & Phosphorus; Energy Flow in Ecosystems.
Water Pollution: Water Quality standards, Introduction to Treatment & Disposal of Waste Water. Reuse and Saving of Water, Rain Water Harvesting. Solid Waste Management: Classification of Solid Waste, Collection, Transportation and Disposal of Solid. Recycling of Solid Waste: Energy Recovery, Sanitary Landfill, On-Site Sanitation. Air & Noise Pollution: Primary and Secondary air pollutants, Harmful effects of Air Pollution, Control of Air Pollution. . Noise Pollution Harmful Effects of noise pollution, control of noise pollution, Global warming & Climate Change, Ozone depletion, Greenhouse effect
Text Books:
1. Palancharmy, Basic Civil Engineering, McGraw Hill publishers.
2. Satheesh Gopi, Basic Civil Engineering, Pearson Publishers.
3. Ketki Rangwala Dalal, Essentials of Civil Engineering, Charotar Publishing House.
4. BCP, Surveying volume 1
How to Create a More Engaging and Human Online Learning Experience
Traumagram Spring 2017
1. Greetings,
Welcome to the internal educational program (IEP) of the Vanderbilt University Division of Trauma,
Emergency Surgery and Surgical Critical Care. Our goal is to provide an opportunity to pursue topics
germane to trauma from all aspects of the team. My hope is to explore all areas of interest throughout the
course of the year including pre-hospital care, acute care issues, post-discharge requirements, as well as
injury prevention. We will attempt to outline the care provided to our trauma patient population from
point of injury until the patients care is completed.
As you know, the trauma team consists of the Chief of the Division, Dr. Rick Miller, our Trauma Program
Manager, Melissa Smith, RN, the Performance Improvement Director, Dr. Brad Dennis, the Outreach and
Prevention coordinator, Cathy Wilson, RN, the Trauma Resuscitation Manager, Kevin High, RN, as well as the
entire trauma faculty and Acute Care Surgery Fellows. Our multidisciplinary liaison team includes Tyler
Barrett (EM), Robert Boyce (Ortho), Reid Thompson (Neurosurgery), Shannon Kilkelly (Anesthesia), Peter
Bream (Radiology) and the LifeFlight team. Our goal is to improve the care of the trauma patient in a caring
and consistent manner and to help minimize injury in the Middle Tennessee region through outreach and
prevention efforts determined by the needs of the community. Please take a few minutes to review this
material and complete the survey.
Yours Truly,
Oscar Guillamondegui
Spring 2017
The ACS trauma education requirement (for faculty
who are not liaisons) may be met by documenting
acquisition of 16 hours of trauma-related CME per
year on average or by demonstrating participation in
an internal educational process (IEP) conducted by
the trauma program based on the principles of
practice-based learning and the PIPs program.
2. 1. Most common cause of bladder injury is caused by?
a. Motor vehicle accident
b. Falls
c. Crush Injury
d. Stab wound
2. Symptoms of bladder injury include?
a. Gross hematuria
b. Suprapubic pain and tenderness
c. Inability to void
d. All of the above
3. Indication for operative repair of extraperitoneal bladder injury?
a. Simple extraperitoneal rupture with properly draining catheter without clots.
b. Patient undergoing operative fixation of pelvis requiring hardware and vaginal injury.
c. No extravasation on retrograde cystography on day 10 after foley catheter drainage.
d. Grade I injury: contusion of bladder.
4. Retrograde cystography requires adequate bladder distension with how much contrast?
a. None
b. < 50cc
c. 350-400cc
d. 200cc
5. Bladder lacerations should be repaired with?
a. Absorbable suture
b. Silk suture
c. Prolene suture
d. Skin stapler
Answer Key for Winter 2017 Trauma IEP Newsletter
(answers are in bold and Italics below)
3. Andrew Hopper, MD
Morbidity and mortality secondary to trauma is a global health problem. Over 4 million people die of
injuries every year.1 Estimates put deaths each year, as a result of road traffic injuries, at approximately a
million plus worldwide. It is also estimated that over 1.6 million people die every year because of
intentional acts of interpersonal, collective, or self-directed violence.1 Researchers believe that hemorrhage
is responsible for about a third of in-hospital trauma deaths. Hemorrhage shock is the most common cause
of shock in the injured patient. Hemorrhage has been shown to be a major contributing factor to the
mortality of trauma patients.
When bleeding occurs, the body activates the hemostatic system. This system can be broken up into
three components: primary hemostasis, fibrin formation, and removal of fibrin.2 Primary hemostasis
involves vasoconstriction of vessels (arachidonic acid, thromboxane A2, prostaglandins) followed by
formation of a platelet plug. With platelet plug formation, the coagulation cascade is activated. This then
leads to the combination of thrombin and fibrinogen, to ultimately form a stable fibrin clot. Finally, the
fibrin clot is removed via the fibrinolytic system. This occurs when plasmin cleaves the cross-linked fibrin,
causing clot dissolution. Trauma patients are at risk for the development of hyperfibrinolysis. This
phenomenon can potentially lead to continued bleeding in the severely injured. Antifibrinolytic agents
reduce blood loss in patients with both normal and exaggerated fibrinolytic responses.
The morbidity and mortality secondary to hemorrhage in the critically injured trauma patient is well
established in the literature. The body’s natural hemostatic system is important for control of hemorrhage
in the patient. Fibrinolysis, a component of the hemostatic system is designed to remove the clot. However,
in a trauma patient with on-going bleeding, removal of the clot is not ideal; instead, the patient needs clot
stabilization. One way to prevent hyperfibrinolysis is with the use of tranexamic acid (TXA). Tranexamic
acid is a synthetic derivative of the amino acid lysine. It is believed that tranexamic acid works by being a
competitive inhibitor for the activation of plasminogen to plasmin (Figure 1). Reports indicate that
tranexamic acid has eight times the antifibrinolytic activity of epsilon-aminocaproic acid.
Tranexamic acid is currently being used in trauma patients at hospitals around the world. Multiple
studies have examined the use of TXA in trauma patients. Two of the largest and most recognized studies
are the CRASH 2 and the MATTERs study.
CRASH-2 was a randomized, placebo-controlled trial. In this UK organized study, 20,211 adult
trauma patients from 274 hospitals and 40 countries were included. Patients were randomized to either
tranexamic acid (loading dose 1g over 10min then infusion of 1g over 8h) or matching placebo. Primary
outcome was measured as death in the hospital within 4 weeks of injury. Mortality was significantly
reduced with tranexamic acid vs. placebo (14.5% vs. 16%). The risk of death due to bleeding was
significantly reduced (4.9% vs. 5.7%). Also, the CRASH-2 authors found that early treatment (<1 hour from
injury) significantly reduced the risk of death due to bleeding (5.3% vs. 7.7%). Treatment given between 1
and 3 hours also reduced the risk of death due to bleeding (4.8% vs 6.1%). However, treatment given after
3 hours seemed to increase the risk of death due to bleeding (4.4% vs. 3.1%).3,4
4. The CRASH2 trial is not without critique however. First, concerns exist regarding the study
population. Many argue that the study population does not represent a truly sick trauma population, with
potential that the inclusion criteria diluted out the sick bleeding patients. The data shows that only about a
third of the patients were hypotensive and only half actually required blood transfusions. Furthermore, only
about 5% of patients died from bleeding. Thus, there is debate about the applicability of the results to a truly
sick, bleeding trauma patients. Second, 68% of the patients were blunt trauma patients - which also raises
questions as to how these results apply to sick penetrating trauma patients.5 Third, about 75% of patients
were enrolled in third-world countries. These countries do not have the same training, resources, or
infrastructure typically associated with more developed countries and trauma systems.
In addition to the CRASH-2 trial, there is also the Military Application of Tranexamic Acid in Trauma
Emergency Resuscitation (MATTERs) Study. This study is in military patients and attempts to address some
of the critiques of the CRASH-2 trial. MATTERs is a retrospective observational study that examined 896
consecutive admissions with combat injury. Of the 896 patients reviewed, 293 received TXA. The
investigators used mortality at 24 hours, 48 hours, and 30 days as well as the influence of TXA
administration on postoperative coagulopathy and the rate of thromboembolic complications as their major
outcomes. The TXA group had lower unadjusted mortality than the no-TXA group (17.4% vs 23.9%,
respectively; P=.03). This lower mortality was in spite of being more severely injured: (mean [SD] Injury
Severity Score, 25.2 [16.6] vs 22.5 [18.5], respectively; P<001). The researchers also examined patients that
received massive transfusions. The mortality benefit of TXA was even more pronounced in the massive
transfusion group: (14.4% vs 28.1%, respectively; P=.004). The authors concluded that treatment with TXA
should be implemented into clinical practice as part of a resuscitation strategy following severe wartime
injury and hemorrhage.6 However, this was a retrospective study and therefore has the potential pitfalls
associated with any retrospective study. Also, the patient population was primarily young, healthy, military
patients. Again, how well does this patient population apply to our civilian patient population? Finally, there
was a higher risk of pulmonary embolism (PE) and deep vein thrombosis (DVT) with the TXA group. PE was
more common in the TXA group vs. non-TXA group [8 (2.7%) vs. 2 (0.3%]. This result was also seen with
DVTs [ 7 (2.4%) vs. 1 (0.2%)]. The authors attempt to justify this increased risk of thrombosis because of the
higher injury burden in the TXA group. However, it’s unclear if the higher risk of thrombosis is secondary to
higher injury burden or a side effect of TXA treatment.
The most common side effects seen with tranexamic acid are nausea, vomiting, diarrhea, rash, and
muscle pain. Since tranexamic acid prevents clot dissolution, there is also concern for deep vein thrombosis
and pulmonary vein thrombosis. Garg et. Al. wrote a case report of a patient with ST segment elevation after
receiving a dose of 10 mg/kg of tranexamic acid. The patient had emergent coronary angiography which
demonstrated complete occlusion of the distal right coronary artery. The patient was successfully treated
with thrombectomy and percutaneous coronary intervention.7
Despite these few case reports, overall TXA may be safe to administer. A 2015 Cochrane update on
TXA says that it safely reduces mortality in trauma patients with bleeding without increasing the risk of
adverse events. Per the results of the CRASH-2 trial, the Cochrane editors recommend that TXA should be
given as early as possible and within three hours of injury.1
As emphasized, hemorrhage is a leading cause of morbidity and mortality in trauma patients. The
body’s natural coagulation cascade attempts to control the bleeding. However, in severely injured and
bleeding trauma patients, sometimes the coagulation system gets reversed too soon as the body proceeds to
the fibrinolysis stage. TXA, a lysine analog, appears to disrupt the fibrinolysis system. The two largest
studies using TXA in trauma patients seem to demonstrate that its use is safe and can lead to improved
mortality rates. However, neither study is without critique. There is an ongoing study from the University of
Pennsylvania called the Study of Tranexamic Acid during Air Medical Prehospital transport trial (STAAMP).
The authors will study the effect of infusing TXA during air medical transport on 30 day mortality in patients
5. at risk of bleeding as compared to placebo. They will also examine the effects of TXA on other clinical
outcomes (clotting measurements on arrival to trauma center, total blood transfusion requirements during
the first 24 hours, the development of multiple organ failure, hospital-acquired infection, acute lung injury
and abnormal clotting throughout the body). Ultimately, more prospective, randomized trials in severely
injured trauma patients are needed to provide a more detailed and thorough analysis.
Figure 1: Schematic illustrating the mechanism of action of tranexamic acid and epsilon-aminocaproic acid.
Due to structural similarities to lysine, both tranexamic acid and epsilon-aminocaproic acid moieties
competitively inhibit binding of fibrin to plasminogen via interaction at an active lysine-binding site. The
binding of fibrin to plasminogen is facilitated by a tissue plasminogen activator (t-PA). When either
tranexamic acid or epsilon-aminocaproic acid is bound to the lysine-binding site on plasminogen,
fibrinolysis is prevented, with concomitant stabilization of the fibrin clot over the bleeding vessel. Dunn CJ,
Goa KL: Tranexamic acid: a review of its use in surgery and other indications. Drugs. 1999 Jun;57[6]:1005-
32.) http://reviews.jbjs.org/content/3/6/e1.figures-only
6. References:
1. Ker K, Roberts I, Shakur H, Coats TJ. Antifibrinolytic drugs for acute traumatic injury. Cochrane Database
of Systematic Reviews 2015, Issue 5. Art. No.: CD004896. DOI: 10.1002/14651858.CD004896.pub4.
2. Pieracci Fredric M, Kashuk Jeffry L, Moore Ernest E. “Postinjury Hemotherapy and Hemostasis.” Trauma.
Editors: Mattox Kenneth, Moore Ernest, Feliciano David. McGraw-Hill Companies. 7th edition. Pages: 216-
235.
3. Shakur H, Roberts I, Bautista R, et al; CRASH-2 Trial Collaborators. Effects of tranexamic acid on death,
vascular occlusive events, and blood transfusion in trauma patients with significant hemorrhage
(CRASH-2): a randomized, placebo-controlled trial. Lancet. 2010;376(9734):23-32.
4. Roberts I, Shakur H, Coats T, Hunt B, Balogun E, Barnetson L, et al. “The CRASH-2 trial: a randomized
controlled trial and economic evaluation of the effects of tranexamic acid on death, vascular occlusive
events and transfusion requirement in bleeding trauma patients.” Health Technol Assess 2013;17(10).
5. Inaba, Kenji. “Antifibrinolytics in Trauma Patients. Published Online: October 17, 2011. Arch Surg.
doi:10.1001. /archsurg.2011.286
6. Morrison JJ, Dubose JJ, Rasmussen TE, Midwinter MJ. Military Application of Tranexamic Acid in Trauma
Emergency Resuscitation (MATTERs) Study [published online October 17, 2011]. Arch Surg.
doi:10.1001/archsurg.2011.287
7. Garg, Jalaj MD*; Pinnamaneni, Sowmya MD; Aronow, Wilbert S. MD; Ahmad, Hasan MD. “ST Elevation
Myocardial Infarction After Tranexamic Acid: First Reported Case in the United States.” American Journal
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8. Virgilio, Christian de, Yahoubian Arezou, Smith Jennifer. “Hemostasis.” Review of Surgery for Absite and
Boards. Saunders Elsevier 2010. P107-113.
7. Stop the Bleed Resources:
https://www.dhs.gov/stopthebleed
http://www.bleedingcontrol.org/
http://bulletin.facs.org/2016/03/the-hartford-consensus-iv-a-call-for-increased-national-resilience/
http://bulletin.facs.org/2013/06/improving-survival-from-active-shooter-events/
2017 National Trauma
Awareness Month
The month of May is National Trauma
Awareness Month. This May, National
Trauma Awareness Month celebrates
its 29th anniversary supporting efforts
to StopTheBleed. StopTheBleed is a
nationwide campaign to empower
individuals to act quickly and save
lives. Uncontrolled bleeding injuries
can result from natural and manmade
disasters and from everyday accidents.
If this bleeding is severe, it can kill
within minutes, potentially before
trained responders can arrive.
Providing bystanders with basic tools
and information on the simple steps
they can take in an emergency
situation to stop life threatening
bleeding can save lives. Similar to the
use of CPR or automatic defibrillators,
improving public awareness about
how to stop severe bleeding and
expanding personal and public access
to Bleeding Control Kits can be the
difference between life and death for
an injured person.
Vanderbilt Trauma’s Mission
The Vanderbilt Trauma team will be
providing several StopTheBleed classes
throughout the month of May. Anyone can
attend these classes. It is important for
staff with no medical knowledge to attend
this course as it is designed to help those
individuals control life threatening
hemorrhage.
The class dates will be sent out closer to
the event month and will also be on Nurse
Alerts.
8. Division of Trauma and Surgical Critical Care
For any questions in regards to the IEP or Trauma
cases please contact:
Melissa Smith: 322.6745
or
Brad Dennis: 936.0286
Melissa Smith – Trauma Program Mgr
melissa.d.smith@vanderbilt.edu
Oscar Guillamondegui – Trauma Medical
Director
Oscar.guillamondegui@vanderbilt.edu
Brad Dennis – Trauma PI Director
Bradley.m.dennis@vanderbilt.edu
Cathy Wilson – Trauma Outreach & Injury
Prevention Coordinator
Catherine.s.wilson@vanderbilt.edu
Andrew Hopper– ACS Fellow/IEP editor
julie.valezuela@vanderbilt.edu
Upcoming Courses
2017 Courses:
ASSET- April 11
ATLS Provider – April 20/21
ATLS Instructor – May 11
RTTDC- May 25 (Jennie Stuart)
ATLS Provider (residency course) –
June 8-9